Between weeks 24–27 of pregnancy, 23.5% of fetuses are in a breech presentation, reducing to 2.5% in term pregnancies (Toijonen et al, 2020). A breech is considered a malpresentation that is associated with stillbirth and adverse perinatal outcomes (Carbillon et al, 2020). However, some clinicians consider it a variation from normal (Morris et al, 2018). In breech, the fetal buttocks lie lowermost in the maternal uterus and the fetal head is at the fundus, classified as frank, complete and incomplete (footling), its diagnosis is made by ultrasound. Management of breech birth is controversial and since the publication of the Term Breech Trial (Hannah et al, 2000), planned caesarean section has become the recommended mode of birth for breech birth. External cephalic version, manual manipulation of the fetus from breech to cephalic position, is also routinely offered to women (Impey et al, 2017). However, these practices carry significant risks, including placental abruption and cord prolapse (Dahl et al, 2021).
Moxibustion is a technique derived from traditional Chinese medicine. The procedure involves the use of moxa sticks consisting of dried mugwort (Artemisia vulgaris) herb. The sticks are used as a heat source applied to the bladder 67 acupoint (Figure 1) (Morris et al, 2018). The thermal stimulation to the acupoint causes the adrenal cortex to release glucocorticoids, leading to changes in placental oestrogen and prostaglandin production, thereby increasing myometrial sensitivity and contractility (Schlaeger et al, 2018). Additionally, it encourages adenosine triphosphate release, affecting primarily the fetus. Therefore a slight but regular rise in the fetal heart rate is seen during treatment (Lei et al, 2015). The combination of increased uterine and fetal activity may lead to the fetus turning itself to a cephalic presentation (Tiran, 2018). Under traditional Chinese medicine and Royal College of Obstetricians and Gynaecologists (RCOG) guidelines, the optimum time for treatment is between 33 and 35 weeks gestation (Impey et al, 2017; Tiran, 2018).
Figure 1. Location of the bladder 67 acupoint meridian
A systematic literature search was carried out to identify articles that focused on the benefits of using moxibustion for low-risk women. The definition for low-risk women was agreed by the papers to be a singleton breech presentation with normal growth within 10th and 90th centile, no fetal abnormalities and the absence of predisposing health conditions or uterine abnormalities, such as fibroids or pathology in the current pregnancy (ie infection), or pelvic defects.
Search strategy
The research question was formulated using the population, intervention, comparison and outcome framework. A comprehensive search was undertaken using Maternity and Infant Care, Medline, Cochrane Database of Systematic and CINAHL databases chosen for its credibility within the field (Greenhalgh, 2019). The search terms used were ‘moxibustion’ and ‘childbirth’ or ‘birth’, ‘labour’ or ‘labor’. Boolean operators were used to include each term searched for, and synonyms identified (Aveyard and Sharp, 2017). The inclusion criteria were full-text research articles, written in English and dated July 2010 to July 2020, as this would be the most relevant data range. Five studies were selected in total (Figure 2), four from the initial search, which were two systematic reviews and two randomised controlled trials. A further randomised controlled trial from Cardini and Weixin (1998) was chosen after reading the reference list of the selected papers, as it is known as a seminal study (Rees, 2012). Literature appraisal was carried out using two Critical Appraisal Skills Programme (CASP, 2018a; 2018b) guidelines and the Standards for Reporting Interventions in Clinical Trials of Moxibustion (Cheng et al, 2013). All articles were then individually analysed, and a data table was created to summarise the findings (Table 1).
