Monday, October 11, 2010

Bed rest: friend or foe?

A prescription for bed rest (the "rest cure") was first made popular by the 19th century neurologist, Silas Weir Mitchell, who believed that isolation, confinement to bed, dieting and massage were beneficial for a variety of nervous diseases, particularly hysteria.  His most famous, or at least prolific, patient was the feminist sociologist Charlotte Perkins Gilman, who was inspired to write the short story The Yellow Wallpaper based on her own experience with the rest cure. From the looks of it, the story may not be the most glowing review of the rest cure: the narrator is apparently driven slowly insane.

(I have just discovered that one can order short stories online through the Harvard library system, to be scanned and delivered by email! Very exciting for a woman in my current shoes. So, more on this tale later.)

As a treatment for threatened preterm delivery in pregnant women, bed rest is widely prescribed but has remarkably little (read: no) scientific evidence backing it. The Cochrane Collaboration, an independent, not-for-profit organization whose mission is to compile systematic reviews of primary research in health and health policy, reviewed bed rest for the prevention of preterm birth in high-risk singleton pregnancies (i.e. not twins or multiples) in 2004. They found only one (!) randomized study on the subject ever published. In this 1994 study of about 1200 high-risk women being seen at 8 different Los Angeles County prenatal clinics, women receiving extra education and clinic visits had a significantly lower preterm birth rate compared with those who received standard care. However, the specific intervention of bed rest (prescribed to about 400 of the women) did not significantly lower preterm births. This result could reflect the fact that bed rest really doesn't work to prevent preterm birth, or it could be that this study wasn't designed well enough (for example, didn't enroll enough patients) to show a benefit when there actually was one. The only way to know would be to do another, better study.

The potential harms of prolonged bed rest have been studied as well, perhaps with more gusto than have the benefits. Those who are sedentary have an increased risk of blood clots in the legs that can move dangerously to the lungs, bone loss, muscle deconditioning, hip and back pain, and depression. If a large randomized study of bed rest versus unrestricted activity ever does take place in pregnant woman, it should include careful measurement of these outcomes, since they are an important counterbalance to the potential gains.

And so, my husband and I and many others like us are left to wonder whether the age-old prescription of bed rest applied to the modern day is friend or foe. For now, neither of us is prepared to discount the accumulated wisdom of centuries of experience if it stands even a small chance of staving off harm to our unborn child.  But perhaps we'll think differently when the Charlotte Gilman text arrives.


"The Yellow Wallpaper." New England Magazine 5 (1892): 647-56; Boston: Small, Maynard & Co., 1899
Sosa C et al. Bed rest in singleton pregnancies for preventing preterm birth. Cochrane Database Syst Rev. 2004;1:CD003581.
Hobel C et al. The West Los Angeles Preterm Birth Prevention Project. I. Program impact on high-risk women. Am J Obstet Gynecol. 1994;170:54-62.

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