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How to Reduce Epidurals by 65% and Cesareans by 44%

How to Reduce Epidurals by 65% and Cesareans by 44%

It has been about a year since a study out of Australia about childbirth education generated news reports around the world. In a randomized controlled trial (RCT), researchers at Western Sydney University compared outcomes of women who attended usual hospital childbirth classes to those attending usual hospital classes plus a specialized childbirth education program focusing on complementary pain management strategies, known as the Complementary Therapies for Labour and Birth protocol or CTLB. Remarkably, the researchers found that women who attended the CTLB course had a 65% lower epidural rate and a 44% lower cesarean rate. In this day and age when many hospitals are striving to reduce cesarean rates, how did they do it?

The CTLB program is based on the She Births® childbirth education curriculum created by Nadine Richardson, a childbirth educator, doula, and prenatal yoga instructor in Bondi Beach, Australia. Additional information about acupressure, based on recommendations from Dr. Debra Betts, was incorporated into the CTLB course.  Women attending antenatal clinics in two public hospitals in Sydney, Australia were provided information about the study and invited to participate. Women were eligible for the trial if they were pregnant for the first-time with a singleton pregnancy with a cephalic presentation, were low-risk, and understood English well enough to participate in childbirth classes. The study participants were randomized to either usual care – the standard hospital-based childbirth course – or to usual care plus a two-day CTLB course. The usual hospital classes include topics such as pregnancy changes, exercise and back care during pregnancy, signs of labor, unexpected outcomes in labor and birth, newborn care and breastfeeding, parenthood, and the first weeks of life with a new baby. The CTLB courses were given over a weekend at one of the two hospital meeting places. All twenty CTLB courses included in the study were taught by the lead study investigator, Kate Levett. There was a minimum of two couples per course and a maximum of 12, with an average of 8 couples per course.

In the CTLB course, students learned about the physiology of normal birth and were encouraged to “work with the pain” of labor using six complementary medicine tools:

• Visualization
• Yoga postures
• Breathing techniques
• Massage
• Acupressure
• Facilitated partner support

The study authors note that, according to a Cochrane Library review, evidence shows that all six tools may have a role in reducing pain, although more research is needed. A summary of the first five tools is illustrated in this handout. A short description of each of the tools is provided in the BMJ Open study and detailed information on exactly what was taught for each tool is available online as a supplementary file to the BMJ Open article. The facilitated partner support focuses on “working with the pain” and having the partner advocate for the laboring woman and help her to promote the release of oxytocin and minimize stress. Time is provided in the CTLB course for facilitated discussion and labor rehearsals.

As mentioned in the opening paragraph, researchers found that women who attended the CTLB course had a 65% lower epidural rate and a 44% lower cesarean rate. In addition, the study group reported a reduced rate of augmentation, length of second stage, any perineal trauma, and resuscitation of the newborn. The researchers noted that some of these outcomes may be due to the dramatic reduction in the use of epidural analgesia. There were no statistically significant differences in spontaneous onset of labor, use of pethidine [also known as Demerol], rate of postpartum hemorrhage, major perineal trauma, or admission to the special care or NICU. The women in the CTLB group used an average of almost 4 (3.94) tools each – one type of breathing technique was used by 60.2%; visualization by 55.7%; acupressure by 46.6%; yoga and massage, each by 35.2%; and another breathing technique by 35.2%. In women attending only the usual hospital childbirth classes, less than 5% used any complementary medicine strategies.

As childbirth education courses are decreasing in length, childbirth educators have to take a hard look at their content. If one of the goals of your childbirth classes is to promote normal, physiological birth and decrease cesarean surgery, this study makes a powerful case for emphasizing normal, physiological birth and teaching students a variety of evidence-based complementary pain management strategies to reduce pain and facilitate the progress of labor.


1. Betts, Debra. (2003). Natural pain relief techniques for childbirth using Acupressure – Promoting a natural labour and partner involvement.

2. Jones, L., et al. (2012). Pain management for women in labour: an overview of systematic reviews. Cochrane Library.

3. Levett, Kate M., Smith, C.A., Bensoussan, A. & Dahlen, H.G. (2016). Complementary therapies for labour and birth study: a randomised controlled trial of antenatal integrative medicine for pain management in labour. BMJ Open, 2016 Jul 12;6(7):e010691. doi: 10.1136/bmjopen-2015-010691.

4. Levett, K.M., Smith, C.A., Bensoussan, A. & Dahlen, H.G. (2016). The Complementary Therapies for Labour and and Birth Study making sense of labour and birth – Experiences of women, partners, and midwives of a complementary medicine antenatal education course. Midwifery, 40, 124-131.

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