Women and Birth (2012) 25, 142—148

a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m

journal homepage: www.elsevier.com/locate/wombi

DISCUSSION

Complementary and alternative medicine for

induction of labour
Helen G. Hall a,*, Lisa G. McKenna b, Debra L. Griffiths a

a
Monash University, Faculty of Medicine, Nursing and Health Sciences, School of Nursing & Midwifery, Peninsula Campus, McMahons
Road, Frankston, Victoria 3199, Australia
b
Monash University, School of Nursing & Midwifery, Clayton Campus, Wellington Road, Victoria 3800 Australia

Received 2 February 2011; received in revised form 27 March 2011; accepted 28 March 2011

KEYWORDS Summary
Complementary and Background: Induction of labour is a common obstetric procedure. Some women are likely to turn
alternative medicine; to complementary and alternative medicine in order to avoid medical intervention.
Midwifery; Aim: The aim of this paper is to examine the scientific evidence for the use of complementary and
Induction; alternative medicine to stimulate labour.
Labour; Method: An initial search for relevant literature published from 2000 was undertaken using a
Birth; range of databases. Articles were also identified by examining bibliographies.
Pregnancy Results: Most complementary and alternative medicines used for induction of labour are
recommended on the basis of traditional knowledge, rather than scientific research. Currently,
the clinical evidence is sparse and it is not possible to make firm conclusions regarding the
effectiveness of these therapies. There is however some data to support the use of breast
stimulation for induction of labour. Acupuncture and raspberry leaf may also be beneficial. Castor
oil and evening primrose oil might not be effective and possibly increase the incidence of
complications. There is no evidence from clinical trails to support homeopathy however, some
women have found these remedies helpful. Blue cohosh may be harmful during pregnancy and
should not be recommended for induction. Other complementary and alternative medicine (CAM)
therapies may be useful but further investigation is needed.
Conclusions: More research is needed to establish the safety and efficacy of CAM modalities.
Midwives should develop a good understanding of these therapies, including both the benefits and
risks, so they can assist women to make appropriate decisions.
# 2011 Australian College of Midwives. Published by Elsevier Australia (a division of Reed
International Books Australia Pty Ltd). All rights reserved.

Introduction

* Corresponding author. Tel.: +61 3 9904 4120; fax: +61 3 9904 4655.
Induction of labour (IOL) is a common maternity care proce-
E-mail addresses: Helen.Hall@med.monash.edu.au, dure. A variety of methods are used, either alone or in
Helen.Hall@monash.edu (H.G. Hall). combination, which include, stripping of the membranes,

