Acupuncture in Pregnancy: Effectiveness Gaps in conventional Pregnancy Care
Introduction:
Pregnancy is a special and unique time in any woman’s life that can be full of ups and downs both personally and physically and is often marked with advice, opinions, stories and studies that can leave a woman confused and overwhelmed. The physical adaptations that the body undergoes in pregnancy is truly remarkable and can lead to discomfort in some women, though most are short lived and go untreated, some can be more serious and can lead to medical interventions that are risky to both mother and baby. My professional experience as a Doula witnessing women go through these discomforts, big and small, with little to no safe and effective treatment in standard maternity care inspired me to look at the effectiveness gaps in maternity care and the role acupuncture can play in filling these gaps. Effectiveness gaps (EG) as first written about by Fisher P et al. 2004 are identified as an area of clinical practice where available treatments are not fully effective. Pregnancy is a time when women’s bodies and the fetuses they are growing are considered very delicate and extra caution is advised by both modern and traditional practitioners. Furthermore, due to the ethics of studying pregnant women the availability of good studies is often lacking. In this paper I hope to offer some safe and effective solutions using acupuncture for women suffering from common discomforts of pregnancy.
Methods:
Upon thinking about this research, I began by considering my professional experience in working with pregnant women. From my experience I have seen the following issues come up during pregnancy and thought they may be deemed to be EG by midwives in my area; nausea and vomiting, heartburn, low back, sciatica, rib and pelvic pain, insomnia, anxiety/ depression, bleeding, haemorrhoids, varicose veins, edema, induction, hypertension, breech, posterior position, constipation, anemia, headaches, UTIs, pain relief in labour, itching, gestational diabetes, fatigue and exhaustion. In order to gather further information on EG, I sent invitations to participate in semi-formal interviews to the 32 midwives operating in Victoria, BC and the surrounding area. Of these I received responses from two midwives, of which one lead to a successful and enlightening interview, who for anonymity I will refer to as Sarah. It would have been ideal to interview more midwives, however the one I did speak with had over 20 years experience working in two major centres in Canada, both pre-registration and under registration of the provincial governments of Alberta and BC. The discomforts and diseases that Sarah felt were the biggest EG were: Anxiety and depression, Hypertension, sciatica pain and safe effective induction techniques for VBAC women. With these in mind, I searched the available literature and found studies and historical documents on treating the above issues with acupuncture.
Anxiety and Depression:
Anxiety and depression are two of the leading mental health issues in the world today and women are twice as likely to encounter them throughout their lives, as the WHO’s Department of Mental Health and Substance Abuse 2012 report indicates. As Ormsby et al 2016 cite the morbid consequences of depression in pregnant women include an increased risk of obstetric complications, post-natal depression, alterations in growth, development, autonomic nervous function and mental health in children. The current treatments for anxiety and depression are psychotherapy, antidepressants, and anxiolytics, which have not been studied well in pregnancy and may lead to unwanted side effects.
In my interview. the primary EG that Sarah saw amongst her clients, especially in Victoria is anxiety and depression. She spoke of the stresses to lead a perfect life and the lack of information and therefore choices these women had as major causes of their anxiety and depression and in her professional experience correlated this to increased hospital births and medical interventions such as epidurals and cesareans.
From a Chinese Medicine perspective there are several explanations as to why women suffer from twice as much depression. According to Schnyer 2001 cited in Sniezek & Siddiqui 2013, the relationship between the liver, depression and the menstrual cycle is key, as well as other diagnosis that affect the shen/mind such as kidney and/or lung qi deficiency, liver and spleen blood deficiency, liver blood stagnation, cold invasion causing qi and blood stagnation and Jing and Yuan qi deficiencies. Historically, women during pregnancy were viewed as needing extra care and protection, especially from fright, fear and agitation (Betts 2017). Peaceful sleeping places, calming neutral foods and looking at beautiful things was often recommended to women during pregnancy. In this modern day we can still offer many of these recommendations along with acupuncture to soothe the liver, calm the mind, and nourish the qi and blood.
