Rebecca Dekker: Hi, everyone. On today’s podcast we’re going to talk about the evidence on inducing labor with castor oil and eating date fruit.

Rebecca Dekker: Welcome to the Evidence Based Birth podcast. My name is Rebecca Dekker and I’m a nurse with my PhD and the founder of Evidence Based Birth. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice, see evbirth.com/disclaimer for more details.

Rebecca Dekker: All right, so let’s talk about the evidence on using castor oil to induce labor, as well as eating date fruit to induce labor or make labor start a little bit earlier. You may want to check out Episode 125, when we covered several other methods of natural labor induction, including acupuncture, acupressure, shiatsu, and breast or nipple stimulation. Today, we’re going to continue covering the evidence on natural induction methods. I just have a few disclaimers. First, keep in mind that the research studies that I’m going to talk about may not apply to higher risk people or people with additional medical or pregnancy complications. Also, it’s really important to discuss any plans you may have for natural induction with your care provider, so they can help you decide if the research evidence applies to your unique situation. With that, let’s get started.

Rebecca Dekker: Let’s start with castor oil. Castor oil is also known as Oleum Palma Christi. It’s obtained from the seeds of the castor bean plant. This plant is native to Northeast Africa and the Middle East. Reports dating back to ancient Egypt have suggested that people back then used castor oil to stimulate labor. Castor oil is also a powerful laxative. In research studies, it’s often administered orally to laboratory rats to induce diarrhea in order to then study the antidiarrheal effects of other drugs. I’m going to talk about a Cochrane review from 2013, a systematic review and meta analysis from 2018, and then, a few other studies that have come out since that time. In 2013, Cochran reviewers combined three randomized controlled trials into a meta analysis. They had a total of 223 participants who are pregnant at term and all had Bishop’s score of six or lower, meaning their cervix was not ripened. Back in Episode 125, we talked about cervical ripening. In a lot of these studies, they’ll talk about the Bishop’s score. So as you begin to … your body begins to prepare for labor and birth, the cervix begins to soften or ripen, thin and open. These changes may start a few weeks before labors begin, and the Bishop score is often used to rate the ripeness of the cervix for labor. With this scoring system, a number ranging from 0 to 13 is given to rate the condition of the cervix.

Rebecca Dekker: A Bishop score of less than six means that your cervix may not be ready for labor. Ripening the cervix is a process that helps the cervix soften and thin out in preparation for labor. So some medications, or devices, or natural techniques can be used to ripen the cervix. As I said, in this Cochran review, the participants did not have ripened cervices. Their Bishop’s score was six or lower. They all received a single 60-milliliter dose of castor oil. When they combined the results from these three studies, the Cochrane reviewers found no difference in the Caesarean rate, the use of forceps or vacuum, meconium-stained liquid, or Apgar scores of less than seven at five minutes. Two of the three studies measured nausea, and they found that 63 out of 76 people who took castor oil felt nauseous compared to 0 out of the 71 who did not take castor oil.

Rebecca Dekker: This Cochran review did not report on the outcome of how long it took people to go into labor. It’s probably because it was difficult for the Cochrane reviewers to combine the data from the different three studies to look at it. But individually, all three of the randomized trials included in this Cochran review did find significant results in support of castor oil’s effectiveness for induction of labor. Lets further break it down and look at each of those three randomized trials individually. The Cochrane review was published by Kelly et al. in 2013. One of the three studies was published by Gary. This was a randomized trial in Brooklyn, New York that included a hundred pregnant participants total. Participants in the castor oil group had a significantly increased likelihood of their labor starting in the next 24 hours compared to the group that received no treatment.

Rebecca Dekker: In fact, 58% of the people who received castor oil began active labor within 24 hours compared to only 4% of those who received no treatment, but they did find a side effect. Far more people in the castor oil group reported experiencing nausea. A hundred percent of the participants in the castor oil group had nausea compared to 0% in the other group. [inaudible 00:05:03] conducted a randomized trial in Iran that included 43 pregnant participants total. They found a significant increase in labor initiation during the first 24 hours for people in the castor oil group. About 54% of them went into labor within 24 hours compared to 4% of the control group. The mean Bishop score, or average Bishop score, also increased in the castor oil group.