1871-5192/$ — see front matter # 2011 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
doi:10.1016/j.wombi.2011.03.006
Complementary and alternative medicine for induction of labour
artificial rupture of membranes (ARM) and pharmaceuticals
(prostaglandins, oxytocin). Research has found that IOL is
associated with improved outcomes for women who have a
prolonged pregnancy or pre-labour rupture of membranes
(PROM) but the evidence for other indications is less appar-
ent.1,2 The prevalence of medical induction has been increas-
ing since the 1980s and the rate now exceeds one in five in
many countries.1,3 However, the procedure is not without
risks and studies have revealed that the rising rates are not
associated with increasing benefits.3
Women who undergo IOL tend to be less satisfied with
their birth experience.3 As the childbearing becomes more
medicalised some women will seek out complementary and
alternative medicine (CAM) to support their desire for a
natural birth.4,5 CAM is defined by the National Centre for
Complementary and Alternative Medicine (NCCAM) as ‘. . .a
broad collection of therapeutic practices and products that
are not considered part of conventional medicine’.6 Various
CAM therapies have been traditionally used to initiate labour
and many of these treatments continue to be popular
today.7—9 Common therapies used include, herbal medicine,
acupuncture, homeopathy and self help techniques such as
nipple stimulation.7,8 The purpose of this paper is to review
the current evidence for the use of CAM for induction of
labour.
Literature search strategy
This review examines evidence from systematic reviews,
clinical trials and epidemiological studies for the use of
complementary and alternative medicine to induce labour.
Expert judgement, rather than a formal quality appraisal,
was used to determine which studies were included. Selec-
tion of articles was limited to those published in English
language.
An initial search of literature published from 2000 was
undertaken on AMED (Allied and Complementary Medicine
Database), Medline, CINAHL (Cumulative Index to Nursing,
Allied Health Literature), Proquest and Cochrane data-
bases. Further relevant articles were identified by exam-
ining bibliographies and searching the Internet using the
key words. These included: complementary medicine,
alternative medicine, acupuncture, herbal medicine, aro-
matherapy, massage, natural medicine and homeopathy
cross-referenced with; birth, labour, induction and aug-
mentation.
Results
Herbal medicine for IOL
Herbal medicines have a long history of use throughout the
world and are still frequently used for pregnancy care, even
when Western medicine is available.8,10,11 A combination of
blue cohosh, black cohosh, squaw vine and false unicorn root
have been traditionally used in a herbal concoction com-
monly called ‘mother’s cordial’ to prepare the uterus for
labour in the final weeks of gestation.8,11 The herbal reme-
dies most frequently recommended by midwives to induce
labour include raspberry leaf, blue cohosh black, cohosh,
evening primrose oil and castor oil.8,10,12
143
Raspberry leaf
Raspberry leaf (Rubus idaeus) has a long history of use as
‘partus preparatus’ — a plant which prepares the uterus for
labour.11,13 It is still one of the most common herbs consumed
by pregnant women.14,15 A survey of midwives in the America
found that 63% recommended raspberry leaf to induce
labour.12 While there is evidence from in vitro studies to
suggest raspberry leaf does have an effect on uterine tissue,
at this stage the clinical research is very limited.8,15 Parsons,
Simpson and Ponton16 performed a retrospective study in
which women (n = 57) who had used raspberry leaf during
their pregnancy completed a questionnaire and were com-
pared to 51 randomly selected women who had not used the
herb. The dose and duration of consumption varied consider-
ably amongst the users. While no adverse effects were noted,
no clinically significant differences were found either. Fol-
lowing this, the same group undertook a prospective rando-
mized trial which compared 96 pregnant women who
commenced raspberry leaf tablets (1.2 g twice daily begin-
ning at 32 weeks) with a control group.13 There was a small
reduction in the length of second stage and the need for
forceps birth in the intervention group. However, the trial
was small and the differences were not statistically signifi-
cant. Further research is needed.
Herbs found in ‘mother’s cordial’
A survey of American midwives conducted in 1999 found that
64% had recommended blue cohosh (Caulophyllum thalic-
troides) and 45% black cohosh (Actaea racemosa; formerly
Cimicifuga racemosa) for IOL.12 A search of the literature
failed to identify relevant clinical trials however there is
some evidence that blue cohosh should be avoided during
pregnancy. Although a direct cause-effect relationship has
not been established, it has been associated with the devel-
opment of heart failure in one infant17 and perinatal stroke in
another.18 Furthermore, it is not clear if black cohosh has an
oestrogenic or non-oestrogenic effect.11 The prevailing wis-
dom is that until additional research establishes the safety of
these herbs, they should not be consumed by expectant
women.11 It is concerning that a more recent American
survey (published in 2009) found almost thirty percent of
the responding midwives (n = 227) continue to recommend
these potentially dangerous plants.19
No clinical studies on the use of squaw vine (Mitchella
repens) and false unicorn root (Chamaelirium luteum) for IOL
were found. Until there is scientific evidence regarding the
efficacy and safety of these plants during pregnancy, these
herbs should be treated with caution and only recommended
by suitably qualified herbalists.11
Castor oil
Castor oil is derived from the castor plant (Ricinus communis)
and has been used to stimulate labour since ancient Egyptian
times.20 Its action on the uterus is thought to be a result of a
