American Journal of Obstetrics and Gynecology (2004) 191, 36e44

www.elsevier.com/locate/ajog

AJOG REVIEWS

Complementary and alternative medicine for labor pain:

A systematic review
Alyson L. Huntley, PhD,* Joanna Thompson Coon, PhD, Edzard Ernst, MD

Complementary Medicine, Peninsula Medical School, Universities of Exeter and Plymouth, Exeter, United Kingdom

Received for publication July 4, 2003; revised December 3, 2003; accepted December 9, 2003

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KEY WORDS Objectives: The purpose of this study was to systematically review the literature for, and critically
Labor pain appraise, randomized controlled trials of any type of complementary and alternative therapies for
Complementary and labor pain.
alternative medicine Study design: Six electronic databases were searched from their inception until July 2003. The in-
clusion criteria were that they were prospective, randomized controlled trials, involved healthy
pregnant women at term, and contained outcome measures of labor pain.
Results: Our search strategy found 18 trials. Six of these did not meet our inclusion criteria. The
remaining 12 trials involved acupuncture (2), biofeedback (1), hypnosis (2), intracutaneous sterile
water injections (4), massage (2), and respiratory autogenic training (1).
Conclusion: There is insufficient evidence for the efficacy of any of the complementary and alter-
native therapies for labor pain, with the exception of intracutaneous sterile water injections. For
all the other treatments described it is impossible to make any definitive conclusions regarding
effectiveness in labor pain control.
Ó 2004 Elsevier Inc. All rights reserved.
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The experience of pain during labor is a complex, in- lishment itself.1 In a US survey of women (n = 1583)
dividual, and multi-faceted response to sensory stimuli who had given birth to a single baby in the previous
generated during childbirth. Labor pain and methods 24 months, 63% had received epidural analgesia.2 This
to relieve it are a major concern for the mother and may be because of maternal attitudes before labor,
child, with considerable implications for intra- and post- and a personal preference to avoid the pain normally as-
partum care. The conventional medical approach to the sociated with labor.3 However, a third of women who
management of pain in labor and delivery has increas- responded to the survey either had a limited idea, or
ingly come to rely on the use of anesthetic and analgesic no idea, of her legal right to clear and full information
drugs, in spite of reservations within the medical estab- about offered procedures, tests, or drugs, and her right
to accept or refuse care. In a recent systematic review,
pain and pain relief appeared to have a rather small ef-
* Reprint requests: Alyson L. Huntley, PhD, Complementary
Medicine, Peninsula Medical School, Universities of Exeter and
fect on overall satisfaction with childbirth.4 It was con-
Plymouth, 25, Victoria Park Road, Exeter, EX2 4NT, UK. cluded that 4 factors were consistent in their association
E-mail: alyson.huntley@pms.ac.uk with childbirth satisfaction: amount of support received,

