trabalho parto acupuntura

Acupuncture for pain relief in labour: asystematic review and meta-analysisS-H Cho,a H Lee,b E Ernstc

a Hospital of Korean Medicine, Kyung Hee University Medical Center, Kyung Hee University, Seoul, Korea b Acupuncture and Meridian

Science Research Center (AMSRC), College of Korean Medicine, Kyung Hee University, Seoul, Korea c Complementary Medicine, Peninsula

Medical School, Universities of Exeter and Plymouth, Exeter, UK

Correspondence: Dr H Lee, Acupuncture and Meridian Science Research Center (AMSRC), College of Korean Medicine, Kyung Hee University,

Hoegi-dong, Dongdaemoon-gu, 130-701 Seoul, Korea. Email [email protected]

Accepted 12 March 2010. Published Online 28 April 2010.

Background Acupuncture is frequently used for pain relief in

labour, but the evidence is not clear.

Objectives To critically evaluate the evidence for or against

acupuncture for labour pain management.

Search strategy Nineteen electronic databases, including English,

Korean, Japanese, and Chinese databases, were systematically

searched.

Selection criteria All randomised controlled trials (RCTs)

involving women receiving acupuncture alone, or as an adjunct to

conventional analgesia, for pain relief in labour were considered.

Data collection and analysis Pain intensity on a 100-mm visual

analogue scale (VAS; 0, no pain; 100, worst pain) and use of

other analgesic methods were used as primary outcomes, and for

statistical pooling. Maternal/fetal outcomes were secondary

outcomes, and adverse events were also recorded. Risk of bias was

assessed regarding randomisation, allocation concealment,

blinding, incomplete outcome data, selective outcome reporting,

and other biases.

Main results Ten RCTs involving 2038 women were included.

VAS for pain intensity data were available in seven studies; the

meta-analysis shows that acupuncture was not superior to

minimal acupuncture at 1 hour (pooled mean difference )8.02;

95% CI )21.88, 5.84; I2 = 94%) and at 2 hours ()10.15; 95% CI

)23.18, 2.87; I2 = 92%). Patients reported significantly reduced

pain by 4 and 6% during electroacupuncture (EA) treatment at 15

()4.09; 95% CI )8.05, )0.12) and 30 minutes ()5.94; 95% CI

)9.83, )2.06), compared with placebo EA, but the effect was not

maintained afterwards. Compared with no intervention,

acupuncture reduced pain by only 11% for the first 30 minutes

()10.56; 95% CI )16.08, )5.03). In trials where acupuncture was

compared with conventional analgesia, women receiving

acupuncture required less meperidine (pooled risk ratio 0.20;

95% CI 0.12, 0.33) and other analgesic methods (0.75; 95% CI

0.66, 0.85). No acupuncture-related adverse events were reported.

Most trials did not blind participants, care providers and/or

evaluators.

Author’s conclusions The evidence from RCTs does not support

the use of acupuncture for controlling labour pain. The primary

studies are diverse and often flawed. Further research seems

warranted.

Keywords Acupuncture, labour pain, randomised controlled trial,

systematic review.

Please cite this paper as: Cho S-H, Lee H, Ernst E. Acupuncture for pain relief in labour: a systematic review and meta-analysis. BJOG 2010;117:907–920.

Introduction

Pain relief is an important issue for women in labour.

Whatever method is used to reduce maternal discomfort, it

should be both effective and safe for the mother and child.

Several methods of relieving pain in labour and various

coping strategies have been advocated. They range from

intervention such as breathing exercises to medical tech-

niques like epidural analgesia (EDA). Several complemen-

tary or alternative methods have also been reported to

reduce pain during labour and delivery.1 Cochrane reviews

have demonstrated the value of continuous support and

non-pharmacological approaches to managing pain in

labour.2–4 A recent survey of certified nurse-midwives sug-

gested that the use of complementary and alternative medi-

cine (CAM) by pregnant women is common. More than

90% of midwives reported recommending CAM for their

pregnant women.5

Acupuncture and related techniques are increasingly

practiced in obstetrics and gynaecology for labour pain,

ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology 907

DOI: 10.1111/j.1471-0528.2010.02570.x

www.bjog.orgSystematic review

intraoperative analgesia, dysmenorrhea, pelvic pain in preg-

nancy, and pain during oocyte retrieval.6–8 The use of acu-

puncture to manage labour pain was introduced in the

1970s.9–11 Since then, acupuncture has been employed to

relieve pain and facilitate the process of labour. A previous

systematic review of three trials of acupuncture for labour

pain suggested that acupuncture might play a role in pain

control, but because of the paucity of trial data, the conclu-

sions remained uncertain.6 Several new studies have since

been published, including two placebo-controlled trials and

two sham-controlled trials. It is therefore timely to recon-

sider whether acupuncture reduces labour pain. This sys-

tematic review and meta-analysis are aimed at critically

evaluating the evidence for or against acupuncture as a

treatment of pain during labour.

Methods

Search strategyThe following sources were searched all from their incep-

tion to April 2009: The Cochrane Central Register of Con-

trolled Trials, MEDLINE, EMBASE, Allied and

Complementary Medicine Database (AMED), Cumulative

Index to Nursing and Allied Health Literature (CINAHL),

PsycInfo, Korean medical databases (the National Assembly

Library, KoreaMed, Korean Studies Information Service

System, DBpia, and Korea Institute of Science Technology

Information and Research Information Service System), a

Japanese database (Japan Science and Technology Informa-

tion Aggregator Electronic), and Chinese databases (the

China Academic Journal, Century Journal Project, China

Doctor/Master Dissertation Full Text Database, and China

Proceedings Conference Full Text Database). We also

searched current controlled trials (http://www.controlled-

trials.com), National Center for Complementary and Alter-

native Medicine at the National Institutes of Health (http://

nccam.nih.gov), and the Complementary and Alternative

Medicine Specialist Library at the National Health Service

National Library for Health (http://www.library.nhs.uk/

cam). The reference lists of articles were checked for fur-

ther relevant publications, and experts were asked for infor-

mation concerning any additional trials. A further manual

search was conducted for relevant journals, symposia, and

conference proceedings; all identified publications were

cross-referenced. Personal contact was made with the

authors of the published studies, if necessary, to request for

additional data.