strong cathartic effect and possibly a prostaglandin mediated
process.21 It remained popular into the twentieth century. A
study published in the 1950s22 found that more than 50% of
the department heads of obstetrics recommended castor oil
for IOL. Although it is still common in some parts of the world,
the use of castor oil for IOL has largely been abandoned since
the introduction of oxytocic drugs.10,21,23 A number of studies
have investigated its effectiveness. Boel and colleagues24
144
examined the hospital records of 612 women who were more
than 40 weeks pregnant and attended antenatal clinics on the
Thai-Burmese border. Approximately one third (n = 205)
received castor oil for induction while 407 did not. The time
to birth was not significantly different between the two
groups. The researchers concluded that although the use
of castor oil was safe for both mothers and babies, there
was no evidence from the data that it is effective for induc-
tion of labour. A Cochrane review was undertaken in 2001.20
The one study that met the inclusion criteria compared the
use of a single dose of castor oil (60 ml) with no treatment in
women requiring induction. The participants (n = 103) had
intact membranes and unfavourable cervices.25 Following
administration of castor oil, 30 of 52 women (57.7%) began
active labour within 24 h, compared to 2 of 48 (4.2%) receiv-
ing no treatment. While the researchers conclude that
women who receive castor oil have an increased likelihood
of initiation of labour, the Cochrane reviewers found that the
difference was not significant and the trial was of poor
methodological quality.
Evening primrose oil [EPO]
Traditionally, the oil from evening primrose (Oenothera
biennis) has been administered either orally or vaginally
to ripen the cervix and decrease the incidence of post-
mature pregnancy.12,21 A retrospective study compared
the outcomes of 54 women taking evening primrose oil with
a control group of 54 women who did not.26 The dose regimen
of evening primrose oil was 500 mg orally three times per day
for 1 week beginning at 37 weeks gestation, then 500 mg
orally once per day until labour began. The intervention
group did not have a shorter gestation or length of labour but
did have an increase in the incidence of complications.
However, due to the limited size and scope of the trial no
causal relationships can be made. Currently there is no
convincing evidence from clinical research on the efficacy
of EPO.
Acupuncture for IOL
Acupuncture has been commonly used for more than two
thousand years in some Asian countries27 and has recently
gained popularity in Western societies for the management of
a variety of pregnancy related conditions.27—29 Although it is
generally considered safe, the evidence on the efficacy of
acupuncture for induction of labour is mixed.
A Cochrane review included three trials (n = 212) which
investigated the use of acupuncture for cervical ripening or
labour induction.27 The reviewers found evidence from two
trials (Harper 2006; Gaudernack 2006) that indicated women
receiving acupuncture were less likely to require medical
induction with no differences between groups in other out-
comes. However, these two studies were small, and women
were not blind to their group allocation. The reviewers
conclude that while there are some positive indications that
acupuncture may be beneficial for women requiring IOL,
further research is needed.27
A number of more recent trials have not found significant
differences. A Norwegian study randomized nulliparous
(n = 106) women with premature rupture of membranes to
either an acupuncture group or a control group.30 All women
H.G. Hall et al.
in the intervention group received acupuncture to one spe-
cific point, plus they received additional treatment according
to their individual traditional Chinese medicine diagnosis.
The findings did not reveal significant differences in out-
comes between the two groups. A large Australian trial also
failed to find any significant evidence of effect.31 In this
study, pregnant women (n = 364) who were due for medical
induction (for post-maturity pregnancy) were randomized to
either acupuncture or sham acupuncture and two treatments
were administered. The researchers reported that acupunc-
ture did not increase the number of women who went into
spontaneous labour. An American trial found acupuncture
was not effective in initiating labour compared with sham
acupuncture or usual medical care.32 Participants in this
study were nulliparous women (n = 89) at 38 weeks or
greater. They were randomised to traditional Chinese med-
icine (TCM) acupuncture, sham acupuncture, or usual care
only groups. The results of the trial found no significant
differences in the time to birth, rates of spontaneous labour
or maternal and neonatal outcomes. However, as noted by
the researchers themselves, it is possible that the acupunc-
ture was administered too early in the gestation for a
response. A recently published multi-centre randomised con-
trolled trial was undertaken in Denmark.33 One hundred and
twenty five healthy women at gestational week 41+6 were
randomised into two groups. The intervention group received
acupuncture twice (on the same day) while the control group
received sham acupuncture. No significant differences were
found and the researchers concluded that the use of acu-
puncture for induction of labour may not be effective.
Homeopathy for IOL
Homeopathy is a system of medicine first described in the
18th century by Samuel Hahnemann, a German physician. It is
based on the principle that ‘like cures like’ and therefore
small doses of remedies can be used to stimulate the body’s
natural healing ability. Homeopathic remedies have a long
history of use for stimulating labour, particularly in Europe
and India.34
A Cochrane review by Smith35 assessed two randomised
controlled trials36,37 involving a total of 133 women to
determine the effects of homeopathy for third trimester
