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Bed Rest to Prevent Preterm Birth Both Ineffective and Harmful

 Today, regular contributor, Henci Goer takes a look at the recent study on prescribing bed rest for the prevention of preterm birth.  Despite not preventing a premature baby, and even possibly increasing the likelihood, it is still routinely recommended for pregnant women.  Please enjoy this research review and share your thoughts with Henci and I in the comments section. – Sharon Muza, Science & Sensibility Community Manager.

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© Sindea Horste sindea.org

In May, The New York Times and Reuters ran articles on a study published the following month finding that restricting activity did not prevent preterm birth in first-time moms with a short cervix (less than 30 mm) (Grobman 2013). A secondary analysis of a randomized controlled trial of injected progesterone vs. placebo, investigators looked at the effect of “activity restriction,” defined as restriction from sexual activity, work, or nonwork activity, in 646 women. They found that 39% of women reported being restricted in one or more of these categories, and two-thirds of them (68%) were restricted in all three with the vast majority (25th to 75th percentile) receiving that prescription between 24 and 28 weeks gestation. Birth before 37 weeks was three times (odds ratio: 2.9) more likely in the restricted group (raw difference: 37% vs. 17%). Adjustment for trial assignment group and factors associated with likelihood of being placed on activity restriction, didn’t much change that ratio (odds ratio: 2.4). The same held true for the likelihood of birth before 34 weeks (odds ratio: 2.3). And here’s the kicker: not mentioned in the secondary analysis is that the trial itself found that progesterone treatment made no difference in preterm birth rate at less than 37 weeks (25% vs. 24%) (Grobman 2012 ).

In other words, not prescribing activity restriction was effective; progesterone treatment was not. Study authors speculated that the reason for the paradoxical effect of activity restriction may be that it is stressful and anxiety provoking and that anxiety and stress may increase risk of adverse pregnancy outcomes.

The uselessness of bed rest is hardly “stop the presses” news. We have known that bed rest was ineffective at least since 1994 when a review reported that this particular emperor had no clothes (Goldenberg 1994). Studies since have reinforced that conclusion. An accompanying commentary in the same issue as Grobman et al’s study reports on the findings of Cochrane systematic reviews on the effects of bed rest (McCall 2013). Bed rest neither prevents miscarriage, preeclampsia, or preterm birth with singleton or multiple gestation, nor treats hypertension or impaired fetal growth. Publication dates for the set of Cochrane reviews range from 2000 (impaired fetal growth) to 2010 (multiple pregnancy). The review on preterm birth with singleton gestation, the subject of Grobman et al.’s study, was published in 2004.

These consistent results, however, have not affected practice. An editorial on the Grobman and McCall articles states that 95% of obstetricians recommend activity restriction or bed rest and that 71% of maternal-fetal medicine specialists responding to a survey would recommend it after arrested preterm labor despite the finding that 72% of survey participants didn’t think it would help (Biggio 2013). Why aren’t doctors paying attention to their own research? Biggio thinks it may be fear of liability if a bad outcome were to occur and bed rest hadn’t been prescribed and the belief that bed rest is harmless. It isn’t, and this is known too. McCall, Grimes, and Lyerly quote from an American College of Obstetricians and Gynecologists’ Practice Bulletin on managing preterm labor (ACOG 2012):

Although bed rest and hydration have been recommended to women with symptoms of preterm labor to prevent preterm delivery, these measures have not been shown to be effective for the prevention of preterm birth and should not be routinely recommended. Furthermore, the potential harm, including venous thromboembolism, bone demineralization, and deconditioning, and the negative effects such as loss of employment, should not be underestimated. [Emphasis mine.]

To this, McCall, Grimes, and Lyerly add adverse psychosocial effects on women and their families, including the potential for women blaming themselves when bed rest fails to avert preterm birth, and now Grobman et al’s study suggests the possibility of increasing the risk of preterm birth.

In the Reuters article, Grobman states that “any pregnant woman who is told to restrict her activity or stay in bed should discuss with her doctor whether there is data to support that recommendation given her condition.” Fair enough, but how is she supposed to know to do that? What role can or should childbirth educators and doulas play? What might Lamaze International or other childbirth-related organizations do to spread the word? What are your thoughts?

