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Complementary and alternative medicine in midwifery practice: Managing the conflicts
Complementary Therapies in Clinical Practice 18 (2012) 246e251
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Complementary and alternative medicine in midwifery practice: Managing the conflicts Helen G. Hall*, Debra L. Griffiths, Lisa G. McKenna Monash University, School of Nursing & Midwifery, Peninsula Campus, P.O. Box 527, Frankston, Victoria 3199, Australia
a b s t r a c t Keywords: Complementary and alternative medicine Midwives Maternity care Grounded theory
Background: Midwives commonly endorse the use of complementary medicine. However many work in hospitals where there can be significant opposition to use of these therapies. This paper describes how one group of midwives negotiated the conflicting perspectives. Method: Grounded theory was employed. Twenty five participants were recruited from metropolitan hospitals in Australia. Data was collected from interviews and observations. Results: Midwives’ behaviour was influenced by the meaning they constructed around their professional role and authority. Some emphasised ideological congruence, historical ties, and the ability of certain complementary therapies to reduce medical interventions, in order to legitimise their use. However, many were aware of biomedical opposition and undertook various strategies to protect themselves from conflict. Conclusions: Conflict regarding the use of complementary and alternative medicine is context specific. In some situations midwives can successfully negotiate the competing perspectives and expectations, while at other times they struggle to reconcile the disparities. Ó 2012 Elsevier Ltd. All rights reserved.
1. Introduction ‘Complementary and Alternative Medicine’ (CAM) refers to a diverse group of therapies and products that are not generally considered part of conventional medicine.1 Many of the modalities embedded under the CAM rubric are denoted by a philosophical approach, which promotes the body’s natural healing ability and acknowledges the role of lifestyle choices on wellbeing.2 The discourses of natural, holistic care associated with CAM, hold significant appeal for childbearing women. Research indicates that use of various therapies during pregnancy is common in many parts of the world.3,4 The most recently published Australian survey found that the majority (73%) of the (n ¼ 321) respondents had used CAM in the previous eight weeks of pregnancy.5 Popular modalities included massage, nutritional supplements, meditation and yoga. A third of expectant women used the therapies for a specific condition and a quarter also planned to use them in labour. These findings resonate with other studies which indicate CAM use is widespread6e10 and becoming increasingly popular with expectant women living in Australia.11
* Corresponding author. Tel.: þ61 3 9904 4120; fax: þ61 3 9904 4655. E-mail addresses: [email protected], [email protected] (H.G. Hall). 1744-3881/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ctcp.2012.06.010
Midwives commonly endorse women’s use of CAM to reduce medical intervention and support healthy childbearing.12,13 However, many are employed by hospitals where their daily practice is dominated by biomedical discourse. In this environment, various studies indicate that, despite the growing acceptance within the community and the increasing presence of practitioners, complementary therapies continue to be marginalised.14,15 Negotiating the divergent expectations and approaches between CAM and mainstream biomedicine can therefore present a complex challenge for midwives. This paper draws on a grounded theory study that aimed to explain the attitudes and behaviour of midwives towards CAM in the Australian context. The findings presented here focus on the conflicting perspectives midwives encounter and the strategies they use to manage these. 2. Background 2.1. Midwifery in Australia Traditionally, Australian midwives were required to gain a nursing qualification before undertaking post graduate midwifery education. However, in 2002 the Bachelor of Midwifery (direct entry midwifery) commenced in Victoria, Australia.16 An additional pathway of a double degree in midwifery and nursing has also
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become available over recent years. These courses promote the International Confederation of Midwives (ICM) definition and philosophy of practice, that is with woman.17 The re-orientation has seen an emphasis on holistic practice, working in partnership and promoting natural childbearing. However, this has been embraced to varying degrees and there is significant diversity regarding the approaches of practising midwives. Some remain content with the status quo, while others seek to promote holistic practice and enhance professional autonomy. Tension between midwives and doctors over professional boundaries is common and the Australian midwifery profession has been described as demoralized.18 Although innovations such as team-based and caseload midwifery have been implemented, many maternity services remain fragmented and few midwives currently work to their full scope of practice.19,20 The need for improvements in the maternity sector was recently acknowledged in a national strategy that supports the expansion of current midwifery roles.21 3. Method 22
Consistent with the approach taken by Corbin and Strauss, we employed grounded theory underpinned by symbolic interactionism, to explore midwives’ attitudes and behaviour towards CAM. Twenty five participants were recruited from one private and three public metropolitan hospitals in Victoria, Australia. Data was collected, from semi-structured interviews and non participant observations, over an 18-month period during 2010e2011. Purposive sampling was initially employed, followed by theoretical sampling. Theoretical sampling is a dynamic process that focuses on exploring relevant incidents and is driven by the developing constructs. For example, after initial analysis it became evident that it would be valuable to elicit the views of midwives working with women who had high risk pregnancies. Therefore, midwives who were employed in obstetric clinics were asked to participate. Initially, open ended questions were employed and over time the interviews became more focused to explore the emerging themes. With their permission, the interviews were recorded and subsequently fully transcribed. A subgroup of nine participants was also observed interacting with women during (n ¼ 39) antenatal assessments and 9 hours of childbirth education. Observations place the researcher where the action is and provide a valuable opportunity to gain greater insight into the subtleties of behaviour.22 Field notes were used to record the important characteristics of the exchange and clarification was sought from participants following the observed interaction. Data was analysed using open, axial and selective coding.22 Interview transcripts and field notes were compared and reexamined multiple times until all properties (characteristics) and dimensions (context) were fully explored. The research process continued until theoretical saturation was reached and the relationship among categories was well established. The methodological rigour of the study was enhanced through a number of strategies including prolonged engagement in the field, collection of multiple data sources, constant comparative data process, the use of reflective memos and ongoing peer review. Ethical approval was granted from the relevant university and hospitals committees. Consent was obtained from all participants and from women who were part of the observed clinical interaction. All participants referred to in the paper have been assigned a pseudonym to protect their identity. 4. Findings When midwives are considering the use of CAM they need to reconcile the contradictory paradigms of care and potentially
