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Complementary Therapies in Clinical Practice 16 (2010) 109–113

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Complementary Therapies in Clinical Practice

journal homepage: www.elsevier .com/locate /ctnm

Risk, pregnancy and complementary and alternative medicine

Mary Mitchell*

Department of Nursing and Midwifery, Faculty of Health and Life Sciences, University of the West of England, Blackberry Hill, Stapleton, Bristol BS16 1DD, United Kingdom

Keywords:PregnancyRiskComplementaryAlternative medicine

* Tel.: þ44 0117 3288892; fax: þ44 117 3288411.E-mail address: mary.mitchell@uwe.ac.uk

1744-3881/$ – see front matter � 2009 Elsevier Ltd.doi:10.1016/j.ctcp.2009.10.005

a b s t r a c t

Since the 1990’s sociologists such as Giddens1 and Beck2 have highlighted the complexities of contem-porary western societies in relation to risk. The ‘‘risk society’’ is one in which the advantages of scientificand technological developments are overshadowed with risks and dangers: leading to a world dominatedby anxiety and uncertainty.2,3 Although a complex set of interrelated phenomena the risk society can besummarised under three main changes: including globalisation, scepticism about expert knowledge,Thompson4: 27 and the degree of autonomy individuals have in our detraditionalised society to determinetheir own life choices (Beck5: 13). The discourses of the ‘‘risk society’’ inevitably impact on women duringpregnancy and the potential influence this discourse may have in relation to healthcare choices, particu-larly in the field of complementary and alternative medicine (CAM) are explored.

In this paper it is argued that the apparently growing use of CAM during pregnancy and childbirthcould be interpreted as a response by women to these discourses, that decisions made with regard toCAM may signify a desire for personal fulfilment and a need for autonomy and active participation inhealthcare during pregnancy and childbirth.

� 2009 Elsevier Ltd. All rights reserved.

1. Introduction

Sociologists such as Giddens,1 Beck2 and others6–8 have high-lighted the complexities of contemporary western societies inrelation to risk. The ‘‘risk society’’ is one in which the advantages ofscientific and technological developments are overshadowed withrisks and dangers: leading to a world dominated by anxiety anduncertainty.2,3 Although a complex set of interrelated phenomenathe risk society can be summarised under three main changes:firstly society is dominated by increasing risks of a globalisednature. Secondly, there is recognition that science is not infallible,and scepticism about expert knowledge has increased. Thus, indi-viduals must constantly make reflexive choices in the context ofuncertainty in their daily lives (Thompson4: 27). Thirdly, the indi-vidualisation thesis proposes that traditional institutions no longerhave a stronghold over individual lives, therefore it is up to theindividual to shape their own biographies, autonomy and choiceassume priority (Beck5: 13).

Little is known about how these discourses of risk impact ona woman’s perception and experience of pregnancy. From the earlystages of pregnancy women are exposed to a multiplicity of

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assumptions about risks, many hotly debated9 The medical viewholds pregnancy and childbirth as inherently risky, thereforetechnological interventions are required in order to manage thoserisks. However, for midwives, birth is a physiological event, andinterventions are viewed as the main source of risk10 Marken et al11

believe women’s perception of risk in pregnancy may be exagger-ated in their concern for the wellbeing of their baby and this in turninfluences their behaviour.

The use of complementary and alternative medicine defined as ‘‘a broad domain of healing resources that encompasses all healthsystems, modalities, and practices and their accompanying theoriesand beliefs, other than those intrinsic to the politically dominanthealth system of a particular society’’,12 in pregnancy may be onestrategy which women adopt as a means of coping with feelings offear and uncertainty generated by discourses of risk. Althoughnumerous different therapies are classified as CAM they aregenerally underpinned by similar concepts of holism, vitalism, thebody as self healing, and a focus on wellbeing.13

This paper offers a critical examination of how discourses of riskcontribute to the apparently growing support of CAM duringpregnancy and childbirth. Although there is little empiricalevidence to support a link between risk, pregnancy and CAM it isargued that the use of CAM could be interpreted as a response bywomen to these discourses, that reflexive decisions made withregard to CAM may signify a desire for fulfilment and a need forautonomy and active participation in healthcare.

M. Mitchell / Complementary Therapies in Clinical Practice 16 (2010) 109–113110

2. The globalised nature of risk, pregnancy and CAM

A central theme in the risk society thesis, relates to the globalisednature of risk such as those associated with pollution, globalwarming and food production. These risks are not contained by theboundaries of time and space and therefore have the ability toimpact on everyone.14 Debates and controversies dominate politicaland institutional discourses, raising awareness and compellingindividuals to consider risks on a daily basis (Beck5: 45). In thediscourse of risk there is an intense focus on the pregnant women asshe is she is viewed as being responsible for the wellbeing of herselfand her baby.7,15 Women are bombarded by public health messagesto attend to their wellbeing and to avoid the risk of certain foods,alcohol, smoking and risky behaviours.9 Consequently, many womenperceive pregnancy to be potential risky with the possibility ofunforeseen events always present.10 Those turning to CAM reportdoing so to achieve a state of wellbeing and as a defensive strategy toprotect themselves from the risks of contemporary society.16 Thesefindings may also be relevant to CAM use in pregnancy.

