The aim and ambit of this study pertains to the use of aromatherapy during labour and childbirth. Basing its opinions upon the current findings of academics and policy makers alike the paper then goes on to suggest that awareness should be created with in pregnant mothers pertaining to the use of aromatherapy during childbirth. This change can be brought about with in the newly set up built birth centres in the local maternity units as the adoption of this progress is still a developing phenomena atleast at a national level. It is perceived that this change could actually reduce the need for pharmacological intervention during childbirth due to its proven positive effects on the occurrence of nausea, stress fear and pain during child birth (DoH, 1993,Tiran, 2000).
In the literature critique findings from the literature review are utilised to show that aromatherapy can be potentially beneficial to expectant mothers particularly in relation to the reduction or anxiety and stress commonly experienced during labour. It has been acknowledged however in this paper on the basis of available literature that there is limited evidence as to the safety issues surrounding such the safety aspects of using essential oils to ease the negative symptoms on pregnant commonly associated with childbirth. On the basis of the lack of any documented evidence confirming any significant harm that can occur to pregnant women on the basis of this practice the author has been able to conclude that it is a relatively safe practice and can actually be beneficial to the pregnant mothers health and emotional well being.
In terms of the implementation of a change involving aromatherapy for pregnant mothers the author finds that there are many reasons this change has not yet been carried over in practice. One major reason is the lack of awareness in mothers and midwives alike although a lack of effective government initiatives have also been cited as a reason for the same. Any steps to realise this implementation of change would certainly include an abundant investment in the provision of education, training and support for midwives. Such an investment could bring about a potentially successful introduction and implementation of the use of aromatherapy during childbirth. The author has adopted some of the components of the Lewin (1951) model particularly the freezing/unfreezing analysis and the force-field theory. This is followed by a brief appraisal of the change process through an audit analysis later in the paper.
The author takes this study as an opportunity to review the possible introduction of the application of aromatherapy as a complementary process during labour and childbirth with in (a hypothetical) newly built centre in a local maternity unit. The author believes that the introduction of the same would be conducive to the avoidance of undue Caesareans and would encourage natural birth. Also the success of the same could bring immense emotional and physical benefits for the pregnant mothers thereby reducing the need for medical intervention as well as promoting a better role of midwifery (Russel, Scrutton and Porter, 1997).
The author is well aware of and has reviewed the available literature on the same and believes that a practical change involving financial investment and current midwifery practices will have to be made on the use of aromatherapy and natural therapies in general during pregnancy and labour as a means to an end of achieving successful implementation of the same. Most of these new changes have been manifested via the NMC (2002) and (2002) and (2004) in the midwifery practices (other regulations include the UKCC 1992 and 1994).
To further this aim the author has used this project as an exercise to critically examine whether aromatherapy can infact facilitate the “maternal coping mechanism” of the mother during childbirth to an extent of reducing emotional and psychological trauma during this time. A review of existing literature has not revealed any negative effects of the use of aromatherapy and while this supports a case for implementing change the author proposes to adopt a certain structure for change based on Lewin’s theoretical framework (Lewin, 1951). Based on this model such a change has to be followed by an audit, which is basically an evaluation of the ways and means of bringing about such complementary therapy into healthcare (Mousely, 2005). The author proposes with in the study a methodology that involves the auditing of aromatherapy use records as well as an analysis of the administration of questionnaires to midwives as well as patients to assess their satisfaction or the lack thereof from such a practice.
In the preparation of this paper the author has utilised many paper and electronic sources including the Science Direct Database, MIDIRS Midwifery Database, CINHAL British journal of midwifery, practising midwife and Ovid online Database. The literature reviewed comprises of various studies, which have at their basis randomised controlled trial, and observational studies. The key search words utilised used were ‘’Aromatherapy in childbirth’’, ‘’Lavender childbirth’’, Essential oils, ‘’Complementary therapies ‘’ ‘’Alternative therapies and childbirth’’ and CAM.