Figure 2. PRISMA flowchart showing process of study selection
Table 1. Summary of the main findings from reviewed articles
| Study | Design | Sample and place | Data collection | Main findings |
|---|---|---|---|---|
| Cardini and Weixin (1998) | Randomised, controlled open trial | 260 primiparous women in 33rd week gestation with low-risk pregnancy. Carried out in China | Intervention group received treatment with moxa stick for 7 days, with treatment for additional 7 days if fetus persisted in breech presentation.Control group received routine midwifery care | 35 weeks gestation: cephalic presentation in 75.4% of intervention group and 47.7% of control.At birth: cephalic presentation in 75.4% of intervention group and 62.3% of control. Oxytocin use before or during labour in women who had vaginal birth: 8.6% (intervention), 31.3% (control).Cephalic version used twice a week for 14 days: 79.1% of versions, 55.2% of control were able to turn cephalic.2 vacuum-extractor and 1 forceps birth (intervention group); 2 vacuum-extractor and 3 forceps births (control).Moxibustion is non-invasive, low-cost, and easy to use |
| Vas et al (2013) | Randomised controlled trial | 406 low-risk pregnant women within 33–35 weeks gestation (203 primiparous, 203 multiparous). Carried out in Spain | Women assigned to true moxibustion (n=136) using BL67 point, sham moxibustion (n=136) using SP1 point or routine midwifery care (n=134).True moxibustion and sham moxibustion used for 20 minutes a day for 2 weeks | Rate of cephalic presentation at birth for true moxibustion was 58.1%, sham moxibustion was 43.4% and routine care was 44.8%.Moxibustion found to be safe and efficiently used by women at home |
| Do et al (2011) | Feasability randomised controlled trial | 20 low-risk pregnant women within 34–36.5 weeks gestation (15 primiparous). Carried out in Australia | Women randomised to either routine midwifery care and moxibustion treatment (n=10) or routine midwifery care only (n=10).Moxibustion treatment applied for 20 minutes, twice a day for 10 days | Cephalic at birth: 5 (moxibustion), 2 had external cephalic version; 1 (midwifery), 1 external cephalic version.Caesarean section: 6 (moxibustion); 9 (usual care).Women and professionals found treatment acceptable with no side-effects, although three women found administering difficult and would have liked more assistance |
| Coyle et al (2012) | Systematic review and meta analysis | Eight trials involving 1346 women | Examining moxibustion use against control in women with singleton breech presentation | Moxibustion resulted in decreased oxytocin use compared with no treatment, and reduction in number of breech presentations at birth compared with acupuncture. When combined with acupuncture, moxibustion resulted in reduction in number of breech presentations at birth and number of caesarean sections compared with no treatment.No significant adverse effects noted |
| Miranda-Garcia et al (2019) | Systematic review | Five systematic reviews including 5339 pregnant women with single fetus in non-cephalic presentation | Evaluate efficacy and safety of moxibustion and acupuncture in type of birth, caesarean section rates, oxytocin use and adverse effects | Moxibustion alone or with acupuncture or postural techniques can reduce number of breech presentations at birth. Moxibustion for non-cephalic presentation reduces oxytocin use compared with no treatment.Three trials concluded that moxibustion use against no treatment or with acupuncture reduced caesarean sections.All studies demonstrated no adverse effects during moxibustion treatment |
Critique
Cardini and Weixin (1998)
Cardini and Weixin (1998) undertook a randomised, controlled, open trial aimed to evaluate the efficacy and safety of moxibustion use to correct breech presentation. The study was carried out in China and included primiparous women with low-risk, uncomplicated pregnancies in the 33rd-week gestation and with a diagnosis of breech presentation between April 1995 through August 1996. The treatment group received moxibustion (n=130), and the control group received routine midwifery care (n=130).
The authors have written other articles with similar topics that are still current and cited within the field, demonstrating the researcher's credibility (Panter, 2020). An open trial is a study design where participants and researchers are not blinded to the experiment (Sedgwick, 2014). All the procedures were carried out by midwives except the ultrasound scan and external cephalic version, following the ethical standards of the Declaration of Helsinki (Padulo et al, 2018).
Nine women dropped out of the study, known as a subject mortality rate (Rees, 2012). There was no attrition rate, meaning the loss of participants during a study because of protocol deviation, withdrawal or dropouts, as these women were included in the ‘intention to treat’ analysis (LoBiondo-Wood, 2017; CASP, 2018a). The intervention consisted of 30 minutes of moxa application, once or twice a day for 7 or 14 days. However, moxibustion details were not supplied by the authors, influencing the repeatability of treatment (Cheng et al, 2013).
Inferential statistics are used to assess probability, quantified as the P value. P<0.05 is statistically significant, meaning that findings are likely to generalise to the wider population (Rees, 2012). At 35 weeks gestation, 75.4% of the intervention group had a cephalic presentation, compared to 47.7% in the control group (P<0.001). At birth, 75.4% from the intervention group and 62.3% of the control group had a cephalic presentation (P=0.02). In regards to vaginal birth, 8.6% of women from the intervention group used syntocinon before or during labour versus 31.3% in the control group (P<0.001). There were two vacuum-extractor and one forceps birth in the intervention group and two vacuum-extractor and three forceps births in the control group. The moxibustion regime, used twice a day for a week, obtained 79.1% of versions, whereas 55.2% version were obtained in the control group (P=0.007).
Nevertheless, in the UK, moxibustion treatment is not well known and not included in every maternity service, as in China. Also, women's ethnicity is varied; hence some elements of generalisability and transferability are lost. The authors determined moxibustion to be safe, concluding that moxibustion use in primiparous women is an effective way to increase cephalic versions and is also non-invasive, low-cost, and an easy to use treatment. Van den Berg et al (2010) shows the mean cost-saving in cases where moxibustion is used is £386 (€451) per woman. Still, more studies are needed to determine its usefulness in multiparous women and different populations.
