Journal Pre-proof

Effects of ear and body acupressure on labor pain and duration of labor
active phase: a randomized controlled trial

Zainab Alimoradi, Farideh Kazemi, Maryam Gorji, Mahboubeh

Valiani

PII: S0965-2299(20)30165-5
DOI: https://doi.org/10.1016/j.ctim.2020.102413
Reference: YCTIM 102413

To appear in: Complementary Therapies in Medicine

Received Date: 22 January 2020

Revised Date: 2 April 2020
Accepted Date: 16 April 2020

Please cite this article as: Alimoradi Z, Kazemi F, Gorji M, Valiani M, Effects of ear and body
acupressure on labor pain and duration of labor active phase: a randomized controlled trial,
Complementary Therapies in Medicine (2020),
doi: https://doi.org/10.1016/j.ctim.2020.102413

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© 2020 Published by Elsevier.

Effects of ear and body acupressure on labor pain and duration of
labor active phase: a randomized controlled trial

Zainab Alimoradi 1*, Farideh Kazemi 2, Maryam Gorji 3, Mahboubeh Valiani 4

1*
Ph.D. Assistant Professor of Midwifery, Social Determinants of Health Research

Center, Qazvin University of Medical Sciences, Qazvin, Iran

2
Ph.D. Department of midwifery, Mother and Child Care Research Center, school of

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nursing and midwifery, Hamadan University of Medical Sciences, Hamadan, Iran Email:

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Faridehkazemi21@yahoo.com

3
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MSc. Infertility clinic, Velayat clinical & educational center, Qazvin University of
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Medical Science, Qazvin, Iran Email: maryam.gorji580@gmail.com

4
PhD. Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery,
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Isfahan University of Medical Sciences, Isfahan, Iran Email: valiani@nm.mui.ac.ir

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*
Corresponding Author: Zainab Alimoradi
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Qazvin University of Medical Science, Bahonar blv. Qazvin, Iran.

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Postal code: 34197-59811,

Tel: +9828 33336001-5,

Fax: +982833237268,

Email: Zainabalimoradi@yahoo.com

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ORCID: 0000-0001-5327-2411

Highlights:
 Ear acupressure was significantly effective in both reducing labor pain and shortening

labor active phase.

 Body acupressure reduces labor pain as well as ear acupressure but it was not

effective in reducing active phase duration.

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Abstract

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Objectives: This study sought to compare the effects of multi-point ear and body acupressure

on labor pain and the duration of labor active phase.

Design: Three-armed randomized controlled trial

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Setting: Kowsar Hospital, Qazvin, Iran

Intervention: Participants in the body acupressure group received acupressure on GB21,

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GB30, BL32, LI4, and SP6 points, each for two minutes, at cervical dilation of four, six, and

eight centimeters. For participants in the ear acupressure group, adhesive auriculotherapy-
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specific Vaccaria seeds were attached to their auricles on the zero, genitalia, Shen Men,

thalamic, and uterine 1 and 2 acupoints. The seeds were compressed every thirty minutes,
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each time for thirty seconds. Participants in the control group received routine care services.
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Main outcome measures: Labor pain intensity was assessed using a visual analogue scale at

cervical dilation of four and ten centimeters.

Results: While there was no significant difference between mean scores of pain among three

groups, mean score of labor pain in both acupressure groups was significantly less than that

in the control group (P < 0.001). However, the difference between the acupressure groups

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was not statistically significant (P = 0.12). Moreover, the duration of labor active phase in the

ear acupressure group was significantly less than those in the body acupressure and the

control groups (P < 0.001).

Conclusion: Ear acupressure was significantly effective in reducing labor pain and

shortening labor active phase. However, body acupressure solely reduces labor pain.

Therefore, ear acupressure can be used to reduce labor pain and shorten labor active phase.

