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(Review)
Smith CA, Collins CT, Crowther CA, Levett KM
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2011, Issue 8
http://www.thecochranelibrary.com
Acupuncture or acupressure for pain management in labour (Review)
Copyright 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
T A B L E O F C O N T E N T S
1 HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1 ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2 PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2 BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4 OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4 METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8 RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
14 DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15 AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
16 ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
16 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19 CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
39 DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Acupuncture versus control, Outcome 1 Pain intensity. . . . . . . . . . . . . 41
Analysis 1.2. Comparison 1 Acupuncture versus control, Outcome 2 Satisfaction with pain relief in labour. . . . . 42
Analysis 1.3. Comparison 1 Acupuncture versus control, Outcome 3 Use of pharmacological analgesia. . . . . . 43
Analysis 1.4. Comparison 1 Acupuncture versus control, Outcome 4 Caesarean section. . . . . . . . . . . 44
Analysis 1.5. Comparison 1 Acupuncture versus control, Outcome 5 Assisted vaginal birth. . . . . . . . . . 45
Analysis 1.6. Comparison 1 Acupuncture versus control, Outcome 6 Apgar score < 7 at 5 minutes. . . . . . . 46
Analysis 1.7. Comparison 1 Acupuncture versus control, Outcome 7 Spontaneous vaginal delivery. . . . . . . 47
Analysis 1.8. Comparison 1 Acupuncture versus control, Outcome 8 Augmentation with oxytocin. . . . . . . 48
Analysis 1.9. Comparison 1 Acupuncture versus control, Outcome 9 Relaxation. . . . . . . . . . . . . . 49
Analysis 2.1. Comparison 2 Acupressure versus control, Outcome 1 Pain intensity. . . . . . . . . . . . . 50
Analysis 2.2. Comparison 2 Acupressure versus control, Outcome 2 Satisfaction with childbirth. . . . . . . . 50
Analysis 2.3. Comparison 2 Acupressure versus control, Outcome 3 Use of pharmacological analgesia. . . . . . 51
Analysis 2.4. Comparison 2 Acupressure versus control, Outcome 4 Caesarean section. . . . . . . . . . . . 52
Analysis 2.5. Comparison 2 Acupressure versus control, Outcome 5 Assisted vaginal birth. . . . . . . . . . 52
Analysis 2.6. Comparison 2 Acupressure versus control, Outcome 6 Apgar score < 7 at 5 minutes. . . . . . . . 53
Analysis 2.7. Comparison 2 Acupressure versus control, Outcome 7 Augmentation with oxytocin. . . . . . . . 53
Analysis 2.8. Comparison 2 Acupressure versus control, Outcome 8 Length of labour. . . . . . . . . . . . 54
Analysis 2.9. Comparison 2 Acupressure versus control, Outcome 9 Anxiety. . . . . . . . . . . . . . . 54
54 APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
57 WHATS NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
57 HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
57 CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
57 DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
57 SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
57 DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .
58 NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
58 INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
i Acupuncture or acupressure for pain management in labour (Review)
Copyright 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]
Acupuncture or acupressure for pain management in labour
Caroline A Smith
1
, Carmel T Collins
2
, Caroline A Crowther
3
, Kate M Levett
4
1
Centre for Complementary Medicine Research, University of WesternSydney, Penrith South DC, Australia.
2
Child NutritionResearch
Centre, Womens and Childrens Health Research Institute, Flinders Medical Centre and Womens and Childrens Hospital; Discipline
of Paediatrics, The University of Adelaide, Bedford Park, Australia.
3
ARCH: Australian Research Centre for Health of Women and
Babies, Discipline of Obstetrics and Gynaecology, The University of Adelaide, Adelaide, Australia.
4
University of Western Sydney,
Sydney, Australia
Contact address: Caroline A Smith, Centre for Complementary Medicine Research, University of Western Sydney, Locked Bag 1797,
Penrith South DC, New South Wales, 2751, Australia. caroline.smith@uws.edu.au.
Editorial group: Cochrane Pregnancy and Childbirth Group.
Publication status and date: Edited (no change to conclusions), published in Issue 8, 2011.
Review content assessed as up-to-date: 1 February 2011.
Citation: Smith CA, Collins CT, Crowther CA, Levett KM. Acupuncture or acupressure for pain management in labour. Cochrane
Database of Systematic Reviews 2011, Issue 7. Art. No.: CD009232. DOI: 10.1002/14651858.CD009232.
Copyright 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A B S T R A C T
Background
Many women would like to avoid pharmacological or invasive methods of pain management in labour and this may contribute towards
the popularity of complementary methods of pain management. This review examined evidence supporting the use of acupuncture
and acupressure for pain management in labour.
Objectives
To examine the effects of acupuncture and acupressure for pain management in labour.
Search methods
We searched the Cochrane Pregnancy and Childbirth Groups Trials Register and The Cochrane Complementary Medicine Fields
Trials Register (October 2010), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 4), MEDLINE
(1966 to October 2010), and CINAHL (1980 to October 2010).
Selection criteria
Published and unpublished randomised controlled trials comparing acupuncture and acupressure with placebo, no treatment or other
non-pharmacological forms of pain management in labour. We included all women whether primiparous or multiparous, and in
spontaneous or induced labour.
Data collection and analysis
We performed meta-analysis using risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes.
The outcome measures included pain intensity, satisfaction with pain relief, use of pharmacological pain relief, relaxation, caesarean
section rate, augmentation with oxytocin, length of labour and anxiety.
1 Acupuncture or acupressure for pain management in labour (Review)
Copyright 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Main results
We included 13 trials with data reporting on 1986 women. Nine trials reported on acupuncture and four trials reported on acupressure.
Less intense pain was found from acupuncture compared with no intervention (standardised mean difference (SMD) -1.00, 95%
condence interval (CI) -1.33 to -0.67, one trial, 163 women). One trial increased satisfaction with pain relief compared with placebo
control (RR 2.38, 95% CI 1.78 to 3.19, 150 women). Reduced use of pharmacological analgesia was found in one trial of acupuncture
compared with placebo (RR 0.72, 95% CI 0.58 to 0.88, 136 women), and compared with standard care, however, there was signicant
heterogeneity (RR 0.68, 95% CI 0.56 to 0.83, three trials, 704 women). Fewer instrumental deliveries from acupuncture were found
compared with standard care (RR 0.67, 95% CI 0.46, 0.98, three trials, 704 women). Pain intensity was reduced in the acupressure
group compared with a placebo control (SMD -0.55, 95% CI -0.92 to -0.19, one trial, 120 women), and a combined control (SMD -
0.42, 95% CI -0.65 to -0.18, two trials, 322 women). No trial was assessed as being at a low risk of bias for all of the quality domains.
Authors conclusions
Acupuncture and acupressure may have a role with reducing pain, increasing satisfaction with pain management and reduced use of
pharmacological management. However, there is a need for further research.