Alternative and non-pharmacological therapies for paturients have often included relaxation techniques as well hydro and aromatherapy, which come with in the ambit of “self-help” measures (Dale and Cornwell, 1994). However aromatherapy is now being considered as a part and parcel of alternative therapy options within maternity units as well as an important subject of childbirth preparatory training for the mothers themselves (DoH, 1997) .The aim is to alleviate or reduce labour pain and other symptoms commonly associated with labour thereby causing harmful effects for the mother or infant (Yerby, 2000).
Aromatherapy is the use of “essential oils” to treat emotional and physical symptoms of stress and anxiety as well as other negative health symptoms (Yerby, 2000). This is an external therapy and is conducted by either massaging the oils onto the skin or by inhalation. Ordinarily the same is used side by side with message therapy, acupuncture, reflexology, herbology, chiropractic, and other holistic treatments (Dale and Cornwell, 1994). The essential oils are derived from herbal extracts and are often incorporated as part of a rather holistic approach to healing based on the potentially therapeutic power of the herbal essential oils.Such oils which are commonly used include lavender, orange, clary sage, rose and chamomile (Leach, 2006). Studies show that this practice has gained popularity in the past many decades and is now a part of midwifery practices in many parts of the world. (Burns et al, 1999). It is one of the most popular complementary therapies used during childbirth as revealed in one 1997 NHS survey (NHS Confederation, 1997) due to its ease and compatibility with the overall childbirth care process. It has been reported to facilitate feelings of enhancing the comfort of the pregnant mother and easing her transition into the experience of giving birth (Leach, 2006). Many studies have also reported that such therapy can ease bladder functions and the bodily trauma commonly experienced during natural childbirth.
According to Tiran and Price (2007) the application of essential oils for the pregnant mother can be carried out in a number of ways including massaging droplets on forehead or palm, inhalation and perineal lavage during childbirth. To date the most popular modes of application for aromatherapy during childbirth include the addition of a few drops of the chosen essential oil to a hydrotherapy bath or by a massage using a carrier or lotion (like sweet almond oil) or inhalation by the use of electric vaporizers (Leach, 2006). According to reports the positive effects of this therapy have been noted to include relaxed muscle tones, and a more positive stimulation of the circulatory and excretory processes (Tiran, 1996). It has also been reported academically that such an experience can also build a better relationship between the midwife and the patient thus aiding a foundation of trust and care between the two which is an essential pillar of effective healthcare (Tiran, 2000).
There is medical evidence to show that aromatherapy massage relieves pain by increasing the production of endorphins in the body (Tissrand, 1992) which actually allow the modification of the nerve cells thereby reducing the transmission of signals and thus lowering the patients susceptibility to pain (Smith et al, 1991). A similar view has been taken by Trout (2004) and Tiran (2003) who have suggested that aromatherapy massages can actually decrease the likelihood of childbirth pain due to being conducive to endorphin related stimulation, stimulating mechanoreceptors, stimulating circulation with resultant increased oxygenation to tissues and facilitating the excretion of toxins through the lymphatic system.
The author has not however in the assessment of the risks or possible risks associated with aromatherapy, ignored the part of literature, which throws caution against an overconfident use of aromatherapy as complementary medicine (Tiran, 1996). It should also be noted that despite the substantial amount of medical evidence supporting the benefits of aromatherapy, there is little available evidence on the actual use of aromatherapy. One reason for this may be the fact that this is a relatively new area of research (Einion, 2000). Another and a much simpler reason maybe that the time and cost of the implementation of such a method simply outweighs the perceived benefits of the same (Groot and Weyland, 1993). Finally in the past, in the light of many warnings by health practitioners and the likely sensitivity of the human foetus to smells , many researchers have discarded the same as impractical and thereby such an analysis could have impeded any further research in this area(DoH,1993).This is however an emerging area now in the wake of the emergence of the popularity of CAM as a popular means of therapy (Tiran,2006).
It has been suggested widely that aromatherapy can be widely used in conjunction with other various cognitive pain management strategies which are often aimed at educating the parturient (a woman about to go into labour) as to what they might encounter during the childbirth period (Marsden, 1991). This can provide an excellent way of linking the mental, sensory and physical responses to counter the parturient’s potentially painful ordeal of giving natural birth (Tisserand, 1993).
