Water Birth: Is It Safe and Does It Help?

By Molly J Lawney, MPH

Being pregnant while pursuing a graduate degree in public health can have its downsides. For one, baby brain and academia in general do not go well together. Also, taking Intro to Environmental Health while pregnant is nothing short of terrifying. All I learned in that class is that there are horrible chemicals and compounds everywhere around you, so if you are planning on growing another human being, you should avoid the following: consuming fish, owning furniture, wearing clothing, and breathing the air. On the positive side, I was able to choose assignment topics that were also relevant to my personal life. For instance, when I took Perinatal Health Services and was asked to perform a literature review, I chose to write mine about water birth.

Like most people, I knew what water birth was, but had no idea whether it was safe or useful compared to birth on land. I assumed that because I hadn’t heard much about its safety or efficacy, there must not be a lot of recent research on the subject and I was initially concerned that there would not be enough studies to complete my assignment. The American College of Obstetricians and Gynecologists’ (ACOG’s) stance on water birth also suggested that there was not much research out there on water birth:

Immersion in water during the first stage of labor may be associated with decreased pain or use of anesthesia and decreased duration of labor. However, there is no evidence that immersion in water during the first stage of labor otherwise improves perinatal outcomes, and it should not prevent or inhibit other elements of care. 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.

The ACOG says it right there: “the safety and efficacy… have not been established.” That must mean either no one has studied it properly, or the results were inconclusive. Bummer; there goes my assignment idea. I thought I would look through the library database anyway, just in case. Surprisingly, I found eight relevant studies from peer-reviewed journals, several of which were very large studies (see reference list below).

So then I thought, okay, if there are that many studies but the ACOG still says there is no evidence for its safety or efficacy…

Is water birth unsafe for babies?

The issue of the safety of water birth is largely centered on the risk of infection in the newborn from contact with microbes in the water. Although many of the studies found that the birth water does become contaminated during a water birth, there was no increased risk of infection for the newborn in any of the studies. Additionally, compared with land birth, there was no increased risk of neonatal intensive care unit (NICU) admissions in water-birthed babies. Furthermore, in a study that included over 2,000 water births, there was not a single case of water aspiration (breathing in the water) or drowning during birth.

All right, I thought, maybe the studies didn’t find increased risk of infection or NICU admissions because those are fairly rare events. Maybe the APGAR score, which stands for appearance (skin coloration), pulse (heart rate), grimace response, activity and muscle tone, and respiration (breathing rate and effort) is a better indicator of the health of water birthed babies.  Each of the factors in the acronym is assigned a score of zero to two and then added to determine the overall APGAR score at one, five, and ten minutes after birth. Indeed, the one minute APGAR scores for babies born in water in these studies were lower than in land birthed babies. However, five minute APGARs were the same for water and land birthed babies across the studies and some of the studies even found a higher seven minute score in water birthed babies compared to land birthed babies.

What could this mean? Some of the researchers hypothesized that water birth is a gentler transition into the world for babies, so they don’t necessarily “know” that they have been born right away. This would result in a delay of the first breath and would thus lower the APGAR score. In other words, water birthed babies were just taking a little longer to get going, but it was not harming their health, as evidenced by their higher APGAR scores at ten minutes.

So water birth appears to be safe for babies….

 

What about the safety for moms?

Some of the studies I examined found that water birth resulted in higher post-birth hemoglobin levels in mothers who birthed in water compared with moms who birthed on land, which suggests that water-birthing mothers lost less blood during childbirth. There was less consensus across studies regarding perineal tearing, but overall, it appears that water birth results in higher rates of intact perineums and lower rates of serious tears that require suturing. Additionally, episiotomy rates are far lower in water birthing mothers than in land birthing mothers, likely because access to the area is less convenient for the provider.

If water birth is safe for both moms and babies, but the ACOG still isn’t on board…

Does water birth have any benefits?

Well, as the ACOG admitted, it does appear that water birth decreases the use of anesthesia during labor, as well as the duration of labor, especially during the second stage (the pushing phase). Water birth may also result in a lower need for labor augmentation with Pitocin—a drug often used to intensify contractions in women who do not seem to be progressing. Because of the lower need for pain and augmentation drugs, and the lower rates of tearing and episiotomy, water birth can be substantially less costly than birth on land.

At this point in my research, I was dumbfounded. The only possible question left was…

Is there something wrong with the studies?