P L A I N L A N G U A G E S U M M A R Y
Acupunture or acupressure for relieving pain in labour
Acupuncture or acupressure may help relieve pain during labour, but more research is needed.
The pain of labour can be intense, and may be worsened because of a womans tension, anxiety and fear affecting their labour and birth
experience . Many women would like to labour without using drugs or invasive methods of pain management, and turn to alternatives
to manage the pain. The review of 13 trials, with data reporting on 1986 women, found that acupuncture or acupressure may help
relieve labour pain. Single or limited numbers of trials reported less intense pain, increased satisfaction with pain relief and reduced
use of analgesic drugs with acupuncture compared with placebo or usual care. Acupressure also reduced pain intensity. Acupuncture
involves the insertion of ne needles into different parts of the body to correct the imbalance of energy in the body. The intervention
was administered at term as individualised treatment (six trials) or at standardised acupuncture points in the majority of trials but with
wide variation in the mode of stimulation, duration of needling, number of points used, depth of needling and duration of the trial.
B A C K G R O U N D
This review is one in a series of Cochrane reviews examining pain
management in labour. These reviews contribute to an overview
of systematic reviews of pain management for women in labour
(Neilson 2011b), and share a generic protocol (Neilson 2011a).
Description of the condition
Labour presents a physiological and psychological challenge for
women. As labour becomes more imminent, this can be a time of
conicting emotions: fear and apprehension can be coupled with
excitement and happiness. Tension, anxiety and fear are factors
contributing towards womens perception of pain and may also af-
fect their labour and birth experience. Pain associated with labour
has been described as one of the most intense forms of pain that
can be experienced (Melzack 1984). Pain experienced by women
in labour is caused by uterine contractions, the dilatation of the
cervix and, in the late rst stage and second stage, by stretching of
the vagina and pelvic oor to accommodate the baby. However,
the complete removal of pain does not necessarily mean a more
satisfying birth experience for women (Morgan 1982). Effective
and satisfactory pain management need to be individualised for
each woman.
Description of the intervention
The use of complementary and alternative medicine (CM) has
become popular with consumers worldwide. Studies suggest that
between36%and 62%of adults in industrialised nations use some
form of CM to prevent or treat health-related problems (Barnes
2 Acupuncture or acupressure for pain management in labour (Review)
Copyright 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
2004). Complementary therapies are more commonly used by
women of reproductive age, with almost half (49%) reporting use
(Eisenberg 1998). It is possible that a signicant proportion of
womenare using these therapies during pregnancy. Arecent review
of 14 studies with large sample sizes (N > 200) on the use of CM
in pregnancy identied a prevalence rate ranging from1%to 87%
(with nine falling between 20% and 60%) (Adams 2009). The
review identied use of various complementary therapies includ-
ing acupuncture and acupressure, aromatherapy, massage, yoga,
homeopathy and chiropractic care. The review also showed many
pregnant womenhad used more thanone complementary product
or service (Adams 2009). Many women would like to avoid phar-
macological or invasive methods of pain relief in labour and this
may contribute towards the popularity of complementary meth-
ods of pain management (Bennett 1999).
The Complementary Medicine Field of The Cochrane Collabora-
tiondenes complementary medicine as practices and ideas which
are outside the domain of conventional medicine in several coun-
tries, which are dened by its users as preventing or treating ill-
ness, or promoting healthand wellbeing (Manheimer 2008). This
denition is deliberately broad, as therapies considered comple-
mentary practices in one country or culture may be conventional
in another. Many therapies and practices are included within the
scope of the Complementary Medicine Field. These include treat-
ments people can administer themselves (e.g. botanicals, nutri-
tional supplements, health food, meditation, magnetic therapy),
treatments providers administer (e.g. acupuncture, massage, re-
exology, chiropractic and osteopathic manipulations), and treat-
ments people can administer under the periodic supervision of a
provider (e.g. yoga, biofeedback, Tai Chi, homoeopathy, Alexan-
der therapy, Ayurveda).
The most commonly cited complementary medicine and practices
associated with providing pain management in labour can be cat-
egorised into mind-body interventions (e.g. yoga, hypnosis, relax-
ation therapies), alternative medical practice (e.g. homoeopathy,
traditional Chinese medicine), manual healing methods (e.g. mas-
sage, reexology), pharmacologic and biological treatments, bio-
electromagnetic applications (e.g. magnets) and herbal medicines.
Acupuncture has a long history of use in Asia, including China,
Korea and Japan. Traditional Chinese medicine (TCM), with
acupuncture as one of the major modalities, describes a state of
health maintained by a balance of energy in the body. Acupunc-
ture performed within the context of TCM is a complex inter-
vention involving not only technical needling skill but develop-
ment of a therapeutic relationship, formulation of a diagnosis,
provision of lifestyle advice, and often administering co-interven-
tions such as gua sha (scrapping), tuina (massage), moxibustion
(a type of Chinese medicine which involves burning a herb close
to the skin) or electrical stimulation. In clinical practice, use of
co-interventions is not uncommon although acupuncture is the
primary focus. Acupuncture involves the insertion of ne needles
into different parts of the body to correct the imbalance of energy
in the body. TCM and Classical acupuncture explain disease and
physiological function based on theoretical concepts of Yin and
Yang and the Five Elements. A westernised medical application of
acupuncture involves the use of acupuncture using trigger points,
segmental points and commonly used formula points. Auricular
therapy, a formof Western acupuncture, involves the use of the ear
to make a diagnosis and subsequent needling to points on the ear.
Medical acupuncture may involve the application of acupuncture
based on the principles of neurophysiology and anatomy, rather
than TCM principles and philosophy. The style and approach of
acupuncture characterises the acupuncture point selection and re-
lated treatment parameters administered in clinical practice and
research.
Acupressure has its origins in early China, and is based on the
same paradigm as described for acupuncture. When acupressure
is applied, the therapist uses their hands and ngers to activate
the same points as applied by acupuncture. Sometimes only a few
points need touch applied to alleviate pain, or bring about a feeling
of relaxation. In other circumstances a combinations of points
will be used to achieve a greater effect. There are several forms of
acupressure, whichdrawonthe same knowledge and philosophical
systemas other forms of traditional Asian medicine. Some of these
systems are applied by trained health professionals and others can
be applied by the individual as a form of self-massage.
How the intervention might work
Acupuncture has been used to treat a number of painful condi-
tions, and several theories have been presented as to howacupunc-
ture may work. It has been proposed that acupuncture may
modify the perception of pain, or alter physiological functions
(Stux 1995). Since the majority of acupuncture points are ei-
ther connected to, or located near, neural structures, this suggests
that acupuncture stimulates the nervous system. From a Western
acupuncture perspective, points selected are based according to
the innervation of the target organ, e.g. the uterus. Activation of
muscle afferents at this segmental level transmits signals in the
spinal cord and in the central nervous system. During needle stim-
ulation of common acupuncture points for pain, signals are trans-
mitted to the spinal cord, and via afferent pathways to the mid-
brain. The perception of pain emerges fromthe resulting ow and
integration of this information among specic brain areas, and
may lead to a change in the perception of pain. Another theory
suggests that acupuncture stimulates the body to produce endor-
phins, which reduce pain (Pomeranz 1989). Other pain-relieving
substances called opioids may be released into the body during
acupuncture treatment (Ng 1992). Both segmental and central
mechanisms of acupuncture are likely to be involved in the total
effect of acupuncture (Stener-Victorin 2006).
