Denise and her blog

World Mental Health Day

Today is World Mental Health Day so here, Denise considers some of the complementary therapies and natural remedies which may – or may not be of help.

Most people know that some new mothers can experience postnatal depression, but depression during pregnancy is becoming much better recognised. Antenatal depression may occur in women with a tendency to depression, anxiety or severe stress when not pregnant, or may arise as a result of the hormonal, physical, social and occupational changes brought about by pregnancy. It can be severe, partly because is it not always diagnosed early enough, or because women do not always feel able to talk about it to their midwives or doctors. There are several ways of reducing the severity of antenatal depression, including trying to reduce stress and stressful situations, eating well and having moderate amounts of exercise. Avoiding stimulants such as caffeine, alcohol and nicotine is wise advice in pregnancy anyway, but will also reduce the impact on antenatal depression. Yoga, Pilates, swimming, tai chi and other gentle exercise can all help, especially in a designated antenatal class, in which the opportunity to talk to others can also be helpful. Relaxation therapies such as massage, reflexology, and aromatherapy can be helpful, as can mindfulness training or hypnotherapy from a qualified practitioner. Acupuncture has also been shown to reduce stress hormone levels such as cortisol and to increase feel-good factors including endorphins and encephalins. Expectant mothers, however, should be discouraged from stopping or reducing their current antidepressant medication without medical support and must be advised not to take the herbal remedy St John’s wort, which is not considered safe in pregnancy.

St John’s wort (SJW) is a herbal remedy also known as hypericum (its Latin name is Hypericum perforatum). It is often taken orally for mild to moderate depression and mood disturbance, but can also be useful for polycystic ovary syndrome, menopausal symptoms, seasonal affective disorder and other conditions. However, SJW is not a suitable alternative to antidepressants. Although the evidence is inconclusive, there is some suggestion that it may have adverse effects on the developing baby. Similarly, in breastfeeding, it should be avoided because the baby may be at greater risk of lethargy and drowsiness, as well as intestinal colic

SJW can cause a variety of adverse effects in patients, even those who are taking it appropriately. These include insomnia, restlessness, anxiety, panic attacks, irritability, dizziness, headaches and skin rashes. More serious effects include low blood sugar, high blood pressure , raised thyroid stimulating hormone and sensitivity to sunlight (this latter effect meaning that anyone also using aromatherapy oils should use citrus oils such as orange, bergamot, grapefruit and lime oils cautiously. Significantly, SJW should not be substituted for the selective serotonin reuptake inhibitor (SSRI) antidepressants such as sertraline, citalopram, seroxat or fluoxetine, because its mechanism of action is similar. Women will need to withdraw gradually from SSRIs and the same applies to SJW; they should certainly not be taken together as major adverse effects such as SSRI syndrome can develop in which the person experiences suicidal thoughts and mania.

SJW can also interact with various other medications especially when taken in excessive or prolonged amounts. In addition to SSRIs, SJW can interact with the contraceptive Pill, anticoagulants, immune system suppressants, iron supplements and many other drugs used in cancer care and transplant surgery. It should also be avoided if taking other herbal remedies, notably L-tryptophan, an essential amino acid used to increase serotonin levels in depressive conditions, and red yeast, sometimes used to lower cholesterol.

SJW cream can be used topically to treat bruising and aid wound healing but the herbal remedy should not be confused with the homeopathic version which is much safer since it does not act pharmacologically. SJW cream is however safe enough to use during pregnancy and breastfeeding in small amounts. In non-pregnant women, SJW should be avoided when having fertility treatment and should not be taken with the Pill as it may reduce its contraceptive effects.

