Obstetrical Acupuncture: Reflections on a Much-Needed Special Issue.

As is noted in the thoughtful and wide-ranging introduction to Part I of this special issue by Dr. Xiaoxiong Shen et al., the practice of East Asian medicine, including Traditional Chinese Medicine (TCM), has matured to the point where it supports expert specialization within the field. Nowhere is this specialization more evident than in the use of acupuncture to support fertility. Indeed, a 2012 survey of women undergoing in vitro fertilization at a large U.S. clinic found that 9–47% underwent acupuncture during the cycle.1,2 It is curious that use of acupuncture during pregnancy is not even more common, given pregnancy's high prevalence relative to infertility, and the obvious desirability of a drug-free treatment modality. Both authors (C.C. and D.B.), each having practiced acupuncture in integrative settings for decades, have observed that it is difficult to communicate acupuncture's fundamental beneficence when the biomedical model is that each intervention carries a risk and should be avoided if possible. It is to be hoped that the round-table discussion presented in Part I of the Special Issue will help to allay practitioner concerns regarding safety of acupuncture during pregnancy, as a representative of the main U.S. company providing malpractice insurance to acupuncturists reports that the company has seen no suits alleging pregnancy-related adverse events in its 30 years of providing coverage. The excellent safety review in this issue by Levett and Betts may also help to allay practitioner concerns, at least for care conducted within the bounds of traditional cautions and contraindications. One other factor limiting acupuncture's use during pregnancy may be the poor compatibility of sham-controlled efficacy trials appropriate for pharmacotherapy, with the whole system of individual assessment and iteratively responsive treatment that characterizes clinically appropriate acupuncture care in many situations.3 Like massage or yoga, East Asian medicine has for millennia aimed to improve a patient's own lived experience of health and prevent disease actively, rather than simply treating disorders after they appear. Biomedical concepts of patient-centered care, functional medicine, and personalized medicine seem late to the party by comparison. The specious argument that acupuncture's effects are limited to placebo has been decisively countered by a large meta-analysis showing clear evidence of its specific effects over and above sham control.4 That said, emerging research on the nature of symptom processing in the human brain,5 as well as the remarkable effectiveness of open-label placebo treatment,6 directly questions the assumption that efficacy over and above placebo is the most important measure of a modality's clinical benefit. Indeed, some 60% of acupuncture's benefit, as experienced by patients, can also be elicited with non-penetrating sham acupuncture.7 Even authors historically skeptical of acupuncture concede that “if acupuncture alleviates suffering through a powerful placebo effect which theoretically could exceed the total therapeutic effect of conventional therapeutic options, it should be accepted as a useful treatment.”8 Acupuncturists specializing in women's health have ample reason to believe that acupuncture exceeds the total therapeutic effect of conventional options for many of the types of suffering they encounter. In this issue alone, authors report powerful perceptions of acupuncture's drug-free effect on disorders that are otherwise difficult to treat such as endometriosis, polycystic ovary syndrome, and emotional distress during fertility care, as well as perinatal urinary retention, depressive disorders, and pain following cesarean section. In the hospital, C.C. has seen a patient admitted in a wheelchair with pubic symphysis pain walk out after scalp and battlefield acupuncture; dozens of recalcitrant cervices dilate rapidly after manual reduction of painful gummy nodules on the posteromedial surface of the shin; and innumerable women delivering while in the queue for cesarean section due to arrest of dilatation or descent. D.B.'s experiences meanwhile include midwives reporting women requiring referral for preeclampsia and anemia being able to remain in primary care due to the improvements in their biomedical markers. This use of acupuncture for pre-eclampsia and anaemia is discussed in this issue within the Clinical Pearl's section and provides an interesting area from clinical practice for further research. Our colleague Zena Kocher routinely treats high-risk preeclampsia at the Allina hospital system in Minneapolis, and initial reporting suggests that patients who had received acupuncture safely maintained the pregnancies more than a week longer on average than those who had not (pers. commun., Zena Kocher). One of Zena's extraordinary cases is included in this issue. It can only be hoped that further research explores the use of acupuncture beyond the commonly perceived use of acupuncture in pregnancy being restricted to nausea, muscular skeletal pain, breech, labor preparation, and induction of labor. C.C.'s text message inbox alone is a case series of colleagues' oligohydramnios patients whose amniotic fluid increased two to four points after moxibustion on ST-36. Other conditions for which there are numerous credible anecdotal reports of positive outcomes following acupuncture treatment include threatened miscarriage, PUPPPS rash, adjunct care during intrahepatic cholestasis of pregnancy, facilitation of labor induction in patients with low Bishop score, postpartum recovery, and labor preparation in patients attempting vaginal birth after cesarean (VBAC/TOLAC), among many others. We are deeply grateful to Medical Acupuncture, not only for publishing these timely issues, but also for its longstanding policy of accepting case studies, case series, clinical pearls, and perspective and commentary pieces. The individual patient encounter is the original vehicle for knowledge gathering and transmission in Chinese medicine, and it is the volume of such cases that allow for the development of specialist expertise. 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