American Journal of Obstetrics and Gynecology (2004) 191, 36e44

www.elsevier.com/locate/ajog

AJOG REVIEWS

Complementary and alternative medicine for labor pain:

A systematic review
Alyson L. Huntley, PhD,* Joanna Thompson Coon, PhD, Edzard Ernst, MD
Complementary Medicine, Peninsula Medical School, Universities of Exeter and Plymouth, Exeter, United Kingdom
Received for publication July 4, 2003; revised December 3, 2003; accepted December 9, 2003

KEY WORDS
Labor pain
Complementary and
alternative medicine

Objectives: The purpose of this study was to systematically review the literature for, and critically
appraise, randomized controlled trials of any type of complementary and alternative therapies for
labor pain.
Study design: Six electronic databases were searched from their inception until July 2003. The inclusion criteria were that they were prospective, randomized controlled trials, involved healthy
pregnant women at term, and contained outcome measures of labor pain.
Results: Our search strategy found 18 trials. Six of these did not meet our inclusion criteria. The
remaining 12 trials involved acupuncture (2), biofeedback (1), hypnosis (2), intracutaneous sterile
water injections (4), massage (2), and respiratory autogenic training (1).
Conclusion: There is insucient evidence for the ecacy of any of the complementary and alternative therapies for labor pain, with the exception of intracutaneous sterile water injections. For
all the other treatments described it is impossible to make any denitive conclusions regarding
eectiveness in labor pain control.
2004 Elsevier Inc. All rights reserved.

The experience of pain during labor is a complex, individual, and multi-faceted response to sensory stimuli
generated during childbirth. Labor pain and methods
to relieve it are a major concern for the mother and
child, with considerable implications for intra- and postpartum care. The conventional medical approach to the
management of pain in labor and delivery has increasingly come to rely on the use of anesthetic and analgesic
drugs, in spite of reservations within the medical estab* Reprint requests: Alyson L. Huntley, PhD, Complementary
Medicine, Peninsula Medical School, Universities of Exeter and
Plymouth, 25, Victoria Park Road, Exeter, EX2 4NT, UK.
E-mail: alyson.huntley@pms.ac.uk
0002-9378/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.ajog.2003.12.008

lishment itself.1 In a US survey of women (n = 1583)

who had given birth to a single baby in the previous
24 months, 63% had received epidural analgesia.2 This
may be because of maternal attitudes before labor,
and a personal preference to avoid the pain normally associated with labor.3 However, a third of women who
responded to the survey either had a limited idea, or
no idea, of her legal right to clear and full information
about offered procedures, tests, or drugs, and her right
to accept or refuse care. In a recent systematic review,
pain and pain relief appeared to have a rather small effect on overall satisfaction with childbirth.4 It was concluded that 4 factors were consistent in their association
with childbirth satisfaction: amount of support received,

37

Huntley, Coon, and Ernst

quality of relationship with caregiver, involvement in
decision-making, and personal expectations. Complementary and alternative medicine (CAM) is more likely
to be perceived by patients as consistent with these factors,5-7 and thus, may appeal to the laboring woman.
Indeed, there is evidence to suggest that women seek
advice and treatment from CAM providers for pain
relief during labor.8
This systematic review aims to critically appraise randomized controlled trials (RCTs) of CAM therapies for
labor pain, and thus, contributes to an evidence base for
the efcacy of these treatments during labor.