3 Acupuncture or acupressure for pain management in labour (Review)
Copyright 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Why it is important to do this review
There is interest by women to use additional forms of care to assist
with their pain management in labour. It is important to examine
the efcacy, effectiveness and safety of under-evaluated forms of
treatment to enable women, health providers and policy makers
to make informed decisions about care. A number of clinical tri-
als have been performed to study the efcacy of acupuncture for
pain in labour although it remains uncertain whether the existing
evidence is rigorous enough to reach a denitive conclusion.
This review is one in a series of Cochrane reviews examining pain
relief in labour. These reviews contribute to an overviewof system-
atic reviews of pain relief for women in labour (Neilson 2011b)
and share a generic protocol (Neilson 2011a).
O B J E C T I V E S
To examine the effects of acupuncture and acupressure for pain
management in labour.
M E T H O D S
Criteria for considering studies for this review
Types of studies
Randomised controlled trials (RCTs) only. (We have planned not
to include results from quasi-RCTs in the analyses but we may be
discuss them in the text if little other evidence is available.)
Types of participants
Women in labour. (This includes women in high-risk groups, e.g.
preterm labour or following induction of labour. We planned to
use subgroup analysis for any possible differences in the effect of
interventions in these groups.)
Types of interventions
This review is one in a series of Cochrane reviews examining pain
management in labour. These reviews contribute to an overviewof
systematic reviews of interventions for pain management in labour
(Neilson 2011b), and share a generic protocol (Neilson 2011a).
To avoid duplication, the different methods of pain management
have been listed in a specic order, from one to 15. Individual
reviews focusing on particular interventions include comparisons
with only the interventions above it on the list. Methods of pain
management identied in the future will be added to the end of
the list. The current list is as follows.
1. Placebo/no treatment
2. Hypnosis
3. Biofeedback (Barragn 2006)
4. Intracutaneous or subcutaneous sterile water injection
(Derry 2011)
5. Immersion in water (Cluett 2009)
6. Aromatherapy (Smith 2011)
7. Relaxation techniques (yoga, music, audio)
8. Acupuncture or acupressure (this review)
9. Manual methods (massage, reexology)
10. Transcutaneous electrical nerve stimulation (TENS)
(Dowswell 2009)
11. Inhaled analgesia
12. Opioids (Ullman 2010)
13. Non-opioid drugs (Othman 2011)
14. Local anaesthetic nerve blocks
15. Epidural (including combined spinal-epidural)
(Anim-Somuah 2005; Simmons 2007)
Accordingly, this review includes comparisons of any type of
acupuncture or acupressure compared with any other type of
acupuncture or acupressure, as well as any type of acupuncture or
acupressure compared with: 1. placebo/no treatment; 2. hypnosis;
3. biofeedback; 4. intracutaneous or subcutaneous sterile water
injection; 5. immersion in water; 6. aromatherapy; 7. relaxation
techniques (yoga, music, audio).
Types of outcome measures
Primary outcomes
Effects of interventions
Pain intensity (as dened by trialists)
Satisfaction with pain relief (as dened by trialists)
Sense of control in labour (as dened by trialists)
Satisfaction with childbirth experience
Use of pharmacological pain relief
Safety of interventions
Effect (negative) on mother/baby interaction
Breastfeeding (at specied time points)
Assisted vaginal birth
Caesarean section
Side effects (for mother and baby; review specic)
Admission to special care baby unit/neonatal intensive care
unit (as dened by trialists)
Apgar score less than seven at ve minutes
Poor infant outcomes at long-term follow-up (as dened by
trialists)
4 Acupuncture or acupressure for pain management in labour (Review)
Copyright 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Other outcomes
Cost (as dened by trialists)
Secondary outcomes
Maternal
Length of labour; mode of delivery; need for augmentation with
oxytocin; perineal trauma (dened as episiotomy and incidence
of second- or third-degree tear); maternal blood loss (postpartum
haemorrhage dened as greater than 600 ml); relaxation; anxiety.
Neonatal
Need for mechanical ventilation; neonatal encephalopathy.
Search methods for identication of studies
Electronic searches
We searched the Cochrane Pregnancy and Childbirth Groups Tri-
als Register by contacting the Trials Search Co-ordinator (October
2010).
The Cochrane Pregnancy and Childbirth Groups Trials Register
is maintained by the Trials Search Co-ordinator and contains trials
identied from:
1. quarterly searches of the Cochrane Central Register of
Controlled Trials (CENTRAL);
2. weekly searches of MEDLINE;
3. handsearches of 30 journals and the proceedings of major
conferences;
4. weekly current awareness alerts for a further 44 journals
plus monthly BioMed Central email alerts.
Details of the search strategies for CENTRAL and MEDLINE,
the list of handsearched journals and conference proceedings, and
the list of journals reviewed via the current awareness service can
be found in the Specialized Register section within the edito-
rial information about the Cochrane Pregnancy and Childbirth
Group.
Trials identied through the searching activities described above
are each assigned to a review topic (or topics). The Trials Search
Co-ordinator searches the register for each review using the topic
list rather than keywords.
We searchedthe Cochrane Complementary Medicine Fields Trials
Register using the terms (labor OR labour).
In addition, we searched the Cochrane Central Register of Con-
trolled Trials (The Cochrane Library 2010, Issue 4), MEDLINE
(1966 to October 2010), and CINAHL (1980 to October 2010)
using a combination of subject headings and text words. See
Appendix 1.
We did not apply any language restrictions.
Data collection and analysis
We used the following methods when assessing any reports iden-
tied by the search.
Selection of studies
C Smith (CS), CT Collins (CTC) or K Levett (KL) screened the
titles and abstracts of articles found in the search, and discarded
trials that were clearly not eligible. Two out of the four review
authors (CS, CTC, KL, CA Crowther (CAC)) undertook trial
selection.
CS, KL or CTC independently assessed whether the trials met the
inclusion criteria, with disagreements resolved by discussion with
the fourth author (CAC). When articles contained insufcient
information to make a decision about eligibility, CS attempted to
contact authors of the original reports to obtain further details.
Data extraction and management
Following an assessment for inclusion CS, KL or CTC indepen-
dently extracteddata using the formdesignedby the ReviewGroup
for this purpose. We resolved discrepancies through discussion or,
if required, we consulted a fourth person. For each included trial,
we collected information regarding the location of the trial, meth-
ods of the trial (as per assessment of risk of bias), the participants
(age range, eligibility criteria), the nature of the interventions, and
data relating to the outcomes specied above. We collected in-
formation on reported benets and adverse effects. When infor-
mation regarding any of the above was unclear, we attempted to
contact authors of the original reports to provide further details.