Keywords: Acupressure, Auriculotherapy, Labor active phase, Labor duration, Labor pain

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Background

Labor pain is described as the most severe pain during woman’s lifetime (1, 2). Uncontrolled

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labor pain may result in fetal hypoxia and altered heart rate, reduce neonatal Apgar score, and
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increase midwifery interventions associated with obstetrics complications (3). The great

severity of labor pain causes intense fear over women’s childbirth (4, 5), reduces their
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perceived ability to have a vaginal delivery (6), and eventually requires them to request
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cesarean section (7). A study on 342 Iranian women revealed that all of them had some levels

of fear and 48.2% of them had intense fear over childbirth (8). Another study reported that

fear over childbirth increased the rate of elective cesarean section by 3–6 times (9).
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Painless delivery and effective labor pain management are among the strategies to encourage

vaginal delivery (10). Pharmacological measures are routine medical options for labor pain
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management; however, pain medications have potential maternal and fetal side effects (11).
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A systematic review reported nausea, vomiting, and dizziness as the side effects of inhaled

labor pain medications, highlighting that epidural analgesia results in fetal distress,

hypotension, fever, and urinary retention; hence, it may eventually lead to cesarean (12). In

recent years, non-pharmacological pain management measures have been introduced and

widely used(13).

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The World Health Organization has introduced traditional and complementary medicine as a

main component of healthcare system (14), and its strategic plan is to integrate traditional and

complementary medicine into healthcare delivery system and develop relevant rules and

regulations for encouraging and supervising its safe application up to 2023 (15, 16).

Acupressure, including both ear and body acupressure, is among non-pharmacological pain

management techniques (13) which is based on fundamental principle of activating acupoints

across the meridians (17). Each meridian is a channel within human body connected to

different organs and tissues (18).

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While the exact mechanism of acupressure is not clear, some theories like gate control theory

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(19) and biochemical mechanism (20) can be used to explain how acupressure works. Based

on gate control theory, impulses produced by acupressure are transmitted to the brain four
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times as fast as painful stimuli. When these impulses are continuously transmitted to brain,

the neural gates are closed and impulses from painful stimuli with slower transmission rate
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are blocked. Blocking the transmission of painful impulses to brain improves the pain
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perception threshold (19). Based on biochemical mechanism, stimulation of acupoints leads

to neuro-hormonal responses including increased secretion of cortisol endorphin and

serotonin (21-23).
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There are several acupoints in the body which can be used to induce labor, facilitate labor

progression, and reduce labor pain through stimulating uterine contractions (24). These points
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include the SP6, LV3, BL32, BL21, BL31, LI4, and GB21 (24, 27, 28). The results of two
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systematic reviews revealed that acupuncture and acupressure reduce the duration of labor

and the need for labor induction (25, 26). Previous studies reported that one- or two-point

acupressure on these points reduced labor pain (29-31). A recent systematic review with

meta-analysis by Makvandi et al. (2016) reported that most studies used one of body

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acupoints, most frequently SP6 and then LI4. Using multiple body acupoints was reported

just in two studies (one using LI4+BL67 and the other using LI4+SP6) (32).

Ear acupressure (also known as auriculotherapy) is a division of Chinese acupuncture. During

ear acupressure, acupoints over the auricle are compressed to produce the desired effects.

Previous studies reported the positive effects of ear acupressure on low back pain (33),

dysmenorrhea (34-36) as well as pains associated with hip fracture (37) and polycystic ovary

syndrome (38). However, only a few studies assessed its effects on labor pain, and reported

contradictory results (39, 40).

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To the best of our knowledge, using more than two body acupressure points and comparing

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the effect of body and ear acupressure have not been reported in previous literature.

Therefore, the present study sought to evaluate and compare the effects of multi-point ear and
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body acupressure on labor pain as a primary outcome and the duration of first stage of labor

as a secondary outcome.
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Methods

Study design

This was a three-armed randomized controlled trial. The protocol of study is published
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elsewhere (41). The present manuscript has been prepared based on Revised Standards for

Reporting Interventions in Clinical Trials of Acupuncture (STRICTA): extending the

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CONSORT statement.
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Participants and setting:

Study population comprised all pregnant women who referred to Kowsar hospital for

delivery, the only women’s specialty and referral hospital in Qazvin, Iran. Sampling was

purposively performed based on the following inclusion criteria: having singleton 37-42

weeks gestational age with cephalic presentation, being 19-35 years of age, having above 150

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cm height and no history of chronic diseases and pregnancy complications. In addition,

mothers were included if admitted with cervical dilation of 3-4cm. Participants were

excluded in case of voluntary withdrawal from the study, tetanic uterine contractions,

precipitated labor, fetal distress, placental abruption, oxytocin therapy, cesarean section, or

use of painless delivery techniques such as regional analgesia, opioid therapy, or Entonox

therapy.

