A feasibility randomised controlled trial of acupressure to assist spontaneous labour for primigravid women experiencing a post-date pregnancy

Midwife led randomised controlled trials in Australia and New Zealand: A scoping review

BACKGROUND

Midwives are the largest workforce involved in caring for pregnant women and their babies, and are well placed to translate research into practice and ensure midwifery priorities are appropriately targeted in researched. Currently, the number and focus of randomised controlled trials led by midwives in Australia and New Zealand is unknown. The Australasian Nursing and Midwifery Clinical Trials Network was established in 2020 to build nursing and midwifery research capacity. To aid this, scoping reviews of the quality and quantity of nurse and midwife led trials were undertaken.

AIM

To identify midwife led trials conducted between 2000 and 2021 in Australia and New Zealand.

METHODS

This review was informed by the JBI scoping review framework. Medline, Emcare, and Scopus were searched from 2000-August 2021. ANZCTR, NHMRC, MRFF, and HRC (NZ) registries were searched from inception to July 2021.

FINDINGS

Of 26,467 randomised controlled trials registered on the Australian and New Zealand Clinical Trials Registry, 50 midwife led trials, and 35 peer-reviewed publications were identified. Publications were of moderate to high quality with scores limited due to an inability to blind participants or clinicians. Blinding of assessors was included in 19 published trials.

DISCUSSION

Additional support for midwives to design and conduct trials and publish findings is required. Further support is needed to translate registration of trial protocols into peer reviewed publications.

CONCLUSION

These findings will inform the Australasian Nursing and Midwifery Clinical Trials Network plans to promote quality midwife led trials.

A Comparison of Recruitment Methods for a Prospective Cohort Study of Perinatal Psychoneuroimmunology among Black American Women

Improved understanding of perinatal psychoneuroimmunology is needed, particularly to combat the high rates of maternal and infant mortality witnessed among Black Americans. We compared the success of recruitment by advertisement, in person, or by phone during the course of a prospective cohort study of perinatal psychoneuroimmunology among Black American women. Over 24 months, 363 women were assessed and 96 were enrolled. Women recruited by phone were less likely to complete full screening than women recruited by advertisement (OR = 0.32, p < 0.01) or in person (OR = 0.19, p < 0.01). Women recruited by advertisement were less likely to complete full screening than women recruited in person (OR = 0.60, p = 0.05). Odds of unsuccessful contact were 13.2 and 11.5 times greater among women recruited by phone versus by advertisement or in person, respectively (p values ≤ 0.01). Women recruited by advertisement and in person showed similar odds of unsuccessful contact (OR = 0.87, p = 0.76). Odds of screening decline were similar following recruitment in person or by phone when contact was successful (OR = 0.85, p = 0.76). Focusing on eligible women (n = 142), those recruited in person were significantly less likely to enroll than those recruited by advertisement (OR = 0.28, p < 0.01; Fig. 4). Considering all women (n = 363), odds of enrollment did not significantly differ among the recruitment groups (p values ≥ 0.09). Most (93.8%) enrolled women consented to biological specimen banking. Findings from this brief report provide a starting point for perinatal scientists to critically consider not only how to maximize research efforts but also how research team actions may perpetuate or assuage the research mistrust introduced by long-standing social inequities.

Should treatment effects be estimated in pilot and feasibility studies?

Background

Feasibility studies and external pilot studies are used increasingly to inform planning decisions related to a definitive randomized controlled trial. These studies can provide information on process measures, such as consent rates, treatment fidelity and compliance, and methods of outcome measurement. Additionally, they can provide initial parameter estimates for a sample size calculation, such as a standard deviation or the ‘success’ rate for a binary outcome in the control group. However, the issue of estimating treatment effects in pilot or feasibility studies is controversial.

Methodological discussion

Between-group estimates of treatment effect from pilot studies are sometimes used to calculate the sample size for a main trial, alongside estimated standard deviations. However, whilst estimating a standard deviation is an empirical matter, a targeted treatment effect should be established in terms of clinical judgement, as a minimum important difference (MID), not through analysis of pilot data. Secondly, between-group effects measured in pilot studies are sometimes used to indicate the magnitude of an effect that might be obtained in a main trial, and a decision on progression made with reference to the associated confidence interval. Such estimates will be imprecise in typically small pilot studies and therefore do not allow a robust decision on a main trial; both a decision to proceed and a decision not to proceed may be made too readily. Thirdly, a within-group change might be estimated from a pilot or a feasibility study in a desire to assess the potential efficacy of a novel intervention prior to testing it in a main trial, but again such estimates are liable to be imprecise and do not allow sound causal inferences.

