2020 Cochrane Review Findings:

A 2020 Cochrane Systematic Review looked at the evidence from 13 acupuncture studies (1). In most of these studies, women were asked to rate their pain level on a Visual Analog Scale, which ranked pain on a scale of 1 to 10 or 1 to 100, with lower numbers indicating less pain. The researchers found that when compared to sham (placebo) acupuncture, there is some evidence that acupuncture may increase satisfaction with pain management and reduce the use of pharmacological analgesia. It is interesting to note that 8 of these studies used individualized point prescriptions, which more accurately reflects actual clinical practice. This is in comparison to studies that used standardized point prescriptions for all patients. When acupuncture was compared to usual care, no treatment or other methods of pain relief (such as sterile water injection) the evidence on reduction of pain intensity was rated as low or very low certainty. This means that the researchers are uncertain about its effects and more studies are needed to determine its effects in this area. The largest of the studies reviewed (Borup 2009), with 607 participants, also ranked highest on the NICMAN Scale (a measure of the quality of the acupuncture performed in the study) and found that acupuncture decreased the use of pharmacological and invasive methods during labor and delivery, and was a useful complement to other methods of pain relief.

Notable findings from other studies:

• A review of 16 systematic reviews (Bergamo et al 2018) concluded that “Acupuncture might be an option for alleviating pain during labor” (2).
• A case-control pilot study in a hospital setting by Claudia Citkovitz’s group in 2009 (3) looked at acupuncture in the labor and delivery unit of an urban hospital setting in New York City. Although it was a small study and not a randomized controlled trial, it is interesting because it found that those receiving acupuncture had a decreased cesarean rate and higher reported levels of satisfaction of the birthing parent. 87% of the participants reported that the acupuncture had helped them. Nurses reported that subjectively the patients seemed to do better with acupuncture, noting increased efficiency of contractions and that the acupuncture seemed to help with dilation. From the point of view of feasibility in a hospital setting, a high level of safety was found. No needlestick injuries or other adverse effects (minor or major) were reported, and 83% of nurses said the acupuncture did not interfere with their work.  This is a unique study for a few reasons: first, individualized points were used. Second, most studies looking at acupuncture for pain relief during labor discontinued acupuncture once an epidural was given. In this study, it was allowed to be continued.

Findings on Rates of Cesarean Sections after Acupuncture:

In the 2020 Cochrane Review, most of the studies did not show any reduction in C-Section rate. Citkovitz (3) proposed two possible reasons for this: 

First, Citkovitz points out that the baseline c-section rate where most of these trials were performed is quite low. Many took place in Nordic Countries (Iceland, Finland, Sweden and Norway) with average rates between 15-17%. It is thought that the majority of the c-sections performed in these countries were truly not preventable. In contrast, in countries where the c-section rates are much higher (ranging from 31.7% in the USA in 2019 (source) to 55.8%  average in Brazil (source)), there are likely a large number of preventable surgeries. Supportive therapies may show a greater impact in these countries. In this Cochrane Review, most studies took place in countries with a low baseline c-section rate. For patients receiving acupuncture, across the board no change was found in c-section rates. All studies that looked at this outcome took place in low c-section rate countries with the exception of 1 study from China (Huang 2008) which included a small number of participants and found no significant difference. We need more studies with a larger sample size taking place in countries with a high baseline rate of c-sections. It is interesting to note that studies which looked at acupressure compared with sham acupressure showed a significant decrease in c-sections. The 4 studies that looked at this outcome were all high c-section rate countries (2 studies from Iran, 2 from Brazil).

The second reason Citkovitz proposes is that in most studies, the set of acupuncture points used was strictly prescribed and was unable to be altered based on the situation at hand. In Citkovitz’s study as well as one Norwegian study (Skilnand et al 2002), the person performing the acupuncture was given more room to use their professional judgement and experience, choosing from multiple points. Both of these studies found a decreased rate of cesareans. It would be useful to have pragmatic trial design studies which look at individualized point usage as determined by experienced acupuncture practitioners.