Sample size estimation

Sample size was calculated based on the mean and standard deviation of both labor pain and

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the duration of labor active phase as reported in previous studies (39, 42). Accordingly, with

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a confidence level of 95% and a power of 80%, a sample of 26 women per group was

identified to be adequate for both outcomes. Yet, considering an attrition rate of 10%, the
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sample size was expanded to thirty per group or ninety in total.

Randomization and blinding

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Participants were randomly allocated to control, ear acupressure group, or body acupressure
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group through balanced block randomization with a block size of six. Allocation sequence

was generated at the beginning of the study by a person who was not a member of the

research team. For allocation concealment, the name of each group was written on a card and
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placed in an opaque bag, and thereby, ninety bags, numbered 1–90, were produced based on

the predetermined sequence. Then, they were sequentially opened for newly recruited
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participants to determine their groups.

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For the sake of blinding, one of the authors performed the study intervention and another

author, who was blind to the intervention, collected the data. Moreover, the statistical data

analyst was also blind to the study groups. The author who was responsible for doing

interventions was trained and had the required certification for acupressure during labor.

Intervention

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The intervention procedure, the proposed physiological mechanism for each acupoint and the

illustration of both body and ear acupoints are fully explained in the published protocol of the

present study (41). Therefore, a brief explanation of intervention is provided in this section.

Participants in the body acupressure group were provided with acupressure on the GB21 (Jian

Jing), GB30 (Huan Tiao), BL32 (Ciliao), LI4 (Hegu), and SP6 (San Yin Jiao) points (27).

Each of these points was compressed bilaterally with the thumb for two minutes at three

time-points, i.e. at the cervical dilation of four, six, and eight centimeters. The amount of

pressure on each point was so that one third of the thumb nail bed was blanched. For

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participants in the ear acupressure group, adhesive auriculotherapy-specific Vaccaria seeds

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were unilaterally attached to the left auricle on the zero, genitalia, Shen Men, thalamic,

prostaglandin, oxytocin and uterus 1 and 2 acupoints. Every thirty minutes, the seeds were
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compressed with fingers for thirty seconds in a specific sequence (Prostaglandin, oxytocin,

thalamic, point zero, external genitalia, Shen Men, Uterus 1 &2) for all subjects (43).
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Participants in the control group solely received routine maternity care services which
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included no acupressure.

Outcome measures

The main outcome in this study was labor pain intensity and the secondary was duration of
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first stage of labor. The former was measured using a visual analogue scale which was a ten-

centimeter ruler on which zero showed no pain and ten showed intolerable pain. Visual
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analogue scale is a valid and reliable pain intensity assessment tool (44, 45) and has been
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widely used in Iran for the assessment of different types of pain, including labor pain (13, 39,

42, 46). Pain intensity assessment in the present study was performed twice, i.e. at a cervical

dilation of four and ten centimeters. On the other hand, the latter was measured in minutes as

the time interval between the cervical dilation of four and ten centimeters. Besides, a

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questionnaire was used to collect data on participants’ demographic and midwifery

characteristics and acupressure side effects.

Statistical analysis

Statistical data analysis was done using the Stata v. 13.0 (Stata Corp LLC, Texas, USA).

Categorical data were described using absolute and relative frequency measures, while

numerical data were described using mean and standard deviation. The distributions of

numerical data were assessed using histograms, central tendency and dispersion measures,

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and the Shapiro-Wilks test. Among-group comparisons for participants’ and their neonates’

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characteristics, ==?== were performed using the one-way analysis of variance as well as the

Chi-square, the Fisher’s exact, and the Kruskal-Wallis tests. The one-way analysis of
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variance was used to compare the duration of labor active phase among groups. Moreover,

the analysis of covariance was performed to compare the groups based on labor pain adjusted
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for the effect of its pretest mean score, and the Scheffe’s test was also used for post hoc
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analysis. Cohen’s d (or effect size) for the duration of labor active phase was calculated

through an online effect size calculation module (47). Cohen’s d was interpreted as the

following: 0.2–0.4: small effect size; 0.4–0.7: moderate effect size; and more than 0.7: large
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effect size (48). The level of significance was set at less than 0.05. Our primary and

secondary analyses were based on the ‘intention to treat’ principle.

