Denise and her blog


Denise Tiran FRCM, is an international authority on midwifery complementary therapies.

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Being Professional

Published : 29/11/2020

Today, in what is bound to be a controversial discussion, Denise comments on the numerous worrying posts on social media from aromatherapy and reflexology groups which have caused her to reflect on professionalism in the complementary therapy disciplines.

She says:

I see dozens of posts on social media about complementary therapies and have become increasingly concerned about their professional calibre. Blanket suggestions on using aromatherapy in pregnancy come with no warnings about precautions. Some posts advocate aromatherapy for babies and toddlers, yet it should never be used on or near newborns and rarely, if ever, for toddlers. I've also seen posts on aromatherapy for animals despite the fact that many of the oils can be toxic to household pets.

Even more worryingly, I frequently see pictures of client's feet in reflexology groups posing questions to members on what the possible "diagnosis" might be and asking for suggestions for treatment. No indication is given as to whether client consent has been obtained, and making a diagnosis is impossible without a history and full examination. That's without the fact that reflexologists are taught that they should not "diagnose".

Whilst there are many highly professional complementary therapy practitioners including many who have additional training to treat people with specific clinical conditions, such as cancer, multiple sclerosis and - of course - pregnancy, this sort of posting does the complementary therapy disciplines no favours in terms of credibility, both with the public and with colleagues who are registered healthcare professionalsOf course, you could argue that these ideas are on social - rather than professional -media which has hundreds of inappropriate and dangerous suggestions on all sorts of topics. However when inaccurate and potentially harmful advice is offered by so-called professional practitioners it causes me real.concern. I worry not only about the level of knowledge, understanding and experienc; of the individuals posting, but also, vicariously, about the impact on the wider disciplines of complementary therapies.

Having worked in midwifery complementary therapies for almost 40 years, I have been part of the movement to professionalise complementary and alternative medicine (CAM) that was particularly active in the 1990s when the then Foundation for Integrated Medicine, with the patronage of HRH Prince of Wales, campaigned for increased standards of education and research to facilitate greater integration of complementary therapies with conventional.medicine.

Since then CAM has lost much of its impetus although disciplines such as osteopathy and chiropractic are now firmly included, by law, in the allied health professions and acupuncture and medical herbalism are self-regulated and have high levels of training and professional Codes of Practice to monitor standards. Sadly, however I have to question whether aromatherapy and reflexology have slipped backwards into simply being relaxation therapies with no real professional or clinical credibility.



Expectancy Licensed Consultancy Explained

Published : 20/11/2020

Denise is having a busy week in the office, preparing the prospectus for the new.academic year's courses. She is delighted, but not surprised, already to have received applications for our unique Diploma in Midwifery Complementary Therapies for next September from some very enthusiastic midwives, several of them wanting to combine this with our Licensed Consultancy scheme for private practice. However she questions why so.many.midwives in the last.few.years have been keen to explore the move into having their own businesses offering maternity services such as complementary therapies,. antenatal classes and breast feeding support. Denise says:

Midwives love caring for expectant parents but need also to care for themselves. Midwives are leaving the NHS in droves, newly qualified midwives are choosing not to practise and older midwives are retiring early - and it seems as if this is due, at least in part, to burnout. It may also be due to the insidious erosion of the midwife's role or the risk-averse, litigation-conscious, blame-throwing culture of the NHS.

Conversely, midwives are beginning to realise that the NHS doesn't own them and that they are entitled to use their considerable skills,.knowledge and.expertise to.provide women with what they want - services that are generally not available on the NHS. In the UK there is a grave misconception amongst midwives (and nurses) that they are trained by - and therefore solely for - the NHS but this simply isn't true. Qualification grants midwives a licence to practise midwifery anywhere and in whatever way they choose, subject to national law and professional regulations.

