IJG-08769; No of Pages 7

International Journal of Gynecology and Obstetrics xxx (2016) xxx–xxx

Contents lists available at ScienceDirect

International Journal of Gynecology and Obstetrics

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

1 REVIEW ARTICLE

2Q1 Meta-analysis of the effect of acupressure on duration of

3 labor and mode of delivery

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4Q2 Somayeh Makvandi a, Khadigeh Mirzaiinajmabadi a,⁎, Ramin Sadeghi b, Mitra Mahdavian a, Leila Karimi a

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5 a
Department of Midwifery, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
6 b
Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
7

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8 a r t i c l e i n f o a b s t r a c t

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9 Article history: Background: Acupressure is increasing in popularity as an alternative treatment in obstetrics and gynecology. 18
10 Received 25 December 2015 Objectives: To summarize and assess evidence regarding the effects of acupressure on duration of labor and 19
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Received in revised form 17 April 2016 mode of delivery. Search strategy: Four major databases and Google Scholar were searched using terms related 20
12 Accepted 20 July 2016 to labor and acupressure, without language restrictions, up to November 2015. Selection criteria: Randomized 21
13 controlled trials were included if they examined the effect of acupressure at any acupoint during childbirth on 22
33 Keywords:
duration of labor and/or mode of delivery. Data collection and analysis: Two reviewers independently extracted 23
34
35
Acupressure
Cesarean delivery
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data. The outcome measures were duration of labor and mode of delivery. Random-effects models were used 24
36 Childbirth to pool results. Main results: Thirteen studies were included in meta-analyses. Acupressure increased the chance 25
37 of vaginal delivery when compared with placebo/no intervention (odds ratio [OR] 2.329, 95% confidence interval 26
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First stage of labor
38 Labor duration [CI] 1.348–4.024, P=0.002; risk difference [RD] 8.9%, 95% CI 2.7%–15.0%, P=0.005). Acupressure decreased the 27
39 Second stage of labor duration of the active phase by 1.310 hours (95% CI –1.738 to –0.882; Pb 0.001) and the second stage of labor 28
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by 5.808 minutes (95% CI –1.615 to –0.807; Pb0.001). Conclusions: Acupressure could have a role in reducing 29
the rate of cesarean delivery and decreasing the duration of labor in parturient women. However, there is a 30
need for more reliable randomized controlled trials. 31
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© 2016 Published by Elsevier Ireland Ltd on behalf of International Federation of Gynecology and Obstetrics. 32
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44 1. Introduction providers. Slow progress of labor is a common clinical situation in 61

obstetric practice [8]. A longer duration of labor is associated with a 62
45 Acupressure, a complementary medicine technique, depends on the reduced chance of spontaneous vaginal delivery and an increased risk 63
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46 idea of life energy (qi) that moves through energy pathways (merid- of serious maternal or perinatal complications [9]. The rate of cesarean 64
47 ians) in the body. In treatment, physical pressure is applied to acupoints delivery remains very high in many parts of the world, including in 65
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48 with the purposes of clearing energy blockages in these channels and Iran [10]. The risk of maternal death is five times higher after a cesarean 66
49 regulating qi [1]. This technique has been used for the treatment of delivery than after a normal vaginal birth [11]. 67
50 various conditions in obstetrics and gynecology such as anxiety in The present systematic review and meta-analysis was conducted 68
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51 perimenopausal and postmenopausal women [2], menstrual distress to summarize and critically discuss the evidence from randomized 69
52 [3], and nausea and vomiting after gynecologic surgery [4]. It is also controlled trials (RCTs) regarding the effects of acupressure on the 70
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53 rapidly increasing in popularity as an alternative treatment during the duration of labor and the mode of delivery. The results of the 71
54 pregnancy and postpartum period [5–7]. The applications of acupres- meta-analysis might be useful for health providers who counsel patients 72
55 sure during this period include the relief of nausea and vomiting of on the conduct of labor. 73
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56 pregnancy [5], the treatment of insomnia in postpartum women [6],