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divergent expectations of colleagues and women. The category in our grounded theory study that is conceptualised as managing the conflicts, encompasses the disparities midwives encounter and the activities they utilise in response. The strategies participants employed when they experienced conflicting and perspectives expectations included legitimising CAM and protecting themselves. Although they are presented as separate entities, the numerous processes are closely inter-related and participants may engage in some or all at various times. 4.1. Experiencing conflicting expectations and perspectives Midwives behaviour towards CAM occurs in an environment where competing perspectives collide. Participants commonly described the difficulties of negotiating the conflicting expectations between hospital bureaucracy, their colleagues and the childbearing woman. Kaz’s comments highlight the dilemma faced by many midwives: It’s hard for me, as a midwife,. it feels like a bit of a tug of war. You never feel like you’re doing the right thing. Because if you’re supporting the woman then you’re going a bit against the policies and then if you’re not supporting the woman, well, at the end of the day, being a midwife is supporting the woman and advocating for her. So it’s a bit tricky. Although biomedicine dominated all participants’ daily practice to varying degrees, some midwives, like Leanne, had significant autonomy: “We don’t really call the doctor unless there is a problem with something. So we would never call up them and say is it okay for someone to have acupuncture.” However, most were aware of their subordinate position and wary of challenging medical authority. Madeline stated: “.you’re up against obstetrics. they might object to . complementary therapies.” Likewise Grace said: “We just follow the standard sort of medical things here. .they [doctor] wouldn’t be happy if I recommended acupuncture.” Participants’ perceptions of individual doctors’ attitudes towards CAM ranged from total rejection to various levels of acceptance. Laura reported: “.some of them just go, do whatever you want, others go, no I don’t want you to use it. others are pro using the stuff.” A number of participants, like Una, commented that there appears to be a changing attitude in light of the growing consumer demand for CAM: “I think we’re seeing a very different population of junior obstetric staff that might be very much more influenced by something alternate. And they let the women do what they want.” Apart from the overt presence of medical colleagues, the influence of biomedical discourse is also embedded within the hospital bureaucracy and policies. A number of participants were concerned that advocating complementary therapies may be in breach of hospital policy, which left them open to the threat of being professionally disciplined. Sabina stated: “If you don’t stick to the rules you can get in a lot of trouble” Similarly, Kaz explained: “I work for [hospital]. and that negates what I can do in my practice a little bit. If I go against their protocols, and something happens, I’m in trouble. I don’t want to stop being a midwife.” While many midwives were supportive of the woman’s wishes to use CAM, they held divergent views regarding its integration into practice. Those who had crossed the accepted boundaries within their particular workplace were likely to confront a negative response from their midwifery colleagues. Holly, who commonly integrated CAM into her midwifery practice explained: “I just assume everyone’s like me, but they’re not.” In particular, tension was evident when ‘low risk’ women were cared for in conventional maternity wards dominated by a biomedical approach. In this
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environment, professional boundaries and philosophies are commonly disputed and the endorsement of CAM may be a flashpoint. Sabina described the tension that arose between midwives when a small group promoted the use of CAM in a conventional maternity setting: “We were then seen as oh they’re those weird ones., those mad midwives. it was standard midwifery care and then the holistic midwifery care. Which created this us and them situation.” Although difficulties surfaced when a participant’s approach was in conflict with the prevailing workplace culture, our findings indicate that midwives tended to work in settings congruent with their personal ideology. Nevertheless, negotiating the conflicting approaches can take an emotional toll on those who are passionate about promoting CAM, as Larissa’s comments illustrated: “.it takes a lot of energy, .to meet this sort of negativity all the time.” Tension between participants and childbearing women also occasionally manifested. This was usually a result of the woman persisting with CAM treatments in opposition to the midwife’s judgement about what was safe and desirable. Sue commented: “I was getting really anxious because this woman would not listen to anything the medical people had to say but she was now experiencing medical problems. I was quite cross with the woman.” Jacky’s statement, regarding women who persist with CAM treatments in opposition to medical advice, reflects a similar attitude: “It worries me sometimes because I don’t think they always understand the potential of the situation.” 4.2. Legitimising CAM Participants who endorsed CAM employed various activities to reconcile the disparity and legitimise its use within a conventional setting. Midwifery discourse asserts that pregnancy and birth is essentially a normal life event and the CAM paradigm, characterized by principles of holism and naturalism, was often portrayed as a natural ally. Hannah’s statement reflected this commonly held perspective: “My aim is always to keep it as normal and natural as possible. complementary therapies can help with that.” Many, including Kaz, emphasised the philosophical congruence: “I think complementary medicines just sort of blend with midwifery. .They’re a natural part of holistic care and women want them.” Midwives also frequently highlighted the woman’s autonomy in order to promote CAM practices Judy’s stated: “It’s not about us. It’s about this woman that’s going to have her baby and whatever helps her. .whatever helps her, we’ll do.” Some also evoked historical ties as a means of justifying the therapies. Faye claimed: “This stuff has been around forever. Midwives have been using it literally since Adam was a boy!” Some, like Rosie, demonstrated respect for traditional practices; “A lot of the things used in pregnancy care, like massage and some of the herbs and things, they haven’t been tested clinically but they have been around for hundreds of years. .they have helped thousands of women over the years and I think that we should respect that. .Modern medicine isn’t always the best option.” The findings clearly indicated that midwives who endorsed CAM did not reject conventional medicine as such. Participants tended to use the term complementary rather than alternative and emphasized that the therapies were an adjunct to conventional care. Vicky claimed: “Complementary medicine, .complements Western medicine, and I think they can work hand-in-hand together.” Participants in our study restricted their support for CAM to healthy pregnancies and therefore did not challenge the medical management of illness. If the pregnancy was or became complicated, they encouraged obstetric treatment. Hannah claimed: “There is a line, it’s like walking a tightrope, . if they have high blood pressure or there’s a problem with the baby, . I
