Does moxibustion help turn around a breech baby?

1.         Abstract
2.               Treatment
3.         Background
4.         Objectives
5.         Criteria for including studies
6.         Search strategy
7.         Data collection and evaluation of studies
8.         Description of studies
9.         Methodological quality
10.       Results
11.       Discussion of findings
12.       Conclusions
13.       References
14.      Further Resources

1. Abstract
The incidence of breech presentation at term is approximately 4 in 100 pregnancies. There is an increased risk of harm to the baby with breech presentation when compared with cephalic (head-down) presentation, regardless of the type of delivery. In order to reduce this risk, a number of techniques have been proposed to correct the presentation to cephalic prior to birth.

Moxibustion is a traditional Chinese technique that consists of the burning of sticks or cones made from the herb moxa (Artemisia vulgaris, also known as mugwort). These are positioned on or beside an acupuncture point on the fifth toe of each foot. (Bladder point 65). It is suggested by practitioners of moxibustion that it stimulates the production of maternal hormones, which encourage the lining of the uterus to contract and in turn stimulate foetal activity.

A Cochrane systematic review of three randomised controlled trials and also a fourth more recent randomised controlled trial are the basis for this report.

There is evidence that moxibustion helps to correct breech presentation, though studies were small. Twenty-two percent of women in the most recent study discontinued or interrrupted the use of moxa due to side effects, such as an unpleasant smell causing nausea and throat problems, and abdominal pain caused by contractions.

2. Treatment
Type of treatment: Moxibustion, an acupuncture technique using the herb moxa
Scientific name (genus and species): Artemisia vulgaris
Synonyms and common names: Mugwort
Condition: Breech birth

3. Background
Until the last weeks of pregnancy, a baby is able to move freely in a roomy bag in the womb (the amniotic sac), which is filled with amniotic fluid (‘the waters’). By the eighth month, when the baby is about 50 centimetres long and weighs just over three kilograms, there is less room to move (Ministry of Health 2004).

At this stage, most babies settle into a vertical, head-down position called the cephalic or vertex position. This allows the baby to be born head-first by a vaginal birth. When labour begins most babies are in this position, but a few (up to 4%) will settle into a bottom-first, or breech position.

If the baby remains in a breech position after 36 weeks, an offer may be made to attempt to turn the baby into ‘head-first’ position, as this type of birth is better for both mother and baby. Harm to the baby occurs in about one in every 28 vaginal breech births (Ministry of Health 2004).

The process most likely to turn the baby successfully is called external cephalic version (ECV), which can be carried out from 37 weeks until the onset of labour. ECV has a 67% success rate but sometimes the baby fails to turn or (less frequently) rotates back to a breech position later on. ECV requires specialist skills and is carried out by an experienced obstetrician. The foetal heart rate sometimes alters during ECV but usually settles spontaneously. Serious adverse effects are rare but there have been a few reported cases of premature separation of the placenta and premature onset of labour and so ECV needs to be performed in a hospital with emergency caesarean delivery services (delivery by surgery) (Ministry of Health 2004, American College of Obstetricans and Gynaecologists 2000). If the baby remains breech, the mother may choose to have an elective (planned) caesarean section.

An alternative option sometimes used to try to turn the baby is an acupuncture technique called moxibustion, which involves burning a herb called moxa (Artemisia vulgaris). Sticks or cones of burning moxa are held close to an acupuncture pressure point on the fifth toe of each foot in order to induce a warming sensation. It is suggested that this stimulates the production of maternal hormones (placental oestrogens and prostaglandin) and encourages the lining of the uterus to contract, which in turn stimulates foetal activity. Sometimes acupuncture needles are also used. Moxibustion treatment regimens vary and there is no consensus on the best regimen, but moxibustion may be administered between the 33rd and the 40th week of pregnancy for 15 to 20 minutes, one to ten times daily, for up to 10 days (Coyle 2005).

4. Objectives
To assess the potential benefits and harms of moxibustion for breech presentation, compared with other interventions or with no intervention.

