EBB 418 - Evidence on Natural Labor Induction: Castor Oil and Eating Dates

0:00Dr. Rebecca Dekker: Hi everyone. On today's podcast, we're going to talk about the evidence on naturally inducing labor with castor oil and eating date fruit.

0:12Welcome 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.

0:28Dr. Rebecca Dekker: As a reminder, this information is not medical advice. See ebbirth.com slash disclaimer for more details. Hi everyone. Before we get started with today's episode, I wanted to let you know that something new from EBB is due to arrive next week. We have been wrapping up final touches on four unique educational tools that we've been working on all year, and these tools will be available for you to add to your toolkit on Friday, November 20, or Thursday, November 19, if you sign up for early shopping access. If you've been following EBB for a while, you probably know that we've come out with some incredible tools in the past for educational purposes.

1:11Dr. Rebecca Dekker: And if you're newer to EBB, welcome! We are excited to show you our new resources as well. I'm not going to share exactly what these four educational tools are today because our plan is to reveal each resource in four short podcast episodes over the next week. The first podcast reveal drops on your favorite podcasting app or on YouTube tomorrow. So if you're at all interested in getting access to four of Evidence-Based Birth's best educational resources at the best price possible, I highly recommend you get on our waitlist for this new release. Just go to evbirth.com slash waitlist and sign up today for special perks and early access.

1:49Dr. Rebecca Dekker: And if you're listening to this episode after November 2026, you can find all of our available educational tools at ebbirth.com slash shop. And with that, let's get started on today's podcast, which I'm sure is going to be a popular episode all about the evidence on castor oil and eating date fruit. Today, I'm so excited to talk with you all about the evidence on using castor oil to induce labor, as well as eating date fruit to ripen the cervix or make labor start a little bit earlier and go a little bit smoother. You might want to check out episode 441 when we covered several other methods of natural labor induction, including acupuncture, acupressure, and breast stimulation.

2:32Dr. Rebecca Dekker: And we're going to cover more topics in future episodes. But today we're going to focus on castor oil and eating date fruit. Before we get started, I have a few disclaimers. First, keep in mind that the research studies that I'm going to talk about might not apply to you if you have a higher risk condition or you have a medical or pregnancy complication. Also, it's important to discuss any plans you may have for natural induction with your care provider so that they can help you decide if the research evidence applies to your unique situation. I also wanted to give you a brief reminder about the Bishop score.

3:08Dr. Rebecca Dekker: In a lot of the studies that we're going to cover, they talk about the Bishop score. And so what that means is as your body begins to prepare for labor and birth, the cervix begins to soften or ripen, it thins, it may start to open, and these changes may start a few weeks before labor begins. And the Bishop score is often used to rate the readiness of the cervix for labor or for a labor induction. So with this scoring system, a number ranging from 0 to 13 is given to rate the condition of the cervix. A Bishop score of less than 6 means that if you had a medical induction of labor right now, you'd be less likely for that induction to be successful.

3:51Dr. Rebecca Dekker: So in that case, ripening the cervix would be a process that helps the cervix soften and thin out in preparation for labor or for a labor induction. So some medications or devices or even natural techniques can be used to ripen the cervix. And with that, let's get started. So castor oil is also known as oleum palma christi. It's obtained from the seeds of the castor bean plant and 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 commonly used as a laxative to help relieve constipation and it can be sold in pharmaceutical grade for that purpose.

4:37Dr. Rebecca Dekker: In research studies, castor oil is commonly administered orally to laboratory rats to induce diarrhea in order to then study antidiarrheal treatments. And the active ingredient in castor oil is something called racinoleic acid. You might be wondering why would castor oil help induce labor? Well, the exact mechanism of how castor oil works to induce labor contractions is not fully understood, but it's suspected to increase the production of prostaglandins, which are a hormone that helps soften and ripen the cervix in preparation for labor. Also, some people believe that stimulating the bowels can help stimulate uterine contractions.

5:20Dr. Rebecca Dekker: There's also one interesting laboratory study where researchers exposed pieces of human uterine tissue to castor oil, and they found that the strips of tissue that came from women who were recently pregnant. When these strips were exposed to castor oil, it significantly increased contractions compared with strips that were exposed to a salt water control solution. So there might be some direct effect of castor oil that creates or stimulates uterine contractions or maybe encourages or enhances contractions in addition to its effects of stimulating the digestive system. Back in the early 1950s, over half of US-based academic obstetrical departments were using castor oil orally in combination with enemas to help people go into labor.

