BIRTH 36:1 March 2009 5

Acupuncture as Pain Relief During Delivery:

A Randomized Controlled Trial
Lissa Borup, RM, Winnie Wurlitzer, RM, Morten Hedegaard, MD, PhD,
Ulrik S. Kesmodel, MD, PhD, and Lone Hvidman, MD, PhD

ABSTRACT: Background: Many women need some kind of analgesic treatment to relieve pain
during childbirth. The objective of our study was to compare the effect of acupuncture with
transcutaneous electric nerve stimulation (TENS) and traditional analgesics for pain relief and
relaxation during delivery with respect to pain intensity, birth experience, and obstetric outcome.
Methods: A randomized controlled trial was conducted with 607 healthy women in labor at term who
received acupuncture, TENS, or traditional analgesics. Primary outcomes were the need for
pharmacological and invasive methods, level of pain assessed by a visual analogue scale, birth
experience and satisfaction with delivery, and pain relief evaluated at 2 months postpartum.
Secondary obstetric outcomes were duration of labor, use of oxytocin, mode of delivery, postpartum
hemorrhage, Apgar score, and umbilical cord pH value. Analysis complied with the intention-to-treat
principle. Results: Use of pharmacological and invasive methods was significantly lower in the
acupuncture group (acupuncture vs traditional, p < 0.001; acupuncture vs TENS, p = 0.031). Pain
scores were comparable. Acupuncture did not influence the duration of labor or the use of oxytocin.
Mean Apgar score at 5 minutes and umbilical cord pH value were significantly higher among infants
in the acupuncture group compared with infants in the other groups. Conclusions: Acupuncture
reduced the need for pharmacological and invasive methods during delivery. Acupuncture is a good
supplement to existing pain relief methods. (BIRTH 36:1 March 2009)

Key words: acupuncture, labor, pain relief, TENS

Giving birth is often associated with severe pain, and
many women need some kind of analgesic treatment.
Conventional analgesic treatment may have adverse
effects for both the mother and the infant (1–4). Many
Danish women ask for alternatives to the pharmaco-
logical and invasive methods commonly used in child-
birth, and during the past decade, the use of
acupuncture for pain relief during delivery has
increased in Danish delivery wards.
At the time the present trial was launched, only
observational studies had been published. They indi-
cated that acupuncture may lower the need for

Lissa Borup and Winnie Wurlitzer are Research Midwives in the
Department of Obstetrics and Gynecology at the Aarhus University
Hospital, Skejby; Morten Hedegaard is the Head of the Department of
Obstetrics at the Rigshospitalet, Copenhagen; Ulrik S. Kesmodel is an
Associate Professor in the Department of Epidemiology at the Institute
of Public Health, University of Aarhus, Aarhus; and Lone Hvidman is
a Consultant Obstetrician in the Department of Obstetrics and
Gynecology at the Aarhus University Hospital, Skejby, Denmark.
The study was sponsored by the Aase and Ejnar Danielsen’s Founda-
tion, Kgs. Lyngby, Denmark; Knowledge and Research Center for
Alternative Medicine, Aarhus, Denmark; Sophus Jacobsen Foundation,
Copenhagen, Denmark; The Danish Midwifery Organisation, Copen-
hagen, Denmark; Lundbeck Foundation, Copenhagen, Denmark; Mads
Clausens Foundation, Nordborg, Denmark; Hede Nielsen Foundation,
Horsens, Denmark; The Research Fund at Aarhus University Hospital,
Aarhus, Denmark; Else and Mogens Wedell-Wedellsborgs Foundation,
Copenhagen, Denmark; and King Christian the 10th Foundation,
Copenhagen, Denmark.
Address correspondence to Lissa Borup, RM, Department of Obstetrics
and Gynecology, Aarhus University Hospital, Skejby, Brendstrupgaardsvej,
8200 Aarhus N, Denmark.
Accepted September 1, 2008.
Ó 2009, Copyright the Authors
Journal compilation Ó 2009, Wiley Periodicals, Inc.

