Summary of Systematic Reviews:
In the last 10 years, two major Systematic Reviews have been conducted in order to pool the results of studies that looked at similar treatments.
A 2012 Cochrane Systematic Review by Coyle et al. (7) looked at 8 trials (1346 participants) that assessed the use of moxibustion, acupuncture, postural techniques and usual care for breech presentation. Of those 8 trials, 3 studies (594 participants) compared moxibustion treatment alone to usual care and found no significant difference in the rate of cephalic babies at birth. However, a more recent 2021 Systematic Review by Liao et al. (8) looked at the same 3 studies plus an additional 10 trials (2063 participants) and found that those using moxibustion at UB 67 versus those receiving usual care did have an increased rate of cephalic presentation at birth.
These two systematic reviews also looked at studies comparing acupuncture plus moxibustion versus usual care. The 2012 Cochrane review (7) looked at 1 study with 226 participants and found an increased rate of head-down babies at birth as well as a reduced number of cesarean sections. The more recent 2021 review (8) looked at 2 studies (346 participants) and similarly found an increased rate of head-down babies at birth when acupuncture and moxibustion are combined for treatment.
Only the 2012 Cochrane review (7) compared moxibustion plus postural techniques versus postural techniques alone: 3 studies with 470 participants found an increase in the number of head-down babies at birth.
Finally, the 2021 Systematic review (8) looked at trials which compared acupuncture alone to a control group. Two studies (146 participants) found no difference in the number of head-down babies at birth. Because this finding is represented by only two studies and both were small, additional, larger studies are needed to have more certainty about the impact of acupuncture alone on cephalic presentation.
Discussion of 2012 Cochrane Systematic Review:
The 2012 Cochrane Review (7) included 8 trials and 1346 study participants. It was limited to studies available in English language publications.
This review found that acupuncture and moxibustion combined resulted in fewer non-cephalic babies at birth and fewer cesarean sections. Moxibustion combined with postural techniques also decreased the number of non-cephalic babies at birth when compared with postural techniques alone.
Moxibustion alone showed no significant difference in cephalic presentation rates when compared to no treatment at all. Moxibustion alone did reduce the need for oxytocin before and during labor. However, the three studies that contributed data to this outcome deserve a closer look:
The first study, Cardini 1998 (11) was the largest (n=260) and had a low risk of all types of bias. The trial included women in China at 33 weeks gestation who used moxibustion on UB 67 once or twice daily for 15 minutes on each toe. The comparison group received no intervention. This study, which was well-designed and clinically relevant resulted in a statistically significant reduction in non-cephalic presentation both at 35 weeks (p<.001, RR 1.58, 95% CI) and at birth (P=0.02, RR 1.21, 95% CI) for participants who received moxibustion. The researchers also found that during treatment, fetal activity was significantly increased in the moxibustion group, demonstrating a potential mechanism for how moxibustion might help to turn breech babies.
The second study, Cardini 2005 (12), involved 123 women in Italy at 32-33 weeks gestation. The trial was discontinued before it recruited enough participants to become adequately powered. 22% of participants were not compliant with the moxibustion treatment, and a number of participants reported adverse events including unpleasant odor from the moxibustion, nausea and abdominal pain. The authors concluded the study did not demonstrate whether or not moxibustion changed outcomes since it had to be discontinued after only 46% of the planned number of participants had been recruited. It’s interesting to note that the Cardini 1998 study (11) took place in China, in a cultural context where there was already a high degree of familiarity with and trust in moxibustion. Cardini 2005 (12) took place in Italy, and the authors noted that a large number of potential study participants declined to participate because of mistrust in the treatment and fear of harm to their baby.
The third study, Guittier 2009 (13) included 212 participants at 34-36 weeks gestation. It compared daily moxibustion at UB 67 for 10 minutes on each side for 2 weeks versus no treatment. No statistically significant difference was found in non-cephalic presentation with 18% of participants experiencing cephalic version in the moxibustion group versus 16% of those receiving usual care. In contrast to the high rate of study withdrawal and adverse effects reported by participants of the Cardini 2005 study in Italy, this study, conducted in Switzerland had excellent compliance and participants reported no adverse events. Participants overall felt the process of completing moxibustion was relaxing.
Discussion of 2021 Liao et al. Systematic Review:
The Liao et al. 2021 Systematic Review included 16 studies and a total of 2555 participants. Unlike the 2012 Cochrane review, it did not limit results to English language publications. An additional difference was the inclusion of two studies using acupuncture only (no moxibustion) compared with a control. These two inclusions are in contrast to the Cochrane Review which only included studies that used moxibustion, with or without other modalities.
In studies comparing moxibustion alone to control (13 studies, 2063 participants), researchers found a statistically significant effect for increased numbers of cephalic presentation babies at birth (RR = 1.39; 95% CI = 1.21–1.58). These studies included 2013 Vas et al (9), a large, well-designed study. A sensitivity analysis excluding two trials with a high risk of bias confirmed these findings.
In studies comparing moxibustion plus acupuncture to control (2 studies, 346 participants), researchers found a statistically significant effect for increased numbers of cephalic presentation babies at birth (RR = 1.53; 95% CI = 1.26–1.86). After sensitivity analysis, Yang 2010 (n=120) was excluded due to high risk of bias. The one remaining trial (Neri 2004, n=240) showed an increase in cephalic presentation at birth.
There was no significant difference in studies comparing acupuncture alone at UB 67 versus control (2 studies, 146 participants). One of these studies (Li 1996, n=111) was excluded due to high risk of bias and results remained the same.
Liao et al found that moxibustion with or without acupuncture has a positive effect overall on correcting breech presentation. The authors conducted a subgroup analysis and found moxibustion was particularly effective when used in Asian populations although it did show effectiveness though to a lesser degree in non-Asian populations. It is possible that in the existing trials examined there is better compliance and comfort with using moxibustion at home because it is already a widely known and accepted modality in Asian cultures. Though effectiveness and compliance in using moxibustion are certainly not limited to Asian populations (as demonstrated in Vas 2013 Spanish population, Guittier 2009 Swiss population and Do 2011 Australian population, among others), Cardini 2005 (12) showed major issues with willingness to complete or even begin treatment and poor compliance in an Italian population. Future research might investigate specific cultural factors which contribute to compliance and shape attitudes around moxibustion, including how (and by whom) the method is taught and explained to potential study participants.