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Acupuncture for induction of labour

  1. Caroline A Smith1,*,
  2. Caroline A Crowther2,3,
  3. Suzanne J Grant1

Editorial Group: Cochrane Pregnancy and Childbirth Group

Published Online: 15 AUG 2013

Assessed as up-to-date: 14 DEC 2012

DOI: 10.1002/14651858.CD002962.pub3


How to Cite

Smith CA, Crowther CA, Grant SJ. Acupuncture for induction of labour. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD002962. DOI: 10.1002/14651858.CD002962.pub3.

Author Information

  1. 1

    University of Western Sydney, Center for Complementary Medicine Research, Sydney, New South Wales, Australia

  2. 2

    The University of Adelaide, ARCH: Australian Research Centre for Health of Women and Babies, The Robinson Institute, Discipline of Obstetrics and Gynaecology, Adelaide, South Australia, Australia

  3. 3

    The University of Auckland, Liggins Institute, Auckland, New Zealand

*Caroline A Smith, Center for Complementary Medicine Research, University of Western Sydney, Locked Bag 1797, Sydney, New South Wales, 2751, Australia. caroline.smith@uws.edu.au.

Publication History

  1. Publication Status: New search for studies and content updated (conclusions changed)
  2. Published Online: 15 AUG 2013

SEARCH

 

Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
 

Description of the condition

Sometimes it is necessary to bring on labour artificially because of safety concerns for the mother or baby. This review is one of a series of reviews of methods of labour induction using a standardised protocol. For more detailed information on the rationale for this methodological approach, please refer to the currently published 'generic' protocol (Hofmeyr 2000). The generic protocol describes how a number of standardised reviews will be combined to compare various methods of preparing the cervix of the uterus and inducing labour.

 

Description of the intervention

The use of complementary and alternative medicine (CM) has become popular with consumers worldwide. Studies suggest that between 36% and 62% of adults in industrialised nations use some form of CM to prevent or treat health-related problems (Barnes 2004). A recent review of 14 studies with large sample sizes (N > 200) on the use of CM in pregnancy identified a prevalence rate ranging from1% to 87% (with nine falling between 20% and 60%) (Adams 2009). The review identified use of various complementary therapies including acupuncture and acupressure, aromatherapy, massage, yoga, homeopathy and chiropractic care. The review also showed many pregnant women had used more than one complementary product or service (Adams 2009). In Europe, between 12% and 19% of the population report using acupuncture, according to consumer surveys (Fisher 1994). Some women look to alternative therapies during pregnancy and childbirth to be used alongside conventional medical practice. A recent survey described the prevalence and use of complementary therapies among 82 nurse-midwives in North Carolina (Allaire 2000). Almost 20% of nurse-midwives reported use of acupuncture during pregnancy, with 6% of responders specifically recommending its use to ripen the cervix (the process of softening and dilating the cervix) and/or induce labour. In the same survey, 27 respondents (33%) reported using herbal therapies for labour stimulation. For some women with a prolonged pregnancy, an induction of labour may be perceived to intervene in the natural process of pregnancy and may drastically change their expected plan of care during pregnancy. The reasons why pregnant women are interested in using complementary therapies to ripen the cervix and/or induce labour is an important question and needs to be answered when evaluating new options of care.

Acupuncture has been used for more than two thousand years in China and Japan. The diagnosis and treatment prescribed by traditional Chinese medicine (TCM) is influenced by the systems of medicine and philosophy of ancient China. Acupuncture involves the insertion of fine needles into the skin and underlying tissues at precise points on the body. The needle can be left alone or stimulated by turning in various ways or stimulated by electricity. Electro-acupuncture involves the use of electricity to stimulate the acupuncture point. To do this a needle is inserted and a terminal is attached to the handle, the other terminal is connected to a second needle or neutral electrode. Over time, different styles of acupuncture have been practiced by acupuncturists. Acupuncture treatment is composed of needling aspects (choice or points and needling techniques), specific components relating to the style of diagnosis and treatment used, and generic non-specific needling components not specific to acupuncture such as belief, time and attention given to the patient.

In parts of Europe and Asia acupuncture has been described as a method to alleviate labour pains, and ripen the cervix. More recently it has been used to stimulate the onset of labour.

Three case series document the role of acupuncture for the induction of labour (Tsuei 1974; Tsuei 1977; Yip 1976). Induction of labour using electro-acupuncture has been reported by Yip 1976. Labour was successfully induced in 21 of the 31 women, with pregnancy duration ranging from 38 to 42 weeks. The pattern of uterine activity was similar to that of normal labour. In a second study acupuncture with and without electrical stimulation was used to induce labour in 12 pregnant women with a gestational age from 19 to 43 weeks (Tsuei 1974). The success rate was 83% and average induction to delivery time was 13.1 hours. In the third study, 34 term and post term women and seven women with an intrauterine fetal death were induced using electro-acupuncture. Labour was successfully induced in 32 (78%) women (Tsuei 1977). The limited observational studies to date suggest acupuncture for induction of labour appears safe, has no known adverse effects to the fetus, and may be effective.

Two non-randomised trials have examined whether acupuncture could initiate contractions in women at term (Kubista 1975: Theobald 1973). In the trial by Theobald (Theobald 1973), four electrodes were applied to the skin of the abdomen to induce labour in the treatment group. Treatment was given to 27 women and compared with 102 women who were controls. In the treatment group 20 (77%) women gave birth on or up to four days before the estimated date of confinement, compared with 47 (46%) in the control group. In the second trial, electro-acupuncture was administered to 35 women, and 35 women received no electro-acupuncture. An increase in the intensity of labour contraction frequency was observed in 31 women in the treatment group. In the control group, no increase in labour activity was observed (Kubista 1975).

 

How the intervention might work

The mechanism underlying acupuncture to induce labour is speculative at this stage but may involve stimulation of the uterus by hormonal changes or by the nervous system. In animal studies low frequency electrical stimulation of the neuro-hypophyseal system induces the secretion of oxytocin. Parasympathetic stimulation close to term has been shown to have an influence on the uterus (Bell 1972). Stimulation of acupuncture points is known to increase the discharge of thalamic nuclei and the hypothalamic anterior pituitary system (Liao 1979). It is hypothesised that acupuncture neuronal stimulation may increase uterine contractility either by central oxytocin release or by parasympathetic stimulation of the uterus (Tempfeer 1998), without influencing locally active factors such as IL-8 and PGF2 either by central oxytocin release or by parasympathetic stimulation of the uterus (Tempfeer 1998).

 

Why it is important to do this review

Consumers generally perceive complementary medicine to be more natural than conventional medicine and have fewer concerns about side-effects. There are reports in the literature of rare adverse reactions to acupuncture, for example pneumothorax, infection or cardiac injury (Yamashita 1999). The general advice for the treatment of conditions arising during pregnancy is to exercise caution particularly during the first trimester of pregnancy, and to avoid some acupuncture points which may stimulate uterine activity. Treatment during the third trimester of pregnancy is thought to carry a lower risk.

This review is one of a series of reviews of methods of labour induction using a standardised protocol. For more detailed information on the rationale for this methodological approach please refer to the currently published protocol (Hofmeyr 2009).

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

To determine, from the best available evidence, the effectiveness and safety of acupuncture for third trimester cervical ripening or induction of labour.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
 

Criteria for considering studies for this review

 

Types of studies

Clinical trials comparing acupuncture for cervical ripening or labour induction, with placebo/no treatment, sham acupuncture or other methods listed above it on a predefined list of methods of labour induction; the trials included some form of random allocation to either group; and they reported one or more of the pre-stated outcomes.

The control group in a trial of acupuncture can involve sham (mock) acupuncture where the needles are inserted away from the usual location, with the depth and needle stimulation being the same. Or alternatively, minimal acupuncture which involves needles being inserted away from the usual location, with very shallow needling and very slight stimulation, or the use of the non invasive placebo needle (Streitberger 1998).

 

Types of participants

Pregnant women due for third trimester induction of labour, carrying a viable fetus. We planned to use subgroup analysis for any possible differences in the effect of interventions in these groups.

 

Types of interventions

Acupuncture compared with placebo, no treatment, sham acupuncture or any other method above it on a predefined list of methods of labour induction, as detailed below.

To avoid duplication of data in a series of reviews on interventions for labour induction, the labour induction methods were listed in a specific order, from one to 27, as outlined below. The methods for these reviews are described in the generic protocol for cervical ripening and labour induction in late pregnancy (Hofmeyr 2009). Each review included comparisons between one of the methods (from two to 26) with only those methods above it on the list.

Thus, this review of acupuncture (20) could include comparisons with any of the following: (1) placebo/no treatment; (2) vaginal prostaglandins; (3) intracervical prostaglandins; (4) intravenous oxytocin; (5) amniotomy; (6) intravenous oxytocin with amniotomy; (7) vaginal misoprostol; (8) oral misoprostol; (9) mechanical methods including extra-amniotic Foley catheter; (10) membrane sweeping; (11) extra-amniotic prostaglandins (12) intravenous prostaglandins; (13) oral prostaglandins; (14) mifepristone; (15) oestrogens with or without amniotomy; (16) corticosteroids; (17) relaxin; (18) hyaluronidase; (19) castor oil, bath, and/or enema.