Rebecca Dekker: Also, Gilad conducted a randomized control trial in Israel that included 80 pregnant women total. This was a placebo-controlled trial, whereas the other ones had no treatment in the control group. So in this third study, half of the people were randomized to receive castor oil and the other half were randomized to receive a placebo, which was sunflower oil. They found that the odds of beginning active labor within 12 hours were three times higher with castor oil compared to sunflower oil. They concluded that castor oil is safe and effective for induction of labor in post-date pregnancies. All three of these studies only included people who were pregnant between 40 and 42 weeks gestation.

Rebecca Dekker: Next, [inaudible 00:06:09] published a systematic review and meta analysis in 2018. In this meta analysis, they combined eight studies that examined castor oil for induction of labor. The dose in all of the studies was 60-milliliters. In one study out of the eight, the treatment was repeated one week later if the person hadn’t given birth yet. The researchers found that there were results with the castor oil, that participants were more than three times as likely to go into labor within 24 hours, and they found no evidence of any harms. They found no differences in rates of Caesarean, use of forceps, episiotomy, rates of hemorrhage, meconium-stained amniotic fluid, NICU admissions, maternal death, stillbirth, or uterine rupture.

Rebecca Dekker: Some people have wondered why the castor oil is effective. They think maybe it stimulates the bowels, and that’s what gets labor going because it’s a laxative. But I also want to point out that there is an interesting laboratory study where researchers exposed pieces of uterine tissue from a pregnant human to castor oil. They found that the strips of tissue that were exposed to castor oil had significantly increased contractile activity compared with the strips that were exposed to a salt solution that was the control. That study was published by O’Sullivan et al. in 2010. There does seem to be some effect of castor oil that creates uterine contractions, or encourages uterine contractions, in addition to encouraging stimulation of the bowels. I also want to point out that the systematic review by [inaudible 00:07:42] et al. in 2018 found that castor oil was more effective among people who had given birth before. So if you’d had a prior vaginal birth, the castor oil was much more effective than if you were a first-time mom.

Rebecca Dekker: So besides potential nausea, are there any other side effects? Well, a non-randomized study published by Nary et al. in 2017, this was carried out in Egypt. They were looking backwards in time at results from using castor oils. This is what we call retrospective study. They found a shorter time to birth with people who used castor oil, but also more nausea, vomiting, fatigue, diarrhea, meconium-stained amniotic fluid, and low first-minute Apgar scores. This study was not included in the 2018 meta analysis because it was rated as very low quality. The treatment and control groups were not comparable and confounders were not adjusted for. For example, many people who took castor oil were post-dates or post-term, and they did not take this into account when they did the analysis.

Rebecca Dekker: Another randomized control trial from 2018 that had 81 participants, reported that 42% of women who consumed castor oil experienced an increase in bowel movements versus 37% of women who consumed the sunflower oil placebo. This result was not statistically significant. They actually did not see an increase in bowel movements between castor oil and the placebo group. Another retrospective study from 2018 published by de Maria et al. found that of 323 women who had consumed castor oil, seven had nausea, three had vomiting, and one had severe diarrhea. Less than 7% of mothers had these side effects. Also, the rate of labors with meconium-stained fluid was very low, at 1.5%.

Rebecca Dekker: In looking for research on side effects, we also looked to see if there was any research on case reports. Case reports can be helpful for documenting rare, severe side effects that may be seen. We found two case reports documenting rare, severe adverse effects from castor oil, one from 1988 and one from the year 2003. The case report from 1988 reported an amniotic fluid embolism in someone who had ingested castor oil during pregnancy. An amniotic fluid embolism is a rare obstetric emergency, a life threatening condition, in which amnionic fluid enters the bloodstream of a mother and triggers a serious reaction. In this case report, they could not establish a cause-effect relationship between the castor oil and the amniotic fluid embolism. The researchers noted that it was a full-term normal pregnancy, and the mother did not have any risk factors for amniotic fluid embolism. They observed a time association between the ingestion of castor oil and the start of cardiopulmonary arrest in the patient. That was published in 1988.

