The effects of shiatsu on post-term pregnancy:using an audit to establish a research base
This is an article I originally wrote for the Shiatsu Society Journal in 2005.
I’m pleased to let you know that finally we have managed to get an audit carried out at my local maternity hospital published in Complementary Therapies in Medicine, volume 13, issue 1, March 2005, pages 11-15. Ingram, J., Domagala, C., Yates, S., 2005. You can view the whole article, including references on the website www.sciencedirect.com. The article is entitled “The effects of shiatsu on post-term pregnancy by Jennifer Ingram (research officer), Celina Domagala (the midwife) and me, Suzanne Yates.
For me it is exciting as it puts shiatsu in the news and shows how safe and effective it can be during pregnancy. It also shows what a valuable self help tool it is. Some aspects of shiatsu can be shown to midwives, and also parents, and they are able to use it themselves both safely and effectively. Finally it shows how important it is for us as practitioners to keep good records of the work that we do, so that we can ultimately present our findings to underpin research.
Reading it through, you might wonder why we only used 3 points, and why we didn’t use more women.
“The shiatsu points taught to women were Gall Bladder 21 (GB-21) (in the hollow on top of the shoulder), Large Intestine 4 (LI-4) (between thumb and forefinger on the back of the hand) and Spleen 6 (SP-6) (3 thumb widths above the tip of the anklebone), Each point has a slightly different effect, so all points were shown and held with thumb pressure as deep as the woman found to be comfortable until a reaction was felt. If a reaction was felt on the point, then the woman was encouraged to work the point as deeply and firmly and for as long and often as was comfortable. If a woman experienced no reaction from a point, then she would probably not use that particular point. If her partner was present, they were also shown how to work the point with pressure. “
In fact, the audit began as a piece of coursework carried out by a midwife who attended my full 6 day course for midwives at my local hospital, St Michael’s in 2000. Due to the nature of this course, I have tended to simplify the shiatsu approach to some specific techniques and approaches to make it accessible to midwives within a short space of time. In reality when I as a shiatsu practitioner work with “induction of labour” (I don’t call it that! I call it “preparing for birth”), I am assessing the individual drawing upon all my skills. I may use those 3 points in my work, but I also often use a range of other approaches. These may include balancing overall energy, focusing more on the Extraordinary Vessels, or more on achieving a structural (often sacral ) release, or by connecting the mother with her baby and her emotions.
However, I have also learnt through teaching midwives and parents, that the essence of shiatsu can be taught easily – it is about tapping into an energy which we can all connect with. Midwives are connected strongly to the energy of birth and induction and I find that teaching a little can go a long way. The midwife was working in the antenatal clinic at the time and seeing a lot of women who were coming up for induction. She decided to apply what I had taught. The obstetricians enthusiastically took up the idea, so she started using it in the antenatal clinic when she was on duty and, importantly, keeping records of what she was doing. “All consultants had given permission for the techniques to be used on their patients and shiatsu was approved as an acceptable complementary therapy to be used within the United Bristol Healthcare Trust. ”
She was so impressed with the results, that we decided that it would be good to try and get a much bigger study, involving thousands of women over several years. We wanted to see the effects of using shiatsu for getting labour started and so we began a long process with Jennifer Ingram from the research department of drawing up proposals for a bigger study. We envisaged this to be a large randomised controlled trial.
Results of the audit
“Post-term women who used shiatsu were significantly more likely to labour spontaneously than those who did not (chi-square test, p = 0.038). Of those who had used shiatsu, 17% more went into spontaneous labour compared to those who were not taught shiatsu. If those who had emergency caesarean sections (15) are excluded from the analysis, the difference between the groups is even greater with 68% (41) of spontaneous labours in the shiatsu group and 46% (31) in the comparison group (22% difference, chi-square test, p = 0.012).”
