Holistic Pregnancy & Childbirth

Holistic Pregnancy & Childbirth
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Research

Research

Contributor(s)
Kathryn Leggitt, RNC, MS, CNM
Reviewer(s)
Deborah Ringdahl, DNP, RN, CNM

doing reiki during labor

As you might imagine, there is a wealth of research on pregnancy and childbirth. However, it might surprise you to learn that, despite all of this information, healthcare providers still don't have definite answers to many of the questions surrounding childbearing.

What types of research exist?

The "gold standard" of clinical research is the large double-blind study, wherein one group of participants receives the treatment being studied and one group does not. These groups are assigned randomly in order to reduce bias. Neither the people participating in the study nor the people conducting it know who is actually getting the treatment and who is not.

This type of research is very hard to conduct among pregnant people. The health and wellbeing of the baby must be considered, along with the health and wellbeing of the parent. It is especially difficult to design a "blind" study when considering holistic alternatives. For example, if researchers were doing a study on the effects of hydrotherapy on childbirth, it would be obvious to the person in the study, their care provider, and the researchers if she were using a shower or bathtub during labor.

Care providers must depend on research that might not meet the double-blind gold standard, but that has credibility because it has been repeated several times with similar results, or because it tested the same participants before and after an intervention. They also rely on case studies, their own knowledge base of physiology and biochemistry, and on the practices of other obstetric providers.

What are practice standards?

All these types of knowledge are used to develop evidence-based practice standards, which reflect the current understanding of pregnancy and childbirth. In evidence-based practice standards, the research and other evidence supporting a particular practice is graded. A practice that was demonstrated to be effective and safe based on a large double-blind study would receive a higher grade than a practice based on a smaller study, an observational study, or on the opinion of childbirth experts. Thus, an evidence-based practice standard gives the care provider an indication of how strong the evidence about the practice is, and whether the practice is likely to be helpful, likely to be harmful, or somewhere in between. As new research is done, the suggested best practices change.

This article reflects these limitations, and you should understand that while you will not find absolute answers here, you might gain a deeper understanding of some childbearing issues.

What do we know about holistic childbearing?

woman in labor with Midwife & HusbandThere is considerable research that indicates that pregnant people who are fully involved in their prenatal care and birth, who are able to advocate for their wishes and for their infant's healthcare, and who feel that their wishes have been honored by their caregivers feel more satisfied with and empowered by their experiences. (1,2)

Several holistic practices and complementary therapies have been studied in pregnancy and childbirth. There is some evidence that pregnant people who use holistic therapies have increased satisfaction with their birth experience, and have lower rates of medical interventions during birth. (2) The following is a partial list of holistic practices and complementary therapies used in childbirth, along with benefits noted in the research. (The numbers refer to the articles listed in the References.)

  1. Massage: Associated with enhanced satisfaction, better coping, and lower intervention rates. May promote relaxation, promote labor progress, and decrease pain perception. (2,5,6,7,20)
  2. Aromatherapy: Associated with enhanced satisfaction, better coping, lower intervention rates, and less medication use. (2,4,13,14)
  3. Hydrotherapy: Associated with enhanced satisfaction, lower intervention rates, less medication use, fewer epidurals, and better fetal positioning. May promote labor progress. (2,8,9,10,11,12,20)
  4. Acupressure: Associated with enhanced satisfaction, lower intervention rates, and shortened labor time. May provide pain relief. (2,3,15)
  5. Hypnosis: Associated with increased satisfaction, less pain medication, and fewer epidurals. May provide pain relief. (3,16,17)
  6. Music: Associated with enhanced coping, reduced stress, and reduced pain perception. (18,19,20)
  7. Doulas: Associated with increased satisfaction, less use of pain medication, less use of epidurals, shorter labors, less use of oxytocin, fewer cesarean sections, fewer vacuum or forceps deliveries, and higher newborn APGAR scores. (21,24,25)
  8. Waterbirth: Associated with increased satisfaction, less use of pain medication, less perineal trauma, fewer episiotomies, fewer infant complications, and higher newborn APGAR scores. (22,23)
  9. Reiki: Not specifically studied with regard to childbirth pain, but associated with decreased pain, increased relaxation, and decreased anxiety in other situations. (46,47) Case studies of use for labor patients are reported by an obstetrician/Reiki practitioner. (45)