The current list is as follows:

(1) placebo/no treatment;
(2) vaginal prostaglandins (Kelly 2009);
(3) intracervical prostaglandins (Boulvain 2008);
(4) intravenous oxytocin (Alfirevic 2009);
(5) amniotomy (Bricker 2000);
(6) intravenous oxytocin with amniotomy (Howarth 2001; Bimbashi 2012);
(7) vaginal misoprostol (Hofmeyr 2010);
(8) oral misoprostol (Alfirevic 2006);
(9) mechanical methods including extra-amniotic Foley catheter (Jozwiak 2012);
(10) membrane sweeping (Boulvain 2005);
(11) extra-amniotic prostaglandins (Hutton 2001);
(12) intravenous prostaglandins (Luckas 2000);
(13) oral prostaglandins (French 2001);
(14) mifepristone (Hapangama 2009);
(15) oestrogens with or without amniotomy (Thomas 2001);
(16) corticosteroids (Kavanagh 2006b);
(17) relaxin (Kelly 2001b);
(18) hyaluronidase (Kavanagh 2006a);
(19) castor oil, bath, and/or enema (Kelly 2013);
(20) acupuncture (this review);
(21) breast stimulation (Kavanagh 2005);
(22) sexual intercourse (Kavanagh 2001);
(23) homoeopathic methods (Smith 2003);
(24) nitric oxide donors (Kelly 2011);
(25) buccal or sublingual misoprostol (Muzonzini 2004);
(26) hypnosis (protocol in progress);
(27) other methods for induction of labour.

 

Types of outcome measures

 

Primary outcomes

Clinically relevant outcomes for trials of methods of cervical ripening/labour induction have been prespecified by two authors of labour induction reviews (Justus Hofmeyr and Zarko Alfirevic) (Hofmeyr 2009). Differences were settled by discussion.

Five primary outcomes were chosen as being most representative of the clinically important measures of effectiveness and complications. It was agreed that subgroup analyses would be limited to the primary outcomes:
(1) vaginal delivery not achieved within 24 hours;
(2) uterine hyperstimulation with fetal heart rate (FHR) changes;
(3) caesarean section;
(4) serious neonatal morbidity or perinatal death (e.g. seizures, birth asphyxia defined by trialists, neonatal encephalopathy, disability in childhood);
(5) serious maternal morbidity or death (e.g. uterine rupture, admission to intensive care unit, septicaemia).

Perinatal and maternal morbidity and mortality are composite outcomes. This is not an ideal solution because some components are clearly less severe than others. It is possible for one intervention to cause more deaths but less severe morbidity. However, in the context of labour induction at term this is unlikely. All these events will be rare, and a modest change in their incidence will be easier to detect if composite outcomes are presented. The incidence of individual components will be explored as secondary outcomes (see below).

 

Secondary outcomes

Secondary outcomes relate to measures of effectiveness, complications and satisfaction.

Measures of effectiveness:
(6) cervix unfavourable/unchanged after 12 to 24 hours;
(7) oxytocin augmentation.

Complications:
(8) uterine hyperstimulation without FHR changes;
(9) uterine rupture;
(10) epidural analgesia;
(11) instrumental vaginal delivery;
(12) meconium-stained liquor;
(13) Apgar score less than seven at five minutes;
(14) neonatal intensive care unit admission;
(15) neonatal encephalopathy;
(16) perinatal death;
(17) disability in childhood;
(18) maternal side-effects (all);
(19) maternal nausea;
(20) maternal vomiting;
(21) maternal diarrhoea;
(22) other maternal side-effects;
(23) postpartum haemorrhage (as defined by the trial authors);
(24) serious maternal complications (e.g. intensive care unit admission, septicaemia but excluding uterine rupture);
(25) maternal death.

Measures of satisfaction:
(26) woman not satisfied;
(27) caregiver not satisfied.

Acupuncture specific outcomes:
(28) use of other induction methods;
(29) time from trial intervention to the birth of the baby;
(30) length of labour.

While all the above outcomes were sought, only those with data appear in the analysis tables.

The terminology of uterine hyperstimulation is problematic (Curtis 1987). In the reviews we used the term 'uterine hyperstimulation without FHR changes' to include uterine tachysystole (more than five contractions per 10 minutes for at least 20 minutes) and uterine hypersystole/hypertonus (a contraction lasting at least two minutes) and 'uterine hyperstimulation with FHR changes' to denote uterine hyperstimulation syndrome (tachysystole or hypersystole with fetal heart rate changes such as persistent decelerations, tachycardia or decreased short term variability).

 

Search methods for identification of studies

 

Electronic searches

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register by contacting the Trials Search Co-ordinator (23 November 2012).

The Cochrane Pregnancy and Childbirth Group’s Trials Register is maintained by the Trials Search Co-ordinator and contains trials identified from: 

  1. monthly searches of the Cochrane Central Register of Controlled Trials (CENTRAL);
  2. weekly searches of MEDLINE;
  3. weekly searches of Embase;
  4. handsearches of 30 journals and the proceedings of major conferences;
  5. weekly current awareness alerts for a further 44 journals plus monthly BioMed Central email alerts.

Details of the search strategies for CENTRAL, MEDLINE and Embase, the list of handsearched journals and conference proceedings, and the list of journals reviewed via the current awareness service can be found in the ‘Specialized Register’ section within the editorial information about the Cochrane Pregnancy and Childbirth Group

Trials identified through the searching activities described above are each assigned to a review topic (or topics). The Trials Search Co-ordinator searches the register for each review using the topic list rather than keywords.   

In addition, we searched PubMed (1966 to 23 November 2012), EMBASE (1980 to 23 November 2012), Dissertation Abstracts (1861 to 23 November 2012), CINAHL (1982 to 23 November 2012) and the WHO International Clinical Trials Registry Portal (ICTRP) (23 November 2012). See Appendix 1 for search strategies used.

 

Searching other resources

We handsearched reference lists of trial reports and reviews.

We did not apply any language restrictions.

The search for the initial version of the review was performed simultaneously for all reviews of methods of inducing labour, as outlined in the generic protocol for these reviews (Hofmeyr 2000).

 

Data collection and analysis

For methods used in the previous version of this review, see Appendix 2; Appendix 3. These methods followed those described in the generic protocol (Hofmeyr 2009), which was developed in order to provide a standardised methodological approach for conducting a series of reviews examining the various methods of preparing the cervix of the uterus and inducing labour.

For this update we used the following methods when assessing the reports identified by the updated search.

 

Selection of studies

Two review authors C Smith (CS) and S Grant (SG) independently assessed for inclusion all the potential studies we identified as a result of the search strategy. We resolved any disagreement through discussion or, if required, we consulted a third person. When articles contained insufficient information to make a decision about eligibility, CS attempted to contact authors of the original reports to obtain further details.

 

Data extraction and management

Following an assessment for inclusion CS, SG independently extracted data using a data extraction form Appendix 4. A third independent person extracted data for a trial undertaken by CS and CC. We resolved discrepancies through discussion or, if required, we consulted a third person. We entered data into Review Manager software (RevMan 2012) and checked for accuracy.

When information regarding any of the above was unclear, we attempted to contact authors of the original reports to provide further details.

 

Assessment of risk of bias in included studies

Two review authors independently (third for the Smith 2008 trial) assessed the risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We resolved any disagreement by discussion or by involving a third assessor.

 

(1) Random sequence generation (checking for possible selection bias)

We described for each included study the method used to generate the allocation sequence in sufficient detail to allow an assessment of whether it should produce comparable groups.

We assessed the method as:

  • low risk of bias (any truly random process, e.g. random number table; computer random number generator);
  • high risk of bias (any non-random process, e.g. odd or even date of birth; hospital or clinic record number);
  • unclear risk of bias.   

 

 (2) Allocation concealment (checking for possible selection bias)

We described for each included study the method used to conceal allocation to interventions prior to assignment and assessed whether intervention allocation could have been foreseen in advance of, or during recruitment, or changed after assignment.

We assessed the methods as:

  • low risk of bias (e.g. telephone or central randomisation; consecutively numbered sealed opaque envelopes);
  • high risk of bias (open random allocation; unsealed or non-opaque envelopes, alternation; date of birth);
  • unclear risk of bias.   

 

(3.1) Blinding of participants and personnel (checking for possible performance bias)

We described for each included study the methods used, if any, to blind study participants and personnel from knowledge of which intervention a participant received. We considered that studies were at low risk of bias if they were blinded, or if we judged that the lack of blinding would be unlikely to affect results. We assessed blinding separately for different outcomes or classes of outcomes.

We assessed the methods as:

  • low, high or unclear risk of bias for participants;
  • low, high or unclear risk of bias for personnel.

 

(3.2) Blinding of outcome assessment (checking for possible detection bias)

We described for each included study the methods used, if any, to blind outcome assessors from knowledge of which intervention a participant received. We assessed blinding separately for different outcomes or classes of outcomes.

We assessed methods used to blind outcome assessment as:

  • low, high or unclear risk of bias

 

(4) Incomplete outcome data (checking for possible attrition bias due to the amount, nature and handling of incomplete outcome data)

We described for each included study, and for each outcome or class of outcomes, the completeness of data including attrition and exclusions from the analysis. We stated whether attrition and exclusions were reported and the numbers included in the analysis at each stage (compared with the total randomised participants), reasons for attrition or exclusion were reported, and whether missing data were balanced across groups or were related to outcomes. Where sufficient information was reported, or was supplied by the trial authors, we planned to re-include missing data in the analyses where possible. Trials with greater than 20% missing data were classified at a high risk of bias.

We assessed methods as:

  • low risk of bias (e.g. no missing outcome data; missing outcome data balanced across groups);
  • high risk of bias (e.g. numbers or reasons for missing data imbalanced across groups; ‘as treated’ analysis done with substantial departure of intervention received from that assigned at randomisation);
  • unclear risk of bias.

 

(5) Selective reporting (checking for reporting bias)

We described for each included study how we investigated the possibility of selective outcome reporting bias and what we found.

We assessed the methods as:

  • low risk of bias (where it is clear that all of the study’s pre-specified outcomes and all expected outcomes of interest to the review have been reported);
  • high risk of bias (where not all the study’s pre-specified outcomes have been reported; one or more reported primary outcomes were not pre-specified; outcomes of interest are reported incompletely and so cannot be used; study fails to include results of a key outcome that would have been expected to have been reported);
  • unclear risk of bias.

 

(6) Other bias (checking for bias due to problems not covered by (1) to (5) above)

We described for each included study any important concerns we had about other possible sources of bias.