6:12Dr. Rebecca Dekker: Not a very fun way of historically inducing labor with an enema. However, castor oil is not as common anymore in the US. It's not a standardized way of inducing labor. Instead, it's a steady part of the natural induction toolkit used by parents and midwives. And it's commonly used in home births and freestanding birth centers. And it's used in some hospitals in European countries, which we'll talk about later on. In 2022, Maradi et al. published a meta-analysis all about the effects of castor oil on labor induction and cervical ripening. So meta-analysis is when researchers take multiple studies and combine the data all together to do one big meta-analysis.

6:57Dr. Rebecca Dekker: These researchers combine data from eight studies on castor oil. These studies were published in English and Persian. Eight of the 10 studies were carried out in Iran. One came from Israel, and one study was from Nigeria. The smallest sample size was 30, and the largest was 211, and there were a total of 902 participants included in the data analysis. All eight of the studies tested a single dose of 60 milliliters of castor oil in the intervention group. Some of the studies were at risk for bias, and only two of the eight studies included a placebo. Most of the studies were comparing castor oil to no intervention, which can be a problem because the placebo effect is real and can be quite strong.

7:46Dr. Rebecca Dekker: So if you have a placebo, that would strengthen the quality of the research. There were also some other small inaccuracies in this meta-analysis. For example, they called hyperstimulation of the uterus, hypertension of the uterus, which is incorrect. And they said in the introduction that post-term pregnancies cause death. So in general, there were some problems with this meta-analysis, and this might come from the crossover publishing in English. But still, it's a useful review to look at because they did do a thorough search for all of the randomized trials on the use of castor oil for inducing labor at 40 weeks or later, and they were able to include and review papers published in Persian, which might have been excluded by another research group.

8:30Dr. Rebecca Dekker: So it kind of expands their ability to look at all the research on this subject. So what did Maradi et al. find? Well, they combined data from four studies that specifically measured the Bishop score after administering castor oil, and they found that castor oil did significantly increase or improve the Bishop score. They were not able to combine data from the other studies on other topics on whether castor oil causes contractions to start or shortens the length of pregnancy, because all of the data were collected too differently in order to combine them statistically, but they did summarize what each study found, and they reported that six of the eight studies found that castor oil was associated with the onset of labor, and they did not see any increase in cesarean rates or any problems with newborn APGAR scores.

9:25Dr. Rebecca Dekker: I also want to point out that a prior systematic review by Nasiri et al. published in 2018 found that castor oil was more effective if you had given birth before. So if you'd had a prior vaginal birth, the castor oil was much more effective than if it was your first time giving birth. Next, I thought it might be helpful for us to zoom in and take a closer look at two randomized trials on castor oil that were included in the Marati et al. meta-analysis. One of the larger studies in this review came from Okoro and colleagues. It was published in 2019 and this was a randomized control trial conducted in a Nigerian teaching hospital.

10:04Dr. Rebecca Dekker: The final sample was made up of 211 participants, all of whom had a singleton head-down baby and a favorable cervix, and they were randomly assigned to either receive castor oil, a 60-milliliter single oral dose, and it was a pharmaceutical-grade castor oil, versus the control group, which received a vaginal exam and a Bishop score only, they did not have castor oil and they did not have a placebo. Both of these groups were around 40 to 41 weeks pregnant. There were 105 people in the castor oil group and 106 in the control group. The authors found that that single dose of 60 milliliters of castor oil significantly lowered the chance of a post-term pregnancy.

10:50Dr. Rebecca Dekker: Only 17 % of the castor oil group made it all the way to 42 weeks versus 42 % of the control group, which ended up making it to 42 weeks. So 57 % of participants who received castor oil gave birth within 24 hours versus only 4 % in the control group. Finally, the castor oil group was also less likely to have their labor augmented with pitocin versus the control group. 47 % had pitocin augmentation in the castor oil group versus 71 % in the control group. There were no significant newborn complications or maternal complications in either group. There were no cases of infection, uterine hyperstimulation, uterine rupture, or meconium staining of the waters in either group.