Both Beck2 and Giddens1 refer to the phenomenon of manu-factured uncertainties: the risks that have arise through scientificprogress. One such example is the alarming rise in caesareansection (CS) rates as a result of increasing technological surveillanceduring labour.17 As a CS may pose serious health implications thishas become a public health issue of concern to professionals andwomen (RCOG 2001).63

There is some evidence that midwives and women areembracing CAM in an effort to reduce CS rates and to supportnormal birth.18,19 In addition many women wish to avoid the sideeffects of technology or pharmaceuticals and the use of CAM ther-apies may be seen as a backlash against technology and signifya return to what are perceived as more ‘‘natural’’ products.20

There has also been a proliferation in expert knowledgesurrounding the concept of risk. The medical model adopts a realistperspective, i.e. risk is viewed in terms of probabilities, impact andrisk avoidance.21 Risk is taken for granted and there is little concernwith questions of the social nature of risk.22 This assumptionimplies that rational beings will attempt to reduce risks by followingexpert advice. Non-compliance is seen as irrational or riskybehaviour23 Douglas6: 14 argues that this approach intensifiespeople’s fears and anxieties. The impact of this stance on pregnantwomen is evident in studies of preterm labour24 and infantfeeding.25 In these studies women were asked to follow medicaladvice on risk reduction without taking into account social orindividual needs. Health professionals were noted to reprimand orjudge women if they failed to follow this advice. Women felt pun-ished and stigmatised, they experienced anxiety, fear and a sense ofuncertainty about whether they were doing the right thing orharming their baby. Many responded to these experiences by non-disclosure of risky behaviour and avoidance of professional contact.Women who chose CAM in pregnancy also report these underlyingcurrents of disdain and condescending attitudes from profes-sionals.26 Dissatisfaction with conventional medical care and thedesire for a more authentic relationship with caregivers has beenwell documented as reasons for choosing CAM27 and thus may bea driving force behind CAM consumption in pregnancy.

Social and cultural influences impact on risk and risk percep-tion.28 It is argued that risks are not objective perceptions of risk areinextricably linked with our understandings of what constitutesa danger or a threat.7,6,14 The concept of ‘‘risk culture’’ as opposed to‘‘risk society’’ is thus preferable as this embraces all kinds ofinterpretation and sense making processes about risks. There is anargument that the debate over real/constructed risk is not impor-tant what is important is the individual’s perception of risk andhow it impacts on their life.2 Certainly studies of response to risk in

pregnancy and in relation to CAM confirms the complexity of riskperception as a multidimensional concept.29,30 This is well illus-trated when women reject pharmaceuticals for fear of their tera-togenic effect on the fetus but make the assumption that ‘natural’means safe, and take a variety of herbal products during pregnancydespite evidence of risks.31

Hier32 questions Gidden’s and Beck’s claim that individuals areovertly influenced by global risks, as immediate local and personalexperiences are more influential. There is some empirical evidencefor this for e.g. people are aware of global risks but their responsesare moderated by practical constraints of everyday life.33 Pregnancymay alter these perceptions and responses as women experiencea heightened awareness of the world to which they will bring theirnewborn. Thus CAM with its philosophy of holism and self healingcould be interpreted as symbolic of an individuals perspective ofthe location of risk in globalised pharmaceutical industries andmedicine.9

3. Reflexivity, pregnancy and CAM

The invisibility of contemporary risks means that they must berevealed and interpreted by experts.7 Risks can thus be interpreteddifferently by individuals and institutions, be overemphasised ormanipulated,34 therefore, power and access to knowledge isparticularly important in the risk society. Beck35 suggests theclassification of risk is not always in the interests of public but aboutclaims of the legitimacy of particular forms of knowledge andexpertise leading to a loss of faith in scientific authority. Thisgenerates anxiety and insecurity and impels people to develop theirown strategies for achieving certainty.36 Gidden’s37 refers to this asreflexive modernisation; individuals have to learn to negotiatecontradictory discourses and exercise their autonomy in findingways of dealing with risks of everyday life. Thus pregnant womenmake decisions about risk behaviours that are relevant to theirsocial and situational context,38 possibly against medical advice.Seeking CAM could be viewed as a way of negotiating contradictorydiscourses. Indeed many CAM users reject scientific evidence infavour of their own assessment.39 Women who have used CAM inpregnancy do not seem to be concerned with the lack of researchevidence or the lack of medical support preferring to accept thetherapy based on their own risk assessment and subjective judge-ment of efficacy.26

Living in a risk society involves being faced with the require-ment for continuous decision making in the face of uncertainty,conflicting information and a multiplicity of choices.40 There islittle doubt that many women find the experience of pregnancystressful, one that provokes fear, feelings of vulnerability and loss ofcontrol.41 CAM practices with their emphasis on stress relief andparticipatory relationships may offer women way of dealing withthese feelings. (Astin42: 103, Sointu43,44).