The only possible reason left for the ACOG not to support water birth based on the current scientific evidence is that the studies related to water birth are fundamentally flawed in some way. One criticism of the aforementioned studies is that they are observational. The “gold standard” for scientific studies would be the randomized clinical trial; in all of these studies, the women opted for a water birth or not—they were not assigned to one of the options, randomly or otherwise. This is because it would be neither ethical, nor practical, to assign women to a water birth versus land birth. Thus, the type of women who decide to birth in water may be different from those who opt to birth on land in a way that could affect the outcomes of the studies. Perhaps they have a higher pain tolerance or they are in better overall physical health. Still, because it is unethical to assign women to a birthing condition, there is no way future studies could do so. Thus, obstetrical groups like the ACOG need to make a decision based on the evidence at hand. Furthermore, I needed to make a decision based on the evidence at hand for my assignment.

 

The Take-Home Message

Although the ACOG did not seem to think there was enough evidence to promote water birth, I disagreed. The studies that I found suggested that water birth is a safe and cost-effective labor and delivery technique. Water birth does not pose increased risk to newborns and it does provide effective, natural pain relief and protective health effects for the mother. Given the rapid rise in medical intervention in obstetrics over the last several decades, which has not necessarily been accompanied by improvements in maternal and neonatal outcomes, water birth deserves more attention as a possible solution to the problem of rising childbirth costs.

In case you are wondering what effect this assignment had on my personal decisions, I decided to have a birthing pool available to me. Although I did not ultimately give birth in the water, I did labor in the birthing pool for many hours. Not only did it relieve some of the pain from contractions, but it also relieved the horrible muscle spasms I had all throughout labor, which is one of the lovely side-effects of labor that no one tells you about ahead of time. I honestly do not think I would have succeeded at giving birth naturally without that birthing pool. In fact, my midwives even recorded in my chart that I said I wanted to marry the birthing pool!

Ultimately the decision to labor and/or give birth in water should be up to the laboring mother and her birth attendant. Unfortunately, because of the ACOG’s recommendations against water birth except in the setting of clinical trials, it means that birthing pools are not readily available to most women who opt to give birth in a hospital setting in the United States. If, however, enough women express an interest in water birth or laboring in water, it could change hospital policies and ultimately encourage the ACOG to reevaluate the recommendations.

 

References

1. Maternal and neonatal infections and obstetrical outcome in water birth, published in the European Journal of Obstetrics & Gynaecology and Reproductive Biology;
2. Water birth: is the water an additional reservoir for group B streptococcus? Published in the Archives of Gynecology and Obstetrics;
3. The effects of immersion in water on labor, birth and newborn and comparison with epidural analgesia and conventional vaginal delivery, published in the Journal of the Turkish-German Gynecologic Assocation.;
4. Waterbirths: A Comparative Study, published in Fetal Diagnostic Therapy;
5. Maternal and perinatal outcomes amongst low risk women giving birth in water compared to six birth positions on land: A descriptive cross sectional study in a birth centre over 12 years, published in Midwifery;
6. A retrospective comparison of water birth and conventional vaginal birth among women deemed to be low risk in a secondary level hospital in Australia, published in Women and Birth;
7. Review of 1600 water births: Does water birth increase the risk of neonatal infection? Published in the Journal of Maternal and Fetal Neonatal Medicine;
8. An economic evaluation of water birth: the cost-effectiveness of mother well-being, published in the Journal of Evaluation in Clinical Practice.

Childbirth and Pelvic Organ Prolapse

Hello, friends of midwives! Today we have a guest post from Elizabeth Carrollton of drugwatch.com. She is writing about an issue — pelvic organ prolapse — that is very important for childbearing women.

Pregnancy and childbirth are the leading causes of pelvic organ prolapse (POP). Fortunately, POP is completely avoidable and/or manageable with a focus on pelvic health and pelvic muscle strength. In best case scenarios, women would focus on their pelvic health before they ever become pregnant; however, it is never too late to prevent or mitigate the symptoms of POP.