What does the research tell us about common pregnancy and childbirth practices?

labor with midwifeThe Cochrane Library is a collection of research analyses, with about one-third of its articles devoted to childbearing. The Cochrane Library evaluates the evidence for pregnancy and childbirth practices and assigns one of the following categories:

  • Clearly beneficial
  • Likely to be beneficial
  • Trade-off between beneficial and adverse effects
  • Unknown effectiveness
  • Unlikely to be beneficial
  • Likely to be harmful (26)

Some of the most controversial, yet common, practices encountered in pregnancy and childbirth are outlined in the slideshow below, along with research findings. We also include the likelihood of the practice being beneficial, as concluded by Enkin et al.'s review of the Cochrane Library findings. (30)

Of course, there are many other topics of interest surrounding pregnancy and childbirth, and not all can be covered in this slideshow. If you are interested in reading further about childbearing research, the Childbirth Connection website has an excellent summary of current evidence and research findings.

Summary of evidence from Cochrane reviews

Cochrane reviews are highly regarded by researchers and medical professionals because they summarize the evidence around a particular practice or therapy in a non-biased manner.  

Cochrane reviewers find all the research studies conducted for a particular practice or therapy, for example continuous fetal monitoring, and evaluate the quality of each study.  Good quality studies are included in a statistical analyses, which determines the category assigned to the practice.

Group B Strep screening and treatment 

Research findings: Antibiotic treatment in labor of individuals colonized with GBS appears to reduce the likelihood of the infant becoming ill with GBS sepsis.30 Risks of universal screening and treatment include antibiotic allergic reaction. The GBS infection rate among newborns has decreased with universal screening, but the rate of neonatal e-coli infection has simultaneously increased. (31)   
Benefit:Clearly beneficial

Epidurals, intrathecals, or spinal anesthesia 

Research findings: Most effective at providing pain relief for most individuals in labor. Birthing individual remains alert and conscious. Side effects may include increased risk of cesarean section, vacuum or forceps delivery, low blood pressure, headache, backache. (30,32,33,34)  
Benefit:Trade-off between beneficial and adverse effects

Pain medication (non-epidural forms) 

Research findings: May provide adequate relief from pain for some birthing individuals. Side effects may include a "drugged" feeling, respiratory depression in the newborn,  newborn irritability. (30,35,36) 
Benefit:Trade-off between beneficial and adverse effects

Lying on one's back 

Research findings: May decrease oxygenation of the uterus by up to 30%, resulting in less oxygen to the baby and less effective contractions.30 May promote posterior positioning of the baby. (37)   
Benefit:Likely to be harmful

Obstetric ultrasound 

Research findings: May be done to resolve questions of estimated due date, the number of babies, the size, anatomy, and wellbeing of the baby, the amount of amniotic fluid, and the position of the placenta. (30) A few studies have questioned the safety of obstetric ultrasound, raising issues such as dyslexia and low birth weight, but the findings have not been repeated with larger well-designed studies. (38,39,40)  Nevertheless, the U.S. Food and Drug Administration cautions against the use of ultrasound unless it is medically indicated, as does the American Institute of Ultrasound in Medicine. 
Benefit:Likely to be beneficial

Continuous fetal monitoring 

Research findings: The use of continuous fetal monitoring has been associated with an increase in cesarean section, forceps, and vacuum extractor rates, without any evidence of benefit to the infant. It has not been associated with a decrease in infant mortality rates, increased APGAR scores, or a decrease in problems associated with a lack of oxygen to the baby. (41,42,43,44)    
Benefit: Trade-off between beneficial and adverse effects

