By Ellen Feldman, MD
Altru Health System, Grand Forks, ND
Dr. Feldman reports no financial relationships relevant to this field of study.
• This updated Cochrane Review of acupuncture and acupressure in pain management during labor includes results from 28 trials involving 3,960 women, representing an increase of 17 studies from the 2011 review.
• Outcomes include pain intensity, satisfaction with pain relief, quantity of pharmacological agents used, reduced assisted vaginal birth, reduced cesarean sections, and Appearance, Pulse, Grimace, Activity, and Respiration scores < 7 at five minutes.
• Positive findings for acupuncture vs. sham control include moderate-certainty evidence of increased satisfaction of pain management and decreased use of pharmaceutical agents.
• Positive findings for acupressure vs. sham control include moderate-certainty evidence of reduced rate of cesarean delivery, and, compared to combined control (placebo and no treatment), moderate-certainty evidence of pain intensity reduction.
SYNOPSIS: This Cochrane review evaluating acupuncture and acupressure for pain management during labor finds acupuncture may lead to reduced use of pharmacological agents for pain control while acupressure may reduce pain intensity. Higher-quality studies are needed.
SOURCE: Smith CA, Collins CT, Crowther CA, Levett KM. Acupuncture or acupressure for pain management during labour. Cochrane Database Syst Rev 2020;2:CD009232.
Cochrane, an international, nonprofit organization dedicated to providing unbiased reviews of medical research in healthcare, serves patients, providers, researchers and “anyone interested in using high-quality information to make health care decisions.” The well-stocked Cochrane Library online database holds reviews of more than 8,000 medical interventions, more than 2,000 protocols, and more than 160,000 medical trials.1
Smith et al contribute to this knowledge base with a fresh look at the role of acupuncture and acupressure in pain management during labor. This work updates the 2011 Cochrane review. Conclusions in 2011 were that while both acupuncture and acupressure had suggestive evidence of a role in managing pain during labor, including mitigating pain intensity, increasing satisfaction of pain management, and reducing pharmacological interventions, significant bias and poor-quality evidence did not allow firm recommendations.2
For this 2020 review, 28 studies (including 11 from the 2011 review) incorporating data from 3,960 women are covered. In addition, a newer method of determining quality of the acupuncture or acupressure intervention is employed (the National Institute for Complementary Medicine Acupuncture Network scale). This metric permits a more nuanced view of the quality of the studies and a standardized approach to evaluation by reviewers.3 Evidence from the studies is weighed using the Grading of Recommendations, Assessment, Development and Evaluations approach — providing a reliable algorithm to determine the strength of evidence and compare among studies.4
Pain during labor has multifactorial origins, with physiological, psychological, and even cultural components and influences. Most studies in the field agree that individualization of pain management is important.5 Smith et al explain that consideration of both pain control efficacy and effectiveness is a major factor in evaluating responses. For example, efficacy trials usually compare acupuncture or acupressure to a sham treatment, while effectiveness trials typically compare the intervention(s) to standard treatment. Thus, although efficacy trials may measure pain scores (usually on a visual analog scale [VAS], typically from 1 to 10), effectiveness trials look at reduction in pain medication and/or satisfaction scores among participants.
Acupuncture and acupressure, both originating in Asia and based on energy theories of yin and yang, differ in significant ways. Acupuncture is a major component of traditional Chinese medicine and involves needle insertion into specific body areas to correct energy imbalances. In addition, there is a modified, or westernized, approach to acupuncture based on neurophysiological factors.6 Acupressure uses manual pressure (hands and fingers) rather than needles to activate specific points and restore balance.7 Both are complex techniques, involving not only physical touch, but also a therapeutic relationship.6,7
In the Smith et al study, acupuncture is compared to sham control, usual care, no treatment, and water injection. Acupressure is compared to sham control, usual care, and combined control (placebo and usual care). Table 1 (available at https://bit.ly/2XX9gdd) provides result details. Results indicate moderate-certainty evidence that acupuncture, compared to a sham control or water injection, increases satisfaction with pain management and reduces use of pharmacologic agents during labor. Additionally, there is moderate-certainty evidence that acupressure may reduce the need for cesarean sections when compared to a sham control. There is also moderate-certainty evidence that acupressure, compared to a placebo and usual care, reduces pain intensity of labor, although there are few trials measuring this (two trials; 322 women).