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Ethical considerations

This study was approved by the Institutional Review Board and the Ethics Committee of

Qazvin University of Medical Sciences, Qazvin, Iran (approval code: IR.QUMS.1396.417).

In addition, it was registered in the Iranian Registry of Clinical Trials (Registration code:

IRCT20180218038789N1). Participants were informed about the study aim, their freedom to

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participate in or withdraw from the study, and the confidential management of their data.

Then, their informed consents were secured. Study interventions were provided by a trained

midwife.

Results

Ninety women, thirty in each group, participated in this study. Age means in the ear

acupressure, body acupressure, and control groups were 24.30±4.47, 24.23±5.21, and

24.23±4.94, respectively. No considerable differences were revealed based on participants’

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demographic and midwifery characteristics (Table 1). Eight women were excluded due to

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oxytocin therapy, spinal anesthesia, and cesarean section during intervention. Figure 1 shows

the study flowchart.

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Comparison of the mean score of labor pain intensity, adjusted for the effect of its pretest

value as covariate, indicated a significant difference among the groups. The results of the
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Scheffe’s post hoc test illustrated that the posttest mean score of pain intensity in the control
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group was significantly greater than those in the body acupressure group (p<0.001; Cohen’s

d= –1.37, 95% CI: –1.93, -0.80) and the ear acupressure group (p<0.001; Cohen’s d= –1.93,

95% CI: –2.54, -1.31). Yet, the difference between the ear acupressure and the body
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acupressure groups was not statistically significant based on the posttest mean score of pain

intensity (P=0.10; Cohen’s d=–0.54, 95% CI: –1.05, -0.02) (figure 2, Table 2).
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The one-way ANOVA showed a significant difference among the groups in terms of the

duration of labor active phase. The Scheffe’s post hoc test revealed that the duration of labor

active phase in the ear acupressure group was significantly shorter than those in the control

group (P < 0.001; Cohen’s d = –1.39, 95% CI: –1.96 to –0.82) and the body acupressure

group (P = 0.001; Cohen’s d = –1.18, 95% CI: –1.72 to –0.62). However, the duration of

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labor active phase was not significantly different between the body acupressure and the

control groups (P = 0.37; Cohen’s d = –0.36, 95% CI: –0.16 to 0.87) (Table 3); and no harms

or side effects were observed in participants.

Discussion

This study was among the first studies regarding the effects of multi-point ear and body

acupressure on labor pain and the duration of labor active phase. The findings revealed that

both ear and body acupressures significantly and similarly reduced labor pain. In line with

our findings, the results of an earlier study also reported that multi-point ear acupressure (on

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the uterine, pituitary, hip, adrenal, endocrine, Shen Men, spleen, and thorax points)

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significantly reduced labor pain (39). However, another study found that 120-minute multi-

point ear acupressure (on the Shen Men, uterine, anxiety, and endocrine points) did not
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statistically significant reduce labor pain, but had a point estimate of standardized mean

difference of 1.2 (95% CI: -0.07; 1.76) based on D Glass which shows the considerable effect
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of auriculotherapy compared to sham- control and routine care comparison group with low
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sample size (based on wide confidence interval) (40). This statistical contradiction is

probably due to the differences in sample size (10 versus 30 in our study). In addition, we had

a higher point estimate of standardized mean difference (1.93 versus 1.2), which might be
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due to the number of acupoints (six acupoints in our study vs. four acupoints in the other

study). It is worth noting that while we had a routine control, Mafetoni et al. had both sham-
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controlled and routine care control groups, but there was no statistical and clinical difference
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between these comparison groups (40). Moreover, in line with our findings, several former

studies reported significant labor pain reductions as a result of one-point acupressure on the

LI4 (3, 13, 29, 49-51), BL32 (13, 52, 53), and SP6 (51, 54-58) points.