6 BIRTH 36:1 March 2009
conventional analgesics without influencing the
mother and child negatively, but the evidence was
weak (5–11). The aim of the present study was to
investigate the effect of acupuncture on pain relief
and relaxation during delivery in a randomized con-
trolled trial.
Methods
The study was performed as a randomized controlled
study, without blinding. The study was conducted
between March 1, 2001, and February 29, 2004, at
one delivery ward at a university hospital with 4,500
to 4,800 deliveries annually. Acupuncture was used in
a pilot study in the period from January 3, 2000, to
February 28, 2001. During the study period, acupunc-
ture was only available to trial participants.
The trial was approved by the regional ethics com-
mittee, and the trial is registered at the Danish Data
Agency Board. The trial is registered in www.
clinicaltrials.gov.
Healthy, Danish-speaking women in labor with a nor-
mal singleton pregnancy who were giving birth at term
(37–42 completed wk) and with a fetus in cephalic pre-
sentation were eligible for the study. Women with med-
ical diseases or complicated pregnancies and women
who already had received analgesics during labor were
excluded. The midwife informed all women antenatally
about the project, both in writing and in verbally. They
were given neutral information about the various meth-
ods of pain relief to avoid bias in favor of one of the
methods. Moreover, it was stated that the effect of acu-
puncture was not sufficiently clarified. The women were
informed that participation was voluntary and that their
consent could be withdrawn at any time.
Women in labor who requested pain relief were
asked to take part. If they consented, they were ran-
domized to receive acupuncture, transcutaneous
electric nerve stimulation (TENS), or traditional anal-
gesics at a ratio of 2:1:1 by a computer-controlled
‘‘voice response system.’’ The system needed the
unique civil registration number in the log before
the allocation code was given. Randomization was
stratified according to parity. Women randomized
to the traditional group could choose among all anal-
gesic methods available (sterile water papules, nitrous
oxide, warm tub bath, pethidine, and epidural analge-
sia). A specific analgesic was chosen by the woman
after informed choice. Pain treatment was initiated
immediately after randomization.
Project midwives who were trained in acupuncture
and TENS cared for all participants, irrespective of
allocation group. Fifty midwives were certified after
completing a 5-day course in Western techniques of
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obstetric acupuncture and receiving at least 6 months
clinical training using acupuncture during labor. A
project midwife was present in the delivery suite all
times during active labor.
Based on international experience (12) and experi-
ence from the pilot project, 34 specified acupuncture
points could be used (Fig. 1). Treatment was individ-
ualized according to the woman’s mobility and local-
ization of pain. Needles were sterile stainless steel
acupuncture needles in three lengths: 0.20  15, 0.30 
30, and 0.35  50 mm. No electric stimulation was used.
The duration of needling could vary from 30 minutes to
2 hours and could be repeated. The needles were
removed if the woman felt uncomfortable or in women
with obstetric pathology. The needling was also discon-
tinued if no project midwife was available to take over.
The TENS treatment was carried out using a TENS
120Z unit (ITO CO. LTD. 3-3-3; Toyotama-Minami,
Nerima-ku, Tokyo, Japan). Two to four electrodes
were placed on the skin of the lower back. The units
were set in constant mode, initially with a pulse width
of 60 microseconds and a pulse rate of 100 pulses per
second. The treatment lasted from 20 to 45 minutes
and could be repeated. The intensity of stimulation
could be adjusted by the woman or the midwife.
In the acupuncture and TENS groups, supplemen-
tary conventional analgesics were provided on request.
The supplementary treatment consisted of bathtub,
sterile water papules, nitrous oxide, pethidine, and
epidural analgesia.
Primary outcomes comprised a need for pharmaco-
logical and invasive methods (pain relief that includes
entrance into the body not necessarily by drugs), expe-
rience of pain, and birth experience. Secondary out-
comes were duration of labor from randomization
until birth, use of oxytocin, mode of delivery, post-
partum hemorrhage, Apgar score, and umbilical cord
blood pH value.
Pain was assessed using a linear 10-cm visual analog
scale (13). Participants scored pain intensity on a hori-
zontal line with marked end points describing ‘‘no pain’’
and ‘‘worst imaginable pain.’’ The researcher noted the
numeric value marked on the opposite side within the
range of 0.0 = no pain to 10.0 = worst imaginable
pain. The participants recorded the degree of pain just
before randomization, 1 hour after randomization, and
subsequently, every 2 hours until the baby was born. A
final recording was made 2 hours after delivery assess-
ing the woman’s total pain experience.
Two months after delivery, the participants com-
pleted a questionnaire about their experience and sat-
isfaction with delivery, pain relief, and possible side
effects of the analgesics used. The birth experience was
assessed by 14 different questions inspired by ques-
tions used in a Canadian study (14), each with seven
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BIRTH 36:1 March 2009 7