We assessed whether each study was free of other problems that could put it at risk of bias:

  • low risk of other bias;
  • high risk of other bias;
  • unclear whether there is risk of other bias.

 

(7) Overall risk of bias

We made explicit judgements about whether studies were at high risk of bias, according to the criteria given in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). With reference to (1) to (6) above, we assessed the likely magnitude and direction of the bias and whether we considered it was likely to impact on the findings. We explored the impact of the level of bias through undertaking sensitivity analyses - see 'Sensitivity analysis'. 

 

Measures of treatment effect

 

Dichotomous data

For dichotomous data, we presented results as summary risk ratio with 95% confidence intervals. 

 

Continuous data

For continuous data, we used the mean difference if outcomes were measured in the same way between trials. We used the standardised mean difference to combine trials that measured the same outcome, but used different methods.  

 

Unit of analysis issues

 

Cluster-randomised trials

We did not identify an cluster-randomised trials for inclusion in this update, but plan to include them if identified in future updates. We will include cluster-randomised trials in the analyses along with individually-randomised trials. We will adjust their sample sizes using the methods described in the Cochrane Handbook for Systematic Reviews of Interventions using an estimate of the intracluster correlation co-efficient (ICC) derived from the trial (if possible), from a similar trial or from a study of a similar population. If we use ICCs from other sources, we will report this and conduct sensitivity analyses to investigate the effect of variation in the ICC. If we identify both cluster-randomised trials and individually-randomised trials, we plan to synthesise the relevant information. We will consider it reasonable to combine the results from both if there was little heterogeneity between the study designs and the interaction between the effect of intervention and the choice of randomisation unit is considered to be unlikely.

We will also acknowledge heterogeneity in the randomisation unit and perform a sensitivity analysis to investigate the effects of the randomisation unit.

 

Other unit of analysis issues

Trials with multiple arms were included and are described in the Characteristics of included studies. For example, acupuncture might be compared with sham acupuncture and with another arm where no acupuncture was delivered. If there were two acupuncture groups, data from both treatment arms were combined into one group. For studies with a sham control and no treatment control group, the shared intervention was divided evenly between groups as described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). Where outcomes were repeated measures, analysis of outcomes was undertaken at the end of the intervention.

 

Dealing with missing data

For included studies, we noted levels of attrition. We aimed to explore the impact of including studies with high levels of missing data in the overall assessment of treatment effect by using sensitivity analysis.

For all outcomes, we carried out analyses, as far as possible, on an intention-to-treat basis, i.e. we attempted to include all participants randomised to each group in the analyses, and all participants were analysed in the group to which they were allocated, regardless of whether or not they received the allocated intervention. The denominator for each outcome in each trial was the number randomised minus any participants whose outcomes were known to be missing. Studies were excluded from the analysis if there was a high level of missing data (greater than 20%).

 

Assessment of heterogeneity

We assessed statistical heterogeneity in each meta-analysis using the T², I² and Chi² statistics. We regarded heterogeneity as substantial if an I² was greater than 30% and either the T² was greater than zero, or there was a low P value (less than 0.10) in the Chi² test for heterogeneity. 

 

Assessment of reporting biases

Had there been 10 or more studies in the meta-analysis, we planned to investigate reporting biases (such as publication bias) using funnel plots. We would have assessed funnel plot asymmetry visually. If asymmetry was suggested by a visual assessment, we proposed to perform exploratory analyses to investigate it.

 

Data synthesis

We carried out statistical analysis using the Review Manager software (RevMan 2012). We used fixed-effect meta-analysis for combining data where it was reasonable to assume that studies were estimating the same underlying treatment effect: i.e. where trials were examining the same intervention, and the trials’ populations and methods were judged sufficiently similar. If there was clinical heterogeneity sufficient to expect that the underlying treatment effects differed between trials, or if substantial statistical heterogeneity was detected, we used random-effects meta-analysis to produce an overall summary if an average treatment effect across trials was considered clinically meaningful. We treated the random-effects summary as the average of the range of possible treatment effects and we discussed the clinical implications of treatment effects differing between trials. If the average treatment effect was not clinically meaningful, we would not have combined trials.

Where we used random-effects analyses, we presented the results as the average treatment effect with 95% confidence intervals, and the estimates of  T² and I².

 

Subgroup analysis and investigation of heterogeneity

Had we identified substantial heterogeneity, we planned to investigate it using subgroup analyses and sensitivity analyses. We would have considered whether an overall summary was meaningful, and if it was, we would have used random-effects analysis.

Subgroup analyses were not prespecified in the earlier version of the review (Smith 2004).

We planned to carry out the following subgroup analyses:

  1. nulliparity versus multiparity; 
  2. cervix unfavourable, versus favourable versus undefined;
  3. membranes intact or ruptured;
  4. classical/traditional acupuncture versus single point therapy, or auricular acupuncture.

We planned to assess subgroup differences by interaction tests available within RevMan (RevMan 2012) and report the results of subgroup analyses quoting the χ2 statistic and P value, and the interaction test I² value.

 

Sensitivity analysis

Where subgroup analysis failed to explain the heterogeneity, we planned to analyse the data using a random-effects model. A priori, we planned to perform sensitivity analysis on the results to look at the possible contribution of: (1) differences in methodological quality, with trials of high quality (low risk of bias) compared to all trials; and (2) publication bias by country. If publication bias was present, we planned to undertake a sensitivity analysis excluding trials from countries where there was a greater publication bias.

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies; Characteristics of studies awaiting classification.

 

Results of the search

The original review included three trials and seven trials were excluded. This updated review includes 14 trials, and excludes eight trials. Three trials previously excluded due to no clinically relevant outcomes are now included (Martinez 2004; Romer 2000; Tremeau 1992). One trial is currently awaiting assessment (Liu 2012).

 

Included studies

 

Study design

All studies were parallel design. Nine trials had two groups (Gaudernack 2006; Gaudet 2008; Gribel 2011; Harper 2006; Modlock 2010; Rabl 2001; Romer 2000; Selmer-Olsen 2007; Smith 2008), two trials had three groups (Asher 2009; Tremeau 1992) and one trial had five groups (Mackenzie 2011). Seven studies used sham controls (Asher 2009; Gaudet 2008; Mackenzie 2011; Modlock 2010; Romer 2000; Smith 2008; Tremeau 1992) and eight trials used standard care (Asher 2009; Gaudernack 2006; Gribel 2011; Harper 2006; Mackenzie 2011; Rabl 2001; Selmer-Olsen 2007; Tremeau 1992).

 

Samples sizes

Sample size of the included studies ranged from 16 (Gaudet 2008) to 553 (Romer 2000).

 

Study location and sources of women

Two studies were undertaken in Norway (Gaudet 2008; Selmer-Olsen 2007), two in the United States (Asher 2009; Harper 2006), and one each from Austria (Rabl 2001), Australia (Smith 2008), Brazil (Gribel 2011), Canada (Gaudet 2008), China (Long 1994), Denmark (Modlock 2010), France (Tremeau 1992), Germany (Romer 2000) the Phillipines (Martinez 2004) and the United Kingdon (Mackenzie 2011).

 

Participants

Six studies recruited nulliparous women only (Asher 2009; Gaudet 2008; Harper 2006; Mackenzie 2011; Romer 2000; Selmer-Olsen 2007). Six trials recruited both nulliparous and primiparous women (Gaudernack 2006; Gribel 2011; Modlock 2010; Rabl 2001; Smith 2008; Tremeau 1992). Parity was unclear in two trials (Long 1994; Martinez 2004).

 

Types of interventions

Eight studies used manual acupuncture only (Asher 2009; Gaudernack 2006; Modlock 2010; Rabl 2001; Romer 2000; Selmer-Olsen 2007; Smith 2008; Tremeau 1992), one trial used electro-acupuncture only (Gribel 2011), and three trials used manual and electro-acupuncture (Gaudernack 2006; Gaudet 2008; Harper 2006). Fixed points were used in nine trials (Asher 2009; Gaudet 2008; Gribel 2011; Harper 2006; Mackenzie 2011; Modlock 2010; Rabl 2001; Romer 2000; Tremeau 1992) and three trials used individualised treatment (Gaudernack 2006; Selmer-Olsen 2007; Smith 2008). There was significant variation in the acupuncture points used but included; Stomach 36 (ST36), Liver 3 (LR3), Conception Vessel 4 (CV4), Three Heater 6 (TH6), Large Intestine 4 (LI4), Gall Bladder 41 (GB41), Kidney 6 (KI6), Spleen 6 (SP6), Heart 7 (HT7), and Lung 7 (LU7), Bladder 31 (UB31), Bladder 32 (UB32), Bladder 60 (UB60) Bladder 67 (UB67), Governing Vessel (GV20).

The number of treatments varied from three trials administering one treatment (Gaudernack 2006; Mackenzie 2011; Rabl 2001), two treatments (Gaudet 2008; Modlock 2010; Selmer-Olsen 2007; Smith 2008) and five providing three of more (Asher 2009; Gribel 2011; Harper 2006; Romer 2000; Tremeau 1992).

Gaudet 2008 used a combination of manual and non active electro-stimulation for the control group.

Few details were reported in two trials (Long 1994; Martinez 2004).

 

Outcome measures

Few trials reported on the primary outcomes relating to this review. Nine trials reported on caesarean section (Asher 2009; Gaudet 2008; Gribel 2011; Harper 2006; Mackenzie 2011; Modlock 2010; Selmer-Olsen 2007; Smith 2008; Tremeau 1992), although all trials reported on a selection of the secondary outcomes included in this review.

 

Excluded studies

Eight trials were excluded; see Characteristics of excluded studies.

Four trials were excluded due to insufficient reporting of randomisation (Dorr 1990; Kubista 1974; Li 1996, So 1979) and we were unable to obtain details from authors. One trial was excluded due to an evaluation of acupuncture on pain relief in labour (Bo 2006). One trial reported on women already in labour (Lyngso 2010). Two trials used a form of stimulation not relevant to this review (Aghamohammadi 2011; Dunn 1989).