57 and the reduction of labor pain and labor duration [7].
2. Materials and methods 74
58 Shortening the duration of labor is an essential aspect of obstetric
59 care and a highly desirable objective of intrapartum care, both from a
2.1. Data sources and search strategy 75
60 perspective of maternal and fetal well-being and for the birth service

The Cochrane library, Cochrane Central Register of Controlled Trials 76

(CENTRAL), MEDLINE/PubMed, Scopus, and Google Scholar were 77
⁎ Corresponding author at: Department of Midwifery, School of Nursing and Midwifery,
searched from their inception to November 30, 2015. Two investigators 78
Mashhad University of Medical Sciences, Daneshgah Street, Mashhad, 9137913199, Iran.
Tel.: +98 9123740580; fax: +98 5138597313. (S.M. and L.K.) conducted the searches independently using the 79
E-mail address: mirzaiikh@mums.ac.ir (K. Mirzaiinajmabadi). following search strategy: “(acupressure OR shiatsu OR shiatzu) AND 80

http://dx.doi.org/10.1016/j.ijgo.2016.04.017
0020-7292/© 2016 Published by Elsevier Ireland Ltd on behalf of International Federation of Gynecology and Obstetrics.

Please cite this article as: Makvandi S, et al, Meta-analysis of the effect of acupressure on duration of labor and mode of delivery, Int J Gynecol
Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.04.017
 2 S. Makvandi et al. / International Journal of Gynecology and Obstetrics xxx (2016) xxx–xxx

81 (labor OR labour OR birth).” No language restrictions were imposed. The P b0.05 was considered statistically significant. All analyses were 136
82 reference lists of articles were checked for further relevant publications. performed using Comprehensive Meta-Analysis version 2 (Biostat, 137
Englewood, NJ, USA). 138
83 2.2. Study selection
3. Results 139
84 RCTs that examined the effect of acupressure at any acupoint during
85 childbirth on labor duration and/or mode of delivery (vaginal or 3.1. Identified studies 140
86 cesarean) compared with placebo/no intervention were eligible for
87 inclusion. Eligible studies could include nulliparous or multiparous The electronic search identified 132 publications (Fig. 1). After the 141
88 women with healthy full-term pregnancies in the first stage of labor. exclusion of irrelevant records on the basis of a review of the title and 142
89 Studies with inadequate data for calculation of effect size were excluded abstract, the full text of 30 studies was reviewed. Fifteen met the 143
90 from meta-analyses. inclusion criteria. Two studies were excluded from the meta-analysis 144
91 Two investigators (S.M. and L.K.) independently screened the titles because of inadequate data for calculation of effect size; therefore, 145
92 and abstracts of articles found in the search and excluded studies that thirteen studies were included in the meta-analysis. Authors of two 146

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93 were clearly irrelevant. For seemingly relevant studies, they retrieved published studies [13,14] were approached by personal contact to 147
94 the full text and assessed whether the trials met the inclusion criteria. request additional data. 148

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95 Any discordance was resolved through discussion until a consensus
96 was reached.
3.2. Study characteristics 149

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97 2.3. Outcome measures
The number of participants in the included studies ranged from 60 150
[15] to 212 [16] (Supplementary Material S1). Six studies [7,14,17–20] 151

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98 The outcome measures were the mode of delivery and the duration
recruited both nulliparous and primiparous women, whereas nine 152
99 of labor. The duration of labor comprised the lengths of the active phase
studies [13,15,16,21–26] recruited nulliparous women only. Nine studies 153
100 and the second stage of labor. The beginning of the active phase of labor

