WHEREVER we are in medical practice now, most doctors will remember their experience on the labour ward – whether it was as a medical student or junior doctor.

Labour ward has a culture of its own. It’s a place where life begins, but also, rarely, ends. Where healthy young women endure severe pain. Where babies negotiate a potentially hazardous entry into the world. Where there is joy but risk of tragedy.

Pregnancy and delivery care involves a unique collaboration between midwives and obstetricians. The relationship is inextricably linked, but also potentially fraught. At its best, this is teamwork par excellence. Lurking in the background, however, are serious differences in culture and ideology.

It’s on this background that the story emerged recently of the endorsement of the Australian College of Midwives (ACM) of training in “alternative” therapies. The comments of Emeritus Professor of Obstetrics and Gynaecology, Alastair MacLennan, reached the international news. Professor MacLennan, an executive member of Friends of Science in Medicine, which promotes the adoption of scientifically based principles in all health and medical courses, expressed concern about continuing professional development points for certain courses offered by the ACM in areas including moxibustion for “turning” breech babies, and in the use of “acuneedling”. Both of these are practices derived from traditional Chinese medicine, and are described by Professor MacLennan as “dark arts” and as having “no scientific evidence of safety”.

Moxibustion involves burning a herbal preparation of Artemisia vulgaris (mugwort) close to the skin of a specific acupuncture point until the heat produces redness. To promote version of a breech presentation, moxibustion is applied to the acupuncture point bladder 67 (located on the outer corner of the fifth toenail).

Such a mechanism is, frankly, implausible.

Midwives are well trained in the physiology and natural course of labour and birth, and routinely use drugs and procedures to modify these processes. Midwives were one of the first groups of specialised nurses to adopt advanced practice, applying medical interventions that save lives. In Australian public hospitals, most uncomplicated births are entirely managed by midwives, including monitoring, analgesia, use of medications and suturing.

In defending the moxibustion courses, the ACM argued that “in order to provide appropriate advice it is essential that midwives have an understanding of practices that women are interested in, including complementary therapies”. The spokesperson opined that “all health professionals, including midwives, have the critical thinking skills to enable them to suitably analyse and assess any practice or research to determine whether it can be incorporated into their evidence-based practice”.

This explanation doesn’t ring true, however, when details of the courses reveal that they are not a review of the valid evidence but teach participants to deliver the “therapy” itself. Courses endorsed by the ACM can be reviewed here.

It’s difficult to understand how a clinician with an expert understanding of pregnancy and birth could suspend disbelief long enough to seriously offer such a service to patients. The stated stance of the ACM cannot justify the endorsement of courses in unscientific practice. It’s likely that many midwives would be appalled by this, but, so far, they have not been publicly vocal.

And so, it appears that these ideological battles over the labour ward remain.

Dr Sue Ieraci is a specialist emergency physician who has also held roles in departmental management and medical regulation. She is an executive member of Friends of Science in Medicine. She can be found on Twitter @SueIeraci.

 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or MJA InSight unless that is so stated.

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Poll

Moxibustion and acuneedling should play no part in obstetric practice
  • Strongly agree (81%, 127 Votes)
  • Agree (7%, 11 Votes)
  • Strongly disagree (4%, 7 Votes)
  • Neutral (4%, 6 Votes)
  • Disagree (4%, 6 Votes)

Total Voters: 157

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10 thoughts on “Ideological battlefield of the labour ward

  1. David Freeman says:

    Where are the controlled clinical trials that support moxibustion/acuneedling?

  2. Anonymous says:

    Any procedure which is not scientifically analysed should not be practised or trained at tax payers expense

  3. Elliot Rubinstein says:

    One thing that seems to be increasingly absent, if you can say such a thing , is clear thinking. It’s an essential part of all of our lives.

  4. Edward Brentnall says:

    Thank you Sue. Once again, a dose of common sense and science, with wonderful and accurate criticisms of dangerous nonsense.
    Edward Brentnall

  5. Tony Krins says:

    It is dishonest and unprofessional to promote (or even allow) “treatments” that have not been shown to be safe or effective. If you promote complimentary medicine in obstetrics, how can you claim to “at least do no harm?”

  6. Anonymous says:

    Coyle ME, Smith CA, Peat B. Cephalic version by moxibustion for breech presentation. Cochrane Database Syst Rev. 2012 May 16;(5):CD003928. dos: 10.1002/14651858.CD003928.pub3. Review. PubMed PMID: 22592693.

  7. Sue Ieraci says:

    Thanks for your comments, Ed. I hope you are well.

  8. Anonymous says:

    Someone has anonymously posted the Cochrane review on this topic. First, it’s worth noting the limitations of the studies considered: “The inclusion criteria were published and unpublished randomised controlled trials comparing moxibustion (either alone or in combination with acupuncture or postural techniques) with a control group (no moxibustion), or other methods (e.g. external cephalic version, acupuncture, postural techniques) in women with a singleton breech presentation.” The studies were poor: “The included trials were of moderate methodological quality, sample sizes in some of the studies were small, how the treatment was applied differed and reporting was limited. While the results were combined they should be interpreted with caution due to the differences in the included studies.”

    Even with these broad criteria, “Moxibustion was not found to reduce the number of non‐cephalic presentations at birth compared with no treatment (P = 0.45)”. This makes sense – the technique is both implausible and demonstrably ineffective.

  9. Emeritus Professor Alastair MacLennan, Vice President of Friends in Science in Medicine says:

    Dear Anonymous,

    The Cochrane review concluded that in regard to the primary outcome “Moxibustion was not found to reduce the number of non‐cephalic presentations at birth compared with no treatment (P = 0.45). ” Data dredging for minor secondary outcomes not specified in the protocol require prospective trials if they can be ethically justified.
    My concern is the use of alternative unproven therapies in pregnancy and labour without ethically approved research protocols, without approved hospital clinical practice protocols and without insurance for this unilateral therapy or “research”. All clinical carers should work together and under the same rules.

  10. Mike Aitken says:

    Great article. The ACM does not really represent the majority of midwives who work with and support the medical model. This episode highlights the differences.

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