 

Risk of bias in included studies

See Figure 1; and Figure 2 for a graphical summary of the 'Risk of bias' assessment by authors of the included studies based on the six domains of bias. One study was at a low risk of bias on all domains (Smith 2008).

 FigureFigure 1. 'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
 FigureFigure 2. 'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

 

Allocation

Twelve trials were rated at a low risk of bias for adequate generation of the randomisation sequence, generation of the randomisation schedule was unclear in two trials (Long 1994; Martinez 2004). The method of concealment was at low risk in 10 trials, with insufficient reporting in four trials (Long 1994; Martinez 2004; Romer 2000; Tremeau 1992).

 

Blinding

Four studies were at low risk of performance bias (Asher 2009; Gaudet 2008; Romer 2000; Smith 2008). Eight studies were assessed at a high risk of bias primarily because participants were not blind to group allocation in the studies using a standard care control. Detection bias was assessed at a low risk in nine trials (Asher 2009; Gaudernack 2006; Gaudet 2008; Gribel 2011; Mackenzie 2011; Modlock 2010; Romer 2000; Smith 2008; Tremeau 1992), one trial was assessed at high risk and four trials were assessed as unclear.

 

Incomplete outcome data

Ten trials were assessed at low risk of bias. Two trials were at high risk. In the Rabl trial (Rabl 2001), there were 11 (20%) post-randomisation exclusions and losses to follow-up. There was an imbalance in the post-randomisation exclusions (five in the treatment group and eight in the control group). The trial author was unable to provide outcome data on the 11 women who had been excluded from analyses. Risk was assessed as unclear in two trials.

 

Selective reporting

The risk of selective reporting was assessed as low in four trials (Mackenzie 2011; Martinez 2004; Modlock 2010; Smith 2008), the risk of bias was unclear in nine trials, and at high risk in one trial (Selmer-Olsen 2007).

 

Other potential sources of bias

The risk of bias was rated as low in seven trials (Asher 2009; Gaudernack 2006; Gaudet 2008; Gribel 2011; Harper 2006; Mackenzie 2011; Modlock 2010;Smith 2008), and unclear in the other seven trials.

 

Effects of interventions

This review included 14 trials of 2220 women.

We included 11 trials in the meta-analysis with data reporting on 1689 women. Because data were not available about the post-randomisation exclusions for the Rabl 2001 trial and an intention-to-treat analysis could not be undertaken, the results of this trial could not be incorporated into the meta-analysis. Primary data from the Long 1994 trial could not be obtained and no data are included in the analysis. Martinez 2004 reported on no clinically relevant outcomes.

 

Primary outcomes

Trials reported on two primary outcomes only: caesarean section and serious neonatal morbidity. No trial reported on vaginal delivery not achieved within 24 hours; uterine hyperstimulation with fetal heart rate (FHR) changes and serious maternal morbidity or death (e.g. uterine rupture, admission to intensive care unit, septicaemia).

 

1.1) Outcome: caesarean section

Data on caesarean section was reported from 9 trials with 1015 women, ( Analysis 1.1).

 
1.1.1 Sham control

There was no difference in caesarean deliveries between groups (average risk ratio (RR) 0.95, 95% confidence interval (CI) 0.69 to 1.30, six trials, 654 women).

 
1.1.2 Usual care

There was no difference in caesarean deliveries between groups (average RR 0.69, 95% CI 0.40 to 1.20, six trials, 361 women; Heterogeneity: Tau² = 0.18; I² = 40% ). There was significant heterogeneity indicated by the I2 statistic and we applied a random-effects model.The heterogeneity may be explained by the Asher 2009 and Selmer-Olsen 2007 trials, although it is unclear which aspects of the intervention may explain the heterogeneity.

 

1.2) Outcome: serious neonatal morbidity

 
1.2.1 Sham control

There was no difference in neonatal seizures between groups (RR 1.01, 95% CI 0.06 to 16.04, one trial, 364 women),  Analysis 1.2.

 

Serious maternal morbidity or death

There were no serious outcomes or maternal death reported in one trial (Smith 2008).

 

Secondary outcomes

Secondary outcomes relate to measures of effectiveness, complications and satisfaction. Trials reported on cervix unfavourable/unchanged after 12 to 24 hours; oxytocin augmentation; epidural analgesia; instrumental vaginal delivery; meconium-stained liquor; Apgar score less than seven at five minutes; neonatal intensive care unit admission; perinatal death; postpartum haemorrhage; other maternal side-effects; maternal death; and woman not satisfied. The following acupuncture specific outcomes were included: use of other induction methods; time from trial intervention to the birth of the baby; and length of labour.

No trial reported on the following outcomes; uterine hyperstimulation without FHR changes; uterine rupture; neonatal encephalopathy; disability in childhood; maternal side-effects (all); maternal nausea; maternal vomiting; maternal diarrhoea; serious maternal complications; and caregiver not satisfied.

 

1.3) Outcome: cervical change within 12 to 24 hours

Data on cervical maturation were available from six trials with data reported in the meta-analysis from two trials,  Analysis 1.3. Data were not combined but in both trials there was a greater change in the cervix for the acupuncture groups compared with the control groups, as measured by Bishop score.

 
1.3.1 Sham control

There was greater cervical change in Bishop score occurring within 24 hours for women receiving acupuncture compared with the sham control, mean difference (MD) 0.40. 95% CI 0.11 to 0.69, one trial, 125 women. Data from the Smith 2008 trial were not included in the meta-analysis and reported an increase in the Bishop score that did not differ between groups (RR 1.08, 95% CI 0.92 to 1.26, one trial 364 women), data not shown.

The Romer 2000 trial did not report on when the cervical change was assessed, however the authors report there was a significant change in the Bishops score (acupuncture 5.9 +/- 1.3 (mean and standard deviation (SD)), non specific acupuncture 4.0, +/- 0.9, and no acupuncture 3.6 +/- 1.0).

 
1.3.2 Usual care

There was an increase in cervical maturation in the acupuncture group compared with the control (MD 1.30, 95% CI 0.11 to 2.49, one trial, 67 women).

Data from the Harper 2006 trial were not included in the analysis, there was no difference in cervical dilatation on the day of admission (3.3.cm versus 2.7 cm, P = 0.28).

Data from the Tremeau 1992 trial did not include means and SDs but reported a significantly greater progression in the Bishop score for the group receiving acupuncture (2.61 points) compared with the placebo group (0.89), and the usual care group (1.08).

 

1.4) Outcome: oxytocin augmentation

Data on this outcome were available from seven trials and 1090 women,  Analysis 1.4.

 
1.4.1 Sham control

There was no difference in the use of oxytocin augmentation between acupuncture and a sham control groups (RR 0.97, 95% CI 0.78 to 1.21, four trials, 833 women).

 
1.4.2 Usual care

There was no difference in the use of oxytocin augmentation between acupuncture and usual care groups (RR 1.08, 95% CI 0.86 to 1.34, three trials, 257 women).

 

1.5) Outcome: need for epidural

This outcome was reported by eight trials and 922 women,  Analysis 1.5.

 
1.5.1 Sham control

There was no difference in the need for epidural between groups (RR 1.02, 95% CI 0.88 to 1.19, five trials, 571 women).

 
1.5.2 Usual care

There was no difference in the use of epidurals between groups (RR 0.92, 95% CI 0.77 to 1.11, five trials, 351 women).

 

1.6) Outcome: instrumental vaginal delivery

Eight trials with 961 women reported on this outcome,  Analysis 1.6.

 
1.6.1 Sham control

There were no differences in the rate of instrumental delivery between groups (average RR 1.19, 95% CI 0.85 to 1.65, five trials, 610 women).

 
1.6.2 Usual care

There was significant heterogeneity indicated by the I2 statistic and we applied a random-effects model. There was no difference between groups (RR 0.91, 95% CI 0.50 to 1.64, five trials, 351 women; Heterogeneity: Tau² = 0.17; I² = 40%).

 

1.7 Outcome: meconium-stained liquor

One one trial (364 women) reported on this outcome,  Analysis 1.7.

 
1.7.1 Sham control

There was no difference in meconium-stained liquor between groups (RR 0.81, 95% CI 0.56 to 1.16).

 

1.8 Outcome: Apgar score less than seven at five minutes

Data on this outcome were reported by six trials (801 women),  Analysis 1.8.

 
1.8.1 Sham control

There was no difference in the Apgar score at five minutes between groups (RR 0.67, 95% CI 0.20 to 2.21, four trials, 559 women).

 
1.8.2 Usual care

There was no difference in the Apgar score at five minutes between groups (RR 0.35, 95% CI 0.01 to 8.48, three trials, 242 women).

 

1.9 Outcome: neonatal care admission

Three trials (186 women) reported on this outcome,  Analysis 1.9.

 
1.9.1 Sham control

There was significant heterogeneity indicated by the I2 statistic and we applied a random-effects model. There was no difference between groups (average RR 0.82, 95% CI 0.02 to 37.11, three trials, 141 women; Heterogeneity: Tau² = 5.42; I² = 72%).

 
1.9.2 Usual care

There was no difference between groups (RR 0.65, 95% CI 0.03 to 14.97, one trial, 45 women).

 

1.10 Outcome: perinatal death

One one trial (364 women) reported on this outcome,  Analysis 1.10.

 
1.10.1 Sham control

There were no deaths in either group.

 

1.11 Outcome: perineal tear

One trial (91 women) reported on this outcome,  Analysis 1.11.

 
1.11.1 Usual care

There was no difference in this outcome between groups (RR 1.22, 95% CI 0.95 to 1.56).

 

1.12 Outcome: maternal infection

Two trials including one three-arm trial (180 women) reported on this outcome,  Analysis 1.12.