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[7,13–15,17,22–25] were conducted in Iran; the remaining studies were 154
101 was defined as a cervical dilatation of 3–5 cm. The duration of the
conducted in Brazil [19], Egypt [21], India [16], Taiwan [18], Turkey [26], 155
102 second stage of labor was defined as the time from full dilatation of
and South Korea [20]. Acupressure was applied at the SP6 acupoint in 156
103 the cervix until complete delivery of the neonate. D
eight studies [13,14,16,19–21,26], and at LI4 in three studies [7,22,25], 157
at BL32 in one study [17], at GB21 in one study [23], at LI4 and BL67 in 158
104 2.4. Data extraction
one study [18], and at LI4 and SP6 in one study [24]. 159
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In 11 studies [7,13,14,16,17,19–23,25], the intervention was 160
105 Data extraction was performed by two independent reviewers (S.M.
performed during the active phase of labor. In two studies [15,24], acu- 161
106 and M.M.) using a form that had been specifically designed for this
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pressure was performed during the active phase and continued during 162
107 purpose. First author’s name, year of publication, country, participants,
the second stage of labor. In a study by Chung et al. [18], external fetal 163
108 type of intervention and comparison, and outcomes were extracted.
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monitoring was performed for 20 minutes once cervical dilatation had 164
109 Discrepancies were resolved by discussion and consensus. Personal
reached 2 cm and acupressure was then performed for 20 minutes. 165
110 contact was made with the authors of the published studies, if
After the procedure, external fetal monitoring was continued for 166
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111 necessary, to request additional data.

another 20 minutes. If the participants were in a manageable position, 167
acupressure was repeated every 60 minutes. In another study [26], the 168
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112 2.5. Risk of bias assessment intervention was performed 15 times at a cervical dilatation of 2–3 169
cm, and 10 times each at a cervical dilatation of 5–6 cm and 8–9 cm 170
113 Two authors (S.M. and L.K.) independently assessed the quality of (i.e. 35 times for each woman). 171
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114 each study using the risk-of-bias tool from the Cochrane Handbook for In 10 trials [7,13,14,16,19–23,25], the intervention was performed 172
115 Systematic Reviews of Interventions [12]. The following six domains once only for 20–30 minutes. In the second group of one of the studies 173
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116 were assessed for each included study: sequence generation and [23], the intervention was performed for a total duration of 40 minutes. 174
117 allocation concealment (selection bias), masking of participants and In two studies [15,24], acupressure was applied for 20 minutes at a 175
118 personnel (performance bias) and outcome assessors (detection bias), dilatation of 4 cm and this process was also performed at dilatations 176
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119 incomplete outcome data (attrition bias), selective outcome reporting of 6 cm, 8 cm, and 10 cm. In two studies [17,26], the total duration of 177
120 (reporting bias), and other sources of bias. the intervention was not described clearly. 178
121 The risk of bias in each domain was rated as low, unclear, or high. In five studies [14,17,18,20,23], the amount of pressure applied to
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179
122 Discordances were resolved by discussion, and further information the acupoints depended on the interventionist and was measured by 180
123 was sought from the primary authors if necessary. electronic scales. In two studies [16,25], the intensity of the pressure 181
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was adapted to reach each woman’s pain threshold. In one study [19], 182
124
Q3 2.6. Statistical analysis the participants in the acupressure group received a medium-intensity 183
pressure of approximately 5–15 kg. In two studies [7,26], the applied 184
125 Risk differences (RDs) and odds ratios (ORs) were calculated to pressure was approximately 3–5 kg; in one study [7], this amount was 185
126 estimate effect sizes for the mode of delivery. Mean differences were ascertained by a researcher who had been trained in an introductory 186
127 calculated to estimate effect sizes for the duration of labor. Random- course for acupressure, whereas the other study [26] did not provide 187
128 effects models were used to pool the results across studies. The results any information about how the amount of pressure was determined. 188
129 of the meta-analyses were presented in forest plots. In two studies [15,24], a person trained in acupressure performed the 189
130 Heterogeneity was evaluated by the Cochrane Q test and the I2 intervention but details were not described. Three studies [13,21,22] 190
131 index. Subgroup analyses were used to estimate effect sizes by type of did not explain how the amount of pressure was determined. 191
132 control group. With regard to the control group, five studies [17,18,21,24,26] 192
133 Publication bias was evaluated visually with funnel plots, and compared acupressure with standard care or no intervention, whereas 193
134 the Egger regression method was used to test the asymmetry of the six studies [7,13,15,20,22,23] compared acupressure with placebo. The 194
135 funnel plots. placebo comprised simple touch at the same acupoints or pressure 195

