 Thank you so much. Here you go. Excellent. So, over to Linda, who I would like to introduce first a little bit. Linda is a registered nurse and a registered midwife, and she has a bachelor in health sciences and a master in midwifery. She's also a diploma in reflexology, and she's currently doing a PhD. Linda has worked in midwifery for over 30 years and as a clinical consultant for the past 14 years. She has a strong interest in complementary alternative medicine, and that is what she's talking about today. So, over to Linda. Thank you, and please go ahead. Thank you very much. Can you hear me okay? Is that loud enough? Very good. Excellent. Yes, yes. Super. Okay. Thank you for the opportunity to present, and this is the first time I'm presenting at the Virtual International Midwives Day Conference. I've been looking forward to all day, and I've actually been teaching, so I can sit back now and relax and present instead. So, my presentation today is titled, Midwives and Conplementary Alternative Medicine or CAME. Does midwives' personal use impact on their clinical practice? And I'm just going to get into that. So, just to provide you an overview of the presentation for today, I'm going to briefly discuss CAME and self-help strategies women use, especially for post-state pregnancy. I'll talk briefly about induction of labour and what research is already out there around CAME and pregnant women, but also what also midwives recommend. And then I'd like to go into some detail about a National Midwives Survey that we've just completed in Australia, and look at some of the findings and discussion, the conclusion, and then finish off the question time. However, there will be an opportunity for halfway through if you want to ask any questions before I get into our survey. So, just to define complementary alternative medicines, or some people say therapies, is a group... And it's interesting to see the definition because no techniques are becoming mainstream. However, current definition is a group of diverse medical and healthcare systems, practices, and perhaps products that are not generally considered part of conventional or western medicine. And these can be categorised into five main areas. So, looking at alternative medical systems, such as homeopathy, naturopath medicine, traditional Chinese medicine, or TCM, which includes atropuntia and hermetic. The second one is mind-body interventions, such as prayer, meditation, spiritual healing, and any therapy that creates or uses a creative outlet such as art, music, and dance. When looking at the biological-based theories, there's herbs, food, vitamins, and minerals, essential oils and dietary supplements. Manipulative and body-based methods such as chiropractic or osteopath, manipulation, reflexology, and massage. And the last one on energy therapies is chiglong, reiki, or therapeutic touch. So, when I was trying to find a definition for self-help strategies, it was a little bit harder to find. So, I've sort of developed my own with help from a previous publication by Evans in 2009. So, it's natural options administered or ingested by a pregnant woman, and the woman feels in control and actively participating in her care. However, this may take time and commitment from the woman as some of these options may take several days to produce a result. However, that could be said also for some of the medical procedures that women undertake as well. So, if you want to have a look at induction of labor, it can be defined as stimulation of the uterus with the aim of starting labor to ensure delivery of the fetus at appropriate time when the baby is thought to be safer outside the uterus than in it. And the most common reason for an induction of labor is women who are post-states or post-term or prolonged pregnancy. And quite often, these terms are used interchangeable. However, when you look at the definition, they are quite different. So, post-states for my study and also by a number of other authors is a pregnancy that continues past the expected date of birthing or confinement. Although I don't like to use the word confinement because if you look in the dictionary it actually means being incarcerated or in jail. So, prefer to use birthing. Whereas post-term or prolonged pregnancy is a gestation length of 294 days or 14 days of the due date which would occur in 5% of all births if women were allowed to go over 14 days which in these days quite often 10 days is now being used as the definition for post-term and prolonged pregnancy in the drive-through delivery countries where women want to give birth sooner rather later. So, when we look at induction of labor methods such as the medical and surgical procedures but when we look at the non-medical or surgical such as CAM or self-help techniques there are a range. So, for example, the CAM techniques used by women vary with limited research to support them. Specific herbs such as evening primrose oil, raspberry leaf and blow-blue carwash as well as date fruit have been examined on their effect on labor induction and contraptions. Other CAM modalities include homeopathic remedies, reflexology, shiatsu and acupressure and acupuncture. Unfortunately, I don't have time to go into the details about these studies. However, the two randomized controlled trials on the use of date fruit did show an increase on center labor compared to standard care. Also, reflexology