wouldn’t be talking to her about fish oils, I’d be referring her to a doctor.” 4.3. Protecting themselves Many participants were cautious of the risks that endorsement of CAM posed to their reputation and engaged a range of strategies to protect themselves. Commonly they concealed their support from colleagues perceived to have a negative view. Kaz claimed: “It’s just so sneaky and behind everybody’s backs,. it’s like an underground movement.” Although there were a few exceptions, most participants viewed debates with doctors as fruitless. Alice stated: “I haven’t gone to an obstetrician and said, ‘I’ve suggested this woman try acupressure points to induce her labour’. . I have a fairly good idea of the response I would get. So I don’t bother, . I don’t put myself in that position.” Likewise Judy explained: “You wouldn’t suggest something like that [aromatherapy] in front of the doctor.. if this doctor says no, that’s no good, how can you come back to the woman?” When written CAM information was provided, it was often done in a surreptitious manner, as Holly’s comments illustrate: “I have an osteopathy . pamphlet . I give it out sometimes, but just like slyly really, saying you know this is not from [hospital name], this is something that you might want to follow up.” On some occasions participants faced potential conflict with expectant women when they chose to use CAM in opposition to conventional practice. In these situations participants tended to negotiate to reach a compromise. For example, a midwife was observed interacting with a woman who wished to try moxibuston in preference to external cephalic version, to turn her breech baby. The midwife encouraged the woman to keep her appointment in the obstetric clinic, following her visit to the acupuncturist, to assess the baby’s position and wellbeing. The discussion and agreed plan was documented in the woman’s history. Usually, participants aimed to work within the institutional system and incorporate CAM without directly contravening normal practice. Leanne’s approach was typical “Well our protocols here, is once they get to 42 weeks, it’s a medical induction but we try and catch them before that. So once they get to 41 weeks . we do things like., acupuncture, telling them to go for walks, sexual intercourse, all that kind of stuff.” Many participants circumvented conflict with their unsupportive colleagues by referring women interested in CAM use to other clinicians. Occasionally midwives, including Laura, suggested to women that they: “. check with your [biomedical] doctor, first.” However, most encouraged women to seek further advice from CAM practitioners. In the following example, Kate explained how her behaviour changed following interpersonal conflict with a colleague: “Once upon a time I would tell people, you should get onto raspberry leaf tea .but I don’t any more. If people ask me.I’ll always suggest that they go and speak to a naturopath.” A few participants used strategies to gain the woman’s compliance with standard practice and thereby avoided being in conflict with the medical approach. Common strategies included avoiding discussing CAM and highlighting medical expertise. For example, a pregnant woman requested information on “natural” options to initiate labour. The midwife stated “. the best thing is to not worry and just do what the doctor advises. He’s the expert. .It’ll be fine.” Later, when interviewed, she claimed; “If I told her to go off and try acupuncture, or castor oil or something like that, he [obstetrician] would be furious.”(Field note #AN5). However, in most situations midwives who restricted CAM information did so because they lacked the appropriate knowledge, rather than a deliberate form of gate keeping. Jacky was observed to deflect CAM questions during a childbirth class later stated when
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interviewed: “I don’t have a problem with it, I just don’t know that much about it.” CAM documentation occurred in a somewhat ad hoc fashion. Some midwives recorded use to distance themselves from the woman’s decision. Hannah advised women: “.if you want to see an acupuncturist that’s your choice but I need to document that you’re not doing what we’re recommending.” Conversely, many participants avoided documenting CAM use in order to evade scrutiny. Judy stated: “If the baby had a real traumatic birth and maybe needs to be adjusted by a chiropractor. you know. just say it quietly. You don’t write it anywhere.” Similarly Sabina explained: “The way we get around it now is just to verbally speak to women . I can’t even write it down. because that might be heresy you know, it might be witchcraft!” 5. Discussion Research has found that patients considering CAM often experience conflict, in various forms, as they attempt to reconcile the disparity between conventional and alternative approaches.23,24 Likewise, hospital based midwives considering the role of CAM in pregnancy care, also find themselves at the intersection of divergent paradigms of care, where conflicting knowledge and practices are contested. The findings from our study indicate that how midwives respond was strongly influenced by the meaning they constructed around their professional role and authority in this environment. CAM and biomedicine are derived from fundamentally different approaches and integration of the two can manifest in a clash of perspectives and expectations. Similarly, obstetric and midwifery ideologies are also not only different, but potentially incongruent.25 While the reductionist paradigm of biomedicine assumes childbearing is risky and aims to control the process, midwifery and CAM share a holistic approach and assert that benefit can be gained from supporting natural physiology. Numerous studies have found that midwives promote CAM to support natural childbearing.13 Indeed, the alliance between midwifery and CAM has been described by one academic as a happy marriage.26 While most midwives accept medical intervention in high risk pregnancies, there can be divergence of opinion regarding the care of low risk woman.18,27 The use of the therapies to support healthy birth therefore provides fertile territory for boundaries to be challenged, which can manifest in significant tension.28,29 Earlier research conducted in Australia reported that CAM integration in a maternity setting “. feeds into wider professional boundary and power struggles .” and midwives were acutely aware of this.30 However, while some participants in our study did promote CAM as a tool to challenge obstetric authority, we found the widespread support was more often simply a pragmatic reaction to women’s interest and an opportunity to reduce medical intervention. Similar to other studies31,32 our findings indicate that the availability of CAM had not significantly altered the status quo within the hospital system. Indeed, when the therapies were integrated into midwifery practice, it was likely to be a consequence, rather than a cause, of increased professional independence. Although some midwives advocate CAM for complex pregnancies,33 our study was consistent with work that indicates most limit their support to healthy pregnancies and areas such as emotional wellbeing.32,34 In these circumstances CAM enthusiasts engaged various strategies designed to promote the therapies as a legitimate part of maternity care. Many participants highlighted the ideological congruence, historical ties, and the ability of some therapies to reduce medical interventions, in order justify their use. Similar to other studies, we found that midwives often presented the
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therapies as harmless32 and emphasised they were “complementary”32,34 and consequently not threatening to medical power. Some midwives claimed doctors are becoming more accepting of CAM which has been identified elsewhere.28 Research exploring obstetricians’ attitudes in both America35 and Australia36 found widespread support for various therapies. Yet, despite the increasing tolerance, our data indicates that many modalities continue to be marginalised in a hospital context. However, direct conflict between participants and doctors regarding use of the therapies was rare. We found that participants were mindful of opposition to CAM from their medical colleagues and their own their subordinate position. As identified in other research,28,32,34,37 midwives tended to contain their support when subjected to closer surveillance by their medical colleagues. In addition, a number also avoided documentation of the woman’s use in order to evade scrutiny, which has also been highlighted in other work.28,38 Despite the rhetoric of natural birth and promoting autonomy, we found midwives were cautious of the possible consequences if they openly promoted CAM. Our data resonates with studies that have found biomedicine engages a process of CAM exclusion, while avoiding direct interpersonal confrontation in the hospital environment.14,39,40 Midwives were more confident to expose their CAM interest to their professional peers, which ironically did sometimes lead to overt conflict. Although there was considerable support for women’s use of CAM, there was a range of views about integration of the therapies into midwifery practice. CAM integration was commonly associated with an attempt to promote a holistic, woman centred care. However, this approach was not always reflected in the prevailing culture of the workplace, which could create significant tension between midwifery colleagues. Indeed, the findings from our study