11:39Dr. Rebecca Dekker: And there were no differences between groups in rates of vomiting or diarrhea. Another study that I wanted to highlight was published by Gilad et al. They published this study in 2018. It came out of Israel. They included 80 participants and all the participants were between 40 weeks, zero days, and 41 weeks, six days. They excluded anyone with a prior cesarean from participating. I specifically wanted to share info from this GILAD study because it was a placebo-controlled trial, and they used sunflower oil as their placebo, which they wrote cannot be distinguished from castor oil. When you mix castor oil with orange juice and sunflower oil with orange juice, they taste the same.

12:25Dr. Rebecca Dekker: So in this study, 38 women were randomized to receive castor oil and 43 were randomly assigned to receive a placebo of sunflower oil. The treatment was given in the presence of a midwife who watched to make sure that the patient didn't vomit in the next 30 minutes. Then the patients were sent home to await labor. There was no statistical difference between the intervention and the control group and the percentage of women who entered labor within the next 24, 36, and 48 hours. However, when they looked only at those who had given birth before, they did find a positive effect with castor oil. 60 % of the castor oil group went into labor within 24 hours compared to 29 % in the control group.

13:09Dr. Rebecca Dekker: They found no differences between groups in the rates of meconium staining of the waters, abnormal fetal heart rate tracings, cesarean rates, and rates of instrumental deliveries with forceps or vacuum. They also found no differences in newborn APGAR scores, the rates of infection, hypertension, retained placenta, or postpartum hemorrhage. There was also no difference between the castor oil group and the sunflower oil group in the rate of having increased bowel movements. These researchers concluded that castor oil is effective for inducing labor in women who are past their due date and have previously given birth before.

13:48Dr. Rebecca Dekker: Moving on from randomized trials, I wanted to share with you two really interesting studies from Germany that were observational studies. Both of these studies were looking backwards in time at what was recorded in medical records after castor oil was given. So this is what we call a retrospective study design. Both of these studies from Germany found high success rates with castor oil, along with no differences in cesarean rates or maternal or newborn complications among those who had a castor oil cocktail compared with those who had a standard medical induction with medications or physical induction methods.

14:26Dr. Rebecca Dekker: The reason this research has been done in Germany is because there's been a lot of public debate in Germany about the use of a common induction medication, misoprostol, the brand name is Cytotec, when it's used for labor induction. Because of that public debate, many women were requesting castor oil for labor induction instead, so much so that it's become a routine care procedure for some hospitals in Germany. So a study by Jakubowski et al. is the largest observational study to date on castor oil. The study was published in 2026 in Germany. They used patient data gathered from medical files from a large university hospital to assess the effects and safety of using castor oil for labor induction compared with standard medical induction methods.

15:18Dr. Rebecca Dekker: They had 824 participants who received a standardized 20 milliliter castor oil cocktail, and the control group with 191 women received other standard methods of medical induction, including being given prostaglandin medications, oxytocin by IV, also known as pitocin, and a cervical balloon which stretches the cervix open. Women can be in this study if they are being induced at 38 weeks or later with either the castor oil method or the standard medical induction method. Women who had a history of a prior cesarean were permitted in the study and there were 109 of them making up about 10 % of each group.

16:01Dr. Rebecca Dekker: Because this was not a randomized controlled trial, there were some baseline differences between the two groups. Women who took castor oil had less favorable bishop scores on average and a higher gestational age at the time of taking the castor oil. There were also more first-time moms in the castor oil group. Women in the study were being induced with castor oil or with medical induction methods for a variety of reasons, the most common being that their waters had broken before labor started. Other reasons included low amniotic fluid, post-term pregnancy, a diagnosis of diabetes, or gestational hypertension.

16:39Dr. Rebecca Dekker: Their induction cocktail had standardized ingredients, including 20 milliliters of castor oil, one tablespoon of almond butter, 150 milliliters of apricot juice, a dash of cinnamon, and 200 milliliters of non-alcoholic sparkling wine or sparkling water. Women were instructed to consume the cocktail within 20 to 30 minutes. The authors found that of those who took the castor oil cocktail, half of them went into labor without need for any other medical induction measures. The other half, though, of the castor oil group did need a second induction method after about 12 hours, whether that was prostaglandins, pitocin, or cervical balloon, in order for labor to start.

17:25Dr. Rebecca Dekker: So that's in contrast to the standard medical induction group. 63 % of them went into labor after their initial medical induction. The time from administering the induction method, whether it was castor oil or the standard medical induction methods, the time from giving that method to giving birth was significantly longer in the castor oil group. It was 27 hours versus 19 hours, but there were no differences in maternal or newborn health outcomes. When they looked at those who had a prior cesarean, both the castor oil and medical induction groups had cesarean rates of about 37 to 47 percent and this was not statistically different between the two groups.