and acupuncture studies have shown to increase contractions and darts above the dilatation. The four acupressure shiatsu studies that have been recently published in the last 10 years vary in outcomes as they have used different aims and objectives. Some have used survival bishop school and some have used on the set of labor. With the self-help options it's interesting that the systematic reviews of sexual intercourse, ingestion of spicy foods or castor oil found little evidence to support their use. Nipple or breast stimulation does appear beneficial in reducing the number of women not in labor after 72 hours. If we have a look at some of the studies that have been published over the... I've only looked at probably a short period of time. There is probably more but trying to keep it more relevant in more modern time is some of these studies are from around the world, as you can see. Some of them are actual national studies but some are specific regions. And so you can see a fairly wide range between, for example, UK, which was a national study, 26.7% of women used complementary therapies in pregnancy. Whereas when you look at specific regions such as the Birmingham study it was up to 57%. Australia, even though it's an old study, back in 2008 was 73%. Italy, Germany, there's got a variety of percentages. And then there were some studies that looked specifically at herbal therapies used during pregnancy as concerns raised about safe issues and the level of dosage in pregnancy. And you can see that there are actually a lot less in the percentage that more around that 30-40% use of herbal supplements in pregnancy. So when the studies have actually asked who do women identify as health professionals they've said that midwives, nurses, general practitioners and obstetricians are their main source of information about care and self-help strategies during pregnancy and for labour induction. And then they also included friends, websites and Facebook. So we have a look at midwife professional use or referral of complementary therapies. Again, there's a wide variety from all different countries. Most studies concentrated on the professional use of CAM, recommending CAM options and referral patterns to CAM practitioners. You can see that the studies are conducted in various countries. We've all been conducted by questionnaires except for one, Adams, which was interviews with 13 qualitative studies which actually, believe it or not, I was part of that study and I completely forgot that I was part of that study. But the response rate varied from 23 to 81% and the numbers, as you can see, involved in the studies varied from 13 up to 343. It was interesting when I reviewed the articles that most of the studies, when they used the word midwife used or uses CAM, when you read the article, the authors are actually referring to their professional use of CAM, not their personal use. So the studies varied with midwives recommending CAM. You've got 58.9% in Turkey, 72% in New Zealand and Canada, 80 to 85% in Australia and 90 to 93% in the USA. Again, some of these studies were not national studies but actually region or state. So the research suggests that midwives are highly likely to offer CAM options to women due to midwives holding the view of CAM as an alternative aid to reducing medical intervention, to empower women in their care and as a means to increase their autonomy. So part of my feasibility randomized control trial on the use of aquapressure to stimulate labour for primary gravitas experiencing post-state pregnancy which has been published in 2016. And part of that we undertook a focus group with doctors and midwives to explore their views and attitudes to complementary therapies and also implementing complementary therapies and aquapressure in clinical practice. Upon reviewing the unpublished qualitative data on midwives' views of CAM, it seems that midwives who personally used CAM were more likely to discuss and recommend CAM to pregnant women. Most of my colleagues when I mentioned this went, duh, of course, that would be... because that makes sense. And I said, but it's interesting that this area has not been researched or published. None of the studies have asked the question, does midwives own personal use of CAM or their personal use influence what they offer to women or discuss or recommend? So there's that significant gap in the literature regarding the midwives' personal use and the relationship with offering and discussing self-help and CAM options, specifically to women experiencing a post-state pregnancy. So we undertook a national survey of Australian midwives. To do this, the best way to do... to capture the majority of midwives was to access the Australian College of Midwives Association, which has 4,677 registered members in all states and territories of Australia. They also had the option where all the midwives who are registered as a member receive a weekly college e-boughton. So when we calculated the sample size to have sufficient statistical power, it was 375 participants with a 5% margin of error and a 95% confidence interval. So we were hopeful that we would get more than 375 out of a possible 4,677. So we tried it. But following ethical approval, the research invitation was distributed in two ways because when we actually looked at recent online survey studies inviting midwives to participate in research, they