The search terms used were (‘acupuncture’ OR ‘electro-

acupuncture’ OR ‘meridian’ OR ‘acupoint’ OR ‘scapular

acupuncture’ OR ‘auricular acupuncture’) AND (‘labour’

OR ‘childbirth’ OR ‘delivery’ OR ‘pregnancy’ OR ‘obstetric’

OR ‘parturi’ OR ‘labouring’). As all of the various databases

searched for this review possessed their own subject

headings, each database was searched independently. No

language restrictions were imposed.

Study selection

Types of studiesRandomised controlled trials (RCTs); quasi-randomised or

non-randomised trials were excluded.

Types of participantsWomen in labour; trials of induced labour were excluded.

Types of interventionTrials testing acupuncture as a sole analgesic method or as

an adjunct to conventional analgesia were considered.

Studies of classical acupuncture, electroacupuncture (EA),

and (electrical) auricular acupuncture were included. Trials

of acupuncture-related techniques (for example, auricular

seed, laser, injection, acupoint-embedding, acupressure,

magnetic device, or moxibustion) were excluded. Studies

that assessed the combined effect of acupuncture with

other related therapies (for example, acupuncture plus

moxibustion therapy) were excluded. Trials that compared

different forms of acupuncture were also excluded.

Types of controlAny form of pain relief, no pain relief, and placebo or

sham acupuncture, such as superficial needling and non-

penetrating sham needles, were included.

Types of outcome measuresOur primary outcome measures were pain relief in labour

and use of other analgesia. Pain intensity outcomes

included a 100-mm visual analogue scale (VAS) or numeric

rating scale, and number of women requiring meperidine,

EDA, or other pain relief. Trials reporting arbitrary or

undetermined grades for VAS scores of pain relief were

excluded to minimise selective outcome reporting. Second-

ary outcomes were maternal and fetal; maternal outcomes

included satisfaction with pain relief in labour, satisfaction

with childbirth experience, duration of labour, augmenta-

tion of labour, and mode of delivery. Fetal outcome mea-

sures were Apgar score at 5 minutes, birthweight, and

umbilical cord blood pH, and adverse events were

recorded.

Data extraction and quality assessmentTwo reviewers (S-HC and HL) independently evaluated

articles for inclusion, followed by data extraction regarding

author, year of publication, country, participants, acupunc-

ture treatment, control types, and primary and secondary

outcomes, using a pre-defined data extraction form. In the

case of duplicate publications and companion papers of a

Cho et al.

908 ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology

primary study, the yield of information was maximised by

simultaneously evaluating all available data. When in doubt

(for example, clinical trials performed in the same hospital

during the same period), the original publication (usually

the oldest version) was given priority.

Quality assessment was also independently performed by

the two reviewers (S-HC and HL) using the assessment tool

for ‘risk of bias’ from the Cochrane Handbook for System-

atic Reviews of Interventions.12 The following characteristics

were assessed. (1) Was the allocation sequence adequately

generated? (2) Was allocation adequately concealed? (3)

Was knowledge of the allocated interventions adequately

prevented during the study? (4) Were incomplete outcome

data adequately addressed? (5) Are reports of the study free

of suggestion of selective outcome reporting? (6) Was the

study free of other problems that could put it at a risk of

bias? This review used Y, U, and N to label judgments: the

answer ‘yes’ indicated a low risk of bias (Y); ‘unclear’ indi-

cated that the risk of bias is uncertain (U), and the answer

‘no’ indicated a high risk of bias (N). Prevention of knowl-

edge of the allocated interventions, i.e. blinding (patient,

care provider, and evaluator blinding), was assessed sepa-

rately. Disagreements were resolved by discussion between

all authors, and further information was sought from the

primary authors if necessary.

Statistical analysisStatistical analysis was carried out using Review Manag-

er v5.0.21 for Windows (The Nordic Cochrane Centre,

Copenhagen, Denmark). Studies were classified and com-

bined in the analysis according to their control types. We

used the mean difference (MD) for VAS for pain intensity,

and for dichotomous data, e.g. number of women requir-

ing meperidine, results were presented as risk ratios (RRs)

with 95% confidence intervals (CIs), using either a fixed or

random-effects model depending on the statistical hetero-

geneity between studies, ascertained by the I2 test. Studies

were combined to assess the net effect of all types of acu-

puncture treatments on labour pain only if statistical heter-

ogeneity was not evident. Heterogeneity was examined with

the I2 test, where I2 values of 50% or more were considered

to be indicators of a substantial level of heterogeneity.13

Results

Study characteristicsFigure 1 shows the flow of our search results.14 Ten studies

met our inclusion criteria and characteristics of these stud-

ies are presented in Table 1. We obtained further necessary

information on one study from the original author.15

Participants and settingsA total of 2038 participants were involved, ranging from 90

to 607 per study. Four studies recruited only nulliparous

women;16–19 five studies had both nulliparous and multipa-

rous women;15,20–23 and parity was not mentioned in one

study.24 The majority of the studies included women at

more than 37 weeks of gestation. All studies were con-

ducted in hospital settings: five in Europe,15,20–23 three in

China,16–18 and two in Iran.19,24

Potentially relevant articles reviewed and retrieved for more detailed evaluation (n = 92)

Excluded (n = 80)• Case studies (n = 14)• No analgesic outcomes (n = 12)• Reviews/surveys (n = 25)• Inadequate data reporting (n = 17)• Acupressure trials (n = 11)• Comparing different forms of acupuncture (n = 1)

Further evaluation regarding randomization (n =12)

Excluded (n = 2)• Not a randomized trial (n = 2)

RCTs included in the systematic review (n = 10)

Figure 1. Flowchart of search.

Current evidence does not support acupuncture for labour pain


Tab

le1.

