The evidence for rebozos

I first encountered the use of the colourful woven shawls that Mexican midwives call a rebozo in about 1997. During a Midwifery Today 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 Mexican 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.

Contemplating purpose

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.

Addressing the indication question

One way of translating traditional practices within a western medical framework is to consider, as Simkin and Ancheta (2000) discuss, whether we are using something for comfort, distraction or progress. This consideration enables us to tease out the indication and be specific about what we are trying to achieve when we are using such tools. Asking ourselves what the indication or rationale for trying something such as rebozo massage is, can also be a way of ensuring that we aren’t interfering unnecessarily with normally-progressing labour. It is all too easy to see a colourful scarf as being very different from an epidural, and yet both are used as interventions in a process which, if left alone, will usually not require intervention.

Another glimmer of light

Although my searches for evidence haven’t discovered any research trials, I was very heartened when I discovered a couple of recent papers on the topic of rebozo use in mainstream midwifery practice. One is a useful discussion of using rebozo in an NHS setting (Davis 2014) and the other originates in the US. I would recommend both to anyone seeking to introduce or continue the use of this tool – or a version of it, since in many hospitals the original woven woollen rebozo is seen as an infection control issue. The answer to this dilemma, as both Davis (2014) and the US paper’s authors, Cohen and Thomas (2015) explain, lies in using a bed sheet, which can be laundered in between uses. Cohen and Thomas (2015) note, however, that if a woman brings her own rebozo then that is used instead. I also want to mention de Keijzer and van Tuyl’s (2010) book on this topic, which is a valuable resource for anyone wanting to learn more.

Importantly, both papers cover the different techniques which they propose can be used within this situation and Cohen and Thomas (2015) share the protocol they created for their use of the rebozo in a hospital setting, along with consideration of health, safety and manual handling issues. Their work specifically focuses on the use of the rebozo to help in situations where women have babies in an occipito-posterior position. This serves to put the rebozo into a more well-defined set of categories; it is an intervention that is offered for a specific indication and with a specifically desired outcome in mind. That kind of clarity renders it more palatable and understandable to those who are used to working solely within the ideological framework of western medicine, though the trade-off is that it makes practice more rigid and doesn’t necessarily respect the more fluid thinking of some of those who promote its use.

WHO and traditional practices

One thing that we need to remember when we are trying to implement new practices is that there is a big and contentious debate around what constitutes effective evaluation. A useful element of Cohen and Thomas’ (2015) paper is the provision of an argument for the use of rebozos in mainstream practice without a body of scientific evidence. This draws upon the World Health Organization (WHO) statement on traditional practices: ‘The use of the rebozo to encourage optimal fetal positioning, although not yet studied in scientific trials, has a long tradition. The WHO clearly states that the lack of scientific studies on traditional practices “should not become obstacles to the(ir) application and development”’ (Cohen and Thomas: 2015: 446).

Whether this argument will be accepted on a wider level remains to be seen. I can say that, in my search for literature on this topic, I did not find concerns about the safety of using rebozos, although it would be remiss of me not to note that anyone using any tool with women and/or their babies needs to have adequately educated themselves and work in accordance with local and professional requirements.

Moving forward

While I love learning about traditional midwifery tools, techniques and practices, I am not of the opinion that everything that is traditional is automatically useful, good or without potential for harm. But I know of plenty of interventions within a western medical framework which are in routine use and which have far greater potential for harm than the simple tool of the rebozo could. Like many of my colleagues who first learned about rebozos in those early workshops and have had a decade or two to use them in practice (including Davis [2014], who also shares practical tips and experiences), I have seen a rebozo massage work wonders, and not just in relation to fetal positioning. I’ve also seen a rebozo massage make no difference at all, but nothing works every time. On balance, while I don’t have a randomised controlled trial to prove that rebozos work, I would bet that, if we could ever get an appropriately-designed study funded, they would be found to be effective.

