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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  • Juan Acosta

    Prescribing bed rest to women with threatened miscarriage, puts the guilty on the woman side when science shows us that pregnancy losses are due to chromosomal abnormalities. We should think in the negative psicologycal consequences of these traditional believes.
    Juan Acosta
    Obgyn

  • 1humanwoman

    I have a series on ned rest concluding with a post on the ethics:
    http://humanwithuterus.wordpress.com/2013/12/06/bed-rest-in-pregnancy-part-iii-human-or-vessel
    The thing is, if there are two equal alternatives, one involving doing nothing, and the other involving a life altering intervention, why would you choose the intervention?

  • ScientistMama

    I am 21 weeks pregnant and have hemorrhaging when I am up and active which slows to nearly nothing if I limit my activity. I am under the care of a midwife who has left the decision to me about what is best for my care (and what makes me feel better). I am happy to have this control over my and my baby’s care. I am left with many questions, however. It’s confusing, especially in light of these recent findings. As with any medical decision, evidence-based practice dictates not ONLY external evidence (as in the recently published results), but patient preferences and the practitioner’s experience and expertise. Bed rest is a great application of this premise.

  • esther

    years ago at an OB/GYN conference held in SF by UCSF , i listened while a thoughtful doctor presented his statistical analysis. it turned out that since the introduction of bedrest and tocolytics with monitoring had been introduced there had been no significant change in the outcomes for women who had preterm labor at around 26 weeks of pregnancy. yet, the practice persists. it seems to me we have a culture of DO SOMETHING, rather than a culture of educare (sic).

  • fellow reader

    This is great to read and think about. thanks!

  • http://www.facebook.com/profile.php?id=1530143 Leyland Del Re

    Excellent article that highlights continued need in obstetrics to follow evidence-based practice. Why bother having all the research done and available just to ignore it? Keep at it, Dr. McCall!

  • Lorie

    Thank you so much for opening a dialogue on bed rest. I like Jon Tod’s comment on questioning practices that seem unwise. Maybe they will end up making sense, but blindly following along just because it’s the norm is not productive. At the very least, you can learn why you’re doing something. In my own pregnancy I was very active until I went into labor. I believe that taking good care of myself was what made a wonderful pregnancy and delivery happen. When I was tired, I took a nap. When I wasn’t I was working, gardening, cleaning – doing the things that need to get done before you have a baby in the house. Articles like this one help women learn and make informed decisions about their own process. Thanks!!

  • http://www.facebook.com/FamilyStrongBirthServices FamilyStrong Birth

    While pregnant with both my two children, bed rest was prescribed by my obstetrician. Each baby was at risk for preterm delivery. My first pregnancy, as educated as I was at the time, I took any and all medical advice quickly and without question. It was only after the birth at 37 weeks, via undesired cesarean section, that it dawned on me that perhaps I should have researched more on my own to balance the advice of one provider with that of the established medical research organizations, peer reviewed journals and the like. My second pregnancy was vastly different despite the same risk for preterm birth. I learned how nutrion, holds an essential role, rest is key for maintaining overall wellbeing, exercise is a wonderful way to prevent many ailments and align your body and baby for optimal positioning at birth, etc. I took advice and guaged it against my thorough research and challenged advice if I found something worth noting. I owned my birth and though more rest was included this last pregnancy, it was far from the typical bed rest we are imagining. My daughter was born at 41weeks in her own home via planned VBAC. Some would claim against “the odds”, and yet according to research, it was within the norm. My advocacy for families’ rights to informed consent begins prior to conception. Education is essential. Know what type of birth your baby deserves, whhat experience the mother deserves. Within most circumstances, mother nature does right by you. We have science to help us get back on track and I am most grateful to those who practice using the utmost regard for quality and integrity within their fields.

