This qualitative case study is the first systematic, empirical exploration of the lived experiences of pregnant women seeking chiropractic care for their LPGP in an Australian context. Four key themes were identified that support a substantive-level theory that chiropractic care for pregnant woman experiencing LPGP improves their pain, function, and pregnancy-related biopsychosocial concerns. The findings may inform antenatal providers and the chiropractic profession about pregnant women’s experience with chiropractic care.
In a previous qualitative study the experience of chiropractic treatment for pregnant women with LBP was explored, and the role of the chiropractors providing care for these patients was addressed (31). The convenience study identified five themes including treatment and effectiveness; chiropractor-patient communication; pregnant patient presentation and chiropractic approach to pregnancy care; safety considerations; and self-care. Similarly to our current study, respondents found chiropractic care a non-pharmaceutical treatment helpful and safe for managing their LBP (31). However, it was unclear due to lack of clinical definitions, if this response to care is also applicable to pregnant women with symptoms of PGP or LPGP. In this qualitative case study, purposive sampling captured experiences in seeking chiropractic care for LBP as well as PGP (LPGP). Findings expand on previous themes from Sadr et al. (31) on the biopsychosocial approach pregnant women experienced in care.
Theme one, “care drivers” described a need to take control and seek care for severe pain and functional disabilities. Pregnant women chose chiropractic care as they indicated their preferences were for non-pharmacological treatment to improve their LPGP and enhance labour process. Non-pharmacological care is warranted, with the lack of research of the effectiveness and safety of medication such as paracetamol to decrease LBP, PGP or LPGP during pregnancy (38). There is concern with PGP associated with increased labour and birth medical intervention (39, 40). Some respondents had anecdotal understanding that improving LPGP with chiropractic care may help with labour and birth. Improvement in LBP, PGP or LPGP and birth outcomes, with chiropractic care are substantive theories which need further investigation. Pregnant women similarly to these respondents are seeking recommendations for LBP, PGP or LPGP care from antenatal carers, family, peers, the Internet, and/or social media (41, 42). It is of concern that social media forums on pregnancy and LBP, PGP or LPGP are a large source of information used by pregnant women which can also promote insufficient or incorrect information (43).
Respondents experiencing unexpected moderate to severe pain described how they felt despondent and inadequate, identified under the “care drivers” theme. The attitude of normal expectation of LBP, PGP or LPGP from antenatal providers and pregnant women, is a common revelation (18, 39, 42, 44) and barrier in seeking out care. Women have reported not wanting to feel bothersome reporting pain or feel judged in their difficulty coping with pain (42). When they received prenatal advice on LPGP, respondents indicated that antenatal reassurance, exercise, relaxation, medication, and ergonomic advice did not improve disabling LPGP, nor improve sleep quality, ability to walk and pain hindered their exercise. Commonly, pregnant women reduce or stop their regular exercise due to LBP, PGP or LPGP (45). Pain in pregnancy is considered a predictor of reducing exercise activity (46). This fear-avoidance mechanism may contribute to strategies of altered movement patterns and contributing to further mal-adaptive responses contributing to LBP, PGP or LPGP.
Theme two, “care barriers” reported by respondents, was a lack of general knowledge that chiropractic could be helpful for their pregnancy related LPGP and relied on information from recommendations and internet searches. Chiropractors are reported to apply an evidence-based approach to care for pregnancy-related LBP, PGP or LPGP (30, 47, 48). However, with low-evidence availability, pregnancy guidelines caution chiropractic care as a treatment for PGP in pregnancy (22). Further investigation into the effectiveness of chiropractic care in pregnancy is needed. A lack of knowledge of the effects of spinal manipulation for LPGP and the negative sentiments associated with the sound of cavitation were perceived by respondents as a barrier to care.
Theme three, “chiropractic treatment” shares similarity to Sadr et al. (31) and reflects a common experience in triage of chiropractic care of LPGP chiropractic treatment of pregnant women (30, 31). Chiropractic care is considered more than just SMT), and when used within a biopsychosocial model of care including chiropractic manual therapy, exercise and education, is considered multimodal care.(49). Similar to Sadr et al (31), respondents described receiving a biopsychosocial approach in care, receiving reassurance, education, self-care management and exercise prescription.
Theme four, “response to care” described respondents experiences of improvement in activities of daily living with pain relief, improved psycho-social well-being, and satisfaction in chiropractic care, which reflect findings in the literature (31, 50). With encouragement and financial support from partners, respondents indicated better mental health and an enriched, positive outlook on birth and motherhood. They reported global satisfaction in LPGP management. Some respondents showed variability in recovery from their episode of pregnancy related LPGP. Differences were found between multigravidas with previous experiences, and those primigravida’s with no previous chiropractic care. This difference needs to be explored further with other factors including gestation period, parity, previous LBP or PGP and psychological factors. The action of internality of health as a locus of control has been used in previous studies in LBP. It has been found that those who seek complementary alternative therapists, (CAM) including for LBP, demonstrate a higher measured internality of health as a locus of control, than those who use conventional care (51, 52). Higher internality of health as a locus of control has been related to improved physical and mental outcomes in chronic LBP rehabilitation and can be used as a predictor in outcome measures in patient care (53).
Limitations
All pregnant women described moderate to severe LPGP. This study did not capture women describing only LBP, who may have had a different experience with possible less severity of pain and disability. Recruiting older than 35 years gravidas may have provided insight of mature women and/or with larger families. Limitation arose from the purposive sample, where there was a lack of contrasting experiences in the theme “responses to care”, in that participating women were most likely to have had a positive experience with their chiropractic treatment. Recruitment failed to capture low socio-economic voices and women without healthcare insurance; however, these women are less likely to seek help for their back pain symptoms (26). Future studies may explore the specific needs of chiropractic treatment for pregnancy-related LBP, PGP or LPGP. This may include differences in specific spinal manipulative forces and postural modifications during treatment in pregnancy. It is suggested that future studies provide clear and standardised definitions for pregnancy-related LBP, PGP or LPGP (54, 55). Future studies also need to report the gestational period when pregnancy-related LBP, PGP or LPGP is experienced to assist with a better understanding of the aetiology, progression, and effectiveness of chiropractic care. The beliefs, attitudes, and knowledge of antenatal providers towards chiropractic care is unknown, and future study to explore these issues may help the integration of chiropractic care in formal antenatal care.