U.K. Support Network for Maternity Acupuncture: Survey of Acupuncturists on the Acupuncture (for Conception to) Childbirth Team

Abstract

Objective: In the United Kingdom, a professional acupuncture network, the Acupuncture (for Conception to) Childbirth Team (ACT), provides education and support for practitioners using maternity acupuncture. However, the nature of treatments their members provide has been unknown. The aim of this survey was to explore how ACT members used acupuncture for maternity care within their women's health practices.

Materials and Methods: An anonymous self-completion questionnaire, hosted by Survey Monkey, was completed by practitioners from 10 ACT branches. Questions covered demographic information, type and frequency of treatment provided in the previous year, and referral networks. Descriptive statistics were used to report the data.

Results: Of 114 survey forms sent, 99 replies were received, a response rate of 86.8%. In addition to fertility and menstrual conditions, the majority of the practitioners (87 [87.8%]) had treated at least 1 pregnant woman each. The most-common maternity situations encountered were: birth preparation (84 [96.5%]); nausea & vomiting (82 [94.2%]); and inducing labor (79 [90.8%]). More than 50% of the practitioners were also treating lower-back and pelvic pain (77 [88.5%]), breech presentations (74 [85.0%]), threatened miscarriages (55 [63.2%]), and headaches/migraines (46 [52.8%]). Only a minority (8 [9.1%]) attended births. A greater number of referrals were received from medical health professionals for pregnancy (54 [65.8%]) than for fertility (16 [19.5%]) or menstrual conditions (8 [9.7%]).

Conclusions: ACT practitioners were treating a wide range of maternity conditions. Referrals from Western medical practitioners were more common for maternity acupuncture than for fertility or menstrual health. It may be that this professional network approach would be beneficial in other countries to support practitioners interested in providing maternity acupuncture.

Introduction

Women are increasingly seeking treatment from acupuncturists for a variety of women's health–related conditions.^1–3 A European Union (EU)/China survey indicated that 41% of EU respondents commonly treated obstetric/gynecologic issues, with just under half of respondents being from the United Kingdom.² In addition, a U.K. survey of acupuncturists reported that, for 15%, fertility was a large part of their practices.⁴ A previous survey of Australian and New Zealand acupuncturists found the most common gynecologic treatments were for premenstrual syndrome, menopause, and primary dysmenorrhea; fertility treatments were for general fertility and to decrease infertility-related stress; and, in pregnancy, the most-common conditions were nausea and vomiting, lower-back or pelvic-girdle pain (LBPGP), and labor preparation and induction.³ Acupuncture during pregnancy and labor has been evaluated as safe when used by a suitably qualified practitioner,⁵ and a growing willingness to refer for pregnancy-related acupuncture has been reported from Western health practitioners.⁶

However, acupuncturists in Australia and New Zealand have expressed concerns about locating quality treatment information and the safety of treating women in early pregnancy.⁷ Safety concerns were also raised in this issue's “Roundtable Discussion, Acupuncture During Pregnancy: An Expert Discussion” (see pp. 251–258), with the consideration that this might be limiting women's access to care. While the practitioners included in this Roundtable Discussion (Moderators: Richard C. Niemtzow, MD, PhD, MPH, and Debra Betts, PhD, LAc; Participants: Sarah Budd, RN, RM (ret), DipAc, BPhil, MSc, Claudia Citkovitz, PhD, MS, LAc, Zena Kocher, LAc, and Cameron Mummery) are examples of acupuncturists offering maternity acupuncture within a hospital setting, the integration of acupuncture within a Western medical setting has not-well researched.⁸

The majority of acupuncturists in countries, such as the United States, the United Kingdom, Australia, and New Zealand, offer maternity treatment through private clinics. In contrast, the majority of maternity acupuncture care in European countries—such as Denmark, Finland, Germany, Norway, Sweden, and Switzerland—is administered by hospital midwives who take short training courses.^9–11 In New Zealand, acupuncture is also provided by midwives, including those acting as lead maternity caregivers (LMCs). These LMCs assume total responsibility for maternity care and use acupuncture for selected conditions, such as nausea, LBPGP, anemia, and preeclampsia, in addition to labor preparation, induction, and pain relief for labor.^12–14 A comparable training program for midwives has also recently commenced in Australia, with women reporting a positive attitude toward receiving acupuncture during pregnancy and with midwives being able to provide this treatment.¹⁵

There an interest in bringing acupuncture into the American health system as an evidence-based nonpharmacologic option.^16,17 There are examples of maternity acupuncture within some U.S. hospitals (see pp. 251–258 for this issue's “Roundtable Discussion”), and midwives, midwifery students, and obstetricians also report that they view acupuncture as a safe and credible therapy.^10,15 However, concerns raised by acupuncturists about locating quality education and the safety of treating patients in this specialized area of practice, can limit access, even when Western health professionals are willing to make referrals.