We entered data into Review Manager software (RevMan 2011)
and checked for accuracy.
Assessment of risk of bias in included studies
Two review authors independently assessed the risk of bias for
each study using the criteria outlined in the Cochrane Handbook
for Systematic Reviews of Interventions (Higgins 2011). We resolved
any disagreement by discussion or by involving a third assessor.
(1) Random sequence generation (checking for possible
selection bias)
We described for each included study the method used to generate
the allocation sequence in sufcient detail to allow an assessment
of whether it should produce comparable groups.
We will assessed the method as:
low risk of bias (any truly random process, e.g. random
number table; computer random number generator);
5 Acupuncture or acupressure for pain management in labour (Review)
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high risk of bias (any non-random process, e.g. odd or even
date of birth; hospital or clinic record number); or
unclear risk of bias.
(2) Allocation concealment (checking for possible selection
bias)
We described for each included study the method used to con-
ceal allocation to interventions prior to assignment and assessed
whether intervention allocation could have been foreseen in ad-
vance of, or during recruitment, or changed after assignment.
We assessed the methods as:
low risk of bias (e.g. telephone or central randomisation;
consecutively numbered sealed opaque envelopes);
high risk of bias (open random allocation; unsealed or non-
opaque envelopes, alternation; date of birth);
unclear risk of bias.
(3) Blinding (checking for possible performance bias)
We judged that blinding of participants and caregiver would not
be possible due to the type of intervention being assessed. For
this reason we assessed whether the lack of blinding was likely to
have introduced bias in the measure of outcomes of interest. We
assessed blinding for primary outcomes as:
low, high or unclear risk of bias.
(4) Incomplete outcome data (checking for possible attrition
bias due to the amount, nature and handling of incomplete
outcome data)
We described for each included study, and for each outcome or
class of outcomes, the completeness of data including attrition and
exclusions from the analysis. We stated whether attrition and ex-
clusions were reported and the numbers included in the analysis at
each stage (compared with the total randomised participants), rea-
sons for attrition or exclusion where reported, and whether miss-
ing data were balanced across groups or were related to outcomes.
Where sufcient information is reported, or can be supplied by
the trial authors, we will re-include missing data in the analyses
which we undertake.
We assessed methods as:
low risk of bias (e.g. no missing outcome data; missing
outcome data balanced across groups);
high risk of bias (e.g. numbers or reasons for missing data
imbalanced across groups; as treated analysis done with
substantial departure of intervention received from that assigned
at randomisation);
unclear risk of bias.
(5) Selective reporting (checking for reporting bias)
We described for each included study how we investigated the
possibility of selective outcome reporting bias and what we found.
We assessed the methods as:
low risk of bias (where it is clear that all of the studys pre-
specied outcomes and all expected outcomes of interest to the
review have been reported);
high risk of bias (where not all the studys pre-specied
outcomes have been reported; one or more reported primary
outcomes were not pre-specied; outcomes of interest are
reported incompletely and so cannot be used; study fails to
include results of a key outcome that would have been expected
to have been reported);
unclear risk of bias.
(6) Other bias (checking for bias due to problems not
covered by 1 to 5 above)
We described for each included study any important concerns we
had about other possible sources of bias.
We assessed whether each study was free of other problems that
could put it at risk of bias:
low risk of other bias;
high risk of other bias;
unclear whether there is risk of other bias.
(7) Overall risk of bias
We made explicit judgements about whether studies are at highrisk
of bias, according to the criteria given in the Handbook (Higgins
2011). With reference to (1) to (6) above, we assessed the likely
magnitude and direction of the bias and whether we considered it
likely to impact on the ndings. We planned to explore the impact
of the level of bias through undertaking sensitivity analyses - see
Sensitivity analysis.
Measures of treatment effect
Dichotomous data
For dichotomous data, we presented results as summary risk ratio
with 95% condence intervals.
Continuous data
We expressed continuous data as mean differences with 95% con-
dence intervals, or as standardised mean differences if outcomes
were conceptually the same in the different trials but measured in
different ways.
6 Acupuncture or acupressure for pain management in labour (Review)
Copyright 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Unit of analysis issues
We planned to include cluster-randomised trials in the analyses
along with individually randomised trials, and adjust their sample
sizes or standard errors using the methods described in the Hand-
book using an estimate of the intra-cluster correlation co-efcient
(ICC) derived from the trial (if possible), from a similar trial or
from a study of a similar population. If we used ICCs from other
sources, we planned to report this and conduct sensitivity analyses
to investigate the effect of variation in the ICC. If we identied
both cluster-randomised trials and individually-randomised trials,
we planned to synthesise the relevant information. We considered
it reasonable to combine the results from both if there was little
heterogeneity between the study designs and the interaction be-
tween the effect of intervention and the choice of randomisation
unit was considered to be unlikely.
We also planned to acknowledge heterogeneity in the randomisa-
tion unit and perform a sensitivity analysis to investigate the ef-
fects of the randomisation unit.
Dealing with missing data
For included studies, we noted levels of attrition. We aimed to
explore the impact of including studies with high levels of missing
data in the overall assessment of treatment effect by using sensi-
tivity analysis.
For all outcomes, we carried out analyses, as far as possible, on
an intention-to-treat basis, i.e. we attempted to include all partic-
ipants randomised to each group in the analyses, and all partici-
pants were analysed in the group to which they were allocated, re-
gardless of whether or not they received the allocated intervention.
The denominator for each outcome in each trial was the number
randomised minus any participants whose outcomes are known
to be missing. We excluded trials with greater than 20% missing
data from the analysis.
Assessment of heterogeneity
We assessed statistical heterogeneity in each meta-analysis using
the T, I and Chi statistics. We regarded heterogeneity as sub-
stantial if T was greater than zero and either I was greater than
50% or there was a low P value (less than 0.10) in the Chi test
for heterogeneity.
Assessment of reporting biases
If there were 10 or more studies in the meta-analysis we planned to
investigate reporting biases (such as publication bias) using funnel
plots. We would assess funnel plot asymmetry visually, and would
use formal tests for funnel plot asymmetry. For continuous out-
comes we would use the test proposed by Egger 1997, and for di-
chotomous outcomes we would use the test proposed by Harbord
2006. If we detected asymmetry in any of these tests or by a vi-
sual assessment, we proposed to perform exploratory analyses to
investigate it.
Data synthesis
We carried out statistical analysis using the Review Manager soft-
ware (RevMan 2011). We used xed-effect meta-analysis for com-
bining data where it was reasonable to assume that studies were
estimating the same underlying treatment effect: i.e. where trials
were examining the same intervention, and the trials populations
and methods were judged sufciently similar. If there was clinical
heterogeneity sufcient to expect that the underlying treatment
effects differed between trials, or if substantial statistical hetero-
geneity was detected, we used a random-effects meta-analysis to
produce an overall summary if an average treatment effect across
trials was considered clinically meaningful. We treated the ran-
dom-effects summary as the average range of possible treatment
effects and we planned to discuss the clinical implications of treat-
ment effects differing betweentrials. If the average treatment effect
was not clinically meaningful we would not combine trials.