To date there have been three studies done on acupuncture to treat anxiety and/or depression in pregnancy. As cited in Ormsby et al 2016, In the first RCT conducted by Manber et al 2004 compared 12 treatments over 8 weeks of individualized acupuncture with sham acupuncture and a massage control in 61 pregnant women with major depression. They reported a 69% improvement in the acupuncture group over 32% in the massage group (p=0.031) and 47% in the sham acupuncture group. The acupuncture group also demonstrated a significantly higher average rate of reduction in depression scores in the first month of treatment when compared with the control (p=0.047). In the second RCT lead by Manber et al in 2010, they utilized a larger population of 150 women and found that the acupuncture group demonstrated significantly decreased severity in symptoms when compared with the combined results of the massage control and the sham acupuncture groups (p<0.05) The third study in 2007, lead by Bosco Guerreiro da Silva compared 51 women quasi-randomized into a pre-programmed acupuncture group and a non-treatment group. They reported a reduction of symptom severity of up to 50% in 15 out of the 25 acupuncture subjects vs 5 of the 19 control subjects (p=0.013). They also found that the acupuncture group experienced a significant reduction in 3 out of 5 life disturbance categories (p<0.05). These studies with their limitations provide good groundwork revealing that acupuncture can provide safe and effective treatment from women suffering from anxiety and depression during pregnancy. More studies are needed and currently Ormsby et al. 2016 are recruiting for a major RCT that will take into account the limitations that affect these three studies; small sample size, quasi-randomization, lack of equivalent care control, unclear randomization generation and concealment, unclear assessor blinding and incomplete baseline and outcome data.
Hypertension and Preeclampsia
The American congress of Ostetricians and Gynaecologists 2015 define Preeclampsia as a disorder specific to pregnancy, where gestational hypertension is seen together with proteinuria or other risk factors such as thrombocytopenia, impaired liver function, renal impairment, pulmonary oedema or new-onset cerebral or pulmonary disturbances. According to the Maternal Hypertension in Canada ( Public Health Agency of Canada, 2010/11) report the rate of gestational hypertension without proteinuria was 46.2%, the rate of preeclampsia was 11.5% and the rate of eclampsia was 0.8%. Zeng et al 2016 cite Steegers et al. 2010 as stating that Preeclampsia remains a leading cause of maternal and perinatal mortality and morbidity and complicates 2-8% of all pregnancies. Preeclampsia can lead to various complications including eclampsia, renal failure, placental abruption and preterm birth. Normal treatment with antihypertensives throughout pregnancy can have many side effects including fetal growth restriction, fetal renal impairment and reduced placental perfusion, as cited by Zeng et al. 2016.
In my interview Sarah mentioned the need for ways to lower maternal blood pressure before it leads to preeclampsia and other issues. In Chinese Medicine, Hypertension can refer to TCM patterns of headache. dizziness, tinnitus and palpitations (Shi & Zeng 2011). These are often connected to the liver, which is easily affected by stress and stagnation that can increase in pregnancy.
In my research I found one study on the effects of acupuncture on preeclampsia in Chinese Women (Zeng et al 2015). In it the authors reference two observational studies looking at acupuncture for treating pregnancy-induced hypertension in which both studies found acupuncture to be safe and effective but lacked control groups to draw any comparisons. In the 2015 study by Zeng et al they compared an acupuncture group (n=11) and a control group (n=11) both receiving standard care at baseline, following treatment, 24 hrs before delivery and 1 day postpartum. They found that though mean differences in systolic blood pressure (SBP) and diastolic blood pressure (DBP) were not found immediately following treatment, the mean differences 24 hrs before delivery and 1 day postpartum were significantly lower in the acupuncture group and that the individual change in BP from baseline was significantly lower in the acupuncture group for both SBP (p=0.007) and DBP (p=0.013). They also found no statistical difference in perinatal outcomes between either group. They do outline two limitations, one that there was no sham acupuncture given to the control group, thereby there is no way to rule out placebo. The second was the very small sample size. Overall, the study does seem to show that acupuncture can safely lower blood pressure in women with preeclampsia alongside standard care.
