Bedrest Is Bunk
There’s little to no evidence to show that restricting pregnant women’s activity has any benefits—so why do doctors still prescribe it?
One quiet Sunday afternoon, shortly before the birth of my second child, I decided it was time to make my great escape. I was in the middle of my third— and longest—hospital stay. For weeks, I’d seen only the inside of my room, a beige cell with a view of the parking lot through a small window. I’d become desperate to escape, even if it was only to the hospital’s sterile corridors.
I peeked out of my lockless door, checked for wandering nurses, and shuffled into the elevator. I could barely remember the last time I’d walked that much. I made it all the way to the cafeteria, where I ran into a pregnant woman I knew. I didn’t recognize her at first; at that point I’d been on bed rest for weeks. We ordered veggie sushi (no raw fish for us!) and discussed how dimly lit the cafeteria was for such a nice hospital. She told me how lucky I was that I didn’t have to work anymore—commuting to and from work was killing her back. She had to wear flats.
I snuck back into my room and buried myself in my hospital bed, pulling the thin blanket and starched sheets over my head. I stayed like that for a long time. I wasn’t moving but my body ached. I was always in bed but never tired. I was receiving long-term disability benefits but wasn’t ill.
"Mama’s in the hospital because the baby is coming,” I told my 3-year-old when she came to visit. “Just like in your books.”
“Sometimes people go to hospitals because they’re very, very sick,” she replied, wrinkling her little brow as she sat in the bed with me, eating orange Jell-O from a plastic cup.
But I wasn’t very, very sick. I was pregnant.
All mothers have a pregnancy and birth story. A natural birth gone wrong, an emergency C-section, a shockingly fast delivery. Mine sounds like a tale from a Victorian novel, something from the days of sanitariums, hysteria, and rest cures.
But for hundreds of thousands of women, bed rest is no fiction: It remains one of the most frequently prescribed treatments for pregnant women at risk of preterm birth. It’s estimated that around 20 percent of women will be prescribed bed rest at some point in their pregnancies. Up to 95 percent of obstetricians report that they’ve prescribed the treatment in some form.
Once I started looking, I saw bed rest everywhere. The TV star Tori Spelling dished about her two months of bed rest to E! News in 2013: “I was flat on my back. I wasn’t allowed to even get up to walk in the halls. My bathroom privileges would be taken away. I wasn’t allowed to shower. Everything was stripped from you.” The Bachelorette star Ali Fedotowsky fretted that her order of modified bed rest was preventing her from preparing for her baby’s arrival. “I’m not doing as well as I would like to be doing,” she told People.
The practice continues despite a growing body of medical evidence showing that bed rest offers little to no benefit to pregnant mothers or their fetuses. The treatment has not proved effective in treating preeclampsia, preterm birth, low infant birth weight, high blood pressure or a shortened cervix. The American College of Obstetricians and Gynecologists, a nonprofit organization of women’s health-care physicians, now advises that bed rest “does not appear to improve the rate of preterm birth, and should not be routinely recommended.” The risks, however, have been well documented: Women prescribed bed rest may suffer from bone loss, muscle atrophy, and a wide range of postpartum psychological disorders at higher rates compared to pregnant women who do not go on bed rest.
Even as they keep prescribing the treatment, most specialists in high-risk pregnancies don’t believe it does all that much. A 2009 survey of U.S. members of the Society for Maternal-Fetal Medicine found that 71 percent of doctors would prescribe bed rest for women in preterm labor and 87 percent would prescribe it for the premature rupture of membranes (water breaking). But a majority said they believed the treatment was associated with “minimal or no benefit.” (Bed rest can mean everything from strict time in bed to limiting some daily activities. Some doctors use the term couch rest—no lifting, no exercise, no sex, and no housework. The details vary widely, perhaps a reason why so many doctors say they’ve prescribed some form of the treatment.)
So why do doctors persist in sending their pregnant patients to bed? In part, it’s because they often don’t have much else to offer. Some researchers attribute the continued use of bed rest — despite all the evidence to the contrary — to a desire by obstetricians to “do something” in the face of limited research. “Unnecessary interventions such as bed rest may make the patient (and sometimes the health care provider) feel that all attempts are being made to ‘save’ the pregnancy,” wrote the authors of a 2013 review of studies on bed rest.
Despite advances in science, pregnancy and many of its complications remain mysterious. “Pregnant women may be the most underrepresented group in the entire clinical research process,” declared a 2011 report by the National Institutes of Health’s Office of Research on Women’s Health. There have been no randomized controlled trials evaluating exercise prescription in women with a history of preterm birth. It’s long been considered unethical to include expectant mothers in clinical trials, leaving scientists and doctors uncertain about the safety of many common medicines during pregnancy. Studies have found that for around 90 percent of medications, their safety in pregnancy remains unclear. Only eight medications are currently approved by the FDA for prenatal use, according to a recent investigation by ProPublica. That lack of research leaves many questions of medical intervention during pregnancy taking place in a murky mix of medicine, culture, and history.
