***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE The purpose of this pilot study was to test the effects of guided imagery on blood loss during the third stage of labor . DESIGN AND SETTING This was a three-group r and omized controlled trial . Recruitment was conducted from a university nurse-midwifery practice . SUBJECTS Sixty ( 60 ) women between pregnancy weeks 36 and 38 participated . INTERVENTIONS The women were r and omized into experimental , placebo , and control groups . OUTCOME MEASURES Intrauterine pressure catheters were used to measure uterine contraction frequency and intensity . Blood loss was measured . Analysis of variance was used to compare the three groups on continuous variables . RESULTS Complete data were collected on 41 subjects . No significant differences were found among the groups on demographic or potentially confounding variables . CONCLUSIONS Blood loss was nominally lower in the experimental group , but conclusions can not be drawn due to the sample size This study examined the effects of a yoga program during pregnancy , on  maternal comfort , labor pain , and birth outcomes .  A r and omized trial was conducted using 74-primigravid Thai women who were equally divided into two groups ( experimental and control ) . The yoga program involved six , 1-h sessions at prescribed weeks of gestation . A variety of instruments were used to assess maternal comfort , labor pain and birth outcomes . The experimental group was found to have higher levels of maternal comfort during labor and 2h post-labor , and experienced less subject evaluated labor pain than the control group . In each group , pain increased and maternal comfort decreased as labor progressed . No differences were found , between the groups , regarding pethidine usage , labor augmentation or newborn Apgar scores at 1 and 5 min . The experimental group was found to have a shorter duration of the first stage of labor , as well as the total time of labor Two studies were conducted to examine the effects of music on analogued labor pain using volunteer nulliparous subjects who were r and omly assigned to treatment groups ( n = 10 per group ) . Assessment s of the treatments were made in a 1-hour session involving twenty 80-second exposures to a laboratory pain stimulus patterned to resemble labor contractions . In the first experiment , it was hypothesized that subjects listening to easy-listening music would report lower pain ratings and cardiovascular responses than subjects listening to rock music , self-selected music , or a dissertation ( placebo-attention ) and subjects in a no-treatment control group . No significant group effects were found ; significant time effects were found for heart rate , systolic and diastolic blood pressure . Subjects spontaneously reported using imagery as a pain reduction technique . In the second study a combination of music and imagery was examined by r and omly assigning subjects to one of five groups : self-generated imagery with music ( SIM ) , guided imagery with music ( GIM ) , self-generated imagery without music ( SI ) , guided imagery without music ( GI ) , or no-treatment control . Again , no significant group effects were obtained . Significant time effects were obtained for heart rate , systolic and diastolic blood pressure CONTEXT A prior national survey documented the high prevalence and costs of  alternative medicine use in the United States in 1990 . OBJECTIVE To document trends in alternative medicine use in the United States between 1990 and 1997 . DESIGN Nationally representative r and om household telephone surveys using comparable key questions were conducted in 1991 and 1997 measuring utilization in 1990 and 1997 , respectively . PARTICIPANTS A total of 1539 adults in 1991 and 2055 in 1997 . MAIN OUTCOMES MEASURES Prevalence , estimated costs , and disclosure of alternative therapies to physicians . RESULTS Use of at least 1 of 16 alternative therapies during the previous year increased from 33.8 % in 1990 to 42.1 % in 1997 ( P < or = .001 ) . The therapies increasing the most included herbal medicine , massage , megavitamins , self-help groups , folk remedies , energy healing , and homeopathy . The probability of users visiting an alternative medicine practitioner increased from 36.3 % to 46.3 % ( P = .002 ) . In both surveys alternative