  • http://www.facebook.com/emily.antul Emily Barrett Antul

    Thank you for researching and writing this piece. I was put on bedrest for my baby, and ended up being induced at 39 weeks, which was the latest I could push off my team of doctors and midwives without signing an AMA form. I had mild pre-eclampsia and they were scared about seizures. I think Downton Abbey had infiltrated their thinking, so I blame PBS for that. They put me on bedrest for several days and I missed some classes. The result of missing the classes was getting lower grades than I could have otherwise due to missing the lectures and now they don’t count for the school I’m going to start at in Fall of 2014. I might have to retake them if I can’t convince the school to let me take challenge tests or something. Bedrest did not help at all. It just inconvenienced and stressed me unnecessarily. My blood pressure was up because I was annoyed, scared and really upset that they weren’t listening to me. The baby was fine, and I’m fine, I just have higher than normal blood pressure. My BP is up when I’m heavier, and obviously pregnancy packs some weight on. It hasn’t really gone down much now that I’ve had the baby. I still have 15-20 pounds to go (and I’d like to lose more than that) and I’m now also on a low dose of medication.

  • http://onestepatatime.co.za/ Heather

    I was on bed rest for high blood pressure a month before I gave birth and I think it was a good decision for me to stop work (a high stress job) and take it easy. Pregnancy definitely affects you, especially towards the end. I did some work at home and it helped me feel useful though. I think to say it is ‘unethical’ is a bit much, especially for those of us who really needed it.

  • Gita Jones

    Bed-rest might be over the top. But having an afternoon nap should be promoted not only for pregnant women but all people. I grew up in a tropical climate and I live in the Southeast( hot and humid). Having a big lunch and having a nap afterwards is one of the ‘best-practices’. I am very productive until 11 p.m. Parents have to use all their wits as their children are growing and after-school time will require lots of productive-wits.

  • John Tod

    When I first started working in surgery, I was told to do things that didn’t make any sense to me, I would ask “WHY?”

    The response was often the same and that was, “Because thats how we have always done that!”

    That wasn’t good enough for me, so I often wouldn’t do what they we suggesting, and I would get me in trouble and I would be written up, by supervisors.

    Once in a while, my questioning authority would receive scrutny from others and old habits that didn’t make sense were changed, but that wasn’t the norm.

    Just because something has been done for years that is wrong, doesn’t necessarily mean we should continue to do it!

    Einstein said it right, doing the same thing over and over and expecting a different result is: insane.

  • http://www.facebook.com/The.MacTavish Anthony Cunningham

    It seems a little quick (and maybe sensationalist) to label the prescription of bed rest as “unethical.” If the evidence suggests that bed rest is not best, then the prescription is poor, but not automatically unethical. Now if physicians either blithely ignore overwhelming medical data (evidence they should know and should heed), refuse to share such data with patients (denying their patients informed consent), or purposely aim at something they know is bad for their patients, then the prescription goes beyond poor to unethical. Not every incorrect prescription is an unethical one. If the real point is that bed rest is probably poor advice, then the campaign should be to educate doctors, not point fingers at them as unethical.

  • Ginny DeHaan

    I was pregnant for the first time in 1980. It truly did blow my mind to learn that for so many common health problems that a person regularly faces, like headaches, or heartburn for example, there was nothing that a pregnant woman could take. If it could have an adverse effect on the fetus then you were advised not to take anything, because there wasn’t anything to take. I immediately thought, ‘if men got pregnant, there’d be stuff I could take!’. In general, I still believe this about women’s health. And in fact, my experiences as a pregnant woman helped contribute to my feminism, which had evolved starting when I was a young girl.

    • John Tod

      I couldn’t agree more with you!
      Also, if men got pregnant gestation would be 26 week plus ten weeks in a hospital for all kids!

  • Paul Marado

    Why would npr even care about a pregnancy? They’re dead set against any human life coming into this world, unless its one of their own.

    • http://www.facebook.com/The.MacTavish Anthony Cunningham

      What a silly comment.

    • John Tod

      How dose one spell
      STUPID STATEMENT?

      • marlo87

        does*

  • Meg

    The article didn’t focus on this particular potential harm of bedrest, but wouldn’t weeks without exercise leave a woman in poor condition for the exertion of labor? This could lead to extended, difficult labor with potential complications for both mother and baby. That being said, some women might need a doctor’s prescription in order to receive the permission/understanding from work, family, or herself to slow down to the appropriate extent for a pregnancy.

