Research www. AJOG.

org

OBSTETRICS
Use of and attitudes toward complementary and alternative
medicine among nurse-midwives in Israel
Noah Samuels, MD; Rachel Y. Zisk-Rony, PhD, RN, MPH; Shepherd R. Singer, MD; Mordechai Dulitzky, MD;
David Mankuta, MD; Judith T. Shuval, PhD; Menachem Oberbaum, MD

OBJECTIVE: The objective of the study was to evaluate the use and at-
titudes of nurse-midwives in Israel toward complementary and alterna-
tive medicine (CAM).
STUDY DESIGN: In a cross-sectional study, nurse-midwives from 5 Is-
raeli medical centers completed the CAM Health Belief Questionnaire, a
validated tool examining data regarding personal health behavior, use
of CAM therapies, and attitudes toward CAM.
RESULTS: One hundred seventy-three of 238 potential respondents
completed the questionnaires (72.7%). Most (87.3%) reported using
CAM (67.1% massage, 48.6% herbal medicine, 42.2% meditation,
40.5% touch therapies, and 39.9% prayer) and agree with many funda-
mental tenets of CAM such as the existence of energy forces, self-heal-
ing, and integrating patients’ health beliefs and values into their care.
CONCLUSION: The majority of nurse-midwives studied reported using
and recommending CAM to their patients and believe that CAM can
complement conventional medical therapies. Health care providers
could benefit from education with regard to the efficacy and safety of
CAM modalities during pregnancy and childbirth.
Key words: attitudes, complementary and alternative medicine,
nurse-midwives

Cite this article as: Samuels N, Zisk-Rony RY, Singer SR, et al. Use of and attitudes toward complementary and alternative medicine among nurse-midwives in
Israel. Am J Obstet Gynecol 2010;203:341.e1-7.

T he use of complementary and alter-

native medicine (CAM) has risen
significantly over the years for most
cians toward CAM are often negative,6
which is thought to be a major reason
why 60% of patients using CAM do not
ogist had used at least 1 CAM treatment
during the previous year. Allaire et al11
observed that the most common CAM
CAM modalities.1 These treatments are a report this use to their physicians.7 As treatments used by pregnant women are
group of diverse medical and health care many as 30% of obstetric patients self- herbal medicine, massage therapy, chi-
systems, practices, and products that are administer remedies or consult indepen- ropractic, mind-body interventions
not generally considered an integral part dent therapists without informing their (hypnosis, biofeedback, and relaxation
of conventional medicine.2 It is thought midwives or doctors, in the belief that, techniques), and acupuncture.
that patients are turning to CAM treat- because they are natural, CAM treat- Nurse-midwives, who play an impor-
ments because they are more congruent ments are also safe.8, 9 tant role in the health of their patients
with their values and health beliefs and The use of CAM by child-bearing during pregnancy, were found to be avid
because they seek control over illness.3 women has been investigated as well. supporters of CAM. As many as 93.9% of
Women use CAM significantly more Pettigrew et al10 found that nearly 70% US nurse-midwives recommend CAM
often than men, especially during their of women waiting to be seen by either a treatments to their pregnant patients,11
reproductive years.4,5 Attitudes of physi- nurse-midwife or obstetrician-gynecol- and 89% were found to have referred pa-
tients to CAM providers.12 McFarlin et
From the Center for Integrative Complementary Medicine, Shaare Zedek Medical Center al13 found that more than half use herbal
(Drs Samuels, Singer, and Oberbaum); Henrietta Szold Hadassah–Hebrew University School preparations to stimulate labor. CAM
of Nursing in the Faculty of Medicine and Hadassah–Hebrew University Medical Center, modalities such as touch, massage, and
Jerusalem, Israel (Dr Zisk-Rony); the Maternity Ward, Hadassah University Hospital, Ein stress management are similar to com-
Kerem (Dr Mankuta); and the Department of Sociology and Anthropology, Hebrew mon nursing interventions, and both
University of Jerusalem (Dr Shuval), Jerusalem, and the Department of Obstetrics and CAM and nursing incorporate holistic
Gynecology, Chaim Sheba Medical Center, Tel Hashomer (Dr Dulitzky), Israel. principles.14 Nurses generally integrate
Received Oct. 24, 2009; revised March 25, 2010; accepted May 4, 2010. diverse therapies into the plan of care,15
Reprints: Noah Samuels, MD, The Center for Integrative Complementary Medicine, Shaare Zedek and Adams16 found that CAM provides
Medical Center, Jerusalem 91031, Israel or Rachel Y. Zisk-Rony, PhD, RN, MPH, Henrietta Szold
patients with an increased sense of au-
School of Nursing, Hadassah Medical Organization, Jerusalem, Israel. refplus@netvision.net.il or
yaffazisk@gmail.com. tonomy, enabling them to move beyond
R.Y.Z.-R. was supported by National Institutes of Health postdoctoral Grant T32PH10010. the control of the doctor and promoting
The first 2 authors contributed equally to this article. empowerment.
0002-9378/$36.00 • © 2010 Mosby, Inc. All rights reserved. • doi: 10.1016/j.ajog.2010.05.001 In many countries health care provid-
ers, patients, and the general population