therapies were used most frequently for chronic conditions , including back problems , anxiety , depression , and headaches . There was no significant change in disclosure rates between the 2 survey years ; 39.8 % of alternative therapies were disclosed to physicians in 1990 vs 38.5 % in 1997 . The percentage of users paying entirely out-of-pocket for services provided by alternative medicine practitioners did not change significantly between 1990 ( 64.0 % ) and 1997 ( 58.3 % ) ( P=.36 ) . Extrapolations to the US population suggest a 47.3 % increase in total visits to alternative medicine practitioners , from 427 million in 1990 to 629 million in 1997 , thereby exceeding total visits to all US primary care physicians . An estimated 15 million adults in 1997 took prescription medications concurrently with herbal remedies and /or high-dose vitamins ( 18.4 % of all prescription users ) . Estimated expenditures for alternative medicine professional services increased 45.2 % between 1990 and 1997 and were conservatively estimated at $ 21.2 billion in 1997 , with at least $ 12.2 billion paid out-of-pocket . This exceeds the 1997 out-of-pocket expenditures for all US hospitalizations . Total 1997 out-of-pocket expenditures relating to alternative therapies were conservatively estimated at $ 27.0 billion , which is comparable with the projected 1997 out-of-pocket expenditures for all US physician services . CONCLUSIONS  Alternative medicine use and expenditures increased substantially between 1990 and 1997 , attributable primarily to an increase in the proportion of the population seeking alternative therapies , rather than increased visits per patient Objective . To study whether use of psychoprophylaxis during labor affects course of labor and experience of childbirth in nulliparous women . Design . Cohort study . Setting . Women were recruited from 15 antenatal clinics in Sweden between October 2005 and January 2007 . Sample . A total of 857 nulliparous women with a planned vaginal delivery . Methods . Using data from a r and omized controlled trial of antenatal education where the allocated groups were merged , we compared course of labor and experience of childbirth between women who used psychoprophylaxis during labor and those who did not . Data were collected by question naires in mid‐pregnancy and three months after birth , and from the Swedish Medical Birth Register . Logistic regression was used to assess associations . Main outcome measures . Mode of delivery , augmentation of labor , length of labor , Apgar score , pain relief and experience of childbirth as measured by the Wijma Delivery Experience Question naire . Results . Use of psychoprophylaxis during labor was associated with a lower risk of emergency cesarean section ( adjusted odds ratio ( OR ) 0.57 ; 95 % confidence interval ( CI ) 0.37–0.88 ) , but an increased risk of augmentation of labor ( adjusted OR 1.68 ; 95 % CI 1.23–2.28 ) . No statistical differences were found in length of labor ( adjusted OR 1.32 ; 95 % CI 0.95–1.83 ) , Apgar score < 7 at five minutes ( adjusted OR 0.82 ; 95 % CI 0.33–2.01 ) , epidural analgesia ( adjusted OR 1.13 ; 95 % CI 0.84–1.53 ) or fearful childbirth experience ( adjusted OR 1.04 ; 95 % CI 0.62–1.74 ) . Conclusion . Psychoprophylaxis may reduce the rate of emergency cesarean section but may not affect the experience of childbirth OBJECTIVE to evaluate a yoga programme provided to primigravidas in the third trimester of pregnancy with the aim of decreasing the discomforts associated with pregnancy and increasing childbirth self-efficacy . DESIGN non-r and omised controlled experimental study . SETTING a hospital in northern Taiwan . PARTICIPANTS the target population was primigravidas at 26 - 28 weeks of gestation ( no high-risk pregnancies ) who had not engaged in regular exercise or yoga for at least one year . The study included 88 individuals ; 43 in the control group and 45 in the experimental group who took part in the prenatal yoga programme .  