 
1.12.1 Sham control

There was no difference between groups (RR 1.29, 95% CI 0.43 to 3.88, one trial, 44 women).

 
1.12.2 Usual care

There was no difference between groups (RR 1.64, 95% CI 0.43 to 6.32, two trials, 136 women).

 

1.13 Outcome: fetal infection

One trial (91 women) reported on this outcome,  Analysis 1.13.

 
1.13.1 Usual care

There were no reports of fetal infection between groups.

 

1.14 Outcome: postpartum bleeding greater than 500 mL

Three trials, 594 women reported on this outcome,  Analysis 1.14.

 
1.14.1 Sham control

There was no difference between groups (RR 1.02, 95% CI 0.67 to 1.54, three trials, 542 women).

 
1.14.2 Usual care

There was no difference between groups (RR 0.50, 95% CI 0.10 to 2.50, one trial, 52 women).

 

1.15 Outcome: maternal death

One trial, 364 women reported on this outcome,  Analysis 1.15.

 
1.15.1 Sham control

There were no maternal deaths in either group.

 

1.16 Outcome: time from trial entry to delivery

Three trials (161 women) reported on this outcome,  Analysis 1.16.

 
1.16.1 Sham control

Two trials reported on this outcome (Asher 2009; Gaudet 2008). Time was reported in hours by Gaudet 2008 and in days by Asher 2009. There was no difference in time to delivery between acupuncture and the sham control (average standardised mean difference (SMD) -0.22, 95% CI -0.99 to 0.55). There was significant heterogeneity indicated by the I2 statistic due to the differing method to record this outcome (Heterogeneity: Tau² = 0.14; Chi² = 1.75, df = 1 (P = 0.19); I² = 43%).

 
1.16.2 Usual care

This outcome was measured in hours by Harper 2006 and in days by Asher 2009. No difference in time to delivery was found between groups (average SMD 0.25, 95% CI -0.77 to 1.27). There was significant heterogeneity indicated by the I2 statistic due to the differing method to record this outcome (Heterogeneity: Tau² = 0.45; Chi² = 5.98, df = 1 (P = 0.01); I² = 83%).

 

1.17 Outcome: maternal satisfaction

One trial (67 women) reported on this outcome,  Analysis 1.17.

 
1.17.1. Usual care

There was no difference in maternal satisfaction between groups (RR 1.29, 95% CI 0.99 to 1.67).

 

1. 18 Outcome: need for induction methods

Seven trials 1236 women reported on this outcome,  Analysis 1.18.

 
1.18.1 Sham control

There was no difference between groups (average RR 1.03, 95% CI 0.91 to 1.16, four trials, 977 women).

 
1.18.2 Usual care

There was significant heterogeneity indicated by the I2 statistic and we applied a random-effects model (Heterogeneity: Tau² = 0.06; I² = 45%). There was no difference between groups (RR 1.00, 95% CI 0.69 to 1.45, four trials, 259 women).

 

1.19 Outcome: length of labour

Four trials (761 women) reported on this outcome,  Analysis 1.19.

 
1.19.1 Sham control

There was significant heterogeneity indicated by the I2 statistic and we applied a random-effects model (Heterogeneity: Tau² = 0.08; I² = 69%). There was no difference between groups (SMD -0.18, 95% CI -0.58 to 0.23, three trials, 694 women).

 
1.19.2 Usual care

The length of labour was shorter in the usual care group compared with acupuncture (MD 0.67, 95% CI 0.18 to 1.17, one trial, 67 women).

 

Data from other studies

In the Rabl trial (Rabl 2001), 11 (20%) women were post-randomisation exclusions and proceeded to have an elective induction of labour. In the acupuncture group, labour was induced for one woman because of fetal heart abnormalities and two inductions were performed due to prelabour rupture of membranes. In the control group, two women requested an elective induction of labour, three women received an induction of labour because of prelabour rupture of membranes, and in three women labour was induced due to abnormal fetal heart rate patterns. Because data were not available about the post-randomisation exclusions and an intention-to-treat analysis could not be undertaken, no results could be incorporated into this review.

 

Sensitivity analysis

It was proposed to undertake a sensitivity analysis on the results to look at the possible contribution of: (1) differences in methodological quality, with trials of high quality (low risk of bias) compared to all trials; and (2) publication bias by country. This was not done due to the small number of trials overall. There was one trial of high quality; there were also too few trials within comparisons to make comparisons to examine the influence of publication bias. Where there was heterogeneity, we applied a random-effects model.

 

Subgroup analysis

We did not undertake subgroup analysis, based on insufficient reporting of trials with the variables of interest by outcome.

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
 

Summary of main results

Findings from this review are based on comparisons between acupuncture and five sham-controlled trials, and comparisons between acupuncture with five trials using usual care controls. Evidence from 14 trials with data reporting on 2220 women suggest very limited benefit from acupuncture to induce labour. There was insufficient evidence of benefit of acupuncture compared with control for any primary endpoint. Benefit was found from individual trials of both sham and usual care controls.

There was greater cervical change occurring with 24 hours for women receiving acupuncture compared with the sham control, mean difference (MD) 0.40. 95% confidence interval (CI) 0.11 to 0.69, one trial, 125 women. Data from two studies not included in the meta-analysis found conflicting results when comparing acupuncture with a sham control (Romer 2000; Smith 2008). There was an increase in cervical maturation in the acupuncture group compared with the control (MD 1.30, 95% CI 0.11 to 2.49, one trial, 67 women). Two studies (Harper 2006; Tremeau 1992) not included in the meta-analysis also reported greater changes in the cervix for the acupuncture group compared with usual care. One trial found the length of labour was shorter in the usual care group compared with acupuncture (average MD 0.67, 95% CI 0.18 to 1.17, one trial, 67 women). Trials were characterised by heterogenous acupuncture point selection and dosage. Although there have been more trials reported since this review was last updated evaluating the role of acupuncture, there continues to be a relatively small number of trials that have provided relevant health outcomes. This limits the power of the review to detect meaningful differences between groups and analyses, suggesting these limited benefits should be interpreted with caution.

 

Overall completeness and applicability of evidence

Trials recruited low-risk nulliparous and primiparous women at term. The majority of trials reported that women offered the opportunity to participate in the trial agreed to participate. Smith 2008 however, reported 18% of women approached declined participation due to a lack of interest in acupuncture.

The systematic review documented wide variation in the delivery of acupuncture. This included the mode of stimulation, duration of needling, number of points used, depth of needling and duration of the trial. It is unclear how representative the treatment protocols used in the research are generalisable to acupuncture as it is usually practiced. There was insufficient reporting of the rationale of the acupuncture used in the research setting. Some trials used a fixed approach to the selection of points whilst other used a flexible approach, with selection of acupuncture points based on their clinical presentation. The variation in the duration, frequency and selection of acupuncture points suggests that the acupuncture may not have been therapeutically effective and in some cases may not represent best clinical practice. The variation may also reflect the country context in which acupuncture is practiced.

 

Quality of the evidence

The 'Risk of bias' tables (Figure 1; Figure 2) demonstrate that acupuncture has not been consistently subjected to consistent rigorous study. Only one trial was assessed at a low risk of bias. Since the publication of this original review the quality of reporting has improved over time. The majority of studies were at a low risk of bias in respect to randomisation. Rates of follow-up were good in the majority of trials with only two trials rated at a high risk of bias. The majority of trials were at a low risk of detection bias. Trials comparing acupuncture with usual care were rated at a high risk of bias due to the inability to blind study participants. The potential for bias however may be low given the use of objective clinical outcomes.

Only one of the sham acupuncture controlled trials used a non -penetrating needle, however these were placed at active acupuncture points and therefore may be associated with some physiological activity. The quality of the evidence is also influenced by small sample sizes, with many studies underpowered to detect changes between groups.

 

Potential biases in the review process

We attempted to minimise publication bias. Our search was comprehensive and we included studies identified in languages other than English. However, we cannot rule out the possibility that some studies have been missed.

 

Agreements and disagreements with other studies or reviews

A systematic review examining the effect of acupuncture on induction of labour and cervical maturation found all studies demonstrated labour induction by acupuncture treatment (Lim 2009). The review included 10 studies consisting of randomised controlled trials, non-randomised studies with and without controls, and a matched pair study. The review by Lim et al concluded a definitive role for acupuncture was still to be established and further research was needed. A recent systematic review of methods of induction of labour included our earlier Cochrane review (Smith 2004), and three other randomised controlled trials published since the 2004 Cochrane review (Mozurkewich 2011). The authors concluded that acupuncture for induction of labour is investigational, and no advantages have been demonstrated. Overall, all reviews identify there is insufficient evidence of a benefit from acupuncture.

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

 

Implications for practice

There are insufficient data to demonstrate whether acupuncture is more effective than a sham control, or no treatment, or whether there is additional benefit from acupuncture when used in combination with usual care.

 
Implications for research

Overall, there are still only a small number of studies assessing the role of acupuncture for induction of labour. Further research is required. We suggest further research focuses on gaining a greater understanding of the specific components of acupuncture treatment in relation to working with women who are overdue. Appropriately powered randomised trials are required to examine the effectiveness of acupuncture on the clinical outcomes described in this review but following a greater understanding of the multi-components of acupuncture, or greater reflection of how acupuncture is practiced in a clinical setting.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

We acknowledge the French to English translation by Peter Smith and the German to English translation by Richmal Oates-Whitehead, with additional translation by Gerald Muench, Julie Brown for data extraction of the Smith 2008 trial, and Xun Li for her assistance with attempted contact with Chinese authors and translations.

As part of the pre-publication editorial process, this review has been commented on by two peers (an editor and referee who is external to the editorial team), a member of the Pregnancy and Childbirth Group's international panel of consumers and the Group's Statistical Adviser.