Char

acte

rist

ics

of

the

incl

uded

studie

s

Firs

tau

tho

r

(year)

Part

icip

an

tsIn

terv

en

tio

n

(n)*

Typ

eo

f

con

tro

l(n

)*

Pri

mary

ou

tco

mes

Seco

nd

ary

ou

tco

mes

Ad

vers

e

even

ts

Mate

rnal

Feta

l

Boru

p(2

009)1

9607

wom

enw

ith

single

ton,

vert

ex

pre

senta

tion,

term

(37–4

2w

eeks

of

ges

tation)

AT

+A

Aan

d

acce

ss

toco

nve

ntional

care

(n=

314)

(a)

TEN

San

dac

cess

toco

nve

ntional

care

(n=

144)

(b)

Conve

ntional

anal

ges

ia(n

=149)

Nee

dfo

ran

yphar

mac

olo

gic

al

and/o

rin

vasi

vepai

nre

lief;

AT

bet

ter

than

conve

ntional

anal

ges

ia(5

9vs

83%

,

P<

0.0

01),

and

TEN

S

(59

vs69%

,P

=0.0

31)

NS

innee

dfo

rm

eper

idin

e

and

nee

dfo

rED

A

NS

indura

tion

of

labour,

use

of

oxy

toci

n,

mode

of

del

iver

y,post

par

tum

hae

morr

hag

e,an

d

birth

exper

ience

NS

inA

pgar

score

at1

min

ute

Signifi

cant

diffe

rence

in

cord

blo

od

pH

valu

e(P

=0.0

39),

and

med

ian

Apgar

score

at5

min

ute

s

(P=

0.0

4)

None

Han

toush

zadeh

(2007)1

8150

nulli

par

ous

wom

enw

ith

single

ton,

term

(>37

wee

ksof

ges

tation)

inac

tive

phas

e(c

ervi

caldila

tation

‡4

cman

d/o

r3

contr

actions

‡40

seco

nds/

10

min

ute

s)

AT

(n=

70)

Min

imal

AT

at

non-a

cupoin

ts

(n=

74);

no

de-

qi*

*

sensa

tion

sought;

nee

dle

sre

move

d

ifnec

essa

ry

VA

Sfo

rpai

n;

AT

bet

ter

than

contr

olat

the

beg

innin

g

(54

vs38,

P<

0.0

01)

and

afte

r2

hours

(57

vs70,

P<

0.0

01)

NS

inV

AS

for

pai

nat

30

min

ute

s,

and

1hour

AT

bet

ter

than

min

imal

AT

indura

tion

of

labour

(3.4

vs4.5

hours

,

P<

0.0

01)

and

use

of

oxy

toci

nunits

(5.6

vs

7.8

,P

=0.0

01)

AT

bet

ter

than

min

imal

AT

inpat

ients

’sa

tisf

action

(P<

0.0

01),

and

will

ingnes

sto

rece

ive

AT

agai

n(P

<0.0

01)

NS

inbirth

wei

ght,

and

Apgar

score

at1

min

ute

None

Huan

g(2

008)1

7324

nulli

par

ous

wom

en

with

single

ton,

vert

ex

pre

senta

tion

EA(n

=82)

(a)

TEN

S(n

=82);

2/1

00

Hz

(b)

EDA

(n=

79)

(c)

No

trea

tmen

t

(n=

81);

bre

athin

g

and

mas

sage*

**

VA

Sfo

rpai

n;

(a)

NS;

(b)

EDA

bet

ter

than

AT

at60

min

ute

s

(P=

0.0

06),

and

120

min

ute

s(P

<0.0

0001);

(c)

AT

bet

ter

than

no

trea

tmen

tat

30,

60,

and

120

min

ute

s(P

<0.0

0001)

Satisf

action

with

pai

nre

lief;

(a)

AT

bet

ter

than

TEN

S(P

=0.0

1);

(b)

EDA

bet

ter

than

AT

(P=

0.0

04);

(c)

NR

NS

inm

ode

of

del

iver

y

NR

NR

Mar

tenss

on

(2008)2

0128

wom

en,

term

(37–4

2w

eeks

of

ges

tation),

sponta

neo

us

phas

e(‡

3co

ntr

actions

/10

min

ute

s)

AT

(n=

62)

Subcu

taneo

us

ster

ile

wat

erin

ject

ion

(n=

66);

0.5

mlin

area

of

pai

n,

repea

ted

if

nec

essa

ry

VA

Sfo

rm

ean

pai

n;

contr

ol

bet

ter

than

AT

(57

vs76,

P<

0.0

01)

VA

Sfo

rm

ean

rela

xation;

contr

olbet

ter

than

AT

(57

vs69,

P<

0.0

03)

NS

inre

quirem

ent

for

additio

nal

pai

nre

lief

met

hods

NS

indura

tion

of

labour,

mode

of

del

iver

y,an

d

will

ingnes

sto

rece

ive

the

sam

ean

alges

ic

met

hod

agai

n

NS

inbirth

wei

ght,

Apgar

score

at

1,

5,

and

10

min

ute

s,

and

blo

od

stat

us

(pH

,BE)

NR

Cho et al.


Tab

le1.

(Continued

)

Firs

tau

tho

r

(year)

Part

icip

an

tsIn

terv

en

tio

n

(n)*

Typ

eo

f

con

tro

l(n

)*

Pri

mary

ou

tco

mes

Seco

nd

ary

ou

tco

mes

Ad

vers

e

even

ts

Mate

rnal

Feta

l

Nes

hei

m(2

003)2

1198

wom

enw

ith

regula

r

contr

actions

atte

rm

(37–4

2w

eeks

of

ges

tation)

AT

and

acce

ss

toco

nve

ntional

care

(n=

109)

Conve

ntional

anal

ges

ia(n

=92)

No.

of

pat

ients

usi

ng

mep

erid

ine;

AT

bet

ter

than

contr

ol(1

1vs

37%

,

P<

0.0

001)

No.

of

pat

ients

usi

ng

any

anal

ges

ia;