INTERVENTION the duration of the prenatal yoga programme was 12 - 14 weeks , with at least three sessions per week . Each workout lasted for 30 minutes . MEASUREMENTS AND FINDINGS women who took part in the prenatal yoga programme reported significantly fewer pregnancy discomforts than the control group ( 38.28 vs 43.26 , z=-2.58 , p=0.01 ) at 38 - 40 weeks of gestation . The subjects who participated in the yoga programme exhibited higher outcome and self-efficacy expectancies during the active stage of labour ( 104.13 vs 83.53 , t=3.24 , p=0.002 ; 99.26 vs 77.70 , t=3.99 , p ≤ 0.001 ) and the second stage of labour ( 113.33 vs 88.42 , t=3.33 , p=0.002 ; 102.19 vs 79.40 , t=3.71 , p ≤ 0.001 ) compared with the control group . KEY CONCLUSIONS the provision of booklets and videos on yoga during pregnancy may contribute to a reduction in pregnancy discomforts and improved childbirth self-efficacy . IMPLICATION S FOR PRACTICE this yoga programme provides health-care professionals with an evidence -based intervention Objective To evaluate the effect of an antenatal integrative medicine education programme in addition to usual care for nulliparous women on intrapartum epidural use . Design Open-label , assessor blind , r and omised controlled trial . Setting 2 public hospitals in Sydney , Australia . Population 176 nulliparous women with low-risk pregnancies , attending hospital-based antenatal clinics . Methods and intervention The Complementary Therapies for Labour and Birth protocol , based on the She Births and acupressure for labour and birth courses , incorporated 6 evidence -based complementary medicine techniques : acupressure , visualisation and relaxation , breathing , massage , yoga techniques , and facilitated partner support . R and omisation occurred at 24–36 weeks ’ gestation , and participants attended a 2-day antenatal education programme plus st and ard care , or st and ard care alone . Main outcome measures Rate of analgesic epidural use . Secondary : onset of labour , augmentation , mode of birth , newborn outcomes . Results There was a significant difference in epidural use between the 2 groups : study group ( 23.9 % ) st and ard care ( 68.7 % ; risk ratio ( RR ) 0.37 ( 95 % CI 0.25 to 0.55 ) , p≤0.001 ) . The study group participants reported a reduced rate of augmentation ( RR=0.54 ( 95 % CI 0.38 to 0.77 ) , p<0.0001 ) ; caesarean section ( RR=0.52 ( 95 % CI 0.31 to 0.87 ) , p=0.017 ) ; length of second stage ( mean difference=−0.32 ( 95 % CI −0.64 to 0.002 ) , p=0.05 ) ; any perineal trauma ( 0.88 ( 95 % CI 0.78 to 0.98 ) , p=0.02 ) and resuscitation of the newborn ( RR=0.47 ( 95 % CI 0.25 to 0.87 ) , p≤0.015 ) . There were no statistically significant differences found in spontaneous onset of labour , pethidine use , rate of postpartum haemorrhage , major perineal trauma ( third and fourth degree tears/episiotomy ) , or admission to special care nursery/neonatal intensive care unit ( p=0.25 ) . Conclusions The Complementary Therapies for Labour and Birth study protocol significantly reduced epidural use and caesarean section . This study provides evidence for integrative medicine as an effective adjunct to antenatal education , and contributes to the body of best practice evidence . Trial registration number ACTRN12611001126909 OBJECTIVES To examine the effectiveness of a birth ball exercise programme during childbirth by measuring childbirth self-efficacy and childbirth pain . In addition , it tested the mediating effects of childbirth self-efficacy on the relationship between the birth ball exercise programme and childbirth pain . DESIGN R and omised controlled trial . PARTICIPANTS AND SETTING The study was conducted from December 2008 to November 2009 , at two birth units , one at a regional hospital and one at a medical centre , with 600 and 1022 annual births , respectively . One hundred and eighty-eight expectant mothers were recruited ( recruitment rate : 47 % ) and were allocated by block r and omisation into the two arms of the study , but only 48 intervention and 39 control group participants completing the trial . INTERVENTIONS The birth ball exercise programme consisted of a 26-page booklet and a 19-minute videotape , with periodic follow-ups during prenatal checks . All members of the experimental group were asked 
    Output:
    
There is no strong evidence that the effects were any different between groups for satisfaction in childbirth , or for caesarean section rate , need for assisted vaginal delivery or need for pharmacological pain relief .
There was insufficient evidence for the role of mindfulness and audio-analgesia .
The majority of trials did not report on the safety of the interventions .