Fig. 1. Acupuncture points. All acupuncture points have Chinese names and those on the meridians also have names
and numbers after the meridian. Two extra points located outside the specific pathways are named Yintang and
Sishencong. Shenmen is an ear point, which corresponds to the lungs and is used for general analgesia and relaxation.

different answer categories: almost always, a lot of
the time, a little more than half the time, half the
time, a little less than half the time, occasionally,
and rarely.
It was assumed that acupuncture treatment could
reduce the need for epidural analgesia and pethidine
from 20 to 10 percent. Assuming that a = 0.05 and
b = 0.20, 198 women were needed in the acupuncture
group and 198 women divided into the TENS and the
traditional group, respectively. Taking into account
a potential dropout rate of one-third, at least 600
women were needed in total. No interim analyses were
performed during the trial.
Data were entered twice into the SPSS software
program to validate the data entry process. Frequen-
cies were analyzed by the chi-square test. For contin-
uous data, means (± SD) or medians were provided.
Data following a normal distribution were compared
using analysis of variance or the t test, whereas data
not following a normal distribution were compared
using the Kruskal-Wallis test or the Mann-Whitney
U test. For pain scores, we compared the mean differ-
ence between the scores at randomization and at dif-
ferent points in time after randomization for each
group. Data analysis was according to the intention-
to-treat principle and included all randomized
women, except analyses on birth experience and sat-
isfaction with pain relief. SPSS version 15.0 and Stata
version 8 were used for analyses (15,16). p Values less
than 0.05 were considered significant.
Results
The number of eligible women was estimated to be
approximately 6,232, most of whom were not asked
to participate because of the unavailability of a project
midwife. Others declined to participate due to fear of
needles. Some women wished to receive epidural anal-
gesia as soon as possible and others wanted to give
birth without any kind of pain relief.
A total of 607 women were enrolled in the study.
They were matched with the entire group of eligible
women on all available parameters (age, start of deliv-
ery, blood loss, umbilical cord pH, and Apgar score at
5 min), except for parity. More nulliparous women
were among the participants compared with nonpar-
ticipants (75% vs 46%).