Methods
The computerized literature searches were performed
with the following electronic databases: Medline (from
1953 to July 2003); Embase (from 1974 to July 2003);
Cinahl (from 1982 to July 2003); AMED (from 1985 to
July 2003); PsychInfo (from the 1800s to July 2003); and
The Cochrane Library (from 1996 to July 2003). The
search terms were labor, birth, parturi, contractions,
obstetric, pain, complementary medicine, alternative
medicine, aromatherapy, therapeutic touch, reexology,
massage, spiritual healing, relaxation, meditation, yoga,
autogenic training, herbal medicine, traditional Chinese
medicine, medicinal plant, ayurvedic, acupuncture, acupressure, chiropractic, osteopathy, homeopathy, ower
remedies, hypno, Feldenkrais, music therapy, rolng,
shiatsu, randomized controlled trial.
The bibliography of papers found by the search and
relevant reviews were examined for references of further
trials. Colleagues both within Complementary Medicine
at the Peninsula Medical School, Exeter University, and
experts in the elds were consulted as to the existence of
any additional studies. There were no restrictions on the
language of publication.
The inclusion criteria for the studies were that they
involved healthy pregnant women at term. The type of
intervention could be any type of CAM for pain relief
during labor. This review excluded any studies of articially induced labor pains or trials that had other obstetric outcomes. The denition of CAM for this review is
dened as those medical systems, professions, practices, interventions, modalities, therapies, applications,
theories, or claims that are currently not a part of the
dominant or conventional medical system.9 Thus, this
review excluded such treatments as hydrotherapy or
the use of transcutaneous electrical nerve stimulation
(TENS). The use of a doula during labor has been reviewed extensively recently, and thus, this supportive
therapy was not included.10
All interventions, or strategies including other therapies, no treatment, or placebo, were considered as suit-

able control groups. Studies were included if they

contained outcome measures of pain, preferably by the
parturient, either by diary or by pain scales such as visual analog scales (VAS). Medication use was also discussed if this information was reported.
The papers were identied and screened by the rst
author. Both the rst and second author assessed the eligibility of the studies and extracted the data into tables
with predened headings. All 3 authors discussed any
discrepancies. The quality of the included trials was assessed with the Jadad Score.11 This scale measures the
likelihood of bias based on description of randomization, blinding, and withdrawals on a scale of nought
(minimum) to 5 (maximum). Because of clinical and statistical heterogeneity of the data, statistical pooling of
the data was not possible.

Results
Our search strategy found 18 RCTs investigating CAM
therapies for labor. Six of these did not meet our inclusion criteria because they either studied laboratorysimulated labor pains or did not use specic pain
outcome measures.12-17 The remaining 12 trials involved
acupuncture (2), biofeedback (1), hypnosis (2), intracutaneous sterile water injections (4), massage (2), and
respiratory autogenic training (1) The putative mode
of action of these therapies for labor pain is listed in
Table I, and these RCTs are summarized in Table II
and described in detail below.

Acupuncture
A study by Ramnero et al involved 90 parturients both
primiparous and multiparous.18 The women were randomized either to receive acupuncture or no additional
treatment during labor. The acupuncture treatment was
individualized, whereby each midwife chose points suitable for the pain localization as labor progressed. As a
rule, relaxing points were combined with local and distant
analgesic points. Pain intensity was assessed hourly before any given analgesia and 15 minutes after by a pain
score (rated 0-10). Painless and well-relaxed were dened
as 0, worst pain imaginable, and very tensed were dened
as 10.
Assessments of pain intensity were equal between the
2 groups (mean difference 0.29, (95% CI 0.9 to 0.32).
However, the need for epidural analgesia was signicantly reduced in the acupuncture group compared with
the non-acupuncture group (12% vs 22%, relative risk
[RR] 0.52, 95% CI 0.3 to 0.92). Regarding other analgesic methods, no differences were seen except the use of
the non-pharmacologic methods (warm rice bag, bath,