Further, there is a demand from expectant parents for services to be available that provide them with services that ease their progress through pregnancy and birth and transition to becoming a parent. These services are not available in the NHS largely because the maternity services are obstetric-led for the benefit of the majority of users. The maternity services remain focused on the biological (physical) wellbeing of pregnancy and, give less credence to the psychosocial elements.

Pregnancy is a stressful time, more so now than ever before. To be able to call upon a professional who can provide relaxation treatments such as massage or reflexology, antenatal advice and support or specialist services to ease backache, nausea or avoid induction of labour is very appealing to many during pregnancy, and expectant parents are often prepared to pay for them.

Our team of Expectancy-trained midwives working in private practice is growing and more and more women are discovering the benefits of having the support they can offer. This current academic year we had more midwives than ever before choosing to join us to train as Licensed Consultants so that they too can provide a range of complementary therapy services for expectant and new parents. Why don't you come and join us?



Chips With Everything

Published : 15/11/2020

Denise was delighted to receive a ‘phone call this week from an old friend, Fiona. Denise, who developed and managed the BSc (Hons) degree in complementary therapies at the University of Greenwich, and Fiona, who was a health visitor, were lecturers in complementary therapies in the 1990s and early 2000s and were both instrumental in promoting the practice of complementary therapies within their respective professions. As is the way when you have not heard from someone for a while, they fell to reminiscing about the “good old days”. Denise left the University of Greenwich in December 2004 to set up Expectancy and Fiona reminded her of those early forays into freelance work.

Denise had arranged her very first private aromatherapy course for midwives and had booked a room in a small local hotel to run the course for eight weeks on a Tuesday evening from 5-8 pm. Nearing the day, she was worried that only four midwives had booked on the course and she asked Fiona if she should cancel it – to which Fiona replied “absolutely not!”. In order to boost numbers to a viable group, Denise then offered the course at a knock-down price to some of her midwifery friends, asking them to act as a pilot, so in the end there were eight midwives who attended. 

The course was not without a few issues. The hotel room overlooked the car park and the windows did not have curtains wide enough to close – so when the midwives were due to do the practical work, including back massage for labour, they had to tape all their coats over the windows to stop hotel residents coming in from the car park from looking into the room. Another problem was that all the midwives had rushed to the hotel ready to start the course at the end of an already tiring day of clinical work. Denise had originally requested teas and coffees to be available – but the midwives were so hungry and tired on that first day that she ordered chips to be brought in with the drinks. This became the routine every week and it was great fun studying aromatherapy whilst munching on hot chips with salt and vinegar – but Denise does admit that it meant she made no profit at all from that first course! Thankfully, things have improved and although she no longer provides chips with the courses, midwives still keep coming and Denise has now taught complementary therapies such as aromatherapy to over 3000 midwives since starting her business in 2004. Fiona was obviously right then!



Are Complementary Therapies Safe In Pregnancy 

Published : 08/11/2020

The use of complementary therapies (CTs) by expectant parents is at an all-time high – but are they actually safe? Today, Dr Denise Tiran considers the minefield around the advice available to those expecting a baby who wish to use therapies such as aromatherapy, acupuncture, reflexology and herbal medicine. She says: 

The advice pages on www.NHS.org.uk take a cautious approach to CTs, stating that there is generally insufficient research evidence to support their use during pregnancy, yet making blanket statements for the apparent safety of massage, aromatherapy and (incorrectly) ginger for pregnancy sickness. The National Institute for Health and Care Excellence (NICE) goes further by actively discouraging women from using modalities that, they suggest, are inadequately researched. Similarly, Cochrane systematic reviews, whilst being somewhat more sympathetic, also consider the inadequacy of research on the safety of CTs for pregnancy and birth. Unfortunately, these national guidelines fail to acknowledge the huge number of expectant parents seeking support from professional therapists or – more worryingly – self-administering natural remedies. CTs such as massage, aromatherapy, and reflexology are commonly used for relaxation; acupuncture and hypnotherapy are accessed for the treatment of specific physical and emotional symptoms. Natural remedies (NRs), including aromatherapy oils, herbal medicines and homeopathic remedies, are increasingly being used at home to prepare for and encourage the onset of labour. 