suggest that use of the therapies in practice may highlight the conflicting ideological positioning between some midwives. Research conducted in the UK revealed that midwives who espoused the ‘new midwifery’ approach may threaten the established hospital culture and, in some contexts, this can result in conflict between midwives.41 When established boundaries are challenged, oppressed groups sometimes internalise the values of those in power, and engage in a process of ‘horizontal violence’ to ensure colleagues return to the behavioural norms.41 This behaviour was evident in the reports of some participants who described an ‘us’ and ‘them’ mentality. In these instances, those who breached accepted practice were subjected to actions that ranged from lack of inclusion to incidences of explicit ridicule. As a result midwives who held a strong belief in the value of CAM were more cautious about promoting the therapies in an unsupportive environment and on a number of occasions had changed work places in order to find a maternity unit that was more compatible to their approach. Although most midwives respected the pregnant woman’s decision to use CAM, tension occasionally arose when her choice was considered unsafe or it was in direct opposition to the customary practice of their workplace. In these situations midwives tended to work with women to reach a compromise that was acceptable to both. While institutional policies have been found to limit the use of CAM in UK hospitals,32 participants in our study were usually not constrained by specific CAM clinical guidelines. As a consequence they often had the opportunity to work within the system and negotiate the use of various therapies without directly breaching written directives. Patients have reported that conventional clinicians sometimes withhold information to restrict CAM use.42 Furthermore, midwives sometimes control the release of information to women, in order to protect themselves.43 We found this practice was occasionally evident participants’ behaviour. In some situations
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midwives restricted open dialogue and therefore avoided confronting a possible conflict. In some instances, participants circumvented the potential clash of ideals by encouraging women interested in using CAM to seek advice from other clinicians. On a few occasions women were directed to a biomedical doctor but more usually midwives recommended that they seek out a qualified CAM practitioner. The practice of referring women to CAM therapists is common among midwives.36,38,44,45 While we found that this strategy is often related to concerns regarding their limited knowledge, it also enabled midwives to avoid being an active partner in the woman’s decision to contravene conventional practice. Although meaning and action is central to grounded theory, the attitudes and responses of participants needs to be put into context.22 We found that conflict regarding CAM use was very context specific which has been also reported in other studies.32,46 Midwives tended to work in units congruent to their personal views. Those who enjoyed a greater level of professional independence (typically in midwifery-led units) had more opportunity to align to a holistic philosophy and escape the immediate gaze of biomedicine. In these situations they commonly discussed and integrated CAM without fear of negative consequences. Other midwives worked in a maternity setting dominated by a medical hierarchy. While some who were interested in CAM did successfully transverse the various boundaries, it usually required considerable effort. A number of midwives appeared exhausted by their endeavour to promote the therapies as part of holistic care, and the backlash that sometimes ensued. Our findings are consistent with work that reveals integration of CAM requires significant skill,32 and attempts to balance conflicting ideologies can be emotionally draining.47,48 6. Limitations & strengths The qualitative nature of our study does not allow for generalisations to be made. However it provides sufficient detail to facilitate others to establish if the findings may translate to different areas. A key strength of our study is that we collected data from a wide range of maternity settings and included midwives who did not integrate CAM into practice. Further, observations of participants in clinical practice enabled us to consider the discrepancy between reported attitudes and observed behaviour. 7. Conclusion The encroachment of CAM into the hospital settings represents both an opportunity and a challenge for the midwifery profession. Integration of the therapies into practice is often aligned with a holistic, women-centred approach to childbearing. However, CAM and the dominating conventional approach are derived from fundamentally different assumptions. This dichotomy can create significant tension and compels midwives to employ various strategies to manage the conflicts. Midwives usually aim to work with women interested in CAM to facilitate their informed choices. In some situations the competing perspectives and expectations can be negotiated, while at other times, they struggle to reconcile the disparities. Many midwives working in hospital environments are mindful of their subordinate position, and often they constrain their enthusiasm for CAM, rather than confront a negative response from their medical colleagues. However, CAM advocates may be more open with their midwifery peers which in some contexts, highlights the conflicting ideological positioning.
Conflict of interest There is no conflict of interest. References 1. National Center for Complementary and Alternative Medicine. What is complementary and alternative medicine?. USA: National Institutes of Health; 2011. 2. Hall H. Complementary therapies. In: Dempsey J, French J, Hillege S, Wilson V, editors. Fundamentals of nursing and midwifery; a person centred approach. Philadelphia: Lippincott Williams & Wilkins; 2009. p. 738e57. 3. Adams J, Lui C-W, Sibbritt D, Broom A, Wardle J, Homer C, et al. Women’s use of complementary and alternative medicine during pregnancy: a critical review of the literature. Birth 2009;36(3):237e45. 4. Hall H, Griffiths D, McKenna L. The use of complementary and alternative medicine by pregnant women: a literature review. Midwifery 2011;27(6):817e24. 5. Skouteris H, Wetheim E, Rallis S, Paxton S, Kelly L, Milgrom J. Use of complementary and alternative medicines by a sample of Australian women during pregnancy. 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H.G. Hall et al. / Complementary Therapies in Clinical Practice 18 (2012) 246e251 30. Adams J. An exploratory study of complementary and alternative medicine in hospital midwifery: models of care and professional struggle. Complementary Therapies in Clinical Practice 2006;12:40e7. 31. Turner P. The emerging role of alternative midwifery within the wider sociopolitical sphere. In: Adams J, Tovey P, editors. Complementary and alternative medicine in nursing and midwifery. London & New York: Routledge; 2008. p. 33e51. 32. Cant S, Watts P, Ruston A. Negotiating competency, professionalism and risk: the integration of complementary and alternative medicine by nurses and midwives in NHS hospitals. Social Science & Medicine 2011;72(4):529e36. 33. Mitchell M, Williams J. The role of midwife-complementary therapists; data from in-depth telephone interviews. Evidence-Based Midwifery 2007;5(3):93e9. 34. Shuval J, Gross S. Midwives practice CAM: feminism in the delivery room. Complementary Health Practice Review 2008;13(1):46e62. 35. Furlow M, Patel D, Sen A, Liu J. Physician and patient attitudes towards complementary and alternative medicine in obstetrics and gynecology. BMC Complementary & Alternative Medicine 2008;8(35). 36. Gaffney L, Smith C. Use of complementary therapies in pregnancy: the perceptions of obstetricians and midwives in South Australia. Australian and New Zealand Journal of Obstetrics and Gynaecology 2004;44(1):24e9. 37. Hirschkorn K, Bourgeault I. Structural constraints and opportunities for CAM use and referral by physicians, nurses, and midwives. Health: An Interdisciplinary Journal for the Social Study of Health, Illness & Medicine 2008;12(2):163. 38. Harding D, Foureur M. New Zealand and Canadian midwives’ use of complementary and alternative medicine. New Zealand College of Midwives Journal 2009;40:7e12.