References 

ACOG practice bulletin no. 127: Management of preterm labor. (2012). Obstet Gynecol, 119(6), 1308-1317. doi: 10.1097/AOG.0b013e31825af2f0

Biggio Jr, J. R. (2013). Bed Rest in Pregnancy: Time to Put the Issue to Rest.Obstetrics & Gynecology121(6), 1158-1160.

Goldenberg, R. L., Cliver, S. P., Bronstein, J., Cutter, G. R., Andrews, W. W., & Mennemeyer, S. T. (1994). Bed rest in pregnancyObstetrics & Gynecology,84(1), 131-136.

Grobman, W. A., Gilbert, S. A., Iams, J. D., Spong, C. Y., Saade, G., Mercer, B. M., … & Van Dorsten, J. P. (2013). Activity restriction among women with a short cervixObstetrics & Gynecology121(6), 1181-1186.

Grobman, W. A., Thom, E., Spong, C. Y., Iams, J. D., Saade, G. R., Mercer, B. M., … & Van Dorsten, J. P. (2012). 17 alpha-hydroxyprogesterone caproate to prevent prematurity in nulliparas with cervical length less than 30 mm.American journal of obstetrics and gynecology.

McCall, C. A., Grimes, D. A., & Lyerly, A. D. (2013). “Therapeutic” Bed Rest in Pregnancy: Unethical and Unsupported by DataObstetrics & Gynecology,121(6), 1305-1308.

ACOG, Bed Rest, Childbirth Education, Evidence Based Medicine, Guest Posts, Maternal Quality Improvement, Maternity Care, Medical Interventions, New Research, Pre-term Birth, Research , , , , , , , ,

  1. avatar
    Olivia Arakawa
    July 9th, 2013 at 12:48 | #1

    Are there any conditions for which bed rest *is* useful?

  2. July 9th, 2013 at 17:11 | #2

    Well, if there are, it doesn’t appear to be the common ones for which it is prescribed. The commentary citing the Cochrane systematic reviews on bed rest makes that clear.

  3. avatar
    Kelly Wagner
    July 9th, 2013 at 19:16 | #3

    This is a totally irresponsible and article and typical of something reported in the NY Times. No OB/GYN worth their salt would refute that such interventions do indeed help prevent life threatening/damaging preterm deliveries. I have been on the receiving end of such interventions ( bed rest and progrsterone tratments) with 2 pregnancies and an thankful that my physician took such interventions to see that my babies were brought to as close to 40 weeks as possible. No amount of holistic/hypno methods would have reversed the fact that 2 out of my 3 wonderful babies were ready to make their entrances far too early. Thank goodness for my wonderful doctors that are educated in science, not chance

  4. July 9th, 2013 at 23:16 | #4

    I am very glad that your babies were born healthy, but the consistent finding of the scientific research is that bed rest was not responsible for deferring labor. It may appear to be so because many women who are at increased likelihood to deliver preterm and even who experience preterm labor go on to have their babies at or close to term even if nothing is done. For this reason, ineffective treatments such as bed rest can appear to be effective. This is why we need studies such as the one I reported on that compare results in women who received a particular treatment with those who didn’t. But you don’t have to take my word for this. You have a simple way to test who has the right of it: if you become pregnant again, and your doctors recommend bed rest, just take Dr. Grobman’s advice and ask them to show you the evidence supporting bed rest to prevent preterm delivery. If they can, great! If not, well, then you will know whether they are, in fact, “educated in science, not chance.”

  5. July 10th, 2013 at 00:57 | #5

    Not all “scientific ” research supports these six studies and the physiology does not. Pressure on the internal os can trigger the release of prostaglandins in some women with significant cervical change.All bed rest does is get the weight of the baby off the cervix. In my 40 years of clinical experience this has assisted wit MANY improved dates. Tonya Brooks

  6. avatar
    Jane
    July 10th, 2013 at 05:11 | #6

    Perhaps the bed rest prescription prevails in spite of the science because there is no other alternative. Are there studies being conducted to find an evidenced based alternative to bed rest?