Rebecca Dekker: In 2003, researchers published a case report of a woman who was 39 weeks pregnant and had a prior Caesarean birth. With her subsequent pregnancy, she ingested a very small amount of castor oil, only five-milliliters, and shortly after, began having severe abdominal pains and ruptured membranes. 45 minutes later, the baby’s fetal heart rate decelerations prompted a Caesarean. During the surgery, part of the umbilical cord was coming out of a rupture of a lower transfer scar from her prior Caesarean. So in that case report, the person had had a very small dose of castor oil, but castor oil dosages used throughout the US for labor induction range from as little as five milliliters to as high as 120 milliliters.

Rebecca Dekker: It’s not known whether the effects associated with the use of castor oil are dose-related. This person ingested only that five milliliters, but the authors of the report think that the short time interval between ingestion of the castor oil and onset of uterine contractions suggested an association between the two events. However, they say that even if the uterine rupture was merely coincidental, which is possible, castor oil has not been sufficiently studied in obstetric practice for its use to be recommended to people with a prior Caesarean or prior uterine surgery. So in summary, the evidence does support that castor oil can increase the chances of you going into labor within 24 hours if you’re pregnant at 40 weeks or later. It’s most effective if you’ve had a prior vaginal birth and if you’re at or beyond your known estimated due date.

Rebecca Dekker: It’s really important for parents who are considering using castor oil to discuss use of castor oil with their care provider. Now, some care providers are more familiar and comfortable with induction routines with castor oil than others. We were fortunate to be contacted by a retired certified nurse midwife, Louise Aucott. She wrote to us in 2017 with her castor oil protocol that she had developed after attending 1500 births in the community setting. She wrote that she offered castor oil to anyone beyond 41 weeks, anyone with prom or premature rupture of membrane at term for more than 12 hours, or anyone facing a possible medical induction in the hospital for a variety of reasons. She said that she did not offer castor oil to anyone with borderline blood pressure readings, because she says the increase in the contractility of smooth muscle can extend to all smooth muscle, including the circular muscle fibers in the intimal sheet of arteries and arterials.

Rebecca Dekker: She recommended to her clients, that the first dose be ingested first thing in the morning after making sure your midwife or care provider is available. She always had her clients repeat the dose in four hours if there was still no regular pattern of contractions. She said the time to call the midwife for a home birth, or head to the hospital, or birth center, was usually about one and a half to four hours later. In her experience, typically, the babies were born 8 to 15 hours after the first dose. Louise also noted that she only uses USP grade, which is US pharmaceutical grade castor oil, because it does not contain impurities. It’s important with castor oil to avoid dehydration.

 Midwife Louise Aucott Protocols:

Rebecca Dekker: Also, to keep a note that we still have a lack of safety information for people with prior Caesarean births. There is no research on the safety, and we do have that one case report with a negative outcome.

In writing and talking about castor oil, it’s been really interesting to talk with midwives around the world about their protocols for how they serve the castor oil. I can say that personally, with my third baby, I considered castor oil, and I even went to the pharmacy and bought it. But when I unscrewed the top and poured some out, I could not bring myself to take it. So I found it interesting that midwives have some really unique protocols for making the castor oil more palatable. Because it’s an oil, it can’t just be dissolved in some kind of fluid. So typically, the recipes that people send me today have some kind of fat agent in it. For example, one midwife recommended four to six ounces of orange juice with a big scoop of vanilla ice cream to make a pleasant creamsicle taste. Or, another recipe that was sent to me included one cup of champagne, one cup apricot nectar, and four tablespoons almond butter. Regardless of the recipe, most midwives recommend a 60-milliliter dose, which is two ounces, or 60ccs, blended and served cold with a straw. The purpose of the straw is so that it goes straight to the back of your throat. The only evidence we have on castor oil is on a single dose, but some expert midwives have stated that they recommend a repeat dose in four hours if there’s still no regular pattern of contractions.