Characteristics of the women, drugs used during labour and type of delivery for the shiatsu and comparison group.
|Shiatsu group (66)||Comparison group (76)||Chi-square, and p-value|
|Primiparous||39 (59.1%)||37 (48.7%)||1.54, 0.22|
|Entonox||48 (75.0%)||61 (80.3%)||0.56, 0.46|
|Pethidine||18 (27.7%)||16 (21.1%)||0.84, 0.36|
|Epidural||24 (36.9%)||21 (28.0%)||1.27, 0.26|
|Foetal distress||24 (36.4%)||36 (47.4%)||1.75, 0.19|
|Caesarean delivery||6 (9.1%)||9 (11.8%)||0.28, 0.60|
|Induced labour||25 (37.9%)||42 (55.3%)||4.28, 0.04*|
Unfortunately we still haven’t been able to obtain the money for the bigger study, but we decided to publish the audit in any case to at least put something into the research literature on shiatsu, which is very sparse. By doing this, we hope that it will make future research projects on the use of shiatsu more possible. It has taken 5 years to publish it.
The conclusions are worth having in the literature.
“The relatively small size of the study and the fact that women were not randomly allocated to the shiatsu or control groups means that the findings can only be used as an indication of the generalisability of shiatsu in this context, but the results are interesting and the use of these techniques in midwives’ daily practice can be justified.”
“Since current best practice, as reflected in the NICE guidelines, can only recommend invasive or uncomfortable procedures (sweeping the membranes or pharmacological induction) for inducing labour, this seems to be an appropriate time to investigate the use of less invasive techniques to enable women to labour spontaneously with well-designed randomised trials. “
“This preliminary study raises the hypothesis that the use of specific shiatsu techniques on post-term women by midwives reduces the number of labours that need to be induced pharmacologically. “
This whole process has highlighted for me various key issues. One is the realisation of how hard it is to get money and support to fund research into shiatsu, which is one of the reasons why there is so little research. I would urge all of you to support the European shiatsu study which is about to begin, because this kind of study will make the way easier in the future to get funding for further research. We still haven’t given up in our quest to establish a future induction study – and I am often in contact with people around the world who are trying to get shiatsu studies started. It is a very exciting time – but it is also a bit of a “chicken and egg” situation as the current literature and research base is so small, that it is hard to get the funding for the big studies. This is why it is important to do what we can, with our limited resources. Auditing our own practice and keeping detailed records of what we are doing are ways of doing this. We may not have access to statisticians to number crunch and randomise for us, but we do have the very important work we are doing day to day to inform us.
So you may ask, why do we need research, especially when shiatsu has been around for so long, and indeed is a randomised controlled trial (RCT) the best way of conducting research? Firstly, I don’t necessarily think that a RCT is the best way: shiatsu works with the individual not the condition and RCT’s are by their nature limiting in their scope. The European shiatsu study shows that another model, using qualitative data rather than exclusively quantative data, and practitioner and client feedback and evaluation based on individual shiatsu for individual conditions rather than points or techniques for the same condition, is often more effective for extracting useful data. However I don’t think we should write off the RCT model. Certain aspects of shiatsu can be researched using the RCT and this small audit, and other studies on acupuncture, especially those using HP6 for nausea show this. ((44) Jewell D; Young G Interventions for nausea and vomiting in early pregnancy (Cochrane Review). (Date of most recent substantive update: 15 January 2001) In: The Cochrane Library. Oxford: Update Software , issue 2, 2002 .) By having some rigorous RCT’s we can at least show that shiatsu is safe and effective, the key criteria for inclusion within the National Health Service (NHS).
We can then argue, do we want shiatsu to be part of the NHS? That is also an interesting debate. I am sure that many shiatsu practitioners would not want to work within the NHS and value their self employed freedom. I for one, while I find teaching and working in hospitals from time to time, both challenging and interesting, would not want my whole working life to be within this setting. Indeed, this is one of the reasons why I set up my “Shiatsu for Midwives” course in the first place. I have seen so many times how parents can use shiatsu effectively themselves and felt that midwives could equally use it effectively and they are already in hospitals, attending women in labour. This study shows to me how effective their input can be and also how they can contribute to raising the profile of shiatsu in all areas.
The study has also shown to me, the value of audit and of good record keeping. It is a way that case studies can be used as a basis for data collection and to underpin further research. If we can audit our practice we can draw upon this data to make the case for shiatsu as being an important part of an integrated health care system.
Let’s keep putting shiatsu in the news and keeping it on the health care agenda.