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Determinants of Women Consulting with a Complementary and Alternative Medicine Practitioner for PregnancyRelated Health Conditions a

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Amie Steel MPH BHSc(Nat) , Jon Adams PhD MA BA(Hons) , David a

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Sibbritt PhD MMedStat BMath , Alex Broom PhD MA BA(Hons) , Cindy b

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Gallois PhD MA BSL & Jane Frawley MCSc BHSc(CompMed) a

Australian Research Centre in Complementary and Integrative Medicine, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia

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School of Social Science, University of Queensland, St Lucia, QLD, Australia Accepted author version posted online: 13 Jan 2014.Published online: 12 Mar 2014.

To cite this article: Amie Steel MPH BHSc(Nat), Jon Adams PhD MA BA(Hons), David Sibbritt PhD MMedStat BMath, Alex Broom PhD MA BA(Hons), Cindy Gallois PhD MA BSL & Jane Frawley MCSc BHSc(CompMed) (2014) Determinants of Women Consulting with a Complementary and Alternative Medicine Practitioner for Pregnancy-Related Health Conditions, Women & Health, 54:2, 127-144, DOI: 10.1080/03630242.2013.876488 To link to this article: http://dx.doi.org/10.1080/03630242.2013.876488

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Women & Health, 54:127–144, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0363-0242 print/1541-0331 online DOI: 10.1080/03630242.2013.876488

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Determinants of Women Consulting with a Complementary and Alternative Medicine Practitioner for Pregnancy-Related Health Conditions AMIE STEEL, MPH, BHSc(Nat), JON ADAMS, PhD, MA, BA(Hons), and DAVID SIBBRITT, PhD, MMedStat, BMath Australian Research Centre in Complementary and Integrative Medicine, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia

ALEX BROOM, PhD, MA, BA(Hons) and CINDY GALLOIS, PhD, MA, BSL School of Social Science, University of Queensland, St Lucia, QLD, Australia

JANE FRAWLEY, MCSc, BHSc(CompMed) Australian Research Centre in Complementary and Integrative Medicine, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia

The objective of this study was to explore the determinants that are related to women’s likelihood to consult with a complementary and alternative medicine (CAM) practitioner during pregnancy. Primary data were collected as a sub-study of the Australian Longitudinal Study on Women’s Health (ALSWH) in 2010. We completed a cross-sectional survey of 2,445 women from the ALSWH “younger” cohort (n = 8,012), who had identified as being pregnant or had recently given birth in 2009. Independent Poisson backwards stepwise regression models were applied to four CAM practitioner outcome categories: acupuncturist, chiropractor, massage therapist, and naturopath. The survey was completed by 1,835 women (79.2%). The factors associated with women’s consultation with a CAM practitioner differed by practitioner groups.

Received June 5, 2013; revised November 19, 2013; accepted December 7, 2013. Address correspondence to Amie Steel, MPH, BHSc(Nat), Australian Research Centre in Complementary and Integrative Medicine, Faculty of Health, University of Technology Sydney, Level 7, Building 10, 235-253 Jones Street, Ultimo, NSW, 2006 Australia. E-mail: [email protected] 127

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A range of demographic factors were related, including employment status, financial status, and level of education. Women’s health insurance coverage, health status, and perceptions toward both conventional maternity care and CAM were also associated with their likelihood of consultations with all practitioner groups, but in diverse ways. Determinants for women’s consultations with a CAM practitioner varied across practitioner groups. Stakeholders and researchers would benefit from giving attention to specific individual modalities when considering CAM use in maternity care. KEYWORDS medicine