38
Table I

Huntley, Coon, and Ernst

Description of mode of action of therapies used for alleviation of labor pain

Therapy

Mode of action

Acupuncture

It has been suggested that acupunctures mechanism of pain relief is similar to that of transcutaneous electrical
nerve stimulation (TENS) units, in that stimulating large myelinated fibers blocks the smaller
fibers from transmitting painful stimuli. Other theories include altering the bodys levels of chemical
neurotransmitters and influencing the natural electrical or electromagnetic fields.
Biofeedback
Biofeedback is a treatment that uses monitoring instruments to provide either visual or acoustic feedback to
patients physiologic information of which they are normally unaware. It puts the patients in control and
gives them a sense of self-reliance that is an important factor for the laboring woman.
Hypnosis
Hypnosis is a state of attentive and focused concentration in which the patient can be relatively unaware, but not
completely blind to their surroundings. During this trance-like state, therapeutic suggestions may be given.
Hypnotic suggestions focus on diminishing the awareness of pain, as well as fear and anxiety. The treatment
for preparation for birth is based on the premise that if the patient is sufficiently educated and prepared
regarding the process, her anxiety is reduced, she would require less medication during and after the birth and
recovery, and healing would proceed at a faster pace with fewer complications.
Intracutaneous Counter irritation is the process by which localized pain felt in one part of the body may be relieved by irritating
the skin in same dermatomal distribution with either a hot, cold, scratchy, or electrical stimulus. The sterile
injections
of sterile water water injections are thought to cause distension in the skin, which stimulates nociceptors and
mechanoreceptors. Two intracutaneous injections of 0.1 mL are made bilaterally, approximately 2 cm inferior
and 1 cm medial to the posterior superior iliac spines. The placement of these injections does not need to be
precise. Sterile water is thought to produce a better affect than isotonic saline.
Massage
Massage during labor is most commonly used for its stress reduction and relaxation. Massaging muscles and other
tissues not only relaxes the muscles, it also alleviates pain. Massage can be analgesic through distraction,
although it is also thought to have a physiologic basis, blocking pain impulses by increasing A-fiber
transmission, or by stimulating the local release of endorphins.
Respiratory autogenic training derives from the autogenous training based on progressive relaxation methods. It
Respiratory
comprises a series of exercises in which the woman learns to diminish her muscle tonus by deep relaxation
autogenic
and by concentrating on her body sensations. The autonomic effects of deep relaxation are diametrically
training
opposed to those characteristic of anxiety, and are related to feelings of calmness.

shower), which were signicantly reduced in the acupuncture group.

In the trial by Skilnand et al, 210 healthy parturients
in spontaneous, active labor were randomly assigned to
receive either real acupuncture or false acupuncture.19
Real acupuncture consisted of a treatment protocol
from the Norwegian School of Acupuncture. The number of needles used varied from 2 to 12, with 7 as an average. The same type and number of needles were used
for the control group (false acupuncture), inserting them
at points that were not on the classic meridians, and
mainly in areas used for vaccination and other injections. The method is dened as minimal acupuncture.
Pain was assessed using a linear 10-cm VAS (0 = no
pain, 10 = worst possible pain) recorded at 30, 60, and
120 minutes after treatment. The needles were removed
and evaluation of pain with VAS was stopped if the
woman converted to epidural analgesia, intramuscular
pethidine, or nitrous oxide inhalation. There were significantly lower pain scores at 30, 60, 120 minutes after
treatment and 2 hours after birth (P!.00), and signicantly less need for epidural analgesia and intramuscular
pethidine (P = .01, P!.001, respectively) in the real
compared with the false acupuncture group.

Biofeedback
In a study by Duchene, 55 primigravidas were randomly
assigned to either childbirth classes or childbirth classes
plus training sessions in biofeedback, which was then
used during labor.20 Pain was monitored during labor
with a VAS and a verbal descriptor scale (VDS). Forty
women completed the study (93% white, 7% black); attrition occurred because of the need for cesarean section.
Results showed that women using biofeedback during
childbirth reported signicantly lower pain than control
women at admission (VAS P!.05, VDS P!.01), at delivery (VDS P!.005) and 24 hours postpartum (VDS
P!.01). Seventy percent of the women in the control
group requested and used epidural anesthesia compared
with 40% of the women of the biofeedback group
(P!.05).

Hypnosis
In the study by Freeman et al, 82 primigravidas were assessed for hypnotic susceptibility and randomized to receive weekly, individual hypnosis sessions for relaxation

39

Huntley, Coon, and Ernst

Table II

Randomized controlled trials of acupuncture, biofeedback, hypnosis, ISW injections, and massage for labor pain

Citation
Acupuncture
Ramnero,
2002

Jadad
Score Participants

Treatment

Control
treatment

Pain outcome
measures
Pain score
(0-10) hourly
and 15
minutes after
analgesia
VAS score
before
treatment,
30, 60, 120
minutes and
hours after
delivery

90 women (n = 42
primiparas and
n = 48
multiparas)

Individualized
acupuncture

No
acupuncture

210 women
(n = 101
primiparas
and n = 107
multiparas)
in spontaneous,
active labor

Real acupuncture

False
acupuncture

Biofeedback
Duchene,
1989

40 women
(primpars)