only had a response rate of anything from about 7% to 19%. So what we did was, at a national midwifery conference, we distributed surveys to 160 eligible midwives of participants. And the second one, where we actually included our research invitation, was electronically sent by the college e-bulletin with a short information section and a link to a survey monkey questionnaire. And that was emailed twice. And then we only had about 200 response. So we then went with a dedicated e-bulletin four weeks apart to try and increase the response rate. So part of that was they had an information sheet. We explained that the participation was voluntary but there was no formal consent required as it was implied by completing the survey. As the researchers did not collect information on email or internet protocol addresses, it was possible the participants may have completed the survey more than once. However, we thought unlikely as midwives were usually very busy people. The presentation today, I'd like to concentrate on the first three sections of the survey. So looking at the demographic, looking at their clinical practice and looking at their personal use, not only for their health and well-being but also the midwives and pregnancies as well. The other two components, I'm still working on the data. Okay, hopefully some of these have moved a little bit slightly. So we had 579 respondents which was about 12.2%, which well truly was above the 375 that we needed to make it worthwhile. Of those, the majority of course were registered midwives. However, we did have eight student midwives who also completed the survey. As you can see, the demographic data was represented midwives around Australia, from all the states and territories. We also checked the percentage against the ACM membership and that was representative and also against the Australia Registration Board membership as well. We also looked at the age and again that bell curve was representative of the membership and also the Australian midwifery and board. And I don't know if you can see that clearly, however, the majority of the midwives indicated they worked in all areas of the maternity care, which is about 90, 15% percent. The other areas were antinatal, interpartum, postnatal. There was also community, group private practice, midwifery group practice or caseload, education and management and other. And there was only eight student midwives in the survey. We did not do a separate analysis and the remainder of this presentation, rather than saying registered midwives, student midwives, I'll refer to the total respondents as midwives. So what did we find? Surprising or not surprising that the majority of respondents, 91.2%, discussed self-help and CAM options to pregnant women experiencing a post-late pregnancy. And 88.6% recommend the self-help CAM options to pregnant women experiencing a post-late pregnancy. When we actually looked at the statistical significance, it was highly significant that midwives were more likely to discuss these options when they felt confident in having the knowledge to discuss or recommend these strategies, which is worthwhile. However, of concern, 26% of respondents who did discuss and or recommend CAM did not feel confident in their knowledge of complementary therapies. So, oh, missing the title. So when we had a look at the top five, we did more than five. So, other studies in the previous slide only allowed respondents to select four or up to 10 CAM options. In our study, we actually gave respondents 23 CAM options to choose from, but I'm only going to show you the top five in this presentation. So as you can see, the top five complementary therapies recommended by midwives for women who are experiencing a post-stake pregnancy was acupuncture followed by apropressure at 58%. Raspberry Leaf, evening... Oh, sorry, that's a typo. It should actually be raspberry leaf rather than evening primrose. My mistake. At 52%. Massage at nearly 39%. And then hypnosis, reversing or hypnotherapy at 35.7%. When we actually looked at the self-help options, as you can see that sexual intercourse was rated high as a recommended self-help strategy at 83%. Exercise such as walking and swimming at 82%. Nipple stimulation at nearly 80%. And then followed to a lesser degree by eating spicy food at 16.8%. And even castor oil at 5.8%. As mentioned earlier, the copper reviews had not found any particular benefit from eating spicy food or castor oil. But midwives are still recommending their use of castor oil, although on a much smaller percentage. This is still common practice. I haven't learned the data to actually check to see whether there was any particular specifics around the midwives who did recommend castor oil. Because I know when I first did my training many, many years ago, it was a suggested recommendation. So I may actually have a look at midwives' personal use of chem when they're not pregnant. It was interesting that 80% of participants had used chem strategies in the past for their own personal use, with many of the participants using multiple modalities. However, the top five here are in reverse order. So we've got massage at 80%. Acupuncture, followed by rheumatherapy. Chiro, nearly 60%. And then apple pressure at 55.7%. When we actually asked them how they experienced it, 91% of them found that their personal experience was very positive or positive. When