0002-9378/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.ajog.2003.12.008
Huntley, Coon, and Ernst
quality of relationship with caregiver, involvement in
decision-making, and personal expectations. Comple-
mentary and alternative medicine (CAM) is more likely
to be perceived by patients as consistent with these fac-
tors,5-7 and thus, may appeal to the laboring woman.
Indeed, there is evidence to suggest that women seek
advice and treatment from CAM providers for pain
relief during labor.8
This systematic review aims to critically appraise ran-
domized controlled trials (RCTs) of CAM therapies for
labor pain, and thus, contributes to an evidence base for
the efficacy of these treatments during labor.
Methods
The computerized literature searches were performed
with the following electronic databases: Medline (from
1953 to July 2003); Embase (from 1974 to July 2003);
Cinahl (from 1982 to July 2003); AMED (from 1985 to
July 2003); PsychInfo (from the 1800s to July 2003); and
The Cochrane Library (from 1996 to July 2003). The
search terms were labor, birth, parturi, contractions,
obstetric, pain, complementary medicine, alternative
medicine, aromatherapy, therapeutic touch, reflexology,
massage, spiritual healing, relaxation, meditation, yoga,
autogenic training, herbal medicine, traditional Chinese
medicine, medicinal plant, ayurvedic, acupuncture, acu-
pressure, chiropractic, osteopathy, homeopathy, flower
remedies, hypno, Feldenkrais, music therapy, rolfing,
shiatsu, randomized controlled trial.
The bibliography of papers found by the search and
relevant reviews were examined for references of further
trials. Colleagues both within Complementary Medicine
at the Peninsula Medical School, Exeter University, and
experts in the fields were consulted as to the existence of
any additional studies. There were no restrictions on the
language of publication.
The inclusion criteria for the studies were that they
involved healthy pregnant women at term. The type of
intervention could be any type of CAM for pain relief
during labor. This review excluded any studies of artifi-
cially induced labor pains or trials that had other obstet-
ric outcomes. The definition of CAM for this review is
defined as ‘‘those medical systems, professions, practi-
ces, interventions, modalities, therapies, applications,
theories, or claims that are currently not a part of the
dominant or conventional medical system.’’9 Thus, this
review excluded such treatments as hydrotherapy or
the use of transcutaneous electrical nerve stimulation
(TENS). The use of a doula during labor has been re-
viewed extensively recently, and thus, this supportive
therapy was not included.10
All interventions, or strategies including other thera-
pies, no treatment, or placebo, were considered as suit-
37
able control groups. Studies were included if they
contained outcome measures of pain, preferably by the
parturient, either by diary or by pain scales such as vi-
sual analog scales (VAS). Medication use was also dis-
cussed if this information was reported.
The papers were identified and screened by the first
author. Both the first and second author assessed the el-
igibility of the studies and extracted the data into tables
with predefined headings. All 3 authors discussed any
discrepancies. The quality of the included trials was as-
sessed with the Jadad Score.11 This scale measures the
likelihood of bias based on description of randomiza-
tion, blinding, and withdrawals on a scale of nought
(minimum) to 5 (maximum). Because of clinical and sta-
tistical heterogeneity of the data, statistical pooling of
the data was not possible.
Results
Our search strategy found 18 RCTs investigating CAM
therapies for labor. Six of these did not meet our inclu-
sion criteria because they either studied laboratory-
simulated labor pains or did not use specific pain
outcome measures.12-17 The remaining 12 trials involved
acupuncture (2), biofeedback (1), hypnosis (2), intra-
cutaneous sterile water injections (4), massage (2), and
respiratory autogenic training (1) The putative mode
of action of these therapies for labor pain is listed in
Table I, and these RCTs are summarized in Table II
and described in detail below.
Acupuncture
A study by Ramnero et al involved 90 parturients both
primiparous and multiparous.18 The women were ran-
domized either to receive acupuncture or no additional
treatment during labor. The acupuncture treatment was
individualized, whereby each midwife chose points suit-
able for the pain localization as labor progressed. As a
rule, relaxing points were combined with local and distant
analgesic points. Pain intensity was assessed hourly be-
fore any given analgesia and 15 minutes after by a pain
score (rated 0-10). Painless and well-relaxed were defined
as 0, worst pain imaginable, and very tensed were defined
as 10.
Assessments of pain intensity were equal between the
2 groups (mean difference ÿ0.29, (95% CI ÿ0.9 to 0.32).
However, the need for epidural analgesia was signifi-
cantly reduced in the acupuncture group compared with
the non-acupuncture group (12% vs 22%, relative risk
[RR] 0.52, 95% CI 0.3 to 0.92). Regarding other analge-
sic methods, no differences were seen except the use of
the non-pharmacologic methods (warm rice bag, bath,
38 Huntley, Coon, and Ernst