  7. avatar
    Fenevad
    July 10th, 2013 at 07:15 | #7

    Kelley wrote: “Thank goodness for my wonderful doctors that are educated in science, not chance.”

    This seems to indicate that the commenter didn’t read the posting (or simply didn’t believe it) since the science says the exact opposite of what she seems to think it does, as demonstrated in the posting. Add to that that she seems to think you are advocating things never stated in the posting (“holistic/hypno methods”) and I think you have someone responding to an article she made up, not the one you actually wrote.

    Unfortunately, for far too many things, when evidence contradicts “common sense,” common sense wins. So if it seems plausible that bed rest helps people, it must have. And the fact that someone didn’t have a particular negative effect and pursued some particular course of action prior to it often prompts a post hoc ergo propter hoc fallacy, which is clearly what Kelley is engaging in: her doctor told her to rest and she didn’t lose her babies, therefore she didn’t lose her babies because of the bed rest. (Never mind that the bed rest *increased* her risk of harm to her babies.)

  8. avatar
    Shelia A.
    July 10th, 2013 at 12:56 | #8

    After losing our first 2 children to pre-term labor, you will try anything that the doctor recommends on the 3rd try. After bed rest and injections we have 2 beautiful girls to show for it. I would have stood on my head if it was recommended. To say that studies show that bed rest doesn’t help doesn’t seem worth the risk.

  9. avatar
    Jess
    July 10th, 2013 at 13:51 | #9

    Ya know….. Many persons “utilize” this diagnosis in the face of inadequate antepartum relief from job duties…. Soooo if a “medical diagnosis” of bedrest is allowing women time to rest and nest in the few weeks before baby arrives, and relieves this insane idea that women should work their 40hrs until they go into labor to preserve their precious vacation HOURS to use after baby arrives….. Welp I’m all for it! *steps off soapbox*. ( P.S. <3 you Henci )

  10. July 10th, 2013 at 15:44 | #10

    @Tonya:
    These weren’t six individual studies; they were systematic reviews. Systematic reviews are studies of studies on a particular topic. Systematic reviews aggregate data from all studies that meet appropriate criteria, in contrast to narrative reviews, where the author or authors pick among studies for the data that illustrate their points or support their ideas. Often, systematic reviews contain meta-analyses, which are statistical techniques for pooling data from the studies. As such, the conclusions systematic reviews draw are much stronger than those from individual studies. I’m not saying they are unassailable. As with every study type, they have their weaknesses. Nonetheless, the uniformity of their conclusions on the lack of benefits for bed rest is convincing.

  11. July 10th, 2013 at 16:47 | #11

    @Jane
    The decades have seen various drugs intended to stop contractions come and go. None of them have been found to do more than delay labor by a few days. And they all can have some quite serious side effects. Of course, even delaying labor by a few days can make a difference. And even a brief delay can gain time to administer steroids to mature the baby’s lungs, which has made a huge difference. Still, they haven’t had the benefits that was hoped for them. And it doesn’t follow that the lack of viable alternatives makes it reasonable to prescribe a treatment known to be useless.

    The current treatment du jour is administering progesterone to women at risk of preterm birth. There is evidence to support this, but as I wrote in an S&S blog post a few years back http://www.scienceandsensibility.org/?p=789, I think the studies finding benefits have some serious problems that undermine their conclusions. I would love to be proved wrong about that. I’m also quite concerned that we know nothing about the long-term adverse effects of extra progesterone on the fetus–especially male fetuses. We won’t know that for decades. I hope even more strongly that my fears on that head prove groundless. That being said, the jury may still be out on progesterone, but the verdict is in on bed rest.

  12. July 10th, 2013 at 17:05 | #12

    @Jess
    The bed rest prescription actually can result in acute financial hardship: http://rhrealitycheck.org/article/2010/09/17/breaking-bank-rest/. The ACOG Practice Bulletin I quoted above acknowledges this potential as well.