The National Institute for Health Research (NIHR) is the largest single funder of the Cochrane Pregnancy and Childbirth Group. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
Download statistical data

 
Comparison 1. Acupuncture versus control

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Caesarean section9Risk Ratio (M-H, Random, 95% CI)Subtotals only

    1.1 Acupuncture versus sham control
6654Risk Ratio (M-H, Random, 95% CI)0.95 [0.69, 1.30]

    1.2 Acupuncture versus usual care
6361Risk Ratio (M-H, Random, 95% CI)0.69 [0.40, 1.20]

 2 Neontal seizure1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    2.1 Acupuncture versus sham
1364Risk Ratio (M-H, Fixed, 95% CI)1.01 [0.06, 16.04]

 3 Cervical maturity within 24 hours (Bishop score)2Mean Difference (IV, Fixed, 95% CI)Subtotals only

    3.1 Acupuncture versus sham acupuncture
1125Mean Difference (IV, Fixed, 95% CI)0.40 [0.11, 0.69]

    3.2 Acupuncture versus usual care
167Mean Difference (IV, Fixed, 95% CI)1.30 [0.11, 2.49]

 4 Oxytocin augmentation7Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    4.1 Acupuncture versus sham
4833Risk Ratio (M-H, Fixed, 95% CI)0.97 [0.78, 1.21]

    4.2 Acupuncture versus usual care
3257Risk Ratio (M-H, Fixed, 95% CI)1.08 [0.86, 1.34]

 5 Need for epidural8Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    5.1 Acupuncture versus sham acupuncture
5571Risk Ratio (M-H, Fixed, 95% CI)1.02 [0.88, 1.19]

    5.2 Acupuncture versus usual care
5351Risk Ratio (M-H, Fixed, 95% CI)0.92 [0.77, 1.11]

 6 Instrumental vaginal delivery8Risk Ratio (M-H, Random, 95% CI)Subtotals only

    6.1 Acupuncture versus sham
5610Risk Ratio (M-H, Random, 95% CI)1.19 [0.85, 1.65]

    6.2 Acupuncture versus usual care
5351Risk Ratio (M-H, Random, 95% CI)0.91 [0.50, 1.64]

 7 Meconium-stained liquor1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    7.1 Acupuncture versus sham
1364Risk Ratio (M-H, Fixed, 95% CI)0.81 [0.56, 1.16]

 8 Apgar score less than 76Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    8.1 Acupuncture versus sham
4559Risk Ratio (M-H, Fixed, 95% CI)0.67 [0.20, 2.21]

    8.2 Acupuncture versus usual care
3242Risk Ratio (M-H, Fixed, 95% CI)0.35 [0.01, 8.48]

 9 Neonatal care admission3Risk Ratio (M-H, Random, 95% CI)Subtotals only

    9.1 Acupuncture versus sham
3141Risk Ratio (M-H, Random, 95% CI)0.82 [0.02, 37.11]

    9.2 Acupuncture versus usual care
145Risk Ratio (M-H, Random, 95% CI)0.65 [0.03, 14.97]

 10 Perinatal death1364Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    10.1 Acupuncture versus sham
1364Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 11 Perineal tear191Risk Ratio (M-H, Fixed, 95% CI)1.22 [0.95, 1.56]

    11.1 Acupuncture versus usual care
191Risk Ratio (M-H, Fixed, 95% CI)1.22 [0.95, 1.56]

 12 Maternal infection2Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    12.1 Acupuncture versus usual care
2136Risk Ratio (M-H, Fixed, 95% CI)1.64 [0.43, 6.32]

    12.2 Acupuncture versus sham
144Risk Ratio (M-H, Fixed, 95% CI)1.29 [0.43, 3.88]

 13 Fetal infection191Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    13.1 Acupuncture versus usual care
191Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 14 Postpartum bleeding > 500 mL3Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    14.1 Acupuncture versus sham
3542Risk Ratio (M-H, Fixed, 95% CI)1.02 [0.67, 1.54]

    14.2 Acupuncture versus usual care
152Risk Ratio (M-H, Fixed, 95% CI)0.5 [0.10, 2.50]

 15 Maternal death1364Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    15.1 Acupuncture versus sham
1364Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 16 Time from trial entry to birth of baby (days; hours)3Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    16.1 Acupuncture versus sham acupuncture
261Std. Mean Difference (IV, Random, 95% CI)-0.22 [-0.99, 0.55]

    16.2 Acupuncture versus usual care
2100Std. Mean Difference (IV, Random, 95% CI)0.25 [-0.77, 1.27]

 17 Maternal satisfaction167Risk Ratio (M-H, Fixed, 95% CI)1.29 [0.99, 1.67]

    17.1 Acupuncture versus usual care
167Risk Ratio (M-H, Fixed, 95% CI)1.29 [0.99, 1.67]

 18 Need for induction methods7Risk Ratio (M-H, Random, 95% CI)Subtotals only

    18.1 Acupuncture versus sham
4977Risk Ratio (M-H, Random, 95% CI)1.03 [0.91, 1.16]

    18.2 Acupuncture versus usual care
4259Risk Ratio (M-H, Random, 95% CI)1.00 [0.69, 1.45]

 19 Length of labour4Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    19.1 Acupuncture versus sham
3694Std. Mean Difference (IV, Random, 95% CI)-0.18 [-0.58, 0.23]

    19.2 Acupuncture versus usual care
167Std. Mean Difference (IV, Random, 95% CI)0.67 [0.18, 1.17]

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
 

Appendix 1. Search Strategies

 

PubMed

1. exp Acupuncture Therapy (10724)

2. exp Medicine, East Asian Traditional (3238)

3. exp Acupuncture/ (15070)

4. (acupuncture or acupressure or acupoint* or electroacupuncture or electro-acupuncture or TENS

5. 1 OR 2 OR 3 OR 4 (32010)

6.  exp induction of labour (1496)

7. exp labour (21925)

8. labo?r

9.  6 OR 7 OR 8

10. 5 AND 9 (101)

11. randomized controlled trial.pt.

12. controlled clinical trial.pt.

13. randomized.ab.

14. placebo.ab.

15. drug therapy.fs.

16. randomly.ab.

17. trial.ab.

18. groups.ab.

19. 11 or 12 or 13 or14 or 15 or 16 or 17 or 18

20.  10 AND 20 (31)

 

CINAHL Plus search strategy

1.       (MH "Acupuncture+") OR (MH "Acupuncture Points") OR (MH "Acupuncture, Ear") OR (MH "Acupuncturists") OR (MH "Acupuncture Analgesia")

2.       electroacupuncture OR electro-acupuncture

3.       acupressure OR acupoint* OR TENS

4.       #1 OR #2 OR #3 (10,266)

5.       (MH "Labor, Induced+") OR (MH "Labor Stage, First") OR (MH "Labor Stage, Second") OR (MH "Labor Stage, Third") OR (MH "Labor Support")

6.       Caesarean OR Pregnancy OR uterine cervix ripening OR Prostaglandin OR intravaginal drug administration OR Oxytocin OR misoprostol OR labo*r induction OR induction of labo*r

7.       #5 OR #6 (113,359)

8.       (MM "Randomized Controlled Trials") OR (MM "Clinical Trials+") 

9.       randomized controlled trial.pt.  OR controlled clinical trial.pt. OR randomized.ab. OR placebo.ab. OR drug therapy.fs. OR randomly.ab. OR trial.ab. OR groups.ab.

10.   #8 OR #9 (146,052)

11.   #4 AND #7 AND #10 (118)

 

Embase search strategy

1.       exp acupuncture analgesia/

2.       acupuncture.mp.

3.       exp acupuncture/

4.       exp acupuncture needle/

5.       electroacupuncture OR electro-acupuncture

6.       acupressure OR acupoint* OR TENS

7.       1 OR 2 OR 3 OR 4 OR 5 OR 6 (39862)

8.       cesarean section/ or pregnancy/ or prostaglandin/ or intravaginal drug administration/ or oxytocin/ or uterine cervix ripening/ or prostaglandin E2/ or misoprostol/ or labor induction/ or induction of labour.mp. or prostaglandin derivative/ (732108)

9.       7 AND 8 (1165)

10.   Limited to Human and yr=2012 (59)

11.   Randomization.mp/ or controlled clinical trial.pt. / or double blind procedure/ or randomized controlled trials.mp or (topic)/ or random allocation.mp. / or double blind method.sh. / or meta analysis/ or single-blind method.sh. / or single blind procedure/  or clinical trial.pt.

12.   11 AND 9 (16)

 

Dissertations and Theses A&I (ProQuest)

Acupuncture AND [labour OR labor] in Title, Subject, Abstract

 

WHO International Clinical Trials Registry Platform (ICTRP)

Acupuncture AND (labour OR labor)

 

Appendix 2. Methods used to assess trials included in previous versions of this review

Prior to 2001, data extraction was conducted centrally using the methods outlined below, for all reviews on interventions for labour induction.

From 2001, the data extraction was no longer conducted centrally. This meant that the data extraction was carried out by the reviewers of the primary reviews if new trials were found when the search strategy was rerun, and the reviews updated.

The following methods were used to assess Gaudernack 2006; Harper 2006; Rabl 2001.

A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. Many methods have been studied, examining the effects of these methods when induction of labour was undertaken in a variety of clinical groups e.g. restricted to primiparous women or those with ruptured membranes. Most trials are intervention-driven, comparing two or more methods in various categories of women. Clinicians and parents need the data arranged according to the clinical characteristics of the women undergoing induction of labour, to be able to choose which method is best for a particular clinical scenario. To extract these data from several hundred trial reports in a single step would be very difficult. We therefore developed a two-stage method of data extraction. The initial data extraction was done in a series of primary reviews arranged by methods of induction of labour, following a standardised methodology. The intention was then to extract them from the primary reviews into a series of secondary reviews, arranged by the clinical characteristics of the women undergoing induction of labour.

