About 20 years ago, it was while sitting on the floor among friends at a Midwifery Today conference that I first encountered the use of the colourful woven shawls that Mexican midwives call rebozos. During a workshop led by midwife Naolí Vinaver, those present learned how traditional midwives use a rebozo to provide physical comfort and massage to pregnant, labouring and postpartum women, and we practised techniques that midwives use to aid optimal fetal positioning. I left the conference with a rebozo of my own, which I still own and now use to teach others some of those same techniques.
THE REBOZO-EVIDENCE GAP
It struck me recently that, even though I was teaching several classes on evidence and research at that same conference, it didn’t even occur to me to ask if there was evidence to support the things that we were learning in the rebozo class. I didn’t imagine for a moment that there was, and nor did I really need there to be. We were soaking up traditional, experiential midwifery knowledge and, as far as those of us in attendance were concerned, the validity of what we were learning could be found in the deep knowledge of the midwife teaching it, and the many stories she shared of its use.
In the years since I attended that class, however, I have thought a lot about how evidence relates to the use of the rebozo in modern midwifery practice – and I mean here in the UK and in similar countries rather than in areas where traditional midwifery is practised. Recently, ‘Is there evidence for rebozo use in labour?’ has become one of the most frequently asked questions that I hear from midwives and birth workers. This is a consequence of the increased interest in rebozos to support women in labour, juxtaposed within a context where research evidence is often demanded before such ‘innovations’ will be considered.
I don’t consider myself an expert in rebozo use, but I have used mine many times in practice and, since I and some of the other UK-based participants from that first workshop first encountered those skills and knowledge, we’ve had many conversations about this tool. I’ve continued those conversations with workshop participants, and found it fascinating to consider how many areas of discussion are raised by the use of this simple tool. In this two-part article, I’m going to look at some of the issues raised by the use of the rebozo in midwifery practice and answer the question about the evidence for its use.
CONTEMPLATING ORIGINS AND KNOWLEDGE
Some of the most interesting questions about the use of the rebozo concern how women, midwives and other birth supporters began to use such tools and techniques. Because one important thing to know about the rebozo is that it isn’t an intervention that was created to solve a specific problem – for instance in the way that the obstetric forceps or ventouse extractor were. It is an article of clothing that has traditionally been worn in central and southern Mexico. Perhaps, at some point in the past, a midwife or other birth companion felt that something was needed to help a woman relax, and she conscripted her shawl into use to jiggle or massage the woman. Maybe, when it worked, she tried it again. Or maybe her hands were tired so she used her shawl to save her aching muscles. Perhaps it was a short step from using a rebozo to carry a baby to seeing how it could also be used to cradle a labouring woman. To my mind, the fact that we’ll never know exactly how this came about makes it more, rather than less, interesting to contemplate.
But what are rebozos being used for? This question is also fascinating because the range of uses is wide. Over the years, I have heard and seen people use rebozos for – and this list is almost certainly incomplete – carrying babies, giving a relaxing massage, covering the woman’s eyes with the aim of helping her ‘turn inwards’ during labour, turning babies who are perceived to be in less-than-optimal positions, keeping a woman warm, putting gentle pressure on a part of the woman’s body, assistance with pushing (where sometimes it is used to give the women something to pull on), helping a woman jiggle, move and/or relax, helping to open the pelvis and assist fetal descent, and as an aid to dancing during labour and birth. So it has myriad uses or – in medical-speak – indications, which brings us to the first of the tricky elements of that rebozo-evidence gap.
FROM PURPOSE TO INDICATION
Although I acknowledge (and, OK, frequently and heartily complain about) the fact that there exists scant evidence to support a good few of the interventions and practices that birthing women are subject to in modern western maternity services, the current political and economic reality means that, where women and midwives want to introduce tools and techniques into these maternity services, they are often asked to produce evidence of their effectiveness and safety. However, the fact that the playing field is not level is not generally accepted as a valid reason for waiving such a requirement. And, while we should absolutely be working to point out the proverbial emperor’s lack of attire, in the meantime we have to work with the current reality, which entails consideration of why and what evidence is required if we are to be able to use rebozos in mainstream settings.
Although I’m going to look at a discussion paper on rebozo use in part two of this article, I don’t think I’m issuing any big plot spoilers if I mention now that there isn’t a Cochrane review on their use, and neither will I be sharing a lovely table listing the results of the randomised controlled trials in this area. Nobody has done one of those. There’s no money to be made for a start, so funding won’t be easily available, but there’s another reason that is also worth our consideration.
THE PROBLEM OF THE RCT
The purpose of a randomised controlled trial is to test an intervention that is given to a specific group of people in order to see if it can bring about a specific difference in outcome between those people and similar people who have not been exposed to the intervention. To spell it out a bit further, this means that, in order to gather evidence on the effectiveness of a rebozo, we would have to pick just one of those purposes in the list I gave above and work out how to measure it. If you look back over the list, you’ll see that that’s not an easy task and, as I said above, the rebozo evolved as a tool rather than being invented to solve a specific, measurable problem. But the difficulty in evaluating rebozo effectiveness isn’t a reflection of the inappropriateness of tools such as rebozos. It reflects the uneasy relationship that exists between the very rigid thinking and evaluation means of western medicine and the more fluid knowledge that exists within and around other healing modalities, such as traditional midwifery.
But there is hope, as I’ll explain next month.