Episiotomy 

Research findings: Individuals most likely to receive episiotomy are first-time birthing people, those with a long pushing stage, or pregnant people whose baby's have a low heart rate at the end of labor. (48,49,50) Episiotomies are associated with increased pain after birth and more severe tears. (48)   
Benefit:Likely to be harmful

Elective induction 

Research findings: Elective inductions are those undertaken for the convenience of the pregnant parent and the provider, and may be done for many reasons: to take advantage of help from extended family, work schedules, living a great distance from the hospital, or general discomfort at the end of pregnancy. Especially for first-time parents, elective inductions are associated with a higher cesarean section rate than found for pregnant individuals who enter labor spontaneously. (51,52,53,54) Induction has also been associated with higher use of forceps or vacuum extractor and postpartum hemorrhage. (51,55,56) 
Benefit:Not evaluated

Inducing after rupture of membranes (water breaking) before labor starts 

Research findings: The bag of water provides protection from infection, and therefore it has been common for birthing people to have labor induced if the water breaks. However, most birthing people will start to have contractions within a day of their water breaking, and the most recent research does not indicate an increased infection risk after 24 hours. Avoiding vaginal exams in the absence of active labor seems to be the best way to avoid infection. (57,58) 
Benefit:Trade-off between beneficial and adverse effects

 

Restricting food and liquids during labor 

Research findings: Initially used to reduce risk of breathing the stomach contents into the lungs if a patient vomited while under anesthesia, a real but rare risk. The work of the intestines slows during labor, as the body's resources are devoted to the contractions of the uterus, however, labor is a strenuous activity requiring calories, and fasting during labor has not been shown to guarantee an empty stomach should anesthesia become necessary. Dehydration can result from restricting fluid intake. (26,30)   
Benefit:Unlikely to be beneficial

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Are pregnant people receiving the best pregnancy and childbirth care?

With the development of the Cochrane Library, the field of obstetrics was among the first to promote widespread distribution of research findings through searchable research reviews. (27)  Sadly, there is some evidence that pregnant people are not receiving care that reflects our understanding of best childbirth practices. The Childbirth Connection, a 90-year-old organization devoted to promoting maternity care, conducted recent surveys of parents and found that beneficial practices were not as widely used as they should be.

Holistic practices and beneficial activities that should be used by all healthy birthing people, such as walking during labor, drinking liquids, and using an upright position for pushing, were only used by a few.

The Childbirth Connection

Excess interventions and disempowerment

Additionally, many birthing parents reported experiencing several interventions not generally indicated for healthy individuals.

Birthing parents also reported being disenfranchised from decision-making and feeling pressured into interventions by their caregivers. Although most of the survey participants noted that they wanted full information about risks and benefits of interventions, their level of knowledge at the time of the survey indicated that they lacked complete information. (28,29)

Clearly, birthing families must ask questions of their care providers about any proposed plans, and childbirth professionals must remain alert to recommended practice changes and evidence-based practice standards.

1 Johnson, T.R., Callister, L.C., Freeborn, D.S., Beckstrand, R.L., & Huender, K. (2007). Dutch women's perceptions of childbirth in the Netherlands. MCN, American Journal of Maternal Child Nursing, 32(3), p. 170-177.

2 Williams, J., & Mitchell, M. (2007). Midwifery managers' views about the use of complementary therapies in the maternity services. Complementary Therapies in Clinical Practice, 13(2), p. 129-135.

3 Smith, C.A., Collins, C.T., Cyna, A.M., & Crowther, C.A. (2003). Complementary and alternative therapies for pain management in labour. The Cochrane Database of Systematic Reviews, Issue 2, Article No. CD003521.

4 Maddocks-Jennings, W., & Wilkinson, J. M. (2004). Aromatherapy practice in nursing: Literature review. Journal of Advanced Nursing, 48(1), p. 93-103.