Vas et al (2013)
Vas et al (2013) carried out a multicentre randomised controlled trial in Spain, between April 2008 and December 2010, recruiting women with uncomplicated pregnancies and a breech fetus between 33 and 35 weeks gestation. The women (equal number of primiparous and multiparous) were assigned to true moxibustion (n=136), sham moxibustion (n=136) or routine midwifery care (n=134) groups. The purpose was to measure the effectiveness and safety of moxibustion use.
Randomisation was double-blinded, hence internal validity was preserved (Cluett, 2006; CASP, 2018a). Apart from the routine care group, for which blinding was not feasible after randomisation (Sedgwick, 2014). The sample was stratified to each healthcare centre by software-generated cards, meaning that random sampling is carried out differently for each centre (Greenhalgh, 2019). The goal of this process is to achieve better representativeness of the population. Both the moxibustion and the placebo procedure were identified in regards to the description of treatment, reasoning and extent of each regime, ensuring treatment repeatability and generalisability (Cheng et al, 2013).
Outcomes for cephalic presentation at birth demonstrated relative risk of 1.29 (95% confidence interval 1.02–1.64) for moxibustion use against routine care, and relative risk of 1.34 (95% confidence interval 1.05–1.70) for moxibustion against sham moxibustion. Secondary outcomes were the high acceptance rate of moxibustion treatment, with only 4.2% women declining to participate and no severe effects found among the treatment group. Nevertheless, results can be transferable to the UK maternity population, as services are also provided within the public system, midwifery-led, and are in developed countries. The authors recommended moxibustion to be effective and safe to correct breech presentation at birth and be efficiently used by women at home.
Do et al (2011)
Do et al (2011) performed a feasibility randomised controlled trial in Australia between December 2009 and June 2010. Participants were primiparous (n=16) and multiparous (n=4) women with uncomplicated pregnancies and breech fetuses between 34–36.5 weeks of gestation. Primary outcomes included cephalic presentation at birth, the need for external cephalic version, mode of birth, perinatal morbidity and mortality, maternal complications and adverse events. Women were randomised to either moxibustion treatment (n=10) or routine midwifery care (n=10). The researchers gave an estimated sample size of 30, a plausible figure to the feasibility nature of the research (National Institute for Health Research, 2019). However, only 20 women were recruited, and according to researchers, recruitment was slower than anticipated. This is a strength of the study, as authors are explicit about unforeseen recruitment challenges (LoBiondo-Wood, 2017). On the other hand, small sample size is seen as a limitation of the study (Greenhalgh, 2019).
The moxibustion protocol encompassed the use of smokeless and odourless moxa sticks, for 20 minutes, twice a day for 10 days. To encourage compliance and improve reliability, the intervention group received their first treatment in hospital, where the technique was explained, and moxa sticks were given for the duration of treatment, which was done at home. The procedure and explanation given to participants were appropriate to the repeatability and generalisability of results. The researcher providing treatment was reported as having 15 years of clinical experience in acupuncture, adding validity to the study (Cheng et al, 2013).
The results showed five infants to be cephalic at birth from the moxibustion group (two had external cephalic version), compared to one in the midwifery care, who had an external cephalic version (P=0.11). Six women who had moxibustion required caesarean sections (P=0.15), compared to nine in usual care (P=0.15). Given the P value, the findings are not statistically significant. Primiparous women have a rate of spontaneous version of 46%, multiparous with previous breech of 32% and multiparous without previous breech fetus of 78% (Cardini and Weixin, 1998). The women and professionals involved found the treatment acceptable with no side effects, although three women would have liked more assistance, but the authors did not provide further details. Nevertheless, the findings have promising results to justify further research.
Coyle et al (2012)
Coyle et al (2012) undertook a systematic review and meta-analysis using six relevant databases to select original articles, from 1966 until 2011. Looking at moxibustion use against a control group in women with singleton breech presentation, a total of eight trials involving 1346 women were analysed. It aimed to examine the safety and effectiveness of moxibustion for turning a breech, the need for external cephalic version, mode of birth, perinatal morbidity and mortality, maternal satisfaction and adverse events.
The researchers should have read the full text of each article to determine its inclusion on the review; however, there was no transparency in confirming this step was followed (CASP, 2018b). Statistical heterogeneity, seeing as wide-ranging characteristics of interventions, participants and trial effect estimates, were addressed by authors with subgroup analysis (Bigby, 2014). Still, differences in intervention frequency, duration and administration of moxibustion were reported (Cheng et al, 2013).
