What is the issue?
Breech presentation (when the baby is bottom down) is common in the second trimester of pregnancy. Most babies turn so that their head is down, ready for birth, before the onset of labour; however, some do not. A baby coming bottom or feet first can have more difficulty being born. This can cause problems for the mother and baby, and the baby is more likely to be born by caesarean section.
Moxibustion is a type of Chinese medicine that may help turn a breech baby. It involves burning a herb (Artemesia spp.) close to the skin at an acupuncture point on the little toe to produce a warming sensation and provide stimulation to the uterus. This can be performed by the mother or by a family member or friend after they have received training on how to administer moxibustion safely.
Why is this important?
Vaginal birth when the baby is in the breech position is possible with experienced doctors and midwives and well-equipped hospitals, and unplanned vaginal breech births can occur outside of primary care settings. However, not all hospitals can offer vaginal birth to women with breech babies, and birth by caesarean section may be planned. Many healthcare providers and mothers want to avoid caesarean section because it has risks for the current and future pregnancies. We wanted to know whether moxibustion treatment, which can be self-administered at home by the woman or her family or friends, can help the baby turn so that it is head-down for birth.
What evidence did we find?
We searched for evidence to 3 November 2021 for studies that tested moxibustion plus usual care (alone or combined with other treatments, such as acupuncture or postural positions) with usual care, sham moxibustion (moxibustion at a point not relevant to breech presentation; used to blind participants to group allocation), postural positions, or other treatments. We evaluated 13 studies involving a total of 2181 women and their babies. We identified seven new trials. We judged the evidence for most outcomes as low to moderate certainty.
Moxibustion plus usual care probably reduces the number of breech babies at birth more than usual care alone or sham moxibustion plus usual care. There were very few data on the effect of moxibustion plus usual care on the need for external cephalic version (where a doctor attempts to turn the baby). Moxibustion plus usual care probably does not reduce the number of babies born by caesarean section (whether compared to usual care alone or sham acupuncture plus usual care). We are uncertain whether moxibustion plus usual care can reduce the chance of the membranes rupturing early. Moxibustion plus usual care probably reduces the use of oxytocin, a hormone used to begin or improve contractions during labour. There were very few data on the effect of moxibustion plus usual care on how acidic the umbilical cord blood is; we are uncertain about these results because the study results varied, and the results were imprecise. We are very uncertain whether moxibustion plus usual care increases the chance of side effects, because only one study reported side effects according to which treatment women received, and all side effects occurred in the treatment group (27/65 versus 0/57).
The most frequently reported side effects were increased fetal movements, uterine contractions, nausea, headache, and burns from holding the moxibustion stick too close to the skin.
What does this mean?
Starting moxibustion treatment before 37 weeks of pregnancy probably reduces the chance of baby being head-up at birth, but does not reduce the number of babies born by caesarean section. We need more evidence to determine the risk of side effects of moxibustion.
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.
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.
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.
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.
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.
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.
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.