Conclusion

Treatment effects calculated from pilot or feasibility studies should not be the basis of a sample size calculation for a main trial, as the MID to be detected should be based primarily on clinical judgement rather than statistics. Deciding on progression to a main trial based on these treatment effects is also misguided, as they will normally be imprecise, and may be biased if the pilot or feasibility study is unrepresentative of the main trial.

Traditional Chinese Medicine Self-Care and Lifestyle Medicine Outside of Asia: A Systematic Literature Review

Background: Chinese medicine, when applied as a whole system of care, traditionally incorporates self-care techniques and patient understanding as key aspects of patient recovery and health maintenance. Objectives: This review aims to explore the literature to date on Traditional Chinese Medicine (TCM) self-care in settings outside of Asia, beyond the sole application of t'ai chi or qigong, to consider simple self-care techniques as health care interventions that may be generalized to a wider population. Design: AMED, CINAHL, EMBASE, PubMed, and MEDLINE databases were searched for articles from inception to July 2018. Studies were included, which were undertaken in settings outside of Asia and/or Asian communities, and were excluded if they solely examined t'ai chi or qigong. Results: Findings of the included studies (n = 37) were categorized into four key areas in relation to the TCM self-care component evaluated: self-acupressure, self-acupuncture, self-moxibustion, and the adoption of prescribed lifestyle, diet, and exercise advice based on a TCM diagnosis. The studies included randomized clinical trials, case studies, hospital audits, and qualitative evaluations. The studies assessed TCM self-care in relation to a wide range of health conditions, with the majority of studies concluding positive findings. Conclusion: This review draws attention to the potential role of TCM self-care techniques, in settings outside of Asia, beyond the sole practices of t'ai chi and qigong, as an adjunct to health maintenance and recovery. Only tentative conclusions can be drawn from the existing research, however, due to variability across studies in reporting transparency and the overall low number of studies retrieved. Further research is warranted.

Acupuncture in Postdate Pregnancy Management

OBJECTIVES

Pharmacological labor induction is obtained through prostaglandins application and/or oxytocin infusion; however, the use seems to be related to fetal and maternal side effects. Traditional Chinese Medicine advocates the use of acupuncture to soften the cervix and induce uterine contractions. at which presented for The primary outcome was the rate of women admitted for labour induction in case of prolonged pregnancy at 41 + 5 weeks, and the secondary outcome was the rate of induction planning for other indications.

METHODS

After obtaining informed consent, 375 undelivered women after 40 + 2 gestational age were enrolled for the study: 112 women received acupuncture and 263, routine care. Acupuncture was applied every odd day starting from 40 + 2 weeks up to 41 + 4 weeks. Women allocated to the control group received standard care. At 41 + 5 weeks, a pharmacological induction was planned.

RESULTS

The rate of labor induction significantly differed between acupuncture and observation groups (19.6% vs. 38%; p < 0.01); in particular, women receiving acupuncture showed a lower rate of induction, indicating prolonged pregnancy (5.3% vs. 10.1%; p < 0.01). As far as the pharmacological device is concerned, no differences were observed with regard to the prostaglandins use, whereas oxytocin infusion rate was lower in the acupuncture group than in the observation group.

CONCLUSIONS

The present study suggested that acupuncture applied at term of pregnancy seems to be effective in reducing the rate of labor induction which is performed for prolonged pregnancy at 41 + 5 weeks. Moreover, acupuncture also seems to be able to reduce oxytocin use; such a "saving" effect could play a role in childhood, considering that a recent study underlined the adverse effect of oxytocin on birth outcomes.

Acupuncture or acupressure for induction of labour

BACKGROUND

This is one of a series of reviews of methods of cervical ripening and labour induction. The use of complementary therapies is increasing. Women may look to complementary therapies during pregnancy and childbirth to be used alongside conventional medical practice. Acupuncture involves the insertion of very fine needles into specific points of the body. Acupressure is using the thumbs or fingers to apply pressure to specific points. The limited observational studies to date suggest acupuncture for induction of labour has no known adverse effects to the fetus, and may be effective. However, the evidence regarding the clinical effectiveness of this technique is limited.

OBJECTIVES

To determine, from the best available evidence, the effectiveness and safety of acupuncture and acupressure for third trimester cervical ripening or induction of labour.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2016), PubMed (1966 to 25 November 2016), ProQuest Dissertations & Theses (25 November 2016), CINAHL (25 November 2016), Embase (25 November 2016), the WHO International Clinical Trials Registry Portal (ICTRP) (3 October 2016), and bibliographies of relevant papers.

SELECTION CRITERIA

Randomised controlled trials comparing acupuncture or acupressure, used for third trimester cervical ripening or labour induction, with placebo/no treatment or other methods on a predefined list of labour induction methods.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked them for accuracy. The quality of the evidence was assessed using GRADE.