There are different views however as to when the therapy should actually begin for the parturient and much of the pain management literature suggests that to be at its most effective it should not be utilized during the course of the actual childbirth but from several weeks leading up to the actual labour (Marsden, 1991). As a sensory interventions touch or massage including the use of aromatic oils has the potential of promoting a comforting response to the parturient’s bodily and to reduce symptoms of clinical depression including shorter labour ordeals and lesser tendency to stay in the hospital afterbirth or develop post natal depression (Tisserand, 1993).
The reason there is a need to focus on the non pharmacologic measures to address the pain levels of the parturient is not only their low cost but also because pharmacologic measures have sometimes led to adverse effects later on for the mother and child. If aromatherapy is to be brought upon the agenda of childbirth educators there is an immediate need to realize that the mother has a right to choose and receive an intervention that will allow her to address and cope with her physical pain and that she must not be forced to choose a particular method of the same (Tiran, 2006). Therefore while proposing aromatherapy as a means of intervention during childbirth many health policymakers have thrown in a caution that parturient’s be given a choice based on their personal medical histories in a maternity unit offering aromatherapy as to whether they really want to opt for the same to alleviate their childbirth pain (Mc George and Steele, 1991). At the same time it also has to be realized that since aromatherapy is a kind of non-drug intervention and it can complement but not wholly substitute proper medical care, which might possibly involve some mandatory pharmacologic interventions (Pages et al, 1990). Also while the “relaxing” aspect of aromatherapy is well document its effectiveness in actually reducing pain has been sharply questioned in many well-controlled medical trials (Magnum et al, 1985).
This section compares and critiques two articles from a similar series of studies and compares their relative credibilities.The section then goes on to draw parallels between both studies and whether they have effectively proven their stated aim and objective in comparison to the other popular literature on the area and ambit of Aromatherapy in Childbirth. The author has utilised and sought to answer the ten question framework contained with in the CASP (2002) framework and insights from Coughlan et al, 2007) essentially to raise and discuss the following queries:
- Did the study ask a clearly focused question?
- Was this a randomized controlled trial (RCT) and was it appropriately so?
- Were participants appropriately allocated to intervention and control groups?
- Were participants, staff and study personnel ‘blind’ to participants’ study group?
- Were all of the participants who entered the trial accounted for at its conclusion?
- Were the participants in all groups followed up and data collected in the same way
- Did the study have enough participants to minimize the play of chance?
- How are the results presented and what is the main result?
- How precise are these results?
- Were all-important outcomes considered so the results can be applied?
(Adopted from CASP (2002))
Article Review: Critique
Critique of Burns et al (2000)
The reduction of pain during childbirth has been at the forefront of the focus of gynaecological practitioners and this has led to the discovery and ultimately formulation of a wide range of pain relief measures including pharmacological interventions, which focus on the alleviation of pain for the pregnant mother who goes into labour. The works of Burns et al ranging from 1994-2000 (Burns et all (1994,1999,2000)) have been an effort to investigate the prospect of helping parturients through Aromatherapy during labour. This was a well-written study but came under a lot of academic attack in the later years due to an over all lack of credibility.
Burns et al (2000) was a result of a series of investigations conducted between the time periods of 1996-1999, which culminated into a publishing of the findings of the same in the form of Burns et al (1999), which was basically aimed at mainly being of an evaluative nature with a rather ambitious sample base of 8058 mothers. The tests and studies were conducted in maternity home, which was also a teaching and learning base for midwives. The aim of this study was to investigate the impact of aromatherapy on the parturient’s emotional and physical challenges commonly characterised by fear, anxiety and pain.
Primary respondents to the study were mothers themselves who were asked to rate either negative or positive, the impact of the Aromatherapy administered to them. Burns et al (1999) and Burns et (2000) have stated that there was a consistently positive response to the stable administration of aromatherapy. Other benefits that were stated by the sample base were the ease, cost effectiveness and convenience of the same. The authors (Burns et al, 2000) based their assertion on the ground that not only was there a “positive response” from the mothers who had experience aromatherapy in labour but that only 100 out of a sample base of more than eight thousand mother reported unease or allergies with the administration of essential oil. While the authors seemed very enthusiastic about the possible potential of Aromatherapy with in management of the emotional and physical unease with childbirth, the author the credibility of this study can be and indeed has been challenged by many contemporary critics. The paragraphs below deal with the same in line with the Coughan guidelines (Coughan et al, 2007).