Rebecca Dekker: That’s the evidence on castor oil to induce labor. Now, lets talk about eating date fruit to start labor. Date fruit is also called date palm or the Phoenix dactylifera plant. Date fruit is considered a sacred fruit, especially in Islamic traditions. It’s recommended during pregnancy and postpartum in Islamic medical literature. The Holy Koran, the holy book of Islam, Allah instructs the Virgin Mary [inaudible 00:15:35] to consume date fruits when she gives birth to prophet, Issa, peace will be upon him. The verse says, “And shake toward you, the trunk of the Palm tree, it will drop upon you ripe fresh dates.” Today, dates are still consumed traditionally during pregnancy and postpartum in regions of Asia and Africa.

Rebecca Dekker: Dates are very nutritious. They contain a high percentage of carbohydrates, B vitamins, calcium, magnesium, and potassium. In fact, they have 15 types of salts and minerals, proteins, and vitamins. They also have fat. The efficacy of date fruit consumption in late pregnancy and during labor is attributed to its nutritional and biochemical properties. It’s assumed that if you eat date fruits during labor, that this can be helpful in supplying energy due to the high proportion of carbohydrates, which is mostly fructose and glucose. Researchers also think that date fruits affect oxytocin receptors and help the uterine muscles respond better to your own oxytocin, resulting in more effective uterine contractions.

Rebecca Dekker: In Iran, researchers conducted a cross-sectional survey of nearly a thousand pregnant mothers to better understand traditional, and complimentary, and alternative medicine practices during pregnancy. In this study published in 2012 by [inaudible 00:16:52] found that date fruit was the most common fruit used by mothers during pregnancy, with about 26% of mothers saying that they ate date fruit during pregnancy. In 2019, Nassiri et al. published a systematic review and meta analysis about date fruit consumption. They included randomized control trials that assessed the effects of date fruit consumption on any type of pregnancy labor or birth outcomes among low risk participants. Being low risk was defined as the lack of these conditions in the current pregnancy. So not being pregnant with multiples or a breach baby, no complications, such as placenta previa, no bleeding during pregnancy, no ruptured membranes, preeclampsia, hypertension, diabetes, or any other medical conditions.

Rebecca Dekker: Participants who were included in the review were between 18 and 35 years of age with a gestational age ranging from 36 to 42 weeks. Eight of the 11 studies were able to be combined in the meta analysis. So they had statistics that could be combined together into one large study. Six of the studies were considered high quality, and only one study was a double blind controlled trial. The authors had looked at all studies between 2007 and 2017,, so this was over a 10 year time span and they looked at studies in all languages. I do think it’s important to point out that one of the exclusion criteria was people with diabetes, or gestational diabetes, because of the high carbohydrate content of the date fruit. Ten of the 11 randomized control trials in the systematic review had the pregnant parents eat dates in whole form, and one trial used date syrup instead of whole dates. That study that used date syrup did have an appropriate method of blinding. There was a placebo group that received a syrup made with sodium saccharin, which is an artificial sweetener. In three of the studies, people only ate date fruit for one day, and in eight of the studies, the participants were told to eat date fruits for anywhere from 10 to 28 days of pregnancy.

Rebecca Dekker: In the systematic review with the 11 randomized trials, the researchers found that people who are randomly assigned to eat dates had a shorter length of the early phase of labor, fewer cases of postpartum bleeding, fewer women needed to be induced or have augmentation, fewer of them had vacuum-assisted deliveries, there were fewer cases of ruptured membranes before admission, a higher Bishop score on admission to the hospital, so their cervix were more ripe, and fewer cases of prolonged first and second stages of labor. In the meta analysis of the eight randomized control trials, where they were able to combine the data all in one and analyze it together, found that date fruit reduced the length of pregnancy in the studies where women started eating dates at 37 weeks of pregnancy or earlier, ate 70 grams a day or more of dates and ate date fruit for more than 20 days. They also found that people who ate date fruit during pregnancy had increased cervical dilation on admission to the hospital and a shorter length of the first stage.

