Cephalic version by moxibustion for breech presentation

Complementary and alternative medicine use by pregnant women in Japan: a pilot survey

BACKGROUND

Complementary and alternative medicine (CAM) are popular among women, and are used during their pregnancy in Japan. This study aimed to survey the prevalence of CAM use by healthy pregnant women as a health-care prescribed therapy or self-care and to investigate the factors associated with CAM use in Japan.

METHODS

In this cross-sectional study, pregnant women after 34 weeks of gestation were asked to respond to a questionnaire at the clinic or online. The questionnaire comprised questions on the participants' characteristics and their use of CAM for therapy and self-care. Descriptive statistics were calculated in the analyses, and bivariate and multivariate logistic analyses were performed to evaluate the associations between factors and CAM use.

RESULTS

A total of 394 women responded from three hospitals, two clinics, and two midwifery birth centers. CAM was received as treatment by practitioners during pregnancy by 75 women (19.0%). The following therapies were used: traditional Chinese medicine (7.9%), chiropractic (6.9%), moxibustion (6.4%), and acupuncture (5.3%). One or more types of therapy were used as self-care by 348 women (88.3%). Highly used CAM for self-care were: folic acid supplementation (75.4%), other supplements (51.5%), herbs (20.8%), and yoga (19.0%). Multiple logistic regression analyses revealed that the factors associated with CAM use as a therapy were midwifery birth centers for planned childbirth settings (adjusted odds ratio [AOR] 3.64, 95% confidence interval [CI] [1.69-7.83]) and pregnancy complications diagnosed (AOR 2.46, 95%CI [1.38-4.39]). The factors associated with CAM use for self-care were age 30-39 years (AOR 4.48, 95%CI [2.14-9.73]) and over 40 years (AOR 3.92, 95%CI [1.10-13.91]), junior college education or above (AOR 2.30, 95%CI [1.18-4.51]), and primiparas (AOR 3.82, 95%CI [1.86-7.86]). The most common source of information was the "Internet" (43.8%).

CONCLUSIONS

Approximately 20% of Japanese pregnant women received CAM as therapy by practitioners, and the related factors were: tended to have baby at midwifery birth center and pregnancy complications. Almost 90% of respondents used CAM as self-care and the related factors were: older, had a higher educational level and tended to be primiparas. They used the Internet as their main source of information about CAM. Health care providers need to provide evidenced-based information on CAM and to help decision making to ensure safe and effective CAM utilization by pregnant women.

Impact of full vs empty urinary bladder on external cephalic version success: a randomized controlled trial

BACKGROUND

External cephalic version is a procedure used to turn a fetus from a breech position to a cephalic position before delivery. The success rate of the external cephalic version can be affected by various factors; however, the effect of bladder volume on the success rate of the external cephalic version remains controversial.

OBJECTIVE

This study aimed to determine the effect of urinary bladder status (full or empty) on the success rate of the external cephalic version through a prospective randomized study.

STUDY DESIGN

This was a prospective randomized controlled trial conducted at a tertiary care obstetrical center. Overall, 70 women with a singleton breech presentation at term undergoing external cephalic version were randomly allocated into 2 groups: external cephalic version with an empty bladder and external cephalic version with a full bladder. The external cephalic version procedure was performed by experienced obstetricians under ultrasound guidance. The primary outcome was the success rate of the external cephalic version.

RESULTS

The success rate of the external cephalic version was 67.56% (25/37) in the full bladder group and 54.54% (18/33) in the empty bladder group, with no statistically significant difference between the groups (P=.26). In addition, the relative risk of successful external cephalic version was 1.23 (95% confidence interval, 0.84-1.81), indicating no significant difference.

CONCLUSION

This randomized controlled trial demonstrated that the presence of a full or empty urinary bladder does not significantly affect the success rate of the external cephalic version in women with singleton breech presentation at term. Our findings suggest that women undergoing an external cephalic version do not need to have a full bladder to improve the success rate of the procedure.

Cephalic version by moxibustion for breech presentation

BACKGROUND

Breech presentation at term can cause complications during birth and increase the chance of caesarean section. Moxibustion (a type of Chinese medicine which involves burning a herb close to the skin) at the acupuncture point Bladder 67 (BL67) (Chinese name Zhiyin), located at the tip of the fifth toe, has been proposed as a way of changing breech presentation to cephalic presentation. This is an update of a review first published in 2005 and last published in 2012.

OBJECTIVES

To examine the effectiveness and safety of moxibustion on changing the presentation of an unborn baby in the breech position, the need for external cephalic version (ECV), mode of birth, and perinatal morbidity and mortality.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register (which includes trials from CENTRAL, MEDLINE, Embase, CINAHL, and conference proceedings), ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) (4 November 2021). We also searched MEDLINE, CINAHL, AMED, Embase and MIDIRS (inception to 3 November 2021), and the reference lists of retrieved studies.