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39. Mizrachi N, Shuval J. Between formal and enacted policy: changing the contours of boundaries. Social Science & Medicine 2005;60(7):1649e60. 40. Mizrachi N, Shuval J, Gross S. Boundary at work: alternative medicine in biomedical settings. Sociology of Health & Illness 2005;27(1):20e43. 41. Hunter B. Emotion work and boundary maintenance in hospital-based midwifery. Midwifery 2005;21(3):253e66. 42. Tovey P, Broom A. Oncologists’ and specialist cancer nurses’ approaches to complementary and alternative medicine and their impact on patient action. Social Science & Medicine 2007;64(12):2550e64. 43. Levy V. Protective steering: a grounded theory study of the processes by which midwives facilitate informed choices during pregnancy. Journal of Advanced Nursing 2006;53(1):114e22. 44. Hastings-Tolsma M, Terada M. Complementary medicine use by nurse midwives in the U.S. Complementary Therapies in Clinical Practice 2009;15(4): 212e9. 45. Bayles B. Herbal and other complementary medicine use by Texas midwives. Journal of Midwifery & Women’s Health 2007;52(5):473e8. 46. Shuval J, Gross S. Nurses and midwives in alternative health care: comparative processes of boundary re-configuration in Israel. In: Adams J, Tovey P, editors. Complementary and alternative medicine in nursing and midwifery. London & New York: Routledge; 2008. p. 113e34. 47. Blix-Lindström S, Johansson E, Christensson K. Midwives’ navigation and perceived power during decision-making related to augmentation of labour. Midwifery 2008;24(2):190e8. 48. Hunter B. Conflicting ideologies as a source of emotion work in midwifery. Midwifery 2004;20(3):261e72.
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Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp
Complementary and alternative medicine in midwifery practice: Managing the conflicts Helen G. Hall*, Debra L. Griffiths, Lisa G. McKenna Monash University, School of Nursing & Midwifery, Peninsula Campus, P.O. Box 527, Frankston, Victoria 3199, Australia
a b s t r a c t Keywords: Complementary and alternative medicine Midwives Maternity care Grounded theory
Background: Midwives commonly endorse the use of complementary medicine. However many work in hospitals where there can be significant opposition to use of these therapies. This paper describes how one group of midwives negotiated the conflicting perspectives. Method: Grounded theory was employed. Twenty five participants were recruited from metropolitan hospitals in Australia. Data was collected from interviews and observations. Results: Midwives’ behaviour was influenced by the meaning they constructed around their professional role and authority. Some emphasised ideological congruence, historical ties, and the ability of certain complementary therapies to reduce medical interventions, in order to legitimise their use. However, many were aware of biomedical opposition and undertook various strategies to protect themselves from conflict. Conclusions: Conflict regarding the use of complementary and alternative medicine is context specific. In some situations midwives can successfully negotiate the competing perspectives and expectations, while at other times they struggle to reconcile the disparities. Ó 2012 Elsevier Ltd. All rights reserved.
1. Introduction ‘Complementary and Alternative Medicine’ (CAM) refers to a diverse group of therapies and products that are not generally considered part of conventional medicine.1 Many of the modalities embedded under the CAM rubric are denoted by a philosophical approach, which promotes the body’s natural healing ability and acknowledges the role of lifestyle choices on wellbeing.2 The discourses of natural, holistic care associated with CAM, hold significant appeal for childbearing women. Research indicates that use of various therapies during pregnancy is common in many parts of the world.3,4 The most recently published Australian survey found that the majority (73%) of the (n ¼ 321) respondents had used CAM in the previous eight weeks of pregnancy.5 Popular modalities included massage, nutritional supplements, meditation and yoga. A third of expectant women used the therapies for a specific condition and a quarter also planned to use them in labour. These findings resonate with other studies which indicate CAM use is widespread6e10 and becoming increasingly popular with expectant women living in Australia.11
* Corresponding author. Tel.: þ61 3 9904 4120; fax: þ61 3 9904 4655. E-mail addresses: [email protected], [email protected] (H.G. Hall). 1744-3881/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ctcp.2012.06.010
Midwives commonly endorse women’s use of CAM to reduce medical intervention and support healthy childbearing.12,13 However, many are employed by hospitals where their daily practice is dominated by biomedical discourse. In this environment, various studies indicate that, despite the growing acceptance within the community and the increasing presence of practitioners, complementary therapies continue to be marginalised.14,15 Negotiating the divergent expectations and approaches between CAM and mainstream biomedicine can therefore present a complex challenge for midwives. This paper draws on a grounded theory study that aimed to explain the attitudes and behaviour of midwives towards CAM in the Australian context. The findings presented here focus on the conflicting perspectives midwives encounter and the strategies they use to manage these. 2. Background 2.1. Midwifery in Australia Traditionally, Australian midwives were required to gain a nursing qualification before undertaking post graduate midwifery education. However, in 2002 the Bachelor of Midwifery (direct entry midwifery) commenced in Victoria, Australia.16 An additional pathway of a double degree in midwifery and nursing has also
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become available over recent years. These courses promote the International Confederation of Midwives (ICM) definition and philosophy of practice, that is with woman.17 The re-orientation has seen an emphasis on holistic practice, working in partnership and promoting natural childbearing. However, this has been embraced to varying degrees and there is significant diversity regarding the approaches of practising midwives. Some remain content with the status quo, while others seek to promote holistic practice and enhance professional autonomy. Tension between midwives and doctors over professional boundaries is common and the Australian midwifery profession has been described as demoralized.18 Although innovations such as team-based and caseload midwifery have been implemented, many maternity services remain fragmented and few midwives currently work to their full scope of practice.19,20 The need for improvements in the maternity sector was recently acknowledged in a national strategy that supports the expansion of current midwifery roles.21 3. Method 22
Consistent with the approach taken by Corbin and Strauss, we employed grounded theory underpinned by symbolic interactionism, to explore midwives’ attitudes and behaviour towards CAM. Twenty five participants were recruited from one private and three public metropolitan hospitals in Victoria, Australia. Data was collected, from semi-structured interviews and non participant observations, over an 18-month period during 2010e2011. Purposive sampling was initially employed, followed by theoretical sampling. Theoretical sampling is a dynamic process that focuses on exploring relevant incidents and is driven by the developing constructs. For example, after initial analysis it became evident that it would be valuable to elicit the views of midwives working with women who had high risk pregnancies. Therefore, midwives who were employed in obstetric clinics were asked to participate. Initially, open ended questions were employed and over time the interviews became more focused to explore the emerging themes. With their permission, the interviews were recorded and subsequently fully transcribed. A subgroup of nine participants was also observed interacting with women during (n ¼ 39) antenatal assessments and 9 hours of childbirth education. Observations place the researcher where the action is and provide a valuable opportunity to gain greater insight into the subtleties of behaviour.22 Field notes were used to record the important characteristics of the exchange and clarification was sought from participants following the observed interaction. Data was analysed using open, axial and selective coding.22 Interview transcripts and field notes were compared and reexamined multiple times until all properties (characteristics) and dimensions (context) were fully explored. The research process continued until theoretical saturation was reached and the relationship among categories was well established. The methodological rigour of the study was enhanced through a number of strategies including prolonged engagement in the field, collection of multiple data sources, constant comparative data process, the use of reflective memos and ongoing peer review. Ethical approval was granted from the relevant university and hospitals committees. Consent was obtained from all participants and from women who were part of the observed clinical interaction. All participants referred to in the paper have been assigned a pseudonym to protect their identity. 4. Findings When midwives are considering the use of CAM they need to reconcile the contradictory paradigms of care and potentially
