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Suspicious Activity

It is a physician’s responsibility to give patients information about strategies that will help prevent adverse outcomes. As a doctor who focuses on high-risk pregnancies, I often ask expectant parents to assume the responsibilities and sacrifices of parenting before their children are born — asking them to come into the office more frequently, for example, or to make dietary changes. There is one treatment, however, that I do not recommend to my patients: bed rest. Alexandra Kleeman [“The Bed-Rest Hoax,” Essay, December] correctly notes the dangers of activity restriction, which is one of the interventions prescribed most frequently during pregnancy, especially to prevent preterm birth.

Bed rest continues to be a part of the obstetrician’s armamentarium despite the lack of good evidence that it provides any benefit. There is, however, growing evidence of the adverse effects of activity restriction in pregnancy, including an increased risk of maternal anxiety and depression, deconditioning (which may lead to an inability to resume normal life activities after delivery), an increase in bone loss, and an increase in venous and arterial clots.

The practice persists perhaps in part because there is a clear disconnect between clinicians and patients about the value and risks of activity restriction during pregnancy. Though I do not prescribe activity restriction, patients often ask to be placed on bed rest or impose it on themselves, despite my warnings.

I applaud Kleeman for exposing the alleged benefits of bed rest for what they are: a myth. It is time to put activity restriction itself to rest until there is sufficient evidence that its benefits outweigh its risks.

Anthony Sciscione, D.O.
Director of Maternal–Fetal Medicine
and Director of the Obstetrics and Gynecology Residency
Christiana Care Health System
Newark, Del.

Alexandra Kleeman does an excellent job of detailing the damaging physical effects of bed rest. Unfortunately, however, her depiction of modern bed rest during pregnancy matches a misconception that most people have. The strict bed rest that she describes as the norm is prescribed only for the most serious conditions, particularly those in which the life of the mother or fetus is immediately threatened — for instance, preterm premature rupture of membranes, a bulging amniotic sac, active preterm labor, preeclampsia, and conditions related to how the placenta has attached to the uterus. Making a blanket statement that strict bed rest “offers no benefits to the fetus or to the mother” without qualifying that statement is irresponsible.

The studies that Kleeman refers to used full-term delivery as the end point. In the real world, bed rest might provide a woman’s baby a few extra days in the womb to allow steroid shots to speed lung development. In another case, bed rest might allow a woman four extra weeks of pregnancy after her water breaks at twenty-four weeks.

Among the studies Kleeman cites, only one meets the standard of the Cochrane reviews, which she says are “the most comprehensive assessment of the available science.” But there is not “a growing body of clinical evidence” that bed rest offers no benefits, as her essay states. In fact, the 2015 Cochrane review addressing bed rest for the prevention of preterm birth casts aside all earlier studies but one. From that study, the Cochrane authors included just 1,266 women from eight hospitals and, in summary, wrote, “This updated review finds no evidence to support or refute bed rest in preventing preterm birth.” That isn’t the same as saying there are no benefits.

There is new evidence that bed rest can reduce the frequency of very preterm birth and very low birth weights — which provides a lifelong benefit to those babies. In 2015, a study titled “Maternal Bed Rest and Infant Health” reviewed data collected from more than 200,000 women throughout the United States who experienced a range of problems during pregnancy. The study showed that limiting activity reduced the likelihood of preterm birth before thirty-three weeks by a minimum of 7.7 percent, and the likelihood of babies being born weighing less than 1.5 kilograms by at least 15.4 percent.

As the founder of a website for women experiencing high-risk pregnancies, I have talked to thousands of women on bed rest, and I can tell you that when they read headlines like “The Bed-Rest Hoax” or sentences that scold them for “believing in their own ability to control their pregnancies,” they are far more likely to ignore their doctors’ recommendations or to hesitate to ask family or friends for help out of fear of looking foolish or lazy.

The decisions a woman makes regarding pregnancy are her choice. Limiting activity may or may not prevent the loss of a child or the lasting complications caused by premature birth, but it’s a chance most mothers will choose to take.

Angela Davids
Founder of
Ellicott City, Md.