  13. July 10th, 2013 at 18:24 | #13

    @Shelia A.
    Of course you would! So would any woman. That’s what makes it so wrong to prescribe treatment that is not only ineffective but, worse yet, harmful. We trust that our doctors and midwives know what will help and what won’t and that their treatment recommendations will be based solely on what best promotes the health of mothers and babies. Of course, sometimes there is disagreement about what is best to do, and effective treatment doesn’t always work, but bed rest doesn’t fall in either of these categories.

  14. avatar
    Stephanie
    July 10th, 2013 at 22:10 | #14

    I have to say that I have also been put on bed rest for a pregnancy and it was effective. The doctor let me off of bed rest once in the middle to try and go back to work, which worsened my condition and I was back on bed rest. My doctor let me off of bed rest at 37 weeks, I went into labor that night. Although the statistics may show otherwise, I think there may be cases where bed rest is very beneficial. In my case, I was about to forego any other medicial intervention while on bed rest (no drugs, injections, etc.). It was one of the hardest things I had to do in my life and I had days that were physically, emotionally, and mentally hard, and finances were tough for my husband and I, but I would do anything recommended by my doctor for my child. I’m paying my doctor for her advice and services, and educated enough to ask the right questions during treatment. Everyone needs to be their own advocate.@Kelly Wagner

  15. avatar
    shari
    July 14th, 2013 at 20:52 | #15

    I am probably older than some of the recent women who posted but I am a DES daughter and had a cervical cone when I was in my mid 20′s for carcinoma in situ. I became pregnant less than 6 months after my conization and began preterm labor at 24 weeks. 12 weeks of hospitalized bed rest on IV meds (terbutaline and another common preterm medication) and being in trendelenberg for 3 weeks allowed me to carry my daughter to 36 weeks. 10 years later I had a son and was on bed rest for 6 weeks and only on oral terbutaline. Would I do it again, absolutely. I was made to visit a NICU prior to my voluntary bedrest and that was the motivation I needed. It is very stressful to be on bedrest both in a hospital and at home. I wore a uterine monitor at home during both pregnancies and it was able to objectify uterine contractions and manual exam confirmed cervical changes. It is very stressful for pregnant women to be shamed about their choices. It takes alot of strength to stand up to medical professionals and often their recommendations aren’t correct. But in pregnancy you are always weighing your choices and concerns about your unborn baby. The responsibility prior to birth is overwhelming because “what if you make the wrong choice”. The element in trusting your own intuition and your medical providers makes it a partnership. Their is nothing wrong with questioning recommendations but you have to live with your decisions forever.Both my children are alive, healthy and wonderful humans (28 and 18 respectively) and I am always thankful for the medical care I received.

  16. avatar
    steinbej
    July 15th, 2013 at 06:56 | #16

    @Olivia Arakawa

    There is actually a systematic review and meta-analysis done by an Australian looking for evidence on bed rest for ANY situation in all of medicine. Bed rest failed to improve outcomes in any, and worsened outcomes in many.

    Don’t take my word for it, check the literature yourself. Here is the citation. The abstract is available to the public for free, although the full text may be behind pay-firewall.

    Article: Bed rest: a potentially harmful treatment needing more careful evaluation
    Author: Allen, Chris et. al.
    Journal: The Lancet (British edition)
    Date: 10/1999
    Volume: 354
    Issue: 9186
    Page: 1229 – 1233
    DOI: 10.1016/S0140-6736(98)10063-6

  17. July 15th, 2013 at 08:51 | #17

    @Stephanie
    If this were the best of all possible worlds, a woman threatening preterm labor would strategize with her care provider about ways she might reduce stress in her life, including spending less time on her feet. They would decide together what was realistic for her given her circumstances, and she would be invited to experiment with what reduced contractions and what made them stronger and more frequent and what made her feel better or worse. That would be a practical approach with no adverse effects on her or her baby’s physical health, her psychological health, or her finances. The draconian prescription to get into bed and stay there is not. The evidence for it simply isn’t there and it isn’t harmless.

  18. July 15th, 2013 at 09:16 | #18

    @shari
    First of all, no one is shaming women for their choices. If anything, I would shame doctors for prescribing a treatment long established as ineffective and harmful for women who are trusting them to know what is best. You, yourself, are a case in point. I’m sure your mother agreed to DES because her doctor told her it would prevent miscarriage, which it turned out not to do. Doctors back in your mother’s day at least had some excuse. There was much less emphasis on practicing evidence-based medicine than there is today, but what if doctors went on prescribing DES after the evidence was in that it didn’t work and it did harm? The situations aren’t quite alike because the harms of bed rest aren’t as blatant and devastating as the harms of DES, but the principle is the same.

