European Journal of Obstetrics & Gynecology and Reproductive Biology 254 (2020) 147–152

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Review article

Squatting position in the second stage of labor: A systematic review

and meta-analysis
Fatima Dokmaka , Irmina Maria Michalekb , Michel Boulvainc, David Desseauveb,*
a
Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
b
Women-Mother-Child Department, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
c
GHOL Hôpital de Nyon, Switzerland and University of Geneva, Nyon, Switzerland

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: The influence of squatting during delivery on maternal and fetal outcomes remains unclear.
Received 25 March 2020 We performed a systematic review and meta-analysis to evaluate the benefits and risks of adopting a
Received in revised form 8 September 2020 squatting position during the second stage of labor.
Accepted 11 September 2020
Study design: Search Strategy: A systematic search in the three major electronic databases (CENTRAL,
PubMed and Embase) was performed, from their respective inception dates to the 14th of December
Keywords: 2019, using ‘squatting’, and a combination of keywords to identify delivery.
Delivery
Eligibility criteria: Randomized controlled trials comparing squatting position to any supine position
Obstetric
Parturition
during the second stage of labor.
Squatting Statistical analyses: Risk ratio for dichotomous outcomes, mean difference for continuous outcomes,
Position with 95 % confidence intervals. Fixed-effects meta-analysis (Mantel-Haenszel method) or random-effects
model (inverse variance method), for low and high heterogeneity between trials, respectively.
PROSPERO Registration number: CRD42018093244
Results: Seven randomized controlled trials (n = 1219) were included. Three studies were assessed as low
risk of bias, three others as moderate and one study as high risk of bias. The main limitation is the lack of
reporting on the methods to achieve randomization and concealment of allocation in most of the studies.
There was no difference in the duration of the second stage of labor (mean -11.09 min; 95 %CI -38.85 to
16.68). In the squatting group, the risk of caesarean section was increased (RR 2.26, 95 %CI 1.07–4.80) and
the risk of instrumental delivery was decreased (RR 0.60, 95 %CI 0.45 0.81), which results in a similar
probability of spontaneous delivery. There were no differences regarding the other maternal and fetal
outcomes.
Conclusions: The available evidence does not show the squatting position during childbirth to be
beneficial. As there is no evidence for or against squatting, women should be able to choose the position
they prefer.
© 2020 Elsevier B.V. All rights reserved.

Contents

1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
2 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
2.1 Data sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
2.2 Eligibility criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
2.3 Main outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
2.4 Data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
2.5 Assessment of risk of bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
2.6 Assessment of the quality of evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

Abbreviations: RR, risk ratio; 95%CI, 95%confidence interval.

* Corresponding author at: Centre Hospitalier Universitaire Vaudois, Women-Mother-Child Department, Avenue Pierre-Decker 2, 1011, Lausanne, Switzerland.
E-mail address: David.Desseauve@chuv.ch (D. Desseauve).

https://doi.org/10.1016/j.ejogrb.2020.09.015
0301-2115/© 2020 Elsevier B.V. All rights reserved.
148 F. Dokmak et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 254 (2020) 147–152

2.7 Statistical analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

2.8 PROSPERO registration number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
3 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
3.1 General characteristics of the studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
3.2 Risk of bias of included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
3.3 Synthesis of the results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
4 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
4.1 Main findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
4.2 Overall completeness and applicability of evidence and comparison with existing literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
4.3 Implications for clinical practice and field of knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
4.4 Limitations of the review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
5 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Funding information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Ethical approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Contribution to authorship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151