SELECTION CRITERIA

The inclusion criteria were published and unpublished randomised or quasi-randomised controlled trials comparing moxibustion either alone or in combination with other techniques (e.g. acupuncture or postural techniques) with a control group (no moxibustion) or other methods (e.g. acupuncture, postural techniques) in women with a singleton breech presentation.

DATA COLLECTION AND ANALYSIS

Two review authors independently determined trial eligibility, assessed trial quality, and extracted data. Outcome measures were baby's presentation at birth, need for ECV, mode of birth, perinatal morbidity and mortality, maternal complications and maternal satisfaction, and adverse events. We assessed the certainty of the evidence using the GRADE approach.   MAIN RESULTS: This updated review includes 13 studies (2181 women), of which six trials are new. Most studies used adequate methods for random sequence generation and allocation concealment. Blinding of participants and personnel is challenging with a manual therapy intervention; however, the use of objective outcomes meant that the lack of blinding was unlikely to affect the results. Most studies reported little or no loss to follow-up, and few trial protocols were available. One study that was terminated early was judged as high risk for other sources of bias. Meta-analysis showed that compared to usual care alone, the combination of moxibustion plus usual care probably reduces the chance of non-cephalic presentation at birth (7 trials, 1152 women; risk ratio (RR) 0.87, 95% confidence interval (CI) 0.78 to 0.99, I2 = 38%; moderate-certainty evidence), but the evidence is very uncertain about the effect of moxibustion plus usual care on the need for ECV (4 trials, 692 women; RR 0.62, 95% CI 0.32 to 1.21, I2 = 78%; low-certainty evidence) because the CIs included both appreciable benefit and moderate harm. Adding moxibustion to usual care probably has little to no effect on the chance of caesarean section (6 trials, 1030 women; RR 0.94, 95% CI 0.83 to 1.05, I2 = 0%; moderate-certainty evidence). The evidence is very uncertain about the effect of moxibustion plus usual care on the the chance of premature rupture of membranes (3 trials, 402 women; RR 1.31, 95% CI 0.17 to 10.21, I2 = 59%; low-certainty evidence) because there were very few data. Moxibustion plus usual care probably reduces the use of oxytocin (1 trial, 260 women; RR 0.28, 95% CI 0.13 to 0.60; moderate-certainty evidence). The evidence is very uncertain about the chance of cord blood pH less than 7.1 (1 trial, 212 women; RR 3.00, 95% CI 0.32 to 28.38; low-certainty evidence) because there were very few data. We are very uncertain whether the combination of moxibustion plus usual care increases the chance of adverse events (including nausea, unpleasant odour, abdominal pain and uterine contractions; intervention: 27/65, control: 0/57), as only one study presented data in a way that could be reanalysed (122 women; RR 48.33, 95% CI 3.01 to 774.86; very low-certainty evidence). When moxibustion plus usual care was compared with sham moxibustion plus usual care, we found that moxibustion probably reduces the chance of non-cephalic presentation at birth (1 trial, 272 women; RR 0.74, 95% CI 0.58 to 0.95; moderate-certainty evidence) and probably results in little to no effect on the rate of caesarean section (1 trial, 272 women; RR 0.84, 95% CI 0.68 to 1.04; moderate-certainty evidence). No study that compared moxibustion plus usual care with sham moxibustion plus usual care reported on the clinically important outcomes of need for ECV, premature rupture of membranes, use of oxytocin, and cord blood pH less than 7.1, and one trial that reported adverse events reported data for the whole sample. When moxibustion was combined with acupuncture and usual care, there was very little evidence about the effect of the combination on non-cephalic presentation at birth (1 trial, 226 women; RR 0.73, 95% CI 0.57 to 0.94) and at the end of treatment (2 trials, 254 women; RR 0.73, 95% CI 0.57 to 0.93), and on the need for ECV (1 trial, 14 women; RR 0.45, 95% CI 0.07 to 3.01). There was very little evidence about whether moxibustion plus acupuncture plus usual care reduced the chance of caesarean section (2 trials, 240 women; RR 0.80, 95% CI 0.65 to 0.99) or pre-eclampsia (1 trial, 14 women; RR 5.00, 95% CI 0.24 to 104.15). The certainty of the evidence for this comparison was not assessed.

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence that moxibustion plus usual care probably reduces the chance of non-cephalic presentation at birth, but uncertain evidence about the need for ECV. Moderate-certainty evidence from one study shows that moxibustion plus usual care probably reduces the use of oxytocin before or during labour. However, moxibustion plus usual care probably results in little to no difference in the rate of caesarean section, and we are uncertain about its effects on the chance of premature rupture of membranes and cord blood pH less than 7.1.  Adverse events were inadequately reported in most trials.

The relationship of publication language, study population, risk of bias, and treatment effects in acupuncture related systematic reviews: a meta-epidemiologic study

BACKGROUND

There are debates in acupuncture related systematic reviews and meta-analyses on whether searching Chinese databases to get more Chinese-language studies may increase the risk of bias and overestimate the effect size, and whether the treatment effects of acupuncture differ between Chinese and non-Chinese populations.