AT

bet

ter

than

contr

ol(6

6vs

82%

,

P<

0.0

5)

NS

indura

tion

of

labour,

and

mode

of

del

iver

y

NS

inbirth

wei

ght,

and

Apgar

score

at1

and

5m

inute

s

None

Ram

ner

o(2

002)2

2100

wom

enw

ith

single

ton,

vert

expre

senta

tion,

term

(‡37

wee

ksof

ges

tation)

in

sponta

neo

us

phas

ean

d

cerv

ical

dila

tation

(£6

cm)

atad

mis

sion

AT

and

acce

ss

toco

nve

ntional

care

(n=

46)

Conve

ntional

anal

ges

ia(n

=44)

NS

inN

RS

for

pai

n,

nee

dfo

r

mep

erid

ine,

and

nee

dfo

roth

er

phar

mac

olo

gic

anal

ges

ia

AT

bet

ter

than

contr

ol;

no.

of

pat

ients

requirin

gED

A

(26

vs50%

,

P<

0.0

5),

TEN

S

(P<

0.0

5),

war

m

rice

bag

(P<

0.0

1),

and

show

er(P

<0.0

5)

NRS

for

rela

xation;

AT

bet

ter

than

contr

ol(P

<0.0

5)

NS

inm

ode

of

del

iver

y,

use

of

oxy

toci

n,

dura

tion

of

labour,

and

ante

par

tum

hae

morr

hag

e

NS

inbirth

wei

ght,

and

Apgar

score

at1

and

5m

inute

s

None

Skiln

and

(2002)2

3210

wom

enw

ith

single

ton,

vert

expre

senta

tion,

term

(37–4

2w

eeks

of

ges

tation)

insp

onta

neo

us

phas

e

AT

(n=

106)

Min

imal

AT

at

non-a

cupoin

tsuntil

conve

rsio

nto

conve

ntional

anal

ges

iaor

del

iver

y

(n=

102)

VA

Sfo

rpai

n;

AT

bet

ter

than

contr

ol(P

<0.0

5)

Nee

dfo

rED

A;

AT

bet

ter

than

contr

ol(1

0vs

26.5

%,

P=

0.0

1)

Nee

dfo

rm

eper

idin

e;A

Tbet

ter

than

contr

ol(1

4vs

35%

,

P<

0.0

01)

Dura

tion

of

labour;

AT

bet

ter

than

contr

ol(P

=0.0

1)

Use

of

oxy

toci

n;

AT

bet

ter

than

contr

ol

(14

vs35%

,P

<0.0

01)

NS

inm

ode

of

del

iver

y

NS

inA

pgar

score

at5

min

ute

s

None

Zhan

g(2

006)1

6120

nulli

par

ous

wom

enw

ith

single

ton,

vert

expre

senta

tion,

term

(37–4

2w

eeks

of

ges

tation)

inre

gula

r

contr

actions

and

cerv

ical

dila

tation

(2–3

cm)

atad

mis

sion

EA(n

=39)

(a)

Plac

ebo

EA,

iden

tica

l

stim

ula

tion

with

non-p

enet

rating

nee

dle

atac

upoin

t

SP6

(n=

40)

(b)

No

trea

tmen

t

(n=

40)

VA

Sfo

rpai

n;

(a)

EAbet

ter

than

pla

cebo

EA(P

<0.0

5)

at15,

30

min

ute

s,an

d3

hours

afte

rEA

;

(b)

EAbet

ter

than

no

trea

tmen

t

(P<

0.0

1)

at15,

30

min

ute

s,

and

1an

d2

hours

afte

rEA

Dura

tion

of

labour;

EAbet

ter

than

pla

cebo

EA(P

=0.0

07)

NS

inA

pgar

score

at1

and

5m

inute

s

bet

wee

nEA

and

pla

cebo

EA

None



Tab

le1.

(Continued

)

Firs

tau

tho

r

(year)

Part

icip

an

tsIn

terv

en

tio

n

(n)*

Typ

eo

f

con

tro

l(n

)*

Pri

mary

ou

tco

mes

Seco

nd

ary

ou

tco

mes

Ad

vers

e

even

ts

Mate

rnal

Feta

l

Zhou

(2007)1

5111

nulli

par

ous

wom

enw

ith

single

ton,

vert

ex

pre

senta

tion,

term

(37–4

2w

eeks

of

ges

tation)

inre

gula

r

contr

actions

and

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Cho et al.


Acupuncture interventionsThe types of acupuncture used in the trials were classical

acupuncture and EA: individualised (50%), standardised

(30%), and semi-standardised (20%) acupuncture styles

were tested (semi-standardised acupuncture is defined as a

set of acupoints supplemented by some additional points

individually chosen for each patient). The SP6 acupoint

was most commonly used (Table 2).

Types of control groupsA range of comparison groups were used including

transcutaneous electrical nerve stimulation (TENS),18,20

conventional analgesia,20,22,23 minimal acupuncture at non-

acupoints,15,19,24 EDA,18 subcutaneous sterile water injec-

tion,21 placebo EA,16,17 and no intervention.16–18,24 Two

studies16,17 from China employed placebo EA where needle

penetrating was simulated, followed by needle fixing on an

acupoint with adhesive tapes and connected to an inactive

electric device. Minimal acupuncture was defined as super-

ficial needling in places that are not regarded as acupoints,

but are mainly used as injection sites, such as buttocks,

thighs, and arms.15,19,24

Outcome measuresSeven studies reported labour pain on a 100-mm

VAS.15–19,21,24 Five studies assessed the number of women

requiring other pain relief at any time.15,20–23

Methodological qualityOur ‘risk of bias’ assessments are shown in Figure 2:

sequence generation was adequately described by descrip-

tion in eight trials.15,17–23 One study referred to a ran-

dom number table,18 five studies used computer-

generated randomisation for sequence generation,17,19–22

and two studies assigned groups by drawing lots.15,23 The

other trials did not describe the sequence generation pro-

cess.16,24

Allocation concealment was adequate in seven studies;