Series of training
sessions in
biofeedback
as an adjunct
to childbirth
classes

Childbirth
classes

Hypnosis
Freeman,
1986

82 women
(primiparas)
expecting
a normal
pregnancy

60 women
(primiparas)
screened for
hypnotic
susceptibility

Routine
Routine weekly
weekly
antenatal classes
antenatal
plus weekly
classes
individual
hypnosis
sessions for
relaxation and
pain relief
Hypnotic induction Relaxation and
breathing
as an adjunct to
exercises
childbirth class
typically
used in
childbirth
classes

Skilnand,
2002

Harmon,
1990

ISW injections
Ader, 1990 4

Trolle, 1991 3

45 women (n = 30
primiparas and
n = 15
multiparas)

ISW injections

ISW injections
272 women in
labor complaining
of severe lower
back pain (both
primiparas and
multiparas-no
further details
provided)

Reports of
pain by VAS
and VDS at
admission,
delivery, and
postpartum

Main results
No significant
difference between
groups

Significant
improvement in real
acupuncture group
compared with
control at 30, 60,
120 minutes and 2
hours after birth
(P!.00)
Biofeedback group
reported less pain
at admission (VAS
P!.01, VDS P!.05)
At delivery (VDS
P!.01)
24 hours postpartum
(VDS P!.01)

No significant difference
Linear analog
between the groups
scale for pain
relief,
retrospectively

McGill Pain
Questionnaire
(MPQ) within
24 hours of
delivery

All 5 subscales of the MPQ

were improved with
hypnosis compared with
control group (P!.01)

Mean VAS score was

VAS score
reduced in serum group
at 10, 45, and
compared with placebo
90 minutes
group 10 minutes:
after
P!.00 45 minutes:
treatment
P!.02 90 minutes:
P!.05
89.4% of sterile water
Treatment with
VAS score
group noted an
saline solution
before
analgesic effect
injections
treatment
compared with 45% in
and 1 and 2
saline group (P!.0005)
hours after
treatment

Subcutaneous
injections
of isotonic
saline

40

Huntley, Coon, and Ernst

Table II

continued

Citation

Jadad
Score Participants

ISW injections
Martensson, 4
1999

Labrecque,
1999

Treatment

Control
treatment

Pain outcome
measures

Placebo
VAS score
99 women at 37 to Four injections of
treatment
at 10 and 45
0.1 mL sterile
42 weeks
minutes after
water
gestation (n = 40
treatment
intracutaneously
primiparas and
or subcutaneously
n = 59 multiparas),
requiring pain
relief for severe
lower back pain
VAS scales for
ISW injections
Standard care
34 women (n = 22
intensity and
including
primiparas and
affective
back massage,
n = 12 multiparas),
dimensions of
whirlpool,
considered low risk
pain at 15, 60,
liberal
and suffering from
90, 120, and
mobilization
lower back pain
180 minutes
or TENS
during labor
after initial
intervention

Main results
Both treatment groups
had reduced pain
compared with placebo
at 10 and 45 minutes
(P = .002, P = .006)

Reduction of intensity
and unpleasantness of
pain in ISW group
compared with control
and TENS (P = .011,
P = .03)

Massage
Field, 1997 2

Mothers self-rating Pain was reduced from

Coaching in
Massage (taught
28 middle
5.0 to 3.5 in the
their labor pains
breathing
after the
socioeconomic
massage group
on the 5-point
alone
admissions
status women (no
Pain increased from
Likert Scale before
interview) in
further details
4.3 to 5.0 in the
and after massage
addition to
provided)
control group
and control
coaching in
Statistical analysis
sessions
breathing from
was unclear
their partner
during labor
Lower PBI scores in
30 minute massage Standard nursing The nurse-rated
Chang,
3
60 women
PBI scale
the massage group
care and 30
during uterine
2002
(primiparas)
compared with the
minutes of
contractions, first
expected to
control group during
the researchers
by researcher,
have a normal
all 3 phases of labor
attendance and
and then by the
childbirth
(P%.002)
casual
partner in each
conversion
phase of labor
during each
(1-3)
phase
Respiratory autogenic training
RAT participants
Pain thermometer
Nine weekly
Nine weekly
53 women
Zimmerman- 3
reported less pain than
0 (no pain at all)
sessions of
sessions
(primiparas) in
Tansella,
PTT participants
to 100 (pain
traditional
RAT for childbirth
the seventh
1979
unbearable) during (P!.02) No difference
(PTT) for
preparation
month of
in retrospective
labor and pain
childbirth
pregnancy
pain assessment
assessment,
preparation
retrospectively
ISW, Intracutaneous sterile water; TENS, transcutaneous electrical nerve stimulation; RAT, respiratory autogenic training; PBI, present behavioral
intensity; PTT, psychoprophylactic training; VAS, visual analog scale; VDS, visual descriptor scale.