Rebecca Dekker: That systematic review is published in 2019. There were two other randomized control trials published in 2018 that also showed positive findings. These studies were not part of that systematic review, because they were published after the systematic review stopped collecting data in 2017. In the first one, published by Ahmed et al. in 2018, the study took place in Saudi Arabia. 89 mothers were assigned at hospital admission to either have seven date fruits with 250-milliliters of water, plus they received IV fluids. That was one group. The other group was told to eat seven dates and had IV fluids only. Then, there was a third group that was not given dates or water, just IV fluids. The researchers found a shorter first stage among the two groups that were assigned to eat dates during labor. There were no differences between the three groups and rates of spontaneous vaginal birth, epidurals, episiotomies, Cesareans, forceps, or vacuum. Unfortunately, this study does not appear to be of high quality. We noticed several errors in the reporting of their results.

Rebecca Dekker: The second study was published by Tavani et al. in 2018. This study took place in Iran, and 80 first-time mothers with no pain medications were assigned at hospital admission in labor to either consume date syrup or water-only. The date syrup was prepared by blending six dates in 150 milliliters of water. The researchers found that pain scores were high in both groups, so these people were not able to have epidurals, but pain scores were significantly lower in the date syrup group at one hour, 90 minutes, two hours, and two and a half hours after consuming the date syrup. There was no difference between the two groups 30 minutes after the intervention.

Rebecca Dekker: If zero was no pain and 10 was the worst pain, the date group reported pain levels between 7.8 and 9.3, and the water-only group reported levels between 9.1 and 9.9. A strength of this study is that the people who assessed the pain intensity were blinded, so they didn’t know what the mothers had consumed. But the mothers were not blinded to their group assignment, and that could have introduced the placebo effect. Also, pain scores were very high in both groups, regardless of which group they were assigned to. Those studies are interesting because they kind of give us some info about eating dates during labor.

Rebecca Dekker: What are some potential date fruit protocols? It’s important to keep in mind that the studies do not apply to pregnant people with diabetes or gestational diabetes. You should talk with your care provider before eating dates if you have any concerns about your blood sugar levels. Researchers have found beneficial effects when people start eating date fruits by at least 36 to 37 weeks of pregnancy. The studies that found beneficial results, instructed people to eat 70 to a hundred grams of date fruits daily. This is the equivalent of three to four large medjool dates that are pitted or six to 10 smaller [inaudible 00:23:04] dates that are also pitted. The research studies don’t commonly report which type of date they used. There’s no evidence, at this time, to show whether eating the dates in one sitting is preferable to spreading consumption throughout the day. Also, research suggests that date fruit might make a good snack in labor, that you can nibble on them and small amounts for energy.

Rebecca Dekker: That concludes the research evidence that we have available on castor oil and eating date fruits for labor induction. Again, keep in mind that the research studies may not apply to higher risk people with additional medical or pregnancy complications. It’s important to discuss any plans for natural induction with your care provider so that they can help you decide if the evidence applies to your unique situation. I hope you found this information helpful.

Rebecca Dekker: Today’s podcast was brought to you by the Comfort Measures for Labor and Delivery Nurses Workshop. Last year at Evidence Based Birth, we hosted focus groups and talked with nurses from across the US who told us that they wish they had a way to learn or refresh their comfort measure skills to use with birthing clients, so we created the Comfort Measures for Labor and Delivery Nurses Workshop. This is a three hour in-person workshop with nursing contact hours. If you’re a nurse, midwife, or doula who wants hands-on practice with massage, acupressure, upright birthing positions, and more, visit evidencebasedbirth.com/events to find a workshop near you.