8 BIRTH 36:1 March 2009
Of the 607 women randomized to the study (Fig. 2),
517 completed the treatment and 490 returned the
questionnaire on birth experience and satisfaction
with pain relief. At randomization, no significant or
substantial differences were observed among the three
groups (Table 1). Four women in the TENS group
and three women in the traditional group also
received acupuncture. Only women allocated to the
TENS group received TENS.
No significant or substantial differences were
observed between those completing the treatment and
the 90 persons who did not with respect to age, parity,
onset of delivery, mean cervical dilatation, pain score at
randomization, induction of labor, postpartum hemor-
rhage, Apgar score, and umbilical cord pH value.
However, significant differences were observed for
duration of labor (289 vs 365 min, p = 0.012), mode
of delivery (8% spontaneous vs 61%, p < 0.001), and
use of pethidine (1.7% vs 5.6%, p = 0.026) and epidu-
ral analgesia (15.7% vs 30.0%, p = 0.001).
Significantly fewer women in the acupuncture group
were treated with nitrous oxide, pethidine, or sterile
water papules compared with the traditional group
and fewer chose sterile water papules compared with
the TENS group (Table 2). A nonsignificant trend
was observed toward fewer women having epidural
analgesia in the acupuncture and TENS groups, respec-
Fig. 2. Flow chart of total number of eligible women, distribution of participants in the three randomized groups, and
subsequent dropouts.
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tively, compared with the traditional group (Table 2).
Significantly fewer women in the acupuncture group
received pharmacological or invasive pain relief, or
both, compared with the other groups (Table 2).
The mean pain score at randomization was 6.8
(median = 7.0) with no significant differences among
the three groups (Table 1). No significant differences
were found in pain scores among the three groups at
any point during labor (Table 5). A pain score cover-
ing the entire delivery was obtained 2 hours after deliv-
ery. The mean pain score was 7.5 (median = 8.0) for all
participants and 7.3 (7.9), 7.7 (8.0), and 7.8 (8.1) for the
acupuncture group, the TENS group, and the tradi-
tional group, respectively. The mean difference in pain
score at randomization and 2 hours after delivery was
0.6 in the acupuncture group, 1.1 in the TENS group,
and 0.7 in the traditional group (p = 0.217).
In the acupuncture group, 59 percent of the women
thought that acupuncture gave some or substantial
pain relief, 55 percent that it had a somewhat or very
calming effect, and 86 percent that it had no side
effects. Asked if they would want to use acupuncture
again in connection with a future delivery, 53 percent
answered positively, 18 percent negatively, and 29 per-
cent did not know. In the TENS group, 34 percent of
the women reported that TENS gave some or sub-
stantial pain relief, 23 percent that it had a somewhat
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BIRTH 36:1 March 2009 9

Table 1. Baseline Information on Women Randomized to the Acupuncture, Transcutaneous Electric Nerve Stimulation
(TENS), and Traditional Groups (n = 607)

Acupuncture TENS Traditional

Maternal Characteristics at Baseline (n = 314) (n = 144) (n = 149) pa
Age (mean, SD) (yr) 30.3 (4.1) 30.1 (3.5) 30.2 (4.3) 0.933
Parity (%)
Primiparous 74.2 77.1 75.8 0.790
Start of delivery (%)
Spontaneous 85.4 90.3 92.6 0.053
Median cervical dilatation in centimetersb 4 (3–7) 4 (2–7) 4 (2–7) 0.978
(10th/90th percentile)
Median pain score before randomization 7.0 (3.6–9.0) 7.0 (2.9–9.0) 7.2 (4.8–9.5) 0.204
(10th/90th percentile)c
a
Comparison of all three groups; bfor cervical dilation, n = 592; cfor pain score, n = 539.
TENS = transcutaneous electric nerve stimulation.

Table 2. Use of Pharmacological and Invasive Methods in Women Randomized to the Acupuncture, Transcutaneous Electric
Nerve Stimulation (TENS), and Traditional Groups (n = 607)

Acupuncture TENS Traditional

Pain Relief Method No. (%) No. (%) No. (%) pa
Warm tub bath 215 (68.5) 89 (61.8) 100 (67.1) 0.368
Epidural analgesia 53 (16.9) 23 (16.0) 32 (21.5) 0.389
Nitrous oxide 142 (45.2) 73 (50.7) 88 (59.1) 0.020b
Pethidine 4 (1.3) 2 (1.4) 8 (5.4) 0.160c
Sterile water papules 49 (15.6) 43 (29.9) 72 (48.3) <0.001d
Any pharmacological 185 (58.9) 100 (69.4) 124 (83.2) <0.001e
and/or invasive pain
relief (not warm tub bath)
a
Comparison of all three groups; bacupuncture versus traditional, p = 0.005; other pairwise comparisons, p > 0.05; cacupuncture versus traditional,
p = 0.010; other pairwise comparisons, p > 0.05; dall pairwise comparisons, p<0.001; eacupuncture versus TENS, p = 0.031; acupuncture versus
traditional, p<0.001; TENS versus traditional, p = 0.005.
TENS = transcutaneous electric nerve stimulation.