If we used the random-effects analyses, we have presented the
results as the average treatment effect with its 95% condence
interval, and the estimates of T and I.
Subgroup analysis and investigation of heterogeneity
We investigated substantial heterogeneity using subgroup analyses
and sensitivity analyses. We considered whether an overall sum-
mary was meaningful, and if it was, we undertook a random-ef-
fects analysis.
We planned to carry out the following subgroup analyses.
1. Spontaneous labour versus induced labour.
2. Primiparous versus multiparous
3. Term versus preterm birth
4. Continuous support in labour versus no continuous support
For xed-effect inverse variance meta-analyses we planned to assess
differences between subgroups by interaction tests. For random-
effects and xed-effect meta-analyses using methods other than
inverse variance, we planned to assess differences between sub-
groups by inspection of the subgroups condence intervals; non-
overlapping condence intervals indicate a statistically signicant
difference in treatment effect between the subgroups.
Sensitivity analysis
Where subgroup analysis failed to explain the heterogeneity, we
planned to analyse the data using the random-effects model. A
priori, we planned to performsensitivity analyses on results to look
at the possible contribution of: (1) differences in methodological
quality, with trials of high quality (lowrisk of bias) compared to all
trials; and (2) publication bias by country. If publication bias was
7 Acupuncture or acupressure for pain management in labour (Review)
Copyright 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
present we planned to undertake a sensitivity analysis excluding
trials from countries where there was a greater publication bias.
R E S U L T S
Description of studies
See: Characteristics of included studies; Characteristics of
excluded studies; Characteristics of studies awaiting classication;
Characteristics of ongoing studies.
Results of the search
The original review included a range of complementary therapies.
This updated review includes acupuncture and acupressure tri-
als only; we included 13 studies, and excluded nine studies. We
included eight new studies (Borup 2009; Hantoushzadeh 2007;
Hjelmstedt 2010; Huang 2008; Kashanian 2010; Martensson
2008; Qu 2007; Ziaei 2006) and ve studies await further assess-
ment. See Characteristics of included studies, Characteristics of
excluded studies, Characteristics of studies awaiting classication,
and Characteristics of ongoing studies.
Included studies
Study design
All studies were parallel design. Eight studies had two groups
(Hantoushzadeh 2007; Kashanian 2010; Lee 2004; Martensson
2008; Nesheim2003; Qu 2007; Ramnero 2002; Skilnand 2002).
Four studies had three groups (Borup 2009; Chung 2003;
Hjelmstedt 2010; Ziaei 2006) and one study had four arms
(Huang 2008). Comparative and control groups varied. Six studies
used placebo controls (Hantoushzadeh 2007; Hjelmstedt 2010;
Kashanian 2010; Lee 2004; Skilnand 2002; Ziaei 2006). Placebo
techniques varied between invasive and non-invasive techniques.
Comparison with medication was used in two studies (Borup
2009; Huang 2008). Other control groups included standard care;
passive supportive care by the midwife (Chung 2003); or unspeci-
ed care standard care in three studies (Hjelmstedt 2010; Nesheim
2003; Ramnero 2002). Huang 2008 used transcutaneous electri-
cal nerve stimulation and a breathing group; Martensson 2008
used sterile water injections, and no intervention was reported in
two studies (Qu 2007; Ziaei 2006).
Sample sizes
Studies included in the review ranged from 36 (Qu 2007) to 607
(Borup 2009).
Study location and sources of women
Three studies were undertaken in Iran (Hantoushzadeh 2007;
Kashanian 2010; Ziaei 2006), two studies each were undertaken
in China (Huang 2008; Qu 2007), Norway (Nesheim 2003;
Skilnand 2002) and Sweden (Martensson 2008; Ramnero 2002),
and one study each in Denmark (Borup 2009), India (Hjelmstedt
2010), Korea (Lee 2004) and Taiwan (Chung 2003).
Participants
Seven studies recruited both nulliparous and primiparous women
(Borup 2009; Chung 2003; Lee 2004; Martensson 2008; Nesheim
2003; Ramnero 2002; Skilnand 2002). Nulliparous women were
recruitedinthree studies (Hantoushzadeh 2007; Hjelmstedt 2010;
Kashanian 2010). Parous women only were recruited in two stud-
ies (Huang 2008; Qu 2007), and parity was unclear in one study
(Ziaei 2006). Women were recruited in spontaneous labour in
eight studies (Chung 2003; Hantoushzadeh 2007; Martensson
2008; Nesheim 2003; Qu 2007; Ramnero 2002; Skilnand 2002;
Ziaei 2006). Two studies recruited women in both spontaneous
and induced labour (Borup 2009; Hjelmstedt 2010). Reporting
on the onset of labour was unclear in three studies (Huang 2008;
Kashanian 2010; Lee 2004).
The intervention was administered at term for the majority of
trials studies except Huang 2008 where details were not reported.
Types of intervention
Four studies used acupressure (Chung 2003; Hjelmstedt 2010;
Kashanian 2010; Lee 2004) and nine studies used acupuncture
(Borup 2009; Hantoushzadeh 2007; Huang 2008; Martensson
2008; Nesheim 2003; Qu 2007; Ramnero 2002; Skilnand 2002;
Ziaei 2006) (includes manual andelectro-acupuncture). Acupunc-
ture and acupressure varied in point selection, frequency of treat-
ment and number of treatments, with commonly used points in-
cluded SP6, LI4, BL23, BL32, HT7, GB34, LR3, ST36. A xed
set of acupuncture points only were administered in three studies
(Qu 2007; Skilnand 2002; Ziaei 2006). A xed set of acupres-
sure points was used in four studies (Chung 2003; Hjelmstedt
2010; Kashanian 2010; Lee 2004). Individualised treatment was
administered in six studies (Borup 2009; Hantoushzadeh 2007;
Huang 2008; Martensson 2008; Nesheim2003; Ramnero 2002).
See Characteristics of included studies.
Outcome measures
All studies reported on pain. Maternal outcomes (satisfac-
tion, sense of control) were reported in nine studies (Borup
2009; Chung 2003; Hjelmstedt 2010; Huang 2008; Lee 2004;
Martensson 2008; Qu 2007; Ramnero 2002; Ziaei 2006), and
clinical outcomes were reported in the majority of studies ex-
cept for Huang 2008. See details of all outcomes reported within
Characteristics of included studies.
8 Acupuncture or acupressure for pain management in labour (Review)
Copyright 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Excluded studies
We excluded nine trials; see Characteristics of excluded studies.