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divergent expectations of colleagues and women. The category in our grounded theory study that is conceptualised as managing the conflicts, encompasses the disparities midwives encounter and the activities they utilise in response. The strategies participants employed when they experienced conflicting and perspectives expectations included legitimising CAM and protecting themselves. Although they are presented as separate entities, the numerous processes are closely inter-related and participants may engage in some or all at various times. 4.1. Experiencing conflicting expectations and perspectives Midwives behaviour towards CAM occurs in an environment where competing perspectives collide. Participants commonly described the difficulties of negotiating the conflicting expectations between hospital bureaucracy, their colleagues and the childbearing woman. Kaz’s comments highlight the dilemma faced by many midwives: It’s hard for me, as a midwife,. it feels like a bit of a tug of war. You never feel like you’re doing the right thing. Because if you’re supporting the woman then you’re going a bit against the policies and then if you’re not supporting the woman, well, at the end of the day, being a midwife is supporting the woman and advocating for her. So it’s a bit tricky. Although biomedicine dominated all participants’ daily practice to varying degrees, some midwives, like Leanne, had significant autonomy: “We don’t really call the doctor unless there is a problem with something. So we would never call up them and say is it okay for someone to have acupuncture.” However, most were aware of their subordinate position and wary of challenging medical authority. Madeline stated: “.you’re up against obstetrics. they might object to . complementary therapies.” Likewise Grace said: “We just follow the standard sort of medical things here. .they [doctor] wouldn’t be happy if I recommended acupuncture.” Participants’ perceptions of individual doctors’ attitudes towards CAM ranged from total rejection to various levels of acceptance. Laura reported: “.some of them just go, do whatever you want, others go, no I don’t want you to use it. others are pro using the stuff.” A number of participants, like Una, commented that there appears to be a changing attitude in light of the growing consumer demand for CAM: “I think we’re seeing a very different population of junior obstetric staff that might be very much more influenced by something alternate. And they let the women do what they want.” Apart from the overt presence of medical colleagues, the influence of biomedical discourse is also embedded within the hospital bureaucracy and policies. A number of participants were concerned that advocating complementary therapies may be in breach of hospital policy, which left them open to the threat of being professionally disciplined. Sabina stated: “If you don’t stick to the rules you can get in a lot of trouble” Similarly, Kaz explained: “I work for [hospital]. and that negates what I can do in my practice a little bit. If I go against their protocols, and something happens, I’m in trouble. I don’t want to stop being a midwife.” While many midwives were supportive of the woman’s wishes to use CAM, they held divergent views regarding its integration into practice. Those who had crossed the accepted boundaries within their particular workplace were likely to confront a negative response from their midwifery colleagues. Holly, who commonly integrated CAM into her midwifery practice explained: “I just assume everyone’s like me, but they’re not.” In particular, tension was evident when ‘low risk’ women were cared for in conventional maternity wards dominated by a biomedical approach. In this
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environment, professional boundaries and philosophies are commonly disputed and the endorsement of CAM may be a flashpoint. Sabina described the tension that arose between midwives when a small group promoted the use of CAM in a conventional maternity setting: “We were then seen as oh they’re those weird ones., those mad midwives. it was standard midwifery care and then the holistic midwifery care. Which created this us and them situation.” Although difficulties surfaced when a participant’s approach was in conflict with the prevailing workplace culture, our findings indicate that midwives tended to work in settings congruent with their personal ideology. Nevertheless, negotiating the conflicting approaches can take an emotional toll on those who are passionate about promoting CAM, as Larissa’s comments illustrated: “.it takes a lot of energy, .to meet this sort of negativity all the time.” Tension between participants and childbearing women also occasionally manifested. This was usually a result of the woman persisting with CAM treatments in opposition to the midwife’s judgement about what was safe and desirable. Sue commented: “I was getting really anxious because this woman would not listen to anything the medical people had to say but she was now experiencing medical problems. I was quite cross with the woman.” Jacky’s statement, regarding women who persist with CAM treatments in opposition to medical advice, reflects a similar attitude: “It worries me sometimes because I don’t think they always understand the potential of the situation.” 4.2. Legitimising CAM Participants who endorsed CAM employed various activities to reconcile the disparity and legitimise its use within a conventional setting. Midwifery discourse asserts that pregnancy and birth is essentially a normal life event and the CAM paradigm, characterized by principles of holism and naturalism, was often portrayed as a natural ally. Hannah’s statement reflected this commonly held perspective: “My aim is always to keep it as normal and natural as possible. complementary therapies can help with that.” Many, including Kaz, emphasised the philosophical congruence: “I think complementary medicines just sort of blend with midwifery. .They’re a natural part of holistic care and women want them.” Midwives also frequently highlighted the woman’s autonomy in order to promote CAM practices Judy’s stated: “It’s not about us. It’s about this woman that’s going to have her baby and whatever helps her. .whatever helps her, we’ll do.” Some also evoked historical ties as a means of justifying the therapies. Faye claimed: “This stuff has been around forever. Midwives have been using it literally since Adam was a boy!” Some, like Rosie, demonstrated respect for traditional practices; “A lot of the things used in pregnancy care, like massage and some of the herbs and things, they haven’t been tested clinically but they have been around for hundreds of years. .they have helped thousands of women over the years and I think that we should respect that. .Modern medicine isn’t always the best option.” The findings clearly indicated that midwives who endorsed CAM did not reject conventional medicine as such. Participants tended to use the term complementary rather than alternative and emphasized that the therapies were an adjunct to conventional care. Vicky claimed: “Complementary medicine, .complements Western medicine, and I think they can work hand-in-hand together.” Participants in our study restricted their support for CAM to healthy pregnancies and therefore did not challenge the medical management of illness. If the pregnancy was or became complicated, they encouraged obstetric treatment. Hannah claimed: “There is a line, it’s like walking a tightrope, . if they have high blood pressure or there’s a problem with the baby, . I
