Margaret Simon spent the last four months of her pregnancy lying in bed on a doctor's orders, hoping to prevent a miscarriage and a preterm birth. As a result, Simon lost her job, struggled to care for her two older children and grew so unfit that she got winded taking showers.
"Everything that made me who I am, being a wife, mother and employee, all got yanked out from under me," said Simon, 34, who had been the family bread-winner and described bed rest as the "darkest, most conflicting" time of her life.
Yet experts say there's little evidence that immobility leads to better outcomes for those women. And although bed rest is often assumed to be a safe intervention, it can be a physical, emotional and financial nightmare for expectant mothers, especially those who don't have strong support systems.
The American College of Obstetricians and Gynecologists states that "bed rest, hydration and pelvic rest does not appear to improve the rate of preterm birth and should not be routinely recommended." A scientific review of the literature, published by the Cochrane Database of Systematic Reviews in 2004, found that pregnant women should not be systematically prescribed bed rest "due to the adverse effects that bed rest could have on women and their families, and the increased cost for the healthcare system."
Most doctors are aware of the scant evidence. Yet they perpetuate the old-fashioned practice, mostly because they have no better options, it doesn't need to be cleared by an insurance company or cost anything at the outset and, though few like to admit it, it's the way things have always been done. A fear of liability and medical malpractice lawsuits plays a role too.
"There's no evidence-based way to keep someone from delivering prematurely," said John Thorp, a maternal-fetal specialist at the University of North Carolina School of Medicine in Chapel Hill who helped draft the ACOG statement. By prescribing bed rest, Thorp said, "we're ruining lives, at least temporarily."
"The risks of placing a woman on bed rest outweigh the current evidence it improves outcomes," said Anthony Sciscione, director of the Division of Maternal-Fetal Medicine at Delaware's Christiana Hospital, who is awaiting funding to conduct a randomized study of activity restriction in women at risk for pre-term birth.
Bed rest isn't the peaceful vacation one might fantasize about. Women on "modified" bed rest may need to rest for an hour, three times a day. Others stay horizontal 24/7, rising only to use the bathroom. They can't ride in a car, have sex, walk up stairs, lift a laundry basket, cook dinner or stand in the shower, let alone take care of children or work. Some women take it so seriously they crawl to the bathroom.
Proponents say bed rest can buy extra time for a pregnancy; the closer a baby is born to term, the better. Lying down, they say, can reduce women's stress, increase blood flow to the uterus, diminish uterine activity and decrease pressure on the cervix.
And then, some say bed rest is just common sense, based on the perception that contractions mean a baby is on the way. Sarah Jacobs, of Brooklyn, N.Y., said that whenever she was up for too long, her contractions increased.
"It was really clear to me that lying down kept the baby inside," said Jacobs, who was on bed rest for six months during her third pregnancy.
But experts say that most preterm births occur in women without risk factors and that contractions are a poor predictor of preterm birth, as they don't always produce the changes in the cervix that lead a baby to be born.
"While women might experience worse contractions with activity or standing, it is important to differentiate contractions from labor," said Dr. William Grobman, an associate professor of obstetrics and gynecology at Northwestern Memorial Hospital. "Having (contractions) doesn't always mean you are in labor."
Still, expectant mothers may feel they have too much at stake to argue with a recommendation to go on bed rest.
"I wasn't willing to risk the outcome of not doing it, because there are no second chances," said Elizabeth Witherspoon, of Durham, N.C., who had four months of bed rest with each of her two children because of a congenital condition.
After the first birth, her muscles were so weak that her knee caps wouldn't line up or track properly when she walked. "It was very hard caring for a newborn while being so weak and also finding a way to get exercise and get reconditioned," said Witherspoon, who recovered with physical therapy. "This is a serious, difficult side effect of bed rest; women need support well after the delivery."
The longer women are on bed rest, the more severe their symptoms and the longer it takes them to recover, said Judith Maloni, a professor of nursing at Case Western Reserve University who has been researching pregnancy and bed rest since 1989.
"People have this image rest is good for you, but after you lie around for a while, you begin to ache and your muscles begin to atrophy — starting as soon as 48 hours — so it's easy to injure the muscles in the postpartum," said Maloni, who recommends all women on bed rest get a physical therapy assessment after delivery.