Do We Need a Cochrane Review to Tell Us That Women Should Move in Labor?

October 25th, 2009 by avatar

I am reposting this post from the archives in anticipation of this week’s Healthy Birth Blog Carnival about movement in labor. It was one of the first posts I ever wrote, back before anyone was reading this blog. It’s also one of my personal favorites.

Earlier this year, media outlets shared the news of a new Cochrane review that concludes upright positions are beneficial because they shorten labor by about one hour. The birth blogs were buzzing about this, and the consensus is that we should feel delighted and vindicated to have the scientific evidence to prove what women and midwives have always known.

ResearchBlogging.orgCochrane reviews synthesize all of the research on a particular topic, and because the reviewers bring together and analyze all of the data from many studies, the study population gets very big. Big populations yield greater statistical power and often (but not always) more reliable findings.

Prior to this Cochrane review there was a large body of literature on movement in labor, including a good sized U.S. randomized controlled trial. There was even another systematic review! But this body of research never consistently supported the hypothesis that movement improved labor and birth outcomes. Now we have a Cochrane review, which is the gold standard for evidence-based practice.  So we can put the evidence-based “stamp of approval” on freedom of movement.

But, were we any less justified in endorsing freedom of movement before the Cochrane? Although studies have given us inconsistent results as to whether movement shortens labor or decreases the need for c-section, a few conclusions have been loud and clear from the literature since researchers began looking at maternal position and movement:

  1. Women prefer to move around, primarily because they experience less pain when they can move.
  2. Women who stay in bed usually do so because they are connected to machines or IV lines, and/or because a health care provider tells them to.
  3. Movement and walking are not harmful to the woman or the baby.

Freedom of movement is the thing that would happen if women did not have any interaction with a health care system or provider in labor. In other words, it’s the default state of affairs. Anything that we do in the name of “health care” to improve upon this normal unfolding of things is referred to as an “intervention”. In scientific research, researchers compare a control group, which should represent the default/normal, with an experimental group, which represents the intervention. The burden of proof should be on the intervention.

Somehow, things have gotten turned around, and the normal condition is now the “experiment” and the intervention is the “control”. In addition to being irrational, this is a set-up to perpetuate conventional obstetric care, which imposes unhealthy and unfounded restrictions on women in labor. This is because in “intervention versus control” research, you have to show that the intervention performs significantly better, otherwise the control condition remains standard practice. While many of us believe that encouraging a laboring woman to move when and how she wants to is healthier and safer than making her stay in bed, waiting for evidence that it produces better health outcomes is putting a burden of proof on normal birth that has never been applied to routine intervention. Besides, lack of evidence of harm, less pain, and maternal satisfaction are valid and important outcomes in and of themselves, and provide the justification we need to reject routine policies and practices that restrict maternal movement.

Lawrence A, Lewis L, Hofmeyr GJ, Dowswell T, & Styles C (2009). Maternal positions and mobility during first stage labour. Cochrane database of systematic reviews (Online) (2) PMID: 19370591

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  1. October 28th, 2009 at 10:59 | #1

    Thanks for reposting this. What a great post!

    “Somehow, things have gotten turned around, and the normal condition is now the “experiment” and the intervention is the “control”.” This!

  2. December 2nd, 2009 at 13:52 | #2

    I think you’re right here.. though in my practice most folks have epidurals are in bed. I totally agree that the burden of proof is on the intervention, not the natural state. I have the same thought process when I think about early cord clamping.

  3. December 2nd, 2009 at 16:39 | #3

    The Cochrane review was of women without epidurals, of course. I do think it is reasonable to test the safety of walking with epidurals, because all bets are off as far as normal physiology is concerned. My understanding of the research on “walking epidurals” is that it is generally safe, though it doesn’t necessarily improve outcomes.

    I often go back to this particular framework when evaluating research – what would happen if the woman had no contact with a “health care system” – if there’s evidence that whatever the system is offering results in better outcomes, then go for it. If not, it’s best to support and facilitate normal physiology and/or defer to women’s preferences instead. E.g., “first, do no harm.”

  1. October 28th, 2009 at 13:43 | #1
  2. November 1st, 2009 at 21:03 | #2
  3. January 20th, 2010 at 22:15 | #3
  4. June 24th, 2011 at 21:22 | #4