Complementary Therapies Explained

As a midwifery lecturer, I have been teaching complementary therapies for over 30 years and have long held that they must be set in the context of the culture in which they are used. Where a culture combines mainstream health care with ancient local or regional medicine systems including the use of indigenous plants and techniques, the population has a far greater appreciation of the clinical effects of treatment, both positive and negative. For example, in China, Hong Kong, Taiwan and other Far Eastern countries traditional Chinese medicine is integrated into the healthcare facilities available to the public and medical students are taught about both systems. Similarly, in India there has traditionally been cross-referral of patients between orthodox and complementary practitioners, and further legal changes to integrate the two systems more comprehensively have been made in recent years. Guidelines for the registration of traditional African medicine were published by the World Health Organisation some years ago to facilitate greater integration into the healthcare provision across the continent, particularly in sub-Saharan Africa. In South America, countries vary in respect of acceptance and regulation of traditional medicine, but some such as Brazil have introduced legislation to ensure consistency of standards and to preserve local traditions Indeed, the World Health Organisation has accepted a wide range of traditional medical modalities into its global compendium.  In the Western world, things are rather different. Complementary – or alternative – medicine does not have the respect of mainstream medicine. This may be partly due to the prevailing medical system and the status of the medical professions. The political standing of doctors is considerable in some developed countries. One only has to look at the power of the British Medical Association to appreciate the influence of doctors on healthcare policy. Scientists frequently demean complementary medicine as not being sufficiently evidence-based – largely because it is difficult to undertake randomised controlled trials when using modalities that need, by their very definition, to be individualised to the person. The pharmaceutical companies also exert immense financial pressure on governments, and there is an underlying emphasis on the benefits of drugs to treat disease. In addition, the focus of medical practice is on the suppression of symptoms rather than on finding the cause of disease; there is still poor appreciation of the impact of lifestyle factors such as diet and stress on illness. Added to this is the short-term healthcare policy-making of governments in which the controlling political party may no longer be in power to witness the impact of any long term health promotion initiatives.  Furthermore, populations differ widely between cultures in which people generally defer to authority compared to westernised democracies in which individuals can make their own decisions about whether to accept medical advice and treatment or to find their own alternatives. It could be argued that the rise in the use of complementary and alternative medicine is a rebellion against paternalistic orthodox medicine. The Internet too has added to the potential “knowledge-base” of healthcare consumers, although it must be acknowledged that information is not always accurate, comprehensive and balanced and may, on occasion, be downright dangerous. There is also a misplaced notion in the west that “more is better”. Nowhere do we see this more than amongst the pregnant population. Women in westernised countries want to take control of their childbearing experience; they search the Internet for solutions to the discomforts of pregnancy and notably take it on themselves to interfere in the normal process of going into labour, arguably the most common reason for pregnant women to resort to natural remedies and complementary therapies. Added to this is the ill-informed advice given by healthcare professionals about natural methods, in an attempt to be seen as mothers’ advocates. Only today, I saw on Facebook a proudly displayed post from a UK birth centre actively encouraging women to eat dates to promote labour onset. This is not, in itself a bad suggestion, but incomplete advice put out by an organisation deemed to be the “authority” for women using the service can risk some women experiencing negative effects which may go unrecognised by staff who are not in possession of the full facts. Also, there was no advice to restrict the use of natural remedies that may interact with other complementary practices or with conventional medical induction of labour. This, then, is the nub of the argument: in the developed countries there are so many options for dealing with various health conditions, ranging from highly sophisticated contemporary medical treatments for specific problems to well-known and popular complementary therapies to the fringe alternatives (commonly used by desperate cancer patients seeking solutions), that people are unaware of the issues that may occur when they are combined. It is well known that herbal remedies, which act pharmacologically, carry a significant risk of interaction with other pharmacological agents, including both prescribed and recreational drugs and other natural remedies (See my forthcoming book on Using Natural Remedies Safely in Pregnancy and Childbirth, due to be published March 2021).  Having spent almost my entire career practising, researching, writing about, teaching and promoting the use of complementary therapies in pregnancy and childbirth, I would be doing a disservice to everyone to suggest that their use should now be limited. However it is vital that midwives, doctors, doulas, antenatal teachers and other maternity professionals, as well as people attempting to conceive, and those in the antenatal, labour and postpartum periods, understand that these “alternatives” are powerful and may be either beneficial or hazardous. I always say, if something has the power to do good, it also has the power to do harm if not used appropriately. As with any medicinal product, natural remedies and complementary therapies MUST be adapted to the individual, used correctly, in the smallest “dose” needed to achieve a positive effect. Professionals must understand the reasons for use and those people who should not use a particular remedy or therapy; they must understand the way in which the therapy works, and be alert to side effects and adverse reactions – and know how to deal with them. Their use of alternatives must be set in the context of the culture in which they are working – and in developed countries that usually means the national healthcare services. In the UK, the NHS works for the good of the majority rather than the interests of individuals; it is focused on using evidence-based practices and dismissing those without “proof” of both effectiveness and safety. The NHS is litigation conscious and policy is largely directed towards the “just in case” scenario, utilising routine practices in an attempt to show that everything has been done correctly – just in case there is a legal case arising from possible malpractice or other factors. Whilst we may not like the culture in which NHS employees work, that is the prevailing situation and any alternative options must be used or offered with this in mind.

In honour of National Curry Week (5th to 11th October) Denise questions whether curry will bring on labour

Eating curry is one of many so-called “old wives’ tales” about starting labour. To my knowledge, there is no research to prove this but it is thought to work because the hot spices stimulate the gut which may have an indirect effect on the nearby nerves and muscles of the uterus, thus triggering contractions. Diarrhoea and loose stools can be a sign of impending labour but are natural responses to the changes already occurring in the body in readiness for labour. Other popular natural ways of getting yourself into labour include pineapple (the core contains a chemical which can cause contraction of uterine muscle) and dates, which have been shown in a couple of studies to have some effect on contractions. Dates contain fatty acids that help in the production of prostaglandins, as well as other chemicals which may contribute to smooth muscle contraction. Aubergine and tomatoes with parmesan is a popular Italian recipe that is also though to contribute  to labour onset, but its success is more likely to be due to the herbs used in the recipe - basil and oregano should be used with caution during pregnancy as they are known, in large quantities to cause threatened miscarriage. So – in honour of national curry week, perhaps the best curry recipe to trigger labour would be one with aubergine, tomatoes, pineapple and dates in it! However, my advice is to take care with all natural ways of starting labour and just to let your body do its own work – after all that’s what you’re designed for.