A fantastic new program has opened in the Jim Pattison outpatient clinic at Surrey Memorial Hospital for expecting mothers in Surrey, Delta, White Rock and Langley. The Community Birth Program is modelled after the South Community Birth Program in Vancouver, BC.
Both the Vancouver and Surrey programs are based on the groundbreaking and innovative Collaborative Care model where Physicians, Midwives, Nurses and Doulas work together as a team. Doulas are provided to clients at no charge because of funding from Fraser Health Authority. That means that even low-income women, immigrant women or women who have never even heard of Doulas can have one to support them through pregnancy, labour and post-partum. The women are thrilled to bits to have someone give them personalized attention, in their own homes, and help them navigate the new territory of parenthood, especially if it’s also in a new country. (If you’re not sure what a doula does, read my page What is a Doula?)
Fraser Health decided to provide funding for this program because of the immense success the Vancouver program is having. Significantly lower c-section rates, shorter hospital stays and higher breastfeeding rates. These is all great news for mothers and babies, but also for the budget of the Medical Services Plan so it makes sense to fund doulas and midwifery/physician collaborative care if it’s going to save on the other end with reducing unnecessary medical procedures.
Normally, reducing the medical budget compromises patient safety, but for maternity care in particular, there’s lots of room for reducing unnecessary medical procedures while not compromising necessary ones. For example, the World Health Organization suggests that the optimal C-section rate is probably around 15%. Less than that and women who really need it, may not be getting it, which is often the case in impoverished countries. But more than 15% and probably too many women are having cesareans that may not always be necessary.
To find out what the cesarean rate is in the hospitals near you in BC, go to British Columbia Cesarean Rates. For example, Surrey Memorial Hospital has a cesarean rate of 28.65%. So there’s room for reduction. While a small number of mother’s would rather have a cesarean, the vast majority would rather avoid one. So reducing rates would benefit moms as well as reduce costs. Pioneering programs, such as the Community Birth Program and many others that are effective at reducing intervention rates without compromising safety are important for helping maternity care providers as a whole understand how to effectively reduce rates.
I’m really glad the Surrey Community Birth program has finally opened after years of preparation. It’s going to be a really positive direction for expecting moms in Surrey and the Fraser Valley. While maternity services in BC are already so good, and has continued to improve over the past years, there is always room for improvement.
What I would like to see is good quality prenatal education that is available to ALL first-time moms – that effectively teaches pregnancy nutrition, making informed choices and real labour coping strategies. (I say “effective” and “real” because obviously, I have my opinions about how ineffective and unrealistic some prenatal classes are in regards to those topics)
Choosing an appropriate caregiver for pregnancy is one of the most important decisions women make that effects the path their birth will take. I always teach in my prenatal classes how to figure out if your caregiver matches the kind of birth you want. But by the time they come to my classes, their already in their third trimester. It would be great if women got more information about caregiver choices early on (like before they even get pregnant, or at least in early pregnancy). When women go to their doctors for the first pregnancy test, what I would really like is for those doctors to provide a handout about the three kinds of maternity care providers in BC – Family Physicians and Midwives for low-risk pregnancies and Obstetricians for high-risk pregnancies.
I would also like every pregnant woman to be informed by her initial doctor about what a doula is and how a doula can help her in labour and delivery. It is up to the woman to choose if she wants one or not, but I believe every woman should at least get the information that such support exists and is proven to be helpful. There have been numerous scientific studies which prove the effectiveness of doula support at reducing unnecessary medical procedures while increasing maternal satisfaction and breastfeeding rates. If a doula were a drug, it would be unethical for doctors to not recommend them. But doulas are not a drug, and are not at the moment funded by the Medical Services Plan, so expecting families hire a doula privately. Maybe someday there will be MSP funded doulas available to all women. But for now, there are three options:
2. Interview a few doulas in your area and ask if they are flexible with their rates or if they have payment plans. I am very flexible with my rates because I know not everyone can afford them but I am passionate about providing support to women who want it, and lots of doulas feel the same way.
3. Register with the South Community Birth Program if you live in Vancouver or the Community Birth Program if you live in Delta, Surrey or Langley to get access to midwifery care, physician care and doula support.