pregnancy,

complementary

and

alternative

INTRODUCTION The Examination of Complementary and Alternative Medicine Use in Pregnancy The use of complementary and alternative medicine (CAM)—defined as a range of products and treatments not traditionally associated with the conventional medical profession or medical curriculum (Adams et al., 2012; Adams and Tovey, 2008; Andrews, Adams, & Segrott, 2009)—in pregnancy has been reported to be as high as 87%, with more conservative estimates ranging between 20 and 60% (Adams et al., 2009). Previous research in this area has predominantly focused on evaluating the prevalence of use and clinical effectiveness of herbal medicine (Adams et al. 2009; Parsons, Simpson, & Ponton, 1999; Simpson et al. 2001); however, a number of studies have reported consultation rates during pregnancy with CAM practitioners (Adams et al., 2009; Steel et al., 2012). According to these studies, the practitioners visited by pregnant women include acupuncturists, massage therapists, chiropractors, and naturopaths. However, the findings from these studies only reported prevalence rates, and did not examine the factors associated with women’s consultation with these practitioner groups. This has led to recommendations that the role of CAM practitioners be examined more closely (Adams, 2011; Steel & Adams, 2011).

Determinants of CAM Use During Pregnancy A number of factors have been found to be related to women’s use of CAM during pregnancy, although the research in this area has either focused on CAM as a broad category or on specific CAM products and treatments, such as herbal medicine (Adams et al., 2009). Use of CAM during pregnancy was identified in a review of international literature to be related to women’ age,

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level of education, and income (Adams et al., 2009). Women’s health history, current health status, previous or habitual use of CAM, parity, smoking status, and intended birth plans (e.g., planning a natural birth) also affects the likelihood of using CAM during pregnancy (Adams et al., 2009; Frawley et al., 2013). Further research has indicated women were more likely to use specific CAM, such as herbal medicine, if they had taken a multivitamin, but were less likely to do so if they had a higher body mass index (BMI) or were taking multiple pharmaceuticals (Moussally, Oraichi, & Bérard, 2009). Women’s perceptions and attitudes may also be associated with their use of CAM during pregnancy. Those women who used CAM during pregnancy have been found to perceive CAM as more natural and safe, and as being at least as equally effective as conventional maternity treatments (Adams et al., 2009). Safety, in particular, is held to be an important feature of any treatments and interventions by many pregnant women often resulting in attempts to avoid pharmaceutical treatments during pregnancy (Nordeng, Koren, & Einarson, 2010) or to approach the use of such therapeutic options with caution (McDonald, Amir, & Davey, 2011). These findings have been supported by recent research that has reported 81% of women consider herbal medicines to be effective, although many other women also raised concerns about the safety of herbal medicines during pregnancy (Fakeye, Adisa, & Musa, 2009). Beyond the specifics of herbal medicine, a survey that examined a wide range of CAM found most women to be unafraid of side effects and to consider CAM to be a reasonable addition to conventional treatment (Kalder et al., 2010). In addition to these views, a growing body of clinical research has been examining the effectiveness and safety of CAM treatments accessed during pregnancy (Borggren 2007; Khorsan et al., 2009; Oliveira et al., 2011; Parsons et al., 1999; Sarris & Byrne, 2011; Simpson et al., 2001; Smith & Cochrane, 2009; Stuber & Smith, 2008; Sturgeon et al., 2009; Walker et al., 2011; Xiying, Cuizhu, & Wanming, 2007; Zheng et al., 2010). The role of conventional care providers in the referral and provision of CAM to pregnant and birthing women may also warrant consideration as a factor related to women’s use of CAM during pregnancy. This has been identified as an important issue in an international context (Adams et al., 2011) and although recent research has reported no significant association between consultations with a CAM practitioner and medical practitioner consultations, the role of midwives were not considered in the analysis (Sibbritt, Adams, & Lui, 2011). Additionally, the data used in this recent research did not specifically indicate consultations with a CAM practitioner for pregnancy-related health conditions.