and pain relief, in addition to the routine weekly antenatal classes or the antenatal classes alone (control
group).21 Pain relief was recorded with a VAS and no
signicant differences were seen between the 2 groups.
In addition, there was no signicant difference in the
use of Entotox, pethidine, or epidural analgesia between
the groups.

Harmon et al studied the benets of hypnotic analgesia as an adjunct to childbirth education in 60 primiparous, white women.22 Subjects were assessed for
hypnotic susceptibility, and then randomized to receive
either hypnotic induction classes or relaxation and
breathing exercises during 6 childbirth classes. They measured thresholds for ischemic pain before labor, and then

41

Huntley, Coon, and Ernst

rated pain during labor with the McGill Pain Questionnaire (MPQ).23 The MPQ was scored on the following
scales: present pain intensity; sensory distress; affective
distress; evaluative distress; and miscellaneous, and were
signicantly improved with hypnosis compared with the
control group (P!.001, P!.01, P!.01, P!.05, P!.05,
respectively). In addition, fewer hypnotically trained
women received medication in terms of tranquilizers
(P!.001) and narcotics (P!.001) compared with the
women in the control group.

Intracutaneous injections of sterile water

(ISW)
In the double-blind study by Ader et al, 45 pregnant
women in the rst stage of labor presenting with lower
back pain were randomized to receive either ISW in
the lumbosacral region or subcutaneous injections of
isotonic saline in the same region (control group).24
VAS scores were recorded at 10, 45, and 90 minutes after treatment. In the group that received ISW the mean
VAS score was signicantly more reduced compared
with the control group at 10, 45, and 90 minutes
(P!.001, P!.02, P!.05, respectively). The midwives
blind estimation of the effectiveness of treatment was
consistent with the VAS assessment. However, the requirement for pethidine was similar in both groups.
Trolle et al evaluated the analgesic effect of intradermal sterile water blocks in 272 women in labor complaining of severe lower back pain.25 The women were
randomly assigned to either sterile water or saline solution blocks. Pain intensity was monitored with a VAS
before treatment, plus 1 and 2 hours after treatment.
In the sterile water group, 126 (89.4%) of the women
noted an analgesic effect of the blocks, compared with
59 (45%) in the saline solution group (P!.0005). No
adverse events were noted, and patient acceptability
was high. When asked after the birth, a signicantly
greater proportion of the women in the sterile water
group (68%) compared with the saline solution group
(50%) said they would request the same type of analgesia if they underwent delivery again. The frequencies of
other medication use did not differ signicantly between
the groups.
In a study by Martensson et al, 99 pregnant women
requiring pain relief for severe lower back pain during
the rst stage of labor were randomized to receive either
4 injections of 0.1 mL sterile water intracutaneously, or
4 injections of 0.5 mL sterile water subcutaneously, or 4
injections of 0.1 mL isotonic saline subcutaneously (placebo).26 Labor pain was measured with a VAS. The median VAS pain score was signicantly lower in both
treatments group compared with placebo at 10 and 45
minutes post treatment (P = .002, P = .006, respec-

tively). There were no signicant differences between

the 2 treatments at any time. There were no details of
any additional analgesia during labor. The pain experienced during the injections was less intense in the placebo group than in either of the 2 active groups
(P!.001). However, the women in the study groups
were signicantly more enthusiastic about their treatment than those in the placebo group (P!.001), if in
need of treatment in the future.
In a 3-arm RCT conducted by Labrecque et al, 34
women suffering from lower back pain during labor were
randomized to receive ISW, TENS, or standard care,
which included back massage, whirlpool bath, and liberal
mobilization.27 Women self-evaluated both the intensity
and affective dimensions of pain with use of a VAS at
15, 60, 90, 120, and 180 minutes after the initial intervention. Women in the ISW group rated the intensity and
unpleasantness of pain during the experimental period
signicantly lower than women in the TENS (P = .003)
or the standard care group (P = .001). Similar results
were observed for intensity (P = .01) and unpleasantness
(P = .03) of pain assessed just before delivery or request
for an epidural. Mean pain intensity at 15 and 60 minutes
was signicantly reduced in the ISW group compared
with the other 2 groups. However, there were no signicant differences between the 3 groups regarding the proportion of women requesting and receiving epidural
analgesia, and fewer women in the ISW group indicated
that they would like to receive the same treatment for
back pain during another delivery.

