In May 2006, a letter copied to the editor of The Times made headline news across the UK. Written by a group of physicians and scientists in response to the government-funded Smallwood Report, it urged the Chief Executives of all Acute and Primary Care Trusts in the UK to reconsider the use of complementary therapies because the signatories were “concerned about ways in which unproven or disproved treatments are being encouraged … in the NHS” (Baum et al 2006).
More than a decade later, the same argument is still being used to cut services which have been making a difference to women, babies and families. I have become aware of a number of CCGs who are effectively banning complementary therapies by not commissioning them. This isn’t just affecting things like acupuncture, but also services such as NHS yoga and pilates classes which combine with physiotherapy to help women with pelvic floor issues after birth. I have heard concern and objection to this expressed by clinicians, by those who use health services and by members of Maternity Voices Partnerships, all of whom are distressed not to have been consulted on this decision.
As the responses to the 2006 letter also illustrated, this kind of stance isn’t particularly justifiable, either in relation to the evidence or the ethics. And the situation today is no different. One of the key issues was highlighted by Denise Tiran, who pointed out that it is surely far better for health care providers to acknowledge women’s use of alternative therapies and incorporate these into existing services than to drive women’s use of these underground.
This point is an important one; particularly as many midwives place a lot of emphasis on the importance of having open and honest relationships with the women they attend. Other significant issues relate to the argument put forward by the authors that holistic therapies should not be used in the NHS either because they are as yet ‘unproven’ or because they have been ‘disproved’.
There are, of course, rather a lot of unproven practices and treatments in use in the NHS, and most of them are unlikely ever to be tested in randomised controlled trials, for a variety of reasons. Who, for example, would approve a trial to test whether rubbing up a contraction was actually a useful element of dealing with a postpartum haemorrhage, given that this would not then be a part of the care given to the women who ended up in the control group? To my knowledge, we have no proof that it is useful to offer a cold wet facecloth to women who have become hot from their efforts in labour, or that women recovering from cesarean sections feel better if someone plumps up their pillows and helps them get comfy. I suspect, however, that even the most evidence-based of practitioners would support the continuation of these practices, not least because common sense tells them that they are beneficial. This is why we need to acknowledge that evidence is only part of the bigger picture. We need to take other kinds of knowledge into account as well.
As far as holistic therapies being ‘disproved’ is concerned, we have to remain cognisant of the fact that that many alternative therapies cannot be fairly evaluated by the favoured research methods of Western medicine (Sheran and Wickham 2006). Because it seeks to pinpoint precise relationships between very specific problems, treatments and outcomes, the ‘gold standard’ of the randomised controlled trial does not fit well with the holistic nature of some of these modalities. As a consequence, if a controlled trial shows that a holistic therapy is ineffective, there is often no way of knowing whether the therapy itself is ineffective, or whether it simply appears that way because the study design failed to accommodate the ideology behind the treatment.
Another huge issue raised by this letter is the question of plausibility. In the original debate, Baum et al (2006) describe homeopathy as ‘implausible’, and, during the media coverage which followed the publication of this letter, experts on homeopathy were ridiculed by journalists for admitting that they did not understand how and why homeopathy works. Perhaps, as some of them admit, it works only because of the placebo effect, which is arguably not a huge problem, because many people would much sooner feel better as a result of the placebo effect than not feel better at all. However, it is also possible that homeopathy and similar modalities which are mocked by some as being ‘pseudo science’ actually work on a level that we do not yet understand, but which one day someone will win a Nobel Prize for explaining.
For something to be plausible, it needs to be believable within the current understanding, context and expectations that we hold. In relation to health and healing, many people’s understanding, context and expectations are based around the Western biomechanical model, and therapies such as homeopathy may well seem absurd and implausible within that framework. Rubbing up a contraction to stop a PPH, however, is very plausible from that standpoint, because it is something that can be imagined, seen and felt by the practitioner on a physical level.
As Denise Tiran’s point implies, an increasing number of women are interested in using therapies that sit outside of the biomedical framework. It seems to me that a there is a need to intensify the debate between those people who are only interested in practices which fit with their existing ideas and beliefs, and those people who are willing to look outside of their own views, consider other possibilities and, perhaps most importantly, ask individual women what they want from a service which is, by definition, supposed to serve them.
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This blog post is partly based on an article originally published as Wickham S (2006). Holistic therapies, proof and plausibility. TPM 9(10):51.
Baum M et al (2006) Doctors’ campaign against alternative therapies. The Times, May 23, 2006.
Sheran I and Wickham S (2006) Chapter 6. In: Wickham S (2006) Appraising Research into Childbirth: An Interactive Workbook. Butterworth Heinemann, Oxford.