5 Brown, S., Douglas, C., & Floor, L. A. (2001). Women's evaluation of intrapartum nonpharmacological pain relief methods used during labor. Journal of Perinatal Education, 10(3), p. 1-8.

6 Chang, M., Wang, S., & Chen, C. (2002). Effects of massage on pain and anxiety on labor: A randomized controlled trial in Taiwan. Journal of Advances in Nursing, 38, p. 68-73.

7 Field, T., Hemandez-Reif, M., Taylor, S., Quintino, O., & Burman, I. (1997). Labor pain is reduced by massage therapy. Journal of Psychosomatics in Obstetrics & Gynecology, 18, p. 286-291.

8 Benfield, R. (2002). Hydrotherapy in labor. Journal of Nursing Scholarship, 34(4), p. 347-352.

9 Cluett, E., Pickering, R., Getliffe, K., & Saunders, N. (2004). Randomised controlled trial of labouring in water with standard of augmentation for management of dystocia in first stage labour. British Medical Journal, 328(7435), p. 314.

10 Eckert, K., Tumbull, B., & MacLennan, A. (2001). Immersion in water in the first stage of labor: A randomized controlled trial. Birth, 28, p. 84-93.

11 Ohlsson, G., Buchave, P., Leandersson, U., Nordstrom, L., Rydhstrom, H., & Sjolin, I. (2001). Warm tub bathing during labor: Maternal and neonatal effects. Acta Obstetricia et Gynecoogical Scandinavica, 80, p. 311-314.

12 Rush, J., Burlock, S., Lambert, K., Loosley-Millman, M., Hutchison, B., & Enkin, M. (1996). The effects of whirlpool baths in labor: A randomized, controlled trial. Birth, 23(3), p. 136-143.

13 Burns, E., Zobbi, V., Panzeri, D., Oskrochi, R., & Regalia, A. (2007). Aromatherapy in childbirth: a pilot randomised controlled trial. BJOG: An International Journal of Obstetrics & Gynaecology, 114(7), p. 838-844.

14 Burns, E., Blamey, C., Ersser, S.J., Lloyd, A.J., & Barnetson, L. (2000). The use of aromatherapy in intrapartum midwifery practice an observational study. Complementary Therapies in Nursing & Midwifery. 6(1), p. 33-34.

15 Lee, M.K., Chang, S.B., & Kang, D. (2004). Effects of SP6 acupressure on labor pain and length of delivery time in women during labor. Journal of Alternative and Complementary Medicine, 10(6), p. 959-965.

16 Letts, P.J., Baker, P.R.A., Ruderman, J., & Kennedy, K. (1993). The use of hypnosis in labor and delivery: a preliminary study. Journal of Women's Health, 2(4), p. 335-341.

17 Cyna, A.M., McAuliffe, G.L., & Andrew M.I. (2004). Hypnosis for pain relief in labour and childbirth: a systematic review. British Journal of Anaesthesia. 93(4), p.505-511.

18 Browning, C.A. (2000). Using music during childbirth. Birth. 27(4), p. 272-276.

19 Phumdoung, S., & Good, M. (2003). Music reduces sensation and distress of labor pain. Pain Management Nursing, 4(2), p. 54-61.

20 Brown, S.T., Douglas, C., & Flood, L.P. (2001). Women's evaluation of intrapartum nonpharmacological pain relief methods used during labor. Journal of Perinatal Education, 10(3), p. 1-8.
 
21 Hodnett, E. D., Gates, S., Hofmeny, G. J., & Sakala, C. (2003). Continuous support for women during childbirth (Cochrane review). The Cochrane Database of Systematic Reviews, (3), CD003766.AQ

22 Geissbuehler, V., Stein, S., & Eberhard, J. (2004). Waterbirths compared with landbirths: an observational study of nine years. Journal of Perinatal Medicine, 32(4), p. 308-314.

23 Geissbuhler, V., & Eberhard, J. (2000). Waterbirths: a comparative study. A prospective study on more than 2,000 waterbirths. Fetal Diagnosis & Therapy, 15(5), p. 291-300.