METHODS

In this meta-epidemiological study, we searched the Cochrane library from its inception until December 2021, and identified systematic reviews and meta-analyses with acupuncture as one of the interventions. Paired reviewers independently screened the reviews and extracted the information. We repeated the meta-analysis of the selected outcomes to separately pool the results of Chinese- and non-Chinese-language acupuncture studies and presented the pooled estimates as odds ratios (OR) with 95% confidence interval (CI). We calculated the Ratio of ORs (ROR) by dividing the OR of the Chinese-language trials by the OR of the non-Chinese-language trials, and the ROR by dividing the OR of trials addressing Chinese population by the OR of trials addressing non-Chinese population. We explored whether the impact of a high risk of bias on the effect size differed between studies published in Chinese- and in non-Chinese-language, and whether the treatment effects of acupuncture differed between Chinese and non-Chinese population.

RESULTS

We identified 84 Cochrane acupuncture reviews involving 33 Cochrane groups, of which 31 reviews (37%) searched Chinese databases. Searching versus not searching Chinese databases significantly increased the contribution of Chinese-language literature both to the total number of included trials (54% vs. 15%) and the sample size (40% vs. 15%). When compared with non-Chinese-language trials, Chinese-language trials were associated with a larger effect size (pooled ROR 0.51, 95% CI 0.29 to 0.91). We also observed a higher risk of bias in Chinese-language trials in blinding of participants and personnel (97% vs. 51%) and blinding of outcome assessment (93% vs. 47%). The higher risk of bias was associated with a larger effect estimate in both Chinese-language (allocation concealment: high/unclear risk vs. low risk, ROR 0.43, 95% CI 0.21 to 0.87) and non-Chinese-language studies (blinding of participants and personnel: high/unclear risk vs. low risk, ROR 0.41, 95% CI 0.23 to 0.74). However, we found no evidence that the higher risk of bias would increase the effect size of acupuncture in Chinese-language studies more often than in non-Chinese-language studies (the confidence intervals of all ROR in the high-risk group included 1, Table 3). We further found acupuncture appeared to be more effective in Chinese than in non-Chinese population (Table 4).

CONCLUSIONS

The findings of this study suggest the higher risk of bias may lead to an overestimation of the treatment effects of acupuncture but would not increase the treatment effects in Chinese-language studies more often than in other language studies. The difference in treatment effects of acupuncture was probably associated with differences in population characteristics.

TRIAL REGISTRATION

We registered our protocol on the Open Science Framework (OSF) ( https://doi.org/10.17605/OSF.IO/PZ6XR ).

What to do when it is breech? A state-of-the-art review on management of breech presentation

Any non-cephalic presentation in a fetus is regarded as malpresentation. The most common malpresentation, breech, contributes to 3%-5% of term pregnancies and is a leading indication for cesarean delivery. Identification of risk factors and a proper physical examination are beneficial; however, ultrasound is the gold standard for the diagnosis of malpresentations. External cephalic version (ECV) refers to a procedure aimed to convert a non-cephalic presenting fetus to cephalic presentation. This procedure is performed manually through the mother’s abdomen by a trained health care provider, to reduce the likelihood of a cesarean section. Studies have reported a version success rate of above 50% by ECV. The main objective of this review is to present a broad perspective on fetal malpresentation, ECV, and delivery of a breech fetus. The focus is to elaborate all clinical scenarios of breech and to provide an evidence-based clinical approach for them. After discussing breech prevalence, risk factors, diagnosis, and management, an updated review of ECV is presented. Moreover, ECV indications/contraindications, alternatives, clinical techniques on how to perform ECV and breech vaginal delivery, and obstetrical considerations for the delivery of malpresentations are thoroughly discussed.

Effectiveness of Moxibustion for Breech Presentation: A Prospective Study

OBJECTIVE

To evaluate the moxibustion for turning fetuses from breech to vertex presentation.

MATERIALS AND METHODS

This was a single-center prospective study. All pregnant women carrying a fetus in breech presentation between the 32 and 35 gestational weeks were offered moxibustion application. The primary outcomes were vertex presentation at 37 weeks of gestation, vertex presentation at birth, and vaginal birth rates. A secondary analysis was performed to understand the effect of parity, type of breech presentation, body mass index (BMI), placental location, gender, and fetal birth weight on the presentation at birth.

RESULTS

There were 63 cases in the study group and 245 cases in the control group. The rate of vertex presentation at term was found to be higher in the moxibustion group compared to controls (66.7 vs. 48.2%, p=0.022). There were 45 (71.4%) and 131 (53.5%) fetuses with vertex presentation at birth in the study and control groups, respectively (p=0.020). Overall, vaginal delivery rate was higher in the study group (50.8 vs. 37.1%, p=0.048). Multiparity and higher birth weight were associated with increased rates of vertex presentation in the moxibustion and control groups.