Since the aim of this critique of the article is to explore the response and credibility with in the medical Academia to a recent study in aromatherapy, which has, over the past two decades emerged as a non-pharmacologic intervention for women during or about to go into labour. For many academics however as noted further below the effectiveness of the same is doubtful and merely “anecdotal” coming from inexperienced, self-styled Aromatherapists who are not medical practitioners. Such accusations do hold a basis atleast in terms of the Coughan Criteria (Coughan et al, 2007) because the very design of questioning and investigating for the studies seems more often than not, fundamentally defective. In an anxiety to identify the “goodness” of aromatherapy, the authors have evaded the need to identify the scientific premises supporting the contention. Indeed this has been the primary criticism of all studies by Burns et al (1999 and 2000) as well as Burns and Blamey (1994) coming from Cooke and Ernst, 2000). Even though other academics (Tiran, 2000) have suggested more positive results and effects of Aromatherapy and have been less pessimistic as to the results of the same (see also the views of Trout, 2006).
The main strength of Burns et al (2000) is its literature review as it draws from a wide variety of academic and practitioner texts. Such a utilisation of a commendable range of literature does according to the Coughan criteria suggest that there is a strong basis for forming the basic opinion that aromatherapy during childbirth should from becoming a purely academic and informal concept go on to be designed and implemented in such a way so as to become a part of evidence-based practice to really bring about good changes for women in childbirth. It is further suggested in the article (Burns et al, 2000), based on the responses by the pregnant mothers that aromatherapy being by nature a sensory therapy and of a non-pharmacologic nature brings with it the benefits of cheap and less intrusive than other therapies with a similar aim .A similar view has been taken by Tiran (2000). It has also been reported that overall with in informal studies of female patients going into labour there is a higher rate of satisfaction and a feeling of empowerment which contributes to a better midwife-patient relationship. Burns et al (2007) in contrast take a more scientific view however while acknowledging that the aim of aromatherapy based interventions remains simple, that is to make the patient “relax” to allow for a reduced catecholamine response which reduces muscular tension especially for women going into natural birth labour and increased uterine blood flow, and decreased muscle tension.
The main pitfall of the study has been its methodology and failure to discuss the negative aspects of the same. In an over whelming bout of goodwill and optimism about aromatherapy, which is not an offence in itself, the authors have overlooked the need to critically evaluate the real effectiveness of Aromatherapy with scientific evidence. In terms of the Coughan guidelines such an omission can seriously jeopardize the credibility of a study. It would be worth mentioning that unlike Burn’s et al (2007) a primary academic criticism of Burn’s et al (2000) has been (as well as that of most attempts at randomised control trials); that most of these so called “success stories” pertaining to Aromatherapy’s effectiveness upon the childbirth experience are based on subjective and qualitative parturient attitudes and perceptions with no medical or scientific standing. Arguably as seen by most academics like Cooke and Ernst (2000) and Tiran (2000) the “relaxing effect” cannot itself be attributed to as substantial benefit in itself because. From a strictly medical and logical perspective Burns and Blaney (1994) and Burns et al (1999, 2000) as an observatory six-year study at Oxford suffer from the deficiency of not having maintained continuity in their timing. Indeed in Burns et al (2000) as an RCT there is a complete lack of record of the exact timing of childbirth stage at which the treatment was administered and this discrepancy causes problems in observing the over all positive (if any) effect of the trial and basically makes way for bias in interpretation. Cooke and Ernst (2000) and many other academics have cast serious doubt as to the credibility of this study, even though it is a large evaluative study as its basic tenets of proof are based on theories and “hearsay” rather than concrete medical evidence. This shortcoming of the Burns et al (2000) study, despite it being taken out in good faith as an exercise to explore the dynamics of introducing an alternative therapy for mothers in labour, has led to serious doubts as to its credibility and ultimately been declared as “biased” for basing observations on attributes which were not clinically proven in both the 1994 to 2000 studies. Furthermore if the findings of the same are reviewed it becomes evident that the number of patients who had not responded to the pain therapy either negatively or positively was not stated at all. To give a realistic account of success instead of just listing the small number of subjects who had suffered side effects from aromatherapy and basing the success of the same upon it, it would have been better to see the amount of parturients who found the treatment as harmless but useless. This would be a factor in deciding the cost effectiveness of introducing any such therapy in a hospital maternity home in the future. Such concerns were later echoed with in the seminal review of aromatherapy as CAM by Cooke and Ernst (2000) where as the authors were careful to base their observations on relevant and reliable clinical trials and evidence. The lack of a subscription to such proper scientific techniques in the Burn’s studies have led authors like Cooke and Ernst (2000) to be extremely suspicious of the common benefits attributed to aromatherapy based on what could be adduced from clinical trials although the results of individual parturient studies were more positive. According to Coughan et al (2007) such omissions can and have in this case, become a cause for rethinking the credibility of this study.