six studies ensured that allocations were concealed by using

envelopes.15,17,19,21–23 One study used a code-generating

system based on the unique civil registration number in

the log.20 The other trials were rated ‘unclear’, as they did

not have clear descriptions of their method of allocation

concealment.16,18,24

Because of the nature of the intervention and the condi-

tion, it was difficult for the women, care-givers, and out-

come assessors to be blinded. Not a single RCT had

masked women, care providers, and evaluators. Two stud-

ies in which minimal acupuncture was used in the control

groups had adequate participant and assessor blinding.15,19

In three trials participants were blinded using minimal acu-

puncture or placebo EA, but it was not clear whether the

care providers or evaluators were blinded.16,17,24

Seven studies had no participant losses, or the missing

data were balanced in numbers across intervention

groups.15–19,21,23 In two studies,20,22 an ‘intention-to-treat’

analysis was performed with one drop-out datum. The risk

of bias in the remaining trial is unclear because the number

of participants analysed in each group was not reported.24

As far as we could see, all studies included were free of

selective outcome reporting and other potential sources of

bias.

Adequate sequence generation

Allocation concealment

Participant blinding

Care provider blinding

Evaluator blinding

Incomplete outcome data addressed

Free of selective outcome reporting

Free of other bias

0 25 50 75 100 %

Yes (low risk of bias) Unclear No (high risk of bias)

Figure 2. Risk of bias graph.



Outcomes

Primary outcomesFigure 3 shows the forest plots with MDs in VAS for pain

intensity and RRs for the number of women requiring

analgesic methods, with 95% CI.

Electroacupuncture versus placebo EA (two studies):

combining two studies (154 participants) that compared

EA with placebo EA yielded a significant pain reduction in

favour of EA at 15 and 30 minutes of treatment (pooled

MD )4.09; 95% CI )8.05, )0.12; pooled MD )5.94; )9.83,

)2.06; respectively).16,17 The effect was not sustained

1–3 hours after EA. There was no significant statistical het-

erogeneity between these trials (I2 = 0.7%).

Acupuncture versus minimal acupuncture (three stud-

ies): three trials compared manual acupuncture with mini-

mal acupuncture, and reported VAS for pain.15,19,24 No

difference between the groups was found. One trial

reported a large difference in favour of acupuncture

30 minutes, 1 hour and 2 hours after acupuncture treat-

ment,15 whereas the other study failed to do so (MD 1.67;

95% CI )3.72, 7.06).19 No significant differences were also

found 1 and 2 hours after acupuncture (MD 4.30; 95% CI

)3.80, 12.40; MD 3.90; )3.57, 11.37; respectively).24 Con-

siderable heterogeneity was detected between studies for

this outcome, with I2 values ranging from 92 to 98%.

Acupuncture versus no intervention (four studies): four

trials compared EA,16,17,18 or manual acupuncture,24 with

no acupuncture intervention. Using a fixed-effects model

provided a significant pain reduction by EA (two studies)

at 15 and 30 minutes (pooled MD )6.81; 95% CI )10.77,

)2.81; pooled MD )10.56; )16.08, )5.03; respectively).16,17

Another study also reported a significant pain relief for the

EA group 30 minutes after acupuncture (MD )16.20;

95% CI )21.41, )10.99).18 No significant difference was

found between manual acupuncture and no acupuncture at

1, 2 and 3 hours after acupuncture. Substantial heterogene-

ity between studies was detected, except for VAS, after

15 minutes of EA (I2 = 0%).

Acupuncture versus conventional analgesia (three stud-

ies): less women receiving acupuncture required meperidine

compared with those receiving conventional analgesia alone

(pooled RR 0.20; 95% CI 0.12, 0.33; I2 = 0%).20,22,23

Whereas combined results from two studies did not reach

a statistical significance in the requirement for EDA (poo-

led RR 0.68; 95% CI 0.46, 1.00; I2 = 26%),20,23 the use of

any pharmacological and/or invasive methods (EDA,

nitrous oxide, meperidine, sterile water injection) was sig-

nificantly lower in the acupuncture groups (pooled RR

0.75; 95% CI 0.66, 0.85, I2 = 40%).20,22

Acupuncture versus other treatments (two studies): two

studies compared acupuncture or EA with TENS.18,20 In

the largest study comparing acupuncture plus conventional

care with TENS plus conventional care,20 the RR was 0.85

regarding the need for any pharmacological and/or invasive

pain relief (95% CI 0.74, 0.98). There was no significant

difference in the need for meperidine, and EDA (RR 0.92;

95% CI 0.17, 4.95; RR 1.06; 95% CI 0.68, 1.65; respec-

tively). In another study comparing EA with TENS,18 no

significant difference was reported after 30 minutes, or 1 or

2 hours after EA.

Secondary outcomesMore women in the acupuncture groups were satisfied with

their pain relief in two studies,18,19 were more relaxed,23 or

expressed a willingness to choose acupuncture for future

delivery.19 Women receiving acupuncture reported a signif-

icantly shorter duration of labour in three trials out of

eight reporting this outcome measure.15,17,19 Less oxytocin

use by the acupuncture group was reported in three out of

six studies.15,19,24 Acupuncture has no effect on the mode

of delivery or the extent of postpartum haemorrhage. Fetal

outcomes such as Apgar scores or birthweights were also

unaffected (Table 1).

Adverse eventsSix studies reported that there were no adverse events

caused by acupuncture treatment.15,17,19,20,22,23 The other

studies failed to mention adverse events.

Discussion and conclusion

Summary of main findingsThis systematic review of ten RCTs found little convincing

evidence that women receiving acupuncture are more likely

to experience less labour pain than those in the control

groups. Women rated their pain intensity on VAS in seven

studies; acupuncture was not effective compared with mini-

mal acupuncture in three studies. Patients reported signifi-

cantly less pain during EA treatment (after 15 and

30 minutes) compared with placebo EA, but, in two studies,

the effect was not maintained. When compared with no

treatment,16–18,24 acupuncture was effective only for the first

30 minutes. In trials where acupuncture was compared with

conventional analgesia women receiving acupuncture

required less meperidine and other analgesic methods.20,22,23

Acupuncture did not seem to have any impact on other

maternal or fetal outcomes, nor was it associated with harm.