5. Criteria for including studies
Types of study: published systematic reviews or randomised controlled trials of moxibustion compared with either no treatment or with other interventions

Types of participants: women with a singleton baby in breech presentation

Types of intervention: moxibustion administered alone or in conjunction with acupuncture.

Types of outcome measures: baby's presentation at birth, need for external cephalic version, mode of birth, perinatal morbidity and mortality, maternal complications and satisfaction and adverse events.

6. Search strategy
We searched the following databases in October 2005: The Cochrane Library, MEDLINE, EMBASE, CINAHL. We also checked the reference lists of publications retrieved by the search for further relevant studies.

7. Data collection and evaluation of studies
We used the above search strategy to obtain titles and abstracts of studies that were potentially relevant to this review. Where studies met the criteria for inclusion they were assessed in full text. The quality of each study was evaluated using the SIGN criteria (http://www.sign.ac.uk/methodology/checklists.html). Where primary studies were included in a good quality systematic review, the systematic review was included rather than the individual primary studies.

The overall quality of the body of evidence (considering all the included studies) was graded according to the Centre for Evidence-Based Medicine (CEBM) levels of evidence system (www.cebm.net/levels_of_evidence.asp).

Relevant data were extracted from the studies selected for inclusion.

8. Description of studies
Two studies met the criteria for inclusion, comprising a recent Cochrane systematic review of randomised controlled trials (RCTs) of moxibustion (Coyle 2005) and one randomised controlled trial published since the publication of the systematic review (Cardini 2005).

Summary details of the trials included in the systematic review are as follows:

Study

Participants

Intervention/Comparison

Outcomes measured

Comment

Cardini 1998

Jiangxi province, China

N=260

Inclusion: primigravidae in 33nd week of pregnancy with breech confirmed by ultrasound

(1) Moxibustion alone (30-60 mins daily for 7 days administered by the pregnant woman)

(2) No intervention

· Number of cephalic presentations at 35 weeks and at birth

· Foetal motor activity

· Caesarean rates

Women could have ECV if still in breech at 35 weeks and outcomes analysed by ITT

Li 1996

N=111

Inclusion: Pregnant women over 28 weeks gestation with breech, transverse or occipitoposterior presentation

(1) Moxibustion alone (administered bilaterally for 20 mins per day for 6 days)

(2) Electroacupuncture (administered to same acupoint (BL67) for 30 mins per day for 6 days)

(3) No intervention

· Number of cephalic presentations at birth

· Number of treatments required for correction of presentation

Only 40/111 had breech presentation

Neri 2004

Italy

N=240

Inclusion: Pregnant women between 33 and 35 weeks with singleton breech presentation confirmed by ultrasound.

(1) Acupuncture plus moxibustion to BL67 (biweekly for 2 weeks)

(2) No intervention (routine care)

· Presentation at birth

· Incidence of caesarean section

· Adverse effects

No ECV was offered.

Summary details of the study published since the Cochrane review, are as follows:

Study

Participants

Intervention/Comparison

Outcomes measured

Comment

Cardini 2005

Italy

N=123*

Inclusion: Non-Chinese primigravidae in 33nd week of pregnancy with breech confirmed by ultrasound

(1) Moxibustion alone (30 mins twice daily for 7 days administered by the pregnant woman alone or accompanied by partner or helper)

(2) Observation

· Number of cephalic presentations at 35 weeks and at birth

· Foetal motor activity

· Compliance with treatment

· Adverse events

Women could have ECV if still in breech at 35 weeks and outcomes analysed by intention to treat.

* The study was interrupted after 46% of the planned sample had been recruited because of a high number of treatment interruptions

9. Methodological quality
Both the Cochrane review (Coyle 2005) and the primary study (Cardini 2005) were of fair quality overall when evaluated using the SIGN criteria.

10. Results
In the Cochrane review, the findings of the three trials were not pooled in meta-analysis because of differences in the interventions and participants. Notably, over half the women in one of the trials had babies in a transverse or occipitoposterior position, rather than breech (Li 1996). In all three trials the women in the moxa group were significantly less likely to have a non-cephalic presentation at birth. No differences in non-cephalic presentation were found in the when moxibustion was compared with electroacupuncture alone (Li 1996).