CONCLUSION

Moxibustion application increased the rate of vertex presentation at birth and also vaginal delivery rate compared with expectant management. Offering moxibustion between the 32nd and 36th week of gestation may provide women with a singleton fetus in breech presentation an opportunity for a vaginal birth.

Correction of Breech Presentation with Moxibustion and Acupuncture: A Systematic Review and Meta-Analysis

Acupuncture-type interventions (such as moxibustion and acupuncture) at Bladder 67 (BL67, Zhiyin point) have been proposed to have positive effects on breech presentation. The aim of this systematic review and meta-analysis was to evaluate the effectiveness and safety of moxibustion and acupuncture in correcting breech presentation. We searched PubMed, MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), the Chinese Electronic Periodical Services (CEPS), and databases at ClinicalTrials.gov to identify relevant randomized controlled trials (RCTs). In this study, sixteen RCTs involving 2555 participants were included. Compared to control, moxibustion significantly increased cephalic presentation at birth (RR = 1.39; 95% CI = 1.21–1.58). Moxibustion also seemed to elicit better clinical outcomes in the Asian population (RR = 1.42; 95% CI = 1.21–1.67) than in the non-Asian population (RR = 1.20; 95% CI = 1.01–1.43). The effects of acupuncture on correcting breech presentation after sensitivity analysis were inconsistent relative to control. The effect of moxibustion plus acupuncture was synergistic for correcting breech presentation (RR = 1.53; 95% CI = 1.26–1.86) in one RCT. Our findings suggest that moxibustion therapy has positive effects on correcting breech presentation, especially in the Asian population.

Smoke or smokeless moxibustion treatment for breech presentation: A three-arm pilot trial

AIMS

We conducted a pilot trial to compare the effects of smoke and smokeless moxibustion with a control as a possible supplement to external cephalic version (ECV) for converting breech to cephalic presentation and increasing adherence to cephalic position, and to assess their effects on the well-being of the mother and child.

METHODS

We used a quasi-experimental design with 3 arms: a smoke moxibustion (SM) (n = 20) and smokeless moxibustion (SLM) (n = 20) groups (20-min acupoint BL67 stimulation once or twice daily for 10-14 days), and a control group (n = 20). The participants had singleton breech presentations between 33 and 35 gestation weeks. The primary outcome was cephalic presentation at the conclusion of intervention. The secondary outcomes were cephalic presentation at birth and effects on mother and child well-being.

RESULTS

At the conclusion of intervention, cephalic presentation was higher in the SLM (60.0%) than the control groups (25.0%), Relative Risk 2.40, 95% Confidence Interval [1.04-5.56]; there was no significant difference for SM. At birth, there were no significant differences in cephalic presentation or well-being.

CONCLUSION

SLM treatment showed an increasing trend towards cephalic presentation at the conclusion of intervention. Although significant differences were not observed at birth possibly due to the small samples and non-randomization, moxibustion was safe, and not associated with perinatal morbidity and mortality. A randomized controlled trial with a larger sample is warranted to ascertain SLM treatment as a possible ECV supplement for converting and increasing adherence to cephalic position.

PRISMA extension for moxibustion 2020: recommendations, explanation, and elaboration

BACKGROUND

Moxibustion is a common intervention of Chinese medicine (CM). Systematic reviews (SRs) on moxibustion are increasing. Although the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement provides guidelines for SRs, the quality of moxibustion-related SRs is still not satisfactory. In particular, descriptions of the interventions and the rationale for using moxibustion are insufficient. To address these inadequacies, the working group developed this PRISMA extension for reporting SRs of moxibustion (PRISMA-M 2020).

METHODS

A group of CM clinical professionals, methodologists of SRs, reporting guideline developers, and journal editors developed this PRISMA-M 2020 through a comprehensive process that includes registration, literature review, consensus meetings, Delphi exercises for soliciting comments, and revision, resulting in this final draft.

RESULTS

Seven of the 27 PRISMA checklist items, namely title (1), rationale (3), eligibility criteria (6), data item (11), additional analyses (16), study characteristics (18), and additional analysis (23), were extended, with specific reference to the application of moxibustion. Illustrative examples and explanations for each item are provided.

CONCLUSION

The PRISMA-M 2020 will help improve the reporting quality of SRs with moxibustion.

SYSTEMATIC REVIEW REGISTRATION

We have registered it on the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) network, particularly under the item of PRISMA-TCM: http://www.equator-network.org/library/reporting-guidelines-under-development/reporting-guidelines-under-development-for-systematic-reviews/#65 .

The quality of Cochrane systematic reviews of acupuncture: an overview

Background

Many systematic reviews of clinical trials on acupuncture were performed within the Cochrane Collaboration, the evidence-based medicine (EBM) most recognized organization. Objective of the article was to systematically collect and identify systematic reviews of acupuncture published in the Cochrane Library and assess their quality from a methodological perspective.

Methods

A comprehensive literature search was performed in the Cochrane Database of Systematic Reviews to identify the reviews of acupuncture conducted until June 2019. The methodological quality of the included reviews was assessed using the AMSTAR 2 checklist, an evaluation tool for systematic reviews.