OCTOBER 2010 American Journal of Obstetrics & Gynecology 341.e1

Research Obstetrics
are reluctant to use CAM treatments. In
Israel a study conducted in 2000 among
the general population found relatively
low rates of reported use of CAM, in-
creasing from 6% in 1993 to 10% in
2000.17 Israeli nurse-midwives are regis-
tered nurses, most with a bachelor’s
degree in nursing science who have un-
dergone training and certification in
midwifery. Although their training does
include the full spectrum of pre-, intra-,
and postpartum care, these midwives are
employed by hospitals to work exclu-
sively in the delivery ward, in which they
are the primary care-givers.
In recent years, nurse-midwives in Is-
rael have been exposed to courses in the
efficacy and safety of CAM treatments in
their initial and ongoing training, al-
though the effects of this training have
not been studied sufficiently. The pur-
pose of this study was to evaluate the use
and attitudes of nurse-midwives in Israel
toward CAM treatments.
M ATERIALS AND M ETHODS
Study population
Participants were hospital nurse-mid-
wives from 5 large medical centers in Is-
rael, 3 in Jerusalem and two in the cen-
tral/Tel Aviv area of the country. A total
of 238 nurse-midwives were listed as be-
ing on staff during the study period
(2008) and were employed at the time in
the labor and delivery wards of their re-
spective hospitals, where they manage
the intrapartum care of their pregnant
patients.
Ethical considerations
Participation in the study was voluntary,
and no identifying or sensitive informa-
tion was collected. Institutional ethical
requirements for all participating hospi-
tals were met by providing a statement at
the front of the questionnaire regarding
the purpose of the study and what the
data will be used for as well as the volun-
tary and anonymous nature of the study.
In accordance with ethical requirements
to maintain respondent anonymity,
signed consent forms (which necessitate
revealing the identity of the participant)
were not used. Respondents were
not offered any incentive for study
participation.
341.e2 American Journal of Obstetrics & Gynecology OCTOBER 2010
Measure: CAM Health Belief
Questionnaire (CHBQ)
The CHBQ was developed by Lie and
Boker and was originally evaluated
among medical students18 and later with
pharmacy students.19 The questionnaire
is comprised of 3 sections, the first re-
garding demographic data such as years
of education, training, and work experi-
ence as well as questions regarding per-
sonal health behavior (routine medical
examinations, exercise, and smoking
habits).
The second section is the CAM Needs
Assessment, evaluating 14 CAM treat-
ment modalities based on the categories
of CAM treatments as listed by the Na-
tional Institutes of Health National Cen-
ter for Complementary and Alternative
Medicine, which consists of at least 40
items.20 Personal use of CAM is exam-
ined as well as whether the respondent
has or would consider recommending
each of the therapies listed.
In the third and final section, 10 items
examine respondents’ attitudes toward
CAM, using a 7 point, Likert-type rating
scale (in which 1 means “absolutely dis-
agree” and 7 means “absolutely agree”).
Items 6, 7, and 8 are worded negatively to
minimize the acquiescence response set,
requiring that the scores of these ques-
tions be reversed prior to data analysis.
The CHBQ was developed for use
among all health professionals. It is a
concise and easy-to-use measure. The
internal consistency of the measure (us-
ing a Cronbach’s alpha) was found to be
0.75.18 In the current study, Cronbach’s
alpha was found to be 0.81.
Procedure
Permission for translation and use of the
CHBQ was granted by the authors of the
original English version. The question-
naire was translated from English into
Hebrew by 2 fully bilingual medical pro-
fessionals and then backtranslated by 2
other fully bilingual medical profession-
als, in accordance with acceptable mea-
surement translation methods.21
All nurse-midwives working at the 5
medical centers during the study period
(2008) were asked to anonymously and
voluntarily complete the structured
questionnaires. The completed ques-
www.AJOG.org
tionnaires were placed in a sealed enve-
lope and sent by mail or courier to the
central study location. Questionnaires
took between 10 and 20 minutes to
complete.
Data management and analysis
The data were entered and managed us-
ing the Microsoft Excel 2003 program
(Richmond, CA), and later analyzed us-
ing SPSS version 16 (SPSS, Inc, Chicago,
IL). All data were examined for univari-
ate and selected items for bivariate statis-
tics, with the CHBQ items tested for re-
liability and validity. For all 10 items
regarding attitudes toward CAM, we cal-
culated the overall CHBQ scores (revers-
ing scores for items Q6-8) and individual
item mean scores and SDs. Construct va-
lidity was assessed by conducting an ex-
ploratory factor analysis of these 10
items calculated using a Varimax rota-
tion factor analysis with a set eigenvalue
of 1.
R ESULTS
Demographic data, training,
and personal health behavior
Of the 238 nurse-midwives currently
employed at the 5 study centers, 173
completed the questionnaires for a re-
sponse rate of 72.7%, with no correction
made for those on vacation or sick leave
at the time of questionnaire distribution.
The demographic data, description of
professional training, work experience,
and personal behavior regarding health
maintenance of the respondents are pre-
sented in Table 1.
Use and recommendation
of CAM therapies
Nearly 70% of respondents reported that
they recommend CAM use, and nearly
half would recommend or consider rec-
ommending CAM treatments to their
patients (Table 2). The most popular
therapy was massage followed by herbal
medicine and then meditation/yoga/im-
agery and therapeutic touch/Reiki and
spirituality/prayer. A small percentage of
respondents (12.7%) use none of the
treatments listed.
Slightly more than 10% of the nurse-
midwives in our study would not recom-
mend any of the listed treatments to pa-
www.AJOG.org Obstetrics Research