Table 3. Birth Experience among Women Randomized to the Acupuncture, Transcutaneous Electric Nerve Stimulation
(TENS), and Traditional Groups; Frequency of Women Answering ‘‘Almost All the Time’’ or ‘‘A Lot of the Time’’ (n = 490)

Acupuncture TENS Traditional

Birth Experience No. (%) No. (%) No. (%)
Felt safe 240 (88) 90 (86) 100 (89)
Felt tense 48 (18) 15 (14) 21 (19)
Understood what happened 234 (86) 91 (87) 94 (84)
Felt relaxed 86 (32) 30 (29) 26 (23)
Wishes and needs were respected 235 (86) 88 (84) 92 (82)
Felt things were unclear and unreal 12 (4) 8 (8) 10 (9)
Completely understood what was going on 214 (79) 84 (80) 83 (75)
Felt in control of the situation 119 (44) 42 (40) 38 (34)
Felt powerless 27 (10) 13 (12) 11 (10)
Accepted what happened 223 (83) 89 (85) 95 (85)
Felt calm 154 (57) 59 (56) 56 (50)
Had an overview of the situation 133 (49) 45 (43) 46 (41)
Felt in the center of attention 259 (95) 97 (92) 99 (88)
Felt I was helped 249 (92) 94 (90) 105 (94)

TENS = transcutaneous electric nerve stimulation.

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10 BIRTH 36:1 March 2009

Table 4. Comparison of Delivery and Fetal Outcomes among the Acupuncture, Transcutaneous Electric Nerve Stimulation,
and Traditional Group (n = 607)

Acupuncture TENS Traditional

Characteristics of Delivery and Fetal Outcome (n = 314) (n = 144) (n = 149) pa
Use of oxytocin, no. (%) 129 (41.1) 50 (34.7) 64 (43.0) 0.306
Mode of delivery, no. (%)
Spontaneous vaginal 250 (79.6) 110 (76.4) 108 (72.4) 0.418
Instrumental 38 (12.1) 21 (14.6) 28 (18.7)
Cesarean section 26 (8.3) 13 (9.0) 13 (8.7)
Apgar score<7 at 5 min, no. (%) 1 (0.3) 0 (0.0) 2 (1.3) 0.213
Median time in minutes (range) from 249 (13–1,228) 255 (16–869) 275 (83–847) 0.485
randomization until birthb
Median blood loss in milliliters (range) 300 (30–3,000) 300 (50–3,000) 300 (100–3,500) 0.776
during delivery
Median Apgar score at 5 min (range) 10 (5–10) 10 (8–10) 10 (4–10) 0.04c
Cord blood pH value, median (range)d 7.29 (6.90–7.48) 7.29 (7.00–7.47) 7.27 (6.80–7.42) 0.039e
a
Comparison of all three groups; bdata missing for 25 women; cacupuncture versus traditional, p = 0.012; other pairwise comparisons, p > 0.05; ddata
missing for 37 children; eacupuncture versus traditional, p = 0.031; TENS versus traditional, p = 0.018; other pairwise comparisons, p > 0.05.
TENS = transcutaneous electric nerve stimulation.