Study findings also showed that the duration of labor active phase in the ear acupressure

group was significantly shorter than those in the control and the body acupressure groups

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(Cohen’s d=–1.18 95% CI: –1.72, -0.62). This finding implies the effectiveness of ear

acupressure in significantly shortening the duration of labor active phase. The only study

regarding the effects of multi-point ear acupressure on the duration of labor active phase

reported statistically insignificant effects, while there was a moderate effect of

auriculotherapy based on D Glass standardized mean difference of 0.52 (95% CI: -0.2; 1.61)

compared to sham- controlled group and 0.25 (95% CI: -0.56; 1.2) compared to routine care

comparison group, but wide confidence intervals confirmed low sample size and inconclusive

results (40). The lager sample size and the greater number of acupoints in the present study

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may justify this contradiction, but uncontrolled placebo effect should also be considered. Ear

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acupressure includes a wide variety of acupoint patterns, each consisting of a series of master

and primary points. The master points in the present study were the zero, Shen Men, and
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thalamic points, while the primary points were the uterine 1 and 2, genitalia, and oxytocin (or

prostaglandin) points (43). Some points on the ear have a general effect. These points are
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known as master points, which can be combined for use in a wide variety of treatments (59).
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Zero point stimulation promotes homeostasis, and balances energy, hormones, and brain

activity. Acupressure on the Shen Men is usually used to promote relaxation and

coordination, and to manage health problems such as stress, pain, tension, anxiety,
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depression, insomnia, and oversensitivity. Thalamic point acupressure also positively affects

the transmission of sensory information to the cerebral cortex, regulates the brain and
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hypothalamic activities, and reduces most acute and chronic pains (43). While master
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auricular points are considered to have general effects, primary auricular points are the most

effective set of auricular points for the treatment of a specific health condition or for a

physiological dysfunction (43). The uterine and the genitalia were selected primary auricular

acupoints, suggested to improve the physiological status of the uterine and the cervix,

accelerate labor progression through promoting cervical dilation and effacement, and

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facilitate fetal descent. Finally, acupressure on the oxytocin primary point promotes the

coordination of uterine contractions, regulates their intensity, and thereby, facilitates the

process of labor (43).

Apart from that, the duration of labor active phase was not different between the control and

the body acupressure groups, denoting the insignificant effects of body acupressure on the

duration of labor active phase. However, several studies found shortening of labor active

phase following one-point body acupressure on the SP6 point (58, 60) and the BL32 point

(61). Another study also found the positive effects of two-point acupressure on the LI4 and

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the SP6 points (24). This contradiction might be attributable to the facts that while our

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participants were nulliparous and were included at a cervical dilation of 3–4 centimeters,

participants in those studies were both multiparous and nulliparous (53, 61) and they were
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recruited at a cervical dilation of more than four centimeters (61). Labor progress in active

phase (after cervical dilation of 4 centimeter) is different in multiparous and nulliparous.

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Multiparous women are expected to have shorter labor duration (approximately 3-4 hours),
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while duration of active phase for nulliparous women will be 5-6 hours (11). Therefore, when

individuals are recruited to intervention with a cervical dilation of more than four centimeters

or when they are multiparous compared to nulliparous with cervical dilation of four
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centimeters, which means that active phase is started, they are expected to have a shorter

labor. Moreover, we compressed each body acupoint for two minutes at the cervical dilation
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of four, six, and eight centimeters, while those studies frequently applied acupressure on the
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intended points (24, 58) even for 35 times (58). These contradictory results highlight the

necessity of further studies to assess the effects of acupressure on the duration of labor active

phase adjusted for cervical dilation and number of parities. Apart from that, comparative

studies are needed to determine the effects of different acupressure protocols on both labor

pain and the duration of labor active phase.

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Limitations

While the aim of current study was to compare the effects of ear and body acupressure, the

results should be interpreted with regard to the limitations of the present study including

uncontrolled placebo effect, stimulation time difference and relatively low sample size. Based

on the aim of this study (comparing two different acupressure methods), the two intervention

groups were set as body acupressure and ear acupressure. While these two methods need

different sham groups, we decided to have a control group with standard care to be suitable

for both intervention groups. Choosing a control group with no sham control might lead to

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response bias. Trials assessing patient reported outcomes (including VAS used in the current

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study) are susceptible to response bias, and having no sham-control group might increase this

bias. While we have reported the results of comparing the intervention groups versus standard
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care control group, it should be addressed that these parts of results might be biased.