tients, whereas more than 20% do
recommend 7 or more treatments, and
close to half of the sample have used or
have recommended at least 4 treatment
modalities. Finally, only a quarter of the
respondents have never recommended
or would not consider recommending
any of the CAM therapies listed.
Attitudes toward CAM treatments
plained 64% of the variance. The first
factor (items 3-5, 9-10), CAM beliefs, TABLE 1
addresses the belief that the health care Demographic data, training and
profession has much to learn from CAM, experience, and personal health
which recognizes the body’s natural maintenance of respondentsa
therapeutic powers and emphasizes the Demographic n (%)
importance of integrating patients’ val- Age group, y
..................................................................................................
ues and beliefs in the healing process. 20-39 53 (31.4)
The second factor (items 1-2), life-en- ..................................................................................................
40-59 112 (66.3)
hancing forces, addresses one of the fun- ..................................................................................................

The majority of respondents strongly
agreed (scoring 6-7 of the possible 7)
with many of the fundamental tenets of
CAM. The nurse-midwives listed high
scores to the belief in the existence of an
damental axioms of CAM, that the body ⱖ60 4 (2.3)
...........................................................................................................
contains a life-enhancing force or en- Country of birth
..................................................................................................
ergy, which is responsible for health Israel 113 (65.3)
when in balance and disease when in dis- ..................................................................................................
Outside Israel 60 (34.7)
harmony. The third factor (items 6-8), ...........................................................................................................

underlying energy/vital force and the
balance between positive and negative
forces (item 1: 56.1%; item 2: 55.6%;
item 4: 54.8%), the concept of self-heal-
ing (item 3: 70.0%), and the importance
questions regarding CAM, presents the Family status
..................................................................................................
concerns of conventional medicine re- Married 144 (83.7)
..................................................................................................
garding CAM: whether it is no more than Single, divorced, widowed 28 (16.3)
a placebo effect or possible detrimental ...........................................................................................................
Country of training
effects on patients’ health. ..................................................................................................

of integrating patients’ expectations, Israel 156 (90.2)

health beliefs, and values into the patient
care process (item 5: 83.4%).
Most respondents listed high scores to
Factors predicting attitudes
toward CAM
A correlation was conducted between
..................................................................................................
Outside Israel 17 (9.8)
...........................................................................................................
Work experience, y
..................................................................................................

demographic data, personal health prac- ⱕ10 36 (20.9)

the items stating that conventional med- ..................................................................................................

icine could benefit from ideas and meth-
ods of CAM (item 9: 70.8%) and that
most complementary therapies stimu-
late the body’s natural therapeutic pow-