Results

Out of a total of 126 eligible reviews, 50 systematic reviews were included. According to the AMSTAR 2, 52% of Cochrane Systematic Reviews (CSRs) were of low quality, due to the presence of one or more weaknesses in at least one of the domains defined as critical for the methodological quality assessment. The less satisfied critical domain was inadequate investigation and discussion of publication bias. Declaration of potential sources of conflict of interest, and funding of the authors of the review and of the included studies were other important weaknesses.

Conclusions

The main methodological flaws in the included CSRs were related to topics of relatively new concern in the conduction of systematic reviews of the literature. However, both, lack of attention about retrieval of negative studies, and statements about conflict of interests are crucial point for the evaluation of therapeutic interventions according to EBM methodology.

Bibliometric Analysis of Moxibustion Research Trends over the Past 20 Years

Objectives: A bibliometric approach using network analysis was applied to identify the development and research trends for moxibustion. This study also examined the network hub of moxibustion research by investigating the collaborative work of organizations and authors. Methods: Academic articles on moxibustion research published from 2000 to 2019 were retrieved from the Web of Science database. Extracted records were analyzed according to publication year, research area, journal title, country, organization, and authors. The VOSviewer program was utilized to visualize the trends in moxibustion research and to explore the influential organizations and authors. Results: Analyses of 1146 original and review articles written in English demonstrated that the number of publications related to moxibustion research has increased consistently over the last 20 years. China issued the most articles in this field, and the most represented research area was integrative complementary medicine. A network analysis based on the co-occurrence and publication year of keywords identified the relevant characteristics and trends of moxibustion research. By assessing the total link strength of organizations and authors, influential organizations and authors who have contributed to moxibustion research were identified. Conclusions: The current study examined research on moxibustion using bibliometric analysis and identified a time-based development of moxibustion research and a global network hub of moxibustion research.

Effectiveness and Safety of Acupuncture and Moxibustion in Pregnant Women with Noncephalic Presentation: An Overview of Systematic Reviews

Background

Breech presentation at the time of delivery is 3.8–4%. Fetuses that maintain a noncephalic presentation beyond 32 weeks will have a lower probability of spontaneous version before labor. Given the increasing interest in exploring the use of complementary medicine during pregnancy and childbirth, the moxibustion technique, a type of traditional Chinese medicine, could be another option to try turning a breech baby into a cephalic presentation.

Objectives

To review the evidence from systematic reviews (SR) on the efficacy and safety of acupuncture and moxibustion in pregnant women with noncephalic presentation.

Main Results

Our SR synthesizes the results from five clinical trials on pregnant women with a singleton noncephalic presentation. There is evidence that moxibustion reduces the number of noncephalic presentations at the time of birth compared with no treatment. The adverse effects that acupuncture and moxibustion can cause seem to be irrelevant. Most SRs agree that there are no adverse effects directly related to acupuncture and moxibustion.

Conclusions

Even though the results obtained are positive and the five reviews conclude that moxibustion reduces the number of noncephalic presentations at birth (alone or combined with postural techniques or acupuncture), there is considerable heterogeneity between them. Better methodologically designed studies are required in the future to reaffirm this conclusion.

Turning Foetal Breech Presentation at 32-35 Weeks of Gestational Age by Acupuncture and Moxibustion

Introduction

Foetal breech presentation is an obstetric problem that often leads to caesarean section. Stimulation of the acupoint BL67 by moxibustion may correct breech presentation.

Methods

We observed 93 pregnant women in the 32nd-35th week of gestation with normal pregnancy and ultrasound diagnosis of breech presentation. The patients received stimulation of acupoint BL67 by self-administered moxibustion once a day for two weeks and if foetuses still were in breech presentation, moxibustion, and needle in the points BL65 and SI1, lasting 30 minutes, for three days in one week. The main outcome was vaginal birth with vertex presentation at delivery; the secondary outcome was compliance in the self-administration of the moxibustion treatment.

Results

We observed cephalic version and natural childbirth in 62.4% of all treated women. The treatment was accepted by 98.9% women (93/94), and compliance was 91.4% (85/93) for self-administered moxibustion and 37.5% (12/32) for moxibustion and needle treatment.

Conclusions

On the basis of our results, self-administered home treatment moxibustion followed by moxibustion and needle stimulations may be an effective and low-cost treatment for inducing cephalic version.

First, keep it safe: Integration of a complementary medicine service within a hospital

OBJECTIVES

This paper sought to explore risk/safety considerations associated with the integration of a complementary medicine (CM) service within a public academic medical centre in Israel.

METHODS

We reviewed various sources pertaining to the CM service (interviews with CM staff, patients' electronic charts, service guidelines, correspondence with hospital administration) and conducted a thematic analysis to evaluate safety-related incidents during the 7 years of operation. In addition, we systematically assessed the charts for reports of treatment-associated adverse effects, which were documented in an obligatory field on treatment reports.