Please cite this article as: Makvandi S, et al, Meta-analysis of the effect of acupressure on duration of labor and mode of delivery, Int J Gynecol
Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.04.017
 S. Makvandi et al. / International Journal of Gynecology and Obstetrics xxx (2016) xxx–xxx 3

Records identified through

search (n=132)

Excluded on basis of
title/abstract review (n=102)

Full-text assessment (n=30)

Excluded (n=15)
- Duplicates (n=8)

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- Only abstract available (n=3)

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- Ineligible intervention (n=3)
- Ineligible placebo (n=1)

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Included in systematic

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review (n=15)

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Excluded from meta-analysis
because data inadequate for
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calculation of effect size (n=2)
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Included in meta-analysis
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(n=13)
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Fig. 1. Studies included in systematic review and meta-analysis.

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196 on ineffective areas. In four studies [14,16,19,25], acupressure was that acupressure increased the chance of vaginal delivery (OR 2.329, 220
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197 compared both with placebo and with no intervention. 95% confidence interval [CI] 1.348–4.024; P = 0.002) (Fig. 2). The Q 221
value was 22.81 (P = 0.029) and the I2 value was 47.395%. Subgroup 222
198 3.3. Risk of bias analyses by type of control group showed no significant difference in 223
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chance of vaginal delivery between acupressure and no intervention 224

199 None of the included trials had a low risk of bias in all domains (pooled OR 1.848, 95% CI 0.809–4.221; P=0.145), but a significant dif- 225
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200 (Supplementary Material S2). The method of sequence generation was ference between acupressure and placebo (pooled OR 2.790, 95% CI 226
201 not mentioned in six studies. In eight trials, the risk of bias from 1.345–5.786; P=0.006). 227
202 sequence generation was rated as low. The method used to conceal The Egger test indicated that there was no significant asymmetry in 228
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203 group allocation was also frequently not described in the trials. the funnel plot (Egger regression intercept –0.1195; P=0.9091). After 229
204 Only five studies reported adequate allocation concealment using the removal of studies with a high risk of attrition bias [14,19], meta- 230
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205 sequentially numbered envelopes [18] or numbered sealed opaque analysis indicated that acupressure still significantly increased the 231
206 envelopes [13,16,24,26]. chance of vaginal delivery (OR 2.983, 95% CI 1.370–4.494, P = 0.006; 232
207 In most trials, masking of the participants or their clinical carers to the Q=18.156, P=0.020; I2 =55.938%) (Supplementary Material S3). 233
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208 type of intervention was not possible. Therefore, most studies had a high The meta-analysis of RDs showed that acupressure increased the 234
209 or unclear risk of performance bias. Nine studies [13,17–19,21,22,24–26] chance of vaginal delivery (RD 8.9%, 95% CI 2.7%–15.0%; P = 0.005) 235
210 had an unclear risk of detection bias because masking of the outcomes (Fig. 3). The test for heterogeneity was statistically significant 236
211 assessors to the group allocation was not described. (Q = 43.883, P b0.001; I2 = 72.654%). Subgroup analyses by type 237
212 Four studies [14,18,19,26] had a high risk of attrition bias. For exam- of control group showed no significant difference in chance of 238
213 ple, one study [19] had incomplete data because all births by cesarean vaginal delivery between acupressure and no intervention (RD 239
214 delivery were excluded from the labor duration analysis, and the pro- 7.5%, 95% CI –2.7% to 17.6%; P = 0.148), but a significant difference 240
215 portion of missing data was unbalanced across the groups. The risk of between acupressure and placebo (RD 9.7%, 95% CI 2.0%–17.4%; 241
216 reporting bias was low in 10 trials [7,14,16,17,19,21–24]. P = 0.014). The funnel plot indicated the possibility of publication 242
bias with an Egger regression intercept of 4.5762 (P = 0.0366). 243
217 3.4. Effect of acupressure on mode of delivery After the removal of studies with a high risk of attrition bias [14,19], 244
acupressure increased the chance of vaginal delivery (RD 10.8%, 245
218 Nine studies [7,13,14,16,17,19,21–23] evaluated the effect of acu- 95% CI 2.9%–18.7%, P = 0.007; Q = 35.130, P b 0.001; I2 = 77.22%) 246
219 pressure on the mode of delivery. The meta-analysis of ORs showed (Supplementary Material S4). 247

