The effect of breast stimulation on the duration of labor stages: A systematic review and meta-analysismeta-analysis

Document Type : Review Article


1 Assistant professor, Department of Reproductive Health, Social Determinants of Health Research Center, School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran.

2 PhD student of Midwifery, School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran.

3 Assistant professor, Department of Midwifery, Bonab Branch, Islamic Azad University, Bonab. Iran.



Introduction: Prolonged labor stages can have serious consequences for both mother and infant. Positive effects and encouraging results of nipple stimulation on the duration of labor have been observed in some studies. This study was performed with aim to determine the effects of breast stimulation on the duration of labor (primary outcome) and Apgar score and method of delivery (secondary outcomes).
Methods: This systematic review and meta-analysis was conducted according to the PRISMA guidelines. A search of published Persian and English texts without time restrictions up to July 2023 was performed in reputable databases including Scopus, Web of Science, Google Scholar, PubMed, and the SID Persian database with English keywords of Stimulation, Physical stimulation, Labor progress, Labor stage, Duration of labor, Breast, Nipple, and Labor, as well as their equivalent Persian keywords. Two authors independently assessed the quality of the articles using the Cochrane Risk of Bias tool and ROBINS-I tool, and the meta-analysis was conducted using RevMan software (version 5.3).
Results: Out of 307 identified studies, 10 articles met the inclusion criteria. According to the subgroup analysis based on the control group, nipple stimulation compared to no intervention significantly reduced the duration of the first stage of labor (4 studies, mean difference: -2.66; 95% confidence interval: -1.70 to -3.61; p<0.001) and the second stage of labor (3 studies, mean difference: -8.22; 95% confidence interval: -3.62 to -12.83; p<0.001).
Conclusion: Although breast stimulation compared to no intervention may reduce the duration of labor, due to the limited studies in this area, further high-quality studies are needed before recommending its use.