One study did not meet the inclusion criteria based on the criteria
for interventions: for example, the use of point injection therapy
(Zhang 2000). We excluded four studies due to insufcient re-
porting of randomisation, or other aspects of study design, or no
clinically relevant data (Bo 2006; Deen 1985; Li 2006; Ternov
1998) and we were unable to ascertain true randomisation status
from the author. No clinically relevant outcomes were reported in
three trials (Li 1996; Shalev 1991; Shang 1995). One study was
reported as an abstract only with insufcient reporting to deter-
mine inclusion (Park 2003). Further background information on
these trials is presented in Characteristics of excluded studies.
Risk of bias in included studies
See Figure 1 and Figure 2 for a graphical summary of the risk of
bias assessments by authors of the included studies based on the
six risk of bias domains. No study was at a low risk of bias on all
domains.
Figure 1. Methodological quality graph: review authors judgements about each methodological quality
item presented as percentages across all included studies.
9 Acupuncture or acupressure for pain management in labour (Review)
Copyright 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Figure 2. Methodological quality summary: review authors judgements about each methodological quality
item for each included study.
10 Acupuncture or acupressure for pain management in labour (Review)
Copyright 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Allocation
Method of allocation
Most of the trials (92%) were rated at a low risk of bias for
adequate generation of the randomisation sequence. In 53% of
the trials the sequence was computer generated (Borup 2009;
Hantoushzadeh 2007; Hjelmstedt 2010; Huang 2008; Kashanian
2010; Martensson 2008; Nesheim 2003). The sequence was by
lot drawing in two trials (Qu 2007; Skilnand 2002), coin tossing
in one trial (Chung 2003), randomnumber tables in one trial (Lee
2004), and shufing cards in one trial (Ramnero 2002).
Allocation concealment
Allocation concealment was described as low risk in nine trials
(69%). Sealed envelopes were used in seven trials (Hantoushzadeh
2007; Hjelmstedt 2010; Kashanian 2010; Martensson 2008;
Nesheim2003; Ramnero 2002; Skilnand 2002), central randomi-
sation in one trial (Borup 2009) and sequential numbers in one
trial (Chung 2003).
Blinding
Blinding was assessed at low risk in three trials (Hantoushzadeh
2007; Lee 2004; Skilnand 2002). The risk of blinding was unclear
in ve trials due to poor reporting. The intervention could not be
administered blind.
Incomplete outcome data
Outcome reporting was assessed at a low risk of bias in 69% of
trials.
Selective reporting
The risk of bias from selective reporting was unclear in all trials
due to the absence of a study protocol.
Other potential sources of bias
The risk of bias from other sources of bias was rated as low in
eight trials (Borup 2009; Chung 2003; Kashanian2010; Lee 2004;
Martensson 2008; Nesheim 2003; Qu 2007; Ramnero 2002).
Effects of interventions
We included 12 trials in the meta-analysis with data reporting
on 1950 women using different modalities of pain management.
Data were not reported in a form that could be included in the
meta-analysis from the Qu 2007 study.
1) Acupuncture
Primary outcomes
1.1) Outcome: pain intensity
Data on pain intensity were reported from four trials with 493
women (Analysis 1.1).
1.1.1 Placebo control
There was signicant heterogeneity indicated by the I statistic and
we applied a random-effects model. There was no difference in the
intensity of pain between groups (standardised mean difference
(SMD) 0.04, 95% condence interval (CI) -0.22 to 0.30, two
trials 240 women).
1.1.2 Standard care
There was no difference in pain intensity between groups (SMD
-0.14, 95% CI -0.55 to 0.28, one trial, 90 women).
1.1.3 No treatment
Women receiving acupuncture reported less intense pain com-
pared with women receiving no intervention (SMD -1.00, 95%
CI -1.33 to -0.67, one trial, 163 women). The electro-acupuncture
group reported a lower intensity of pain compared with the con-
trol group (26 participants, one trial Qu 2007 study (P = 0.018)).
1.2) Outcome: satisfaction with pain relief in labour
Data on satisfaction with pain relief in labour were available from
four trials and 784 women (Analysis 1.2).
1.2.1 Placebo control
Acupuncture increased satisfaction with pain relief in labour com-
pared with placebo control (risk ratio (RR) 2.38, 95% CI 1.78 to
3.19, one trial, 150 women).
1.2.2 Standard care
There was no difference in satisfaction between groups (RR 1.08,
95% CI 0.95 to 1.22, one trial, 90 women). Comparative data
between two groups were not available, fromthe Borup 2009 trial,
59% of women receiving acupuncture thought acupuncture gave
some or substantial pain relief.
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1.2.3 Water injection
Continuous data were reported and not included in the meta-
analysis from the Martensson 2008 trial. Women receiving water
injection were more satised with pain relief from water injection
compared with acupuncture (mean difference (MD) 18.60, 95%
CI 11.54 to 25.66, one trial, 128 women).
1.3) Outcome: use of pharmacological analgesia
Five trials, 968 women (Analysis 1.3).
1.3.1 Placebo control
One small trial of acupuncture compared with placebo found a
reduction in the use of pharmacological analgesia (RR 0.72, 95%
CI 0.58 to 0.88, one trial, 136 women).
1.3.2 Standard care
Use of pharmacological analgesia was lower in the acupuncture
group compared with standard care, however there was signicant
heterogeneity (RR 0.68, 95% CI 0.56 to 0.83, three trials, 704
women).
1.3.3 Water injection
There were no differences between groups (RR0.84, 95%CI 0.54
to 1.30, one trial, 128 women).
1.4) Outcome: caesarean section
Data on caesarean delivery were reported in seven trials and 1245
women (Analysis 1.4).
1.4.1 Placebo control
There was no difference between groups with caesarean delivery
(RR 1.39, 95% CI 0.62 to 3.10, three trials, 448 women).
1.4.2 Standard care
There was no difference between groups with caesarean delivery
(RR 0.86, 95% CI 0.47 to 1.60, two trials, 506 women).
1.4.3 No treatment
There was no difference between groups with caesarean delivery
(RR 0.76, 95% CI 0.35 to 1.83, one trial 163 women).
1.4.4 Water injection
There was no difference between groups with caesarean delivery
(RR 1.33, 95% CI 0.37 to 4.73, one trial, 128 women).
1.5) Outcome: assisted vaginal birth
Six trials reported on this outcome, 1203 women (Analysis 1.5).
1.5.1 Placebo control
There was no difference between groups (RR 0.64, 95% CI 0.27
to 1.50, one trial, 208 women).
1.5.2 Standard care
Three trials found a reduction with instrumental delivery favour-
ing acupuncture compared with standard care (RR 0.67, 95% CI
0.46 to 0.98, 704 women).
1.5.3 No treatment
There was no difference between groups (RR 0.49, 95% CI 0.18
to 1.38, one trial, 163 women).
1.5.4 Water injection
There was no difference between groups (RR 1.60, 95% CI 0.47
to 5.39, one trial, 128 women).
1.6) Outcome: Apgar score less than seven at ve minutes
Four trials, 914 women reported on this outcome (Analysis 1.6).