If you are expecting and would like to register with the Community Birth Program go to Fraser Health – Community Birth Program for more information. If you would like to BECOME a doula with them, also contact them.
With my clients, I always get them to think about things critically. I explain the difference between evidence-based practice in medicine and non-evidence based practice. While most people would assume that ALL medical practice is evidence-based, in reality this is not practical. It is impossible for everything to be evidence based simply because new evidence is being generated on a daily basis. Sometimes research can be contradictory, or new evidence can refute old practices that have been the standard practice for decades. It is difficult for medical professionals to be always changing the way they practice to keep up with all the new research. Also, what works for some people with certain conditions may not work with other people who have variations of the condition, or compounding factors. The reason I have taken the time to explain all this is because the research on bedrest may surprise you.
The assumption is that while bedrest may be uncomfortable, inconvenient, cause muscle atrophy and make moms-to-be bored out of their minds, it is all worth it as along as it helps prevent preterm labour and reduce health problems for the baby. Any pregnant mom would be willing to do whatever it takes to have better health for her baby. I was pretty shocked, to say the least, when I examined the evidence around pregnancy bedrest, that the research doesn’t quite support the common assumption.
Surprisingly, not very much research has been done on the risks vs benefits of bedrest in pregnancy. Of the studies done, they showed that bedrest either did not improve outcomes, or it caused worse outcomes.
”Some benefits may be there, but they haven’t been documented,” said Dr. Judith A. Maloni of the Bolton School of Nursing at Case Western Reserve University, who just completed a $1.7 million study of bed rest supported by the National Institutes of Health. In fact, as Dr. Maloni’s study showed, there is good evidence that bed rest in pregnancy can cause harm, resulting in more than a dozen consequences, including babies who are smaller than normal and mothers who are too weak and tired to care for them. Their babies also tended to weigh less than normal, perhaps because there were fewer blood cells to carry oxygen and nutrients to the womb.
Dr. Robert L. Goldenberg, an expert in maternal-fetal medicine at the University of Alabama at Birmingham, said in an interview: ”Most obstetricians believe bed rest will reduce the risk of preterm births and other pregnancy complications like preeclampsia, incompetent cervix and intrauterine growth retardation. But the data are mostly nonexistent.
Dr. Goldenberg noted, for example, that in two of four clinical trials of preventive bed rest in twin pregnancies, the women randomly assigned to hospital bed rest experienced a greater rate of preterm births than those who weren’t. The other two studies showed no difference.
So why do doctors persist in prescribing bed rest, not only when prematurity threatens but often preventatively, especially in pregnancies involving two or more babies? In Dr. Goldenberg’s view, ”physicians don’t have any real tools to prevent preterm birth, but they want to do something so they choose one they think is innocuous.”
After giving birth, many of the women found themselves so out of shape that they had trouble getting out of a car or using their legs to stand up, and they were so fatigued that their ability to care for their newborns was compromised.
Dr. Maloni suggested that after childbirth, women who have been on bed rest should undergo cardiovascular and physical assessments and receive a rehabilitation program.
Physical problems aside, women who have endured enforced bed rest describe themselves as bored, frustrated, depressed, irritable, guilty and scared. Many mention increased family and spousal tensions and angry young children at home. Fathers, meanwhile, have to take over all the household responsibilities while continuing to work and wait on their wives or visit them.
The economic burdens can be great, as well, especially if the women have jobs that they can’t perform in bed and young children who need care. One study estimated the cost of bed rest per woman at $1,400.So why do so many women follow prescriptions of bed rest? Mostly because they are afraid not to. As Kris explained: ”I was told that there were no concrete studies. But fear plays a big part. You’ve got to play it conservatively. After all, it’s not just about you. It’s about one or more other beings. You have to rely a lot on the experience of your providers who believe that if a woman is put on bed rest, the pregnancy will last a little longer.”
Research indicates, that bed-rest treatment is ineffective for preventing preterm birth and fetal growth restriction, and for increasing gestational age at birth and infant birthweight. Studies of women treated with pregnancy bed-rest identify numerous side effects, including muscle atrophy, bone loss, weight loss, decreased infant birthweight in singleton gestations and gestational age at birth, and psychosocial problems. Antepartum bed-rest treatment should be discontinued until evidence of effectiveness is found.
