Social media has exploded recently in response to the local announcement of a pause in water birth services. This article is our attempt to clarify the Christie Clinic Department of Ob/Gyn’s stance on water birth. Our goals include: to discuss the differences between laboring and birthing in the water, to review the scientific evidence as it stands today, and to discuss possible means for providing this service in the future.
What Does the American College of OB/GYNs say about Water birth?
First let’s look at what the American College of Obstetricians and Gynecologists (ACOG) says about water birth as published in their Committee Opinion #594 “Immersion in Water During Labor and Delivery”. ACOG is an organization of physicians whose goal is to improve healthcare for women. Leading experts reviewed the known scientific data and published this opinion. They state that laboring in the water is a perfectly reasonable option. There is evidence that supports this as a safe and helpful method for managing pain in labor. However, they then state:
“In contrast, the safety and efficacy of immersion in water during the second stage of labor have not been established, and immersion in water during the second stage of labor has not been associated with maternal or fetal benefit. Given these facts and case reports of rare but serious adverse effects in the newborn, the practice of immersion in the second stage of labor (underwater delivery) should be considered an experimental procedure that only should be performed within the context of an appropriately designed clinical trial with informed consent.”
So what does this mean in layman’s language? This means that when you look at all the research studies available, we haven’t quite been able to prove any benefit and there are small reports of babies suffering bad outcomes when they are born underwater. Because of this, we should not continue to offer this service unless we are part of a well-planned scientific study.
What Is the Difference Between Water Labor and Water Birth?
There is an important difference between laboring in the water and birthing in the water. Laboring in the water means getting into the tub during the phase of labor when the contraction pains are trying to fully dilate the cervix to 10cm. This phase of labor can last anywhere between a few hours and a few days. Once the cervix is completely dilated, a woman enters the second stage of labor – the pushing phase. This is when a woman tries to bear down and push the baby through the birth canal. The pushing phase lasts between 5 minutes and 4 hours. This is the phase of labor where the evidence currently does not support being underwater. Our department will continue to offer water labor throughout this period of time while we await further evidence on water birth. However, we will not be offering the option of birthing in water.
What Does Science Tell Us About the Risks and Benefits of Water Birth?
(For the purposes of this article, each paragraph describing the research results will be summarized into 1 of 3 categories:
1. This study supports water birth.
2. This study does not support water birth.
3. This study raises concern about water birth.
- Cesarean section risk: Several studies assessed the chances of vaginal birth versus cesarean birth in water birth. However, none of them actually separated out the benefits of water labor from water birth. In a study by Chaichan from 2009 patients were placed into groups – either planned water birth or planned land birth. However, they did not control whether patients labored in the water or just birthed in the water. Of the 53 women who planned water birth, 100% were able to achieve vaginal birth. In contrast, of the 53 women who planned land birth, 12 had to have a cesarean section. *This study supports water birth.
A review of 1519 water births by Henderson from 2014 showed a cesarean section rate of 4.4% in water births. Again this article did not separate out water labor versus water birth. Another complicating factor is that women who experience complications of labor are asked to get out of the tub for necessary medical interventions. These are then the women who have a much higher risk of cesarean section because of their labor complications. By moving from the tub group to the land group, they increase the cesarean section rate in the land group and decrease the rate in the water group. *This study supports water birth.
In a similar, but larger, study with 16577 midwife births, Lukasse reported a 20% reduction in cesarean section rate compared to the national average. However, we have to remember that midwives, by policy, take care of the patients that are at lowest risk for cesarean section. It is impossible to know if the reduction they saw was because they were taking care of lower risk patients or because a portion of their patients chose water birth. *This study supports water birth.
The 2014 Cochrane Review of 12 studies and was unable to detect a difference in cesarean sections rates between water and land birth. *This study does not support water birth.
- Risk of vaginal tearing: Vaginal tears are a consequence of vaginal birth. They can be associated with increased pain and problems with urination and bowel movements. Several studies have found an increased risk of vaginal tears in the tub. These include a study of 301 water births by Otigbah in 2000, a study of 3617 water births by Geissbuehler in 2004, a study of 89 water births by Zanetti-Dualenbach in 2007, a study of 53 patients by Chaichian in 2009, a study of 160 water births by Cortes in 2010, and a study of 207 water births by Mollamahmutoglu in 2013. *These studies demonstrate concerns for water birth.
Three research studies demonstrated no difference in the risk of vaginal tearing. These include a study of 1327 water births by Burns in 2001, a study of 1600 water births by Thoeni in 2005, and a study of 219 water births by Menakaya in 2013. The 2014 Cochrane Review did not demonstrate a difference in the risk of tearing. *These studies do not support water birth.
As a related side note, there is a growing body of evidence that tells us that episiotomies (using scissors to make a surgical cut in the opening of the vagina) increase the risk of more severe tears. Because it is our department policy to only perform this procedure if it is absolutely necessary for the baby’s safety, our patients rarely get them. Our rate is typically less than 1%. Therefore data regarding risk of severe tears with episiotomies is not applicable to our decision and will not be reviewed here.