1.6.1 Placebo control
The number of babies with low Apgar scores at ve minutes was
small. There was no difference between groups (RR 0.32, 95% CI
0.01 to 7.79, one trial, 208 women).
1.6.2 Standard care
There were no differences between groups (RR0.60, 95%CI 0.12
to 2.99, three trials, 706 women).
1.7) Outcome: vaginal delivery
Three trials, 415 women reported on this outcome (Analysis 1.7).
1.7.1 Placebo control
There was signicant statistical heterogeneity betweentrials. There
were no differences between groups (RR 1.00, 95% CI 0.87 to
1.14, two trials, 325 women).
1.7.2 Standard care
There were no differences between groups (RR0.98, 95%CI 0.89
to 1.08 women, one trial, 90 women).
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1.8) Outcome: augmentation with oxytocin
Five trials, 710 women reported on this outcome (Analysis 1.8).
1.8.1 Placebo control
There was signicant heterogeneity between trials; there were no
differences between groups (RR 0.62, 95% CI 0.15 to 2.52, two
trials, 358 women).
1.8.2 Standard care
There were no differences between groups (RR0.88, 95%CI 0.72
to 1.08, two trials, 224 women).
1.8.3 Water injection
There were no differences between groups (RR1.16, 95%CI 0.85
to 1.58, one trial, 128 women).
1.9) Outcome: relaxation
Three trials reported on this outcome, 308 women (Analysis 1.9).
1.9.1 Placebo control
There were no differences between groups (SMD -0.27, 95% CI
-0.72 to 0.17, one trial, 90 women).
1.9.2.Standard care
Acupuncture increased relaxation compared with standard care
(SMD -0.51, 95% CI -0.93 to -0.09, one trial, 90 women).
1.9.3 Water injection
Water injection increased womens reported of relaxation com-
pared with acupuncture (SMD 0.55, 95% CI 0.20 to 0.91, one
trial 128 women).
1.10) Outcome: length of labour
Length of labour was reported differently between trials, and not
combined in a meta-analysis.
1.10.1 Placebo control (two trials)
The active phase of labour was shorter in the acupuncture group
compared with control (3.41, 3.06 to 3.77 versus 4.45, 4.06
to 4.83, P < 0.001) (Hantoushzadeh 2007). Length of labour
from the initiation of acupuncture was signicantly in favour of
acupuncture (MD 71 fewer minutes, 95% CI -123.70 to -18.30)
(Skilnand 2002).
1.10.2 Standard care
Ramnero 2002 reported on the duration of labour from less than
4 cm to birth, there was no difference between groups (MD-0.30,
95% CI -1.79 to 1.19, one trial, 100 women).
1.10.3 Water injection
Martensson 2008 reported on the time fromtreatment to delivery
in minutes, there was no difference between groups (MD -90.1,
95% CI -187.02 to 6.82, one trial 300 women).
2) Acupressure
Primary outcomes
2.1) Outcome: pain intensity
Three trials, 462 women reported on this outcome (Analysis 2.1).
2.1.1 Placebo control
Pain intensity was reduced in the acupressure group compared
with the placebo control (SMD -0.55, 95% CI -0.92 to -0.19,
one trial, 120 women).
2.2.2 Combined control (placebo and no treatment)
Pain intensity was reduced in the acupressure group compared
with the combined control (SMD -0.42, 95% CI -0.65 to -0.18,
two trials, 322 women).
2.2) Outcome: satisfaction with childbirth
One trial, 211 women reported on this outcome (Analysis 2.2).
2.2.1 Combined control
There was no difference between groups (MD4.80, 95%CI -2.29
to 11.89, one trial, 211 women).
2.3) Outcome: use of pharmacological analgesia
Two trials, 287 women reported on this outcome (Analysis 2.3).
2.3.1 Placebo control
There was no difference between groups (RR 0.54, 95% CI 0.20
to 1.43, one trial, 75 women).
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2.3.2 Combined control
There was no difference between groups (RR 0.94, 95% CI 0.71
to 1.25, one trial, 145 women).
2.4) Outcome: caesarean section
Two trials, 332 women reported on this outcome (Analysis 2.4).
2.4.1 Placebo control
Caesarean section was reduced in the acupressure group compared
with the placebo control group (RR 0.24, 95% CI 0.11 to 0.54,
one trial, 120 women).
2.4.2 Combined control
Caesarean section was reduced in the acupressure group compared
with the placebo control group (RR 0.48, 95% CI 0.22 to 1.04,
one trial, 222 women).
2.5) Outcome: assisted vaginal birth
One trial, 222 women (Analysis 2.5).
2.5.1 Combined control
There was no difference between groups (RR 0.81, 95% CI 0.39
to 1.67, one trial, 212 women).
2.6) Outcome: Apgar score less than seven at ve minutes
2.6.1 Placebo control
One trial reported on this outcome. No infants met this criteria
(Analysis 2.6).
2.7) Outcome: augmentation with oxytocin
Two trials, 332 women reported on this outcome (Analysis 2.7).
2.7.1 Placebo control
Augmentation was lower in the acupressure group compared with
placebo control (RR 0.66, 95% CI 0.46 to 0.94, one trial, 120
women).
2.7.2 Combined control
There was no difference between groups (RR 1.01, 95% CI 0.77
to 1.31, one trial, 222 women).
2.8) Outcome: length of labour
2.8.1 Placebo control
There was signicant heterogeneity betweentrials; lengthof labour
was lower in the acupressure group compared with placebo control
(SMD -1.06, 95% CI -1.74 to -0.38, two trials, 195 women)
(Analysis 2.8).
2.9) Outcome: anxiety
2.9.1 Placebo control
Acupressure reduced anxiety compared with placebo control (MD
-1.40, 95%CI -2.51 to -0.29, one trial, 75 women) (Analysis 2.9).
Sensitivity analysis
It was proposed to undertake a sensitivity analysis on the results
to look at the possible contribution of: (1) differences in method-
ological quality, with trials of high quality (low risk of bias) com-
pared to all trials; and (2) publication bias by country. This was
not done due to the small number of trials overall. There were no
trials of high quality; there were also too few trials within com-
parisons to make comparisons to examine the inuence of publi-
cation bias. Where there was heterogeneity, we applied a random-
effects model.
Subgroup analysis
We did not undertake subgroup analysis, based on insufcient
reporting of trials with the variables of interest by outcome.