Table 5. Mean Difference (95% CI) in Pain Score at Randomization and at Different Points in Time 1 to 9 Hours after
Randomization but before Delivery among the Acupuncture, Transcutaneous Electric Nerve Stimulation, and Traditional
Groups

Time after Acupuncture TENS Traditional

Randomization (hr) No. Mean (95% CI) Mean (95% CI) Mean (95% CI) pa
1 471 0.6 ( 0.8 to 0.3) 0.8 ( 1.1 to 0.5) 0.8 ( 1.2 to 0.4) 0.373
3 308 0.7 ( 1.1 to 0.2) 1.3 ( 2.0 to 0.5) 0.7 ( 0.4 to 0.9) 0.409
5 166 1.3 ( 1.9 to 0.6) 1.1 ( 2.5 to 0.3) 0.6 ( 1.8 to 0.6) 0.588
7 73 1.4 ( 2.8 to 0.0) 0.5 ( 3.0 to 2.0) 0.2 ( 1.8 to 0.1) 0.540
9 28 0.7 ( 3.8 to 2.4) 1.5 ( 5.7 to 2.8) 0.7 ( 3.8 to 2.5) 0.934
a
Comparison of all three groups.
TENS = transcutaneous electric nerve stimulation.

or very calming effect, and 84 percent that it had no Discussion

side effects. Asked if they would want to use TENS again
in connection with a future delivery, 18 percent answered
positively, 66 percent negatively, and 16 percent did not
know. No signs of serious or prolonged side effects were
found, neither by using acupuncture nor TENS.
No substantial or significant differences were seen
in the distribution of answers in the three groups con-
cerning birth experience. This finding was indepen-
dent of whether we used the original, seven-answer
categories or whether they were grouped together in
2 or 3 categories (Table 3).
Median duration of labor was not significantly dif-
ferent in the three groups (p = 0.485). Restriction to
deliveries lasting 1 to 10 hours did not change the result
(p = 0.700) (Table 4). Blood loss, mode of delivery,
and Apgar score at 1 minute did not differ in the three
groups. Slight differences were observed with respect
to Apgar score at 5 minutes and umbilical cord pH
value (Table 4). Restricting analyses to the 517 women
who completed the treatment did not substantially
change any of the preceding results (data not shown).
This randomized controlled trial showed that acu-
puncture during labor reduced the need for pharma-
cological and invasive methods, mainly nitrous oxide,
pethidine, and sterile water papules, without affecting
birth outcome. We conducted the study because the
effect of acupuncture on labor pain was poorly docu-
mented. All studies published before 2002 were small,
retrospective, or uncontrolled (5–11), and only a few
randomized controlled trials have evaluated the effec-
tiveness of acupuncture for pain relief during labor
since 2002 (17–25). These studies vary in size and
quality.
Our study of 600 women is the largest randomized
controlled study so far to examine the effect of acu-
puncture on labor pain. Moreover, randomization
was done using a computer telephone procedure,
thereby eliminating allocation bias. In previous stud-
ies, numbered, sealed envelopes were used for ran-
domization, a method known to be associated with
a considerable risk of bias.