Critique of Burns et al (2007)
This article /study (Burns et al, 2007) is a more recent effort made in the same spirit and purpose Burns et al (2000) was undertaken. With respect to Coughan et al’s guidelines (Coughan et al, 2007) Burns et al (2007) with much credibility goes on to dispel most of the not so optimistic accounts of the virtues of aromatherapy given by Cooke and Ernst (2000). However according to the watermark set up by Coughan et al (2007) the acknowledged strengths of study may not have been exhaustive dealt with by the writer and there is a need to analyse the same with more depth. In the same spirit the paragraphs below deal with these issues.
Over all the review is well written by qualified authors. The abstract is clear and concise to the extent but slightly more technical for the reader or midwife less well versed in technical jargon (Coughan et al, 2007). Since 2000 there have been many other scientific clinical trials which have aimed to discuss the actual effectiveness of aromatherapy based intervention for the parturient the most more recent review being by Burns et al (2007) which was an effort to conduct a pilot RCT (Randomised Control Trail) with the aims thereby of conducting a comparison between parturients who opted for aromatherapy during childbirth and those who did not. In terms of the Coughan criteria the study owes its credibility to specifically including a preference aim and allowing the parturient a freedom of choice in order to enable the testing of preference effect by the use of aromatherapy through essential oils as a means of facilitating the childbirth process with the aim of reducing the potential rate of “intrapartum intervention”, (Burns et al, 2007).
In terms of the ethical considerations which particularly relate to RCT’s they seem to have been accounted for by the author by mentioning the exact amount of people in the random and control group and the information supplied to them so as not to make the results biased or unethical. Another possible contributing factor to the credibility of the same unlike previous works by Burns et al (1994; 2000) is that this time the stated (and perhaps more realistic) aim of the study was clearly to determine the feasibility of conducting RCT on the use of aromatherapy during child birth as an alternative care option with the hopes of exploring its positive maternal and neonatal outcomes without relying too much of the “hearsay” based on traditional “old wives” tales. As mentioned before this was one of the many Oxford university trials undertaken by Burns et al (the other major ones being in 1994 and 2000) the credibility of which has been questioned widely before. However this RCT does not seem to suffer from the previous defects of Burns et al (1999,2000). The academic standards of all three researches seem to be more credible and published with in a much respected and peer reviewed journal in midwifery. This study is better than its predecessor, Burns et al (2000) with a clear and concise abstract and a subscription to clear aims and objectives of the study. These aims have been set out as to being an exercise in determining the feasibility of an RCT on the use of aromatherapy during labour as an alternative care option that could improve maternal outcomes (Burns et al, 2007).
The literature review displays a logical structure and in line with the Coughan criteria primary and empirical sources have been well addressed. The authors have further made an effort to justify the same basing their observations of the increasing popularity complementary alternative medicine (CAM) with in the health sector in United Kingdom and it seems to have become an integral concern for health care professionals. The popularity of CAM has been well documented within WHO studies, which state that CAM is being widely adopted to alleviate physical and emotional health issues in preference to pharmacological interventions due to its non-intrusive and cost effective nature (Tiran (2000). Due to these virtues this becomes an attractive option for midwives making an effort to alleviate the emotional and physical trauma their patients might possibly go through, by means of CAM. While recognising Aromatherapy at childbirth as one of these alternatives to intrusive pharmacological measures, the authors then discuss the possibility of utilising the same to facilitate the parturient in maximising her innate coping mechanisms while facing the trauma of childbirth through extensive massages involving essential oils and counselling. The findings of the literature review are easy to relate with the discussion undertake later on as the background of most the premises of the conclusions are well covered here.
