I was speaking with my mom the other day and we were chit chatting away about my work. My mom is really interested in “this bed rest stuff” as it was not really common when she was having us in the late 50′s and early 60′s. My mom asked me, “Is bed rest really that common?”
Bed rest is certainly more common now than when my mom was having kids and there are a myriad of reasons. Just to bring folks up to speed, according to the CDC the numbers are still holding at some 750,000 women going on bed rest annually in the United States. But my mom’s question is one that hounds me. Why are so many women going on bed rest? I tried to find a specific answer and while the literature is not specific, here is what I have been able to gleen.
1. Bed rest is more common right now because we have more diagnostic tools to diagnose conditions for which bed rest is recommended. When my mom was having my sisters and I, many of the ultrasound machines and fetal monitors that are used today to evaluate a mama and her unborn child simply didn’t exist. If a woman had a short cervix, she simply had a short cervix. Now I can hear the collective cyber gasp at that statement. But at the same time it makes you wonder, “How many women over the centuries had a shortened cervix during pregnancy and had a completely healthy baby?” One could give the opposing view, “Well how many women lost babies due to shortened cervix?” We don’t know the answers to these questions, but it does make for interesting mental gymnastics.
I am currently researching the life and career of my great grandmother, a “granny midwife” in the south from the late 1910′s to the early 1950′s. I hear tell that she had an uncanny way of knowing which women were going to have problems and which women were going to be “good breeders”. I also am learning that she had phenomenal clinical skills. I wonder if she was able to examine a woman and note if her cervix was shortened? Or if she would have preterm labor? I do know that she saw a lot of women through their pregnancies and advised them when to stop working (most were farm women) and to rest. It’s an interesting historical perspective and as I learn more, I will certainly share with you all.
2. Bed rest is more common because we have more women having children later in life. I don’t know if I completely agree with this. My grandmother gave birth to my dad at age 43 and he was her 15th child, 13th pregnancy (2 sets of twins, yikes!!) Now one could argue that her body was accustomed to having kids (one about every 18 months!). But one could also argue that her body was “worn out”. As far as I know, she had no problems during pregnancy, no bed rest and no still births. She did lose the twin boys to infant illnesses.
One thing that my reproductive endocrinologist told me when I was in the “height of my childbearing years” is that ovarian age can be uncertain. By that he meant that some women may be 20 yet have the ovarian age of a 40 year old, and some 40 year old women will have more youthful ovarian tissue and function than their much younger counterparts. There is no way to predict which women will have “youthful” ovarian function and which women will not. Likewise, there is no way to predict when a woman will cease to have ovarian function. When we speak of advanced maternal age, we know that in general, as a woman ages, her ovarian function decreases as well as the quality of her eggs. However, we all know of older women who have had completely healthy, unassisted pregnancies, labors and deliveries, and young 30 somethings who have struggled. The best that we can say for now is, relatively speaking, as a woman ages, her chances of having difficulty conceiving and having complications during her pregnancy are increased and continue to increase as she ages.
3. Assisted Reproductive Technologies (ART). Today there are thousands of women who become pregnant as a result of assisted reproductive technologies (IVF, GIFT, ZIFT, IUI, ICI, Surrogacy/gestational carrier). The use of ARTs is a relative risk factor for a woman being prescribed bed rest because women who use ART are often older and often have pre-existing reproductive issues that would predispose them to complications any way. Additionally, women who conceive via ART are at greater risk for having a multiple pregnancy which increases the risk of going on bed rest.
3. Stress. I have written extensively in previous blogs about the role that stress plays on a woman’s ability not only to become pregnant but to maintain that pregnancy. Today more than ever women are balancing the demands of a career, a family that they have created, caring for family members from family of origin (parents or even grand parents) or have other pressing responsibilities not common to women 30 or more years ago. The work of Kathleen Kendall-Tackett PhD and others shows that the stress response has a direct effect on the cervix and preterm labor. Women who are under stress are releasing neurochemicals that soften the cervix and “ripen” it in preparation for labor and delivery-even if it isn’t time. Stress also increases a mama’s blood pressure and may cause her not to eat or take optimum care of herself so her baby may experience Intrauterine growth retardation (IUGR). It is critical that pregnant women avoid stress as much as possible not only for their own health but also for the health of their unborn babies.
4. Litigation. I hate bringing this topic into the argument, but in our current culture, litigation is probably closer to the top as opposed to the bottom of the list of reasons some OB’s put patients on bed rest. Currently, there is not scientific or medical evidence that bed rest is beneficial in preventing preterm labor or preterm birth. In a review article published just over a year ago, I reviewed the current medical literature regarding the efficacy of bed rest and again found no solid medical or scientific evidence for the use of bed rest as a treatment to prevent preterm birth. But as a former clinician, I also understand why OB’s prescribe bedrest. If on the off chance an OB discovered an anomaly with the pregnancy, yet did not prescribe bed rest and the pregnancy had an unhappy ending, that OB can count on being sued and would likely lose his or her ability to practice as an obstetrician. At the current time, medicine in the United States (or globally) has not discovered any other, more effective ways to deal with the complications of pregnancy that often result in the bed rest prescription. Until that occurs, bed rest, effective or not, will remain a “standard of care” in the management of pregnancy complications.
Now whether or not a woman should be put on bed rest is still a heated debate. Given that there is no scientific or medical evidence that bed rest is effective in the treatment of preterm labor, one could argue that we are potentially creating more problems for mamas and babies than solving. But to mamas who have been on bed rest and now have healthy babies, there is no other route to go and no talking her out of the fact that bedrest saved her baby’s life.