Table I Description of mode of action of therapies used for alleviation of labor pain
Therapy Mode of action
Acupuncture It has been suggested that acupuncture’s mechanism of pain relief is similar to that of transcutaneous electrical
nerve stimulation (TENS) units, in that stimulating large myelinated fibers blocks the smaller
fibers from transmitting painful stimuli. Other theories include altering the body’s levels of chemical
neurotransmitters and influencing the natural electrical or electromagnetic fields.
Biofeedback Biofeedback is a treatment that uses monitoring instruments to provide either visual or acoustic feedback to
patient’s physiologic information of which they are normally unaware. It puts the patients in control and
gives them a sense of self-reliance that is an important factor for the laboring woman.
Hypnosis Hypnosis is a state of attentive and focused concentration in which the patient can be relatively unaware, but not
completely blind to their surroundings. During this trance-like state, therapeutic suggestions may be given.
Hypnotic suggestions focus on diminishing the awareness of pain, as well as fear and anxiety. The treatment
for preparation for birth is based on the premise that if the patient is sufficiently educated and prepared
regarding the process, her anxiety is reduced, she would require less medication during and after the birth and
recovery, and healing would proceed at a faster pace with fewer complications.
Intracutaneous Counter irritation is the process by which localized pain felt in one part of the body may be relieved by irritating
injections the skin in same dermatomal distribution with either a hot, cold, scratchy, or electrical stimulus. The sterile
of sterile water water injections are thought to cause distension in the skin, which stimulates nociceptors and
mechanoreceptors. Two intracutaneous injections of 0.1 mL are made bilaterally, approximately 2 cm inferior
and 1 cm medial to the posterior superior iliac spines. The placement of these injections does not need to be
precise. Sterile water is thought to produce a better affect than isotonic saline.
Massage Massage during labor is most commonly used for its stress reduction and relaxation. Massaging muscles and other
tissues not only relaxes the muscles, it also alleviates pain. Massage can be analgesic through distraction,
although it is also thought to have a physiologic basis, blocking pain impulses by increasing A-fiber
transmission, or by stimulating the local release of endorphins.
Respiratory Respiratory autogenic training derives from the autogenous training based on progressive relaxation methods. It
autogenic comprises a series of exercises in which the woman learns to diminish her muscle tonus by deep relaxation
training and by concentrating on her body sensations. The autonomic effects of deep relaxation are diametrically
opposed to those characteristic of anxiety, and are related to feelings of calmness.

shower), which were significantly reduced in the acu- Biofeedback

puncture group.
In the trial by Skilnand et al, 210 healthy parturients
in spontaneous, active labor were randomly assigned to
receive either real acupuncture or false acupuncture.19
Real acupuncture consisted of a treatment protocol
from the Norwegian School of Acupuncture. The num-
ber of needles used varied from 2 to 12, with 7 as an av-
erage. The same type and number of needles were used
for the control group (false acupuncture), inserting them
at points that were not on the classic meridians, and
mainly in areas used for vaccination and other injec-
tions. The method is defined as ‘‘minimal acupuncture.’’
Pain was assessed using a linear 10-cm VAS (0 = no
pain, 10 = worst possible pain) recorded at 30, 60, and
120 minutes after treatment. The needles were removed
and evaluation of pain with VAS was stopped if the
woman converted to epidural analgesia, intramuscular
pethidine, or nitrous oxide inhalation. There were signif-
icantly lower pain scores at 30, 60, 120 minutes after
treatment and 2 hours after birth (P!.00), and signifi-
cantly less need for epidural analgesia and intramuscular
pethidine (P = .01, P!.001, respectively) in the real
compared with the false acupuncture group.
In a study by Duchene, 55 primigravidas were randomly
assigned to either childbirth classes or childbirth classes
plus training sessions in biofeedback, which was then
used during labor.20 Pain was monitored during labor
with a VAS and a verbal descriptor scale (VDS). Forty
women completed the study (93% white, 7% black); at-
trition occurred because of the need for cesarean section.
Results showed that women using biofeedback during
childbirth reported significantly lower pain than control
women at admission (VAS P!.05, VDS P!.01), at de-
livery (VDS P!.005) and 24 hours’ postpartum (VDS
P!.01). Seventy percent of the women in the control
group requested and used epidural anesthesia compared
with 40% of the women of the biofeedback group
(P!.05).
Hypnosis
In the study by Freeman et al, 82 primigravidas were as-
sessed for hypnotic susceptibility and randomized to re-
ceive weekly, individual hypnosis sessions for relaxation
Huntley, Coon, and Ernst 39