  19. July 15th, 2013 at 09:22 | #19

    “In the Reuters article, Grobman states that “any pregnant woman who is told to restrict her activity or stay in bed should discuss with her doctor whether there is data to support that recommendation given her condition.” Fair enough, but how is she supposed to know to do that? What role can or should childbirth educators and doulas play? What might Lamaze International or other childbirth-related organizations do to spread the word? What are your thoughts?”

    I’ve pasted in the last paragraph of my post. I would still love to hear from viewers on what role childbirth educators, doulas, and organizations could appropriately play in helping women make a truly informed decision about bed rest.

  20. avatar
    Avery
    July 16th, 2013 at 11:33 | #20

    Henci – I think that as with so many aspects of pregnancy and childbirth educators and doulas can make a big impact simply by raising issues and asking questions, and by encouraging women to do the same with their healthcare providers. Although medicine has come a long way from the paternalism and ‘don’t ask any questions’ attitude of decades past, it can still take a lot of courage for women and their partners to question procedures and practices. Sad to say there are providers out there who do not appreciate educated questions. Having a doula or educator who reminds women that they should be asking questions and that it is their right to receive an explanation they can understand about recommended treatments goes a long way to opening up the dialog between providers and patients.

    On a related note, this discussion reminds me of the updated recommendations on pap smears and mammograms. Exhaustive research showed we were performing both screenings too often and catching cancers that would have gone away on their own. Harm was being done by over-screening and over-treating women who did not actually need treatment. Unfortunately, it’s difficult for a woman who believed she survived cancer thanks to a pap-smear or mammogram to accept that she didn’t need cancer treatment and would have been better off not receiving the screening. Doing so denies the intense emotional journey she’s taken as a cancer survivor. In the same way I think it’s difficult for women who were put on bed rest to believe that it didn’t alter their birth timing. Doing so makes it seem as if their suffering was for nothing and they were duped. I think it may take many years before women and their providers can emotionally come to terms with these new recommendations.

  21. July 16th, 2013 at 11:43 | #21

    Thank you for your thoughtful comment.

  22. July 27th, 2013 at 07:15 | #22

    As a doula and educator, I think I can help my clients and students by encouraging questions, first and foremost. Using the traditional “BRAINED” acronym seems to go a long way in giving clients specific direction to go when asking questions.

    I also outline for my clients that there are risks to each of her choices, and she is the only one with the power to decide which set of risks she can live with long-term. I try to fill in any gaps left by her provider, and point her to evidence-based resources. I encourage open-ended questions. “So, I have read the bed rest is not only ineffective, but potentially harmful. What are your thoughts on bed rest, and when/why might you recommend it for me?” for example. As opposed to “Would you let me get out of bed if I struggle with preterm labor?”

    I appreciated the comment about a collaborative effort between a woman and her care provider about stress management, and I actually do some of that kind of work with my clients.

    I ask them how they normally cope with stress in general, and teach them some basic tools to help them. In class, I talk about the effects of stress on pregnancy and baby’s health and brain development. I emphasize strongly the importance of managing stress levels in life – not just in pregnancy. We also created a handout of open-ended questions designed for the birthing woman and her support person to evaluate themselves and spot any areas where stress management or emotional work might be needed.

    I would love to see more work and studies done on the effect of good stress management on preterm labor…

    Thanks for a great article. I appreciate the chance to learn.

  23. July 29th, 2013 at 08:30 | #23

    Thank you for this. I’m sure viewers will find it helpful. Also, I am aware of the BRAIN acronynm–Benefits, Risks, Alternatives, Intuition/Instinct, No or Not now–but what do the E and D stand for? And do you know who invented it. I’d love to credit whoever it is when I use it.

  1. July 9th, 2013 at 04:57 | #1
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  3. July 15th, 2013 at 08:23 | #3