Acupuncture with manual and electrical stimulation for labour pain : a longitudinal randomised controlled trial

Background: Acupuncture is commonly used to reduce pain during labour despite contradictory results. The aim of this study is to evaluate the effectiveness of acupuncture with manual stimulation and acupuncture with combined manual and electrical stimulation (electro-acupuncture) compared with standard care in reducing labour pain. Our hypothesis was that both acupuncture stimulation techniques were more effective than standard care, and that electro-acupuncture was most effective.  Methods: A longitudinal randomised controlled trial. The recruitment of participants took place at the admission to the labour ward between November 2008 and October 2011 at two Swedish hospitals. 303 nulliparous women with normal pregnancies were randomised to: 40 minutes of manual acupuncture (MA), electro-acupuncture (EA), or standard care without acupuncture (SC). Primary outcome: labour pain, assessed by Visual Analogue Scale (VAS). Secondary outcomes: relaxation, use of obstetric pain relief during labour and post-partum assessments of labour pain. The sample size calculation was based on the primary outcome and a difference of 15 mm on VAS was regarded as clinically relevant, this gave 101 in each group, including a total of 303 women.  Results: Mean estimated pain scores on VAS (SC: 69.0, MA: 66.4 and EA: 68.5), adjusted for: treatment, age, education, and time from baseline, with no interactions did not differ between the groups (SC vs MA: mean difference 2.6, 95% confidence interval [CI] -1.7-6.9 and SC vs EA: mean difference 0.6 [95% CI] -3.6-4.8). Fewer number of women in the EA group used epidural analgesia (46%) than women in the MA group (61%) and SC group (70%) (EA vs SC: odds ratio [OR] 0.35; [95% CI] 0.19-0.67).  Conclusions: Acupuncture does not reduce women's experience of labour pain, neither with manual stimulation nor with combined manual and electrical stimulation. However, fewer women in the EA group used epidural analgesia thus indicating that the effect of acupuncture with electrical stimulation may be underestimated. These findings were obtained in a context with free access to other forms of pain relief.

Acupuncture with manual and electrical stimulation for labour pain : a two month follow up of recollection of pain and birth experience.

BACKGROUND: In a previous randomised controlled trial we showed that acupuncture with a combination of manual- and electrical stimulation (EA) did not affect the level of pain, as compared with acupuncture with manual stimulation (MA) and standard care (SC), but reduced the need for other forms of pain relief, including epidural analgesia. To dismiss an under-treatment of pain in the trial, we did a long-term follow up on the recollection of labour pain and the birth experience comparing acupuncture with manual stimulation, acupuncture with combined electrical and manual stimulation with standard care. Our hypothesis was that despite the lower frequency of use of other pain relief, women who had received EA would make similar retrospective assessments of labour pain and the birth experience 2 months after birth as women who received standard care (SC) or acupuncture with manual stimulation (MA). METHODS: Secondary analyses of data collected for a randomised controlled trial conducted at two delivery wards in Sweden. A total of 303 nulliparous women with normal pregnancies were randomised to: 40 min of MA or EA, or SC without acupuncture. Questionnaires were administered the day after partus and 2 months later. RESULTS: Two months postpartum, the mean recalled pain on the visual analogue scale (SC: 70.1, MA: 69.3 and EA: 68.7) did not differ between the groups (SC vs MA: adjusted mean difference 0.8, 95 % confidence interval [CI] -6.3 to 7.9 and SC vs EA: mean difference 1.3 CI 95 % -5.5 to 8.1). Positive birth experience (SC: 54.3 %, MA: 64.6 % and EA: 61.0 %) did not differ between the groups (SC vs MA: adjusted Odds Ratio [OR] 1.8, CI 95 % 0.9 to 3.7 and SC vs EA: OR 1.4 CI 95 % 0.7 to 2.6). CONCLUSIONS: Despite the lower use of other pain relief, women who received acupuncture with the combination of manual and electrical stimulation during labour made the same retrospective assessments of labour pain and birth experience 2 months postpartum as those who received acupuncture with manual stimulation or standard care. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01197950.