wouldn’t be talking to her about fish oils, I’d be referring her to a doctor.” 4.3. Protecting themselves Many participants were cautious of the risks that endorsement of CAM posed to their reputation and engaged a range of strategies to protect themselves. Commonly they concealed their support from colleagues perceived to have a negative view. Kaz claimed: “It’s just so sneaky and behind everybody’s backs,. it’s like an underground movement.” Although there were a few exceptions, most participants viewed debates with doctors as fruitless. Alice stated: “I haven’t gone to an obstetrician and said, ‘I’ve suggested this woman try acupressure points to induce her labour’. . I have a fairly good idea of the response I would get. So I don’t bother, . I don’t put myself in that position.” Likewise Judy explained: “You wouldn’t suggest something like that [aromatherapy] in front of the doctor.. if this doctor says no, that’s no good, how can you come back to the woman?” When written CAM information was provided, it was often done in a surreptitious manner, as Holly’s comments illustrate: “I have an osteopathy . pamphlet . I give it out sometimes, but just like slyly really, saying you know this is not from [hospital name], this is something that you might want to follow up.” On some occasions participants faced potential conflict with expectant women when they chose to use CAM in opposition to conventional practice. In these situations participants tended to negotiate to reach a compromise. For example, a midwife was observed interacting with a woman who wished to try moxibuston in preference to external cephalic version, to turn her breech baby. The midwife encouraged the woman to keep her appointment in the obstetric clinic, following her visit to the acupuncturist, to assess the baby’s position and wellbeing. The discussion and agreed plan was documented in the woman’s history. Usually, participants aimed to work within the institutional system and incorporate CAM without directly contravening normal practice. Leanne’s approach was typical “Well our protocols here, is once they get to 42 weeks, it’s a medical induction but we try and catch them before that. So once they get to 41 weeks . we do things like., acupuncture, telling them to go for walks, sexual intercourse, all that kind of stuff.” Many participants circumvented conflict with their unsupportive colleagues by referring women interested in CAM use to other clinicians. Occasionally midwives, including Laura, suggested to women that they: “. check with your [biomedical] doctor, first.” However, most encouraged women to seek further advice from CAM practitioners. In the following example, Kate explained how her behaviour changed following interpersonal conflict with a colleague: “Once upon a time I would tell people, you should get onto raspberry leaf tea .but I don’t any more. If people ask me.I’ll always suggest that they go and speak to a naturopath.” A few participants used strategies to gain the woman’s compliance with standard practice and thereby avoided being in conflict with the medical approach. Common strategies included avoiding discussing CAM and highlighting medical expertise. For example, a pregnant woman requested information on “natural” options to initiate labour. The midwife stated “. the best thing is to not worry and just do what the doctor advises. He’s the expert. .It’ll be fine.” Later, when interviewed, she claimed; “If I told her to go off and try acupuncture, or castor oil or something like that, he [obstetrician] would be furious.”(Field note #AN5). However, in most situations midwives who restricted CAM information did so because they lacked the appropriate knowledge, rather than a deliberate form of gate keeping. Jacky was observed to deflect CAM questions during a childbirth class later stated when
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interviewed: “I don’t have a problem with it, I just don’t know that much about it.” CAM documentation occurred in a somewhat ad hoc fashion. Some midwives recorded use to distance themselves from the woman’s decision. Hannah advised women: “.if you want to see an acupuncturist that’s your choice but I need to document that you’re not doing what we’re recommending.” Conversely, many participants avoided documenting CAM use in order to evade scrutiny. Judy stated: “If the baby had a real traumatic birth and maybe needs to be adjusted by a chiropractor. you know. just say it quietly. You don’t write it anywhere.” Similarly Sabina explained: “The way we get around it now is just to verbally speak to women . I can’t even write it down. because that might be heresy you know, it might be witchcraft!” 5. Discussion Research has found that patients considering CAM often experience conflict, in various forms, as they attempt to reconcile the disparity between conventional and alternative approaches.23,24 Likewise, hospital based midwives considering the role of CAM in pregnancy care, also find themselves at the intersection of divergent paradigms of care, where conflicting knowledge and practices are contested. The findings from our study indicate that how midwives respond was strongly influenced by the meaning they constructed around their professional role and authority in this environment. CAM and biomedicine are derived from fundamentally different approaches and integration of the two can manifest in a clash of perspectives and expectations. Similarly, obstetric and midwifery ideologies are also not only different, but potentially incongruent.25 While the reductionist paradigm of biomedicine assumes childbearing is risky and aims to control the process, midwifery and CAM share a holistic approach and assert that benefit can be gained from supporting natural physiology. Numerous studies have found that midwives promote CAM to support natural childbearing.13 Indeed, the alliance between midwifery and CAM has been described by one academic as a happy marriage.26 While most midwives accept medical intervention in high risk pregnancies, there can be divergence of opinion regarding the care of low risk woman.18,27 The use of the therapies to support healthy birth therefore provides fertile territory for boundaries to be challenged, which can manifest in significant tension.28,29 Earlier research conducted in Australia reported that CAM integration in a maternity setting “. feeds into wider professional boundary and power struggles .” and midwives were acutely aware of this.30 However, while some participants in our study did promote CAM as a tool to challenge obstetric authority, we found the widespread support was more often simply a pragmatic reaction to women’s interest and an opportunity to reduce medical intervention. Similar to other studies31,32 our findings indicate that the availability of CAM had not significantly altered the status quo within the hospital system. Indeed, when the therapies were integrated into midwifery practice, it was likely to be a consequence, rather than a cause, of increased professional independence. Although some midwives advocate CAM for complex pregnancies,33 our study was consistent with work that indicates most limit their support to healthy pregnancies and areas such as emotional wellbeing.32,34 In these circumstances CAM enthusiasts engaged various strategies designed to promote the therapies as a legitimate part of maternity care. Many participants highlighted the ideological congruence, historical ties, and the ability of some therapies to reduce medical interventions, in order justify their use. Similar to other studies, we found that midwives often presented the