Moxibustion compared to acupuncture had the most statistically significant result for non-cephalic presentation at birth (relative risk: 0.25, 95% confidence interval: 0.09–0.72) and moxibustion use against no treatment resulted in decreased oxytocin use before and during labour (relative risk: 0.28, 95% confidence interval: 0.13–0.60. Lastly, when combined with acupuncture against no treatment, moxibustion use reduced the rates of caesarean section (relative risk: 0.79, 95% confidence interval: 0.64–0.98). No significant adverse effects were noted. Nonetheless, the authors reported clinical heterogeneity and disparity in clinical outcomes because of small sample sizes, differences in intervention and limited reporting, thus warranting caution when interpreting the results.
Miranda-Garcia et al (2019)
Miranda-Garcia et al (2019) conducted a systematic review by searching four databases from June 2012 to 2018 and selecting five papers that included 5339 pregnant women with a single fetus in a non-cephalic presentation. The study aimed to evaluate the efficacy and safety of moxibustion and acupuncture in regards to the type of birth, caesarean section rates, syntocinon use and adverse effects. However, for this review, acupuncture will not be analysed. The literature search was comprehensive, with the inclusion of Spanish and English language. However, in moxibustion research, it would be fundamental to include Chinese language studies (Cheng et al, 2013).
The authors could have searched the reference list of the articles included, hand-searched influential journals and looked at unpublished literature such as ‘grey’ literature (not published in public domains, such as a dissertation) and contact experts (CASP, 2018b). However, the inability to search the literature widely introduces publication bias, that is, the propensity of articles with beneficial outcomes to be published more often than those with unfavourable results (Aveyard, 2018), thus posing a threat to internal validity and applicability of findings (Ortega and Barker, 2019).
The authors found seven different techniques for cephalic version, but the most significant being moxa applied to bladder 67 (Cheng et al, 2013). The authors concluded that moxibustion could reduce the numbers of breech presentation at birth and that moxibustion practice for breech presentation decreases syntocinon use compared with no treatment. No adverse effects were directly attributed to moxibustion usage. However, the results should be interpreted with caution becuase of clinical heterogeneity. The researchers state that blinding in moxibustion trial is not feasible, suggesting using external cephalic version as a comparison for future research.
Conclusions
The authors of the five studies reviewed found that moxibustion use for low-risk pregnancies with a fetus in a breech presentation can assist cephalic version of the fetus. Cardini and Weixin (1998), Coyle et al (2012) and Miranda-Garcia et al (2019) reported a reduction in the use of synthetic oxytocin before and during labour, while Cardini and Weixin (1998) saw a slight reduction in instrumental birth. In combination with acupuncture, moxibustion decreases the rate of caesarean section, as Coyle et al (2012) and Miranda-Garcia et al (2019) described. These findings coupled with the low-cost, minimal side-effects including nausea, abdominal pain and local burning, and women and professional's acceptability to the procedure, as Vas et al (2013) and Do et al (2011) outlined, makes service providers more willing to offer it, as it demonstrates safety, it gives women choice and reduces the cost for the NHS and the burden of an already overstretched healthcare (NHS Improvement, 2016). For women, it normalises childbirth and offers a chance to attempt a vaginal birth. The heterogeneity of the data must be acknowledged regarding moxibustion treatment effect, duration, frequency, type, use at different gestations and parities and the unsuitability of randomisation for this type of intervention. Therefore, it warrants further investigation with appropriate procedure and methodology that will elucidate reliable and up-to-date outcomes, thus informing and developing practice changes.
Key points
- This study was a literature review of five papers that examine the use of moxibustion during breech birth
- The reviewed studies determined moxibustion to be safe, concluding that moxibustion use in primiparous women is an effective way to increase cephalic versions and is also non-invasive, low-cost, and an easy to use treatment
- The studies analysed were of mixed quality because of differences in treatment protocol, the inability to blind participants and differences in outcome measured. However, researchers try to achieve the gold standard of research design by using randomised controlled trials
- The researchers of one paper state that blinding in a moxibustion trial is not feasible, and suggest using external cephalic version as a comparison for future research
- Moxibustion use for low-risk pregnancies with a fetus in a breech presentation can assist cephalic version of the fetus, as well as reducing the need for synthetic oxytocin before and during labour. In combination with acupuncture, it decreases the rate of caesarean section
CPD reflective questions
- What is your local hospital guideline and policy on the use of moxibustion for breech presentation? Are moxibustion practices promoted in your hospital?
- Great training is needed for midwives to understand the principles and practice of moxibustion use in pregnancy. Is there a service in place to train midwives in using moxibustion for breech presentation?
- How can healthcare professionals, such as midwives ensure that they are using evidence-based information when delivering moxibustion advice to pregnant women? Are there information leaflets used in your hospital, to inform women of the service?