Acupuncture for labour pain

Background: Acupuncture involves puncturing the skin with thin sterile needles at defined acupuncture points. Previous studies are inconclusive regarding the effect of acupuncture on labour pain, but some studies have found a reduction in the use of pharmacological pain relief when acupuncture is administered. The appropriate dose of acupuncture treatment required to elicit a potential effect on labour pain has not been fully explored. The dose is determined by many different factors, including the number of needles used and the intensity of the stimulation. In Sweden, manual stimulation of the needles is common practice when acupuncture is used for labour pain, but electrical stimulation of the needles, which gives a higher dose, could possibly be more effective. The overall aim of this thesis was to evaluate the effectiveness of acupuncture with manual stimulation (MA) of the needles as well as acupuncture with a combination of manual and electrical stimulation (EA) in reducing labour pain, compared with standard care without any form of acupuncture (SC). Methods: The study was designed as a three-armed randomised controlled trial in which 303 nulliparous women with normal pregnancies were randomised to MA, EA, or SC. The primary outcome was labour pain, assessed using the Visual Analogue Scale (VAS). Secondary outcomes were relaxation during labour, use of obstetric pain relief, and associations between maternal characteristics and labour pain and use of epidural analgesia respectively. Also, labour and infant outcomes, recollection of labour pain, and maternal experiences, such as birth experience and experience of the midwife, were investigated two months after the birth. The sample size calculation was based on the potential to discover a difference of 15 mm on the VAS. Data were collected during labour before the interventions, the day after birth, and two months later. Besides using the VAS, information was collected by means of study specific protocol, questionnaires and medical records. Results: The mean VAS scores were 66.4 in the MA group, 68.5 in the EA group, and 69.0 in the SC group (mean differences: MA vs. SC 2.6 95% CI -1.7 to 6.9, and EA vs. SC 0.6 95% CI -3.6 to 4.8). Other methods of pain relief were used less frequently in the EA group, including epidural analgesia, MA 61.4%, EA 46%, and SC 69.9%. (EA vs. SC OR 0.4 95% CI 0.2 to 0.7). No statistically significant differences were found in the recollection of labour pain between the three groups two months after birth (mean VAS score: MA 69.3, EA 68.7 and SC 70.1). A few maternal characteristics were associated with labour pain (age, dysmenorrhea, and cervix dilatation), but none of the investigated characteristics predicted the outcome of the acupuncture treatment in MA or EA. Women in the EA group experienced acupuncture as being effective for labour pain to a higher extent than women who received MA, MA 44.4%, EA 67.1% (EA vs. MA OR 2.4 95% CI 1.2 to 4.8). Women in the EA group also spent less time in labour (mean 500 min) than those who received MA (mean 619 min) and SC (mean 615 min) (EA vs. MA HR 1.4 95% CI 1.0 to1.9, EA vs. SC HR 1.4, 95% CI 1.1 to 2.0), and had less blood loss than women receiving SC, (EA vs. SC OR 0.1 95% CI 0.3 to 0.7). The women’s assessment of the midwife as being supportive during labour (MA 77.2%, EA 83.5%, SC 80%), overall satisfaction with midwife care (MA 100%, EA 97.5%, SC 98.7%), and having an overall positive childbirth experience (MA 64.6%, EA 61.0%, SC 54.3%) did not differ statistically. No serious side effects of the acupuncture treatment were reported. Conclusion: Acupuncture, regardless of type of stimulation, did not differ from standard care without acupuncture in terms of reducing women’s experience of pain during labour, or their memory of pain and childbirth overall two months after the birth. However, other forms of obstetric pain relief were less frequent in women receiving a combination of manual and electrical stimulation, suggesting that this method could facilitate coping with labour pain.