Please cite this article as: Makvandi S, et al, Meta-analysis of the effect of acupressure on duration of labor and mode of delivery, Int J Gynecol
Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.04.017
 4 S. Makvandi et al. / International Journal of Gynecology and Obstetrics xxx (2016) xxx–xxx

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Fig. 2. Forest plot for the effect of acupressure on the mode of delivery on the basis of odds ratios. The blue diamonds represent the results of subgroup analyses. Abbreviation: CI,
confidence interval. D
248 3.5. Effect of acupressure on the duration of the active phase of labor The funnel plot showed no statistically significant asymmetry (Egger 259
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regression intercept –4.223; P =0.0598). After the removal of a study 260
249 Ten trials [7,13,15,17,18,20–24] provided data about the duration of with a high risk of attrition bias [18], meta-analysis indicated that 261
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250 the active phase or the first stage of labor. Compared with the control acupressure decreased the duration of the active phase of labor by 262
251 group overall, acupressure decreased the duration of the active phase 1.211 hours (95% CI –1.615 to –0.807; P b 0.001) (Supplementary 263
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252 of labor by 1.310 hours (95% CI –1.738 to –0.882; P b 0.001) (Fig. 4). Material S5). There was significant heterogeneity between studies 264
253 The subgroup analyses showed a pooled mean difference of –1.594 (Q=94.454, Pb 0.001; I2 =89.30%). 265
254 hours (95% CI –2.344 to –0.844; Pb 0.001) for the comparison with the
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255 no-intervention group, and a pooled mean difference of –1.173 hours 3.6. Effect of acupressure on the duration of the second stage of labor 266
256 (95% CI –1.694 to –0.652; Pb0.001) for the comparison with the placebo
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257 group. There was significant heterogeneity between the studies In eight studies [7,15,17,20–24], the duration of the second stage of 267
258 (Q=94.398, Pb0.001; I2 =89.407%). labor was reported. Overall, the second stage of labor was shorter in 268
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Fig. 3. Forest plot for the effect of acupressure on the mode of delivery on the basis of risk differences. The blue diamonds represent the results of subgroup analyses. Abbreviation: CI,
confidence interval.

Please cite this article as: Makvandi S, et al, Meta-analysis of the effect of acupressure on duration of labor and mode of delivery, Int J Gynecol
Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.04.017
 S. Makvandi et al. / International Journal of Gynecology and Obstetrics xxx (2016) xxx–xxx 5

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Fig. 4. Forest plot for the effect of acupressure on the duration of the active phase of labor in hours. The blue diamonds represent the results of subgroup analyses. Abbreviation: CI,
confidence interval.

