Italian midwives attitude toward complementary and alternative medicine

The growing interest in Complementary and Alternative Medicine (CAM) applies also to the field of obstetrics and this encouraged midwives to support the application during pregnancy and delivery. Application of CAM is complete according to the skills and the aims of the midwife’s professional profile, representing as it does a safe non pharmacological approach which endorses both the autonomy of women and midwives’ professional autonomy. The aim of the present study is to investigate the midwives attitude to CAM application in Emilia-Romagna region located in the NorthItaly. This observational study investigated by a written questionnaire 525 midwifes referred to the hospitals and freelancers of Modena, Reggio Emilia, Forlì Rimini and Cesena cities. In such sample, a high involvement of midwives in CAM reaching the 90 to 100% either for hospital/territorial workers or freelancers was observed. Breech presentation and labour management represents the most frequent indication followed by hyperemesis gravidarum. The methods most frequently applied are acupression and moxibustion, homeopathy, relaxation and massage and osteopathy. These midwives were also interviewed about the CAM training expectations: the opportunity to receive teaching during degree is wished by 70% of them, whereas 30% preferred a post-degree training. This represents a preliminary study facing for the first time the attitude toward CAM in Italy, even if the sample size do not allow to reach strong conclusion, some considerations could be drawn: the high compliance showed by midwives should stimulate the increase of CAM offered in public health services and the request also for a qualified training during degree or post-degree studies should promote an enlargement of teaching offer.


INTRODUCTION
The growing interest in Complementary and Alternative Medicine (CAM) applies also to the field of obstetrics.This encouraged midwifes to support the application during pregnancy and delivery.The application of CAM is in complete agreement with the skills and the aims of the midwife"s profession, representing as it does a safe non pharmacological approach which endorses both the autonomy of women and midwives" profession (Hall et al., *Corresponding author.E-mail: sabella.neri@unimore.it. Author(s) agree that this article remain permanently open access under the terms of the Creative Commons Attribution License 4.0 International License 2012).
However, the involvement of midwives in the application of CAM raises the question regarding educational training, because non-conventional medications are not included in the teaching program.
The available data in the application of CAM are not consistent and fragmentary.A study performed in South Australia by a postal questionnaire showed that 78% of the 145 midwives interviewed advised women to use CAM during pregnancy and delivery (Gaffney and Smith, 2004).Similar data were found in North-American countries (Hasting-Tolsma and Terada, 2009).Conversely, a study performed in New-Zealand and Canada reported a 40% usage of CAM in a sample of 648, midwives motivated by a lack of interest, religious conflicts and doubts about suitability (Harding and Foureur, 2009).Furthermore, an investigation in Turkey showed that, aside the applications of CAM, 60% of 129 midwives of the family health centers were particularly interested in herbal treatment (Koc et al., 2012).
The aim of the present study is to investigate the techniques of the application of CAM by midwives in Emilia-Romagna region located in the Northern Italy.To date, no data about such issue have been published in Italian countries.

MATERIALS AND METHODS
The 525 midwives referred to the hospitals and also freelancers of Modena, Reggio Emilia, Forlì Rimini and Cesena cities were invited to fill questionnaires.The questionnaire included 17 items on CAM techniques.The questionnaires were sent by mail and the answers were requested within 60 days.
A written consent to participate in the study was requested at the end of questionnaire with a specific sentence: "Do you agree that the data obtained by questionnaire be processed and published?" In details, questionnaire included information as follows (Figure 1): (1) Demographic data, school degree, previous work experience and actual work position (Group 1-6 items); (2) Knowledge, motivations and frequency of MNC utilization in the clinical practice (Group 2-7 items); (3) Most frequent techniques used (Group 3-2 items); (4) Kind of training received and eventual further training needed to deep the knowledge (Group 4-2 items).
The questionnaire was structured to take into account the interviews reported in the previous studies (1-5).Before commencement of the study, the questionnaire was administered to a sample of 10 midwives who were referred to the Mother-Infant Department, in order to check eventual misunderstanding and difficulties in filling the questions.The results of such evaluation were not included in the final analysis.The e-mail invoice endorsed to reach a large sample of midwives, referred to the whole region.However, such approach caused several methodological biases.Lack of information on the eventual difficulties in filling the questionnaire or misunderstanding causing higher rate of drop-out was more peculiar.

Demographic data
Among the 525 midwives interviewed, only 154 of them filled the questionnaire and the final analysis was performed on 147 cases, because 7 of them were not completely filled.The mean age is about 37.7 (years) and 144 cases were females.The participants" job experience is homogeneously represented: lower than 5 years, 28%; between 5 and 20 years, 35%; and 20 years and above, 37%.All the midwives are graduates and 17% of them have also obtained a post-degree master.The hospital is the most prevalent place of work (71%) followed by territorial service (22%) and Freelancer represent just 7% of the sample.

CAM application
All the midwives interviewed refer to well-known CAM and 75% of them were reported to have conversed with women about the possible use of such methods not just during pregnancy but also in other periods of life like, postmenopausal transition or menstrual disorders.
Also, about 90% of the midwives working at the hospital and all of them at the territorial service (100%) advice women to use CAM.Similarly, the direct involvement is very high.Midwives at the hospital (75%), territorial service (97%), and freelancer midwives (90%) apply CAM during their daily clinical practice with 90% of women"s compliance.As far as the midwives motivation to apply CAM is concerned, the most relevant is the safety for both mother and neonate followed by selfresources empowerment (Figure 2).
Breech presentation and labour management represent the most frequent indications to CAM use followed by hyperemesis gravidarum and breastfeeding support.Other indications rarely reported are: low-back pain, neck and arms pain, hemorrhoids, constipation, insomnia, fatigue and common cold.
The commonly applied methods are acupression and moxibustion, homeopathy, relaxation and massage,

DISCUSSION
This study reports a high involvement of midwives in CAM reaching 90 to 100% either for hospital/territorial workers or freelancers.Breech presentation and labor management represents the most frequent indication followed by hyperemesis gravidarum.A further analysis should give more information about the application for labor and delivery which was not particularly be indicated in the questionnaire.
Acupressure and moxibustion are the most frequent methods applied followed by massages, phytotherapy and homeopathy.In Italy, acupuncture application is not allowed by midwives.Five years ago, Emilia Romagna region started with specific moxibustion training for midwives to offer a no pharmacologic approach for breech presentation.This explains the increase in the percentage of midwives who prescribe the use of moxibustion and acupressure.
A plan for acupressure training for labor and delivery has also been organized in order to offer the method to the women considered not eligible or refusing epidural analgesia.
As far as homeopathy and phitotherapy use is concerned, the questionnaire did not investigate the kind or dosage of the substances that are prescribed to the women.Further evaluation should be taken into account, and more details of each method considered.
Midwives stated they would want to be trained by private courses or by hospital and territorial service.In fact, the need to receive a CAM teaching during degree was reported by 70% of them.Such data could be considered by universities institution.
The small sample of questionnaire processed does not allow for strong conclusions about CAM use.Further evaluations should consider different investigation approach in order to avoid the high rate of drop-out experienced at the onset of the present study.
However, considerations that could be drawn from the first study are the high rate of midwives who are looking forward to a qualified training during degree or postdegree studies.Furthermore, their high compliance should stimulate the increase in the application of CAM offered in public health services.