tices, and work experience (section 1 of 10-20 63 (36.7)
..................................................................................................
the questionnaire) with attitudes of re- ⱖ21 73 (42.4)
spondents to the use of CAM (section 3). ...........................................................................................................
Last routine medical checkup
Aside from 2 correlations, all other fac- ..................................................................................................

tors were not statistically significant or Never 13 (7.6)

ers (item 10: 57.4%). As for the nega- ..................................................................................................

tively worded items, a large proportion
disagreed (scoring 1-2) with the state-
ment that CAM poses a threat to public
health (item 6: 85.3%) as well as with the
need to discourage treatments that have
approaching significance in predicting Within last 5 y 124 (72.5)
..................................................................................................
the attitudes of respondents to CAM ⬎5 y 34 (19.9)
therapies. ...........................................................................................................
Cholesterol checked within 122 (70.5)
The 2 factors that were found to be
last 5 y
predictive were exercise and smoking ...........................................................................................................

habits. Respondents who exercised for Blood pressure checked 43 (25.0)

not been scientifically proven (item 7: periodically
47.6%), and the assumption that the ef- 30 minutes or more at least 3 times a ...........................................................................................................

week tended to agree more with the Exercise for ⱖ30 minutes 3 74 (43.0)
fects of CAM are no more than a placebo times a week
effect (item 8: 61.1%). statement, “Complementary therapies ...........................................................................................................

include ideas and methods from which Currently a cigarette smoker 16 (9.3)
As can be seen in Table 3, all of the ...........................................................................................................
positively framed questions (items 1-5, conventional medicine could benefit” a
Work experience refers to both general nursing and

items 9-10) have mean scores greater
than 5 (ie, strong agreement), whereas
the 3 negatively framed questions (items
6-8) had lower scores, indicating less en-
dorsement of the statement. A total
CHBQ mean score of 55.78 (SD 9.98)
was calculated, with a range of 15-70
(possible range, 7–70).
Factor analysis
To examine the construct validity of the
section regarding attitudes toward CAM,
we conducted a varimax rotation factor
analysis (Table 4). The factor analysis
produced a 3-factor solution, which ex-
(question 9; r ⫽ – 0.2, P ⫽ .011). The
second predictive factor was smoking,
with those participants who are cur-
rently nonsmokers agreeing more with
the statement, “Treatments not tested
in a scientifically recognized manner
should be discouraged” (question 7; r ⫽
0.18, P ⫽ .02).
C OMMENT
This study examined the use and atti-
tudes toward CAM among Israeli nurse-
midwives. The main findings were that
many respondents report using CAM
treatments frequently as well as recom-
nurse-midwifery.
Samuels. CAM among nurse-midwives in Israel.
Am J Obstet Gynecol 2010.
mending them to their patients. Respon-
dents overwhelmingly agree with many
of the fundamental tenets of CAM, such
as the belief that the body’s energies are
vital for both maintaining and promot-
ing health.
The findings also demonstrate that the
nurse-midwives believe that CAM can
complement conventional medical ther-
apies and should be considered a valid
treatment option. And although CAM