18:09Dr. Rebecca Dekker: There were two uterine ruptures among those who were having a trial of labor after cesarean. Both of these uterine ruptures occurred after consuming castor oil and both of them happened when the mom got to full dilation, emergency cesareans were carried out, and the mothers and the newborns survived and recovered. The authors found that overall castor oil appears to be a safe but slightly less effective method of induction of labor and that it can work about half the time even in a high-risk population and they said that the rate of complications that they observed seemed to be comparable to established medical methods of induction.

18:50Dr. Rebecca Dekker: There was another interesting observational study also carried out in a German hospital. This hospital offered a standardized castor oil cocktail with 20 milliliters of castor oil. They've been doing this since 2010 and they put it into their hospital guidelines in 2012. And one of the reasons that they offer castor oil in the hospital is to avoid people doing it on their own at home without clinical guidance. So researchers analyzed the patient outcomes, including rates of vaginal birth, newborn health, and whether the castor oil cocktail worked within 12 hours of being given. So from the years 2014 to 2021, there were 1 ,140 participants, all of whom had given birth before.

19:35Dr. Rebecca Dekker: These participants underwent induction of labor at the hospital and 148 of them, or 13%, requested the castor oil cocktail. The authors then matched a control group consisting of 296 participants who had established medical induction methods. Their castor oil cocktail was very similar to the other one that I listed, except that they did allow sparkling wine. It didn't have to be non-alcoholic wine. They used quality tested castor oil from their hospital pharmacy, and the two groups were similar at baseline except that the castor oil group tended to be further along in their pregnancy, have a higher gestational age and a lower pre-pregnancy body mass index.

20:21Dr. Rebecca Dekker: Participants in both groups were mainly being induced due to post-term pregnancy, some of them because their waters had broken before labor, some of them had problems with their placenta, and some of them were suspected to have a big baby. So a total of 109 people got the castor oil cocktail and 75 % of them went into labor within 12 hours. For the other 25%, the castor oil did not induce labor within 12 hours. So those people had to be further induced with medications or other medical methods. The researchers found that the participants who had the castor oil cocktail had significantly shorter labors than the medical labor induction group, and they were more likely to have a time to birth of less than 24 hours.

21:07Dr. Rebecca Dekker: There were also significantly more babies admitted to the NICU in the standard medical induction group, 8 % versus 2 % in the castor oil group. The authors ended by arguing that more hospitals need to offer a standardized castor oil cocktail for induction like their own institution is doing. This would allow more people to have access to the benefits of this alternative method of induction with supervision and clinical guidance versus people just taking it on their own at home without supervision and without talking with their care provider about it. So what are some potential side effects or reasons you might not want to take castor oil for a labor induction?

21:47Dr. Rebecca Dekker: There was an expert review published in 2022 by Sanchez Ramos, and they had a team of medical doctors. They discussed some potential complications of castor oil for labor induction, including meconium staining of the waters, perhaps maternal electrolyte abnormalities from diarrhea, and that people with nut allergies have the potential to have an anaphylactic allergic reaction and should avoid castor oil. Looking back at the systematic review by Moratti et al. that we cited earlier, there were no complications in six of the eight studies reviewed, but there were complications in two of the studies, which included hyperstimulation of the uterus, nausea, and vomiting.

22:30Dr. Rebecca Dekker: Another study from 2018 that looked back in time at people who had been using castor oil for labor induction found that out of 323 women who consumed castor oil, seven had nausea, three had vomiting, and one had severe diarrhea. Less than 7 % total of the sample had any of these side effects. Also, the rate of labors in the sample that had meconium-stained waters was very low, 1.5%. However, these studies I've been referring to that found side effects or reported these side effects, none of them had a placebo group. So they were comparing castor oil to no treatment. Other researchers who've used a placebo have not found increases in side effects when castor oil is compared with a placebo or in observational studies when it's compared with another intervention, such as a standard medical induction method.

23:25It's important to note that castor oil has not been sufficiently studied for use to be recommended in those with a prior cesarean or prior uterine surgery.

23:35Dr. Rebecca Dekker: If someone with a scar in their uterus would like to use castor oil for labor induction, the research we have so far indicates that uterine rupture can happen with castor oil. In the 2026 study published by Jakubowski and team from Germany that we discussed earlier, there were those two uterine ruptures that followed the castor oil cocktail once the participant got to full dilation. Based on the sample size, this would match the expected uterine rupture rate for a trial of labor after cesarean. So it's not clear if these uterine ruptures were due to the castor oil induction or if they would have happened regardless of its use.