Table II Randomized controlled trials of acupuncture, biofeedback, hypnosis, ISW injections, and massage for labor pain
Jadad Control Pain outcome
Citation Score Participants Treatment treatment measures Main results
Acupuncture
Ramnero, 3 90 women (n = 42 Individualized No Pain score No significant
2002 primiparas and acupuncture acupuncture (0-10) hourly difference between
n = 48 and 15 groups
multiparas) minutes after
analgesia
Skilnand, 3 210 women Real acupuncture False VAS score Significant
2002 (n = 101 acupuncture before improvement in real
primiparas treatment, acupuncture group
and n = 107 30, 60, 120 compared with
multiparas) minutes and control at 30, 60,
in spontaneous, hours after 120 minutes and 2
active labor delivery hours after birth
(P!.00)
Biofeedback
Duchene, 2 40 women Series of training Childbirth Reports of Biofeedback group
1989 (primpars) sessions in classes pain by VAS reported less pain
biofeedback and VDS at at admission (VAS
as an adjunct admission, P!.01, VDS P!.05)
to childbirth delivery, and At delivery (VDS
classes postpartum P!.01)
24 hours postpartum
(VDS P!.01)
Hypnosis
Freeman, 2 82 women Routine weekly Routine Linear analog No significant difference
1986 (primiparas) antenatal classes weekly scale for pain between the groups
expecting plus weekly antenatal relief,
a ‘‘normal’’ individual classes retrospectively
pregnancy hypnosis
sessions for
relaxation and
pain relief
Harmon, 3 60 women Hypnotic induction Relaxation and McGill Pain All 5 subscales of the MPQ
1990 (primiparas) as an adjunct to breathing Questionnaire were improved with
screened for childbirth class exercises (MPQ) within hypnosis compared with
hypnotic typically 24 hours of control group (P!.01)
susceptibility used in delivery
childbirth
classes
ISW injections
Ader, 1990 4 45 women (n = 30 ISW injections Subcutaneous VAS score Mean VAS score was
primiparas and injections at 10, 45, and reduced in serum group
n = 15 of isotonic 90 minutes compared with placebo
multiparas) saline after group 10 minutes:
treatment P!.00 45 minutes:
P!.02 90 minutes:
P!.05
Trolle, 1991 3 272 women in ISW injections Treatment with VAS score 89.4% of sterile water
labor complaining saline solution before group noted an
of severe lower injections treatment analgesic effect
back pain (both and 1 and 2 compared with 45% in
primiparas and hours after saline group (P!.0005)
multiparas-no treatment
further details
provided)
40 Huntley, Coon, and Ernst

Table II continued
Jadad Control Pain outcome
Citation Score Participants Treatment treatment measures Main results
ISW injections
Martensson, 4 99 women at 37 to Four injections of Placebo VAS score Both treatment groups
1999 42 weeks’ 0.1 mL sterile treatment at 10 and 45 had reduced pain
gestation (n = 40 water minutes after compared with placebo
primiparas and intracutaneously treatment at 10 and 45 minutes
n = 59 multiparas), or subcutaneously (P = .002, P = .006)
requiring pain
relief for severe
lower back pain
Labrecque, 3 34 women (n = 22 ISW injections Standard care VAS scales for Reduction of intensity
1999 primiparas and including intensity and and unpleasantness of
n = 12 multiparas), back massage, affective pain in ISW group
considered low risk whirlpool, dimensions of compared with control
and suffering from liberal pain at 15, 60, and TENS (P = .011,
lower back pain mobilization 90, 120, and P = .03)
during labor or TENS 180 minutes
after initial
intervention
Massage
Field, 1997 2 28 middle Massage (taught Coaching in Mothers self-rating Pain was reduced from
socioeconomic after the breathing their labor pains 5.0 to 3.5 in the
status women (no admissions alone on the 5-point massage group
further details interview) in Likert Scale before Pain increased from
provided) addition to and after massage 4.3 to 5.0 in the
coaching in and control control group
breathing from sessions Statistical analysis
their partner was unclear
during labor
Chang, 3 60 women 30 minute massage Standard nursing The nurse-rated Lower PBI scores in
2002 (primiparas) during uterine care and 30 PBI scale the massage group
expected to contractions, first minutes of compared with the
have a normal by researcher, the researchers’ control group during
childbirth and then by the attendance and all 3 phases of labor
partner in each casual (P%.002)
phase of labor conversion
(1-3) during each
phase
Respiratory autogenic training
Zimmerman- 3 53 women Nine weekly Nine weekly Pain thermometer RAT participants
Tansella, (primiparas) in sessions sessions of 0 (no pain at all) reported less pain than
1979 the seventh RAT for childbirth traditional to 100 (pain PTT participants
month of preparation (PTT) for unbearable) during (P!.02) No difference
pregnancy childbirth labor and pain in retrospective
preparation assessment, pain assessment
retrospectively
ISW, Intracutaneous sterile water; TENS, transcutaneous electrical nerve stimulation; RAT, respiratory autogenic training; PBI, present behavioral
intensity; PTT, psychoprophylactic training; VAS, visual analog scale; VDS, visual descriptor scale.