OCTOBER 2010 American Journal of Obstetrics & Gynecology 341.e3

Research Obstetrics www.AJOG.org

TABLE 2
Use of CAM therapies by nurse-midwives, %
Have you ever used Have you ever recommended
it or are currently Would you recommend it to patients or would you
Modality using it? using it? consider recommending it?
Biofeedback 6.4 21.4 16.8
................................................................................................................................................................................................................................................................................................................................................................................
Hypnosis 8.1 16.2 11.0
................................................................................................................................................................................................................................................................................................................................................................................
Meditation/yoga/imagery 42.2 49.1 34.1
................................................................................................................................................................................................................................................................................................................................................................................
Tai chi/chi gong 10.4 17.3 10.4
................................................................................................................................................................................................................................................................................................................................................................................
Chinese medicine (acupuncture) 32.9 47.4 28.3
................................................................................................................................................................................................................................................................................................................................................................................
Ayurveda 8.7 12.1 5.2
................................................................................................................................................................................................................................................................................................................................................................................
Chiropractic 17.9 20.8 17.9
................................................................................................................................................................................................................................................................................................................................................................................
Massage 67.1 68.8 49.1
................................................................................................................................................................................................................................................................................................................................................................................
Osteopathy 9.2 10.4 7.5
................................................................................................................................................................................................................................................................................................................................................................................
Therapeutic touch/Reiki 40.5 36.4 29.5
................................................................................................................................................................................................................................................................................................................................................................................
Spirituality/prayer 39.9 41.0 28.9
................................................................................................................................................................................................................................................................................................................................................................................
Herbal/supplements 48.6 41.6 37.0
................................................................................................................................................................................................................................................................................................................................................................................
Homeopathy 38.7 39.3 33.5
................................................................................................................................................................................................................................................................................................................................................................................
No treatments 12.7 11.0 25.4
................................................................................................................................................................................................................................................................................................................................................................................
At least 4 treatments 48.6 51.4 38.2
................................................................................................................................................................................................................................................................................................................................................................................
CAM, complementary and alternative medicine.
Samuels. CAM among nurse-midwives in Israel. Am J Obstet Gynecol 2010.

therapies were not offered as part of the (nearly 90%) are significantly higher This finding is significant, especially
routine, Ministry of Health– covered in- than those reported in a 2000 study because of the fact that the majority of
trapartum care during the study period, among the general population in Israel, respondents were born and trained in Is-
birthing centers have since been opened, as mentioned in previous text.17 How- rael and suggests that education may be
offering Israeli women complementary ever, these rates are comparable with the reason for the much higher rates of
therapies in addition to standard care. those reported among nursing profes- use than the general population in the
The high rates of CAM use reported sionals in other countries, such as the country.17 The CAM treatments most
by the participating nurse-midwives United States and Australia.22,23 popular among respondents in the cur-

TABLE 3
Attitudes of nurse-midwives to CAM
Item Mean ⴞ SD
1 The physical and mental health are maintained by an underlying energy or vital force. 5.33 ⫾ 1.90
................................................................................................................................................................................................................................................................................................................................................................................
2 Health and disease are a reflection of balance between positive life-enhancing forces and negative destructive forces. 5.41 ⫾ 1.71
................................................................................................................................................................................................................................................................................................................................................................................
3 The body is essentially self-healing and the task of a health care provider is to assist in the healing process. 5.75 ⫾ 1.56
................................................................................................................................................................................................................................................................................................................................................................................
4 A patient’s symptoms should be regarded as a manifestation of a general imbalance or dysfunction affecting the 5.43 ⫾ 1.55
whole body.
................................................................................................................................................................................................................................................................................................................................................................................
5 A patient’s expectations, health beliefs, and values should be integrated into the patient care process. 6.21 ⫾ 1.29
................................................................................................................................................................................................................................................................................................................................................................................
6 Complementary therapies are a threat to public health. 1.68 ⫾ 1.34
................................................................................................................................................................................................................................................................................................................................................................................
7 Treatments not tested in a scientifically recognized manner should be discouraged. 3.17 ⫾ 2.10
................................................................................................................................................................................................................................................................................................................................................................................
8 Effects of complementary therapies are usually the result of a placebo effect. 2.57 ⫾ 1.77
................................................................................................................................................................................................................................................................................................................................................................................
9 Complementary therapies include ideas and methods from which conventional medicine could benefit. 5.87 ⫾ 1.46
................................................................................................................................................................................................................................................................................................................................................................................
10 Most complementary therapies stimulate the body’s natural therapeutic powers. 5.49 ⫾ 1.59
................................................................................................................................................................................................................................................................................................................................................................................
CAM, complementary and alternative medicine.
Samuels. CAM among nurse-midwives in Israel. Am J Obstet Gynecol 2010.