Burns et al (2007) was a study undertaken to basically compare the effect of aromatherapy with standard care outcomes for women in childbirth. This study was undertaken in a local maternity unit in Italy along with a sample base of 251 parturients who were held it a randomised group and around 262 parturients which were in the control group. The subjects of study were administered selected essential oils during childbirth by trained midwives through massage-based application. The aim was to see whether there would be positive and significant impact upon caesareans, premature or natural births as well as “first- and second-stage augmentation, pharmacological pain relief, artificial rupture of membranes, vaginal examinations, episiotomy, labour length, neonatal wellbeing “ (Burns et al, 2007:838) and this was assessed through Agar scores. The study also aimed to see how quickly the Aromatherapy could help the parturient recover from the natural shocks of labour and avoid a further need for neonatal intensive care.
Unlike the Burns et al (2000) study the Burns et al (2007) study is careful to acknowledge the areas where there have been no significant impacts of Aromatherapies and have identified them as “caesarean section, ventouse, Kristeller manoeuvre, spontaneous vaginal delivery, first-stage and second-stage augmentation” (Burns et al, 2007:838). The authors (Burns et al (2007) report that significantly more babies born to paturients who did not receive aromatherapy did need neonatal intensive care compared to those who receive aromatherapy and this also held true for reduced levels of pain.
The credibility of the study comes from the author’s acknowledgment of the factum that despite some positive outcome the research was “underpowered”(Burns et al, 2007:838-9). However as to the outcome and credibility of their own study the authors state clearly that “this study demonstrated that it is possible to undertake an RCT using aromatherapy as an intervention to examine a range of intrapartum outcomes, and it provides useful information for future sample size calculations”, (Burns et al, 2007:844). This study has significant potential for actually allowing any further research to reach a more credible and precise decision as to the ambit of truth about aromatherapy in childbirth. However as seen by the author’s (Burns et al, 2007) own acknowledgement the sample size remains quite small atleast in comparison to Burns et al (2000) and it can be seen that despite being more credible than its former counterparts it lacks weight in terms of large scale evaluation. Any further research in this area, it is recommended, should have a larger sample base to lend weight to the over all weight of the credibility of the study.
Finally coming to an overall comparison of Burns et al (2000) and Burns et al (2007) it is possible to see that looking at these two studies and other contemporary studies one cannot help but appreciate the ongoing efforts of the medical academia of bringing about a change in the health care sector aiming to introduce alternative and cost effective alternative care. While the reduction of pain during childbirth has indeed been at the forefront of the focus of gynaecological academics and practitioners alike and efforts are being made to bring such measures like Aromatherapy into practice consistently for a large part of the past two decades. However there is much criticism from sceptics and public sectors as to the real cost of such treatments from the point of view of budgetary concerns as well as the over all effectiveness of the same. The sections below will now discuss the popular concern amongst those concerned in making aromatherapy as a part and parcel of Maternity units as well as the a subject of childbirth preparatory training for the mothers themselves.
IMPLEMENTATION OF CHANGE
The aim and ambit of this section of the project is to discuss the intricacies involved in actually bringing about such a change with in a maternity centre which would introduce Aromatherapy as a tool in alleviating problems for mothers experiencing the trauma of labour. The undergoing assumption in the following discussion would be that such a maternity centre is relatively new and thus the lack of staff and funds will be duly taken into account. As a prerequisite to this discussion it is worth noting a number of political, economic and ethical problems as well interprofessional rivalries between midwives and doctors which may and infact do bring about barriers any such implementation of Aromatherapy based change. These have been recently discussed by Tiran (2006) who states that midwives are in a better position of using CAM and in particular aromatherapy in their medical practice .CAM is less popular with doctors and obstetricians as they are more concerned with the pathological aspects of the parturient’s condition. Iran (2006:341) has suggested that the “rivalry” between midwives and doctors may be a primary hinderance to bringing about implantation of such practice and goes on to state that “ A degree of inter-professional rivalry exists between midwives and doctors, with many doctors appearing threatened by the shift in power-base, both between midwifery and obstetric care, and between conventional and complementary medicine” (Tiran, 2006:341).