Low back and Pelvic Pain
Low Back and Pelvic Pain (LBPP) is a common complaint of pregnant women, with loosening ligaments, changes in lumbar curvature and balance due to a growing belly and increased weight, a decreased ability to exercise in the last trimester and often days filled with sitting at a desk, the low back and pelvis structures can stretch, pull, pinch and compress. According to the 2013 Cochrane Review on Interventions for treating and preventing pelvic and back pain in Pregnancy they report several studies (Greenwood 2001; Mousavi 2007; Skaggs 2007) finding that approximately two-thirds of women experience low back pain and one-fifth of women experience pelvic pain and nearly 50% of women receive very little to no treatment at all. The Review also references studies (Van De Pol 2007; Kalus 2007; Mogren 2007; Skaggs 2007) that found for many women, pain interferes with their daily activities, their work, their sleep and leads to increases in depressive symptoms. Common interventions that have been used and that were looked at by the Review are exercise, manual therapy, acupuncture, pelvic belts and pillows and multi-modal approaches each having varying degrees of effectiveness.
During my interview with Sarah, she particularly spoke of the need for effective treatment for Sciatica pain that some of her clients experienced. She stated that she has had good results treating hip pain with a homeopathic dose of Hypericum Perforatum. In Chinese Medicine, Pain is most often associated with Stagnation of Qi or Blood in a channel that can arise from invasion of a pathogenic factor (wind, cold, damp, heat), injury or an internal organ disharmony affecting a channel (Betts 2006). According to Betts 2006, LBPP is most commonly seen as tenderness and pain along the bladder and gall bladder channels with an internal organ disharmony of either kidney deficiency or Liver qi stagnation.
In the Cochrane Review 2013 they cite three studies that looked into the use of Acupuncture in treating Pelvic Girdle Pain and Four studies that looked at treating LBPP with Acupuncture. The first, a study by Elden 2008, looked at 108 participants with Pelvic Girdle Pain, the results they found were mixed. The overall pain relief from usual care plus acupuncture vs usual care plus sham acupuncture was insignificant (p=0.483), however there was a significant improvement in daily living in the acupuncture group (p=0.001). Another study by Elden 2005, also looking at pelvic girdle pain amongst 330 participants who received either usual care, stabilizing exercises or acupuncture, found that the usual care group experienced much more severe evening pain then the acupuncture (p=<0.001) and stabilizing exercises (p=0.0245) groups and that the acupuncture group experienced more evening pain relief than the stabilizing exercises group (p=0.0130). The third study by Lund 2006, compared the use of Deep vs superficial acupuncture to treat pelvic girdle pain in 47 participants, though no significant differences were found between the two techniques, 68% of the women receiving superficial acupuncture found improvement in their evening pain and 72% of women receiving deep acupuncture found improvement in their evening pain.
Of the studies that were included looking at women who suffered both low back and pelvic pain, all four found improvement in pain and function, though they were all deemed low quality by the review. Ekdahl 2010 looked at 32 women who began treatment at either 20 weeks or 26 weeks gestation, they found that the group that started at 26 weeks saw a greater improvement in pain relief. In the study by Kvorning 2004 that looked at 72 women either receiving acupuncture plus usual care or acupuncture alone, found that only 14% of women receiving usual care found improvement in their pain vs 60% of the women receiving acupuncture. In the third study, Wang 2009a looked at 152 women who receive either ear acupuncture, sham ear acupuncture or were on a wait list control. They found that all women reported an improvement in pain, with the acupuncture group reporting significant improvement in pain relief and function compared with the sham group (p=0.02) and the wait list group (p<0.001). Wedenberg 2000 compared 46 women receiving either acupuncture or physiotherapy, while all women experienced improvement in evening pain and disability the acupuncture group reported significantly less intense pain (p<0.01) and disability scores than the physiotherapy group. All of these studies were deemed safe with few mind adverse effects (bleeding and pain at site of insertion) they were all classified as low quality evidence, except Elden 2005 which was considered moderate quality. The review calls for more studies to further illustrate the effectiveness of acupuncture in treating LBPP.