Massage
A study by Field et al involved 28 middle socioeconomic
status women (34% white, 9% black, and 57% Hispanic) who were randomized to receive massage (head,
shoulder/back, hand, and foot) in addition to coaching
in breathing, or to receive coaching in breathing alone
(control).28 The mothers self-rated their labor pains on
the 5-point Likert scale before and after massage or control procedure. There was a reduction in pain from 5.0
to 3.5 in the massage group, and an increase in pain
from 4.3 to 5.0 in the control group. Statistical reporting
was difcult to interpret as signicant differences were
pre- and post- within groups or between groups. No information was reported of other analgesic support, conventional or otherwise.
In the study by Chang et al, 60 primiparous women
expected to have a normal childbirth were randomly assigned to either receive massage intervention comprising
abdominal efeurage, sacral pressure, and shoulder/
back kneading during their labor, or attention control.29
In the massage group, the woman received a 30-minute
massage during uterine contractions rst by the researcher and then by the partner during each of the

42
3 phases of labor. The standard care group received the
researchers attendance and causal conversation for the
same time periods. The nurse-rated present behavorial
intensity (PBI) was used as a measure of labor pain, with
use of the self-reported present pain intensity (PPI) scale
to validate. Signicantly lower PBI scores were recorded
in the massage group compared with the control group
during all 3 phases of labor (P = .00, P = .002, P =
.000, respectively), and these data were validated by
the PPI scales. No information was reported of other
analgesic support, conventional or otherwise.

Respiratory autogenic training (RAT)

In a controlled trial by Zimmermann-Tansella et al,
53 women in the seventh month of pregnancy were
randomly assigned to either 9 weekly sessions of RAT
(n = 23) or a traditional psychoprophylactic course
(TPP) (n = 30) for childbirth preparation under partial
double-blind conditions.30 Pain was assessed every hour
during labor on a pain thermometer which ranged from
0 (no pain at all) to 100 (pain unbearable). In addition,
the women retrospectively evaluated the pain experience
during labor on a scale of 5 discrete categories (uncomfortable; mildly painful; painful; very painful; unbearable). Ten women (4 RAT) delivered elsewhere, 6
women (5 RAT) had a cesarean delivery, and for 3
women (all TPP) no data were collected during labor;
thus, 34 women completed the study (14 RAT; 20
TTP). The RAT participants tended to report less pain
during labor than the TPP women (P!.02), but the difference was only statistically signicant after removing
the inuence of the unbalanced initial anxiety level in
the 2 groups. No difference emerged in the judgement
of pain experience made by the women some days after
delivery (most of them choosing the categories painful
or very painful). The womens evaluation of their delivery
experience did not differ for the 2 groups. No information
was reported of other analgesic support, conventional or
otherwise.

Comment
In total we identied 12 RCTs that met our inclusion
criteria. They were all published during the last 2 decades, mostly by US authors, and frequently in conventional medicine journals. Their methodologic quality is
variable and often low. Their sample size is generally
small.
There is insufcient evidence for the efcacy of any of
the CAM therapies described for labor pain, with the exception of ISW treatments. There is some evidence for
the benet of massage therapy during labor. For all