Applicability of evidenceOur optimistic conclusion from the previous systematic

review was based on just three RCTs.6 The more negative

results of the present review are based on more and better

data. Before we accept that acupuncture has no effect on

labour pain, a careful look at the included studies is

required. The included studies originate from five different

Cho et al.


EA vs placebo EA: 100 mm VAS for pain

Study

A

B

/year

1.1.1 15 min for EA

Zhou 2007Zhang 2006Subtotal (95% CI)

Test for heterogeneity: I ² = 0%Test for overall effect: Z = 2.02 (P = 0.04)

1.1.2 30 min for EA



1.1.3 1 hour after EAZhou 2007

Zhang 2006Subtotal (95% CI)


1.1.4 2 hours after EA



1.1.5 3 hours after EA



Weight

17.2%82.8%

100.0%

18.4%81.6%

100.0%

11.7%

88.3%100.0%

25.4%74.6%

100.0%

19.8%80.2%

100.0%

IV, fixed, 95% CI

–0.59 [–10.16, 8.98]–4.81 [–9.17, –0.45]–4.09 [–8.05, –0.12]

–5.70 [–14.76, 3.36]–6.00 [–10.30, –1.70]–5.94 [–9.83, –2.06]

–2.91 [–11.28, 5.46]

–1.56 [–4.61, 1.49]–1.72 [–4.59, 1.15]

–6.92 [–14.67, 0.83]–2.75 [–7.27, 1.77]–3.81 [–7.72, 0.10]

1.20 [–8.71, 11.11]–4.66 [–9.59, 0.27]–3.50 [–7.91, 0.91]

Mean difference Mean differenceIV, fixed, 95% CI

–10 –5 0 5 10Favours acupuncture Favours control

Acupuncture vs minimal acupuncture: 100 mm VAS for pain

Study/year

1.2.1 30 min after acupunctureHantoushzadeh 2007Skilnand 2002Subtotal (95% CI)Test for heterogeneity: I ² = 98%Test for overall effect: Z = 0.87 (P = 0.39)

1.2.2 1 hour after acupunctureHantoushzadeh 2007Skilnand 2002Ziaei 2006Subtotal (95% CI)Test for heterogeneity: I ² = 94%Test for overall effect: Z = 1.13 (P = 0.26)

1.2.3 2 hours after acupunctureHantoushzadeh 2007Skilnand 2002Ziaei 2006Subtotal (95% CI)Test for heterogeneity: I ² = 92%Test for overall effect: Z = 1.53 (P = 0.13)

Weight

49.9%50.1%

100.0%

34.1%33.9%31.9%

100.0%

34.2%33.2%32.6%

100.0%

IV, Random, 95% CI

1.67 [–3.72, 7.06]–23.20 [–28.12, –18.28]–10.79 [–35.16, 13.58]

–6.13 [–11.27, –0.99]–21.50 [–26.94, –16.06]

4.30 [–3.80, 12.40]–8.02 [–21.88, 5.84]

–13.40 [–18.92, –7.88]–20.60 [–27.39, –13.81]

3.90 [–3.57, 11.37]–10.15 [–23.18, 2.87]

Mean difference Mean differenceIV, Random, 95% CI


Figure 3. (A) EA versus placebo EA: 100-mm VAS for pain. (B) Acupuncture versus minimal acupuncture: 100-mm VAS for pain. (C) Acupuncture

vs. no intervention: 100-mm VAS for pain. (D) Acupuncture vs. conventional analgesia: use of meperidine, EDA, or any analgesia. Vertical line shows

no effect point; CI, confidence interval; EA, electroacupuncture; EDA, epidural analgesia; VAS, visual analogue scale.



Acupuncture vs no intervention: 100 mm VAS for pain

Study/year

1.3.1 15 min for EAZhang 2006Zhou 2007Subtotal (95% CI)Test for heterogeneity: I ² = 0%Test for overall effect: Z = 3.37 (P = 0.0008)

1.3.2 30 min for EAZhang 2006Zhou 2007Subtotal (95% CI)Test for heterogeneity: I ² = 46%Test for overall effect: Z = 3.75 (P = 0.0002)

1.3.3 30 min after EA

Huang 2008Subtotal (95% CI)

Test for heterogeneity: Not applicableTest for overall effect: Z = 6.10 (P < 0.00001)

1.3.4 1 hour after acupunctureHuang 2008Zhang 2006Zhou 2007Ziaei 2006Subtotal (95% CI)Test for heterogeneity: I ² = 92%Test for overall effect: Z = 1.95 (P = 0.05)

1.3.5 2 hours after acupuncture

Huang 2008Zhang 2006Zhou 2007Ziaei 2006Subtotal (95% CI)


1.3.6 3 hours after EAZhang 2006Zhou 2007Subtotal (95% CI)Test for heterogeneity: I ² = 53%Test for overall effect: Z = 1.71 (P = 0.09)

Weight

77.7%22.3%

100.0%

63.0%37.0%

100.0%

100.0%100.0%

–16.20 [–21.41, –10.99]–16.20 [–21.41, –10.99]

27.3%28.0%23.8%20.9%

100.0%

28.6%27.2%24.0%20.2%

100.0%

58.6%41.4%

100.0%

IV, Random, 95% CI

–5.81 [–10.30, –1.32]–10.28 [–18.68, –1.88]

–6.81 [–10.77, –2.84]

–8.40 [–12.67, –4.13]–14.24 [–21.48, –7.00]–10.56 [–16.08, –5.03]

–15.20 [–18.69, –11.71]–3.53 [–6.10, –0.96]

–13.12 [–19.80, –6.44]2.60 [–6.29, 11.49]

–7.71 [–15.48, 0.06]

–11.60 [–15.14, –8.06]–3.65 [–8.19, 0.89]

–12.59 [–19.15, –6.03]5.50 [–3.34, 14.34]