The other limitation of the present study is different intervention procedures for these groups.
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The intervention procedure for body acupressure was defined on the basis of the most
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common procedures based on literature review (3, 13, 24, 53). This decision was made in an

attempt to increase the comparability of the results with those obtained in previous studies.

When designing the present study, there were limited studies regarding auriculotherapy for
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controlling labor pain (39, 40) with different intervention protocols. Rastegarzadeh et al. did

auriculotherapy using manual auriculotherapy probe with stimulation of the acupoints in 4,

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6,8 cm cervical dilatation(39); while Mafetoni used adhesive auriculotherapy-specific

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Vaccaria seeds which were placed at 4 cm cervical dilatation withoutmentioning how many

times they were pressed during the labor process (40). Based on auriculotherapy-related

textbooks(43, 59, 62), auriculotherapy using vaccaria seeds needs more frequent self-pressure

of acupoints in order to maximize the effectiveness. Hence, based on these facts, the research

team decides to examine auriculotherapy using vaccaria seeds stimulated each 30 minutes

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and compare it with the most frequent pattern used for body acupressure. These different

interventional protocols should be considered when interpreting the results.

Conclusion

This study suggests that ear acupressure and body acupressure are both effective in reducing

labor pain, but ear acupressure, compared to body acupressure, can shorten the active phase

of labor more effectively. Given the greater simplicity and the easier applicability of ear

acupressure compared to body acupressure, it can be used to reduce labor pain, shorten labor

active phase, and thereby, turn normal vaginal delivery into a less stressful experience for

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women.

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List of Abbreviations

STRICTA= Revised Standards for Reporting Interventions in Clinical Trials of Acupuncture:

extending the CONSORT statement

GB21= Gall Bladder 21 acupoints

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GB30= Gall Bladder 30 acupoints
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BL32= Bladder 32 acupoints

BL21= Bladder 21 acupoints

BL31= Bladder 31 acupoints

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LI4= large Intestine 4

SP6= Spleen 6 acupoints

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LV3= Large Vessel 3 acupoints

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Conflict of interest: None to declare

Financial support: The Vice-chancellor (Research) of Qazvin University of Medical

Sciences has provided financial support to this project. The funding body had no role in the

design of the study, collection, analysis, interpretation of data and writing the manuscript.

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Authors’ statement

FK, ZA, and MV designed the study and prepared the protocol. MG performed the

interventions and ZA carried out the data collection and completion of the

questionnaires. FK analyzed the data; FK and ZA contribute for interpretation of results.

All the authors scrutinized and confirmed the final protocol. All authors critically revised

the manuscript, agreed to be fully accountable for ensuring the integrity and accuracy of

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the work, and read and approved the final manuscript to be published. All authors met

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the criteria for authorship and that all entitled to authorship were listed as authors in the

title page.
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Funding: This study was financially supported by the Research Administration
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of Qazvin University of Medical Sciences, Qazvin, Iran. (Grant code= 108;

December 23, 2017). Funders had no role in research design, data collection and
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results interpretation.
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Acknowledgements: We would like to gratefully thank the authorities and the

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maternity staff of the study setting as well as the pregnant women who agreed to
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participate in the study.

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 Table 1. Reporting baseline characteristics in three groups

Groups Body
Ear acupressure Control
Characteristics acupressure
(n = 30) (n = 30)
(n = 30)
Mean (SD) mean (SD) mean (SD)
Maternal age (Year) 24.23 (5.21) 24.23 (4.94) 24.30 (4.47)
Gestational age (Week) 39.13 (1.01) 38.43 (2.45) 38.27 (3.81)
Neonatal weight (Kg) 3.24 (0.24) 3.14 (0.37) 3.15 (0.37)
NO (%) NO (%) NO (%)
Primary and
8 (26.7) 8 (26.7) 9 (30.0)
guidance school
Educational
High school and
level 17 (56.6) 13 (43.3) 16 (53.3)
diploma
University 5 (16.7) 9 (30.0) 5 (16.7)

of
Employment Employed 5 (16.7) 5 (16.7) 5 (16.7)
status Housewife 25 (83.3) 25 (83.3) 25 (83.3)
Neonatal Female 15 (50.0) 14 (46.7) 17 (56.7)