- Pain assessment: Many people argue that water birth decreases women’s perception of pain and need for pain medication. They quote several studies such as the study of 50 water births by Torkamani from 2010 and a study of 207 water births by Mollamahmutoglu from 2012. This seems to be true in water labor but hasn’t been proven specifically in water birth. One thing to remember: most hospital policies require that patients get out of the tub if they want to use medication. Therefore no one in the tub gets pain medication, and the only people who get medication are those on land. This bias makes the research results of lesser value. *These studies support water birth.
The argument was completely debunked by a very well designed study by Eberhard involving 3327 water births in 2005, women’s pain reports were monitored through each stage of labor. Then they were asked to look back on their pain after delivery and re-rate their pain. During the first phase of labor, women laboring in the tubs reported lower pain scores. However during the pushing phase of water birth, women actually reported higher pain scores than those women laboring on land. Then surprisingly, after the birth when they re-rated their pain, the water birth women reported much lower scores of their pushing phase then they did during the actual experience whereas women who birthed on land reported very consistent scores when they looked back on their pain. Researchers have suggested that the experience of the pain itself is actually no different between birthing inside or outside the tub. But, a woman’s success with water birth can alter their memory of the pain in a positive manner. With similar findings, the 2014 Cochrane review could not detect a difference in pain assessment between water and land births. *These studies do not support water birth.
- Length of labor: Some studies have shown a decrease and some have shown an increase in the length of both the first stage of labor (water labor compared with land labor) and the second stage of labor (water birth). Whereas the study by Zanetti-Daellenbach of 89 water births in 2007 showed a shorter first and second stage of labor, the study of 219 water births in 2013 by Menakaya showed no difference in the lengths of the first and second stage of labor. One study even found an increase in the length of labor (Mollamahmutoglu 2012). And finally, the 2014 Cochrane Review could not detect any difference in length of labor. *These studies do not support water birth.
- Loss of blood: Again, some of the studies say there is a reduced risk of high blood loss with water birth but other studies show no benefit at all. The studies that showed decreased blood loss include Geissbuehler, Zanetti-Daellenbach, and Dahlen. These studies combined looked at 4525 patients. The studies that showed no difference in blood loss include Otigbah, Thoeni, and Menakaya. These studies combined looked at 2120 patients. The 2014 Cochrane Review demonstrated no difference in blood loss when they evaluated three additional studies. *These studies do not support water birth.
- Permanent injury causing pelvic floor dysfunction: One study has attempted to evaluate the risk of water birth versus land birth on pelvic floor muscle functioning at 6 months postpartum. It was a small study of only 25 water births compared to 27 land births performed by Mistrangelo in 2007. There was no difference detected but this was a very small study. *This study does not support water birth.
- Risk of baby going to the neonatal intensive care unit (NICU): One study that combined information from 3 other research projects, noted an increased rate of admission to the NICU. This study was performed by Cluett in 2009. *This study raises concern about water birth.
In contrast, the 2014 Cochrane Review found no difference in reported admissions to NICU. *This study does not support water birth.
- Risk of low APGAR scores: APGAR scores are a way to try to assess the health of a baby at 1 and 5 minutes after birth. It involves looking at the baby’s strength of cry, muscle tone, heart rate, and pink coloring. A study by Mollamahmutglu of 207 water births in 2012 and a study by Manakaya of 219 water births in 2013 demonstrated lower APGAR scores at one minute in those born underwater. In contrast, studies by Otigbah, Zanetti-Daellenback, Chaichian, and Pagano found no differences in APGAR scores. These studies when combined looked at 553 patients. Similarly the 2014 Cochrane review did not find any difference in AGARS scores when they looked at 5 trials. *These studies do not support water birth.
- Other risks to baby: there are a number of small studies and case reports documenting a variety of injuries to babies born underwater. These injuries include infections, electrolyte (salts in blood stream) abnormalities, umbilical cord ruptures, and even fetal deaths such as drownings. *Although these numbers are very, very small, these reports raise concern about water birth.
When the 2014 Cochrane Review looked at overall mortality rates between water birth and land birth, no difference could be detected. However, we need again to look at some complicating factors. The most complicated, high risk patients are not allowed into the tub. Patients in the tub are the lowest risk, healthiest patients. Therefore, we would expect the mortality rate would be higher in the land birth group because of their medical complications. When we don’t see a difference between death rates of our high risk patients on land, and death rates in our low risk patients in the tub, this actually represents a significant problem. *This study raises concern about water birth.
How Do We as Christie Clinic Providers Interpret All This Data?
We agree with the American College of Obstetricians and the American Academy of Pediatrics that there is not sufficient evidence that water birth improves outcomes for mother or baby and there is a small but real concern for possible harm. Until further scientific studies can prove benefit of the practice of birthing underwater, we do not support water birth but will continue to support water labor.
Is There a Possibility that Water Birth Will Be Allowed in the Future?
Yes, the Department of Christie Clinic, in coordination with our midwifery providers, is currently evaluating the option of partnering with other institutions to participate in a study on water birth. If such a partnership can be obtained, our midwives will once again offer the service of water birth as an experimental procedure. At that time, women desiring water birth will be asked to sign a consent form recognizing that they are part of a research study and that they willingly accept the risks of water birth. As further research is published, we will continue to evaluate risks and benefits. Should the benefits of water birth be proven, we will be happy to once again open up the opportunity for water birth in this community.