Acupuncture and acupressure for pain management in labour and birth: A critical narrative review of current systematic review evidence

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Summary

Background

Reviews of maternity services highlight the need for a reduction of medical interventions for women with low risk pregnancies and births to prevent the potential cascade of interventions and their associated risks. Complementary medicines (CM) such as acupuncture and acupressure have claimed to be effective in reducing interventions in labour; however, systematic reviews of evidence to date are conflicting.

Aims

To examine current evidence from systematic reviews on the topic of acupuncture and acupressure for pain management in labour and birth, and to evaluate the methodological and treatment frameworks applied to this evidence.

Methods

A search limited to systematic reviews of the MEDLINE, CINAHL, PUBMED, EMBASE and Cochrane databases was performed in December 2013 using the keywords ‘CAM’, ‘alternative medicine’, ‘complementary medicine’, ‘complementary therapies’, ‘traditional medicine’, ‘Chinese Medicine’, ‘Traditional Chinese Medicine’, ‘acupuncture’, ‘acupressure’, cross-referenced with ‘childbirth’, ‘birth’, labo*r’, and ‘delivery’. The quality of the evidence is also evaluated in the context of study design.

Results

The RCTs included in these systematic reviews differed in terms of study designs, research questions, treatment protocols and outcome measures, and yielded some conflicting results. It may be inappropriate to include these together in a systematic review, or pooled analysis, of acupuncture for labour with an expectation of an overall conclusion for efficacy. Trials of acupuncture and acupressure in labour show promise, but further studies are required.

Conclusion

The use of current systematic reviews of the evidence for acupuncture and acupressure for labour and birth may be misleading. Appropriate methods and outcome measures for investigation of acupuncture and acupressure treatment should more carefully reflect the research question being asked. The use of pragmatic trials designs with woman-centred outcomes may be appropriate for evaluating the effectiveness of these therapies.

Section snippets

Background

Birth is a complex cultural, social and physical event, and evidence suggests that acupuncture and acupressure may be effective for managing pain in labour. The pain experienced in labour is affected by the processing of multiple physiological and psychosocial factors,1, 2 and where labour is proceeding normally, does not reflect an abnormal pathological process. Perceptions of labour pain intensity vary, and interventions used in pain management can have a primary focus of helping women to

Methods

Systematic reviews provide a methodology to appraise, collate and summarise data from individual studies.39 These reviews are key documents in providing an overview for policy makers and clinical decision makers. Where more than one review exists on a topic, and where the results or conclusions may be inconsistent, it is important to compare and contrast the methodology and findings from separate reviews to ascertain the most cohesive evidence possible.39 A search of the MEDLINE, CINAHL,

Efficacy and effectiveness studies

Reviews were examined specifically as to whether they were designed to answer questions of efficacy or effectiveness.25, 26, 28 These trial designs are dependent on the clinical or research question being asked, however the terms are sometimes used interchangeably, and are often misunderstood. Efficacy trials are designed to show the extent to which a specific treatment or component of an intervention is effective under ideal clinical circumstances with patient populations specifically selected.

Results

One Cochrane systematic review and three other systematic reviews were identified from the search and evaluated for effects on labour outcomes.25, 26, 27, 28 They covered the CM interventions of acupuncture and acupressure for pain management in labour and birth and included both efficacy and effectiveness studies.

Smith et al.25 in the most recent Cochrane systematic review of acupuncture and acupressure, has examined evidence from RCTs to answer the question of whether acupuncture and

What is the evidence really saying? Are we comparing apples with oranges?

In this review of the evidence, it is important to highlight the different clinical questions as the basis for the reviews themselves, but also the different clinical questions, methods, designs and outcome measures of individual trials included in each review. Table 3 outlines the studies incorporated into the reviews, including: type of therapy; population of women; choice of control groups, treatment protocols used and outcome measures used to assess the research question.

In the four

Treatment intent and capturing the treatment outcome

The question of matching the intent of treatment protocols with study design, as well as the outcome measure used, is useful to consider. Generally, the reviews report that in studies where acupuncture was compared with usual care, often reflecting pragmatic trial designs, broader outcomes of the effect of treatment as a whole were often more apparent. These included reduced requirement for pharmacological analgesia, lower rates of instrumental deliveries and greater relaxation and greater

Discussion

Women are large consumers of CM, and they continue to use it during pregnancy and labour. Evidence from these four systematic reviews of acupuncture and acupressure for labour25, 26, 27, 28 suggests that acupuncture and acupressure techniques show promising point specific effects and more generalised holistic effectiveness in the support and management of pain in labour and birth, and the results are varied.

Acupuncture research to date has largely centred on questions of efficacy for the

Conclusion

Overall, the purpose of these approaches to pain management is not the same, and effectively the combining of these studies into a systematic review seems like ‘comparing apples with oranges’. The benefit of acupuncture may lie largely in the capacity to help women manage labour and avoid pharmacological medication in the context of hospital based maternity care. The point specific and point combination effects for analgesia and anaesthesia and the relative benefits of different forms of

Conflict of interest

Kate Levett is currently completing a PhD which involves the evaluation of CAM therapies for labour and birth. The other authors are also Kate Levett's PhD supervisors. This is a mixed methods study being conducted with the assistance of an Australian Post-Graduate Award. KL and CS are both authors of the Cochrane reviews cited in the text.

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    Sources of support: Kate Levett is a PhD student supported by an Australian Post-Graduate Award.

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