In the meantime, I salute those who are taking the woman-centred path and incorporating rebozos – or sheets – into midwifery practice. I hope you’ll consider evaluating and writing about your own experiences so we can further add to our knowledge about these traditional tools.

More evidence for rebozos

In 2017, a small study added to our knowledge of this area. The title, ‘Danish women’s experiences of the rebozo technique during labour: a qualitative study’ (Langeland et al 2017) is pretty self-explanatory.

The researchers recruited 17 women who had used a rebozo during their birth in one of two different hospitals and interviewed them about their experiences over the phone.

Why rebozos?

In about half of the women, the midwife suggested the use of a rebozo because they thought that the baby was malpositioned, and the women frequently reported that the rebozo seemed to help with this.

“Receiving rebozo was described as a harmless mediator for reducing pain because it alleviated labour pain without medication. The women expressed that rebozo contributed to bodily pleasure and drew parallels to massage:

When she [the midwife] tried gently to rub my bottom with the towel, it was as if she was massaging my back and massaging my belly, that was what I felt… (I, 16)

They attributed the pleasure to the movement in their hips and described that it made their muscles relax. The women positively articulated that they had less need of medical pain relief as a response to using the rebozo, which was in accordance with the majority’s pre-existing wishes of as little medication as possible. The women expressed a sceptical attitude towards “everything must be done on medication”; on the contrary, rebozo was seen as a healthy and natural alternative. In particular, the women articulated pain relief in relation to lower back pain.” (Langeland et al 2017)

And the results?

So the results were very positive, and the following key points were among those drawn from the research.

Rebozo as a harmless, user-friendly and easy applicable labour technique.
Positive bodily sensations lead to a feeling of pain relief.
The rebozo technique affected the labour process to move forward.

This is a tiny study but, if you’re looking for studies to support the use of rebozos in practice, this is one to check out. This paper will also be quite useful for anyone who is interested in learning about the ‘nuts and bolts’ of carrying out this kind of qualitative research. The the researchers give a very good and not too jargon-filled description of how they went about recruiting and interviewing women and undertaking the research.

Reflections and Resources

I learned about rebozos from my dear friend Naoli Vinaver. I often take a few to workshops, in my teaching basket. And not just because they’re great shawls for wearing on planes and to take on and off when you’re going from one climate to another. But I like to include a couple of easy-to-remember rebozo techniques for occasional use at births.

For me, the word occasional is the most important one in that last sentence. Women’s bodies really do know how to give birth, and most of the time we don’t need any of these tricks and tools that we carry around, be they rebozos, amnihooks or peppermint oil.

I often wonder how many women would be better off if we all spent more time sitting on – or perhaps knitting with – our hands and I like to talk about how the Mexican midwives use their rebozos as an everyday item of clothing (to keep them warm while knitting) and as an only occasional low-tech tool to help keep things normal.

That said, low-tech tools can be useful now and again, and I’m finishing this blog post by sharing a few resources that might help you to learn more.

I have a bookmark in this brief but lovely video of a workshop led by Naol í, who taught me how to use a rebozo. You can visit Naoli’s website here.

British midwife Jude Davis has been teaching rebozo skills, and she has made a series of free videos for women and midwives who want to learn when certain techniques can be used and how to do them correctly. Her site is at http://midwifejude.com/ Jude has also written an article about the use of rebozo in an NHS setting.

There aren’t loads of good books on the use of rebozos yet, but one that I have seen and liked is by Dutch doulas and childbirth educators Thea van Tuyl and Mirjam de Keijzer. They have now translated this and made it available in English as well as Dutch. You can see and buy their book from www.rebozo.nl/ and they have also written a blog post sharing the story of how they came to write the book.

Finally, Gail Tully is an American midwife whose ‘Spinning Babies‘ website and workshops offers details of a number of techniques, some of which involve rebozos.

References

Langeland M, Midtgaard J, Ekelin M et al (2017). Danish women’s experiences of the rebozo technique during labour: A qualitative explorative study. Sexual and Reproductive Healthcare. https://doi.org/10.1016/j.srhc.2016.10.005