The issue of research evidence is almost irrelevant if CTs and NRs continue to be used by expectant parents (and by those attempting to conceive). Certainly, the amount of evidence available is limited and largely explores the effectiveness of different CTs – it is impossible to conduct formal research into the safety of different types of CTs. So how should maternity professionals advise expectant parents about CTs and NRs? It is a difficult balancing act for midwives, doctors, doulas and others providing care for the pregnant population. Simply advising against CTs and NRs risks people using them surreptitiously without informing their maternity care providers. Avoiding the subject altogether similarly risks people taking remedies or receiving CTs which may be inappropriate at that time and potentially harmful. Lack of knowledge amongst health professionals risks them giving inaccurate or – more often - incomplete information which may equally compromise maternal, fetal or pregnancy wellbeing. Conversely, advocating the benefits of CTs and NRs without adequate and specific knowledge, may lead to side effects and complication from inappropriate use.

Suggested guidelines for maternity professionals and complementary therapy practitioners working with expectant parents:

  • Enquire about clients’ use of CTS and NRs prior to and during pregnancy – at booking and at various stages throughout pregnancy
  • Advise caution with ALL CTs and NRs unless prescribed or administered by a fully qualified practitioner
  • Advise extreme caution with herbal remedies including herbal teas, which may have adverse effects such as blood thinning or toxicity
  • Maternity professionals should be adequately trained and insured to administer / advise on CTs and NRs
  • CTs practitioners should be trained and insured to treat pregnant clients
  • Communication between maternity professionals and complementary practitioners should be encouraged
  • If in doubt, do not use – especially if there are any individual medical or obstetric complications
  • Less is more – never exceed the dose, duration or frequency of administration of any CTs / NRs
  • Remember – “natural” does not always mean “safe”



Fantastic news!!!!

Published : 27/10/2020

We are delighted to announce that our very own Denise Tiran, CEO and Education Director for Expectancy, has been awarded an honorary doctorate by the University of Greenwich for her pioneering work in developing “complementary therapies” as a specialist area of practice, education, research and publication in midwifery. Her award was conferred at a graduation ceremony held mostly online on 27th October, but Denise was able to visit the University and receive her award in person from the Vice Chancellor (socially distanced, of course).

Denise, who also received a Fellowship from the Royal College of Midwives in 2018, says;

I am so proud to receive this honour from the University of Greenwich where I spent many happy years as a midwifery lecturer and had the opportunity to develop the UK’s first practice-based BSc (honours) degree in complementary therapies. I feel the award acknowledges the area of complementary therapies as a specific discipline and aids the credibility of a subject that still has many sceptics. This award is not only for me; it is for all those midwives who are interested in complementary therapies, all those I have taught, both in the University and, since 2004, via my own company, Expectancy, around the world. Most of all, it is for my son, Adam, who makes it all worthwhile – looking forward to celebrating with friends and family when circumstances allow us to be together again.



Changing Childbirth

Published : 26/10/2020

Denise reflects on changing childbirth since she first became a midwife over 40 years ago.

When I was first a midwife, women became pregnant spontaneously, if they were lucky - there was no fertility treatment available for those who could not conceive. The maternity benefits system allowed those who worked to start maternity leave at around 32 week's gestation without financial penalties so they could test and prepare for the birth and parenthood.

Pregnancy was accepted as a set of physiological symptoms and women coped with the sickness, backache and swollen ankles. Labour started when it started and lasted as long as it took.....
There were no scans in pregnancy and no monitors in labour - midwives and doctors used their five senses to monitor progress and wellbeing of mother and baby. There were no epidurals for pain relief - but midwives had time to be "with woman" and provide physical and emotional support.
Caesareans were rarely carried out and only for life threatening emergencies. Mostly women stayed at home to care for their babies and the local community provided support for new families.