One of the trials in this review (Cardini 1998) compared the need for external cephalic version (defined as breech presentation at the end of the trial intervention) in the two groups. Moxibustion resulted in a significantly decreased need for external cephalic version.

In the trial published since the systematic review, recruitment was discontinued with only 46 per cent of the planned sample size. This was due to poor compliance with treatment: among the moxa group, 27 of 65 participants (41%) complained of unpleasant symptoms, the most common being unpleasant odour with or without nausea and throat problems (14 cases), and abdominal pain because of contractions (11 cases). Fourteen participants (22%) interrupted or withdrew from the treatment because of these symptoms. There were two cases of preterm delivery at 34 weeks associated with definite (1 case) or suspected (1 case) premature rupture of membranes (PROM). The authors suggested that further studies are necessary to assess the frequency of PROM with moxibustion. This study found no significant difference in cephalic presentation either in the 35th week of pregnancy or at birth.

Summary of results for the oucome Non-cephalic presentation at birth

Study	Sample size	Comparison	Relative risk (95% confidence interval)
Cardini 1998	235*	Moxibustion vs no treatment	0.55 (0.38 to 0.31)
Li 1996	63	Moxibustion vs no treatment	0.30 (0.16 to 0.55)
Neri 2004	126	Moxibustion plus acupuncture vs no treatment	0.73 (0.57 to 0.94)

*Excludes 25 women who had ECV at end of trial period

11. Discussion of findings
Despite statistically significant results showing a benefit for moxa in the three included trials, the authors of the Cochrane review concluded that there was insufficient evidence to support the use of moxibustion to correct breech presentation, though they reported that it might be beneficial in reducing the need for external cephalic version and might decrease the use of oxytocin in labour.

It is hard to draw any conclusions about the effectiveness of moxa from the most recent study (Cardini 2005), due to its interruption and low sample size. The authors of this study, which included only non-Chinese participants, suggested that the high level of non-compliance related to unpleasant side effects may have been due to cultural or contextual factors, which could have negatively influenced the researchers and/or participants. However, these difficulties were not experienced in the other trial with non-Chinese participants (Neri 2004), which was included in the Cochrane review.

12. Conclusion
The three small randomised controlled trials included in the systematic review provide level 2 evidence that moxibustion, with or without the insertion of acupuncture needles, can help correct breech presentation.

However, there is a need for larger well-designed trials to adequately evaluate the benefits and safety of moxibustion, both alone and in combination with acupuncture. The difficulties experienced by the most recent trial (Cardini 2005) underline the potential methodological challenges of evaluating a traditional treatment transferred from a different cultural context.

13. References
· Cardini F, Weixin H. Moxibustion for correction of breech presentation. JAMA 1998;280(18):1580-4.

· Cardini F, Lombardo P, Regalia AL, Regaldo G, Zanini A, Negri MG, Panepuccia L, Todros T. A randomised controlled trial of moxibustion for breech presentation. BJOG 2005;112(6):743-7.

· Cochrane review: Cephalic version by moxibustion for breech presentation
http://ww.mrwinterscience.wiley.com/cochrane/clsysrev/articles/CD003928/frame.html

· Li Q, Wang L. Clinical observation on correcting malposition of fetus by electro-acupuncture. Journal of Traditional Chinese medicine 1996; 16(4): 260-2.

· Ministry of Health 2004 http://www.healthed.govt.nz/upload/PDF/HP3860.pdf]).

· Neri I, Airola G, Contu G, Allais G, Facchinetti F, Benedetto C, Acupuncture plus moxibustin to resolve breech presentation: a randomised controlled study. Journal of Maternal-Fetal and Neonatla Medicine 2004; 15:247-52.

14. Further Resources
· New Zealand Guidelines Group, November 2004. Care of Women with Breech Presentation or
Previous Caesarean Birth http://www.nzgg.org.nz/guidelines/0074/Caesarean_Full_Guide_(web).pdf

Report prepared: 27 Jan 2006 Last updated: 7 Feb 2006