–6.23 [–12.91, 0.46]

–2.84 [–7.80, 2.12]–9.46 [–16.79, –2.13]–5.58 [–11.97, 0.81]

Mean difference Mean differenceIV, Random, 95% CI


Acupuncture vs conventional analgesia: use of meperidine, EDA, or any analgesia

Study/year

2.1.1 Use of meperidine

Borup 2009Nesheim 2003Ramnero 2002Subtotal (95% CI)

Test for heterogeneity: I ² = 0%Test for overall effect: Z = 6.40 (P < 0.00001)

2.1.2 Use of EDA

Borup 2009Ramnero 2002Subtotal (95% CI)


2.1.3 Use of any analgesia

Borup 2009Nesheim 2003Subtotal (95% CI)

Test for heterogeneity: I ² = 40%Test for overall effect: Z = 4.43 (P < 0.00001)

Weight

17.4%79.3%3.3%

100.0%

63.1%36.9%

100.0%

60.3%39.7%

100.0%

IV, Random, 95% CI

0.24 [0.07, 0.78]0.18 [0.10, 0.31]0.96 [0.06, 14.83]0.20 [0.12, 0.33]

0.79 [0.53, 1.16]0.52 [0.30, 0.92]0.68 [0.46, 1.00]

0.71 [0.63, 0.80]0.81 [0.69, 0.96]0.75 [0.66, 0.85]

Risk ratio Risk ratioIV, Random, 95% CI

0.1 0.2 0.5 1 2 5 10Favours acupuncture Favours control

C

D

Figure 3. (Continued)

Cho et al.


Table 2. Acupuncture interventions in the included studies

First author (year) Type of

acupuncture

Acupoint

selection

Acupuncture

treatment

rationale

Treatment regimen

Borup (2009)19 MA + AA Individualised Previous reports

and pilot projects

Needle size: 0.20 · 15, 0.30 · 30,

or 0.35 · 50 mm

Needles left for 30 minutes–2

hours, or repeated; removed

if necessary

Unclear whether de-qi response

elicited

Selected from 34 specified acupoints

Hantoushzadeh (2007)18 MA Individualised Textbooks Bilateral insertion

Needles removed if necessary

De-qi sensation sought

LI4, LR3, and ST36 for analgesia

and general pain; BL32 and BL60

for back pain; SP6 for severe pain

during contraction; GB34 for

cervical rigidity; and HT7 for anxiety

and nervousness

Huang (2008)17 EA Basic + individualised NR 2/100 Hz

Basic acupoints: ST36, CV3, and CV4

Adjunctive points: BL32 and LR3 for

excessive pattern; LI4 and SP6 for

deficient pattern in TCM diagnosis

Martensson (2008)20 MA Basic + individualised Literature and

selection by

participating midwives

Needle size: 0.30 · 30,

or 0.35 · 50 mm

Needles left for 40 minutes, or

repeated if necessary; needles

were manually stimulated

every 10 minutes


GV20, LI4, and SP6, and between

four and seven individually chosen

points from BL23, BL24, BL54,

EX19, GB25–29, and KI11

Nesheim (2003)21 MA Individualised Selection by


Needle size: different needles for

different points (0.5–1.5 inches,

30/32 gauge)

Needles removed after 10–20 minutes,

or taped and left in place for the

entire duration of labour


GV20, HT7, and LR3 for tension,

nervousness, or tiredness; LR3

and GB34 for cervix rigidity; CV4

for symphysis pain in early labour;

LI10 and LI11 for pain during the

first stage of labour; BL23 and

BL60 for back pain in early labour;

BL27, BL28, and BL32 for back pain

later in labour; LI4 and SP6 for strong

pain during contractions; PC6 and

PC7 for nausea; and ST36 for

any pain



countries, they compared different acupuncture methods

with different controls, they had different inclusion and

exclusion criteria, and a range of outcome measures, and

routine care given to patients varied as well. It was difficult

to determine whether the acupuncture intervention given

was appropriate or optimal for labour pain relief in terms

of acupoint selection, stimulation, duration, or timing.

Only three out of ten included studies specified how many

hours of acupuncture training the study midwives had

received,20,22,23 and it seems safe to assume that their acu-

puncture skills and experience varied greatly, not only

across studies but also within trials. Some studies included

women with cervical dilatation of 2–3 cm at admission,16,17

and in one study women in labour were asked to partici-

pate if they requested pain relief.20 In addition to this high

level of clinical heterogeneity, most of our analyses detected

a significant level of statistical heterogeneity. All this means

that our findings must be interpreted with caution.

Table 2. (Continued)

First author (year) Type of

acupuncture

Acupoint

selection

Acupuncture

treatment

rationale

Treatment regimen

Ramnero (2002)22 MA Individualised Selection by


Needles removed after 1–3 hours,

or when necessary; taped to allow

women to move freely


GV20, Yintang, LU7 for relaxation;

BL25–36, BL54, BL60, GB25–29,

GB41, CV2, CV3, subcutaneous

points, LI4, LR3, KI3, and SP6

for analgesia

Skilnand (2002)23 MA Individualised Treatment protocol from

the Norwegian School

of Acupuncture

2–12 needles (average 7) used;

removed after 20 minutes or

left until conversion to conventional

analgesia or delivery; taped to

allow women to move freely


LU7, HT7, ST29, ST30, ST36, GB34,

SP6, SP8, KI3, LR3, GB41, BL32,

BL34, BL60, BL67, LI4, and GV20

Zhang (2006)16 EA Fixed Literature No manipulation, 25-mm insertion

depth, 2/100 Hz, 20 mA,

for 30 minutes

Rt SP6

Zhou (2007)15 EA Fixed Literature No manipulation, 25–30-mm insertion

depth, 2/100 Hz, electric current

threshold individually adjusted,

for 30 minutes

Rt SP6

Ziaei (2006)24 MA Fixed NR Needles inserted when VAS > 3;

taped and left until delivery


GV20, Yintang for relaxation;

ST36, SP6, LI3, LI4, CV2,

and CV3 for analgesia

De-qi refers to acupuncture-evoked specific sensations such as soreness, numbness, heaviness, and distention at the site of needle placement,

and these sensations may spread to other parts of the body. Acupoint ST36 refers to 36th point of the stomach meridian. Some extra points have

Chinese names.