341.e4 American Journal of Obstetrics & Gynecology OCTOBER 2010

www.AJOG.org Obstetrics Research

TABLE 4
Factor analysis of the CAM Health Belief Questionnaire (CHBQ)
Item Life-enhancing Questions
number CHBQ item CAM beliefs forces regarding CAM
9 Complementary therapies include ideas and methods from which conventional 0.787 (0.011) (0.207)
medicine could benefit.
................................................................................................................................................................................................................................................................................................................................................................................
3 The body is essentially self-healing, and the task of a health care provider is 0.719 (0.253) (–0.124)
to assist in the healing process.
................................................................................................................................................................................................................................................................................................................................................................................
5 A patient’s expectations, health beliefs, and values should be integrated into 0.644 (0.276) (–0.013)
the patient care process.
................................................................................................................................................................................................................................................................................................................................................................................
10 Most complementary therapies stimulate the body’s natural therapeutic 0.634 (0.289) (0.248)
powers.
................................................................................................................................................................................................................................................................................................................................................................................
4 A patient’s symptoms should be regarded as a manifestation of a general 0.631 (0.364) (0.029)
imbalance or dysfunction affecting the whole body.
................................................................................................................................................................................................................................................................................................................................................................................
2 Health and disease are a reflection of balance between positive life-enhancing (0.284) 0.852 (–0.002)
forces and negative destructive forces.
................................................................................................................................................................................................................................................................................................................................................................................
1 The physical and mental health are maintained by an underlying energy or (0.260) 0.843 (0.173)
vital force.
................................................................................................................................................................................................................................................................................................................................................................................
7 Treatments not tested in a scientifically recognized manner should be (–0.057) (0.008) 0.763
discouraged. (reversed)
................................................................................................................................................................................................................................................................................................................................................................................
6 Complementary therapies are a threat to public health. (reversed) (0.027) (0.230) 0.755
................................................................................................................................................................................................................................................................................................................................................................................
8 Effects of complementary therapies are usually the result of a placebo effect. (0.469) (–0.142) 0.678
(reversed)
................................................................................................................................................................................................................................................................................................................................................................................
Values that do not appear in parentheses are associated with the corresponding factor.
CAM, complementary and alternative medicine.
Samuels. CAM among nurse-midwives in Israel. Am J Obstet Gynecol 2010.