Today, couples often leave it late to start a family whilst they develop their careers. When they decide it's time, they expect to get pregnant immediately but are often too stressed out by daily living for the body to do its work.
Once pregnant, women expect to sail through the next nine months and become frustrated when their bodies let them down and they experience the natural aches and pains of pregnancy. They expect (or need) to work almost up to the estimated due date, stop work, go into labour spontaneously and give birth in precisely the way they have planned, whether it is completely naturally or with all the technological interventions available - and feel disappointed and let down when labour doesn't go along with their plans. Parents assume their babies will feed regularly and sleep contentedly between feeds so they can continue with their normal (pre-baby) lives, including returning to work within a few weeks.

Many people planing pregnancy are not well-enough nourished today, despite the plethora of foods available. Environmental pollution adds to the imbalance of healthy chemicals in the body, affecting fertility, as does the negative energy from technology - mobile phones, computers and more. Posture is adversely affected from too much sitting in cars or at work and not enough walking. the incidence of breech pregnancy is higher because the ergonomics of our bodies has changed and women are not on their hands and knees scrubbing the kitchen floor as they did in the 1970s - the ultimate optimal fetal positioning.

Added to this is all the social stress - the negativity in the world, politics, pandemics and a social expectation that you must have a perfect pregnancy (what ever that is) and be seen to be a perfect parent. No wonder pregnancy, birth and parenthood is so stressful.

It concerns me when I see posts from pregnant women on social media trying to find answers to questions that cannot always be answered. Maternity professionals need to encourage expectant parents to chill and take it as it comes a little more. Of course there are some with very real physical, mental or social problems but for those whose pregnancies are progressing well, enjoy it and don't let it get you down. Go with the flow and don't expect too much. Consider all those aches and pains as good signs that your body is doing its work well. And look forward to the birth as "the end of the beginning".



Absolute Aromas

Published : 24/10/2020

A few words from Denise about Expectancy’s essential oils supplier, Absolute Aromas

I have known David Tomlinson, owner and managing director of Absolute Aromas for over 25 years, having met him at one of the annual complementary medicine shows that used to be held every year in Earls’ Court. He and his wife, Kay, are lovely and very knowledgeable about essential oils. Their company has grown considerably since I first met them and they are now based in Alton in Hampshire.

The essential oils are of very high quality and I have used them ever since I met David. We use them on the Expectancy courses (although I always make the point I am not on commission!).
Midwives who have completed our courses can also purchase the specially compiled Expectancy kits for maternity aromatherapy – there is a full set of the 16 essential oils we teach on the courses, together with some carrier oil, a mixing glass and stirrer in a wipe-clean carry case, with space for more oils.
More recently, as a result of changes to our courses due to Covid, we have been teaching our aromatherapy courses online and each midwife who attends receives a mini kit with twelve of the 16 oils we teach, in a lovely wooden presentation box.



World Mental Health Day

Published : 10/10/2020

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

Published : 08/10/2020

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

Published : 06/10/2020

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.



Celebrating World Reflexology Week

Published : 24/09/2020

Did you know there are many different styles of reflexology? The word “reflexology” refers to the use of one small part of the body as a “map” of the whole. Normally reflexology is performed on the feet, with every part of the body being reflected on one of both feet, but the therapy can also be done via the hands, ears, tongue, face or even the back.

The style that Denise and her team teach for midwives and doulas is the German style of clinical reflex zone therapy (RZT) devised by the German midwife, Hanne Marquardt.

RZT fits very well with midwifery because it can be used both as a relaxation treatment but also for more specific conditions such as pregnancy sickness, backache, sciatica, carpal tunnel syndrome and to stimulate the onset of labour. It is good for pain relief in labour and can help with retained placenta. Postnatally, RZT can aid recovery from birth, stimulate lactation and boost the immune system.