Main Subjects

  1. Wang L, Wang H, Jia L, Qing W, Li F, Zhou J. The impact of stage of labor on adverse maternal and neonatal outcomes in multiparous women: a retrospective cohort study. BMC Pregnancy and Childbirth 2020; 20(1):1-11.
  2. Knigin D, Ezra Y, Ben-David A, Elami-Suzin M. The continuum of a prolonged labor and a second stage cesarean delivery. The Journal of Maternal-Fetal & Neonatal Medicine 2022; 35(25):6425-9.
  3. World Health Organization. WHO statement on caesarean section rates. World Health Organization; 2015.
  4. Rafiei M, Ghare MS, Akbari M, Kiani F, Sayehmiri F, Sayehmiri K, et al. Prevalence, causes, and complications of cesarean delivery in Iran: A systematic review and meta-analysis. International journal of reproductive biomedicine 2018; 16(4):221.
  5. Vardo JH, Thornburg LL, Glantz JC. Maternal and neonatal morbidity among nulliparous women undergoing elective induction of labor. The Journal of reproductive medicine 2011; 56(1-2):25-30.
  6. Kiesewetter B, Lehner R. Maternal outcome monitoring: induction of labor versus spontaneous onset of labor—a retrospective data analysis. Archives of gynecology and obstetrics 2012; 286:37-41.
  7. Adler K, Rahkonen L, Kruit H. Maternal childbirth experience in induced and spontaneous labour measured in a visual analog scale and the factors influencing it; a two-year cohort study. BMC Pregnancy and Childbirth 2020; 20(1):1-7.
  8. Henderson J, Redshaw M. Women's experience of induction of labor: a mixed methods study. Acta obstetricia et gynecologica Scandinavica 2013; 92(10):1159-67.
  9. Singh N, Tripathi R, Mala YM, Yedla N. Breast stimulation in low-risk primigravidas at term: does it aid in spontaneous onset of labour and vaginal delivery? A pilot study. Biomed research international 2014; 2014.
  10. Adu-Bonsaffoh K, Seffah J. Factors associated with adverse obstetric events following induction of labour: a retrospective study in a tertiary hospital in Ghana. African Health Sciences 2022; 4(4):348-56.
  11. Marconi AM. Recent advances in the induction of labor. F1000Res 2019; 8:F1000 Faculty Rev-1829.
  12. Highley LL, Previs RA, Dotters-Katz SK, Brancazio LR, Grotegut CA. Cesarean delivery among women with prolonged labor induction. Journal of Perinatal Medicine 2016; 44(7):759-66.
  13. Takahata K, Horiuchi S, Tadokoro Y, Shuo T, Sawano E, Shinohara K. Effects of breast stimulation for spontaneous onset of labor on salivary oxytocin levels in low-risk pregnant women: a feasibility study. PLoS One 2018; 13(2):e0192757.
  14. Takahata K, Horiuchi S, Tadokoro Y, Sawano E, Shinohara K. Oxytocin levels in low-risk primiparas following breast stimulation for spontaneous onset of labor: a quasi-experimental study. BMC pregnancy and childbirth 2019; 19:1-9.
  15. Stark EL, Athens ZG, Son M. Intrapartum nipple stimulation therapy for labor induction: a randomized controlled external pilot study of acceptability and feasibility. American Journal of Obstetrics & Gynecology MFM 2022; 4(2):100575.
  16. Smith CA, Armour M, Dahlen HG. Acupuncture or acupressure for induction of labour. Cochrane Database of Systematic Reviews 2017(10).
  17. Zamawe C, King C, Jennings HM, Mandiwa C, Fottrell E. Effectiveness and safety of herbal medicines for induction of labour: a systematic review and meta-analysis. BMJ open 2018; 8(10).
  18. Ghasemi VI, Fakari FR, Ebadi A, Ozgoli GI, Kariman NO, Gharenaz MS. Effective interventions for the induction of labor: a systematic review. Iranian Journal of Obstetrics, Gynecology and Infertility 2018; 21(1):90-104.
  19. Buckley S, Uvnäs-Moberg K, Pajalic Z, Luegmair K, Ekström-Bergström A, Dencker A, et al. Maternal and newborn plasma oxytocin levels in response to maternal synthetic oxytocin administration during labour, birth and postpartum–a systematic review with implications for the function of the oxytocinergic system. BMC pregnancy and childbirth 2023; 23(1):1-56.
  20. Kavanagh J, Kelly AJ, Thomas J, Cochrane Pregnancy and Childbirth Group. Breast stimulation for cervical ripening and induction of labour. Cochrane Database of Systematic Reviews 1996; 2010(1).
  21. Curtis P, Resnick JC, Evens S, Thompson CJ. A comparison of breast stimulation and intravenous oxytocin for the augmentation of labor. Birth 1999; 26(2):115-22.
  22. Christensson K, Nilsson BA, Stock S, Matthiesen AS, Uvnäs-Moberg K. Effect of nipple stimulation on uterine activity and on plasma levels of oxytocin in full term, healthy, pregnant women. Acta obstetricia et gynecologica Scandinavica 1989; 68(3):205-10.
  23. Begley CM, Gyte GM, Devane D, McGuire W, Weeks A, Biesty LM. Active versus expectant management for women in the third stage of labour. Cochrane database of systematic reviews 2019(2).
  24. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372:n71.
  25. Cumpston M, Chandler J. Chapter IV: Updating a review. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al. Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane, 2022. Available from
  26. Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. Bmj 2011; 343.
  27. Brożek JL, Akl EA, Alonso‐Coello P, Lang D, Jaeschke R, Williams JW, et al. Grading quality of evidence and strength of recommendations in clinical practice guidelines: part 1 of 3. An overview of the GRADE approach and grading quality of evidence about interventions. Allergy 2009; 64(5):669-77.
  28. Modarres M, Rahimi-Kian F. The use of breast stimulation to prevent post-date pregnancy. Medical Journal of the Islamic Republic of Iran 2000; 14(3):211-6.
  29. Elliott JP, Flaherty JF. The use of breast stimulation to prevent postdate pregnancy. American journal of obstetrics and gynecology 1984; 149(6):628-32.
  30. Demirel G, Guler H. The effect of uterine and nipple stimulation on induction with oxytocin and the labor process. Worldviews on Evidence‐Based Nursing 2015; 12(5):273-80.
  31. Hariri N, Tork Zahrani Sh, Hajian S, Shahsavari S. Comparison of the Effect of Nipple Stimulation and Syntocinon Infusion on the Labor Induction and Its Outcomes on Nulliparous Women: Randomized Clinical Trial. Advances in Nursing and Midwifery (Faculty of Nursing of Midwifery Quarterly) 2016; 25(92):89-99.
  32. Beiranvand SP, Akbari S, Azhari S, Birjandi M. A comparison of the effect of nipple stimulation and oxytocin infusion on the duration of phases of labor. Journal of Kermanshah University of Medical Sciences 2009; 13(2).
  33. Suresh V, Soni R. A Quasi Experimental Study to Assess the Effectiveness of Nipple Stimulation in the Progress of Labour among Primipara Women during First Stage of Labour in Selected Hospital of Jabalpur (MP). Indian Journal of Holistic Nursing (ISSN: 2348-2133) 2019; 10(1):1-7.
  34. Ibrahim H, Ghattas V, El-Shabory N. Effect of Nipple and Uterine Stimulation on the Progress of Labor among Primiparous Women. International Journal of Novel Research in Healthcare and Nursing 2021; 8(2):169-80.
  35. Hodgson ZG, Latka P. Canadian Registered Midwives’ Experiences with Nipple Stimulation: An Exploratory Survey in British Columbia and Ontario. Journal of Obstetrics and Gynaecology Canada 2020; 42(7):861-7.
  36. Rahmadaniah I, Anggeriani R, Sari SD, Lamdayani R. The Effect of Nipple Stimulation on the Latent Phase Duration of Labor First Stage. Jurnal Keperawatan 2021; 13(2):557-66.
  37. Dashtinejad E, Abedi P, Afshari P. Comparison of the effect of breast pump stimulation and oxytocin administration on the length of the third stage of labor, postpartum hemorrhage, and anemia: a randomized controlled trial. BMC pregnancy and childbirth 2018; 18(1):1-8.
  38. Damania KR, Nanavati MS, Dastur NI, Daftary SN. Breast stimulation for cervical ripening. J Obstet Gynec India 1988; 38:663-5.