Holloway and Jefferson45 refer to the ‘‘missing subject’’ in thesediscourses of risk and suggest that anxiety is a complex multidi-mensional concept of the human psyche.

Risk perception is highly variable and not enough is taken intoaccount of how socio-economic status or gender influencesresponses to risk. There is a gender differences in risk perception,men are less concerned about hazards compared to women andwomen believe their lives are more stressful than mens’.36,46 It isargued that pregnant women feel intense fears and a heightenedconsciousness about risks and that they demonstrate reflexivity byactively seeking information and take actions to ameliorate risks.7

Women are the main consumers of CAM47 and these feelings ofincreased anxiety during pregnancy may account for the apparentincrease of CAM in pregnancy with its focus on relaxation andstress relief.48

M. Mitchell / Complementary Therapies in Clinical Practice 16 (2010) 109–113 111

Lupton50 has also contended that the educated and well informedare the most concerned about risk. However, the complexity ofscientific knowledge means individuals may not be a position tointerpret it, thus the privileged become even more anxious. CAMusers are generally affluent and well educated42 and there is someevidence that women who access CAM are more anxious than thosewho do not.49 However, individuals respond to risk and uncertaintyin complex ways. Individuals adopt a variety of strategies; attitudesof trust, acceptance, rejection and scepticism all co exist uneasily.50

Pregnant women, particularly those labelled as high risk, viewhealthcare as having an important impact on the health of theirpregnancies demonstrating a reliance on medical wisdom andadvice.51 Individuals must deal with this paradox of reliance onexperts to guide their daily lives but at the same time of experiencinga distrust of their advice.50 There has also been the suggestion thatCAM use illustrates a reliance on just another kind of expert.13

Some writers argue that the notion of reflexivity is not asimportant in everyday life as Beck and Giddens suggest, that wedo not consciously think about our actions all of the time.52,53

Indeed, Bourdieu’s54 theory of ‘‘habitus’’ implies most of our dailypractices are not wholly consciously controlled; actions may becarried out unthinkingly and routinely, as our social world is takenfor granted. One way in which individuals manage their liveswithout constant anxiety is by having trust in individuals andexpert systems.50 The effect of trust impacts on risk perceptionminimizing concern and anxiety. Giddens discusses the notion of‘‘ontological security’’ as the feeling of trust in people, expertsystems and in the consistency of our environment that developsin individuals throughout their lives.1 Feelings of trust providea‘‘cocoon of invulnerability’’ that allows individuals to get on withtheir lives without being paralysed by their choices and risks.7

However, there are times when established routines are breached,of fateful moments in our lives that threaten ontological security.1

The cocoon needs to be re- established to fend off feelings ofuncertainty or dread.50 cites illness as a potential fateful moment.CAM use could signify an attempt to establish ontological securityas its appeal lies in its contribution to an improvement in people’sability to conduct their daily lives, feelings of satisfaction, of peaceand personal fulfilment.55–57 It is possible that pregnancy is alsosuch a time when ontological security is breached and reflexivitycomes to the fore as women make important decisions that havethe potential to significantly impact on their future. Trust isfacilitated by ongoing relationships which is perhaps more likelyto be achieved throught the therapeutic encounter with comple-mentary therapy practitioners.4

4. Individualisation, pregnancy and CAM

The individualisation thesis suggests that globalisation hasresulted in detraditionalisation. Traditions such as church andsocial class no longer provide a structure to guide everyday life.Therefore, it is up to the individual to shape their own lives, choiceand individual agency in decision making assumes priority.Brannen and Nilsen58 argue that the central tenets of individual-isation: choice, autonomy and self-determination are also keyfeatures of institutional policy. The rhetoric of the maternityservices would confirm this view but the reality is somewhatdifferent. Within the NHS, choice is curtailed by the dominance ofthe medical model, disagreements between professional groupsand economics.59 Lankshear et al17 found that women whosepregnancies were labelled at risk felt powerless and vulnerable.The paradox is that individuals in the risk society need to makechoices and be in control but they are constrained against thiswithin healthcare institutions. It is possible women choose CAMto exercise their choice and achieve a degree of control over their

healthcare practices.60 Mitchell and Allen’s study26 revealed thatwomen even extend this desire for autonomy onto their fetus.They rejected medical intervention to facilitate breech birth asthey felt it ‘‘forced’’ the baby to turn but accepted moxibustion (atraditional Chinese therapy) as it was seen to encourage the babyto turn on its own.