This analysis can be posed by way of incorporation into the Lewin (1951) framework which pertains to the classic change theory as the well as the SWOT analysis as discussed by Porter (1998). According to this analysis it is necessary to recognise the need for bringing about material as well as psychological and behavioral changes. This is because this change deals with humans in that it is for humans and humans will bring it about. This brings to the fore the need for dealing with change as a process of experimentation and adoption in line with the organisational capacity and capability while not ignoring the tumultuous human aspect of change (Elliot, 1991). Such a change should foresee a subscription to investigating and understanding human attitudes and such an analysis would support through qualitative research before any major decision pertaining to change is made (Bogdan and Bilken, 1992). An initiation of change, that is in bringing about a shift to CAM techniques like aromatherapy would be incomplete if not based on the results of such research and assessing whether such a process would be easy in terms of team work and cooperation (Deutch, 1949). For an already functioning medical staff this would mean an understanding of the dynamics and necessity of change (Lewin and Lippitt, 1938) as well as an over all consensus as to the need for the same.
Other issues would basically involve assessing the willingness of an individual in the team to understand their role in the change and to be sufficiently motivated to embrace the change (Schein, 1995). Of course in a more political and legal context there is a problem of adopting to the new policies, procedures and structures which need to be communicated via training to the present and new staff (Stringer, 1999) and as pointed out by Tiran (2000) these things are subject to budgetary constraints in terms of training and infrastructure. The personnel involved in the bringing about of the same would involve the possession of key competencies of leadership particularly those involving problem-solving, decision-making, critical thinking, astute assessment and the effective use of interpersonal skills is essential in enforcing a change (Mc Taggart, 1996). Lippitt (1949:100) has argued “change is any planned or unplanned alteration in status quo of an organism, situation, or process”. In contrast Lewin’s (1951) classic change theory defines “‘no change’ as a ‘quasi – stationary equilibrium; state comparable to that of a river which flows with a given velocity in a given direction during a certain time interval”. He goes on to identify three stages in bringing about such a change namely unfreezing, moving and refreezing. This points to the need of leaving quite a few issues in abeyance until change is finalised. Another analysis that can be adopted from Lewin is the force field analysis and once adopted with in the current framework namely the adoption of aromatherapy in childbirth practice, it would help greatly in recognising the legal, political and economic barriers and resistance in achieving such an implementation. The most important stage with in Lewin’s analysis would be the unfreezing stage which would require ensuring a smooth running system of learning and training for midwives in order to facilitate a better development of formal comprehensive guidelines. In line with the above the author also proposes greater interactions between stakeholders as well as gathering early patient feedback to monitor and evaluate the impact of such implementation.
Finally according to Lewin and Lippitt (1949) while training can be one way of achieving successful behavioural change aimed at effective function of a maternity unit post Aromatherapy implementation but should not be relied upon as an exclusive means to an end of achieving the same. As far as education and awareness is concerned Tiran (2007) has rightly pointed out that health and safety is a major issue here and staff should be discouraged from allowing the parturients self or over medication. The supply and source of oils will also be an issue because any episode of negligence cannot only discredit the maternity home by posing a threat to the mothers well being but also attract unpleasant law suits.
The other issues, which are a hinderance in the larger picture, are mainly political and economic. Due to academic suspicions towards CAM initiatives of the introduction of Aromatherapy for childbirth as well as budgetary concerns the health sector bureaucracy has until now had its reservations in bringing the same into practice (Tiran (2006). However with increased regulatory initiatives and funding it is hoped that the health sector particularly small time maternity centres will embrace Aromatherapy as a cost effective alternative to pharmacological measures (Tiran, 2000). Nonetheless EU law still remains ambiguous upon the legality of natural and CAM remedies and this may be an issue before the UK government would like to undertake this as a full-scale measure of the same.