In the United Kingdom, a professional acupuncture network, the Acupuncture (for Conception to) Childbirth Team (ACT), provides specific education, advertising, networking opportunities, and support for acupuncturists interested in treating fertility and pregnancy-related conditions. All ACT members must have qualifications or training in acupuncture and be registered members of U.K. professional bodies (e.g., British Acupuncture Council, Association of Traditional Chinese Medicine (TCM), or British Medical Acupuncture Society). Membership is maintained through continuing professional development within regional groups. The extent and treatments being provided by these acupuncturists for pregnancy-related conditions is not known. This study was conducted to build on the existing limited knowledge of acupuncture use in maternity care by surveying pregnancy-related care for ACT practitioners within their women's heath practices.

Materials and Methods

An anonymous self-completion questionnaire was completed by members of the U.K. ACT on their use of acupuncture for treating women's health conditions. ACT networks are structured across the United Kingdom according to region (county/area) and run by volunteer members with each maintaining a register of members. Regional coordinators were asked to e-mail an invitation letter with a link to the questionnaire to their members. The questionnaire was then accessed through the internet provider Survey Monkey^*.

The survey was adapted from a survey 2 of the current authors (D.B. and M.A.) had previously developed with another collaborator for use in Australia and New Zealand.³ The areas of women's health examined included gynecology, fertility, and pregnancy and postpartum care. Within each section, questions were on practitioners' treatment of various conditions in the previous year, estimated number of treatments for these conditions, and referral networks used. Demographic questions were included to examine the diversity of participants, including their years of experience, location of training, and current practices, and theoretical bases of practice. Survey responses, which took less than 20 minutes to complete, were collected between March and August 2016. Following the initial e-mail invitation, 3 reminders were sent before the survey closed. This study was approved by the London South Bank University Research and Ethics Committee (UREC 1580).

Data Analysis

Survey Monkey data were exported in Microsoft Excel format (Microsoft Corporation, 2010) for analysis. All usable questionnaires were included, and missing data were reported. Descriptive statistics were reported as means and standard deviations for continuous data and as numbers and percentages for categorical data.

Results

Ten ACT branches were identified through their websites and contacted by an ACT member (Alison Savory, LAc), to participate in this survey. Eight coordinators from these regions replied and confirmed that they sent out 103 individual invitations (Hertfordshire n = 21, London n = 20, Berkshire n = 14, Yorkshire n = 12, East Anglia n = 11, Northwest n = 10, Oxford n = 9, Bristol n = 6). In addition, when there were no replies from 2 coordinators, e-mails were sent to members listed on the websites for Brighton & Sussex and Buckinghamshire (n = 11). Thus, a total of 114 invitations were sent with 99 replies received, a response rate of 86.8%. Of these initial 99 responses, 82 (82.8%) participants provided demographic information (Table 1). The majority were female (80 [97.5%]) and had trained in the United Kingdom (69 [84.1%]). There were similar numbers of respondents selecting TCM (30 [35.5%]) and integrated medicine (28 [34.1%]) as their main styles of practice. Approximately half had been in practice for 10 years or longer (44 [53.6%]). The largest numbers of respondents were from the London (20 [24.3]) and Hertfordshire networks (18 [21.9]).

Table 1.

Demographic Characteristics of Participants Responding to the Survey (N = 82)

Participants	N	%
Sex
Female	80	97.5
Male	2	2.4
Age
< 45 yr	22	26.8
≥ 45 yr	60	73.1
Years in practice
< 10 yr	38	46.3
≥ 10 yr	44	53.6
Style of practice
TCM	30	35.5
Integrated	28	34.1
Five Elements	9	10.9
Japanese	5	6.0
Other	10	12.1
Training location
United Kingdom	69	84.1
China	8	9.7
Other	8	9.7
ACT branch
London	20	24.3
Hertfordshire	18	21.9
Yorkshire	11	13.4
Brighton & Sussex	9	10.9
East Anglia	7	8.5
Northwest	4	4.8
Bristol	3	3.6
Oxford	3	3.6
Berkshire	2	2.4
Buckinghamshire	1	1.8
Did not complete	4	4.8

Note: Data only relate to participants completing demographic sections of the questionnaire.

yr, years; TCM, Traditional Chinese Medicine; ACT, Acupuncture (for Conception to) Childbirth Team (network of practitioners).