Manual and electroacupuncture for labour pain : study design of a longitudinal randomized controlled trial

Introduction. Results from previous studies on acupuncture for labour pain are contradictory and lack important information on methodology. However, studies indicate that acupuncture has a positive effect on women's experiences of labour pain. The aim of the present study was to evaluate the efficacy of two different acupuncture stimulations, manual or electrical stimulation, compared with standard care in the relief of labour pain as the primary outcome. This paper will present in-depth information on the design of the study, following the CONSORT and STRICTA recommendations. Methods. The study was designed as a randomized controlled trial based on western medical theories. Nulliparous women with normal pregnancies admitted to the delivery ward after a spontaneous onset of labour were randomly allocated into one of three groups: manual acupuncture, electroacupuncture, or standard care. Sample size calculation gave 101 women in each group, including a total of 303 women. A Visual Analogue Scale was used for assessing pain every 30 minutes for five hours and thereafter every hour until birth. Questionnaires were distributed before treatment, directly after the birth, and at one day and two months postpartum. Blood samples were collected before and after the first treatment. This trial is registered at ClinicalTrials.gov: NCT01197950.

The emerging global tourism geography : an environmental sustainability perspective

The current development of tourism is environmentally unsustainable. Specifically, tourism’s contribution to climate change is increasing while other sectors are reducing their greenhouse gas emissions. This paper has two goals: reveal the main structural cause for tourism’s emission growth and show the consequences thereof for (mitigation) policies. It is reasoned that the main cause for tourism’s strong emission growth is the time-space expansion of global tourism behavior. Contemporary tourism theory and geography fail to clearly describe this geographical development, making it difficult to understand this expansion and develop effective policies to mitigate environmental impacts. Therefore, this paper explores some elements of a ‘new tourism geography’ and shows how this may help to better understand the causes of the environmentally unsustainable development of tourism with respect to climate change and devise mitigation policies.

Too Many Bad Cooks Spoiling the Broth? Effectiveness of NGOs in Addressing Child Labour in El Salvador

The reaction of the first world to the persevering plight of a large part of the third world varies. In response to the sometimes glaring disparities, many international organizations and multinational corporations have recently adopted a pro-development rhetoric with relation to the problem of global poverty. However, the rhetoric rarely translates into action. As David Bacon discusses, leaders of corporations and organizations now tend to conclude their speeches by expressing a desire to reduce the suffering of the third world. However, when it comes to agreeing on specific concessions that could indeed improve the world-wide economic situation, first world countries are reluctant to act. A good example of this type of behavior is the current negotiation of the WTO, the “development round of Doha,” in which the United States along with the European Union pressure countries of the developing South to open up their markets, while at the same time refusing to remove or even decrease their own agricultural subsidies. The first world civil society observes the behavior of international organizations and western based multinational corporations as ineffectual. Taking the matter in its own hands, especially in the past couple of decades, this civil society has created a countless number of development-oriented nongovernmental organizations. These are supposed to compensate for the lack of action by international organizations. Development NGOs are believed to be more locally responsive as well as free of business or political considerations in choosing their strategies, and thus generally more efficient than IOs. However, if they really were how they are alleged to be, the problems of the third world would already be ameliorated by a significant amount, if not completely eradicated. Do development-NGOs indeed possess the characteristics that they claim to possess? What is their real affect on human rights? And how effective are they in their work?

Entrepreneurial risk and labour's share in output

This paper presents a theoretical model which discusses the role played by the entrepreneurial risk on the distribution of the national income. In a two-period general equilibrium framework with competitive risk-averse entrepreneurs it is shown that the highest the risk borne by firms, the lower will be real wages, employment and the labour's share in output. The model helps explain the fall of the labour's share in the Brazilian output during the 1980s.