To avoid duplication of data in the primary reviews, the labour induction methods were listed in a specific order, from one to 25. Each primary review included comparisons between one of the methods (from two to 25) with only those methods above it on the list. Thus, the review of intravenous oxytocin (4) included only comparisons with intracervical prostaglandins (3), vaginal prostaglandins (2) or placebo (1). Methods identified in the future will be added to the end of the list. The current list is as follows:

(1) placebo/no treatment;
(2) vaginal prostaglandins (Kelly 2003);
(3) intracervical prostaglandins (Boulvain 2008);
(4) intravenous oxytocin (Kelly 2001a);
(5) amniotomy (Bricker 2000);
(6) intravenous oxytocin with amniotomy (Howarth 2001);
(7) vaginal misoprostol (Hofmeyr 2003);
(8) oral misoprostol (Alfirevic 2006);
(9) mechanical methods including extra-amniotic Foley catheter (Boulvain 2001);
(10) membrane sweeping (Boulvain 2005);
(11) extra-amniotic prostaglandins (Hutton 2001);
(12) intravenous prostaglandins (Luckas 2000);
(13) oral prostaglandins (French 2001);
(14) mifepristone (Neilson 2000);
(15) oestrogens with or without amniotomy (Thomas 2001);
(16) corticosteroids (Kavanagh 2006b);
(17) relaxin (Kelly 2001b);
(18) hyaluronidase (Kavanagh 2006a);
(19) castor oil, bath, and/or enema (Kelly 2001);
(20) acupuncture (Smith 2004);
(21) breast stimulation (Kavanagh 2005);
(22) sexual intercourse (Kavanagh 2001);
(23) homoeopathic methods (Smith 2003);
(24) nitric oxide (Kelly 2011 );
(25) buccal or sublingual misoprostol (Muzonzini 2004);
(26) other methods for induction of labour.

The primary reviews were analysed by the following subgroups:
(1) previous caesarean section or not;
(2) nulliparity or multiparity;
(3) membranes intact or ruptured;
(4) cervix favourable, unfavourable or undefined.

The secondary reviews would have included all methods of labour induction for each of the categories of women for which subgroup analysis has been done in the primary reviews. There would have thus been six secondary reviews, of methods of labour induction in the following groups of women:

(1) nulliparous, intact membranes (unfavourable cervix, favourable cervix, cervix not defined);
(2) nulliparous, ruptured membranes (unfavourable cervix, favourable cervix, cervix not defined);
(3) multiparous, intact membranes (unfavourable cervix, favourable cervix, cervix not defined);
(4) multiparous, ruptured membranes (unfavourable cervix, favourable cervix, cervix not defined);
(5) previous caesarean section, intact membranes (unfavourable cervix, favourable cervix, cervix not defined);
(6) previous caesarean section, ruptured membranes (unfavourable cervix, favourable cervix, cervix not defined).

Each time a primary review was updated with new data, those secondary reviews which included data which have changed, would also have been updated.

The trials included in the primary reviews were extracted from an initial set of trials covering all interventions used in induction of labour (see above for details of search strategy). The data extraction process was conducted centrally. This was co-ordinated from the Clinical Effectiveness Support Unit (CESU) at the Royal College of Obstetricians and Gynaecologists, UK, in co-operation with the Pregnancy and Childbirth Group of the Cochrane Collaboration. This process allowed the data extraction process to be standardised across all the reviews.

The trials were initially reviewed on eligibility criteria, using a standardised form and the basic selection criteria specified above. Following this, data were extracted to a standardised data extraction form which was piloted for consistency and completeness. The pilot process involved the researchers at the CESU and previous reviewers in the area of induction of labour.

Information was extracted regarding the methodological quality of trials on a number of levels. This process was completed without consideration of trial results. Assessment of selection bias examined the process involved in the generation of the random sequence and the method of allocation concealment separately. These were then judged as adequate or inadequate using the criteria described in Appendix 3 for the purpose of the reviews.

Performance bias was examined with regards to whom was blinded in the trials i.e. patient, caregiver, outcome assessor or analyst. In many trials the caregiver, assessor and analyst were the same party. Details of the feasibility and appropriateness of blinding at all levels was sought.

Predefined subgroup analyses were: previous caesarean section or not; nulliparity or multiparity; membranes intact or ruptured, and cervix unfavourable, favourable or undefined. Only those outcomes with data appear in the analysis tables.

Individual outcome data were included in the analysis if they met the pre-stated criteria in 'Types of outcome measures'. Included trial data were processed as described in the Cochrane Reviewers' Handbook (Clarke 2002). Data extracted from the trials were analysed on an intention-to-treat basis (when this was not done in the original report, re-analysis was performed if possible). Where data were missing, clarification was sought from the original authors. If the attrition was such that it might significantly affect the results, these data were excluded from the analysis. This decision rested with the reviewers of primary reviews and is clearly documented. If missing data become available, they will be included in the analyses.

Data were extracted from all eligible trials to examine how issues of quality influence effect size in a sensitivity analysis. In trials where reporting was poor, methodological issues were reported as unclear or clarification sought.

Once the data had been extracted, they were distributed to individual reviewers for entry onto the Review Manager computer software (RevMan 2000), checked for accuracy, and analysed as above using the RevMan software. For dichotomous data, relative risks and 95% confidence intervals were calculated, and in the absence of heterogeneity, results were pooled using a fixed-effect model.

The predefined criteria for sensitivity analysis included all aspects of quality assessment as mentioned above, including aspects of selection, performance and attrition bias.

Primary analysis was limited to the prespecified outcomes and subgroup analyses. In the event of differences in unspecified outcomes or subgroups being found, these were analysed post hoc, but clearly identified as such to avoid drawing unjustified conclusions.

In 2012 the methods and software for carrying out reviews were updated, as a result of which new reviews and updates, where appropriate, used these new methods (Higgins 2011; RevMan 2012), which are described in the Methods section of all the individual new and updated reviews.

 

Appendix 3. Methodological quality of trials


Methodological itemAdequateInadequate

Generation of random sequenceComputer generated sequence, random number tables, lot drawing, coin tossing, shuffling cards, throwing dice.Case number, date of birth, date of admission, alternation.

Concealment of allocationCentral randomisation, coded drug boxes, sequentially sealed opaque envelopes.Open allocation sequence, any procedure based on inadequate generation.



 

Appendix 4. Data extraction form

The Cochrane Pregnancy and Childbirth Group  

Review title: Acupuncture for induction of labour

 


Review ID:

 
Study ID:

 
Reference ID:

 

Person extracting data:

 
Date of date extraction:

 
Year of study publication:

 

Title:

 

Author:

 

Reference:

 



 

Study design


 

Type of study design (cluster RCT; block randomisation; stratified randomisation; multi-arm; factorial etc):

 

Unit of randomisation:

 



 

 

Participants and setting


 

Describe setting:

Inclusion criteria:

 



 

 

 

Intervention

 

Comparison

Outcomes:

 

Study methods

Risk of bias


Adequate sequence generation

Was the allocation sequence adequately generated?
                                                                                               Yes / Unclear / No

 

Allocation concealment

Was allocation concealment adequate?
                                                                                               Yes / Unclear / No

Describe:   

Blinding

Was knowledge of the allocated intervention adequately prevented during the study?
Participant:                                                                   Yes / Unclear / No

Clinician:                                                                       Yes / Unclear / No

Outcome assessor :                                                                 Yes / Unclear / No

 

Describe:

                                                               

Incomplete outcome  data addressed

Were complete outcome data adequately addressed?

 
                                                                                                 Yes / Unclear / No

 

Describe any loss of participants to follow-up at each data collection point:                                                             

 

Describe any exclusion of participants after randomisation:

Was the analysis intention to treat? If not has the data been able to be re-included?

                                                     

Free of selective reporting bias

Are reports of study free of suggestions of selective reporting bias?

 
                                                                                                   Yes / Unclear / No

Describe:   

Free of other bias

Was the study apparently free of other problems that could put it at high risk of bias?

 
                                                                                                   Yes / Unclear / No

If the study was stopped early, explain the reasons:

 

Describe any baseline in balance:

 

Describe any differential diagnosis:

 



 

 

Additional information requested

Outcomes for main analysis


  

Outcome Measures (Dichotomous)
    Total number of participants in study = 101

 

Intervention group

total no. in study =
Comparison group

Total no. in study =


eventsTotaleventstotal

  Primary:    

1vaginal delivery not achieved within 24 hours;    

2uterine hyperstimulation with fetal heart rate (FHR) changes;    

3

 
caesarean section;    

4serious neonatal morbidity or perinatal death (e.g. seizures, birth asphyxia defined by trialists, neonatal encephalopathy, disability in childhood);    

5serious maternal morbidity or death (e.g. uterine rupture, admission to intensive care unit, septicaemia)    

 Secondary:    

6cervix unfavourable/unchanged after 12 to 24 hours;    

7oxytocin augmentation.    

8uterine hyperstimulation without FHR changes;    

9uterine rupture    

10epidural analgesia;    

11instrumental vaginal delivery;    

12meconium-stained liquor;    

13Apgar score less than seven at five minutes;    

14neonatal intensive care unit admission;    

15neonatal encephalopathy;    

16perinatal death;    

17disability in childhood;    

18maternal side-effects (all);    

19maternal nausea;    

20maternal vomiting    

21maternal diarrhoea;    

22other maternal side-effects;    

23postpartum haemorrhage (as defined by the trial authors);    

24serious maternal complications (e.g. intensive care unit admission, septicaemia but excluding uterine rupture);    

25maternal death    



 


  

Outcome Measures (Continuous)  
      Total number of participants in study =

 

Intervention group

Total no. in study =
Control group

Total no. in study =


totalmeanSDtotalmeanSD

  Secondary      

1woman not satisfied;      

2care giver not satisfied      

3use of other induction methods;      

4time from trial intervention to the birth of the baby;      

5length of labour      



 

Outcomes for subgroup analyses

previous caesarean section or not;

nulliparity or multiparity;

membranes intact or ruptured, and cervix unfavourable, favourable or undefined. Other subgroup analyses will examine the effects of different styles of acupuncture (for example classical/traditional acupuncture versus single point therapy, or auricular acupuncture), as well as the type of control group.


