Is It ‘Unethical’ To Prescribe Bed Rest For Pregnant Women?

(cscott2006/flickr)

(cscott2006/flickr)

It seems so intuitively right. You’re facing the risk of delivering your baby early and the doctor prescribes bed rest. What could be more cozy and safe? Why wouldn’t you endure a little extra annoyance (you’re pregnant, after all) if it would help keep your tiny, oh-so-vulnerable fetus floating inside the fortress of your womb as long as possible? Even the words “bed” and “rest” feel so inherently soothing and therapeutic.

Think again.

Bed rest, a growing body of research suggests, may be bad for you.  And for physicians to blithely prescribe it is, in a word, “unethical,” argue a trio of doctors from the University of North Carolina School of Medicine.

In a paper called “‘Therapeutic’ Bed Rest in Pregnancy: Unethical and Unsupported by Data” recently published in the journal Obstetrics and Gynecology, Dr. Christina A. McCall and her colleagues make a powerful case against the practice many perceive as cuddly and innocuous.

They cite the medical paradox in which bed rest remains widely used despite no evidence of benefits and, on the contrary, “known harms.” They further suggest that in its current form, strict bed rest should either be discontinued or else viewed as a “risky and unproven intervention” requiring rigorous testing through formal clinical trials.

“If we have anything to learn from the history of medicine it is that instincts and good intentions are a highly fallible compass without the check of scientific controls.”

In an email exchange, Dr. McCall clarifies that she is talking about strict bed rest here and adds:

“If a woman feels that increasing her daily rest lessens anxiety or improves symptoms (whatever they may be), then we are not suggesting this should be discontinued. We are merely suggesting that every woman receive INFORMED CONSENT regarding the literature on bed rest and the autonomy to make her own decision.”

Research suggests that the potential harms for women on bed rest (a broad term that can include everything from total inactivity to limits on strenuous endeavors like household chores, exercise and sex) can be significant. They range from potentially dangerous blood clots and bone demineralization to muscle and weight loss, financial harship due to restrictions on working and a range of psychological suffering, notably depression. A report earlier this month, for instance, found high rates of depression and anxiety among hospitalized pregnant women on bed rest and suggested that all women facing this type of confinement undergo mental health screening.

No Benefits

Dr. McCall’s conclusions are based on a broad review of the medical literature that found bed rest offers no benefit for the most common conditions it’s prescribed for: threatened abortion, hypertension, preeclampsia, pre-term birth, multiple gestations or impaired fetal growth.  (Another study published in the same issue of Obstetrics & Gynecology found that activity restriction did not reduce the rate of pre-term birth in women with a short cervix.)

Even beyond these physiological considerations, Dr. McCall asserts that prescribing bed rest is morally questionable and “inconsistent with the ethical principles of autonomy, beneficence, and justice.”

Still, the practice remains deeply ingrained. Here are the numbers, according to an accompanying editorial:

As many as 95% of obstetricians report recommending activity restriction or bed rest, in some form, in their practices. Nearly 20% of gravid women in the United States — approximately 800,000 per year — will be placed on bed rest between 20 weeks of gestation and delivery.

Questioning the wisdom of bed rest — which has been used for centuries and viewed mostly as an inconvenient, potentially beneficial and essentially harmless cost of pregnancy — isn’t new. For years, data has been mounting on the negative effects of prolonged activity restriction in other medical arenas. Last year the influential American College Of Obstetricians and Gynecologists issued a practice bulletin challenging — but not fully condemning — the practice:

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.”

What About Maternal Harm?

But Dr. McCall and her colleagues go further, suggesting that bed rest should be limited to formal clinical trials, with written protocols, approval from an institutional review boards and informed consent. As it’s currently used, she writes, the practice undermines the spirit of the physician’s premier commandment — “do no harm” — in several ways:

“…bed 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.”

Online Shopping, No Husband

For Kristen Rathjen, pregnant with twins and currently hospitalized and on bed rest at Beth Israel Deaconess Medical Center in Boston, the reasons for staying put are simple: she’s already about 2.5 centimeters dilated at 30 weeks pregnant, and she doesn’t want to give birth to a premature infant in an ambulance rushing from Mashpee, on Cape Cod, where she lives, into the city.

“I’m just doing what’s in the best interest of my child,” says Rathjen, a 32-year-old marine biologist. “Sure there’s stress, I’m not at home, I don’t have my husband or my pets and I’ve definitely gotten weaker. But the big stress of ‘How am I going to get here?’ is off my shoulders.”