rent study were massage, followed by tional medical practice, there are still a midwives, with the doctor involved only
herbal medicine and then meditation. number of issues that first need to be ad- in protracted and complicated cases.
These modalities have been found to be dressed. The primary question of efficacy Several methodological limitations re-
of similar popularity among studies of vs safety is still unresolved with respect to lated to our study should be noted. A
the general population and among preg- many CAM treatments. Although a large proportion of our respondents
nant women in the United States.4,11 number of these treatments have been (68.7%) were over the age of 40 years. A
When examining the attitudes of the found to be both safe and effective, such study published in 2007 of the general
study group toward CAM, most respon- as acupuncture for nausea, vomiting,24 nursing population in Israel found that
dents agreed with the fundamental te- and labor pain,25 others such as herbal only 45% were over the age of 45 years.31
nets of CAM. The high CHBQ score medicine may be harmful to both In the current study, the respondents
(with a mean of 55.8) demonstrated in mother and fetus.26-29 were highly experienced, with 42.4% re-
the current study were higher than those Most doctors are unfamiliar with porting 21 or more years of work experi-
found in a prior study conducted on many of the CAM treatments, and ence. And the sample was highly con-
first- and third-year Czech pharmacy nurse-midwives recommend CAM cerned with personal health, which may
students. In their study, the mean CHBQ treatments such as herbal medicine be reflected in the very low rates of smok-
score was 48.5, with only 50% of individ- based on information gleaned from ing (only 9.3%).
ual items reaching a mean score of 5 or other nurse-midwives and not from for- A study conducted in 2002 among Is-
greater.19 In the current study, all of the mal research publications or education raeli obstetric and gynecology nurses
nurse-midwives scored in favor of CAM. programs.13 In Israel, courses in CAM found smoking rates to be 44.8%,32 al-
Adams16 posited that not only are pa- are being offered to nurse-midwives, though antismoking legislation has been
tients empowered by CAM but also with a high rate of participation.30 The implemented in hospitals and other
nurse-midwives themselves feel that ultimate goal of these courses is to pro- public venues since then. All of these fac-
CAM gives them an increased sense of mote the effective and safe use of CAM tors, age, education, work experience,
autonomy. treatments during pregnancy and child- and personal health concern, may influ-
Whereas most of the nurse-midwives birth. In Israel nearly all of the approxi- ence attitudes toward CAM, although
surveyed felt strongly that CAM should mately 150,000 births taking place each our analysis of the data did not find any
be incorporated into accepted conven- year are performed exclusively by nurse- statistically significant relationship.

OCTOBER 2010 American Journal of Obstetrics & Gynecology 341.e5

Research Obstetrics
This study did not, however, inquire as
to whether respondents received CAM
training and, if so, in which country or
framework this training was given. Fu-
ture studies need to examine this ques-
tion, as well as other cultural factors, on
attitudes toward CAM.
Another limitation of note is that the
study group represents less than 15% of
the more than 1200 licensed nurse-mid-
wives in Israel and may not reflect atti-
tudes and trends in other parts of the
country. In Israel, both patient and staff
ethnic makeup can vary greatly between
the center of the country and the periph-
ery. The nurse-midwives in the current
study were employed in hospitals that
are located in large, central urban cen-
ters, which service a largely Jewish and
Arab middle-class population. In the
south of the country, there is a large
Bedouin population, which is largely
lower class and uneducated (especially
women), whereas in the north, there is a
large Israeli-Arab and Druze population,
which tends to be more middle class and
educated (including women).
Finally, the primary contact between
the Israeli nurse-midwife and the preg-
nant patient may be significantly differ-
ent from that found in other countries.
In Israel, the first and often only interac-
tion between the nurse-midwife and the
birthing mother takes place during la-
bor. This presents a challenge to the
nurse-midwife who wishes to incorpo-
rate CAM into the delivery process,
which may not afford either the time or
opportunity to explain the multifaceted
treatment options, their benefits, and
disadvantages.
Nevertheless, our findings have signif-
icant implications for both clinical care
and research, although future studies are
needed to better understand the positive
attitudes of nurse-midwives to CAM. To
promote this positive attitude, while
maintaining the highest standards of
care, our findings suggest that health
care providers who treat pregnant
women could benefit from education re-
garding CAM. Formal and informal ed-
ucational programs, as well as lectures
presenting up-to-date findings on CAM,
should be incorporated into training
341.e6 American Journal of Obstetrics & Gynecology OCTOBER 2010
and continuing health professional
education.
Further research is also needed to eval-
uate the efficacy and safety of these treat-
ments during pregnancy and childbirth.
Finally, doctors and nurse-midwives
should promote an open dialogue with
their patients, with respect to both con-
ventional and CAM treatments. Work-
ing together will assist in facilitating the
positive experience during pregnancy
and childbirth, ensuring that it remains a
positive and safe experience for both the
mother and the child. f
ACKNOWLEDGMENTS
The authors thank Hava Hacham, RN, Arlette
Mamane, RN, Irene Soudry, RN, and Ilana Go-
lan, RN for their help in distributing and collect-
ing the questionnaires.
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