Other types of reflexology range from the very gentle light touch reflexology, combining traditional reflexology with healing energy techniques, to vertical reflexology, which starts by applying pressure to the weight-bearing tops of the feet or hands, followed by a conventional treatment. Eastern styles include Chinese Five Element reflexology and Taiwanese Rwo Schur, which uses an extremely intense pressure. Most generic reflexologists use the Ingham method, which incorporates more massage-type techniques rather than just pressure point treatments



Denise’s First Course after Lockdown

Published : 21/09/2020

At long last, after lockdown, today was Denise’s first day back to face to face teaching the Expectancy Aromatherapy and Acupressure for Post Dates Pregnancy 2 day course.
She’s been teaching the midwives from Homerton hospital. It was only the second time in six months she’d been in to London but they all had a lovely day despite having to wear face masks!



Aromatherapy in Indonesia

Published : 29/08/2020

Denise gave another lecture on aromatherapy in midwifery to a group of Indonesian midwives this week. After a slight panic due to having a power cut after a storm, she was able to join the session with just a few minutes to spare. She says:

It was lovely to meet more of the midwives from Indonesia this morning and to greet some colleagues who have attended previous sessions. We had some insightful discussion and we shared experiences of women’s use of aromatherapy in both Indonesia and the UK. As there are so many different herbs and spices that grow in Indonesia, local people use them both in cooking and for medicinal purposes, so pregnant women are familiar with using oils during childbirth. Popular oils include ylang ylang and frangipani, both very fragrant oils suitable for pain relief and relaxation. However, it was interesting to hear that clove oil is very popular in Indonesia although it is generally considered unsafe for pregnancy and caution is needed if it’s used in labour, to avoid over-stimulating the contractions. 

I was also asked by one of the midwifery lecturers attending the session if I thought that aromatherapy should be included in pre-registration midwifery training. As many regular readers of my blogs know, I have been campaigning for many years for the subject of “complementary therapies” to be included in UK midwifery training so that, on qualifying, midwives have a basic understanding of the benefits and risks of natural remedies and therapies in pregnancy, birth and breastfeeding. Students need to develop an awareness of what women are using in terms of natural remedies so that they can provide advice on using them safely. However, development of more in-depth knowledge and the specific skills in order to use the therapy in their midwifery practice should be provided as a post-registration qualification. The pre-registration curriculum is already overloaded with essential content and, although I personally feel this is essential to safe practice, the nature of midwifery today precludes its inclusion during basic training.



Do we focus on the positive aspects of complementary therapies and the negative aspects of standard medical treatment? The problem of informed consent.

Published : 24/08/2020

Midwives, doulas and antenatal teachers are passionate about advocacy and promoting normal birth. They empower women to progress through their pregnancies and  labours, as far as possible without intervention. Complementary therapies are a great way of working towards achieving physiological birth, but we must not forget that they are as much of an intervention as medical treatments and other aspects of care.

Informed consent is essential – providing women with sufficient information about both the benefits AND the risks of any care that is offered so that women can make informed decisions about whether or not to accept it. This applies equally to complementary therapies as to Caesarean section. In her recent assignment, one of my students asked: “do midwives focus on the positive aspects of complementary therapies and the negatives of standard medical treatment?”. 

She may have a point. Midwives and doulas who use complementary therapies can be so enthusiastic that it is easy to forget that these therapies are very powerful – and that means powerful in a positive way but also powerful in a negative way when used inappropriately. ALL complementary therapies have risks as well as benefits. When birth workers  introduce the idea of using aromatherapy for pain relief in labour, reflexology for backache in pregnancy, hypnotherapy for smoking cessation  or acupuncture / acupressure for post-dates pregnancy, it is essential that we discuss the whole picture with the women in our care. The positive relaxation effects almost go without saying, despite the relatively poor evidence-base. But how often do we explain to women the potential for adverse reactions from the oils, the reflexology treatment, hypnotic suggestions or acupressure techniques?