1 Introduction the 14th of December 2019. A complete description of the search

Over the past two centuries, in many Western countries,
hospital-based intrapartum care became routine [1,2]. The reasons
for such a change are multifactorial and have been evolving over
time. Such a model of obstetrics shifted the general perception of
pregnancy from a physiological to a pathological condition. It also
resulted in a decrease in woman’s mobility during labor. One of the
causes of this decrease is adopting a lithotomy position, providing
better perineal access whenever an instrumental delivery is
required [1]. Another reason is the increased use of epidural
analgesia [2].
Some women request to adopt a non-lithotomy position during
the second stage of labor. A systematic review and meta-analysis
evaluating any upright position without epidural suggested a
modest reduction in the duration of the second stage, a reduction
in interventions (instrumental delivery and episiotomy), but an
increase in blood loss [3]. These results were not found in another
systematic review and meta-analysis of studies in women with
epidural, including the BUMPES trial, the larger randomized trial
on this subject [4,5]. The results of the trials included in both
reviews are heterogeneous, possibly because of the inclusion of
various upright positions. We focus in this review specifically on
the squatting position.
The potential advantages of the squatting position include the
effects of gravity [1,3,6], a better alignment of the fetus in the birth
canal [7], an increase of the pelvic outlet diameter [8–11], and an
increase in the efficiency of uterine contractions [1]. On the other
hand, it was reported that adopting such a position is associated
with increased risk of peroneal neuropathy [12], a loss of woman’s
body balance and lower efficiency of the pushing efforts during the
second stage of labor [17].
Whether these potential benefits and risks of squatting position
during the second stage of labor translate into clinically relevant
maternal and fetal outcomes is unknown. To address this issue, we
performed a systematic review and meta-analysis of the random-
ized trials evaluating the effects of adopting a squatting position
during the second stage of labor.
strategy is provided in Appendix A. The lists of references in the
identified publications were manually searched. No temporal or
regional restrictions were applied.
Authors of the publications were contacted and invited to
participate in an individual participant data meta-analysis.
However, none of the authors responded to our invitation.
2.2 Eligibility criteria
The inclusion criteria were defined a priori as follows: 1) types
of studies: randomized trial ; 2) type of participants: pregnant
women during the second stage of labor; 3) interventions: unaided
squatting position compared to any supine position during the
second stage of labor (positions described in details in Appendix B).
Since the majority of Western adults find difficult and
exhausting to squat with heels down, several studies proposed a
modified squatting position. In this review, the trials were
excluded if the squatting position was modified using a birth
chair, a birth cushion or the woman was supported by another
person. Because of the minor modification of the position, use of a
bar to facilitate squatting was, however, not considered as
exclusion criteria for the study.
2.3 Main outcomes
1) Primary maternal outcome measure: duration of the second
stage of labor [minutes]; 2) Secondary maternal outcome
measures: mode of birth [caesarean section, instrumental delivery
(forceps or vacuum-assisted delivery), spontaneous vaginal deliv-
ery], pain [Visual Analog Scale], use of any analgesia [non-epidural
analgesia], perineal trauma [second-degree tear, third- or/and
fourth-degree tear, episiotomy], blood loss [> 500 mL blood loss
(mL)]; paraurethral tears; retained placenta; shoulder dystocia; 3)
Types of neonatal outcomes: Apgar score [1-minute Apgar score
and 5-minute Apgar score], admission to neonatal intensive care
unit, perinatal death.

