Part I in this series covers evidence regarding bed rest in pregnancy.

Part II covers risks associated with bed rest in pregnancy.

Stubborn Prevalence of Bed Rest Recommendations

In the June 2013 issue of Obstetrics and Gynecology (subscription needed to access full articles), obstetricians Christina McCall, David Grimes, and Anne Drapkin published an article called “‘Therapeutic’ Bed Rest in Pregnancy: Unethical and Unsupported by Data” in which they conclude,

Because “therapeutic” bed rest has no known benefit yet established harms, its continued use is inconsistent with the ethical principles that govern medical practice. Viewing bed rest as a risky and unproven intervention illustrates the need to limit its use to formal clinical trials. This would require, for the prescription of bed rest, a written protocol, approval by an institutional review board, and appropriate informed consent.

Yet no one reports physicians who prescribe bed rest for ethical violations.  As Emily Oster notes, even doctors who know there is no evidence for bed rest prescribe it anyway.

washington.hillObstetrician Washington Hill presented a webinar called “The Puzzle of the Early Detection of Preterm Labor and Prevention of Preterm Birth”: https://www.youtube.com/watch?v=QWoT2XTQVKQ (If you can’t get there through this link, try here.  You may have to set up an account with the Prematurity Prevention Network, which is part of the March of Dimes.)  In the webinar, Dr. Hill notes that obstetricians get very upset at the notion that they should not prescribe bed rest, even though their own organization has recommended against it for over a decade.

The ACOG President’s Blog says in a post from August 2013, “The Easy Way to Keep Up with Advances in Practice,

A recent study on oophorectomy, or ovary removal, at the time of hysterectomy suggests that physicians haven’t caught up with ACOG’s current practice guidance. Previous studies have found the same to be true for other recommendations such as breast cancer screening, bed rest during pregnancy, HPV vaccination, and Pap screenings.

The post “No Sushi during Pregnancy…and Other Hard-to-Swallow Rules” says, 

Sometimes we even look back and realize our advice missed the mark. I remember a time when bed rest was prescribed for many patients with preterm labor, which we now realize accomplished little. But as doctors, we’re continuously learning. Advising patients to avoid things that we KNOW can cause harm is a good practice…Given the risks, most patients don’t want to use their own child as a test subject.

If what WebMD says is true, that 20% of pregnant women are still prescribed bed rest, then apparently many doctors still haven’t gotten the memo–or at least they haven’t read it.  While some obstetricians speak out against bed rest, it does not appear that they are doing anything to pressure their colleagues to conform to evidence based practice.

At Science and Sensibility, Henci Goer points out that liability concerns may drive continued recommendations for bed rest, but it is unconscionable that women’s bodies should  be sacrificed to protect a physician’s bottom line.

Media Evades Rocking the Boat

Websites for lay people regularly report that bed rest is widely prescribed and suggest what to do to combat boredom without giving women information about the evidence for or against bed rest.

  • The Mayo Clinic mentions that bed rest may be prescribed for preterm labor, high blood pressure, twins, or fetal growth problems, even though the evidence shows that bed rest either doesn’t help or makes these problems worse.
  • The American Pregnancy Association offers a similar list with the caveat, “Bed rest is common, so don’t be alarmed.”  Evidence, however, shows that women and their babies may have long term health consequences from bed rest.  The APA also says, “In most cases, bed rest is used to help the body have the best chance to normalize,” which is simply not true.  The changes that occur in the body in response to bed rest are not normal and are overwhelmingly bad.
  • WebMD notes that 20% of women are put on bed rest at some point in pregnancy.  Although after giving the typical list of reasons for bed rest, they (laudably) say “Because bed rest is no longer recommended for most of these problems, ask your doctor if it’s really necessary.”  However, they go on to say “[some women] must spend their entire pregnancies resting in bed” and give women a list of things to do while on bed rest to keep from going crazy.

This list could go on and on and on.  A Google search of “pregnancy bed rest” primarily provides articles on why it’s recommended and how to cope, not on why it shouldn’t be done.

What Does Refusal to Change Practice Say about Women’s Humanity?

Why is bed rest recommended so cavalierly when it has no evident benefit and many evident harms?  Is the woman merely a container for the baby?  Can she be stored on the shelf (or in a bed) indefinitely until the fetus reaches its expiration date and becomes its own person?  Is the fetus more of a person than the pregnant woman?

Mc Call, et al (cited above) point out that prescribing bed rest to pregnant women is a form of injustice:

[B]ed rest conflicts with the ethical principle of justice. Justice requires that clinicians treat individuals fairly and that the provision of care not be discriminatory. Numerous Cochrane reviews regarding pregnancy and childbirth are available, yet the evidence frequently is ignored or interpreted selectively in a way that disregards maternal interests. For example, findings of fetal harm often lead to immediate prohibitions (such as caffeine or various medications), whereas findings of maternal harm or relative fetal safety are overlooked or slowly integrated into practice.

Since we know bed rest may also cause harm to the fetus, is bed rest a way of restricting and containing pregnant women to indicate that society or institutions control them, as we see in many other issues surrounding pregnant women, including expectations that pregnant women will unquestioningly follow medical orders, that women should not have a say in labor and birth decisions, or  the general belief that pregnancy is by definition an abnormal state?

Women need evidence to make informed decisions about their bodies rather than relying on the comfort zone of a doctor operating on folk wisdom.  To expect women to capitulate to harmful non-evidence based practice is disgraceful.

rosie-riveter-pregnant-bed-rest

*All emphasis in quotes throughout the post is mine

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