and pain relief, in addition to the routine weekly antena-
tal classes or the antenatal classes alone (control
group).21 Pain relief was recorded with a VAS and no
significant differences were seen between the 2 groups.
In addition, there was no significant difference in the
use of Entotox, pethidine, or epidural analgesia between
the groups.
Harmon et al studied the benefits of hypnotic anal-
gesia as an adjunct to childbirth education in 60 primip-
arous, white women.22 Subjects were assessed for
hypnotic susceptibility, and then randomized to receive
either hypnotic induction classes or relaxation and
breathing exercises during 6 childbirth classes. They mea-
sured thresholds for ischemic pain before labor, and then
Huntley, Coon, and Ernst
rated pain during labor with the McGill Pain Question-
naire (MPQ).23 The MPQ was scored on the following
scales: present pain intensity; sensory distress; affective
distress; evaluative distress; and miscellaneous, and were
significantly improved with hypnosis compared with the
control group (P!.001, P!.01, P!.01, P!.05, P!.05,
respectively). In addition, fewer hypnotically trained
women received medication in terms of tranquilizers
(P!.001) and narcotics (P!.001) compared with the
women in the control group.
Intracutaneous injections of sterile water
(ISW)
In the double-blind study by Ader et al, 45 pregnant
women in the first stage of labor presenting with lower
back pain were randomized to receive either ISW in
the lumbosacral region or subcutaneous injections of
isotonic saline in the same region (control group).24
VAS scores were recorded at 10, 45, and 90 minutes af-
ter treatment. In the group that received ISW the mean
VAS score was significantly more reduced compared
with the control group at 10, 45, and 90 minutes
(P!.001, P!.02, P!.05, respectively). The midwives’
blind estimation of the effectiveness of treatment was
consistent with the VAS assessment. However, the re-
quirement for pethidine was similar in both groups.
Trolle et al evaluated the analgesic effect of intrader-
mal sterile water blocks in 272 women in labor com-
plaining of severe lower back pain.25 The women were
randomly assigned to either sterile water or saline solu-
tion blocks. Pain intensity was monitored with a VAS
before treatment, plus 1 and 2 hours after treatment.
In the sterile water group, 126 (89.4%) of the women
noted an analgesic effect of the blocks, compared with
59 (45%) in the saline solution group (P!.0005). No
adverse events were noted, and patient acceptability
was high. When asked after the birth, a significantly
greater proportion of the women in the sterile water
group (68%) compared with the saline solution group
(50%) said they would request the same type of analge-
sia if they underwent delivery again. The frequencies of
other medication use did not differ significantly between
the groups.
In a study by Martensson et al, 99 pregnant women
requiring pain relief for severe lower back pain during
the first stage of labor were randomized to receive either
4 injections of 0.1 mL sterile water intracutaneously, or
4 injections of 0.5 mL sterile water subcutaneously, or 4
injections of 0.1 mL isotonic saline subcutaneously (pla-
cebo).26 Labor pain was measured with a VAS. The me-
dian VAS pain score was significantly lower in both
treatments group compared with placebo at 10 and 45
minutes post treatment (P = .002, P = .006, respec-
41
tively). There were no significant differences between
the 2 treatments at any time. There were no details of
any additional analgesia during labor. The pain experi-
enced during the injections was less intense in the pla-
cebo group than in either of the 2 active groups
(P!.001). However, the women in the study groups
were significantly more enthusiastic about their treat-
ment than those in the placebo group (P!.001), if in
need of treatment in the future.
In a 3-arm RCT conducted by Labrecque et al, 34
women suffering from lower back pain during labor were
randomized to receive ISW, TENS, or standard care,
which included back massage, whirlpool bath, and liberal
mobilization.27 Women self-evaluated both the intensity
and affective dimensions of pain with use of a VAS at
15, 60, 90, 120, and 180 minutes after the initial interven-
tion. Women in the ISW group rated the intensity and
unpleasantness of pain during the experimental period
significantly lower than women in the TENS (P = .003)
or the standard care group (P = .001). Similar results
were observed for intensity (P = .01) and unpleasantness
(P = .03) of pain assessed just before delivery or request
for an epidural. Mean pain intensity at 15 and 60 minutes
was significantly reduced in the ISW group compared
with the other 2 groups. However, there were no signifi-
cant differences between the 3 groups regarding the pro-
portion of women requesting and receiving epidural