  

Outcome Measures (Dichotomous)
    Total number of participants in study =

 

Intervention group

Total no. in study =
Control group

Total no. in study =


eventsTotaleventstotal

  Primary:

 
    

1  

 

 
 

 

 
  

2     

 

 
 

Secondary:
    

3     

4     

5     



 


  

Outcome Measures (Continuous)  
     Total number of participants in study =

 

Intervention group

Total no. in study =
Control group

Total no. in study =


totalmeanSDtotalmean SD

  Primary:

 
  

Median
 

IQR
   

1       

2       

 

 
 

Secondary:
      

3       

4       

5       



                                                     

 

General conclusions

 


 

Very brief summary of study authors main findings/conclusions:

 



 

 

Exclusion after data extraction

 


 

Reasons for exclusion: (study design? participants? interventions/ outcomes? attrition? bias?)

 

 

 

 

 



 

 

 

What's new

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

Last assessed as up-to-date: 14 December 2012.


DateEventDescription

7 February 2013New citation required and conclusions have changedEleven trials have been added since the last update. Conclusions have changed for one outcome: need for induction methods. There is now no difference in the use of additional induction methods between acupuncture and standard care groups.

23 November 2012New search has been performedSearch updated and 18 trial reports identified.



 

History

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

Protocol first published: Issue 2, 2000
Review first published: Issue 1, 2001


DateEventDescription

23 May 2012AmendedSearch updated. Fifteen reports added to Studies awaiting classification.

10 November 2008AmendedContact details updated.

13 August 2008AmendedCorrected typing mistake in the Plain language summary.

8 February 2008New search has been performedSearch updated. We identified nine new trial reports for eight trials, two of which have been included (Gaudernack 2006; Harper 2006a), three excluded (Bo 2006; Martinez 2004a; So 1979), one is awaiting assessment (Coeytaux 2007) and two are ongoing (Lorentzen 2006; Modlock 2006).

8 February 2008AmendedConverted to new review format.

31 October 2003New search has been performedSearch updated. We identified one new trial that met the inclusion criteria (Rabl 2001) and two new trials which we excluded (Dorr 1990;Romer 2000a ).



 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

Caroline Smith conceptualised and took the lead in writing the protocol and the original review. She performed initial searches of databases for trials, was involved in selecting trials for inclusion, performed data extraction and quality assessment of the included trials, was responsible for statistical analysis and interpretation of the data, and wrote the first draft of this update.

Caroline Crowther was involved with selecting trials for inclusion, performed data extraction and quality assessment of the included trials, interpretation of the data and commented on drafts of the protocol and the original review and drafts of this update.

Suzanne Grant was involved with selecting trials for inclusion, performed data extraction and quality assessment of the included trials, interpretation of the data and commented on drafts of this updated review.

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

Caroline Smith and Caroline Crowther are both authors on one of the included trials (Smith 2008), and so a third independent person assessed and extracted data for this trial.

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms
 

Internal sources

  • University of Western Sydney, Australia.
  • University of Adelaide, Australia.

 

External sources

  • No sources of support supplied

 

Differences between protocol and review

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Index terms

Methods updated to current Cochrane Pregnancy and Childbirth Group standard text.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. References to ongoing studies
  23. Additional references
  24. References to other published versions of this review
Asher 2009 {published data only}
  • Asher GN, Coeytaux RR, Chen W, Reilly AC, Loh YL, Harper TC. Acupuncture to initiate labor (Acumoms 2): a randomized, sham-controlled clinical trial. Journal of Maternal-Fetal & Neonatal Medicine 2009;22(10):843-8.
Gaudernack 2006 {published data only}
Gaudet 2008 {published data only}
  • Gaudet LM, Dyzak R, Aung SK, Smith GN. Effectiveness of acupuncture for the initiation of labour at term: a pilot randomized controlled trial. Journal of Obstetrics and Gynaecology Canada: JOGC 2008;30(12):1118-23.
Gribel 2011 {published data only}
  • Gribel GPC, Coca-Velarde LG, Moreira RAS. Electroacupuncture for cervical ripening prior to labor induction: a randomized clinical trial. Archives of Gynecology and Obstetrics 2011;283(6):1233-8.
Harper 2006 {published data only}
  • Harper TC, Coeytaux RR, Chen W, Campbell K, Kaufman JS, Moise KJ, et al. A randomized controlled trial of acupuncture for initiation of labor in nulliparous women. Journal of Maternal-Fetal and Neonatal Medicine 2006;19(8):465-70.
  • Harper TC, Coeytaux RR, Chen W, Campbell K, Kaufman JS, Thorp J, et al. A randomized controlled trial of acupuncture for initiation of labor in nulliparous women [abstract]. American Journal of Obstetrics and Gynecology 2005;193(6 Suppl):S43.
Long 1994 {published data only}
  • Long Z. Auricularpoint-pressing therapy for induced labor in mid- and late pregnancy. Acupuncture Research 1994;19(1):181.
  • Long ZG. 200 cases of ear acupoint press therapy for induced labor by rivanol at middle and late stage. Chinese Acupuncture and Moxibustion 1994;14(5):26.
Mackenzie 2011 {published data only}
Martinez 2004 {published data only}
  • Martinez AC, Rivera LN, Arangel CR. Acupuncture as an alternative technique for uterine contraction in term pregnant patients. 5th World Congress on Controversies in Obstetrics and Gynecology; 2004 June 3-6; Las Vegas, USA. 2004.
Modlock 2010 {published data only}
  • Modlock J. Can acupuncture be used as preparation for induction of labour (ongoing trial). ClinicalTrials.gov (http://clinicaltrials.gov/) (accessed 21 March 2006).
  • Modlock J, Nielsen BB, Uldbjerg N. Acupuncture for the induction of labour: a double-blind randomised controlled study. BJOG: an international journal of obstetrics & gynaecology 2010;117(10):1255-61.
Rabl 2001 {published data only}
  • Rabl M, Ahner R, Bitschnau, Zaisler H, Husslein P. Acupuncture for cervical ripening and induction of labour at term: a randomised controlled trial. Wiener Klinische Wochenschrift 2001;113(23-24):942-6.
Romer 2000 {published data only}
  • Romer A, Weigel M, Zieger W, Melchart F. Prenatal acupuncture: effects on cervical maturation and duration of labour. Geburtshilfe und Frauenheilkunde 2000;60(10):513-8.
Selmer-Olsen 2007 {published data only}
Smith 2008 {published data only}
Tremeau 1992 {published data only}
  • Tremeau ML, Fontanie-Ravier P, Teurnier F, Demouzon J. Protocol for cervical maturation by acupuncture [Protocole de maturation cervicale par acupuncture]. Journal de Gynecologie, Obstetrique et Biologie de la Reproduction (Paris) 1992;21:375-80.

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. References to ongoing studies
  23. Additional references
  24. References to other published versions of this review
Aghamohammadi 2011 {published data only}
  • Aghamohammadi A, Behmanesh F, Zafari M, Tofighi M. Effect of using Transcutaneous Electrical Nerve Stimulation (TENS) in acupuncture points [Hegu (Li4) and Sanyinjiao (Sp6)] on duration of the first stage of labor. Journal of Babol University of Medical Sciences 2011;13(2):19-24.
Bo 2006 {published data only}
  • Bo QX, Zhang JX. Observation on therapeutic effect of scalp acupuncture analgesic on labor. Zhongguo Zhen Jiu 2006;26(9):659-61.
Dorr 1990 {published data only}
  • Dorr A. The possibility of inducing labour using acupuncture. American Journal of Acupuncture 1990;18(3):286-90.
Dunn 1989 {published data only}
  • Dunn PA, Rogers D, Halford K. Transcutaneous electrical nerve stimulation at acupuncture points in the induction of uterine contractions. Obstetrics & Gynecology 1989;73(2):286-90.
Kubista 1974 {published data only}
Li 1996 {published data only}
  • Li GQ. [Effect of electrode-stimulation point for oxytocic]. Shanghai Journal of Acupuncture and Moxibustion 1996;15(4):16.
  • Li XH, Ma WZ, Xu SY. The clinical observation on the effect of electroacupuncture to Sanyinjiao (SP6) and Hegu (LI4) in influencing parturients uterine contraction in the first stage. Journal of Beijing University of Traditional Chinese Medicine 1996;19(6):38.
Lyngso 2010 {published data only}
  • Lyngso CE, Lorentzen IP, Lauszus F. Use of acupuncture for labour augmentation. Ugeskrift for Laeger 2010;172(4):289-93.
So 1979 {published data only}
  • So LK, Sung ML, Yeung KK. Induction of labour by acupuncture [abstract]. 9th World Congress of Gynecology and Obstetrics; 1979 October 26-31; Tokyo, Japan. 1979:281.

Additional references

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. References to ongoing studies
  23. Additional references
  24. References to other published versions of this review
Adams 2009
  • Adams J, Lui C-W, Sibbritt D, Broom A, Wardle J, HomerC, et al. Women’s use of complementary and alternative medicine during pregnancy: a critical review of the literature. Birth 2009;36(3):237-45.
Alfirevic 2006
Alfirevic 2009
Allaire 2000
Barnes 2004
  • Barnes P, Powell-Griner E, McFann K, Nahin R. Complementary and Alternative Medicine Use among Adults. Vol. 343, United States: CDC Advance Data Report, 2002.
Bell 1972
Bimbashi 2012
  • Bimbashi A, Duley L, Ndoni E, Dokle A. Amniotomy plus intravenous oxytocin for induction of labour. Cochrane Database of Systematic Reviews 2012, Issue 4. [DOI: 10.1002/14651858.CD009821]
Boulvain 2001
Boulvain 2005
Boulvain 2008
Bricker 2000
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