I pass no judgement because I know that when I was having my kids, if my OB had told me to spin on my head and shoot marbles out of my nose, I would have done it. I think that high risk pregnancy is an emerging field and one in which there is still much to learn. I am very excited to watch what is emerging in the medicine and science, and I am very excited to be a part of the public health solution of supporting mamas on bed rest.
I just finished reading a very thought provoking article which is pondering the question, “Cost implications to society of delaying childbirth.”
I am somewhat befuddled that this question is even being considered as I have always felt that when and how a woman or couple decide to have a baby is their decision and their decision alone. I know that in other countries, China in particular, there is huge governmental pressure to have only one child and if at all possible, to have a boy. China is currently dealing with a crisis in that they have a generation of males without enough females with whom to make and continue the culture. But that is a discussion for another day and I am going to try to stay on topic with the question of assisted reproductive technologies and women of increased maternal age.
This is a topic that is very near and dear to my heart as I had my first child at age 37 and gave birth to my second child at age 40. I never intended to have children that late in life. In all honesty, I was stressed beyond all recognition when I turned 30 and wasn’t dating and there was no prospect on the horizon. If I had had the option then to freeze embryos, I have to say that in all likelihood, I would have seized the opportunity. It would have alleviated years of stress, anxiety and relieved some of the decisions I have made over the years regarding my career and desire to have a family. I think that this is an aspect of the discussion not addressed. For many women, we don’t choose to delay childbearing, we delay because (not being self pollinating) we can’t conceive children on our own and are waiting for a partner to appear. Now, I also considered purchasing donor sperm and being inseminated when I was in my early 30′s. Again, due to my personal beliefs, I didn’t feel that this was a suitable solution and so I did not journey upon this route to a family. But this conundrum-the desire to have a family vs. not finding a suitable partner with which to raise a family was completely overlooked in this article. I think the underlying tone that women are somehow callous and career seeking is far too simplistic and biased and the assumption that women utilizing assisted reproductive technologies are somehow creating a financial burden on society is also misleading and biased.
Before I offer any more of my own opinions on this topic, I want to share with you all the highlights of the article so that we are all talking about the same things. The article begins by asking the question, Should women without any sort of medical reason (i.e. cancer or autoimmune disorder) be offered the option of freezing either their ovarian tissue, oocytes (eggs) or embryos so that they can delay childbearing? The article is evaluating whether or not the costs of egg or ovarian tissue preservation outweighs the benefit of having a child. One thing that I think this article did well is ask the question, “What is the actual value of having a family?” Who can really answer that question? I think that the answers will vary from person to person, culture to culture and It’s really hard to put a monetary value on bearing a child or having a family. Additionally, the article attempts to assess a cost to these assisted reproductive procedures and quite frankly, there is no uniformity, so it’s hard to say whether or not the costs outweigh the benefit. One thing that is discussed is the fact that currently, women who opt to freeze either ovarian tissue, eggs or embryos most often do so by paying for the procedures themselves. So with that in mind, is it any of society’s business what a woman chooses to spend her money upon? Does society have the right to say that, “The potential cost of having a baby via assisted reproductive technologies is so great that we don’t want women spending their money doing this.” I could see if this is a cost that is being foisted upon society at large, but as previously stated, most women who engage in these cryo-preservation procedures do so at their own expense, so raising this question is, to me, an invasion of privacy.
One question that I do believe we have to ask is, “Are we giving women a false sense of hope for future childbearing?” Many of the cryo-preservation procedures have limited success, and success really varies depending on the health of women, their personal “ovarian age” and many factors that one really can’t quantify. Thus, it’s really hard to say which women will have success with the procedures and which won’t. Now these are questions that, I believe, for which we must get more specific answers. Technology has again preceded ethics and at this point in time, we really don’t know if we should be offering these technologies to any woman who asks for them and is able to pay for them.
I appreciate the author’s attempt to ponder the question, “Should women, given what we know about cryopreservation procedures, be offered cryopreservation of their ovarian tissue, eggs or embryos so that they can delay childbearing?” But I think that the question should be posed as such, from the position of health, safety, efficacy and benefit to the women, not whether or not it presents an unnecessary burden on society. Again, most women who do cryopreservation pay for it out of pocket. Many women are not trying to set childbearing aside in favor of career building. They are trying to give themselves every opportunity to find a suitable mate with whom to raise a family, and are hoping against all hope that once they do find a suitable mate, they will have viable eggs with which they can have the children that they so desire.
Finally, I agree with the article in that we as a society and culture do need to offer more counsel and support to young women (and men because we are not a self polinating species and it is the responsibility of BOTH partners to care for the children they produce!!) as they are coming through their 20′s, the decade deemed “optimal” for child bearing, to make them aware of their potentially waning fertility (women and men!!), and to assist those who do have career aspirations to pursue career and have a family. (i.e. advancing paid family leave legislation, providing better childcare options, etc..)
Mamas on Bedrest, are you 35 or older? When you started your prenatal visits, did your OB/midwife office slap a big “AMA” or “Advanced Maternal Age” stamp or sticker on you chart?
They did on Sharon Munroe’s chart and that one stamp set an uncomfortable tone on her entire pregnancy. Sharon felt inundated with negativity and statistics about why her pregnancy was at risk because she was an older mama. But Sharon wasn’t daunted. She went on to have a completely normal healthy pregnancy and gave birth to a healthy baby boy. This experience prompted her to make changes for her next pregnancy 3 years later.
Sharon now shares her experience, resources and pearls of wisdom with older mamas as the owner and editor of Advanced Maternal Age. Sharon’s mission is to get rid of the label “advanced maternal age” and for obstetrical professionals to view each woman’s pregnancy as a unique entity, while also supporting, informing and empowering older mamas to strive for the pregnancy of their dreams.