The Determinants of Consultations with CAM Practitioners The bulk of the current research examining the determinants of women’s use of CAM during pregnancy focuses on products and treatments (Adams

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et al., 2009). While some CAM practitioners use treatments, such as herbal medicine (Wardle & Steel, 2010), the therapeutic encounter is arguably more complex. Even for those CAM practitioners that commonly prescribe herbal medicine, such as naturopaths, a number of elements are outlined within the consultation process, including negotiating treatment goals and strategies with the patient; actively encouraging the patient to acquire self-help skills (i.e., accessing books, internet resources, and community resources to support recovery and treatment); and consolidate the patient’s independence for future health maintenance (Connolly, 2010). These additional elements of CAM practice may extend the impacts on women’s health decision-making during pregnancy, birth, and further into the future. With this in mind, the practitioner-patient relationship requires focused attention (Steel & Adams, 2011). This study used a nationally representative cohort of women who had recently given birth to examine the determinants linked to women’s consultations with select CAM practitioner groups, namely acupuncturists, chiropractors, massage therapists, and naturopaths.

METHODS Sample The sample was derived from the Australian Longitudinal Study on Women’s Health (ALSWH) (www.alswh.org.au). ALSWH is a longitudinal, populationbased survey examining the health of more than 40,000 Australian women who were randomly selected from the national Medicare database. This sub-study sample was drawn from the youngest (born 1973–1978; n = 8,012) of the three age-stratified ALSWH cohorts (which also included “midage” [born 1946–1951] and “older” [born 1921–1926]). For the most recent general ALSWH survey (Survey 5) conducted in 2009, all women in the young cohort who identified as being pregnant or had recently given birth (n = 2,445) were recruited for the sub-study. We invited this group to complete the sub-study survey in 2010, which examined a range of aspects associated with their health care during the pregnancy and birth of their youngest child. The data from the 2010 sub-study were used for the analysis presented here. Ethics approval for the sub-study reported here was gained from the relevant ethics committees at the University of Newcastle (#H-2010_0031), University of Queensland (#2010000411) and the University of Technology Sydney (#2011-174N).

Demographics We collected data on and examined a range of demographics, including area of residence, employment status at time of birth, income security, health insurance, and educational qualifications. Participants’ area of residence

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was defined according to geo-coding through which women were allocated an Accessibility/Remoteness Index of Australia (ARIA+) remoteness score according to the Australian standard geographical classification (ASGC) released in 2001 by the Australian Bureau of Statistics (Australian Institute of Health and Welfare 2004). This classification categorizes areas of residence as “very remote,” “remote,” “outer regional,” “inner regional,” and “major cities,” based on the road distance between the closest service center and a locality. Due to small sample sizes in regional and remote areas, categories were combined to reflect “urban,” which constituted those residing in a “major cities” locality, and “rural,” which included those living in all other localities.

Pregnancy Health and Maternity Care We also examined the features of participants’ maternal health, including the occurrence of pregnancy-related health conditions (e.g., nausea and vomiting, fatigue, and gestational diabetes) and the location of the birth of their youngest child (e.g., public hospital, private hospital, and community/birth center).

Attitudes and Beliefs We asked participants to respond along a 5-point Likert scale to a number of statements reflecting their attitudes or beliefs relating to CAM both in general and, specifically, in regard to their maternity care.

Consultations with CAM Practitioners Women identified the frequency of their consultations with a CAM practitioner for pregnancy-related health conditions. These included acupuncturists, chiropractor, massage therapist, and naturopath.

Statistical Analysis To determine relationships between frequency of CAM practitioner consultations and a range of demographic, health, and attitudinal factors, we employed a chi-square analysis. To identify the factors associated with women’s likelihood of consulting with different CAM practitioners, a separate Poisson backward stepwise regression was generated for each practitioner group, through which we considered all the demographic, attitudes and beliefs, and pregnancy and maternity care variables. We identified the potential confounders for each independent model through the application of literature/clinical knowledge in combination with statistical evidence via bivariate analyses between potential confounders and each outcome. Confounders to be included in the multivariate models were

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defined by any bivariate test which resulted in a p-value of

Determinants of women consulting with a complementary and alternative medicine practitioner for pregnancy-related health conditions.

The objective of this study was to explore the determinants that are related to women's likelihood to consult with a complementary and alternative med...
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