What is the issue?
This Cochrane review looked at whether massage, reflexology and other manual therapies would help with reducing pain and improve women's experiences of childbirth. We collected and analysed all the relevant trials to answer this question (search date: 30 June 2017).
Why is this important?
The pain of labour can be intense, with tension, anxiety and fear making it worse. Many women would like to labour without using drugs such as narcotics or epidurals, and are interested in complementary therapies to help them manage the pain of labour.
In this review we have looked to see if massage, reflexology and other manual methods are effective. Other complementary therapies like acupuncture, mind-body techniques, hypnosis and aromatherapy have been studied in other Cochrane reviews. Massage involves manipulating the body's soft tissues and it can be done by the midwife or partner. It helps women relax and so reduces tension which in turn may reduce pain in labour. Reflexology is gentle manipulation or pressing on certain parts of the foot to produce an effect elsewhere in the body. Other manual methods include warm packs, osteopathy, shiatsu and zero balancing. It is important to examine if these therapies work and are safe, to enable women to make informed decisions about their care.
What evidence did we find?
This updated review now includes 14 trials. We were able to use data from 10 of the trials, involving a total of 1055 women. We found no trials on reflexology, osteopathy, shiatsu and zero balancing therapy.
In the various included trials, massage was given either by the woman's birth companion, a student midwife, a physiotherapist or a massage therapist (though some trials did not report who gave the massage). Three trials involved a two- to three-hour prebirth course attended by women and their partners, and delivered by a qualified practitioner. In three trials, the intervention was delivered by a qualified health practitioner (massage therapist, physiotherapist or nurse/researcher with unspecified qualifications). In one trial, nurses taught women's partners in the labour ward. There was insufficient reporting of the qualifications of the practitioner teaching massage.
We found that massage and thermal packs, in comparison to usual care or music, may help women manage labour pain intensity during the first stage when the cervix is dilating. However, the quality of this evidence was very low. The effects of massage on assisted vaginal birth, caesarean section rate, the length of labour and use of drugs for pain relief were less clear, and the quality of the evidence was also very low. Two small trials showed increased satisfaction with childbirth, and a greater sense of control for women receiving massage.
Warm packs were associated with reduced pain in the first stage of labour and reduced length of labour (very low-quality evidence).
What does this mean?
Massage may help women cope with pain in labour and may give them a better birth experience, and warm packs and thermal methods may help with pain. However, the quality of the evidence was generally low or very low, partly due to the trials being small and without sufficient numbers of women participating. These findings highlight a need for further research on this topic.
Massage, warm pack and thermal manual methods may have a role in reducing pain, reducing length of labour and improving women's sense of control and emotional experience of labour, although the quality of evidence varies from low to very low and few trials reported on the key GRADE outcomes. Few trials reported on safety as an outcome. There is a need for further research to address these outcomes and to examine the effectiveness and efficacy of these manual methods for pain management.
Many women would like to avoid pharmacological or invasive methods of pain management in labour, and this may contribute towards the popularity of complementary methods of pain management. This review examined the evidence currently available on manual methods, including massage and reflexology, for pain management in labour. This review is an update of the review first published in 2012.
To assess the effect, safety and acceptability of massage, reflexology and other manual methods to manage pain in labour.
For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register (30 June 2017), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 6), MEDLINE (1966 to 30 June 2017, CINAHL (1980 to 30 June 2017), the Australian New Zealand Clinical Trials Registry (4 August 2017), Chinese Clinical Trial Registry (4 August 2017), ClinicalTrials.gov, (4 August 2017), the National Center for Complementary and Integrative Health (4 August 2017), the WHO International Clinical Trials Registry Platform (ICTRP) (4 August 2017) and reference lists of retrieved trials.