D I S C U S S I O N
Summary of main results
Evidence from 13 trials and 1950 women included in the review
suggest a limited benet from acupuncture and acupressure in re-
lation to the primary outcomes of reduced pharmacological anal-
gesia, less intense pain and increased maternal satisfaction. There
was a reduced use of pharmacological analgesia found in one trial
of acupuncture compared with placebo (risk ratio (RR) 0.72, 95%
condence interval (CI) 0.58 to 0.88), and from three trials com-
pared with standard care; however, there was signicant hetero-
geneity (RR 0.68, 95% CI 0.56 to 0.83). There was a reduction
in pain intensity in one trial of acupuncture compared with no
intervention (standardised mean difference (SMD) -1.00, 95%CI
-1.33 to -0.67). One trial reported increased satisfaction with pain
14 Acupuncture or acupressure for pain management in labour (Review)
Copyright 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
relief in labour compared with placebo control (RR 2.38, 95% CI
1.78 to 3.19). There was a reduction with instrumental delivery
from acupuncture compared with standard care (RR 0.67, 95%
CI 0.46 to 0.98). Pain intensity was reduced in the acupressure
group compared with the placebo control (SMD -0.l55, 95% CI
-0.92 to -0.19) and a combined control group (SMD -0.42, 95%
CI -0.65 to -0.18). Currently there are a small number of trials
included within each comparison, and this limits the power of
the review to detect meaningful differences between groups and
analyses, suggesting these limited benets should be interpreted
with caution.
Overall completeness and applicability of
evidence
There remain relatively few trials of acupuncture and acupressure
that assess the role of these interventions in the management of
pain relief in labour. The completeness and applicability of the
evidence is limited from the 13 included trials, with no trial at a
lowrisk of bias on all domains. The inclusion of relevant outcomes
has improved with over 50% of the acupuncture trials reporting
on outcome of safety, and effectiveness. Aweakness of a number of
trials continues to be the inclusion of few outcomes and omission
of safety clinical outcomes.
Trials recruited low-risk nulliparous and primiparous women at
term, mostly in spontaneous labour. Studies were conducted in
different countries and consequently this reects the different
styles of acupuncture administered in the studies.There are many
styles of acupuncture, including individualised traditional Chi-
nese medicine, as illustrated by six trials administering individ-
ualised treatment (Borup 2009; Hantoushzadeh 2007; Huang
2008; Martensson 2008; Nesheim 2003; Ramnero 2002) and
those using standardised acupuncture points as used in the major-
ity of trials in this review. The systematic reviewdocumented wide
variation in the mode of stimulation, duration of needling, num-
ber of points used, depth of needling and duration of the trial. It
is unclear how representative the treatment protocols used in the
research are generalisable to acupuncture as it is usually practiced.
There was insufcient reporting of the rationale of the acupunc-
ture used in the research setting. The variation may also reect the
context in which acupuncture is practiced.
Quality of the evidence
The risk of bias table (Figure 1; Figure 2) demonstrates that
acupuncture has not been consistently subjected to consistent rig-
orous study. The quality of reporting was poor in over 50% of tri-
als. The risk of bias was lowin respect to randomisation (90% and
68%). No one trial was rated at a low risk of bias on all domains.
Rates of follow-up were high in the majority of trials with only a
small number of trials reporting a small loss of participants. For
many studies blinding of participants and the practitioner was not
possible, and reporting indicated that the outcomes could have
been inuenced by a lack of blinding and consequently were rated
at a high risk of bias. The small number of studies within compar-
isons and lack of high-quality trials suggest there remains insuf-
cient evidence of a consistent treatment effect from acupuncture.
The chief investigators of some studies were contacted to provide
additional methodological and statistical information; however,
we obtained only a few responses (Chung 2003; Huang 2008;
Kashanian 2010).
The quality of evidence was affected by unexplained heterogene-
ity in some comparisons arising from both the heterogeneity of
the clinical interventions and study designs. The small number
of studies within comparisons, and lack of high quality trials pre-
vented further investigation of the heterogeneity and the impact
on treatment effects.
Potential biases in the review process
We attempted to minimise publication bias. Our search was com-
prehensive and we included studies identied in languages other
than English. However, we cannot rule out the possibility that
some studies have been missed. The variation in the duration,
frequency and selection of acupuncture points suggests that the
acupuncture may not have been therapeutically effective and in
some cases may not represent best clinical practice.
Agreements and disagreements with other
studies or reviews
There is one other systematic reviews of acupuncture to treat de-
pression (Cho 2010). This review included trials for which we
were unable to ascertain the randomisation details or we excluded
because the trials did not meet the eligibility criteria. Our ndings
and conclusions concerning the role of acupuncture for pain relief
in labour are similar to this review.
A U T H O R S C O N C L U S I O N S
Implications for practice
The data available suggest acupuncture and acupressure may be a
helpful therapy for pain management in labour. However, there
is insufcient evidence to make clinical recommendations. There
are insufcient data to demonstrate whether acupuncture and acu-
pressure are more effective thana placebo control, or whether there
is additional benet fromacupuncture when used in combination
with usual care. The risk of bias was high in the majority of trials
and recommendations for practice cannot be made until further
high quality research has been undertaken.
15 Acupuncture or acupressure for pain management in labour (Review)
Copyright 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Implications for research
Further randomised controlled trials of acupuncture and acupres-
sure for pain management in labour are needed. Further ran-
domised trials should be adequately powered and include clinically
relevant outcomes such as those described in this review. There is
a need for improving the quality and reporting of future trials. In
particular, considerationshouldbe giveninthe analysis andreport-
ing on the person providing the intervention: for example, their
training, length of experience and relationship to the woman. In
addition, further research is required which include data measur-
ing neonatal outcomes and the effects on analgesia requirements
in institutions with and without an on demand epidural service.
A cost-benet analysis should be incorporated into the design of
future studies.
Future studies may need to consider the use of both effectiveness
designs using medication, or other forms of standard care, and
efcacy designs using placebo controls.
A C K N O W L E D G E M E N T S
The review authors would like to acknowledge the Pregnancy and
Childbirth teamfor assistance with the preparation of the original
reviewand its update, including the Trials Search Co-ordinator for
assistance in developing the search strategy, the editors, co-editors
and other staff within the team. We also acknowledge the Chinese
to English translation assistance provided by Song Mei Wu, and
thank Huijuan Cao for her assistance with seeking clarication
from authors in China.
As part of the pre-publication editorial process, this review has
been commented on by three peers (an editor and two referees
who are external to the editorial team), and the Groups Statistical
Adviser.
R E F E R E N C E S
References to studies included in this review
Borup 2009 {published data only}
Borup L, Wurlitzer W, Hedegaard M, Kesmodel US,
Hvidman L. Acupuncture as pain relief during delivery: a
randomized controlled trial. Birth 2009;36(1):512.
Chung 2003 {published data only}
Chung UL, Hung LC, Kuo SC, Huang CL. Effects of
LI4 and BL67 acupressure on labor pain and uterine
contractions in the rst stage of labour. Journal of Nursing
Research 2003;11(4):25160.
Hantoushzadeh 2007 {published data only}
Hantoushzadeh S, Alhusseini N, Lebaschi AH. The effects
of acupuncture during labour on nulliparous women: a
randomised controlled trial. Australian and New Zealand
Journal of Obstetrics and Gynaecology 2007;47(1):2630.
Hjelmstedt 2010 {published data only}
therapy]; Randomized
Controlled Trials as Topic
MeSH check words
Female; Humans; Pregnancy
58 Acupuncture or acupressure for pain management in labour (Review)
Copyright 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.