cervical ripening or induction of labour. The first study,
conducted in France, examined the use of a combination
of homeopathic Caulophyllum, Actea racemosa, Arnica, Pul-
satilla and Gelsemium.37 The primary outcomes measured
were length and difficulty of labour, rather than initiation of
contractions. The homeopathic (or placebo) was adminis-
tered twice daily from 36 weeks gestation to the participants
(n = 93). Although there was a reduction in the average time
of labour (5.1 compared to 8.5 h), and the incidence of
complications (11.3% compared to 40%) in the intervention
group, it is not possible to draw definitive conclusions due to
the small sample size. The second study, conducted in Ger-
many, investigated the use of homeopathic caulophyllum for
induction of labour.36 The participants (n = 40) had prema-
ture rupture of membranes with a gestational age of 38—42
weeks and were randomised to either the intervention group
(n = 20) or the control group (n = 20). Caulophyllum was
administered hourly for a period of 7 h. The primary outcome
Complementary and alternative medicine for induction of labour
of the study was to evaluate the time taken to the onset of
regular uterine contractions. Although there was a slight
difference time for onset of labour (13 h in the treatment
group compared to 13.4 h in the control group), once again
the sample size was small and the differences between the
groups are not statistically significant. It is note worthy that
the Cochrane reviewer35 points out that the method used in
the trials may not reflect routine homeopathy practice which
is usually highly individualised. The review concludes that,
due to insufficient detail in the study papers and inadequate
sample sizes, there is currently insufficient evidence to
recommend the use of homeopathy as a method of labour
induction.35
Breast stimulation and sexual intercourse for IOL
Although there is some debate as to whether breast stimula-
tion and sexual intercourse should be classified as CAM38
these activities are commonly recommended to induce
labour39 and have therefore been included in this review.
Stimulation of the breast, and in particular the nipple, is
thought to cause the release of endogenous oxytocin from the
posterior pituitary gland and has been used historically to
augment and induce labour.39,40 Stimulation can be achieved
in a variety of ways including breast massage, rolling the
nipples and utilising a breast pump.21 Although concerns have
been raised regarding possible effects on placental perfu-
sion, the incidence of abnormal foetal heart rate tracings are
similar to those found with oxytocin challenge tests.21 There
is some evidence to suggest breast stimulation is useful for
augmentation although its role in initiation is less clear.40
Kavanagh, Kelly and Thomas39 undertook a review of the
clinical trials comparing breast stimulation with placebo/no
treatment or other methods. In total six trials, with a total of
719 women, were considered. The evidence revealed sig-
nificantly more women were in labour after 72 h in the breast
stimulation group. Furthermore there was a reduction in
postpartum haemorrhage rates and no instances of uterine
hyper-stimulation. The authors conclude that the use of
breast stimulation to initiate labour may be beneficial in a
low risk population.39 They do however caution that until
additional research has been undertaken, it should not be
considered for use in a high-risk population.
Sexual intercourse is also commonly recommended by
midwives and lay persons for stimulating labour.21,41 Its
possible effects may be related to the release of oxytocin
associated with nipple stimulation and orgasm, and possibly
the direct action of prostaglandins in the semen upon the
cervix.21,40 A Cochrane systematic review42 reported on one
observational study which investigated the effect of sexual
intercourse on cervical ripening and induction of labour in 28
women at term.43 The ‘coitus group’ were asked to have
sexual intercourse for three consecutive nights with vaginal
semen deposit while the control group were asked to abstain
for the same period. Importantly, both groups were asked to
avoid nipple stimulation. A baseline Bishops score was taken
and repeated after three days. The Bishops score did not
differ between the two groups, and there was no difference
in the number of women who gave birth within three days of
the intervention. The reviewers concluded that although
sexual intercourse may stimulate the onset of labour, there
145
is insufficient data at present to make any conclusions
regarding the efficacy. In the absence of placenta previa,
rupture of membranes or active genital infection, sexual
intercourse is generally considered safe21 however, it may
not be an acceptable option for some women late in preg-
nancy.40
Other CAM therapies for IOL
There is also preliminary research to suggest a number of
other CAM modalities may also be helpful for induction of
labour including relaxation techniques such as hypnosis,44,45
shiatsu46 and reflexology.47 More studies are needed to estab-
lish the potential benefits and risks o these therapies.
Discussion
If IOL is deemed necessary, some women are likely to wel-
come suggestions regarding these alternative methods.34,40
Many CAM therapies are recommended on the basis of tradi-
tional knowledge and empirical wisdom and do not have
evidence from clinical trials to support their use. Although
the randomised clinical trial has been elevated to the gold
standard in research, evidence based practice is broader than
this; it encourages the use of the best available evidence, the
woman’s preference and the clinician’s expertise.48 While
the concerns regarding inadequate research evidence of CAM
need to be addressed, Dooley reminds us to keep an open
mind and that ‘‘. . . the baby need not be thrown out with the
bath water’’.49 If a particular therapy has a long history of use
