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