we asked them for their pregnancy use themselves, the highest actually came up with the Raj's Relief to your tablet at 55.8%. Then followed by massage, rheumatherapy, acupuncture at 38.6% and apple pressure at 36.3%. So this represented nearly half of the participants. So 46.8% of the participants had used chem strategies in their own pregnancies. About 23% didn't use it. And a lot of them actually said they were more mature of age and they were to wear and if they had known about it they probably would have used it in some of the comments. And about 30% were applicable. So it's not surprising that the majority of midwives are women and women are high users of chem. So it does reflect a lot of the research does say. So we actually did some logistical regression to actually look at what were the characteristics of a midwife who does recommend or discuss self-help and complementary therapies for post-state pregnancy. And what we were able to find that respondents were more likely to discuss the options for post-state pregnancy if they were personally used chem, were younger or had work less years as a midwife. Also they were more likely to discuss that if they provided chem to women in the perinatal period. Respondents were more likely to recommend the strategies for post-state pregnancy if they personally used it. Chem in the past were younger, worked less years as a midwife, but also if they used it in their own pregnancy and were younger. That actually really surprised me. I thought actually I didn't know what to think because as I said there's not a lot of research out there. So this is the first national survey of self-help and chem strategies for women experiencing a post-state pregnancy. We also looked at the midwife's personal use and its impact on clinical practice. And we also looked at discussing and recommending of the self-help and chem strategies. For us we were able to determine that the five top recommended strategies by midwives was different to other studies. There was a study two studies that were done before conducted in the USA although they were women who were not post-states their average gestation was about 39 to 40 weeks. They found that American women used less strategies like acupuncture, which was only about 2%, or herbal preparations with 1%, with a higher preference for self-help options like walking at 43%, intercourse at 23%, grocery food 11%, for self-induced labour. There was one qualitative study that's been done in Australia by Gatwood in 2010 and our findings are very similar to Hillary in the respect that the Australian midwives in her study had a high use of self-help such as nipple stimulation but also acupuncture, raspberry leaf just stimulate a post-state pregnancy. As this is the first study examining midwives use of chem in their own personal lives and in their pregnancies we are unable to compare our findings to other studies. What we were able to find is that respondent age years of the midwives and personal use had a significant impact on their clinical practice by discussing and recommending self-help and complementary therapies to women with a post-state pregnancy. We were also able to determine that respondent age and personal use during their own pregnancy had a significant impact on their recommending the strategies to women. So in conclusion we were able to undertake a national survey of Australian midwives with representation from every state and territory in Australia. We were able to the evidence shows that women and pregnant women are high users of complementary therapies and alternative medicines and as the majority of midwives are women it is expected that many midwives would personally use chem in their own health and well-being and in their own pregnancies. This increased use of chem by women as I've said generally and pregnant women specifically is linked to the pursuit of more choice of empowerment and great autonomy in healthcare decision making which also fits in with the midwifery philosophy. We recognised the potential limitation of this study was that the sample was self-selected and it was possibly only midwives who were interested in chem would respond to the survey. However it was reassuring that we actually had about 48 participants about 8% who completed the survey who never discussed chem with women, did not have knowledge or education of chem and did not use chem for personal use so they also participated in the study. So overall the majority of respondents did discuss or recommend chem to women experiencing a post-dates and personal use did influence their decisions and recommendations of strategies to women. Now when midwives need to have the confidence and the knowledge to discuss these strategies in an evidence based approach I believe that nursing and midwifery education programs and a number of authors such as Paul and Kieran believe that chem options need to be included in nursing and midwifery programs including their existing safety and efficiency data. We are hopeful that our findings which is in our next section of the survey will be published in the future and that will concentrate on midwifery education and training in chem. The findings included in this presentation have been submitted for publication and we are currently waiting feedback and hopefully will be published this year. Thank you Any questions? Thank you Linda Everybody you can type