To keep childbirth and childbearing as natural as possible, many women express an interest in complementary and alternative medicine (CAM) during pregnancy.8 The Smith et al review of evidence supporting the efficacy and effectiveness of acupuncture and acupressure during labor brings valuable information for patients and providers who are looking for CAM interventions.
Perhaps the biggest limitation to clinical application of the review is the limited number of studies in the general area of acupuncture and acupressure in labor and in each of the subcategories. Larger numbers of studies strengthen the power of a meta-analysis to detect significant differences between interventions. In addition, Smith et al point to a significant degree of bias in most of the studies, especially where participants and providers are not blinded to the intervention. All of the studies included women in low-risk pregnancies, usually at term and when presenting in labor. The researchers note that the style of acupuncture varied among the studies (including eight trials with individualized treatment), as did the duration, depth of insertion, and other components of both acupuncture and acupressure. Additionally, there is no discussion of any negative effects from these interventions — it is possible this is in part because of the self-selected nature of the participants. These factors weaken the ability to generalize and apply findings in clinical practice.
However, based on a limited number of studies, it does appear that, compared to sham treatment, acupuncture may both increase satisfaction with pain management during labor and decrease the use of pharmacologic agents. Acupressure may reduce pain intensity compared to a combined control and compared to a sham control, may reduce the rate of cesarean delivery. Future studies, including a focus on duration and timing of intervention, any contraindications, and the ability to generalize to all patients, as well as methodology to reduce bias, are needed before global acceptance and clinical application.
When working with pregnant women who have questions about these interventions during labor, a provider is on firm ground noting the importance of individualization of pain management during labor, and that studies are not yet conclusive regarding benefits of acupuncture or acupressure during labor. Skilled providers of these techniques are not readily available in all communities, the cost is variable, insurance reimbursement uncertain, and in this era of COVID-19, additional practitioners are restricted from many birthing rooms.
Thus, although it is unlikely that acupuncture and/or acupressure will be a standard of care in United States labor and delivery rooms in the near future, time and further studies will let us know if these will one day play a more central role in births.
REFERENCES
- Cochrane Library. About Cochrane reviews. https://www.cochranelibrary.com/about/about-cochrane-reviews
- Smith CA, Collins CT, Crowther CA, Levett KM. Acupuncture or acupressure for pain management in labour. Cochrane Database Syst Rev 2011;7:CD009232.
- Smith CA, Zaslawski CJ, Zheng Z, et al. Development of an instrument to assess the quality of acupuncture: Results from a Delphi process. J Altern Complement Med 2011;17:441-452.
- Siemieniuk R, Guyatt G. What is GRADE? BMJ Best Practice. https://bestpractice.bmj.com/info/toolkit/learn-ebm/what-is-grade/
- Shah S, Banh ET, Koury K, et al. Pain management in pregnancy: Multimodal approaches. Pain Res Treat 2015;2015:987483.
- White A, Ernst E. A brief history of acupuncture. Rheumatology (Oxford) 2004;43:662-663.
- Mertz MJ, Earl CJ. Labor Pain Management. In: Rakel D., ed. Integrative Medicine. 4th ed. Elsevier;2018.
- Steel A, Adams J, Sibbritt D, et al. Utilisation of complementary and alternative medicine (CAM) practitioners within maternity care provision: Results from a nationally representative cohort study of 1,835 pregnant women. BMC Pregnancy Childbirth 2012;12. https://doi.org/10.1186/1471-2393-12-146