Alexandra Kleeman responds:
The physiological differences between strict bed rest and a more lenient form of activity restriction are significant, and I’m grateful to Angela Davids for reinforcing the distinction. One of the problems with the way bed rest is prescribed for pregnancy is a lack of clarity in the instructions — mothers may be unsure whether they are supposed to be on strict bed rest (lying prone all day, in some cases with no bathroom breaks) or a looser type of activity restriction that might allow them to sit up, shower, and use the bathroom by themselves. It remains the case, however, that each year a large number of women are placed on activity restriction or strict bed rest for conditions that have not been shown to benefit from this treatment. As the 2015 Cochrane review, which I cited in my article, states, “There is no evidence that this practice could be beneficial.” There is also no evidence that strict bed rest or activity restriction prolongs pregnancy.

I addressed the limitations of the data analyzed in “Maternal Bed Rest and Infant Health” in my article. The study relies on responses to a personal survey and makes no distinction between a two-day period of bed rest and much longer periods that are more harmful to the body. Any drug or treatment that manufacturers wished to prescribe to patients would have to prove its safety and effectiveness in controlled clinical trials; survey responses simply wouldn’t cut it. Why would we be any less cautious with bed rest, which has dramatic and well-known negative effects?

I agree wholeheartedly that the decisions a woman makes regarding pregnancy are her choice. Giving patients full access to the existing evidence of risks and benefits empowers them to make an informed decision.

Vote with Your Feet

In reflecting on the inherent structural challenges that have hobbled the Bosnian government [Elisabeth Zerofsky, “The Counterparty,” Letter from the Balkans, December], it’s also important to note a change that was made in the voter-registration law by the Provisional Election Committee, which was working under the direction of the Organization for Security and Cooperation in Europe, before the 1997 municipal elections. The O.S.C.E. was dominated by the United States at the time — a majority of the organization’s top twenty positions were held by U.S. State Department foreign-service officers — and it decided to allow Bosnians of all ethnicities to register in their municipality of postwar displacement. (I was an election officer for the O.S.C.E. in 1997 and 1998.) This was a concession primarily to the Ostanak movement in the Republika Srpska and, to a lesser degree, to the Croats from Cantons 4 and 6 in the Federation. In this way, the Bosnian Muslims who had held a prewar majority in places like Srebrenica, but who were ethnically cleansed during the war, were outnumbered during that year’s municipal elections by internally displaced Serbs.

Even people who were living as internally displaced persons in others’ properties could register. This contravened the fundamental tenets of the Dayton Accords, which stipulated the right to return to prewar properties. The O.S.C.E.’s decision put a finishing touch on ethnic cleansing by legitimizing, through the election process, the illicit territorial gains and manipulation of the ethnic populations that were secured by the aggressors during the war.

Michael Maturo
Rossland, B.C.

Why Trump Towers

For all its panache and canny evocation of the basic paradox of American democracy, Lewis Lapham’s article [“Bombast Bursting in Air,” Essay, November] goes off its inferential rails toward the end. In trying to force fit Donald Trump into an a priori sociopolitical framework — and in using the Donald as the apotheosis of same — Lapham misperceives Trump’s appeal and his implied compact with his supporters. Trump is in fact the American id writ large, an Archie Bunker who somehow came into money and now goes about speaking his mind to those who for so long have had it coming: illegal aliens, the P.C. police, even his own party and its iconic war heroes when it suits him.

Trump’s platform (to the extent that he has one) seems less simplistic than simple — that is, plain-spoken and aspirational. Where success is taken as an article of faith, the how doesn’t matter. The job will get done. For it has always been thus. Who can question the unique alchemy of America? So many moving parts, so many gears that should gnash but instead, improbably, have produced wonder and transcendence.

To his supporters, Trump embodies at least one core belief that I suspect would be endorsed by a percentage of Americans that might shock and appall Lapham. For all its sins, America has managed in a few hundred years to go from a feudal backwater to the world’s lone superpower and, on balance (to paraphrase Churchill), the worst place to live except for all the others. To Trump’s partisans, that is the manifest truth behind manifest destiny. It is a lens on American life that cannot be explained away even in the most gorgeously cynical essay by one of our foremost thinkers.

Indeed, it is precisely Lapham’s intellectual rigor that undoes his efforts to debunk Trump mania. Forgive me — and please keep the gagging to a minimum — but America may be much like love: ineffable, not to be diagrammed or deconstructed. A grand and mystifying gestalt.

In this system of thought, neither philosophical consistency nor moral authority is required of us. To Trump voters this isn’t jingoism; it’s a necessary pragmatism in a world where jets suddenly disappear from Egyptian skies or become one with giant skyscrapers built as totems to a dream that may seem fatuous if not phony to Lapham, but that many Americans, in their heart of hearts, embrace.

Steve Salerno
Collegeville, Pa.

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February 2016

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