Women's Reproductive Health

All participants (99 [100%]), had treated menstrual health, or fertility-related or pregnancy-related conditions in the past year. Ninety-three (93.9%) had treated menstrual health issues, 87 (87.8%) had treated fertility issues, and 87 (87.8%) had treated pregnant women.

These acupuncturists had treated a wide range of conditions within each area of practice (Table 2). For participants responding to the specific questions on menstrual conditions (n = 93), irregular periods, menopause, and premenstrual syndrome were the most commonly treated conditions. For participants answering the questions regarding specific fertility conditions (n = 87), women seeking treatment due to a medical diagnosis, for general fertility health, and for stress and relaxation were the most commonly treated issues. For participants responding to questions about maternity care (n = 87), birth preparation, nausea and vomiting, and labor induction were the most commonly treated situations.

Table 2.

Most-Common Conditions Treated in the Past Year

Menstrual health (N = 93)			Fertility issues (N = 87)			Maternity health (N = 87)
	n	%		n	%		n	%
Irregular periods	85	91.3	Fertility WM diagnosis	81	93.1	Birth preparation	84	96.5
Menopause	84	90.3	General fertility	80	91.9	Nausea	82	94.2
Premenstrual	81	87.0	Stress & relaxation	79	90.8	Induction	79	90.8
Primary dysmenorrhea	77	82.7	Pre & post ER only	76	87.3	LBPGP	77	88.5
PCOS	76	81.7	ART failure: No further WM treatment recommended	76	87.3	Breech	74	85.0
Endometriosis	75	80.6				Threatened miscarriage	55	63.2
Menorrhagia	74	79.5	—			Headaches/migraines	46	52.8
Menstrual headache	63	67.7	—			Anemia	40	45.9

WM, Western medicine; ER, embryo transfer; PCOS, polycystic ovary syndrome; ART, assisted reproductive technology; LBPGP, lower-back and pelvic-girdle pain.

Maternity-related conditions treated less commonly were depression in pregnancy (38 [43.6%]), itching (37 [42.5%]) postnatal depression (36 [41.3%]), varicosities (33 [37.9%]), blood-pressure issues (31 [35.6%]), breastfeeding issues (26 [29.8%]), cesarean-section scar healing (21 [24.1%]), and labor (8 [9.1%]).

Practitioners were asked to estimate asked how often they offered specific treatments across menstrual, fertility, and pregnancy-related care (Table 3). Of those answering these questions, between 40% and 49% estimated that they had treated more than 10 women in the past year for the most-common fertility-related conditions, including treatments for fertility-related stress and relaxation (43 [49.4%]), a Western medical diagnosis (41 [47.1%]), and general fertility health (35 [40.2%]). However, there were only 2 pregnancy-related conditions above 30%—labor preparation (34 [39%]) and induction (30 [34.4%])—and only 2 menstrual conditions at 30%—irregular periods (34 [30.1%]) and premenstrual conditions (28 [30.1%]).

Table 3.

Respondents’ Estimated Treatment for Most-Common Treatments

	≥ 11		1–10		Not treated		No reply
Conditions	N	%	N	%	N	%	N	%
Menstrual-related conditions (n = 93)
Irregular periods	28	30.1	57	61.2	4	4.3	4	4.3
Menopause	16	17.2	65	69.8	4	4.3	8	8.6
Premenstrual	28	30.1	51	54.8	6	6.4	8	8.6
Primary dysmenorrhea	14	15.0	62	66.6	4	4.3	13	13.9
PCOS	23	24.7	52	55.9	11	11.8	7	7.5
Menorrhagia	11	11.8	59	63.4	11	11.8	12	12.9
Menstrual headache	11	11.8	50	53.7	18	19.3	14	15.0
Endometriosis	16	17.2	57	61.2	12	12.9	8	8.6
Fertility-related conditions (n = 87)
Fertility WM diagnosis	41	47.1	32	36.7	8	9.1	6	6.8
General fertility	35	40.2	45	51.7	0	0.0	7	8.0
Stress & relaxation	43	49.4	32	36.7	4	4.5	8	9.1
Pre &post ET only	27	31.0	35	40.2	14	16.0	11	12.6
ART failure: No further WM treatment recommended	17	19.5	37	42.5	22	25.2	11	12.6
Pregnancy-related conditions (n = 87)
Birth preparation	34	39.0	50	57.4	2	2.2	1	1.1
Labor induction	30	34.4	49	56.3	5	5.7	3	3.4
Nausea & vomiting	24	27.5	58	66.6	2	2.2	3	3.4
LBPGP	13	14.9	64	73.8	6	6.8	4	4.5
Breech position	9	10.3	65	74.7	8	9.1	5	5.7