They went on to cite evidence that exercise actually improved outcomes
Sedentary pregnant women were compared with those who participated in more than one type of leisure sports activity . Active women had a significantly reduced risk of preterm birth. Women who engaged in light physical activity (walking) has a 24% reduced risk of preterm delivery and women who engaged in moderate to heavy activity (sports such as tennis, swimming or weekly running, to competitive sports several times a week) had a 66% reduced risk. The greater the intensity of the activity, the greater the reduced risk of preterm birth.
Every major organ system is rapidly affected by reduced hydrostatic gradients, and reduced loading and disuse of weight-bearing tissues during bed rest.
The American College of Obstetricians and Gynecologists has concluded that bedrest does “not appear to improve the rate of preterm birth and should not be routinely recommended.”
The bottom line is that more good scientific studies are desperately needed. In the meantime, caregivers disagree on when and how to prescribe bedrest. Some say that until there’s good evidence to the contrary, bedrest is worth a try. Others argue that bedrest itself can have a variety of negative effects and that women should not be subjected to it until we know that it does more good than harm.
These caregivers tend to believe that the use of complete bedrest should be curtailed, and that some women would be better off just taking it easy.That means restricting their activity level, cutting back on work, avoiding heavy lifting and prolonged standing, and resting for a few hours each day, for example.
If you’re going to be on prolonged bedrest, you may want to line up additional professional support. Ask your practitioner for a referral to a physical or occupational therapist, who can teach you simple exercises to do in bed to improve your circulation and maintain some muscle tone. The therapist may be able to suggest ways to reposition yourself in bed so that you’re more comfortable.
You may also benefit from counseling, since you’re likely to feel torn between your obligation to your unborn child and to your family or job. Counseling can be helpful for your partner as well if your bedrest is putting a strain on your relationship.
Why is bedrest still being recommended?
Why is bed rest still recommended despite the recent evidence that it does not prevent preterm labour? Bed rest for pregnancy problems has been a common recommendation since the early 1900’s, so it has been around a long time. If there are risks that are associated with preterm birth, most expecting mothers would expect their doctor to do be able to do something about it, and they expect bedrest to be one of those things. If a doctor went against the norm and didn’t recommend bedrest, the mom-to-be would likely find him/her to be negligent of proper care.
Furthermore, it makes logical sense that bedrest would decrease the stress put on the cervix and uterus or other systems in the body and so reduce the chance of preterm birth. It could be possible that some amount of rest, destressing and lying down could be very beneficial to high risk pregnancies.
Making sense of the situation
While it seems logical that rest and lying down may have some benefits, extreme amount of inactivity seems to be related to more problems than solutions. It is also logical that if mom’s circulation is severely compromised by long periods of inactivity, this will lead to poor circulation to baby. Also, because mom’s muscles atrophy with long periods of inactivity, she is less likely to be able to look after her newborn normally, and is less likely to have the stamina to do the hard work of labour.
In some situations where mom is doing a lot of strenuous or stressful activity in her job or daily life, having the recommendation for bedrest can be a relief. In those situations bedrest may be fantastic.
Despite the current evidence, if I were a mom who was at risk for preterm birth, I may still feel the need to avoid too much activity or be upright for long periods in the day, but at the same time, make sure I did appropriate exercises to maintain muscle strength and circulation.
This is just general information. Every mom needs to discuss her unique concerns and situation with her doctor or midwife in order to come up with a plan that she can feel comfortable with.
Resources for bedrest
Here are some websites and exercise videos I have found useful:
Isometric exercises focus on tightening and relaxing a muscle group, and prove helpful as a way to prepare for relaxation during labor. To carry out this type of exercise, a woman can focus on each and every muscle group beginning at her feet. Perform this exercise by clenching muscles for a brief period, such as a count of three, and then releasing them. She can squeeze a stress ball to help with hand and arm stiffness. The American Pregnancy Association also suggests simply pressing the hands and feet against the bed as a way to engage multiple muscle groups.