Huntley, Coon, and Ernst

the other treatments described, the lack of studies mean
it is impossible to make any denitive statements.
There were 2 RCTs in the literature that investigated
the efcacy of acupuncture for labor pain. Both of these
studies scored 3 out of a possible 5 on the Jadad Scale
because of lack of double blinding, although in the
Skilnand study, the participants were blinded to their
acupuncture treatment.19 The smaller Ramnero study
utilized acupuncture as an adjunct or complementary
therapy to conventional pain relief, while the larger Skilnand trial studied acupuncture treatment alone.18
It is interesting to note that in the otherwise negative
acupuncture trial by Ramnero et al, there was a statistically signicant reduction in epidural use and additional
non-pharmacologic methods between the acupuncture
and non-acupuncture group. In the positive Skilnand
study, pain measures were reduced, as well as fewer
women opting for conventional analgesia in the real
acupuncture group compared with the false acupuncture
group. This suggests that receiving a physical intervention like acupuncture has an inuence on a womans
pain management during labor, even if it does not improve her pain ratings. More research into the benet
of acupuncture for labor pains is warranted.
There was only 1 poor-quality RCT concerning the
use of biofeedback for pain control in labor.20 There
was no blinding in the study, and the authors fail to describe the method of randomization. The trial had a positive outcome for the use of biofeedback for labor pains,
although with only 1 trial it is difcult to extrapolate
these results. St James-Roberts et al conducted a comparative RCT of 2 methods of relaxation training based
on biofeedback techniques (electromyographic or skin
conductance methods) plus a control group.13 However,
there were no specic pain outcome measures and all the
women in both groups went on to receive epidural analgesia. Overall, better quality research is required to investigate the use of biofeedback during labor.
The reporting of the hypnosis trial by Freeman et al is
brief, and possibly as a result, the Jadad Score is low because of lack of information.21 This trial found no signicant difference in pain measures or epidural use
between the hypnosis and control subjects. It did report
that good and moderate hypnotic subjects used signicantly less epidural analgesia than poor subjects
(P!.01), and that all the good/moderate subjects reported that hypnosis had been instrumental in reducing
anxiety and helping them cope with labor. The more recent hypnosis trial by Harmon et al has a higher Jadad
Score, with description of blinding and dropouts.22 This
trial showed signicant improvement in all subscales of
the MPQ and reduced conventional analgesic use in the
hypnotic group compared with the control group.
Highly susceptible women also reported less pain than
low susceptibility women on 3 of the 5 subscales. These
data from both trials suggest that hypnotic techniques

43

Huntley, Coon, and Ernst

may be of use to women during labor who are good
hypnotic subjects and thus warrants further investigation.
ISW treatments do seem to be of benet as an analgesic to the laboring women with 4 RCTs (all scoring
3 or more on the Jadad scale), showing signicantly reduced pain measures compared with control treatments.24-27 Overall, this treatment seemed to be well
tolerated with few adverse effects, excluding a stinging
sensation during application. It is possible that this
treatment could be useful in reducing the use of conventional analgesic medication that may have potentially
detrimental effects on mother and child. More research
will be needed if this procedure is to be incorporated
into conventional practice. In particular, its effectiveness
relative to accepted therapies for pain control during labor needs dening.
Both of the massage trials showed positive effects for
the relief of pain during labor.28,29 These trials did not
rate highly on the Jadad scale because of lack of blinding, which can be problematic in massage trials. Massage
is a popular intervention for pregnant and laboring
women and is probably practiced frequently during labor, albeit in a less formal way than in these trials.
The one, small trial on RAT is insufcient to provide
any signicant evidence for the benet for labor pain, especially regarding the notable loss of participants during
the study.30 It is important to note that participants did
not favor the RAT over the conventional PPT preparation for labor.
Our review has several limitations, namely the paucity of data, the possibilities of publication bias, the fact
that we did not locate all the relevant trials, and the
poor methodologic quality of many of the trials. All
the trials were conducted in healthy women, at term,
who were considered a low obstetric risk. The results
are therefore not applicable to women in higher risk
populations.
Clearly, further good quality, randomized clinical trials are needed to assess the potential role of CAM in the
relief of labor pain. A greater understanding of the role
of these therapies will enable women to be better informed of the choices available to them. However, it is
important to note that while further safety evaluation
would be useful, there are no serious safety concerns
with any of these therapies specic to their use durng labor. Pending the results of further investigations it is important that women are given the maximum amount of
choice for pain relief during labor.
In conclusion, the data suggest that ISW treatments
may provide relief for labor pain. There is some evidence
for the benet of massage therapy, but for all the other
therapies described there is insufcient evidence at
present.
Alyson Huntley is supported by a research fellowship
provided by The Boots Company.

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