My restrictions began shortly after my 20-week ultrasound, when my doctor discovered that my placenta was in the wrong place. She compared my condition, known as placenta previa, to having a bag of blood hanging between your legs. Moving could cause the bag to burst—threatening the baby and me. Staying still was my best chance of preventing bleeding, said my medical team, an ever-expanding group of ob-gyns, perinatologists, neonatologists, nurses, fellows, and residents. Or, at least, that was their best guess, it seemed to me.
At some point, maybe five weeks in, I just wanted to leave. I called my husband and informed him that I no longer wanted to have this baby. Couldn’t we just call the whole thing off?
I began to suspect I was going insane.
I wasn’t alone: An invisible society of bed-bound pregnant women lurk all over the internet, on message boards, members-only discussion groups, and the reader forums of parenting magazines. An active bed-rest-assistance industry is eager to service moms-to-be, offering survival guides, novels featuring bed-rest-bound protagonists (usually featuring hard-charging “career women” who realize what’s truly important in life once they’re forced to slow down), children’s books, and lists of bed-rest essentials. (The Parents magazine list includes a telephone, hairbrush, laptop, and lip balm. “Your favorite hand and body lotion is a great way to treat yourself to an in-bed spa!” they advise.) Websites like KeepEmCookin.com perkily offer tips for “making the best of bed rest.” It was a type of magical thinking: You can control the uncontrollable if you just stay still.
“Stay focused on your goal—a healthy baby,” recommends Fit Pregnancy and Baby magazine. “If your doc approves, try one (or more!) of these favorite restorative bed rest techniques!
Breathe deep …
Visualize your baby …
Squeeze a ball.”
On message boards, women fret over the details of their prescriptions. Is a walk to the kitchen too much? How about a quick shower? Is it okay to lie on your back or do you have to stay on your side?
Frequently, the moms-to-be blame themselves for their bodies. Contractions are due to carelessness, maybe a quick walk around the room or a decision to pick up a toddler for a hug. After their babies are born, they return to post encouraging notes, attributing their success to those weeks or months of rest.
The internet is full of sad stories. Women who are in the hospital for six months. Who lose their jobs. Who sneak in their other children because there is no one to watch them at home. Who went into debt paying for the care—in my case, the bills amounted to more than a hundred thousand dollars, something my health insurance mercifully covered.
Everyone is depressed. Everyone is anxious. Pages of posts are devoted to debating the merits of various antianxiety medications and sleep aids. I rarely slept in the hospital, even when I took the Ambien my doctor prescribed. At three in the morning, I sat up reading studies on my phone.
A 2004 study of 1,266 pregnant women found that 7.9 percent of those on bed rest had premature babies, versus 8.5 percent of the non-bed-rest group—a difference the researchers said was not statistically significant. Another study published nine years later found that women prescribed some form of activity restriction were more likely to deliver early, even after the researchers controlled for confounding factors. “It is not biologically implausible that activity restriction could result in an increased risk of preterm birth,” wrote the researchers, citing an association between limits on movement and increased stress and anxiety, which have been found to increase risk for low birth weight and preterm deliveries.
At best, the studies recommended more research. At worst, they called the practice unethical. “There have been no complications of pregnancy for which the literature consistently demonstrates a benefit to antepartum bed rest,” wrote the authors of a 2011 article. A 2013 review of studies on bed rest put it even more bluntly: “Prescribing bed rest is inconsistent with the ethical principles of autonomy, beneficence, and justice.” The researchers attributed the continued prescription of bed rest to a long-standing cultural bias that elevates the fetus above the mother. “Evidence frequently is ignored or interpreted selectively in a way that disregards maternal interests,” they wrote. If there’s a risk to the fetus, immediate prohibitions follow—like limiting caffeine or alcohol. But possible risks to the mother were more likely to be overlooked, they said.
That’s certainly the case with bed rest. Various studies found that the physical effects of bed rest like bone loss, muscle atrophy, and cardiovascular deconditioning can persist for months after the baby is born. Women who spend time on bed rest are at higher risk of postpartum depression and anxiety.
One study described a “type of sensory deprivation.” “When women spend long, isolated, fright-filled hours in bed, time is perceived as slowing down … Women also feel out of control of what is happening with their bodies. Women report feeling imprisoned,” wrote the authors.
In ancient Greece, Hippocrates blamed everything from headaches to sudden deaths in women on a wandering womb that would travel around the body. A cough or sore throat? That pesky womb must have wandered north. Chest pain? The womb had taken a wrong turn again. The Greek physician Aretaeus of Cappadocia called the uterus “an animal within an animal.”
English physicians in the late 1600s believed a healthy pregnancy depended on the right use of the classical “non-naturals:” air, food and drink, exercise and rest, sleep and waking, fullness and emptiness, and passions of the minds. Bed rest was rarely recommended. After all, if you went to bed, you might not get up again, particularly in an unsterilized hospital ward. Those ideas began to change with the publication of John Hilton’s Rest and Pain in 1863, an influential book arguing for the benefits of rest on the body. Hilton argued that if rest could help heal broken bones, it could also help heal other organs.