Tightening the abdominal muscles and releasing them can help maintain some of the woman’s core strength. While sit ups and crunches may not be recommended or allowed by a doctor, a static exercise may prove sufficient. Any abdominal muscle engagement should only be done with the permission of a doctor. The health care provider may even recommend carrying these exercises out only with supervision. Static means the body remains in a position, such as reaching out from the chest at a 45 degree angle while lifting the back off the bed. Just a slight bit of resistance can help improve the abdominal strength. Squeezing and releasing the buttock muscles can help build and remain muscle tone in the core areas as well.
Back aches occur frequently during pregnancy. To take some of the pressure off the back, a simple arch and relax exercise can prove helpful. To do this, the woman must lie flat and slightly arch her back for a count of three. She can then rest out flat for a count of three before repeating. Lying flat for more than a few seconds is not recommended, as it can cut off the blood circulation during pregnancy. While resting or sleeping, reduce back pain by using pillows to take the weight off the muscles.
4. Here’s a video for Bedrest Exercises at a website called Educated Pregnancy with Dr Cathy. She’s got tons of other pregnancy videos on there as well.
5. And lastly, Mamas On Bedrest is a website that offers a DVD that is specific to bedrest in pregnancy. Here’s some of what the website says :
Until now there was no readily available, effective exercise program a woman could do while on bedrest. Bedrest Fitness, an exercise DVD, gives women the skills and guidance they need to safely exercise while on bedrest. Without regular exercise, a pregnant woman on bedrest is at increased risk for:
Blood clots in her legs that can lead to strokes, heart attacks or pulmonary embolisms.
“Failure to progress” during labor resulting in cesarean section delivery.
She is less able to care for herself and her new baby post partum and requires additional time to recover from her pregnancy and birth experience.
The Bedrest Fitness exercise program is designed and performed by Darline Turner-Lee, a nationally certified physician assistant, an American College of Sports Medicine Exercise Specialist® and certified perinatal fitness instructor. The exercise DVD takes women through a series of gentle yet effective movements and also offers a brief lecture on bedrest. Women who regularly perform the exercises while on bedrest can expect the following health benefits:
Maintenance of muscle tone and physical strength
Reduction in the risk of leg clots leading to strokes, heart attacks and pulmonary embolisms
Increased endurance during labor
More effective pushes during delivery
Decreased recovery time post partum
The emotional assurance that she is doing something great for herself and her baby
The exercise program adheres to the guidelines set forth by the American College of Obstetricians and Gynecologists for exercise during pregnancy and uses pillows for support and rubber exercise bands for resistance. A rubber resistance band comes with the exercise DVD.
So I hope you have found this information useful. I hope you realise that you don’t have to feel like the situation is out of your control if bedrest has been recommended. Complete bedrest for weeks at a time is not as useful as was previously thought, so a balanced approach seems to be more beneficial. You still have a lot of choices that you can make, and figure out how to balance resting and destressing with strategic activities for muscle strength and circulation, and still live life as normally as possible.
Have fun, and let me know about your experience in the comments below!
Kaurina Danu teaches Prenatal Classes in Surrey / Langley, BC, Canada. She also provides Birth Doula Support to moms in pregnancy, birth and post-partum in the Lower Mainland area. To contact her, email kaurina @ prenataljourney.ca or call 604-809 3288.
Many people say to me when they find out I’m a doula, “What a great job! It must be so nice to be able to hold so many newborn babies!”
But in reality, I am not a doula because I like newborns, although they are fantastically amazing, miraculous, fascinating people newborns are. I do it because of the MOMS. I do it because I know the simple things I do can and will have a life changing impact, not only on the women and their birth experience, but because it changes lives. I do it because when I focus all of my attention on caring for moms at one of the most important, challenging and vulnerable times of their lives, they are better able to care for themselves, their babies, their children and their families. I take care of the emotional needs of the dads as well in that critical period, so that the couple’s memories of the start of their child’s life is that of love, care, pride and strength. Not that of stress, anxiety desperation and disempowerment.
Sometimes it’s hard to know if what I’m doing is making a difference, because pregnancy, birth and the post-partum time can still be fraught with challenges. But the moms and dads make it clear how important it was to have someone there they could always call day or night if they were worried about anything, how it important it was for someone to be only focused on what they were thinking, how they were feeling, and doing all the little things to help them feel good.
In the big picture, I do it because I believe that each family who starts out with love and care, will raise more loving and caring people. And doulas the world over are helping to change the world one birth at a time.