RESULTS

After reviewing transcripts of interviews with 12 CM practitioners and with the director and vice-director of the CM service as well as transcripts of 8560 consultations that included 7383 treatments, we categorised 3 major domains of CM safety management: (i) prevention of safety-related incidents by appropriate selection of CM practitioners and modalities, (ii) actual adverse incidents and (iii) prevention of their recurrence using both hospital and CM service safety protocols. CM staff reported 5 categories of adverse incidents, most of which were minor. Twenty-nine adverse incidents were documented in the 7383 treatment sessions (0.4%).

CONCLUSIONS

Safety management needs to be addressed both before introducing CM services in hospitals and throughout their integration. Important considerations for the safe integration of CM practices in the hospital include communication between CM and conventional practitioners, adherence to hospital safety rules, implementing a systematic approach for detecting and reporting safety-related incidents and continuous adaptation of the CM service safety protocols.

Women's Health: Pregnancy and Conception

Preconception is an ideal time to assist women contemplating pregnancy to modify health behaviors. Dietary needs in pregnancy are critical and may require supplementation. The use of mind-body medicine in the antenatal period assists patients in childbirth preparation. Integrative medicine techniques can be safely and effectively used for common third-trimester obstetric complications of pregnancy.

Development of Acupuncture and Moxibustion Protocol in a Clinical Trial for Irritable Bowel Syndrome

Traditional Chinese medicine encompasses many different practices, most notably acupuncture and moxibustion. Traditionally, these modalities are used in combination to augment treatment but seldom are they tested together in clinical studies. Numerous acupuncture studies have been conducted in Asia, Europe, and the United States but there have been few randomized controlled trials utilizing moxibustion outside of East Asia. Limited studies have described the use of a moxibustion control or placebo procedure. The methods for developing an acupuncture and moxibustion protocol used in a randomized controlled trial for irritable bowel syndrome, diarrhea predominant in adults are described here. Our approach conformed to the scientific rigor for a clinical trial and was consistent to the foundations of traditional Chinese medicine.

The safety of obstetric acupuncture: forbidden points revisited

Background/aim

Although the safety of acupuncture per se in pregnancy is reasonably well accepted, there remains debate regarding needling at points historically considered to be ‘forbidden’ during pregnancy. This article reviews the scientific literature on this topic.

Main findings

There is no objective evidence of harm following needling at forbidden points, summarised by the following four lines of evidence. (1) In 15 clinical trials (n=823 women receiving n=4549–7234 acupuncture treatments at one or more forbidden points) rates of preterm birth (PTB) and stillbirth following are equivalent to those in untreated control groups and consistent with background rates of these complications in the general population. (2) Observational studies, including a large cohort of 5885 pregnant women needled at forbidden points at all stage of pregnancy, demonstrate that rates of miscarriage, PTB, preterm prelabour rupture of membranes (PPROM), and preterm contractions (preterm labour (PTL) or threatened PTL) are comparable with untreated controls and/or consistent with their anticipated incidence. (3) There is no reliable evidence that acupuncture/electroacupuncture (EA) can induce miscarriage/labour, even under otherwise favourable circumstances such as post-dates pregnancy or intrauterine fetal death. (4) Laboratory experiments using pregnant rats have demonstrated that repeated EA at forbidden points throughout gestation does not influence rates of post-implantation embryonic demise or cause miscarriage, fetal loss or resorption.

Conclusions

These findings are reassuring and will help individualised risk:benefit assessment before treating pregnant women. Given the numerous evidence-based indications for obstetric acupuncture and lack of evidence of harm, risk:benefit assessments will often fall in favour of treatment.

Interventions for helping to turn term breech babies to head first presentation when using external cephalic version

BACKGROUND

Breech presentation is associated with increased complications. Turning a breech baby to head first presentation using external cephalic version (ECV) attempts to reduce the chances of breech presentation at birth so as to avoid the adverse effects of breech vaginal birth or caesarean section. Interventions such as tocolytic drugs and other methods have been used in an attempt to facilitate ECV.

OBJECTIVES

To assess, from the best evidence available, the effects of interventions such as tocolysis, acoustic stimulation for midline spine position, regional analgesia (epidural or spinal), transabdominal amnioinfusion, systemic opioids and hypnosis, or the use of abdominal lubricants, on ECV at term for successful version, presentation at birth, method of birth and perinatal and maternal morbidity and mortality.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2014) and the reference lists of identified studies.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing the above interventions with no intervention or other methods to facilitate ECV at term.

DATA COLLECTION AND ANALYSIS

We assessed eligibility and trial quality. Two review authors independently assessed for inclusion all potential studies identified as a result of the search strategy and independently extracted the data using a specially designed data extraction form.