24 Campbell, D.A., Lake, M.F. Falk, M., & Backstrand, J.R. (2006). A randomized control trial of continuous support in labor by a lay doula. JOGNN - Journal of Obstetric, Gynecologic, & Neonatal Nursing, 35(4), p. 456-464.

25 Scott, K.D., Berkowitz, G., & Klaus, M. (1999). A comparison of intermittent and continuous support during labor: a meta-analysis. American Journal of Obstetrics & Gynecology, 180(5), p. 1054-1059.

26 Rooks, J.P. (1999). Evidence-based practice and its application to childbirth care for low-risk women. Journal of Nurse-Midwifery, 44(4), p. 355-369.

27 King, J.F. (2005). A short history of evidence-based obstetric care. Best Practice & Research in Clinical Obstetrics & Gynaecology, 19(1), p.3-14.

28 Declercq, E.R., Sakala, C., Corry, M.P., & Applebaum, S. (2006). Listening to mothers II: Report of the second national U.S. survey of women's childbearing experiences. New York: Childbirth Connection.

29 Sakala, C., & Corry, M.P. (2007). Listening to Mothers II Reveals Maternity Care Quality Chasm, Journal of Midwifery & Women's Health, 52(3), p. 183-185.

30 Enkin, M., Keirse, M.J.N.C., Neilson, J., Crowther, C., Duley, L., Hodnett, E, & Hofmeyr, J. (1999). A guide to effective care in pregnancy and childbirth (3rd ed.). Oxford: Oxford University Press.

31 American College of Nurse-Midwives. (3003). Early-onset group B strep infection in newborns: prevention and prophylaxis Number 2, April 2003 (replaces Clinical Bulletin number 2, January 1997). Journal of Midwifery & Women's Health, 48(5) p. 375-381.

32 Salim, R., Nachum, Z., Moscovici, R., Lavee, M. & Shalev, E. (2005). Continuous compared with intermittent epidural infusion on progress of labor and patient satisfaction Obstetrics & Gynecology, 106,  p. 301-306.

33 Thorp, J.A., Hu, D.H., Albin, R.M, et al. (1993). The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial. American Journal of Obstetrics & Gynecology, 169(4), p. 851-858.

34 Wong, C.A., Scavone, B.M., Peaceman, A.M. et al. (2005). The risk of cesarean delivery with neuraxial analgesia given early versus late in labor. New England Journal of Medicine, 352, p. 655-665.

35 Caton, D., Corry, M.P.,  Frigoletto, F.D., Hopkins, D.P., Lieberman, E., Mayberry, L., Rooks, J.P.,  Rosenfield, A., Sakala, C., Simkin, P., Young, D. (2002). The nature and management of labor pain. American Journal of Obstetrics & Gynecology, 186(5), S1-S15.

36 Varney, H., Kriebs, J.M., & Gregor, C.L. (2004). Varney's midwifery, 4th ed. Sudbury, MA: Jones and Bartlett.

38 Salvensen, K.A., Bakketeig, L.S., Eik-Nes, S.H., Undheim, I.O., & Okland, O. (1993). Routine ultrasonography in utero and school performance at age 8-9 Years. Lancet , 339, p. 85-89.

39 Salvensen, K.A., Vatten, L.J., Eik-Nes, S.H., Hugdahl, K., & Bakketeig, L.S. (1993). Routine ultrasonography in utero and subsequent handedness and neurological development. British Medical Journal, 307(6897), p. 159-164.

40 Newnham, J.P., Evans, S.F., Michael, C.A., Stanley, F.J., & Landau, L.I. (1993). Effects of frequent ultrasound during pregnancy: A randomised control trial. Lancet, 342, p. 887-891.

41 Haverkamp, A.D., Orleans, M., Langendoefer, S., McFee, J., Murphy, J., Thompson, H.E. (1979). A controlled trial of the differential effects of intrapartum fetal monitoring. American Journal of Obstetrics & Gynecology, 35, p. 627-642.