2.4 Data extraction

2 Methods
2.1 Data sources
We performed a systematic review of publications indexed in
three major electronic databases - Cochrane Central Register of
Controlled Trials (CENTRAL), MEDLINE, and Embase. All these
databases were searched from their respective inception dates to
Two independent reviewers (FD and DD) searched titles and
abstracts for publications that initially met the inclusion criteria.
All of the publications meeting the criteria were selected for full-
text analysis. Discrepancies were resolved by discussion. Subse-
quently, the reviewers independently extracted the data and
completed the previously prepared form. Data management was
performed using review manager software (RevMan 5) [13].
 F. Dokmak et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 254 (2020) 147–152
2.5 Assessment of risk of bias
Two independent reviewers (FD and DD) assessed the risk of
bias of each study using the method described in the Cochrane
Handbook for Systematic Reviews of Interventions (version 5.1.0)
[14]. The tool evaluates selection bias [random sequence genera-
tion; allocation concealment], performance bias [blinding of
participants and personnel], detection bias [blinding of outcome
assessment], attrition bias [incomplete outcome data], and
reporting bias [selective reporting]. For each included publication,
the risk of bias table was produced, describing each assessed
variable and its grading as low-, moderate-, and high risk of bias
(Appendix E). In case of disagreement, a third author (IMM) was
consulted.
Information on funding of the included studies was sought.
2.6 Assessment of the quality of evidence
The quality of evidence was assessed using the Grading of
Recommendations, Assessment, Development and Evaluations
(GRADE) software [15]. The following outcomes for squatting and
supine position during labor were compared: 1) duration of the
second stage of labor; 2) mode of birth [caesarean section]; 3)
mode of birth [instrumental delivery i.e. forceps or vacuum
extraction]; 4) pain [VAS]; 5) severe perineal trauma [third-/
fourth-degree tear]; 6) blood loss [> 500 mL]; and 7) admission to
neonatal intensive care (Appendix F).
2.7 Statistical analysis
For dichotomous outcome, we calculated the risk ratio with
the 95 % confidence intervals. For continuous outcomes, when the
measurement method was similar, we used the mean difference.
Statistical heterogeneity was assessed in each meta-analysis
using the Tau2, I2, and Chi2 statistics. The risk of publication bias
could not be assessed using a test for the asymmetry of the funnel
plot, because there were only seven included trials. We pooled the
effects by a fixed-effects meta-analysis (Mantel-Haenszel meth-
od), unless there was significant heterogeneity between trials. In
the presence of heterogeneity (I2 > 40 %), we pooled the estimates
of the effects with the random-effects model (inverse variance
method). The statistical significance of the pooled RR was
determined with Z-test and P-value. We contacted by e-mail
the corresponding authors of the included publications to
supplement missing data. None of the research groups replied
to our request. To include data from the study by Moraloglu et al.,
the Apgar score medians were considered as means and the
standard deviation was estimated as half of the range between
the minimum and the median 18. Statistical analysis was
performed using RevMan 5 [13].
2.8 PROSPERO registration number
CRD42018093244
Fig. 1. Association between childbirth position (experimental - squatting; control - supine) and duration of the second stage of labor (minutes).
149
3 Results
3.1 General characteristics of the studies
A total of 411 publications were initially identified by the
database searches (Figure A1). Only articles written in English or
French were found. After filtering the titles and abstracts, a total of
14 full-text publications met the eligibility criteria [16–29]. Finally,
after full-text analysis, seven randomized controlled trials with a
total of 1219 participants were included in the quantitative
synthesis (Appendix C) [16–22]. We excluded seven trials because
1) results on squatting position presented with other upright
positions [23–26]; 2) position not corresponding to the definition
of squatting position [27,28]; 3) exclusion of a large number of
women not taking the squatting position and intention-to-treat
analysis not reported 29] (Appendix B and D).
Among the studies included in the quantitative synthesis, three
studies [17,18,21] included primiparous women only, three
[16,20,22] studies included both primiparous and multiparous
women and one study [19] did not report on parity. Most of the
studies’ inclusion criteria were gestational age at 37 weeks or
more, with no obstetric or medical complications. Lin et al. [17]
included participants from 38 weeks, and one other study did not
provide information on gestational age [20]. (Appendix C)
In all the included trials, the intervention was defined as a
squatting position, compared to the supine position during the
second stage of labor [16–29]. One study [18] evaluated a modified
squatting position, using a bar. Another study [17] analyzed both
standard and ankle-supported squatting position, compared with
supine. Only the results for the standard squatting position were
included in the meta-analysis.
All of the studies were conducted in hospitals, one in a
university hospital [20]. Six of them took place in Asia (India [16],
Taiwan [17], Turkey [18], Pakistan [19,22], and Iran [21]) and one in
Europe (France [20]).
3.2 Risk of bias of included studies
Three studies [17,18,21] were assessed as low risk of bias and