your questions into the chat box but you could also ask your questions so you just raise your hand and we give you the microphone. Thanks Linda, that was really excellent Thank you We had a first question on the legal status of complementary alternative medicine I think Lindsay asked that in she says that in the UK only those who are firmly qualified can use the techniques with mothers and babies whereas Mary then responded in Australia a midwife can only use acupuncture if she's authorized by the Chinese medicine board. Did you come across these things that there's issues with legal status also? It's interesting up till we went in Australia up to we went to a national registration each state and territory in Australia registration board all had a policy or a position statement on the use of complementary therapies by midwives in their clinical practice and I've kept a copy of each of them and they are still available on the internet and all of them but the midwife has to have the knowledge and the skills and the accredited course they also have to within their scope of practice have a policy or procedure at their hospital where they're working to cover them However since we've gone to a national registration we have been asking for a position statement from the registration board but as yet we still don't have anything What they do is they define scope of practice is that it's a responsibility of each organisation to have a policy or a procedure that includes that so if a hospital or a policy doesn't have sorry if a hospital doesn't have a policy or procedure that identifies that midwives within their scope of practice then yes the midwives are working outside what's accepted and a hospital that I've worked in for many years up till last year I was instrumental in implementing guidelines and clinical practice procedures specifically on reflexology, aromatherapy and acropressure so the midwives who had completed endorsed, qualified training were able to practice into their clinical practice but I believe each country has a different for it like acupuncture a lot of other countries overseas do midwives to undertake acupuncture within their scope of practice after they've completed a recognised course such as the one provided by Deborah Betts from New Zealand Yeah maybe if anybody else has experience from their country please let us know it would be interesting I realised that from your findings that it's mainly young midwives or midwives that have not been long in the profession that recommend or that also discuss this option how do you explain that what is your idea about that Yes actually that's what I thought was really interesting because when I've conducted workshops quite often it's the more mature midwives that are actually coming along at this stage there's very little research looking in Australia looking at all the universities to actually see if they're covering complimentary therapies in their undergraduate course in the Bachelor of the Riffry I actually do teach into a couple of different universities that are included in the program so that way it's actually increasing the profile and looking at safety and research at an undergraduate level so that the younger midwives have the knowledge and the skill that's the only thing that I can think of because it actually did surprise me I thought it would be the other way Yeah I think like in Germany part of the undergraduate curriculum midwifery students would definitely learn something but I also feel that the ones who are longer in the profession have more experience and therefore might be able to use it more or to offer it also more Interesting Yeah I even looked at a variety of options I looked at where they're from whether they had a degree or not whether they so all the demographics are compared and they were the only statistically significant ones that came up Alicia just says that she is 26 and she has worked as a midwife for two and a half years and actually she was brought up using Chinese medicine regularly other complementary therapies and she asked the question maybe there's just this kind of therapies are just becoming more socially accepted and that's maybe also because in this group it's more it's increased What do you think about that? Yeah Just some of the comments of the older midwives when I asked them about do they use complementary therapies in their own pregnancy a number of the midwives there was a section they could actually write a comment in it and that was I was saying it was interesting that the older midwives said that they weren't aware of the complementary therapies when they were pregnant many years ago and if they had known that they actually would have used them so definitely they are growing more and more and when you look at the literature and the studies it's probably been the last 15 years that there seems to be that increase and I would also have a question are these complementary alternative medicines included in any clinical guideline? If you personally write them Yeah So when I looked at it there is a number of looked around the world and what's being published because a lot of them are published there in hospital policies and procedures there was I found a labour guideline from America that it included aqua pressure so they are starting to get more and more there because they realise that women are actually using them and so one the