PCOS, polycystic ovary syndrome; WM, Western medicine; ER, embryo transfer; ART, assisted reproductive technology; LBPGP, lower-back and pelvic-girdle pain.

Referrals

When asked how patients were referred to them, word of mouth was the primary referral pathway (Table 4). For participants treating women in pregnancy, referrals were more frequently from medical health professionals (54 [65.8%]) than for participants treating fertility (16 [19.5%]) and menstrual issues (8 [9.7%]).

Table 4.

Sources of Referrals Received by Acupuncturists (N = 82)

	Menstrual		Fertility		Maternity
Sources	n	%	n	%	n	%
Word of mouth or previous or current patients	64	78.0	76	92.6	75	91.4
Advertising	50	60.9	61	74.3	58	70.7
Complementary or alternative practitioners	23	28.0	42	51.2	42	51.2
Medical-health practitioners (GP, nurse, midwife, specialist)	8	9.7	16	19.5	54	65.8
Unknown	19	32.1	19	32.1	19	32.1

GP, general practitioner.

Discussion

Findings from this survey demonstrated that acupuncturists belonging to ACT were interested in and actively treating women's health conditions. While a higher number of practitioners reported they had seen women presenting in the past year for menstrual related conditions (93 [93.9%]), when asked to estimate the number of women seen for specific conditions, fewer practitioners (28 [30.1%]) reported treating more than ten women for the most common menstrual conditions, compared to the most common presentations for pregnancy (30–34 [34.4%–39.0%]) or fertility (34–41 [40.2%–49.4%]). Although only estimates, it suggests practitioners perceive while they see a greater number of common fertility related conditions in a year, common pregnancy related conditions from a comparable part of their practice to common menstrual disorders.

There was a high response rate from these ACT practitioners (86.8%). In recent years, in the UK, an acupuncture survey on fertility practice achieved a 33% response rate,⁴ although this had been as low as 2% in other U.K. surveys.¹⁸ The high response rate among these ACT practitioners might indicate the advantages of surveying specialized practice groups through local networks.

In contrast, a survey of women's health among general acupuncture practitioners in Australia and New Zealand through national professional bodies only achieved an 11% response rate.³ Despite the differences in response rates between the United Kingdom's Australian and New Zealand surveys, it is interesting that the most frequently treated women's health conditions were similar for both of these populations. For menstrual conditions, the issues were premenstrual conditions, menopause, primary dysmenorrhea, and irregular periods; and, for fertility, a Western medical diagnosis, general fertility, and stress and relaxation. For pregnancy, the settings were nausea, birth preparation, induction, pregnancy-related back and pelvic pain, and breech presentations. It was also reported within both surveys that those practitioners were treating a wide range of pregnancy-related conditions, including anxiety and depression and headaches and migraines. This corresponds to reports from a hospital-based maternity outpatient clinic in New Zealand that, although women most frequently present for lower-back and pelvic pain and for birth preparation, treatments for a wide range of conditions are also sought by women.^19,20

The most-frequent use of acupuncture in pregnancy was that of birth preparation (84 [96.5%]), and this category had the highest number of practitioners estimating that they had treated more than 10 women for that in the past year (34 [39.0%]). There is currently no high-quality evidence to support the effectiveness of acupuncture or acupressure for birth preparation.²¹ There are anecdotal reports from midwives that women receiving birth preparation acupuncture (that does not focus on points to stimulate the onset of contractions) present in early labor with favorable indications related to cervical ripening and the baby's presentation and that these women experience efficient labors.¹³ A small observation study of New Zealand midwives using this birth-preparation acupuncture showed reduced inductions and cesarean sections for women having their first babies and women who were subsequent mothers¹³; however, randomization to a control group is required to explore these findings. It might be a confounding factor for women interested in receiving acupuncture, that time and attention during treatment contributed to the findings.