24:16Dr. Rebecca Dekker: In our literature search, we also found a study published from 2022 by Bayoumi et al. on castor oil for labor induction in patients of the previous cesareans. This is a study specifically focused on that group. They did not report any uterine ruptures from their small sample of only 70 participants. However, this study is currently labeled as under investigation by the medical journal. So we couldn't be sure of the quality of the study and I'm not going to go into any further about that study here. What if someone wants to take castor oil? Well, if you're interested in castor oil as a more natural labor induction method, there is evidence that it can be effective, especially if you've already had a history of giving birth vaginally before.

25:04Dr. Rebecca Dekker: But there are not a lot of clinical guidelines on its use. Community midwives who attend home births and freestanding birth center births may be more comfortable giving recommendations and tips on the use of castor oil. Meanwhile, we've seen that many obstetricians have less experience or lower comfort levels with this induction method. We were fortunate to be contacted years ago by a retired certified nurse midwife, Louise Alcott. She emailed us in 2017 with her castor oil protocol that she had developed after attending more than 1 ,500 births in the community setting. Louise wrote that she offered castor oil to anyone beyond 41 weeks, anyone with premature rupture of membranes, so when your water breaks and labor doesn't start for more than 12 hours, or anyone who's facing a possible medical induction in the hospital and wants to avoid that and try the castor oil first.

26:01Dr. Rebecca Dekker: She said she did not offer castor oil to anyone with a borderline blood pressure reading because the increase in the contractility of smooth muscle could extend to all smooth muscle, including the circular muscle fibers in the arteries and arterials. 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 not a regular pattern of contractions. She said the time to call the midwife for a home birth or the time to head to the hospital or birth center was usually about one and a half to four hours after taking the first dose.

26:43Dr. Rebecca Dekker: In her experience, typically babies were born eight to 15 hours after the first dose of castor oil. She also noted that she only uses USP grade, which is US pharmaceutical grade castor oil because it does not contain impurities. And she also mentioned that it's important with castor oil to avoid dehydration. Louise also interestingly developed her own scale to determine if somebody, one of her clients was an eligible candidate for castor oil. She used a four point scale where she gave one point for being at or beyond a known due date, one point for having had a baby before, one point if the membranes are ruptured, and one point if the cervix was already two centimeters or more dilated if there's been an exam.

27:30Dr. Rebecca Dekker: She said, if all four of these criteria apply, I have never seen a situation where labor did not start within 24 hours after castor oil. Two out of four points, about half of them will be in labor within 24 hours. With just one point on her four point scale, for example, if you're a first time mom, your membranes have ruptured, but you're only 39 weeks and your cervix is unfavorable, it still might work. It's worth a try to avoid the more medical induction methods. But that was her system and I thought it was really interesting to talk with someone who's been practicing with this induction method for many, many years.

28:09I've talked with other midwives

28:11Dr. Rebecca Dekker: from around the world about their protocols for how they serve the castor oil. I can say personally with my third baby, I considered taking castor oil and I even went to the pharmacy and I bought a bottle. But when I unscrewed the top and poured the dose out, I could not bring myself to take it. I was already nauseous at the end of pregnancy. It was just not something that was palatable to me. So I find it really interesting that midwives around the world have developed some really unique protocols for making the castor oil more palatable. Because this is an oil, it can't just be dissolved in any kind of regular fluid.

28:50So typically the recipes that people send us here at Evidence-Based Birth have some kind of fat included. did. 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. Another recipe that was sent to me included one cup of champagne, one cup of apricot nectar, and four tablespoons of almond butter. Regardless of the cocktail recipe, most midwives around the world recommend a 60 milliliter dose, which is two ounces or 60 cc's blended and served cold with a straw. The purpose of the straw is that it can go to the back of your throat.