We included randomised controlled trials comparing manual methods with standard care, other non-pharmacological forms of pain management in labour, no treatment or placebo. We searched for trials of the following modalities: massage, warm packs, thermal manual methods, reflexology, chiropractic, osteopathy, musculo-skeletal manipulation, deep tissue massage, neuro-muscular therapy, shiatsu, tuina, trigger point therapy, myotherapy and zero balancing. We excluded trials for pain management relating to hypnosis, aromatherapy, acupuncture and acupressure; these are included in other Cochrane reviews.
Two review authors independently assessed trial quality, extracted data and checked data for accuracy. We contacted trial authors for additional information. We assessed the quality of the evidence using the GRADE approach.
We included a total of 14 trials; 10 of these (1055 women) contributed data to meta-analysis. Four trials, involving 274 women, met our inclusion criteria but did not contribute data to the review. Over half the trials had a low risk of bias for random sequence generation and attrition bias. The majority of trials had a high risk of performance bias and detection bias, and an unclear risk of reporting bias. We found no trials examining the effectiveness of reflexology.
We found low-quality evidence that massage provided a greater reduction in pain intensity (measured using self-reported pain scales) than usual care during the first stage of labour (standardised mean difference (SMD) −0.81, 95% confidence interval (CI) −1.06 to −0.56, six trials, 362 women). Two trials reported on pain intensity during the second and third stages of labour, and there was evidence of a reduction in pain scores in favour of massage (SMD −0.98, 95% CI −2.23 to 0.26, 124 women; and SMD −1.03, 95% CI −2.17 to 0.11, 122 women). There was very low-quality evidence showing no clear benefit of massage over usual care for the length of labour (in minutes) (mean difference (MD) 20.64, 95% CI −58.24 to 99.52, six trials, 514 women), and pharmacological pain relief (average risk ratio (RR) 0.81, 95% CI 0.37 to 1.74, four trials, 105 women). There was very low-quality evidence showing no clear benefit of massage for assisted vaginal birth (average RR 0.71, 95% CI 0.44 to 1.13, four trials, 368 women) and caesarean section (RR 0.75, 95% CI 0.51 to 1.09, six trials, 514 women). One trial reported less anxiety during the first stage of labour for women receiving massage (MD -16.27, 95% CI −27.03 to −5.51, 60 women). One trial found an increased sense of control from massage (MD 14.05, 95% CI 3.77 to 24.33, 124 women, low-quality evidence). Two trials examining satisfaction with the childbirth experience reported data on different scales; both found more satisfaction with massage, although the evidence was low quality in one study and very low in the other.
We found very low-quality evidence for reduced pain (Visual Analogue Scale/VAS) in the first stage of labour (SMD −0.59, 95% CI −1.18 to −0.00, three trials, 191 women), and the second stage of labour (SMD −1.49, 95% CI −2.85 to −0.13, two trials, 128 women). Very low-quality evidence showed reduced length of labour (minutes) in the warm-pack group (MD −66.15, 95% CI −91.83 to −40.47; two trials; 128 women).
Thermal manual methods
One trial evaluated thermal manual methods versus usual care and found very low-quality evidence of reduced pain intensity during the first phase of labour for women receiving thermal methods (MD −1.44, 95% CI −2.24 to −0.65, one trial, 96 women). There was a reduction in the length of labour (minutes) (MD −78.24, 95% CI −118.75 to −37.73, one trial, 96 women, very low-quality evidence). There was no clear difference for assisted vaginal birth (very low-quality evidence). Results were similar for cold packs versus usual care, and intermittent hot and cold packs versus usual care, for pain intensity, length of labour and assisted vaginal birth.
One trial that compared manual methods with music found very low-quality evidence of reduced pain intensity during labour in the massage group (RR 0.40, 95% CI 0.18 to 0.89, 101 women). There was no evidence of benefit for reduced use of pharmacological pain relief (RR 0.41, 95% CI 0.16 to 1.08, very low-quality evidence).
Of the seven outcomes we assessed using GRADE, only pain intensity was reported in all comparisons. Satisfaction with the childbirth experience, sense of control, and caesarean section were rarely reported in any of the comparisons.