three others [16,20,22] as moderate (Figure A2; Appendix E). One
study was categorized as high risk of bias because of the
inadequate randomization and allocation concealment [19].
Blinding of personnel, participants, and outcome assessors was
impossible in trials evaluating this intervention. We found no
information about funding of the included studies.
3.3 Synthesis of the results
For all women combined (primiparous and multiparous), no
statistically significant difference in the duration of the second
stage of labor was observed (-11.09 min, 95 %CI -38.85 to
16.68 min; 3 trials; 453 women; P = 0.43; Fig. 1). The results of
the studies were heterogeneous (I2 = 99 %). No study presented
results stratified by parity.
150 F. Dokmak et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 254 (2020) 147–152
Fig. 2. Association between childbirth position (experimental - squatting; control - supine) and risk of caesarean section.
With a moderate quality of evidence (Appendix F), the risk of
caesarean section was higher in squatting position than in supine
position (RR 2.26, 95 %CI 1.07–4.80; 5 trials; 1043 women; P = 0.03;
Fig. 2). The risk of using forceps or vacuum was lower in squatting
position (RR 0.60, 95 %CI 0.45 0.81; 5 trials; 1053 women;
P < 0.001; Fig. 3), with a moderate quality of evidence
(Appendix F). No difference in spontaneous vaginal deliveries
was observed (RR 1.01, 95 %CI 0.94–1.08; 4 trials; 653 women;
P = 0.85; Figure A3).
There was no statistically significant difference in pain intensity
between squatting and non-squatting position (-0.64 points in the
VAS, 95 %CI -1.55 to 0.27; 2 trials; 176 women; P = 0.16; Figure A4),
with a low quality of evidence (Appendix F). One trial reported on
the use of pain relief medication, and there was no significant
difference between groups (RR 1.39, 95 %CI 0.83–2.33; 1 trial, 112
women; P = 0.22, Figure A5) [17].
Regarding perineal trauma, no difference between groups in the
risk of second-degree tear (RR 0.93, 95 %CI 0.23–3.84; 4 trials; 614
women; P = 0.92; Figure A6), third- and fourth-degree tear (RR
0.82, 95 %CI 0.46–1.49; 3 trials; 512 women; P = 0.52; Figure A7),
episiotomy (RR 0.94, 95 %CI 0.65–1.35; 5 trials; 1043 women;
P = 0.73; Figure A8), and paraurethral tears (RR 1.26, 95 %CI 0.34–
4.69; 4 trials; 804 women; P = 0.73; Figure A11) was observed, with
a very low quality of evidence (Appendix F).
There were no difference in the risk of hemorrhage (blood loss >
500 mL) (RR 1.08, 95 %CI 0.64–1.83; 3 trials; 741 women; P = 0.78;
Figure A9) and estimated blood loss (mean difference 11.15 mL; 95
%CI -18.18–40.48 mL; 1 trial; 112 women; P = 0.46; Figure A10),
with a very low quality of evidence (Appendix F).
The risk of retained placenta was decreased in the squatting
group (RR 0.09, 95 %CI 0.01 0.70; 2 trials; 502 women; P = 0.02;
Figure A12) with a very low quality of evidence (Appendix F).
This difference is statistically significant but based on no events
in the squatting groups versus 10 events in controls. The risk of
shoulder dystocia, reported in only one trial, was not statistically
different between the experimental and control group (RR 0.20, 95
%CI 0.01–4.11; 1 trial; 200 women; P = 0.30; Figure A13).
No significant difference in 1 and 5-minutes Apgar scores was
observed (mean difference 0.05 point; 95 %CI -0.08 to 0.19; 3 trials;
451 women; P = 0.41; Figure A14 and mean difference of 0.00
point; 95 %CI -0.09 to 0.09; 3 trials; 451 women; P = 0.98;
Fig. 3. Association between childbirth position (experimental - squatting; control - supine) and risk of instrumental delivery (forceps or vacuum-assisted delivery).
Figure A15). Only one trial reported on admission to the neonatal
intensive care unit, without significant difference between groups
(RR 0.60, 95 %CI 0.15–2.38; 1 trial; 100 women; P = 0.47;
Figure A16), with a low quality of evidence (Appendix F). Perinatal
death was reported in one trial, with 2 cases in each group (RR 1.00,
95 %CI 0.14–6.96; 1 trial; 200 women; P = 1.0; Figure A17).
4 Discussion
4.1 Main findings
In the squatting position, the duration of the second stage of
labor was slightly shorter, but the results were not statistically
significant. The risk of instrumental delivery was reduced, but the
number of caesarean sections was higher, which gives a similar
probability of spontaneous vaginal delivery in the two groups. The
other outcomes were similar between groups. Given the small
number of the identified studies, a relatively small pooled sample
size, and some variations in the intervention between studies, we
cannot exclude small differences in the effects of the maternal
position during childbirth.
4.2 Overall completeness and applicability of evidence and
comparison with existing literature
It is impossible to conduct a double-blind, randomized trial to
assess the possible benefits of giving birth in a squatting position.
This is a common problem in obstetrical trials involving non-
pharmacological interventions, which increases the risk of both
performance and detection bias. The most critical aspect regarding
the completeness and applicability of the evidence of this review is
the variation of the intervention, including a variety of squatting
positions, time taking the allocated position and use of aids. We
restricted the inclusion of trials to those evaluating squatting
position, mostly un-aided.
Duration of the second stage of labor was not different between
groups. The small difference in the summary estimate was
influenced by one study with extreme results and unusually small
standard deviation, which could be due to a standardized protocol
used in this hospital18. The hypothesis of a reduction in the