29:30The two German studies that I mentioned earlier also used almond butter and apricot juice, but with just 20 milliliters of castor oil. The only research we have on castor oil looks at like a single dose, but some expert midwives have stated that they recommend a repeated dose in four hours if there's still no regular pattern of contractions. So what's the bottom line on castor oil for natural labor induction? In summary, the evidence does support that castor oil can increase the chances of someone going into labor within 24 hours if you're pregnant at 40

30:04Dr. Rebecca Dekker: weeks or later. Castor oil might also have some impact on the length of the first or last stage of labor, but the evidence is limited and more studies are needed to kind of tease apart the effects of castor oil on the labor process. Castor oil is most effective if you've had a prior vaginal birth and if you're at or beyond your known estimated due date. It's also important for parents who are considering castor oil to discuss its use with their care provider. In an expert review from medical doctors published in 2024, they found that natural induction methods including castor oil along with nipple stimulation, sexual intercourse, and acupuncture are likely safe for both singleton and twin pregnancies based on the latest research.

30:51Also just keep in mind we still have minimal safety information for people with prior cesarean births and castor oil could lead to uterine rupture similar to how other induction methods can increase the risk of uterine rupture. Now let's talk about eating date fruit to start labor or ripen the cervix. Date fruit comes from the date palm plant. Date fruit has an ancient history of being considered a sacred fruit, especially in Islamic traditions. It's recommended during both pregnancy and postpartum in Islamic medical literature, the Holy Quran, the Holy Book of Islam. Allah instructs the Virgin Mary to consume date fruits when she gives birth to the prophet Isa.

31:33Peace will be upon him. The verse says, quote, and shake toward you the trunk of the palm tree. It will drop upon you ripe, fresh dates, end quote. Today, it's still traditional for dates to be consumed during pregnancy and postpartum in regions across Asia and Africa. Dates are very nutritious. They contain a high percentage of carbohydrates, B vitamins, calcium, magnesium, and potassium. In fact, date fruit has 15 types of salts and minerals, proteins, and vitamins. They also contain fat. The effects of date fruit consumption in late pregnancy and during labor are attributed to nutritional and biochemical properties.

32:15It's also thought that if you eat date fruit while you're in labor, that this can be helpful to give you energy due to the high proportion of carbohydrates made up of mostly fructose and glucose. Researchers also think that components from the date fruits affect oxytocin receptors, which are the receptors on the uterus that allow oxytocin to attach to them and activate the contractions. So by helping activate these receptors, it's thought that the date fruit helps the uterine muscles respond better to your own oxytocin that's flowing through your system, resulting in more effective uterine contractions.

32:56In 2012 in Iran, researchers conducted a cross-sectional survey of nearly a thousand pregnant mothers to better understand traditional and complementary medicine practices during pregnancy. They found that date fruit was the most common fruit eaten by mothers during pregnancy with about 26 % saying they ate date fruit during their pregnancy. These days we constantly hear at EBB, hear about people eating date fruit in pregnancy in North America, Europe, India, and many more places. Anecdotally, I would say that the number of people I've met who are pregnant in the U.S. who mention eating date fruit towards the end of pregnancy has increased significantly in the last 10 years as awareness of this method has spread.

33:40Now, when I get into the research on date fruit in a few minutes, you might notice that many of the studies had small sample sizes or would be considered low quality based on standard ratings. Also, many of the studies on eating date fruit in pregnancy come from Middle Eastern or Asian countries where eating dates are a staple. So it can be hard to have a true control group because maybe your intervention is have these people eat a date fruit, but the control group still wants to eat date fruit on their own time. So that can blur some of the findings. Also, none of these research findings apply to people with diabetes or gestational diabetes.

34:18Because eating date fruit can raise your blood sugar, people with diabetes are typically excluded from these studies. So as I get into the research on this topic, I'm going to highlight the evidence from two meta-analyses and then give examples of two studies that had larger sample sizes that were included in those meta-analyses. So as a reminder, a meta-analysis is when researchers combine all the research studies on a topic that meet their criteria, they combine the data and analyze the results. This typically gives you a bigger sample size than if you just look at one or two studies. So when it comes to eating date fruit, there's been a surprising amount of arguments between researchers as to which studies should be included in these meta-analyses and which studies should not be included.

35:03And so there's been some back and forth. There's been quite a few meta-analyses published. It almost seems like the authors are kind of arguing with the last paper and publishing their own, and then somebody else publishes one arguing with the last one. There was a systematic review and meta-analysis published in 2020 by Brigasada. They included eight studies in their final analysis, but it really only represented five independent studies, since some of the studies were the same trial, just kind of published repeatedly, and that is another issue in this area of research. So the authors were very careful to kind of combine and condense down each trial's multiple reports into the meta-analysis only a single time, so you weren't double counting info.