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269 the acupressure group than in the control group, with a mean difference One of the major basic theories of traditional Chinese medicine is 283
270 of –5.808 minutes (95% CI –1.615 to –0.807; Pb 0.001) (Fig. 5). Subgroup meridian theory, which has guided acupuncture and acupressure for 284
analysis showed a mean difference of –6.207 minutes (95% CI –11.012
271
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thousands of years [27]. According to this theory, the body contains an 285
272 to –1.401; P = 0.0114) for the comparison with the no-intervention invisible circuitry of meridians (energy channels), and qi (energy) is 286
273 group and a mean difference of –5.539 minutes (95% CI –9.480 to one of the fundamental substances that circulate through this network. 287
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274 –1.599; P=0.0059) for the comparison with the placebo group. There If the flow of qi is too fast or too slow, or if it is turbulent or static, mental 288
275 was no significant heterogeneity between the studies (Q = 12.393, or physical health is disturbed: to maintain health, qi must remain 289
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276 P = 0.135; I2 = 35.448%). The funnel plot showed no significant balanced [28]. During labor, obstruction of the meridians and blockage 290
277 asymmetry (Egger regression intercept, 1.3345; P=0.4109). of qi are very common. It seems that acupressure—the application of 291
pressure with the fingers to certain acupuncture points—acts as a
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278 4. Discussion stimulus that helps to unblock the meridians, correct the flow of qi, 293
and restore equilibrium [29]. Furthermore, acupressure could increase 294
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279 The present meta-analysis showed that acupressure shortens both the secretion of oxytocin from the pituitary gland, which regulates 295
280 active labor and the second stage of labor, and reduces the rate of cesar- uterine contractions and improves the progress of labor [18]. 296
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281 ean delivery. The precise mechanisms by which acupressure reduces the The decrease in the duration of labor that occurs with acupressure 297
282 duration of labor are unclear, but there are some potential explanations. might also be attributed to a decrease in labor pain. Chaillet et al. [30] 298
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Fig. 5. Forest plot for the effect of acupressure on the duration of the second stage of labor in minutes. The blue diamonds represent the results of subgroup analyses. Abbreviation: CI,
confidence interval.

Please cite this article as: Makvandi S, et al, Meta-analysis of the effect of acupressure on duration of labor and mode of delivery, Int J Gynecol
Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.04.017
 6 S. Makvandi et al. / International Journal of Gynecology and Obstetrics xxx (2016) xxx–xxx

299 reported that the application of acupressure or acupuncture is associ- Additionally, an adequate explanation of standard care or routine care 365
300 ated with a reduced need for epidural analgesia and a higher childbirth was missing in most studies. 366
301 satisfaction. A potential explanation for this observation is based on On the basis of the quantitative findings of the present meta- 367
302 the gate control theory proposed by Melzack in 1965 [31]. As part analysis, we recommend the application of acupressure in parturient 368
303 of this theory, pain messages encounter “nerve gates” in the spinal women as a low-cost intervention to reduce the rate of cesarean 369
304 cord before they can reach the brain. These gates open or close de- delivery and to decrease the duration of labor. Given the significant 370
305 pending on various elements. When the gates are open, pain messages heterogeneity and the high risk of bias in some domains in the in- 371
306 are effectively transmitted and pain can be experienced. When the cluded trials, further well-conducted RCTs are needed to confirm the 372
307 gates close, pain messages are kept from reaching the brain [30]. benefits of acupressure and to support the creation of evidence-based 373
308 This theory predicts that non-painful massage shuts the pain gates in guidelines on the use of acupressure in parturient women attending 374
309 the spinal cord, which prevents the transmission of pain messages to maternity services. 375
310 the brain. On the basis of the gate control theory of pain, stimulation 376
311 of the thick nerve fibers causes neural inhibition at the spinal level Supplementary data to this article can be found online at http://dx. 377
312 that blocks the transmission of pain stimuli to the brain. Acupoints doi.org/10.1016/j.ijgo.2016.04.017. 378

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313 are the areas of sensory receptors with afferent fibers put in the mus-
314 cles. Acupressure activates the fibers and causes the pain gate in the
Conflict of interest 379

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315 spinal cord to be shut, which avoids pain transmission [30,31]. Another
316 potential explanation for acupressure-related pain relief is based on
The authors have no conflicts of interest. 380
317 the endorphin-release theory proposed by Pomeranz in 1976 [32].

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318 According to this line of thought, acupressure triggers the release of
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320 pain suppression [32].

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351 [37]. Moreover, in most of the included studies, masking of participants [16] Hjelmstedt A, Shenoy ST, Stener-Victorin E, Lekander M, Bhat M, Balakumaran L, 422
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354 A third potential limitation is the significant heterogeneity between of the effects of maternal supportive care and acupressure (BL32 acupoint) on 426
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Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.04.017
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Please cite this article as: Makvandi S, et al, Meta-analysis of the effect of acupressure on duration of labor and mode of delivery, Int J Gynecol
Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.04.017