BIRTH 36:1 March 2009
Ideally, a randomized controlled trial should be
blinded. Sham acupuncture (needling on nonacu-
puncture points) potentially has an effect parallel to
acupuncture (26,27). The use of placebo acupuncture
needles (acupuncture simulation with nonpenetrating
retractable blunt needles) was considered (28) but was
found to be unusable in labor since the needles fell off
when the woman changed position. Moreover, it was
impossible to blind the midwife who was doing the
needling. Treatment by acupuncture may have both
a specific analgesic effect by needling and a placebo
effect due to the special nursing by the midwife.
The analgesic effect of TENS—if any—is weak
(29–32). Since TENS also involves nursing by the mid-
wife similar to acupuncture, TENS was chosen as
treatment for one control group to investigate if any
analgesic effect of acupuncture was attributable to the
placebo effect rather than to a specific analgesic effect.
We found some effect of TENS compared with the
traditional treatment group (Table 2) that may repre-
sent a placebo effect. It is worrying, however, that the
number of missing cases in the TENS group was higher
compared with the two other groups. Thus, the study
design has both advantages and disadvantages.
The main finding of this study was the significant
difference in use of pharmacological and invasive
methods, with the lowest use in the acupuncture group,
medium use in the TENS group, and highest use in the
traditional group (Table 2). When interpreting these
differences, one should consider that the laboring
women were randomized at the time they needed pain
relief. Women randomized to the traditional group
were offered traditional methods of pain relief at the
time of randomization. For women in the acupuncture
or TENS groups, the use of supplementary conven-
tional analgesics would be delayed. When acupuncture
would not provide any pain relief, the difference in the
use of pharmacological and invasive methods would
probably be equalized after a certain observation time.
Consequently, we suggest that the observed differences
in the use of other pain relief methods are likely to be
due to a real effect of acupuncture use.
The use of pethidine in our study was similar to
findings in a Swedish study (18) (2.2% in the acupunc-
ture group vs 2.3% in the control group), but much
lower than in other studies, with figures from 11 to 14
percent in the acupuncture group and 35 to 37 percent
in the control group (19,20). The use of pethidine had
decreased dramatically before the start of the study
due to increasing awareness of adverse effects. It
would thus be difficult to reach the significant reduc-
tions reported in other studies.
Epidural analgesia was used less frequently in the
acupuncture and TENS groups, but the difference was
insignificant. Previous Scandinavian studies have found
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11
a decreased use of epidural analgesia in acupuncture
groups (18,19). Traditionally, epidural analgesia has been
used much less in Denmark than in other countries—
even the other Scandinavian countries—which may ex-
plain why our study did not show significant differences.
Baseline use of epidural analgesia was 13.1 percent in the
study period.
The three groups assessed the same degree of pain
intensity during labor (Table 5). The women in the
acupuncture group tended to report a lower score
2 hours postpartum. Since pain during labor is
progressive, most women are likely to experience
more intensive pain regardless of pain treatment.
The results are similar to those from Sweden (18)
and a study from Iran (22), whereas two other studies
(19,25) reported significantly lower scores in the acu-
puncture group compared with the controls.
Women in the acupuncture group tended to report
a higher degree of relaxation and control compared
with the other groups. However, we found no signifi-
cant differences concerning variables illustrating wom-
en’s birth experience (Table 3). These findings are
consistent with those of a Swedish study (18) in which
acupuncture was found to induce a significantly higher
degree of relaxation. This finding is interesting since
other studies demonstrate that the feeling of control
contributes to a good birth experience (33–35).
The duration of labor and the need for augmentation
with oxytocin were similar among the three groups.
Previous studies have shown inconsistent results with
respect to these variables (19–22,25), but other second-
ary outcomes showed either no or small differences of
little clinical relevance. Previous studies have generally
reported no differences for these outcomes (18–20,25).
Ninety women did not complete the allocated treat-
ment, mainly because no project midwife was available
and in some cases because the women did not want to
have the allocated treatment (Fig. 2). The TENS group
experienced a preponderance of dropouts, which might
have been due to participants who wished to receive
acupuncture for pain relief, and consequently, dropped
out when allocated to TENS.
Overall, few differences were observed between those
completing the treatment and those who did not, and no
substantial differences were seen irrespective of whether
or not we included the 90 women who dropped out of
the study in the analyses (intention-to-treat principle).
Conclusions
Based on our results, we report that acupuncture can
be offered to women in labor and that acupuncture is
a good supplement to other types of pain relief. More-
over, it is a useful practice for midwives who can apply

12
acupuncture as an element of their care for the deliv-
ering woman without involving other health practi-
tioners. A practitioner’s education and experience in
acupuncture are important to achieve a successful
result, and the outcome may be even better if a pro-
fessional acupuncturist performed the acupuncture.
However, within the Danish hospital system, it is
unrealistic for all midwives to be trained acupunctu-
rists. Our study is intended to demonstrate the effec-
tiveness of acupuncture as pain relief in a practice that
corresponds to the reality in Danish maternity wards
and to justify its introduction in maternity wards.
Midwives should be trained and certified in obstetric
acupuncture as a minimum requirement for its use.
Acknowledgments
We thank the midwives and participating women in
the delivery ward at the Department of Obstetrics and
Gynaecology, Aarhus University Hospital, Skejby,
for their cooperation.
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