Linkages between growth, poverty and the labour market

From a methodological point of view, this paper makes two contributions to the literature. One contribution is the proposal of a new measure of pro-poor growth. This new measure provides the linkage between growth rates in mean income and in income inequality. In this context, growth is defined as pro-poor (or anti-poor) if there is a gain (or loss) in the growth rate due to a decrease (or increase) in inequality. The other contribution is a decomposition methodology that explores linkages growth patterns, and labour market performances. Through the decomposition analysis, growth in per capita income is explained in terms of four labour market components: the employment rate, hours of work, the labour force participation rate, and productivity. The proposed methodology are then applied to the Brazilian National Household Survey (PNAD) covering the period 1995-2004. The paper analyzes the evolution of Brazilian social indicators based on per capita income exploring links with adverse labour market performance.

Conditional labour supply, quantile functions in Brazil

The estimation of labor supply elasticities has been an important issue m the economic literature. Yet all works have estimated conditional mean labor supply functions only. The objective of this paper is to obtain more information on labor supply, by estimating the conditional quantile labor supply function. vI/e use a sample of prime age urban males employees in Brazil. Two stage estimators are used as the net wage and virtual income are found to be endogenous to the model. Contrary to previous works using conditional mean estimators, it is found that labor supply elasticities vary significantly and asymmetrically across hours of work. vVhile the income and wage elasticities at the standard work week are zero, for those working longer hours the elasticities are negative.

Linkages between pro-poor growth, social programmes and labour market : the recent Brazilian experience

From a methodological point of view, this paper makes two contlibutions to the literature. One contribution is the proposal of a new measure of pro-poor growth. This new measure provides the linkage between growth rates in mean income and in income inequality. In this context, growth is defined as pro-poor (or anti-poor) if there is a gain (or loss) in the growth rate due to a decrease (or increase) in inequality. The other contribution is a decomposition methodology that explores linkages between three dimensions: growth pattems, labour market performances. and social policies. Through the decomposition analysis, growth in per capita income is explained in terms of four labour market components: the employment rate. hours of work, the labour force participation rate. and productivity. We also assess the contribution of different nonlabour income sources to growth patterns. The proposed methodologies are then applied to the Brazilian National Household Survey (PNAD) covering the period 1995-2004. The paper analyzes the evolution of Brazilian social indicators based on per capita income exploring links with adverse labour market performance and social policy change, with particular emphasis on the expansion of targeted cash transfers and devising more propoor social security benefits.

The long term effects of Bolsa Família on child labour and school enrolment

In this paper we study the e ects of conditional cash transfers in school enrolment and tackling child labour. We develop a dynamic heterogeneous agent general equilibrium model, where households face a set of tradeo s while allocating their children's time in leisure activities, schooling and working. We calibrate the model using data from the Brazilian survey PNAD, before the policy was implemented, in order to quantify the e ects of a conditional transfer. We then evaluate the results of a policy experiment that implements a conditional cash transfer scheme similar to the Brazilian Bolsa Fam lia. Our results suggest that the program, in the long term, is able to substantially increase school registration and reduce child labour and poverty. In addition, we nd out that a progressive conditional cash transfer results is even more e ective in tackling child labour and increasing school enrolment.

The long term effects of Bolsa Família on child labour and school enrollment

Neste trabalho, estudamos os impactos de transfer^encias condicionais de renda sobre o trabalho e a educa c~ao infantis. Para tanto, desenvolvemos modelo din^amico de equil brio geral com agentes heterog^eneos, onde as fam lias enfrentam tradeo s com rela c~ao a aloca c~ao de tempo das crian cas em atividades de lazer, em escolaridade e em trabalhar. O modelo e calibrado usando dados da Pesquisa Nacional por Amostra em Domic lios, de modo que podemos quanti car os efeitos de uma pol tica de transfer^encia de renda. Finalmente, avaliamos o impacto de um pol tica semelhante ao atual Bolsa Fam lia. Nossos resultados sugerem que o programa, no longo prazo, e capaz de induzir um aumento substancial na escolaridade, al em de ser efetivo na redu c~ao do trabalho infantil e da pobreza. Al em disso, mostramos que um programa progressivo de transfer^encia condicional de renda resulta em benef cios ainda maiores.