We found that the use of peer reviewed research was the least used source of knowledge and not a major agent of change for acupuncture practitioners, which explains why very few changed their practice due to research alone, despite a substantial increase in the number of clinical trials and improvements in reporting quality of acupuncture publications over time [28–30]. Birch and colleagues  found a total of 1311 publications between 1991–2017 with recommendations for the use of acupuncture, especially in North America, Europe, and Australasia, made by government health institutions, national guideline, and medical specialty groups  but noted that that not all these recommendations are known within the acupuncture or the mainstream medical communities [31, 32] and identified the need to address the lack of presentations focusing on research and implementation at international symposia . A recent analysis supports this lack of awareness, with a recent analysis on Australian guidelines in pregnancy showing significant inconsistences in the recommendation, or in some cases prohibition, of acupuncture for various conditions including nausea and vomiting, and pelvic pain .
Sixty-five percent of our respondents have ten or more years of experience in practice and hold bachelor’s level (60%) or master’s level (21%) qualification, in line with previous findings that 78% of Chinese medicine practitioners in Australia hold a bachelor’s degree or higher . Despite a substantial minority holding post graduate degrees, this did not necessarily make them more likely to use research in their practice. Our findings also suggest that despite being experienced practitioners, those with more than 10 years’ experience are just as likely as newer graduates to change their practice. Our study found that irrespective of qualification and length of time in practice, webinars, seminars, and presentations by experts were key in shaping the acupuncture practice for Australian and New Zealand practitioners. These findings support our team’s qualitative work  on the importance of academic and/or clinician researchers ensuring they are not only publishing within the academy but ensuring they use reputable webinars, seminars, and conferences to reach their clinical peers, to ensure translation of research into clinical practice. Similarly, in the field of naturopathy, the role and relevance of conferences and professional events to inform clinical practice was recently highlighted by Steel and colleagues  who reported that naturopathic practitioners use those almost as often as scientific journals, which are their main source of knowledge to inform their clinical practice . Promoting the engagement of practitioners in generating practice-based knowledge through the publication of their case studies  and of researchers in supporting the translation of their findings into clinical decision-making offers a solid foundation for evidence-based practice. Furthermore, research literacy and knowledge translation skills can also help practitioners to translate evidence and generate content to share on social media and inform prospective patients and the general public .
Previous findings from a survey of TCM practitioners in the U.K. showed that education was seen as necessary to ensure that practitioners stay updated with the medical developments in the fertility field and more than half of the respondents had taken post-qualification training in acupuncture for fertility . Despite this, respondents’ opinions varied on whether the specialized training is essential, while others suggested that overspecialization could impact the holistic nature of the treatment . While there are special interest groups for women’s health in Australia, New Zealand [36, 37], and the U.K.  thus far only North America has an organization examining and registering TCM practitioners specializing in reproductive medicine  and one dedicated to obstetrical acupuncture . These organizations started in the USA and Canada respectively, and although most of the members are from North America, both have recently opened their examination process to practitioners worldwide, providing the applicants meet the required standards, including the continuing education units necessary to sit the exam. Engaging practitioners with organisations such as this may result in improvements in research literacy while also enabling them to contribute with new knowledge from the coalface to better reflect the complexity of acupuncture practice and inform research design accordingly [18, 40]. The two-way avenue of translation of research into practice and vice-versa includes benefits to both the profession and to the public.
Our study found that acupuncturists still treat a wide range of women’s health conditions, and that most of their referrals, especially for menstrual health, come from word of mouth, while for there are a greater proportion of referrals from biomedical practitioners when treating fertility and pregnancy. However overall, the rate of referrals from medical practitioners remains relatively low overall, and it is unclear from our survey if these are formal inter-professional referrals or a less formal ‘it cannot hurt to try’ endorsement. The low medical referral rate may be partly due to a recently identified gap in knowledge by medical practitioners about the availability, provision, and efficacy of acupuncture, leading to less patient referrals to CAM providers . Previously identified communication barriers between patients using CAM and not disclosing it to their healthcare providers [41, 42] may also contribute to this. The dynamics of this communication barrier are self-perpetuated by patients refraining from initiating the disclosure of using CAM treatments due to their expectation that a non-judgemental conversation will be initiated by their primary care clinician, whilst the latter interprets the low levels of report as low levels of use of acupuncture and other CAM modalities by their patients . These factors may contribute towards acupuncturists reporting working in relative isolation from other medical practitioners. Recent calls for greater patient-centred collaborative and integrative models  can potentially address previously identified barriers such as the dominance of the biomedical paradigm  and some clinicians’ uncertainty regarding CAM practitioners’ scope of practice . Despite concerns on the scientific evidence, professional regulation and safety, New Zealand healthcare professionals have a positive attitude towards CAM, with midwives recommending CAM and GPs referring patients to acupuncture [2, 46]. Patient-reported data from a maternity acupuncture service in New Zealand shows that acupuncture offers a safe and beneficial non-pharmacological treatment option for pregnant women with lumbopelvic pain [47, 48]. A recent review of RCTs on the use of acupuncture or acupressure in helping women to manage pain during labour revealed that acupuncture may increase satisfaction with pain management and reduce the use of pharmacological analgesia, while acupressure may reduce pain intensity . In Australia, a program of antenatal education based on complementary therapies for labour and birth demonstrated a reduction of use of hospital resources, which could decrease birth-related healthcare costs by approximately 9% .
There are several important limitations to acknowledge. Firstly, like other practitioner surveys of acupuncturists in Australasia, our overall response rate was low [6, 51]. This is likely due to several factors, primarily that those who were not interested in women’s health were unlikely to fill in the survey, and secondly, due to the low priority that practitioners put on research they may not feel inclined to engage with researchers . Therefore, caution must be taken in extrapolating our findings, however our key findings of lack of engagement with research are in line with previous work, both quantitively  and qualitatively . Secondly, we did not request detailed information regarding the referral interactions with other practitioners. Referral patterns both to and from acupuncture, and other forms of CAM, is a grey area as many ‘referrals’, are not recorded within medical records, and are rather verbal endorsements and often to a modality rather than a specific practitioner, therefore it is likely that these referral interactions are different to those between medical doctors .