Discussion:
Overall, though limited by time, funding and a limited number of studies, the findings of this research show that acupuncture is a safe and effective tool for treating the EG of pregnancy that Sarah pointed out in our interview. In future research I would like to interview more midwives regionally, nationally and even internationally to see if different EG exist within different regions, countries and amongst practitioners themselves, as well asking doctors, obstetricians and gynaecologists what EG they found in their practice would be interesting to compare with the midwives results. It is evident from the research that more studies on acupuncture in pregnancy are needed, including studies into whether cervical ripening acupuncture would improve outcomes for VBAC mothers and if acupuncture can help with gestational diabetes as these were EG that Sarah identified that I could not find any research on. With particular consideration of the unique treatment that acupuncture uses and the many limitations of these studies (small size, quasi-randomization, lack of equivalent care control), more studies with a better system of comparison needs to be utilized by researchers, such as The Stricta (2010) (standards for reporting interventions in controlled trials of acupuncture) protocol developed in conjunction with the CONSORT group. There is also much wisdom that is offered in the historical and modern texts and experiences of practitioners that could shed more light on the use and effectiveness of acupuncture.
Conclusions:
Acupuncture is a safe treatment in pregnancy and seems to offer effective alternative or complementary care for pregnant women with anxiety and/or depression, hypertension, preeclampsia, low back and/or pelvic pain. With Pregnancy being a time of care and caution and being surrounded by a system that is largely adverse to risk, acupuncturists have an important role to providing care to pregnant women when their regular care providers have little to no safe or effective treatments. Many women are told to watch and wait or that it is just part of pregnancy and are often not assisted by their practitioners unless it is deemed critical when interventions are sometimes dangerous, in this acupuncturists can offer women relief from persistent and troubling discomforts in their daily lives and allow for a healthy and happier pregnancy.
References:
Betts, D. (2006) The Essential Guide to Acupuncture in Pregnancy and Childbirth. East Sussex, The Journal of Chinese Medicine Ltd.
Betts, D. (2017). Maternity Acupuncture: Pregnancy, Labour and Postpartum. [Lecture] Pacific Rim College, April, 2017.
Department of Mental Health and Substance Dependence. (2012) Gender Disparities in Mental Health. World Health Organization. Available from: http://www.who.int/mental_health/media/en/242.pdf
Fisher, P., Van Haselen, R., Hardy, K., Berkovitz, S. & McCarney, R. (2004) Effectiveness Gaps: a new concept for evaluating health service and research needs applied to complementary and alternative medicine. Journal of Alternative and Complementary Medicine. 10(4), 627-32. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15353018
Ormsby, S.M., Smith, A.S., Dahlen, H.G., Hay, P.J. & Lind, J.M. (2016) Evaluation of an antenatal acupuncture intervention as an adjunct therapy for antenatal depression (AcuAnteDep): Study protocol for a pragmatic randomized control trial. Trials. 17(93). Available from: 10.1186/s13063-016-1204-9
Pennick, L. & Liddle, S.D. (2013) Interventions for preventing and treating low back and pelvic pain in pregnancy (review). The Cochrane Library. 8. Available from: http://uir.ulster.ac.uk/26553/1/LBPP_in_pregnancy_Cochrane_review_2013.pdf
Public Health Agency of Canada. (2010/11). Maternal Hypetension in Canada. Available from: https://www.canada.ca/content/dam/canada/health-canada/migration/healthy-canadians/publications/healthy-living-vie-saine/maternal-hypertension-maternelle/alt/maternal-hypertension-maternelle-eng.pdf
Shi, A. & Zeng, D. (2011) Essentials of Chinese Medicine Internal Medicine. Second Edition. California, Bridge Publishing Group.
Sniezek, D.P. & Siddiqui I.J. (2013) Acupuncture for treating Anxiety and Depression in Women: A Clinical Systemic Review. Medical Acupuncture. 25(3), 164-172. Available from: 10.1089/acu.2012.0900
Stricta (2010) Checklist for Stricta 2010. Available from: http://www.stricta.info/checklist.html
Task Force on Hypertension in Pregnancy. (2013) Hypertension in Pregnancy. American Congress of Obstetricians and Gynecologists. Available from: https://www.acog.org/Resources-And-Publications/Task-Force-and-Work-Group-Reports/Hypertension-in-Pregnancy
Zeng, Y., Liu, B., Luo T., Chen, Y., Chen, G. & Chen D. (2015) Effects of Acupuncture on preeclampsia in Chinese Women: A Pilot Prospective Cohort Study. Acupuncture in Medicine. 2016(34), 144-148. Available from: 10.1136/acupmed-2015-010893