AA, auricular acupuncture; BL, bladder meridian; CV, conception vessel; EA, electroacupuncture; EX19, extra point 19 (Shiqizhui); GB, gallbladder

meridian; GV, governor vessel; HT, heart meridian; KI, kidney meridian; LI, large intestine meridian; LR, liver meridian; LU, lung meridian; MA,

manual acupuncture; NR, not reported; PC, pericardium meridian; Rt, right; SP, spleen meridian; ST, stomach meridian; TCM, traditional Chinese

medicine; VAS, visual analogue scale.

Cho et al.


It may be confusing that women receiving acupuncture

required less meperidine and other analgesic methods than

the women receiving conventional analgesia alone, whereas

no difference was detected between real and sham acupunc-

ture. It should be noted that acupuncture versus conven-

tional analgesia studies also reported similar pain intensity

ratings between groups, and this is in agreement with the

results from acupuncture versus sham acupuncture studies

(Table 1). Acupuncture is well known for its powerful non-

specific/placebo effect.25 One possible interpretation could

be that the analgesic effect of acupuncture did not reach a

significantly different level from that of the control group,

but that women receiving acupuncture may have felt that

they are being given something, thus did not require more

analgesic methods.

Quality of studiesWe used the ‘risk of bias’ assessment tool by the Cochra-

ne collaboration to evaluate the quality of the primary

studies.12 Although quality rating scales offer simplicity by

calculating a summary score, weights given to different

items of the scale are difficult to justify.26 Instead of

adopting quality scales, we tried to fully report how each

trial has been rated for six critical domains, i.e. randomi-

sation, allocation concealment, blinding, incomplete out-

come data reporting, selective outcome reporting, and

other biases. Yet the ‘risk of bias’ assessment tool may

not be entirely free from subjectivity.27 We tried to mini-

mise this source of bias by working independently to eval-

uate each domain for each study, and solving

discrepancies through discussions. The allocation sequence

generation and concealment were assessed to be adequate

in most studies included. Two studies rated as ‘unclear’

for allocation concealment,18,24 against the notion that

inadequate or unclear allocation concealment is associated

with overestimates of effect,28 did not demonstrate acu-

puncture was better than the sham control. Probably the

highest risk of bias in the included studies lies in blind-

ing. As most studies used subjective outcome measures,

blinding may have a larger impact on the result than the

other domains. None of the included studies blinded the

three parties of participant, care provider, and outcome

assessor. Considering the condition itself and the nature

of acupuncture treatment, blinding all three parties may

not be practical. However, separating the roles of care

provider and outcome assessor would have minimised the

measurement bias: only two of the ten trials blinded

the outcome assessor.15,19 Reviewers agreed that there

were no major flaws in outcome reporting and other

potential biases in the included studies. Consequently,

incomplete blinding of the included trials seems to bring

the highest risk to their overall methodological quality.

Potential biases of the reviewBias can be introduced in every step of reviewing, and our

systematic review is no exception. Heterogeneity may be

caused by known methodological differences between trials,

or it can be related to unknown study characteristics. The

included trials greatly varied in the characteristics of partic-

ipants, labour management protocols, and control types. In

addition, quite different interventions were tested under

the label of ‘acupuncture’, and all these factors may have

influenced the course of labour, analgesic requirements,

including EDA, and accordingly, the outcomes. The statisti-

cal heterogeneity found in the meta-analyses of our pri-

mary outcomes may thus be inevitable. A large number of

studies would be necessary to investigate potential sources

of heterogeneity.

The potential of missing eligible trials always exists in

any systematic review. Even though empirical evidence

tells us that including publications in languages other

than English appears to have little impact on the conclu-

sion of the review,29 we tried to be comprehensive by

searching all available databases across countries without

language restrictions. The three Chinese language articles

do not appear to deviate from the overall findings of our

review.

Implications for practice and researchAcupuncture does not appear to afford more effective

pain relief than sham/placebo acupuncture, conventional

analgesia, or no analgesia at all. Because of the heteroge-

neity of the studies, the findings in this review are diffi-

cult to interpret as firm evidence against acupuncture for

pain relief in labour. Acupuncture appears to reduce the

requirement for other forms of pain relief compared with

conventional analgesia, but the evidence is not strong. No

evidence emerged for any harm caused by acupuncture.

We believe the evidence presented in this review should

be made available to both doctors and women to help

them make informed decisions on whether or not to use

acupuncture for pain control. A number of questions

should be answered in future studies. This review found

the data to be limited on the optimal acupuncture inter-

vention and corresponding sham/placebo controls, the

best timing of outcome measurements, and additional

staff and necessary education. We have no sound data on

the costs associated with providing acupuncture during

labour, but, according to our estimate, they are not exces-

sive. Adverse events were frequently not monitored.

Future studies should be planned and conducted to

address all these issues.

In conclusion, current evidence does not appear to sup-

port the use of acupuncture for labour pain. Acupuncture

might reduce the use of other forms of pain relief, but the



evidence is limited. The heterogeneity of the studies avail-

able to date prevents us making a firm conclusion. Further

research seems to be warranted.

Disclosure of interestsNone.

Contribution to authorshipS-HC formulated the idea for updating the systematic

review; S-HC and HL performed literature searches, study

selection, data extraction, risk of bias assessment, meta-

analysis, and wrote the initial draft; S-HC, HL, and EE

resolved disagreements regarding study selection and risk

of bias assessment, and critically revised the manuscript.

Details of ethics approvalNo ethics approval was required.

FundingHyangsook Lee was supported by the Basic Science

Research Programme through the National Research

Foundation, funded by the Korean Ministry of Education,

Science and Technology (R11-2005-014).

AcknowledgementWe thank Ditlev Fossen, MD, for providing us with addi-

tional data. j

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