35:47They had a total of five independent studies, and the number of participants in those studies ranged from 57 up to 210. In the end, there were 653 total participants included in this meta-analysis, 325 who got an intervention and 328 who got control treatment. There were no standardized doses or protocols for how date fruit was consumed from study to study. The authors found that date fruit can shorten the average length of the active phase of labor and improve the bishop score. This indicates a better readiness of the cervix to go into labor and then a shorter labor as a result. However, they labeled the quality of the available evidence as low quality to moderate quality.

36:32No side effects were reported in any study, and the authors cautioned that more high quality studies are needed. Unfortunately, like many papers on this subject, this paper did not seem to be of high quality. We noticed several errors in the reporting of their results. Next, Next, Silejiga and colleagues published a different meta-analysis on date fruit and pregnancy. They wanted to look at the effects and safety of date fruit across the entire third trimester, including during pregnancy, labor, and postpartum. This was a very large meta-analysis, included 55 studies that did have some overlapping populations and samples.

37:11It was condensed down into 48 independent studies. 15 of them were randomized controlled trials, and 33 of them were not. randomized control trials. Those studies were published anywhere from the year 2007 to 2023 and came from a variety of countries, but most of them came from Indonesia. 30 of the 48 studies were from Indonesia and nine studies came from Iran. They analyzed data from participants who had standard care and oral dates versus standard care alone or with an alternative intervention. and the sample sizes of the individual studies range from 10 to 105 per group. The authors reported that the length of pregnancy as well as the length of the early phase of labor, the active phase of labor, the total first stage of labor, and the third stage of labor were all significantly shorter among those who ate dates versus control.

38:05Only the second stage of labor was found to not be different in length between the two groups. They also found that those who consumed dates had significantly higher cervical dilation upon hospital admission, improved Bishop scores when they got to the hospital, and better rates of spontaneous onset of labor without a medical induction. They also found that those who consumed dates were less likely to need a medical induction. There were no differences between groups on rates of forceps or vacuum-assisted birth or cesarean rates. Two of the randomized trials found a significant reduction in labor pain after intaking date palm syrup during labor compared with control.

38:48And for postpartum, they noted significant increases in breast milk quantity, maternal hemoglobin levels, and maternal iron levels when they compared those who consumed dates plus iron supplements over those who had iron supplements alone. And they also found lower rates of postpartum hemorrhage in the date group. The overall evidence quality of this meta-analysis is low to moderate for most of the outcomes. And many of the results are what we would consider fragile in this meta-analysis, meaning that some of the findings were able to be flipped from negative to positive by excluding a single study.

39:26So it's really difficult to draw strong conclusions from this meta-analysis. Also, most of the studies that they included had inconsistent intervention protocols. Only four out of the 48 studies reported any safety data at all. And participants who chose to eat dates late in pregnancy might have drastically differed from those who don't because they had so many non-randomized trials in this study. So although the results from the study by Sela Jega et al. looks impressive at first glance, or if you're just reading the abstract, remember that the quality of the data that they included was not that great.

40:05Next, I wanted to feature one randomized trial on dates to kind of give you a taste for what the researchers were finding at the smaller group level. This study was published by Roselli et al. in 2017. It was carried out in Malaysia and included low-risk first-time mothers who were at least 36 weeks gestation without any ruptured membranes. They were planning vaginal birth. This study is cited in every meta-analysis on this topic, which is why I wanted to feature it. There were 77 people included in the final analysis. The participants were given a supply of dates and advised to eat seven pieces per day until the onset of active labor, which they considered four centimeters, or until they had a scheduled induction or cesarean or complications.

40:53So seven pieces of dates equals about 80 grams per day or a little less than three ounces. They were asked to record their consumption of the dates on a diary sheet that was provided. And then the control group also had 77 people who were asked to abstain from eating dates. The authors found that the dates group received significantly less augmentation of labor with Pitocin compared to the control group, 37 % in the date group versus 50 % in the control group. And there were no differences between groups with abnormal blood sugar levels, the length of pregnancy, the onset of spontaneous labor, average cervical dilation at hospital admission, the cesarean rate, or the length of the first, second, or third stage of labor.

41:40There were also no differences in any other maternal or newborn outcomes, including APGAR scores or maternal blood loss. Slightly different topic, but I also wanted to share another study published by Tavani et al. This was published in 2018 from Iran, and they looked at how eating date fruit during labor could affect pain levels. So this study was made up of 80 first-time mothers who were in labor and who did not have access to pain medications. They were assigned at hospital admission to either consume date syrup or to have water only for hydration. The date syrup was prepared by blending six dates in 150 milliliters of water.