duration of the second stage of labor was thought as biologically
 F. Dokmak et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 254 (2020) 147–152
plausible according to current knowledge of obstetrical biome-
chanics. It was reported that, in the squatting position, the pelvic
inlet may be closer to the optimal position [6,30]; there is an
increase in the diameter of the pelvis by around 3% [8,9,31]; the
effect of gravity is added to the pushing efforts [6,10]; there is an
increase in the intensity of uterine contractions 1; the position of
the fetus in the birth canal may be improved [17,22]; a better
distribution of pressure on the perineal area increases the urge to
push [19,22]; there is a lower risk of great vessels compression and
a decreased fetal stress [18,22,32]. All these potential advantages
do not, however, translate in improved maternal or neonatal
outcomes.
The lower risk of instrumental delivery may be a genuine
benefit or derive from a lower tendency of performing inter-
ventions by caregivers because of limited perineal access [32,33].
The higher risk of caesarean section in the squatting position is
difficult to explain. This risk is mainly influenced by the results of
one trial [22]. The indications were malpresentation (n = 4),
postdate pregnancy (n = 2) and pre-eclampsia (n = 2), which were
exclusion criteria. Only 4 caesarean sections were performed for
failure to progress. Excluding the above situations, the risk of
cesarean section is lesser and no longer statistically significant (RR
1.82, 95 %CI 0.75–4.40; 5 trials; 1033 women; P = 0.18).
Despite higher pressure exerted on the vagina, typical for the
squatting position, the risk of perineal damage, including third- and
fourth-degree tear, was not increased [34,35]. This may be attributed
to a more homogeneous distribution of pressures over the birth
canal. Peripheral neuropathies, which were raised as a potential
concern with squatting, were not reported in any trial. Blood loss and
risk of postpartum hemorrhage were not increased in the squatting
position. Only one study reported increased bleeding in the squatting
position, but not reaching the traditional threshold of 500 mL to
define hemorrhage [17]. Increased bleeding was a concernwith other
upright positions, but this is probably due to a better detection of
blood loss in these positions, rather than a true effect.
4.3 Implications for clinical practice and field of knowledge
Most of the included studies (six out of seven) were conducted
in Asia, where squatting is usual. Hence, the results of this review
may be difficult to generalize to Western countries, where the
squatting position is difficult to adopt by women, who find it
uncomfortable and challenging to maintain [17,18,29]. Neverthe-
less, the results of the only European trial did not differ from Asian
studies, except lower compliance. In one of the excluded studies
[29], only 16 % of women allocated to the squatting group gave
birth in this position. Adopting a modified squatting position [17],
with bars or the support from another person, may improve the
acceptability of the intervention.
4.4 Limitations of the review
A limitation of the review is the difficulty to standardize the
squatting position and to have a uniform duration of standing in
that position. Differences between studies may contribute to the
observed statistical heterogeneity.
The small number of studies and pooled sample size, the
heterogeneity, the inconsistency in the direction of the effect, and
the generally high or unclear risk of bias between included studies,
and the general poor quality of the studies, worsen the quality of
evidence and limits the conclusions of this review. We choose to
include only randomized controlled trials, the only study design
that provides a valid estimate of the effects of an intervention.
However, there is a lack of reporting on the methods to achieve
randomization and concealment of allocation in most of the
studies.
151
We were unable to stratify by epidural analgesia use or parity. It
might be hypothesized that results in these sub-groups of women
may be different than the overall results.
The low numbers of studies included did not allow us to detect a
publication bias using a funnel plot. There is the possibility of such
bias in this context, as small trials not showing a beneficial effect
may not be published because they were against the opinions of
that time on the value of upright or squatting position. This is
another limitation of this review.
5 Conclusions
Despite the theoretical advantages of a squatting position
during the second stage of labor, this review does not show any
beneficial or harmful effect of squatting during childbirth. The
increase in caesarean sections is, however, concerning. Since there
is no strong evidence for or against squatting position, women
should be allowed to adopt the position of their choice during
pushing efforts, with neutral counselling from the caregivers.
Funding information
None to declare.
Ethical approval
Not required.
Contribution to authorship
Review concept and design: FD, DD
Analysis and interpretation of data: FD, IMM, MB, DD
Drafting the manuscript: FD, IMM
Critical revision of the manuscript for important intellectual
content: FD, IMM, MB, DD
Statistical analysis: FD, MB
Declaration of Competing Interest
No conflict of interest to declare.
Acknowledgments
We acknowledge the Leennards Fondation (Switzerland) for its
support in obstetrical research.
Appendix A. Supplementary data
Supplementary material related to this article can be found, in the
online version, at doi:https://doi.org/10.1016/j.ejogrb.2020.09.015.
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