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therapies as harmless32 and emphasised they were “complementary”32,34 and consequently not threatening to medical power. Some midwives claimed doctors are becoming more accepting of CAM which has been identified elsewhere.28 Research exploring obstetricians’ attitudes in both America35 and Australia36 found widespread support for various therapies. Yet, despite the increasing tolerance, our data indicates that many modalities continue to be marginalised in a hospital context. However, direct conflict between participants and doctors regarding use of the therapies was rare. We found that participants were mindful of opposition to CAM from their medical colleagues and their own their subordinate position. As identified in other research,28,32,34,37 midwives tended to contain their support when subjected to closer surveillance by their medical colleagues. In addition, a number also avoided documentation of the woman’s use in order to evade scrutiny, which has also been highlighted in other work.28,38 Despite the rhetoric of natural birth and promoting autonomy, we found midwives were cautious of the possible consequences if they openly promoted CAM. Our data resonates with studies that have found biomedicine engages a process of CAM exclusion, while avoiding direct interpersonal confrontation in the hospital environment.14,39,40 Midwives were more confident to expose their CAM interest to their professional peers, which ironically did sometimes lead to overt conflict. Although there was considerable support for women’s use of CAM, there was a range of views about integration of the therapies into midwifery practice. CAM integration was commonly associated with an attempt to promote a holistic, woman centred care. However, this approach was not always reflected in the prevailing culture of the workplace, which could create significant tension between midwifery colleagues. Indeed, the findings from our study suggest that use of the therapies in practice may highlight the conflicting ideological positioning between some midwives. Research conducted in the UK revealed that midwives who espoused the ‘new midwifery’ approach may threaten the established hospital culture and, in some contexts, this can result in conflict between midwives.41 When established boundaries are challenged, oppressed groups sometimes internalise the values of those in power, and engage in a process of ‘horizontal violence’ to ensure colleagues return to the behavioural norms.41 This behaviour was evident in the reports of some participants who described an ‘us’ and ‘them’ mentality. In these instances, those who breached accepted practice were subjected to actions that ranged from lack of inclusion to incidences of explicit ridicule. As a result midwives who held a strong belief in the value of CAM were more cautious about promoting the therapies in an unsupportive environment and on a number of occasions had changed work places in order to find a maternity unit that was more compatible to their approach. Although most midwives respected the pregnant woman’s decision to use CAM, tension occasionally arose when her choice was considered unsafe or it was in direct opposition to the customary practice of their workplace. In these situations midwives tended to work with women to reach a compromise that was acceptable to both. While institutional policies have been found to limit the use of CAM in UK hospitals,32 participants in our study were usually not constrained by specific CAM clinical guidelines. As a consequence they often had the opportunity to work within the system and negotiate the use of various therapies without directly breaching written directives. Patients have reported that conventional clinicians sometimes withhold information to restrict CAM use.42 Furthermore, midwives sometimes control the release of information to women, in order to protect themselves.43 We found this practice was occasionally evident participants’ behaviour. In some situations
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midwives restricted open dialogue and therefore avoided confronting a possible conflict. In some instances, participants circumvented the potential clash of ideals by encouraging women interested in using CAM to seek advice from other clinicians. On a few occasions women were directed to a biomedical doctor but more usually midwives recommended that they seek out a qualified CAM practitioner. The practice of referring women to CAM therapists is common among midwives.36,38,44,45 While we found that this strategy is often related to concerns regarding their limited knowledge, it also enabled midwives to avoid being an active partner in the woman’s decision to contravene conventional practice. Although meaning and action is central to grounded theory, the attitudes and responses of participants needs to be put into context.22 We found that conflict regarding CAM use was very context specific which has been also reported in other studies.32,46 Midwives tended to work in units congruent to their personal views. Those who enjoyed a greater level of professional independence (typically in midwifery-led units) had more opportunity to align to a holistic philosophy and escape the immediate gaze of biomedicine. In these situations they commonly discussed and integrated CAM without fear of negative consequences. Other midwives worked in a maternity setting dominated by a medical hierarchy. While some who were interested in CAM did successfully transverse the various boundaries, it usually required considerable effort. A number of midwives appeared exhausted by their endeavour to promote the therapies as part of holistic care, and the backlash that sometimes ensued. Our findings are consistent with work that reveals integration of CAM requires significant skill,32 and attempts to balance conflicting ideologies can be emotionally draining.47,48 6. Limitations & strengths The qualitative nature of our study does not allow for generalisations to be made. However it provides sufficient detail to facilitate others to establish if the findings may translate to different areas. A key strength of our study is that we collected data from a wide range of maternity settings and included midwives who did not integrate CAM into practice. Further, observations of participants in clinical practice enabled us to consider the discrepancy between reported attitudes and observed behaviour. 7. Conclusion The encroachment of CAM into the hospital settings represents both an opportunity and a challenge for the midwifery profession. Integration of the therapies into practice is often aligned with a holistic, women-centred approach to childbearing. However, CAM and the dominating conventional approach are derived from fundamentally different assumptions. This dichotomy can create significant tension and compels midwives to employ various strategies to manage the conflicts. Midwives usually aim to work with women interested in CAM to facilitate their informed choices. In some situations the competing perspectives and expectations can be negotiated, while at other times, they struggle to reconcile the disparities. Many midwives working in hospital environments are mindful of their subordinate position, and often they constrain their enthusiasm for CAM, rather than confront a negative response from their medical colleagues. However, CAM advocates may be more open with their midwifery peers which in some contexts, highlights the conflicting ideological positioning.
Conflict of interest There is no conflict of interest. References 1. National Center for Complementary and Alternative Medicine. What is complementary and alternative medicine?. USA: National Institutes of Health; 2011. 2. Hall H. Complementary therapies. In: Dempsey J, French J, Hillege S, Wilson V, editors. Fundamentals of nursing and midwifery; a person centred approach. Philadelphia: Lippincott Williams & Wilkins; 2009. p. 738e57. 3. Adams J, Lui C-W, Sibbritt D, Broom A, Wardle J, Homer C, et al. Women’s use of complementary and alternative medicine during pregnancy: a critical review of the literature. Birth 2009;36(3):237e45. 4. Hall H, Griffiths D, McKenna L. The use of complementary and alternative medicine by pregnant women: a literature review. Midwifery 2011;27(6):817e24. 5. Skouteris H, Wetheim E, Rallis S, Paxton S, Kelly L, Milgrom J. Use of complementary and alternative medicines by a sample of Australian women during pregnancy. 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