MAIN RESULTS

This updated review includes 22 trials, reporting on 3456 women. The trials using manual or electro-acupuncture were compared with usual care (eight trials, 760 women), sweeping of membranes (one trial, 207 women), or sham controls (seven trials, 729 women). Trials using acupressure were compared with usual care (two trials, 151 women) or sham controls (two trials, 239 women). Many studies had a moderate risk of bias.Overall, few trials reported on primary outcomes. No trial reported vaginal delivery not achieved within 24 hours and uterine hyperstimulation with fetal heart rate (FHR) changes. Serious maternal and neonatal death or morbidity were only reported under acupuncture versus sham control. Acupuncture versus sham control There was no clear difference in caesarean sections between groups (average risk ratio (RR) 0.80, 95% confidence interval (CI) 0.56 to 1.15, eight trials, 789 women; high-quality evidence). There were no reports of maternal death or perinatal death in the one trial that reported this outcome. There was evidence of a benefit from acupuncture in improving cervical readiness for labour (mean difference (MD) 0.40, 95% CI 0.11 to 0.69, one trial, 125 women), as measured by cervical maturity within 24 hours using Bishop's score. There was no evidence of a difference between groups for oxytocin augmentation, epidural analgesia, instrumental vaginal birth, meconium-stained liquor, Apgar score < 7 at five minutes, neonatal intensive care admission, maternal infection, postpartum bleeding greater than 500 mL, time from the trial to time of birth, use of induction methods, length of labour, and spontaneous vaginal birth. Acupuncture versus usual care There was no clear difference in caesarean sections between groups (average RR 0.77, 95% CI 0.51 to 1.17, eight trials, 760 women; low-quality evidence). There was an increase in cervical maturation for the acupuncture (electro) group compared with control (MD 1.30, 95% CI 0.11 to 2.49, one trial, 67 women) and a shorter length of labour (minutes) in the usual care group compared to electro-acupuncture (MD 124.00, 95% CI 37.39 to 210.61, one trial, 67 women).There appeared be a differential effect according to type of acupuncture based on subgroup analysis. Electro-acupuncture appeared to have more of an effect than manual acupuncture for the outcomes caesarean section (CS), and instrumental vaginal and spontaneous vaginal birth. It decreased the rate of CS (average RR 0.54, 95% CI 0.37 to 0.80, 3 trials, 327 women), increased the rate of instrumental vaginal birth (average RR 2.30, 95%CI 1.15 to 4.60, two trials, 271 women), and increased the rate of spontaneous vaginal birth (average RR 2.06, 95% CI 1.20 to 3.56, one trial, 72 women). However, subgroup analyses are observational in nature and so results should be interpreted with caution.There were no clear differences between groups for other outcomes: oxytocin augmentation, use of epidural analgesia, Apgar score < 7 at 5 minutes, neonatal intensive care admission, maternal infection, perineal tear, fetal infection, maternal satisfaction, use of other induction methods, and postpartum bleeding greater than 500 mL. Acupuncture versus sweeping if fetal membranes One trial of acupuncture versus sweeping of fetal membranes showed no clear differences between groups in caesarean sections (RR 0.64, 95% CI 0.34 to 1.22, one trial, 207 women, moderate-quality evidence), need for augmentation, epidural analgesia, instrumental vaginal birth, Apgar score < 7 at 5 minutes, neonatal intensive care admission, and postpartum bleeding greater than 500 mL. Acupressure versus sham control There was no evidence of benefit from acupressure in reducing caesarean sections compared to control (RR, 0.94, 95% CI 0.68 to 1.30, two trials, 239 women, moderate-quality evidence). There was no evidence of a clear benefit in reduced oxytocin augmentation, instrumental vaginal birth, meconium-stained liquor, time from trial intervention to birth of the baby, and spontaneous vaginal birth. Acupressure versus usual care There was no evidence of benefit from acupressure in reducing caesarean sections compared to usual care (RR 1.02, 95% CI 0.68 to 1.53, two trials, 151 women, moderate-quality evidence). There was no evidence of a clear benefit in reduced epidural analgesia, Apgar score < 7 at 5 minutes, admission to neonatal intensive care, time from trial intervention to birth of the baby, use of other induction methods, and spontaneous vaginal birth.

AUTHORS' CONCLUSIONS

Overall, there was no clear benefit from acupuncture or acupressure in reducing caesarean section rate. The quality of the evidence varied between low to high. Few trials reported on neonatal morbidity or maternal mortality outcomes. Acupuncture showed some benefit in improving cervical maturity, however, more well-designed trials are needed. Future trials could include clinically relevant safety outcomes.