So, for the next few weeks, Rathjen is resigned to forgoing work, accepting boredom and generally following her doctor’s advice. “I’ve got books, my laptop, crafts and really bad TV,” she said. “Plus, it’s given me time to research baby products and do some online shopping.”

Dr. Adam Wolfberg, a maternal-fetal specialist with Boston Maternal-Fetal Medicine, says despite the lack of evidence to support bed rest, there is something real, almost a kind of placebo effect, to women feeling like they are doing something to protect their babies, as opposed to doing nothing.

“Obstetrics is a field in which we have a very limited number of tricks up our sleeve when it comes to preventing preterm delivery. So to say, ‘I’m sorry ma’am, there is nothing we can do,’ is harder then saying, ‘Well, there’s no evidence bed rest helps, but it is something we can try.”

“Obstetrics is a field in which we have a very limited number of tricks up our sleeve when it comes to preventing preterm delivery,” he said. “So to say, ‘I’m sorry ma’am, there is nothing we can do,’ is harder then saying, ‘Well, there’s no evidence bed rest helps, but it is something we can try…The idea that there’s something they can do that’s proactive — that can be meaningful.”

In a recent post called “The Truth About Bed Rest” on the Isis blog Parenting Starts Here, Dr. Wolfberg lays out some other reasons why doctors — himself included — continue this “nutty” practice:

Why is it that most obstetricians I know still recommend bed rest, when peer-reviewed literature and the American College of Obstetricians and Gynecologists suggest the practice doesn’t work and might even be dangerous? Here are some possible explanations:

•Bed rest seems logical: the reclining posture theoretically reduces the force of gravity on the cervix – another theory entirely lacking evidence.
•It feels better to prescribe bed rest than to tell a patient, “we really don’t have anything to offer you to reduce the chance that you will deliver early.”
•Women on bed rest are doing something, which feels a whole lot better than doing nothing.
•If bed rest isn’t recommended, and the patient delivers prematurely, they and their doctor will always wonder whether bed rest would have changed the outcome.

Dr. Wolfberg says despite his skepticism, he would not go so far as to brand bed rest as ethically unsound. “There are so many things in medicine we do without evidence, I really don’t think bed rest is unethical. In many ways, medicine isn’t just about evidence, it’s evidence plus — it’s experience and skill and intuition — not to say those are replacements for evidence. But evidence isn’t all there is.”

This may sound good, says ob/gyn Dr. David. A Grimes, co-author on the bed rest article, but doctors should be wary of relying too heavily on instinct alone. “If we have anything to learn from the history of medicine,” Dr. Grimes says via email. “It is that instincts and good intentions are a highly fallible compass without the check of scientific controls.”

And course, every woman is different and the complications of pregnancy vary, notes Angela Davids, who moderates an online forum, keepemcookin.com for women who have been prescribed bed rest. She tells me in an email that 76 percent of her forum participants deliver at 36 weeks or later:

Any one of them will tell you that bed rest helped to prolong their pregnancies, and I think that is what researchers need to look at. Instead of looking at 37 weeks of gestation as a measure of success, look at how many days of gestation there were following the diagnosis of a specific complication. Every additional day in the womb counts toward the health of a baby…

So, what’s an expectant mom to do?

Dr. Wolfberg offers this advice:

•Patients who are worried about pre-term labor, short cervix, or vaginal bleeding should consult their midwife or physician.

•In his own practice, Wolfberg says he works hard to identify patients who would benefit from progesterone and get them on that medication when appropriate.

•He says it is reasonable for women at high risk for pre-term delivery to limit strenuous activities or exercises.

•He says he’s never had a patient suffer long term consequences of bed rest, and notes that since he’s never met a mother who delivered prematurely who didn’t – irrationally – blame herself, he prescribes activity reduction because it’s something patients can do.

•If bed rest is going to interfere with a patient’s need to earn a living, hold down a job, or take care of her family, he says he support her decision to remain active (and cites the evidence that bed rest doesn’t help).

Beyond that, Dr. Wolfberg said, “if they do bed rest and fail, at least they feel like they did everything they could…we all need a little bit of magical thinking to get through the day.”

Oftentimes, what helps or hurts a pregnancy is in the eye of the beholder. A friend offers this memory of her six weeks on bed rest:

I started bleeding and the baby seemed like it was low, plus I’d had two prior miscarriages, so the doctor prescribed “modified bed rest,” meaning I could get up to eat, go to the bathroom, or recline on the sofa. It wasn’t fun — I spent alot of time reading and looking at the clouds…One day I wandered downstairs to rest on the sofa, and saw the 9/11 airplanes hit the twin towers. I think it was the stress that brought on the delivery — a late miscarriage at 19 weeks — and that was that.

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