42 Thacker, S.B., Stroup, D.F., & Peterson, H.B. (1999). Efficacy and safety of intrapartum electronic fetal monitoring: An update. Obstetrics & Gynecology, 86, p. 613-620.

43 American College of Obstetricians and Gynecologists (ACOG). (2005). Intrapartum fetal heart rate monitoring. ACOG practice bulletin No. 70. 2006 Compendium of Selected Publications. Washington, D.C.: ACOG.

44 Thacker, S.B., Stroup, D., & Chang, M. (2001). Continuous electronic fetal heart rate monitoring for fetal assessment during labor. The Cochrane Database of Systematic Reviews, Issue 2, Article No. CD000063.

45 Mills, J. (2001). Tapestry of Healing: Where Reiki and medicine intertwine. Green Valley, AZ: White Sage Press.

46 Vitale, A.T., & O'Connor, P.C. (2006). The effect of Reiki on pain and anxiety in women with abdominal hysterectomies: a quasi-experimental pilot study. Holistic Nursing Practice, 20(6), p. 263-272.

47 Miles, P., & True, G. (2003). Reiki - review of a biofield therapy history, theory, practice, and research. Alternative Therapies in Health and Medicine, 9(2), p. 62-72.

48 Riskin-Mashiah, S. E., O'Brian Smith, E. O., & Wilkins, I. A. (2002). Risk factors for severe perineal tear: Can we do better? American Journal of Perinatology, 19, 225-234.

49 Christianson, L. M., Bovbjerg, V. E., McDavitt, E. C., & Hullfish, K. L. (2003). Risk factors for perineal injury during delivery. American Journal of Obstetrics & Gynecology, 189, 255-260.

50 Albers, L. L., Anderson, D., Cragin, L., Daniels, S. M., Hunter, C., Sedler, K. D., et al. (1996). Factors related to perineal trauma in childbirth. Journal of Nurse Midwifery, 41, 269-276.

51 Dublin, S., Lydon-Rochelle, M., Kaplan, R.C., et al. (2000). Maternal and neonatal outcomes after induction of labor without an identified indication. American Journal of Obstetrics & Gynecology, 183, p. 986-994.

52 Seyb, S.T., Berka, R.J., Socol, M.L., et al. (1999). Risk of cesarean delivery with elective induction of labor at term in nulliparous women. Obstetrics & Gynecology, 94, p. 600-607.

53 Johnson, D.P., Davis, N.R., & Brown, A.J.. (2003). Risk of cesarean delivery after induction at term in nulliparous women with an unfavorable cervix. American Journal of Obstetrics & Gynecology, 188, p. 1565-1572.

54 Yeast, J.D., Jones, A., & Poskin, M. (1999). Induction of labor and the relationship to cesarean delivery: a review of 7001 consecutive inductions. American Journal of Obstetrics & Gynecology, 180, p. 628-633.

55 Cammu, H., Marens, G., Ruyssinck, G., et al. (2002). Outcome after elective labor induction in nulliparous women: a matched cohort study. American Journal of Obstetrics & Gynecology, 186, p. 240-244.

56 Sheiner, E., Sarid, L., Levy, A., et al. (2005). Obstetric risk factors and outcome of pregnancies complicated with early postpartum hemorrhage: a population-based study. Journal of Maternal,  Fetal, and Neonatal Medicine, 18, p. 149-205.

57 Marowitz, A., & Jordan, R. (2007). Midwifery management of prelabor rupture of membranes at term. Journal of Midwifery & Women's Health, 52(3), p. 199-206.

58 Hannah,  M.,  Ohlsson, A.,  Farine, D., Hewson, S.,  Hodnett, E., & Myhr, T. (1996). Induction of labor compared with expected management for prelabor rupture of the membranes at term. New England Journal of Medicine, 334, p. 1005-1010.

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