Detraditionalisation has liberated the individual to negotiatetheir own life course but the individual must still take responsi-bility for their actions and choices: a reflexive biography.5 Withtraditional support systems receding and more complexity ofchoices greater anxiety and uncertainty is faced by individuals.More recently, Furedi61 suggested that this has led to a develop-ment of new structures for people to turn to for support, such ascounselling therapies and CAM practices which emphasiseemotional wellbeing. It is argued that an individual’s healthbecomes a life task, part of the life trajectory requiring commitmentand attention to the maintenance of health and wellbeing.62 ThusCAM may be way of investing in the body, not just to prevent illhealth but as a way of fulfilling and optimising potential. CAM isviewed as a resource to enable the individual to cope with thepressures of everyday life.63 It is also argued that CAM use may bea response to the problems of detraditionalisation and signifya desire to return to traditional practices to support health.64,65

Beck’s individualisation thesis was however, challenged byBrannen and Nilsen58 who argued that such an approach neglectsthe sociological dynamic between the individual and society as itportrays human choices as disembedded from social circumstances.

Indeed, true autonomous choice is not always evident as womenmake pragmatic decisions based on their social context and lifeexperiences.25,66 The provision of CAM in the UK NHS continues tobe extremely limited and often only available to those who have theeconomic means to pay. In addition, little attention is paid to thosewho do not wish to take the responsibility for the choices theymake. In pregnancy this may be particularly pertinent as theresponsibility of decision making lies heavily on women’s shoul-ders as noted by Bluff and Holloway67 who found that womenpreferred to leave decision making to the experts as they wereperceived to ‘‘know best’’.

In creating a life trajectory, an individual’s self identity isfrequently negotiated and renegotiated.50 Women commonlyexperience significant role change that can involve conflictingdemands between their own needs, that of their families and ofsocieties.68 Life choices may indicate a search for identity ‘‘ina runaway world’’.69 It could be suggested that CAM use duringpregnancy may serve to confirm a woman’s self identity asa responsible agent who actively pursues her own wellbeing andthat of her baby. Individualisation can be a mixed blessing as itlimits social and community ties, detracts from the development ofa meaningful life and creates fragmented identities.70 Indeed,women often experience a loss of identity and a sense of isolationduring pregnancy and following birth.70 Group CAM sessions suchas yoga and baby massage may help women establish supportivesocial networks and meaningful relationships71,72 Others haveargued that the rise of women utilising self help strategies such asCAM, is indicative of weakening social structures and of the chal-lenges women face in coming to terms with the gap between whothey are and what society expects them to be.73,74

Such a shift in focus from living a life governed by externalconstraints, to a life more focussed on individual subjective expe-riences can be highly influential in determining life choices.75 Itmay also be that CAM provides an opportunity for people to focuson individualised care as the authenticity and uniqueness of theindividual is honoured76 thus may be particularly relevant forwomen as they come to terms with their changing identity duringpregnancy and childbirth.

M. Mitchell / Complementary Therapies in Clinical Practice 16 (2010) 109–113112

5. Conclusion

Risk discourses seem to impact on a women perceptions andexperiences of pregnancy increasing anxieties and worries aboutthe health of her baby. One proposition is that women use CAMduring pregnancy to achieve a state of wellbeing that serves asa protective strategy against the globalised risks of contemporarysociety. Women’s decision making with respect to risk may beviewed as irrational by the medical profession distancing womenfrom respecting or accepting medical advice. Thus CAM use couldbe interpreted as a demonstration of a lack of faith and trust inscience and in the authority of the medical profession.77

The healing effects of CAM is seen to transcend physical healthand wellbeing and as such it may symbolise a particular kind of selfand self identity.68 For many women the experience of pregnancyand birth is a route to personal fulfilment, a period of self-trans-formation which women wish to invest in78 It could be argued thatthis self-transformation is part of the process of making reflexivechoices.

The use of CAM may be one way in which an individual’s demandfor recognition of their subjective experiences and an acknowl-edgement of an active, choosing, empowered agent is achieved. It isimportant that midwives, obstetricians and other professionalsappreciate the potential impact of the discourses of the ‘risk society’on the decisions women make about healthcare during pregnancyand childbirth. This may also be influential in providing greaterinsight into the meaning that women ascribe to the use of CAMduring pregnancy and childbirth. It may also encourage professionalsto review often dismissive attitudes and beliefs around the use ofCAM.

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