Take post-dates pregnancy, for example. We know that many women turn to complementary therapies to try to avoid medical induction of labour with all its potential for a cascade of intervention. However, onset of labour is a physiological end-point to pregnancy and therefore ANY intervention is an intervention. Inappropriate use of aromatherapy oils, acupressure stimulation, reflexology treatments or other therapies can trigger that cascade of intervention. Even when the therapies are used appropriately, the dynamic nature of birth physiology means that there may come a time when the therapy is no longer appropriate. There is potential for interactions between pharmacological herbal or aromatherapy products with any medication given to the mother to expedite labour – such as clary sage and oxytocin – or for one to be inactivated by the other – for example, certain drugs will inactive homeopathic remedies the mother may be taking.

When midwives and doulas discuss with their clients the best way forward in a pregnancy that continues beyond the estimated date of delivery, they may offer several options – wait and see, have a medical induction or use other methods of encouraging labour onset. All of these have benefits and risks – but how often do birth workers paint the full picture for women wanting to try the “natural” option? It is one thing to act as the mother’s advocate to try and help her avoid medical induction, but we also need to be her advocate to help her make informed decisions about other options. However natural they may be, complementary therapies are NOT a natural way of starting labour – and we need to be sure that women understand the advantages and possible risks of using them at this time. Informed consent is key to all aspects of care and no more so than with complementary therapies.



The value of complementary therapies

Published : 23/08/2020

Denise has spent most of the week marking student assignments. As one of their assignments, midwives on our Diploma in Midwifery Complementary Therapies complete a reflective diary which usually raise some very interesting challenges. Midwives report significantly increased use of complementary therapies by women, sometimes by women who do not fully understand both the benefits and the risks of using complementary therapies in pregnancy and birth. This set of assignments has been no exception and here, Denise reflects on some of the points raised by the midwives. 

Many midwives remain sceptical about the value of complementary therapies, questioning why they should take on additional “tasks” when midwives are already busy with not enough time to do what they need to do.

I think this is about perception of why it is useful to include complementary therapies as new tools in our work. Whilst there is an argument about the time required to provide therapies such as massage or aromatherapy, this can be time well spent in chatting to the mother, answering her questions and easing her stress levels. We know that these therapies can reduce cortisol and other stress hormones and that has a knock-on effect on oxytocin and other birth hormones. Research has shown that having regular treatment with therapies such as reflexology or massage can facilitate physiological birth and women are less likely to require induction of labour for post-dates pregnancy and are more likely to labour well and achieve a normal birth.

Additionally, perhaps we should look at what the use of complementary therapies can bring to the maternity services. Of course, we want individual women to be relaxed and enable their bodies to work naturally, but there IS an impact on the maternity services too. This is not about introducing complementary therapies simply for relaxation but about reducing rates of induction, epidural, Caesarean section and other interventions that not only cost money but also increase the potential for litigation when things go wrong. Helping women to feel empowered by their pregnancy and birth experiences increases maternal satisfaction and reduces the risk of complaints. This is partly also due to the relationships that midwives using therapies can develop with the women – even a ten-minute hand massage can make a woman feel nurtured rather than ignored in the rush of mandatory paperwork.

Midwives wanting to implement therapies such as aromatherapy and acupuncture need to be able to demonstrate in their business plan to management that there is a benefit to the service, rather than niceties for individuals. That sounds cynical but the maternity services are geared up to getting as many pregnant women through “the system” as possible with the shortest of resources, both material and human. Demonstrating that using hypnotherapy or aromatherapy for pain relief in labour can reduce epidural use is an attractive proposition to budget holders. Setting up a service for women whose pregnancies are post-dates can show that aromatherapy and acupressure reduces medical induction rates and the cascade of intervention that often follows. Introducing moxibustion for women with breech presentation empowers them to facilitate cephalic version and reduces the Caesarean rate. Given that the difference in cost between a physiologically normal birth and a Caesarean is in the region of £1800 that is a significant cost saving. 