Tiran (2006:342) however explains the economic dilemma in the implementation of the same quite comprehensively when she states that “therapies such as massages take a longer time to administer and take effect than pharmacological treatments, especially when there is a shortfall of 10,000 midwives in the UK, but the greater satisfaction, relaxation and nurturing which patients feel may increase the number of women booked for delivery in a particular maternity unit, indirectly maternity unit, indirectly increasing financial resource allocation”.(Tiran,2006:341)
Tiran (2000,2006) has further discussed the underlying ethical dilemmas, which may hinder the progress of implementation when she rightly states that such therapies may require “appropriate preparatory education” and budgetary issues to incorporate such practices into normal practice (Tiran, 2006). Also then there is an issue of equity of healthcare, inadequate staffing as well as geographical inequalities which means that this may not become a fully available twenty four hour service for a long time until properly implemented (Tiran, 2006,342).
Finally since the academic evidence as seen in the literature review is still inconclusive of the impact if such evidence-based complementary therapies upon the mother and the foetus and this ethical dilemma still haunt most of the CAM policy making today. However on a more individual level there is a profound need of subscribing to teamwork and proper training to achieve successful implementation of the same at a maternity clinic.
AUDITING THE CHANGE PROCESS.
Last but not the least there is the underlying need for auditing the entire procedure of change and can only happen after a reasonable amount of time has elapsed after the implementation stage and there is a satisfactory outcome of the ongoing monitoring and evaluation. Auditing and review provides a satisfactory means of achieving a good quality of health care and services. Audit has become an integral part of health care in the last two decades despite the negative attitudes of many health care professionals towards the same as being a premature step and an unduly intrusive means of interfering with their current practices.
Experience has however proven otherwise and it has been seen that it actually reinforces trust between the professionals and the patients and is a cornerstone of clinical governance. In the case of the current case of “aromatherapy for childbirth implementation” the author would suggest a vast use of qualitative means of audit like questionnaires and interviews as well observatory sessions and practice examination of records. Of course the need for precise and accurate data collection and interpretation cannot be overstressed.
The method most conducive to achieving success in this case would be to adopt a “consumer” perspective and to view the patient as an end user of a good or service. This will allow the assessment of “client” (patient) satisfaction as well as the revelation of useful perspectives, which could bring about a cost effective means of auditing and future improvement.
In essence in order to achieve a successful audit there is a need according to Mosley (2005) to assessing and gathering an accurate profile of the patterns of the current use of aromatherapy for use in pregnancy and childbirth. The next aim post implementation would be to examine the contribution of the same to the material and emotional well being of the parturient in terms of aiding relaxation and pain alleviation. Furthermore it would be expedient to investigate the effects upon the length of Labour, comparison in terms of cost effectiveness and over all benefits with other available CAM therapies (Mousely, 2005).
Finally the other aims of achieving a successful audit would be to focus upon “effects on the length of labour, evaluating effects on use of other methods of analgesia, identifying outcomes and types of delivery achieved, examining the contribution of aromatherapy to postpartum care, determining training needs of staff, and identifying demand for other complementary therapy services”(Mousely, 2005:206). This would involve not only incorporating mothers previously and currently under treatment at the maternity clinic but also the midwifery staff. An important query would be to ask the mothers who are first time users of aromatherapy during childbirth to compare their experiences with previous pregnancies in a qualitative survey.
All these steps (Implementation, Evaluation and Auditing) would, if done patiently and properly, pave the way for a successful post implementation audit of setting up of an aromatherapy practice with in a maternity ward. It has to be recognized nonetheless that any such approach to Implementation and Audit should understand that the aim of administering aromatherapy is to alleviate the pain and discomfort of a mother having childbirth trauma. Pain is a subjective feeling and cannot be quantified or explained. While the perception of “pain” of childbirth and satisfaction with aromatherapy may vary from patient to patient it is a well-understood fact that ultimately the whole problem boils down to the patient-midwife relationship as well as the quality of service involved. The quality of essential oils available as well as the massaging facilities may be excellent in the maternity centre but if the midwife’s attitude does not alleviate the nervousness and anxiety of the pregnant mother about to go into labour the whole experience of aromatherapy maybe an exercise in futility.
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