analgesia, and fewer women in the ISW group indicated
that they would like to receive the same treatment for
back pain during another delivery.
Massage
A study by Field et al involved 28 middle socioeconomic
status women (34% white, 9% black, and 57% His-
panic) who were randomized to receive massage (head,
shoulder/back, hand, and foot) in addition to coaching
in breathing, or to receive coaching in breathing alone
(control).28 The mothers self-rated their labor pains on
the 5-point Likert scale before and after massage or con-
trol procedure. There was a reduction in pain from 5.0
to 3.5 in the massage group, and an increase in pain
from 4.3 to 5.0 in the control group. Statistical reporting
was difficult to interpret as significant differences were
pre- and post- within groups or between groups. No in-
formation was reported of other analgesic support, con-
ventional or otherwise.
In the study by Chang et al, 60 primiparous women
expected to have a normal childbirth were randomly as-
signed to either receive massage intervention comprising
abdominal effleurage, sacral pressure, and shoulder/
back kneading during their labor, or attention control.29
In the massage group, the woman received a 30-minute
massage during uterine contractions first by the re-
searcher and then by the partner during each of the
42
3 phases of labor. The standard care group received the
researcher’s attendance and causal conversation for the
same time periods. The nurse-rated present behavorial
intensity (PBI) was used as a measure of labor pain, with
use of the self-reported present pain intensity (PPI) scale
to validate. Significantly lower PBI scores were recorded
in the massage group compared with the control group
during all 3 phases of labor (P = .00, P = .002, P =
.000, respectively), and these data were validated by
the PPI scales. No information was reported of other
analgesic support, conventional or otherwise.
Respiratory autogenic training (RAT)
In a controlled trial by Zimmermann-Tansella et al,
53 women in the seventh month of pregnancy were
randomly assigned to either 9 weekly sessions of RAT
(n = 23) or a traditional psychoprophylactic course
(TPP) (n = 30) for childbirth preparation under partial
double-blind conditions.30 Pain was assessed every hour
during labor on a pain thermometer which ranged from
0 (no pain at all) to 100 (pain unbearable). In addition,
the women retrospectively evaluated the pain experience
during labor on a scale of 5 discrete categories (uncom-
fortable; mildly painful; painful; very painful; unbear-
able). Ten women (4 RAT) delivered elsewhere, 6
women (5 RAT) had a cesarean delivery, and for 3
women (all TPP) no data were collected during labor;
thus, 34 women completed the study (14 RAT; 20
TTP). The RAT participants tended to report less pain
during labor than the TPP women (P!.02), but the dif-
ference was only statistically significant after removing
the influence of the unbalanced initial anxiety level in
the 2 groups. No difference emerged in the judgement
of pain experience made by the women some days after
delivery (most of them choosing the categories painful
or very painful). The women’s evaluation of their delivery
experience did not differ for the 2 groups. No information
was reported of other analgesic support, conventional or
otherwise.
Comment
In total we identified 12 RCTs that met our inclusion
criteria. They were all published during the last 2 de-
cades, mostly by US authors, and frequently in conven-
tional medicine journals. Their methodologic quality is
variable and often low. Their sample size is generally
small.
There is insufficient evidence for the efficacy of any of
the CAM therapies described for labor pain, with the ex-
ception of ISW treatments. There is some evidence for
the benefit of massage therapy during labor. For all
Huntley, Coon, and Ernst
the other treatments described, the lack of studies mean
it is impossible to make any definitive statements.
There were 2 RCTs in the literature that investigated
the efficacy of acupuncture for labor pain. Both of these
studies scored 3 out of a possible 5 on the Jadad Scale
because of lack of double blinding, although in the
Skilnand study, the participants were blinded to their
acupuncture treatment.19 The smaller Ramnero study
utilized acupuncture as an adjunct or complementary
therapy to conventional pain relief, while the larger Skil-
nand trial studied acupuncture treatment alone.18
It is interesting to note that in the otherwise negative
acupuncture trial by Ramnero et al, there was a statisti-
cally significant reduction in epidural use and additional
non-pharmacologic methods between the acupuncture
and non-acupuncture group. In the positive Skilnand
study, pain measures were reduced, as well as fewer
women opting for conventional analgesia in the real
acupuncture group compared with the false acupuncture
group. This suggests that receiving a physical interven-