MAIN RESULTS

We included 28 studies, providing data on 2786 women. We used the random-effects model for pooling data because of clinical heterogeneity between studies. A number of trial reports gave insufficient information to allow clear assessment of risk of bias. We used GradePro software to carry out formal assessments of quality of the evidence for beta stimulants versus placebo and regional analgesia with tocolysis versus tocolysis alone.Tocolytic parenteral beta stimulants were effective in increasing cephalic presentations in labour (average risk ratio (RR) 1.68, 95% confidence interval (CI) 1.14 to 2.48, five studies, 459 women, low-quality evidence) and in reducing the number of caesarean sections (average RR 0.77, 95% CI 0.67 to 0.88, six studies, 742 women, moderate-quality evidence). Failure to achieve a cephalic vaginal birth was less likely for women receiving a parenteral beta stimulant (average RR 0.75, 95% CI 0.60 to 0.92, four studies, 399 women, moderate-quality evidence). No clear differences in fetal bradycardias were identified, although this was reported for only one study, which was underpowered for assessing this outcome. Failed external cephalic version was reported in nine studies (900 women), and women receiving parenteral beta stimulants were less likely to have failure compared with controls (average RR 0.70, 95% CI 0.60 to 0.82, moderate-quality evidence). Perinatal mortality and serious morbidity were not reported. Sensitivity analysis by study quality was consistent with overall findings.For other classes of tocolytic drugs (calcium channel blockers and nitric oxide donors), evidence was insufficient to permit conclusions; outcomes were reported for only one or two studies, which were underpowered to demonstrate differences between treatment and control groups. Little evidence was found regarding adverse effects, although nitric oxide donors were associated with increased risk of headache. Data comparing different tocolytic drugs were insufficient.Regional analgesia in combination with a tocolytic was more effective than the tocolytic alone for increasing successful versions (assessed by the rate of failed ECVs; average RR 0.61, 95% CI 0.43 to 0.86, five studies, 409 women, moderate-quality evidence), and no difference was identified in cephalic presentation in labour (average RR 1.63, 95% CI 0.75 to 3.53, three studies, 279 women, very low-quality evidence), caesarean sections (average RR 0.74, 95% CI 0.40 to 1.37, three studies, 279 women, very low-quality evidence) nor fetal bradycardia (average RR 1.48, 95% CI 0.62 to 3.57, two studies, 210 women, low-quality evidence), although studies were underpowered for assessing these outcomes. Studies did not report on failure to achieve a cephalic vaginal birth (breech vaginal deliveries plus caesarean sections) nor on perinatal mortality or serious infant morbidity.Data were insufficient on the use of regional analgesia without tocolysis, vibroacoustic stimulation, amnioinfusion, systemic opioids and hypnosis, and on the use of talcum powder or gel to assist external cephalic version, to permit conclusions about their effectiveness and safety.

AUTHORS' CONCLUSIONS

Parenteral beta stimulants were effective in facilitating successful ECV, increasing cephalic presentation in labour and reducing the caesarean section rate, but data on adverse effects were insufficient. Data on calcium channel blockers and nitric acid donors were insufficient to provide good evidence.The scope for further research is clear. Possible benefits of tocolysis in reducing the force required for successful version and possible risks of side effects need to be addressed further. Further trials are needed to compare the effectiveness of routine versus selective use of tocolysis and the role of regional analgesia, fetal acoustic stimulation, amnioinfusion and abdominal lubricants, and the effects of hypnosis, in facilitating ECV. Although randomised trials of nitric oxide donors are small, the results are sufficiently negative to discourage further trials. Intervention fidelity for ECV can be enhanced by standardisation of the techniques and processes used for clinical manipulation of the fetus in the abdominal cavity and ought to be the subject of further research.

Acupuncture in Australia: regulation, education, practice, and research

Acupuncture was introduced to Australia as early as in the 1880s, and is a form of complementary and alternative medicine in this country. In the past 2 decades since the 1990s, acupuncture has experienced a rapid growth. Today, nearly 4000 acupuncturists are registered with the Chinese Medicine Board of Australia. "Acupuncturist," "Oriental medicine practitioner," and "Chinese medicine practitioners" are protected titles for registered acupuncturists. A bachelor's degree of 4 years in related fields is the minimal requirement for registration in Australia. Three public universities and three major private colleges offer nine undergraduate and three postgraduate programs that are approved by the Chinese Medicine Board of Australia. Those three universities also offer Master-degree and Doctor of Philosophy programs. Acupuncture is well accepted by the Australians, with 10% having received this treatment and 80% general medical practitioners referring their patients to acupuncture service. All private health insurance schemes provide rebates to patients receiving acupuncture treatment, and third-party payment is also available in six of eight Australian states and territories. Research output in acupuncture has increased greatly since 2000. A majority of research focuses on acupuncture and Tai Chi as treatment modalities, and mainly investigates their mechanism of action, associated pain, and gynecological and respiratory conditions. The future direction of acupuncture in Australia is to introduce this medicine in hospitals and gain access to the medical benefit scheme so that acupuncture can be accessed by a wider community, in particular those who come from a disadvantaged background. In conclusion, improved education, regulation, and research of acupuncture in Australia put this country in a leading position among Western countries with respect to acupuncture services.