with no reported adverse effects it would be arrogant to
dismiss simply because it has not undergone sufficient clinical
trials. Lack of scientific verification does not equate to lack of
benefit, it simply means more research is needed before
specific conclusions regarding clinical recommendations
can be made.
Although there are few clinical trials investigating the
effectiveness of herbal medicines for IOL, they have a long
history of traditional use and some women are likely to self
medicate regardless of the lack of research.50 Raspberry leaf
is consumed by thousands of expectant women every year to
prepare the uterus for birth and no adverse outcomes have
been reported.10 The available evidence indicates that it is
safe during pregnancy and may decrease post term births.11
However, there is some evidence that blue cohosh may be
harmful in pregnancy and therefore it should not be con-
sumed until further studies are undertaken. The evidence for
other herbs commonly used to prepare for labour is scarce
and they should be treated with caution.
When used appropriately castor oil is generally considered
safe however caution should be exercised.10 Its ingestion for
induction of labour is associated with an increased incidence
in meconium stained liquor and side effects such as nausea,
vomiting, intestinal colic and diarrhoea are common.8,10,20
Further studies are underway including a randomised clinical
trial being conducted in Israel which is investigating its
effects in post-date pregnancies.51 Evening primrose oil is
also recommended to assist with the onset of labour. At
present there is a lack of evidence from clinical research
to establish the safety or efficacy.
146
The research investigating the use of acupuncture for
initiation of labour is mixed. While some studies have
demonstrated acupuncture may benefit women requiring
induction of labour52,53 others do not.30—33 It should be
noted that the use of sham acupuncture is common in many
of the trials. This involves needles being inserted into
areas that are not a classical acupuncture points.31 How-
ever, there is some evidence that sham acupuncture may
also have an effect and this would have considerable
implications when interpreting results of clinical trials
which use it as a control.54 Although there is a trend
towards a favourable response in some studies, further
research is required. When delivered by a suitably qualified
practitioner acupuncture is generally considered safe and
may be beneficial.
While anecdotal accounts suggest that the homeopathic
medicines such as Caulophyllum may be effective at inducing
labour with few side effects, these assertions are not sup-
ported by the current research. The fact there is little
scientific evidence to support the use of homeopathy is
not unexpected. Homeopaths generally treat in a very indi-
vidualised and holistic manner, yet clinical trials operate
from biomedical assumptions where the participants are
treated with the same therapeutic regime (or pla-
cebo).48,55,56 Although homeopathic remedies are generally
considered safe, the appropriateness of using these remedies
has been challenged. Some claim that the remedies are no
more effective than placebo57 and the potential of this in an
emergency situation, such as postpartum haemorrhage,
could be tragic.58 However, a qualitative study found women
and their partners believed self administering remedies from
a standard homeopathic birthing kit assisted them to become
aware of their needs (both physically and emotionally) and
had an empowering effect on the couple.59 Furthermore,
most women and midwives use CAM as an adjunct, not a
replacement, for conventional therapies.38,50 Although there
is lack of evidence of physiological action, the potential role
of homeopathy in pregnancy and labour is yet to be fully
explored.
There is some evidence that breast stimulation may be
useful for IOL and reduce the incidence of postpartum hae-
morrhage. The results for the use of sexual intercourse are
inconclusive. A great advantage of these approaches is that
they are readily available, cost free and afford women greater
control. Breast stimulation may be particularly relevant in
developing nations when expeditious birth is not neces-
sary.21,39 However, while they may provide a practical option
for some, midwives should reflect on the women’s preferences
and personal situation when considering these options.
It should be noted that, although anecdotal evidence
indicates most CAM therapies that are commonly used to
induce labour are unlikely to be harmful, they are not as
fast as conventional medical methods and this can be a
significant disadvantage in some situations.21 Never the
less, with the limited healthcare resources, it is important
to carefully consider the evidence for safety and efficacy
for methods that may be both cost-effective and accep-
table to women.3,21,49 As the popularity of CAM becomes
more common, health professionals should become
familiar with the potential benefits and risks of these
strategies and engage in more research to advance our
understanding.21
H.G. Hall et al.
Conclusion
Women facing a decision about induction of labour should
have the best available evidence to help them make an
informed choice. Currently there is very limited clinical
research to support the use of CAM for IOL. However mod-
alities with a long history of benefit, and no reports of harm,
may be valid options for women who wish to avoid medical
intervention. Midwives should aim to develop a good under-
standing of these therapies, including both the benefits and
risks, so they can discuss the various options and assist
women to make appropriate decisions. Midwives need to
ensure they have the relevant knowledge, practice within
their professional boundaries and refer women to suitably
qualified practitioners when necessary.
Acknowledgment
No financial or technical assistance was received for this
paper.
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