42:22And the researchers found that pain scores were very high in both groups because epidurals were not available. Other pain medications were not available. But when you compare the two groups, pain scores were significantly lower in the date syrup group at one hour, one and a half hours, 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, so it took about one hour to see a difference. Finally, I wanted to feature a trial published by Cordy et al. in 2017. This was a randomized controlled trial conducted in Hospital in Iran with 182 first-time mothers.

43:01So half of them were assigned to eat 70 to 76 grams of dates starting from the 37th week of pregnancy, and the other half were assigned to the control group to not eat any dates, and there were no significant differences between the groups at baseline. For those participants who ate the dates, they were significantly more likely to begin spontaneous labor on their own. 95 % of those who consumed dates went into labor on their own versus only 41 % in the control group. Those who had spontaneous labor and eight dates also had significantly shorter second and third stages compared to the control group who went into spontaneous labor.

43:42However, for those who were induced, there were no differences between the two groups in the length of time of any of the stages of labor. Also, cervical dilation at the time of clinic admission for labor was significantly higher among those who ate dates versus the control group, with those who ate dates dilated an average of four centimeters when they arrived versus 2.5 centimeters in the control group. The authors called for more research with larger sample sizes to demonstrate the effects of consuming dates on cervical ripening. There are many more studies on date fruits, including several other large meta-analyses that I'm not going to cover today.

44:20Just so you know, a lot of the research on this topic is posted in lower quality journals and we could not trust all of the results. So if your favorite study to cite about the benefits of eating dates is not included in this podcast, that might be a reason why. Now, if you're interested in eating dates towards the end of pregnancy, what are some potential protocols? Are there any recommendations for eating dates? There was a systematic review published by Rana May et al. They found that consuming seven date fruits, which is an average of 80 grams or a little less than three ounces per day for two to four weeks before the estimated due date could lead to a better cervical dilation when you get to the hospital or an improvement of the Bishop score.

45:07They also found a decrease in the need for induction or stimulation of labor and an increase in effective uterine contractions, thus decreasing the length of the pregnancy as well as shortening the different stages of labor. So the review that recommended this amount of dates specifically was published in a medical journal in the country of Oman, and they were looking at about 1 ,600 participants. Other studies that have found beneficial results typically instruct people to eat 70 to 100 grams of date fruits daily. This is the equivalent of three to four large medjool dates that are pitted or six to ten smaller newer dates that are also pitted.

45:51The research studies don't commonly report which type of date they were using and there's no evidence currently to show whether you should eat the dates in one sitting or spread consumption throughout the day. Also, research suggests that date fruit might make a good snack in labor and could potentially lower labor pain. So you could snack on them in small amounts or drink date syrup to gain energy during labor itself. The bottom line on eating dates is that date fruit is a popular and nutritious snack for pregnancy. And there is some research evidence backing up the claims that eating date fruit can ripen the cervix in preparation for labor and possibly shorten the length of labor itself.

46:33However, there are a lot of limitations to this research. Much of it comes from lower or moderate quality studies published in lesser known medical journals, but date fruit has traditionally been consumed in pregnancy and postpartum for thousands of years. it's considered safe, and many people find dates to be delicious as well. The only known side effect is that it may increase blood sugar in someone with diabetes or gestational diabetes. So this concludes the research evidence that we have available on castor oil and eating date fruit for labor induction. Again, keep in mind that the research studies may not apply to higher risk people with additional medical or pregnancy complications, and it's helpful to discuss any plans for natural induction methods with your care provider so they can help you decide if the evidence applies to your unique situation.

47:28I hope you found this information helpful and I'll see you next week. Bye.

47:33Dr. Rebecca Dekker: This podcast episode was brought to you by the book, Babies Are Not Pizzas. They're Born Not Delivered. Babies Are Not Pizzas is a memoir that tells the story of how I navigated a broken healthcare system and uncovered how I could still receive evidence-based care. In this book, you'll learn about the history of childbirth and midwifery, the evidence on a variety of birth topics, and how we can prevent preventable trauma in childbirth. Babies Are Not Pizzas is available on Amazon as a Kindle, paperback, hardcover, and Audible book. Get your copy today and make sure to email me after you read it to let me know your thoughts.

48:13Thank you.