So rather than dismissing complementary therapies as a luxury the NHS can ill afford, perhaps we should turn it on its head and explore the cost savings that can be made by introducing selected aspects of therapies to solve some of the problems of the current NHS maternity services. 



Working for the NHS as a midwife and private practice explained

Published : 15/08/2020

Today I want to discuss the interface between working as a midwife in the NHS and also offering private services such as antenatal classes and complementary therapies. I recently saw a post on social media from a newly qualified midwife intending to work part-time in the NHS and part-time offering private services such as antenatal and postnatal support, “hypnobirthing” classes and acupuncture, aromatherapy, baby massage. Increasing numbers of midwives want to offer maternity-related services outside their NHS work but there are several issues to consider.

First and foremost is the issue of safety of mothers and babies. This midwife would be wise to consolidate her midwifery practice before setting up in private practice and before adding in other therapeutic modalities. It is easy to become so enthusiastic about offering services that women want that normal midwifery responsibilities get forgotten. Her first priority is to her clients’ safety and her second is to the midwifery profession. Even if the midwife is fully qualified in the therapy, she needs to be able to apply the theory and practice of that therapy to its use during pregnancy, birth and the postnatal period when the mother’s and baby’s physiology is adapting dynamically.

We must question what training the midwife has had in “acupuncture, aromatherapy and baby massage” since she admits to not being “dual qualified”. One or two days’ introduction to a therapy during midwifery training is certainly not enough to start offering that therapy privately and she is potentially jeopardising not only mothers and babies but also her midwifery registration. The complementary therapy professions are increasingly concerned that healthcare professionals are “cherry picking” one or two aspects of a therapy and adding it to their own practice. We would not expect a complementary therapist to attend a few days of midwifery training and then start offering midwifery-specific services alongside their standard practice and they should not expect us to do the same. Of course, she may be fully qualified in the therapies she wishes to offer, but I would question how much experience she has of using those therapies for pregnant and childbearing clients, since this is a post-qualifying area of professional development for most therapists.

Conversely, if the midwife has undertaken a short midwifery-specific training in a therapy, does that training provide access to indemnity insurance? There is so much more to the use of complementary therapies in maternity care than simply attending an introductory course which is what is sometimes offered in midwifery pre-registration training. In addition, many complementary therapy courses delivered for midwives on NHS premises are suitable only for NHS work, subject to managerial permission and the development of local clinical guidelines, and certainly do not prepare midwives to use them in private practice.

It may also depend on how this midwife wishes to advertise her services. The Nursing and Midwifery Council prohibits the use of the midwifery qualification to imply that being a midwife makes you somehow a “better” therapist. However, if she is advertising midwifery-related antenatal and postnatal support then she is working as an independent midwife, albeit without offering birth services. Any care given to the mother or baby must comply with normal standards and the midwife must be able to differentiate between midwifery-specific elements of her treatment and those which are not. For example, palpating the abdomen and listening in to the fetal heart constitutes midwifery care. Similarly, extra caution must be employed to distinguish between care that might be provided in a maternity unit or birth centre and that which can be provided in private practice in the community. An example here might be providing treatments for post-dates pregnancy: in the NHS many midwives include a membrane sweep, whereas this may not be appropriate when working privately. It is also vital that the midwife fully appreciates the boundaries between working in the NHS and in private practice. There is huge potential for conflicts of interest which could land her in hot water – advertising, using NHS time (even to answer a phone call from a potential private client), referral of women with complications and much more.

