Do We Need a Cochrane Review to Tell Us that Women Should Move in Labor?
This week, 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 have been 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.
Cochrane 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:
- Women prefer to move around, primarily because they experience less pain when they can move.
- 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.
- 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.
BTW, I’ve had my nose in the literature on mobility in labor for a while and am bringing it all together in a session at the Lamaze International Annual Conference in Orlando this October. The session is titled, “Optimizing Labor Progress: What the Research Does and Does Not Tell Us”. Save the date!
Citation: Lawrence A, Lewis L, Hofmeyr GJ, Dowswell T, Styles C. Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD003934. DOI: 10.1002/14651858.CD003934.pub2
April 18th, 2009 at 9:55 am
It is actually absurd (and not in the funny way) that supporters of normalcy in birth have the onus of proof. Publicizing studies that “prove” common knowledge is good because of the trickle up effect. A woman says she heard that she can eat in labor and tells her care provider, who might go read the study and maybe tell a colleague, who might join them in changing hospital policy, etc.
But really, do we need to produce evidence that vaginal birth is superior health-wise (not morally) to cesarean surgery? Do we need to provide evidence that carrying babies to term is healthier than inducing at 38 weeks, which is a common practice? Do we need to prove that species-specific milk is superior to something from a can?
There’s a internet skeptic culture that makes me laugh because I think they have no idea how ridiculous they look. No RCT? Then it doesn’t exist or happen. Who’s to say the c-section rate is too high? Are there studies to show that these cesareans were not necessary? Then we must assume that they were necessary until proven otherwise. These people (almost always claiming to be physicians) pop in to comment threads to say that if it weren’t for modern medicine and science, women would be dying in childbirth in drove like they did 100 years ago. No other variables there? Just medicine?
It’s not good, hard science. It’s not skepticism or they would be equally skeptical of poor obstetric practice that defies both evidence and common sense. So if it’s not science and not skepticism, it’s really just doctors feeling demonized and wanting to defend their and their colleagues’ profession. Their positions are spot on ONLY if you operate from the assumption that there are no medical errors and the clinical judgment of a physician is always correct. Toss in a few red herrings about the allegedly rare and isolated cases of practice-gone-awry (and subsequently suspension of the pariah’s license) and then the big picture can be totally ignored.
April 18th, 2009 at 9:56 am
By the way, Amy, I’m really glad you’re blogging.
April 18th, 2009 at 6:35 pm
Thanks Jill for your comments, and for welcoming me to the blogosphere, where you have held court with a wonderful blog of your own!
One of the big problems we face in maternity care is that evidence-based practice has come on the scene so late that “comparative effectiveness research” (testing one intervention against another or “placebo”) is too often comparing the frying pan with the fire, e.g., one ineffective or harmful treatment against another ineffective or harmful treatment. What we really need in maternity care is a lot more placebo - i.e., don’t fix it if it ain’t broke. Our system has lost sight of the basic needs of laboring women - support, comfort, movement, nutrition, hydration, patience, freedom to move/vocalize/ask for help, and so on. Only when these needs are met and labor *still* isn’t progressing, or the baby is in distress, or her pain is overwhelming, must we swoop in with modern medicine to safely get the baby out. But to deny women these elements of care and then “treat” problems that occur as a result is just plain bad medicine.
May 4th, 2009 at 9:40 am
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