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gender Male 15 (50.0) 16 (53.3) 13 (43.3)
7 0 (0.0) 1 (3.3) 1 (3.3)
One-minute
8 3 (10.0) 1 (3.3) 0 (0.0)
Apgar score
Five-minute
Apgar score
9
9
10
27 (90.0)
3 (10.0)
27 (90.0)
-p 28 (93.3)
2 (6.7)
28 (93.3)
29 (96.7)
1 (3.3)
29 (96.7)
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Baseline labor pain intensity 9.83 (0.38) 9.97 (0.18) 9.70 (0.79)
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 Table 2. Among-group comparisons based on the mean scores of labor pain intensity

Between group comparison

ANOVA/
Adjusted
Study Group ANCOVA
mean (sd)* Ear body
test Ear-body
acupressure- acupressure-
acupressure
control control
Ear
acupressure 6.20 (1.20) P=0.10 p<0.001 p<0.001
Degree of
(n = 30)
freedom=2
Body Cohen’s d= Cohen’s d= Cohen’s d=
6.86 (1.24) F= 29.02
acupressure –0.54 –1.93 –1.37
P value <

of
(n = 30) (95% CI: – (95% CI: – (95% CI: –
0.001
Control 1.05, -0.02) 2.54, -1.31) 1.93, -0.80)
8.56 (1.24)
(n = 30)

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*adjusted for before intervention of labor pain intensity

Ear Body
Contro
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Table 3. Among-group comparisons based on the mean scores of duration of labor active phase

l Between group comparison

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acupressur acupressur
Mean One-way
Outcome e e
(SD) ANOVA Ear-body Ear Body
Mean (SD) Mean (SD)
(n acupressur acupressure acupressure
(n =30) (n =30)
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=30) e -control -control

Duratio p=0.001 p<0.001 p=0.37
Degree of
n of Cohen’s Cohen’s Cohen’s
freedom=
labor 1.64 2.37 2.65 d=–1.18 d=–1.39 d=0.36
2
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active (0.54) (0.69) (0.87) (95% CI: (95% CI: (95% CI:
F=14.56
phase –1.72, - –1.96, - –0.16,
p< 0.001
0.62) 0.82) 0.87)
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 Figure 1. CONSORT Flow Diagram

Enrollment Assessed for eligibility (n= 145)

Excluded (n=55)
 Not meeting inclusion criteria (n=55)
 Declined to participate (n=0)
 Other reasons (n= 0)

of
Randomized (n=90)

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Allocation

Allocated to Ear Acupressure (n=30)

-p
Allocated to Body Acupressure (n=30) Allocated to control (n=30)
 Received allocated intervention  Received allocated intervention  Received allocated intervention
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(n=30) (n=30) (n=30)
 Did not receive allocated  Did not receive allocated  Did not receive allocated
intervention (give reasons) (n=0) intervention (give reasons) (n=0) intervention (give reasons) (n=0)
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Follow-Up

Lost to follow-up (due to caesarean Lost to follow-up (Induction & spinal Lost to follow-up (due to caesarean
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section & spinal analgesia) (n=2) analgesia) (n=3) section & spinal analgesia) (n=3)
Discontinued intervention (n=0) Discontinued intervention (n=0) Discontinued intervention (n=0)
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Analysis

Analysed (n=28) Analysed (n=27) Analysed (n=27)

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 Excluded from analysis (due to  Excluded from analysis (due to

 Excluded from analysis
caesarean section & spinal caesarean section & spinal
(Induction & spinal analgesia) (n=3)
analgesia) (n=2) analgesia) (n=3)

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 10
9
8
7
6

of
4cm cervical dilatation 10cm cervical dilatation
time

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ear body
control

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Figure 2. Mean (error bars: 95% CI) of pain score between 4 and 10 cm dilatation of cervix in three
groups
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