midwives need to know about them but two they need to acknowledge that the women are going to use a variety of techniques when they are in labour more women are bringing in bronotherapy which is one of the examples that they have to be careful because for example with ramoserapy there are some oils that are not conducive for labour and if someone has just bought some oils out of the counter or used fragrant oils it can be quite toxic and uncomfortable not only for the women but the people who are also in the room including partners, support people and the midwives so for example at our hospital we had a midwife French midwife who was a ramoserapist and so she provided we did education we had an education workbook, midwives were accredited to provide ramoserapy in labour and we actually got the pharmacy company in the hospital to contact one of the companies and we got their data safety sheet and from there we were then able we provided the oils so that we knew that they were the best quality and safely used and stored and they were appropriate for labour but a lot of people just bring in oils which as I said may not be best quality or appropriate in labour okay any more questions by anybody please type them in or raise your hand to ask questions and I can just tell you from Germany there is also midwives are allowed to acupuncture for example if they participated in an accredited course but on the other hand they have to pay like women have to pay that themselves especially acupuncture so it's not part of regular care and it's not covered by the health insurance companies what about this in Australia is it something that is actually covered by your insurance that you are able to provide that it's interesting in Australia only acupuncturists who have completed a recognised acupuncture course that through the colleges allowed to become professionals and are in private practice and people women who want to access them it's only covered through their private health insurance so that it is out of pocket Deborah Betts who teaches the midwife acupuncture course in a variety of different countries came over two years ago to Australia and in other countries such as New Zealand Canada and the UK the midwives were able to use it in their clinical practice however in Australia it was called Aconeedling because it was recognised by our college it was over four weeks six months with a variety of assignments it worked out 140 hours for the midwives to be trained specifically for pregnant labourer and post-later women however the hospitals that they worked at they didn't approve the midwives to actually use it in clinical practice how I believe there is one hospital now who has a clinical guideline and the midwives are now able to provide that care at that hospital for in charge within their clinical practice whereas GP can actually or general practitioners, local doctors can spend a weekend, two days and then actually undertake and provide acupuncture and charge people so Sarah is just recommending the website of Deborah with free downloadable acupressure booklets for labour and she's posting up a link so everybody feel free to have a look there Yes, actually we're taught by Deborah and I continue to teach acupressure and her 23 page PDF booklets for women and their partners and she very much supports and encourages the partners to actually use the acupressure during labour resources Please if anybody else has some good resources just post them it might be interesting What I also was wondering you talked about the demographics of your study participants and I was wondering also of the origin of these midwives do for example midwives maybe you are practicing midwives in Australia with Chinese origin would they more likely to recommend that is that something you could find too in your analysis It was actually about 97% Caucasian Australian Caucasian white background The other 3% was a mix of from a variety of other countries for another ethnic origin No, Chinese didn't come up strongly there at all or European or that Okay, so you could not disaggregate the data there Okay I think let us just wrap up First of all, again, thank you that was excellent and I think I'm looking forward to the findings of the other parts and I'm sure I will hear from it because actually we are fellow PhD students at the University of Technology in Sydney so at some point we might actually meet in reality and so just to wrap up also her session we learned that midwives especially if they have own experience with complementary alternative medicine are more likely to discuss or actually provide these kind of therapies so that was just a gap in literature you found and you addressed for the first time in this national survey and what we also outlined is that the midwives that would recommend it or discuss this kind of therapies are more likely to be younger or a few years in the profession but also if they have positive experience if they made positive experience with CAM before in their own lives in their own pregnancies then they are more likely to recommend it so thank you so much I think all of this is recorded and people will have the chance to listen to it again Linda I give you last word Thank you, no hopefully next year I'll come back and present the rest of the data Excellent we are looking forward to that so thanks to all listening and we will turn off the recording