Next, there is the issue of insurance for both this midwife’s NHS midwifery and for her private practice. It must be noted that the Royal College of Midwives provides medical malpracticeinsurance, not personal professional indemnity insurance, and does not cover members for private practice (except “occasionally” – ie not as part of a formal business). The Royal College of Nursing provides indemnity insurance to full members which covers midwifery practice and some maternity-specific services such as complementary therapies. However, if a midwife chooses to work in private practice, s/he must maintain adequate cover for the midwifery cases that have gone before – if you relinquish your RCM insurance at the point of “going private” then you relinquish your right to legal and professional cover in the event that one of your previous cases comes to court.

Finally, although this midwife does not state whether or not she has any business experience, this is an essential part of setting up in private practice. Enthusiasm to offer services that are not generally part of NHS maternity services should not overwhelm the professional and academic need to understand business issues. I have come across many midwives keen to set up private services who make mistakes – not just financial, but often professional or legal mistakes. Examples include not complying with health and safety requirements, advertising standards, accounting and HMRC regulations and, of course, NMC regulations.



Coffee and Pregnant Ladies

Published : 13/08/2020

Coffee is said to have several benefits including increased mental alertness, aiding fat metabolism and possibly protecting against diseases such as diabetes, Alzheimer's and certain cancers. It is a good source of antioxidants and other nutrients and is even thought to prolong life. Drinking coffee may contribute to smoother skin and reducing depressive thoughts.

On the other hand, pregnant women have long been advised to reduce their coffee intake because of the adverse effects on the developing baby and increased risk of miscarriage. In fact, coffee in itself is not a bad thing - it is the caffeine that is the problem. The NHS advises women to limit caffeine intake - to no more than 1-2 cups of caffeinated coffee a day. Filter coffee contains more caffeine than instant; even decaffeinated coffee still has a small amount of caffeine in it.

However, what is not emphasised is where else caffeine is found - black and particularly green tea, cola, energy and other soft drinks - and chocolate. One bar of chocolate contains almost half of the advised daily amount of caffeine. Hot chocolate drinks and even coffee or chocolate flavoured ice cream can contain a significant amount of caffeine.

Painkillers, cold and flu remedies also often contain caffeine (although pregnant women should use these only on the advice of their midwives or doctors).

Pregnant women are bombarded by advice about what they should and should not do to keep themselves and their babies safe. Reduce coffee, minimal alcohol, quit smoking - and more. It can be equally, if not more, stressful for a woman to worry about what she has or has not done - particularly when much of this advice is given with an implication of maternal blame if the baby is not healthy at birth. Surely, our advice to women should be the golden rule that applies to everyone - moderation in all things. Or, as my grandmother used to say - " a little of what you fancy does you good - and a lot does not".



Preparing for the new academic year

Published : 06/08/2020

Denise has been extremely busy recently winding up the end of the academic year for our current students and getting ready for a new group of midwives starting their courses in September.

She says: Coronavirus has meant that most of our current students have been unable to finish their study programmes as we've had to postpone so many of the modules until the new year. They've been finishing their assignments due in August so I've been chatting to many of them on zoom, offering tutorial support.

I've also been interviewing midwives wanting to join us in September , both for the Diploma and Certificate in Midwifery Complementary Therapies and our acupuncture course. We've got a couple of new programmes as well, enabling midwives to focus on one particular therapy, either aromatherapy or reflex zone therapy (clinical reflexology).

Due to our study days needing to be delivered online until December, I'm also busy wrapping up parcels to send to all the new students including programme handbooks, sets of oils and - for those starting the Licensed Consultancy to prepare for private practice - their starter packs of goodies to help them on their way.

My dining room looks as if a bomb has hit it, with parcels all over the place. I took one lot to the local post office the other day at a time when I thought it would be quiet, but was most embarrassed to find a long queue waiting by the time I had finished.



Previous articles

Being Professional

Expectancy Licensed Consultancy Explained

Chips With Everything

Are Complementary Therapies Safe In Pregnancy 

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Changing Childbirth

Absolute Aromas

World Mental Health Day

Complementary Therapies Explained

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