  • http://twitter.com/chrisjustcnm Chris Just

    This is an excellent piece on the bed rest dilemma. Many thanks to CommonHealth, Dr. Wolfberg and Angela Davids for their input – and to Darline Turner for her thoughtful comments. While practicing as a Certified Nurse-Midwife, I rarely prescribed bedrest for women at risk; instead, I left it up to the womens’ discretion and would “sway” them either way based on their personality. While making it clear there were no proven benefits, I also added that it wouldn’t hurt to increase restful periods as long as the women engaged in some light, in-bed stretching and strengthening exercises to prevent some of the negative physical side effects of bed rest. With regard to easing the psychological and emotional stress of bed rest, I believe social media and online forums such as those offered by Keep Em Cookin and Mamas On Bedrest are of great value. Clearly, there needs to be more research vis a’ vis preventing preterm birth which is why we need to continue to support the March of Dimes and other organizations that study the complex issues surrounding prematurity.

    • http://www.facebook.com/emily.antul Emily Barrett Antul

      Careful with March of Dimes. I understand that only about 10% of their donations go to research. It really is a march of dimes… the other $0.90 goes to “administrative costs”. We’re not getting anywhere on dimes anymore.

  • http://twitter.com/DarlineBedrest Darline Turner

    Hello. As a health care advocate, blogger and researcher and someone who supports high risk pregnant women on bed rest, I won’t go so far as to say that prescribing bed rest is “unethical”, but I will say that, as Dr. Wolfberg states, it’s a questionable practice. In a healthcare culture in which high value is placed on “evidence-based” medicine, it boggles the mind that obstetrics would not only prescribe, but also adhere to a practice for which there is no evidence of efficacy. While it may seem “better than nothing,” are we really doing women a service when we know that they are themselves being subjected to changes in bone mineralization, cardiovascular changes, muscle atrophy and loss, and are at greater risk for perinatal depression? What about their increased risks of induction, cesarean section and NICU admissions for their babies?

    There is a lot of literature out there speaking against bed rest, but what I haven’t seen is a lot in the literature about how we can improve health care practices so that women don’t need bed rest in the first place. While many conditions, such as cervical insufficiency” may not be predictable, is there a way to evaluate a woman either prior to pregnancy or early on to assess her risk? Are there health practices that we can engage in that may reduce a woman’s chance of needing bed rest? And as Angela and I have both noted, women in community fare better on bed rest. So should we be doing more to enhance a woman’s sense of community and support before, during and after pregnancy as a way to improve outcomes?? There are still many unanswered questions and in my opinion, we have not spent enough time seeking answers.

    Bed rest in and of itself is not “unethical”, but I see it as the path of least resistance. It’s easy, it makes everyone feel good. OBs feel like they have given their patients “something”. Mamas feel like they are doing “something.” But the bed rest prescription does not address the underlying issues. Why are nearly a million women annually needing to be put on bed rest during their pregnancies? Why aren’t we looking more closely at ways to treat the common causes of bed rest such as cervical insufficiency, pre-eclampsia, uterine irritability/preterm labor, etc…? I believe that if we pay more attention (i.e. spend more research time and dollars on these areas) to resolving the reasons bed rest is prescribed, we may be able to find the solutions to the bed rest conundrum.

    • AdamsQJohn

      Darline: It’s just a wild guess on my part, but could potential liability (from the OB/GYN doc’s perspective, for example) have anything to do with their apparent disregard of the clinical evidence you point to, and hence their steady reluctance to prescribe that their pregnant patients get out of bed?

    • Frank B.

      It’s always surprised me that “lack of evidence of efficacy” is equated with “evidence of lack of efficacy.” They’re not the same.

    • Jenna

      To be honest, evidence-based practice may be valued in all other areas of healthcare but it is absolutely NOT valued in OB. If it were, C-section rates would be down, fewer women would be needlessly induced, women would not be stuck laboring lying on their backs, women would not be starved while in labor, it would be normal to birth at home if you’re low-risk, cord would not be cut immediately, baby would not be whisked away from mom immediately after birth, baby wouldn’t be scrubbed down immediately after birth, breastfeeding would be the norm until at least one year, and on and on and on.

      But evidence-based doesn’t seem to matter when it comes to this.