tion like acupuncture has an influence on a woman’s
pain management during labor, even if it does not im-
prove her pain ratings. More research into the benefit
of acupuncture for labor pains is warranted.
There was only 1 poor-quality RCT concerning the
use of biofeedback for pain control in labor.20 There
was no blinding in the study, and the authors fail to de-
scribe the method of randomization. The trial had a pos-
itive outcome for the use of biofeedback for labor pains,
although with only 1 trial it is difficult to extrapolate
these results. St James-Roberts et al conducted a com-
parative RCT of 2 methods of relaxation training based
on biofeedback techniques (electromyographic or skin
conductance methods) plus a control group.13 However,
there were no specific pain outcome measures and all the
women in both groups went on to receive epidural anal-
gesia. Overall, better quality research is required to in-
vestigate the use of biofeedback during labor.
The reporting of the hypnosis trial by Freeman et al is
brief, and possibly as a result, the Jadad Score is low be-
cause of lack of information.21 This trial found no sig-
nificant difference in pain measures or epidural use
between the hypnosis and control subjects. It did report
that good and moderate hypnotic subjects used signifi-
cantly less epidural analgesia than poor subjects
(P!.01), and that all the good/moderate subjects re-
ported that hypnosis had been instrumental in reducing
anxiety and helping them cope with labor. The more re-
cent hypnosis trial by Harmon et al has a higher Jadad
Score, with description of blinding and dropouts.22 This
trial showed significant improvement in all subscales of
the MPQ and reduced conventional analgesic use in the
hypnotic group compared with the control group.
Highly susceptible women also reported less pain than
low susceptibility women on 3 of the 5 subscales. These
data from both trials suggest that hypnotic techniques
Huntley, Coon, and Ernst
may be of use to women during labor who are good
hypnotic subjects and thus warrants further investiga-
tion.
ISW treatments do seem to be of benefit as an anal-
gesic to the laboring women with 4 RCTs (all scoring
3 or more on the Jadad scale), showing significantly re-
duced pain measures compared with control treat-
ments.24-27 Overall, this treatment seemed to be well
tolerated with few adverse effects, excluding a stinging
sensation during application. It is possible that this
treatment could be useful in reducing the use of conven-
tional analgesic medication that may have potentially
detrimental effects on mother and child. More research
will be needed if this procedure is to be incorporated
into conventional practice. In particular, its effectiveness
relative to accepted therapies for pain control during la-
bor needs defining.
Both of the massage trials showed positive effects for
the relief of pain during labor.28,29 These trials did not
rate highly on the Jadad scale because of lack of blind-
ing, which can be problematic in massage trials. Massage
is a popular intervention for pregnant and laboring
women and is probably practiced frequently during la-
bor, albeit in a less formal way than in these trials.
The one, small trial on RAT is insufficient to provide
any significant evidence for the benefit for labor pain, es-
pecially regarding the notable loss of participants during
the study.30 It is important to note that participants did
not favor the RAT over the conventional PPT prepara-
tion for labor.
Our review has several limitations, namely the pau-
city of data, the possibilities of publication bias, the fact
that we did not locate all the relevant trials, and the
poor methodologic quality of many of the trials. All
the trials were conducted in healthy women, at term,
who were considered a low obstetric risk. The results
are therefore not applicable to women in higher risk
populations.
Clearly, further good quality, randomized clinical tri-
als are needed to assess the potential role of CAM in the
relief of labor pain. A greater understanding of the role
of these therapies will enable women to be better in-
formed of the choices available to them. However, it is
important to note that while further safety evaluation
would be useful, there are no serious safety concerns
with any of these therapies specific to their use durng la-
bor. Pending the results of further investigations it is im-
portant that women are given the maximum amount of
choice for pain relief during labor.
In conclusion, the data suggest that ISW treatments
may provide relief for labor pain. There is some evidence
for the benefit of massage therapy, but for all the other
therapies described there is insufficient evidence at
present.
Alyson Huntley is supported by a research fellowship
provided by The Boots Company.
43
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