These New Zealand midwives also routinely give interested women information about acupressure in labor. Acupressure has demonstrated statistically significant reductions of medical induction and cesarean section rates when used as part of an overall antenatal-education program that included complementary medicine techniques, such as visualization and relaxation, breathing, massage, yoga, and facilitated-partner support.²² It might be that, as part a complex package of care, acupressure could play a role in promoting efficient labor.

Although using acupuncture to induce labor was reported by these ACT practitioners as one of the most-frequent treatments delivered in the past year (79 [90.8%])—and a third estimated they had treated more than 10 women in the past year (30 [34.4%])—there is currently no quality evidence base to support this as being effective. While the latest Cochrane review,²¹ indicated some promising research related to acupuncture promoting cervical maturity, use of acupuncture did not produce significant differences for the onset of natural labor or improved birthing outcomes for the women compared to controls. This was both in terms of reducing medical interventions and increasing the incidence of natural vaginal births. It might also be the perception from practitioners and women that changes following treatment, such as the onset of contractions, will promote natural vaginal birth, whereas, in reality, this kind of stimulation may not change eventual birthing outcomes.

Although LBPGP is a common presentation in pregnancy and featured in the most-frequently treated conditions treated (77 [88.5%]), only 13 practitioners (14.9%) estimated that they had treated more than 10 women for this in the past year. This is surprising, given that LBPGP is estimated to affect up to two-thirds of pregnant women and that there is promising evidence for using acupuncture, compared to usual care, for pregnancy-related pelvic pain.²³ With interest among physiotherapists in using acupuncture to treat LBPGP^24,25 and with observational studies indicating that women perceive positive clinical benefits from treatment,^12,20 this might be an important area for acupuncturists to promote as part of their clinical practices.

In this survey the majority of referrals from medical-health professionals were for pregnancy-related treatment. This acceptance of acupuncture by medical-health professionals for treatment in pregnancy is mirrored in the first author's (D.B.) experience in New Zealand. In that country, midwives can practice acupuncture, hospital guidelines include using acupuncture in pregnancy, and maternity-acupuncture services are advertised on a hospital website.²⁶ Many practitioners' practice in isolation and focus on individualized clinical practice.⁴ It could be that, belonging to a group such as ACT would help practitioners expand their networks and promote acupuncture an a nonpharmacologic treatment during pregnancy with interested Western-medicine colleagues.

Limitations

While there was a high response rate to this survey the generalizability of these findings is limited as it reflects reflect the practice of a small group of acupuncturists within the United Kingdom who have a specific interest in pregnancy. This high response rate might have also been influenced by the lead author (D.B.) lecturing in the United Kingdom during recruitment. There were also a number of questions that respondents did not answer concerning specific information on their demographics and practices, which, in a small sample size, could have influenced the results reported. Further aspects relating to practitioners' clinical practices—such as if the participants practiced full or part-time and if this aspect of women's health was a focus of their practices—were not explored and could be relevant for future research.

Conclusions

Acupuncturists belonging to ACT were treating a wide range women health issues. The most frequently treated menstrual conditions were for irregular periods, menopause, and premenstrual syndrome, while women seeking treatment due to a medical diagnosis, general fertility health, and stress and relaxation were the most-frequent fertility issues. Although the most frequently treated pregnancy conditions concerned nausea, birth preparation, and labor induction, more than half of the practitioners were also treating pregnancy-related lower-back and pelvic pain, breech presentations, threatened miscarriages, and headaches and migraines. Only a minority of practitioners were attending births. Referrals from medical-health professionals were more common for pregnancy-related conditions than for fertility or menstrual health. It might be that acupuncturists from other countries would benefit from this approach of creating specialized groups to support their practices in women's health, especially maternity acupuncture, to build referral networks with medical-health professionals.

Author Disclosure Statement

Dr. Betts is employed as a clinical supervisor at the Hutt Hospital Maternity Acupuncture Clinic by the New Zealand School of Acupuncture and Traditional Chinese Medicine.

No competing financial interests exist for the 2 remaining authors.

Funding Information

As a medical research institute, the NICM Health Research Institute receives research grants and donations from foundations, universities, government agencies, and industry. Sponsors and donors provide untied and tied funding for work to advance the vision and mission of the Institute. This survey was not specifically supported by donor or sponsor funding to NICM.