Essential pre-pregnancy and pregnancy interventions for improved maternal, newborn and child health

The statistics related to pregnancy and its outcomes are staggering: annually, an estimated 250000-280000 women die during childbirth. Unfortunately, a large number of women receive little or no care during or before pregnancy. At a period of critical vulnerability, interventions can be effectively delivered to improve the health of women and their newborns and also to make their pregnancy safe. This paper reviews the interventions that are most effective during preconception and pregnancy period and synergistically improve maternal and neonatal outcomes. Among pre-pregnancy interventions, family planning and advocating pregnancies at appropriate intervals; prevention and management of sexually transmitted infections including HIV; and peri-conceptual folic-acid supplementation have shown significant impact on reducing maternal and neonatal morbidity and mortality. During pregnancy, interventions including antenatal care visit model; iron and folic acid supplementation; tetanus Immunisation; prevention and management of malaria; prevention and management of HIV and PMTCT; calcium for hypertension; anti-Platelet agents (low dose aspirin) for prevention of Pre-eclampsia; anti-hypertensives for treating severe hypertension; management of pregnancy-induced hypertension/eclampsia; external cephalic version for breech presentation at term (>36 weeks); management of preterm, premature rupture of membranes; management of unintended pregnancy; and home visits for women and children across the continuum of care have shown maximum impact on reducing the burden of maternal and newborn morbidity and mortality. All of the interventions summarized in this paper have the potential to improve maternal mortality rates and also contribute to better health care practices during preconception and periconception period.

Essential interventions: implementation strategies and proposed packages of care

In an effort to accelerate progress towards achieving Millennium Development Goal (MDG) 4 and 5, provision of essential reproductive, maternal, newborn and child health (RMNCH) interventions is being considered. Not only should a state-of-the-art approach be taken for services delivered to the mother, neonate and to the child, but services must also be deployed across the household to hospital continuum of care approach and in the form of packages. The paper proposed several packages for improved maternal, newborn and child health that can be delivered across RMNCH continuum of care. These packages include: supportive care package for women to promote awareness related to healthy pre-pregnancy and pregnancy interventions; nutritional support package for mother to improve supplementation of essential nutrients and micronutrients; antenatal care package to detect, treat and manage infectious and noninfectious diseases and promote immunization; high risk care package to manage preeclampsia and eclampsia in pregnancy; childbirth package to promote support during labor and importance of skilled birth attendance during labor; essential newborn care package to support healthy newborn care practices; and child health care package to prevent and manage infections. This paper further discussed the implementation strategies for employing these interventions at scale.

The practice of acupuncture and moxibustion to promote cephalic version for women with a breech presentation: implications for clinical practice and research

OBJECTIVES

To examine what experienced acupuncture practitioners and researchers considered key aspects of treatment to promote cephalic version for women with a breech presentation, and to establish a treatment protocol through consensus to guide the self administration of moxa by pregnant women.

METHODS AND DESIGN

The Delphi method was used to seek the opinions of key informants. Sixteen English speaking international, Australian and New Zealand acupuncturists working in the area of pregnancy were invited to participate in the study. Participants were given a link to an online survey, and their views sought on treatment parameters guiding the treatment of breech presentation within a research setting.

RESULTS

Two rounds of the Delphi process were undertaken, 12 participants completed round one, and 10 completed round two. Eighty percent of participants agreed that moxa should commence between 34 and 35 weeks gestation. Ninety percent agreed to self administration of moxa by the woman, and use of smokeless and odourless sticks. Seventy percent agreed moxa should be applied for a minimum of 10 days, and be applied once a day for 30min. Monitoring safety was identified as an important outcome. Ninety percent agreed study clinical outcomes should assess side effects including burns, and maternal and foetal outcomes.

CONCLUSION

Findings from our study promote the clinical validity for a future research protocol, and highlight other areas for research to evaluate the role of acupuncture and moxibustion with normalising birth.

Anesthetic management of external cephalic version

Breech presentation is common at term and its reduction through external cephalic version represents a noninvasive opportunity to avoid cesarean delivery and the associated maternal morbidity. In addition to uterine relaxants, neuraxial anesthesia is associated with increased success of version procedures when surgical anesthetic dosing is used. The intervention is likely cost effective given the effect size and the avoided high costs of cesarean delivery.

Patient-reported benefits of acupuncture in pregnancy

As U.S. expenditures on acupuncture treatment rise, so does the need to examine specific acupuncture patient subpopulations because their treatment needs and goals vary. This study focused on treatment benefits reported by former obstetric acupuncture patients, which addresses a critical research gap on subjective patient experiences. Of 265 former clinic patients, 137 (51.7%) completed an internet survey with an open-ended question on treatment benefits. Using standard qualitative analytic strategies, we identified five major themes related to benefits, including, for example, treated chief concerns, helped achieve a desired birth experience, and provided holistic benefit. Identified themes and subthemes spoke to benefits of acupuncture on specific pregnancy symptoms and on the birth process. Clinical and research implications for identified themes, including those related to the birth process and birth setting, are discussed.