Doctors ran with Hilton’s guidance, prescribing rest for indefinite periods of time. Rest became the treatment for heart attacks, tuberculosis, mental illness, ulcers, and rheumatic fever. The bed could cure all ills, leaving doctors and nurses responsible largely for preventing bedsores and maintaining good hygiene.
Several months of confinement, or lying-in, became the norm for affluent pregnant Victorian women. In the 1908 edition of the textbook Obstetrics for Nurses, Joseph B. DeLee recommended that pregnant women be removed from “gossiping neighbors” to “lead a placid, quiet life, avoiding mental as well as physical fatigue and excitement.” Confinement was to begin when the pregnancy began to show. Several weeks of “lying-in”—remaining strictly in bed—would often follow childbirth.
One of the most celebrated medical authorities of the era, Dr. S. Weir Mitchell gained fame for championing what he called the “rest cure” as an answer to the malady of the day: hysteria, a common medical diagnosis reserved largely for women. Mitchell, born to a prominent Philadelphia medical family, was the prolific author of around 170 medical monographs along with novels, poetry, and children’s book. His cure was prescribed to Edith Wharton, Virginia Woolf, and scores of female artists and writers. “Hysterical” women were ordered to bed, isolated from friends and family, and instructed not to move a muscle or engage in intellectual work of any kind. Writing, reading, and sewing were strictly forbidden. Effectively reduced to infants, they were placed on a milk diet with nurses to clean, feed, and even turn them over in bed.
The value of bed rest began to be questioned during World War II, as doctors treating injured soldiers noticed that patients forced to return to battle earlier recovered faster. A few years later, aerospace scientists began to use bed rest as a model to investigate the impacts of weightlessness in space on the body. In multiple studies, the scientists discovered that bed rest produced a wide range of harmful physiological effects, affecting every major organ system. As this research became better known, clinical care for postoperative patients began to change. Increasingly, doctors moved away from having patients convalesce in bed, finding that even short bed confinements were frequently unhelpful.
Many medical experts now see mobility as the next major hospital reform—akin to the move from the Victorian-era open wards to private rooms. Some facilities have begun investing in walking tracks and outdoor “healing gardens,” designed to encourage patients to get up and move.
Such changes haven’t yet made it into many maternity wards. Judith Maloni, a professor at the Frances Payne Bolton School of Nursing at Case Western Reserve University and a leading researcher on the topic of bed rest in pregnancy, suggests a few factors that could to spur a change in practice: better explanation of the side effects to patients, an end to insurance reimbursement for bed-rest care, or patients bringing lawsuits against practitioners who prescribe bed rest. But, she acknowledges, limiting the use of the bed rest may come down to women forcing the change themselves. “If not, it is likely that women will continue to struggle with the untreated side effects of bed rest during pregnancy and the postpartum [period], and wonder why they do not recover like other childbearing women,” Maloni concluded in a 2011 paper.
I am part of a generation raised to believe that co-parenting was not just aspirational but achievable. But trapped in that hospital room, I began to have a sinking feeling about the whole enterprise. After the baby came, there would be breastfeeding, another task only I could do. Because I took a longer leave than my husband, I’d know the doctor and the babysitters, handle the appointments and the scheduling. A version of the sacrifices asked of my time and health during my pregnancy would be expected to continue once the baby was born. Bed rest reflects the culture it takes place in: Assumptions about pregnancies set the tone for the assumptions about the motherhood that follows. Namely, that mothers will put their lives on hold for their children.
I have a journalist friend who spent five months on bed rest. During that time, there was a government coup in the country where she lives. There, this sort of thing happens every couple of years. But still, she missed it. The whole coup. Her daughter is now 13. At a conference last month, she ran into a senator involved in the coup. She couldn’t talk to him, she told me, without feeling an overwhelming sense of rage for those lost months.
As for me, mostly I feel lucky. To have good insurance, a supportive family, to be healthy in the end. I will stay with the doctors who cared for me as long as they’re in practice. As I watch my baby grow—stumbling around my living room as she tries to walk or squawking out her first words—I sometimes feel overwhelmed by my good fortune.
But, like my reporter friend, my time on bed rest stays with me, a nagging memory of those lost months, full of anxiety and depression, Netflix, and hospital food.
My baby is over a year old now. Even if I wasn’t her mother, I think I would recognize that she is the cutest baby in the world. Her pediatrician can’t believe the strength of her dimpled baby legs. My babysitter called her Bolita because she looks like a chubby, smiling ball. She spends much of her time trailing after her big sister. When she sees me enter a room, she laughs.
I laugh too, to see how after all of the fear and frustration, the most difficult fetus can become the happiest baby. Her days are filled with activity now—pulling things off shelves, lunging for the stairs, and ordering around her big sister—and I take a strange joy in seeing her tear around the house. Because one of the hardest things we ever had to do was nothing.