Pelvic organ prolapse is a condition in which the connective tissues and muscles in the pelvic region become so weak that pelvic organs begin to shift out of place. Pregnancy and childbirth are the most prevalent factors for developing POP because these processes stretch pelvic tissues and muscles far beyond their normal size and shape. While pelvic tissues are designed to return to their normal size and shape, they can remain weakened and slightly stretched. There are other factors which can contribute to POP including:

• Obesity
• Smoking
• Genetic predisposition
• Previous pelvic injury
• Hysterectomy

When any of these risk factors are combined, it presents additional strain on pelvic tissues and can cause increased prolapse symptoms.

Natural Methods for Preventing Pelvic Organ Prolapse

Pelvic organ prolapse can usually be prevented with proper focus on overall health, as well as pelvic tissue strength and tone.

Preventing POP prior to pregnancy

Women who are trying to get pregnant can give themselves a head start on pelvic health by maintaining a healthy weight, quitting unhealthy habits such as smoking, and doing exercises which are known to improve abdominal and pelvic muscle tone. Kegel exercises can help to strengthen the muscles in the upper vagina, urethra, and pelvic floor. It is a good idea to do them daily because the stronger the muscles are prior to pregnancy, the more they will be able to support ensuing changes. Yoga and Pilates are also good exercises as they focus on core strength, which can provide further support to pelvic muscles.

Preventing POP during pregnancy

Most women are familiar with pregnancy-related incontinence. As the uterus grows, the baby gains more weight, and a tremendous pressure is placed on the bladder and urethra. Research has shown that daily Kegel exercises can make a significant difference in preventing incontinence which routinely accompanies the third trimester. It also helps women get into the habit of pelvic floor exercises which should be continued through the postpartum period.

Preventing POP after pregnancy

For women who have not already made a habit of pelvic floor exercises, this is the time to take action. Preventative measures can help postpartum tissues to heal faster and become stronger, which can prevent POP later on. Women should consider the following treatments:

• Postpartum massage
• Kegel exercises
• Pelvic physical therapy

Why is Prevention Important?

While mild cases of POP may not require any treatment, moderate to severe cases are often treated with surgical interventions that may come with considerable health risks. One of the common surgical procedures utilizes a device called transvaginal mesh. This mesh product has been linked to severe health complications and has been the subject of multiple transvaginal mesh recalls and lawsuits. The more women work to prevent the onset of POP, the less likely they will be to require surgical intervention. Please be sure to always discuss all treatment options, as well as their side effects, with your doctor.

 

Elizabeth Carrollton writes to inform the general public about defective medical devices and dangerous drugs for Drugwatch.com.

 

That breastfeeding cover photo. . .

Everyone’s talking about the Time cover for this week, with its photograph of a mother nursing her three-year-old son. I think it’s a brilliant, smart photo. The photographer says that he meant to reference images of Jesus and Mary, but frankly, even before I read that, I immediately thought of the many classic nursing Madonna paintings–something like this or this. People have complained that the mother’s prominent nipple, visible underneath her shirt, sexualize the image, but it’s simply the case that a woman’s nipples become more prominent during pregnancy and nursing, so showing the biological norm is fabulous and attempts to reclaim nipples for their purpose (feeding and comforting children) rather than merely as a sexual prop. The mother’s suggested lack of a bra also references the 1970s feminist movement and thereby positions attachment parenting and full-term breastfeeding as heirs to that movement rather than as opponents of it. Brilliantly done.

–Christina

Parenting (Book) Parodies

Recently I read Let’s Panic About Babies, mostly because it was c0-authored by a fellow alum. It’s cute–not 200+ pages cute, but cute and amusing for about 10 pages, or a very quick skim. Then I read this post in the NYTimes Motherlode blog, about another parodic parenting book. I didn’t know parenting book parodies were a “thing” lately, but I suppose they are. I must be in a very Zen state of motherhood lately myself, though (at least according to a certain friend of mine), because the basic idea of these books doesn’t appeal to me at all–the second time around, especially, I’m seeing all the good and none of the bad in parenthood. Read these parodies at your own risk–they may induce feelings of bitternes, or they may make you wonder where the authors are coming from.

–Christina

 

Quick Links: What I’m reading. . .

Huh. . . could having a new baby be keeping me a tad busy? Perhaps. Kid No. 1 is asleep in my bed as I type–we still co-sleep for most/all of the night, but he weaned himself completely (hasn’t even asked to nurse in two weeks, hasn’t latched in two months), very very gently. Kid No. 2 (said baby) is asleep on my chest on the couch, skin to skin, while I type with one arm over her and one arm under. I get to read more than write, these days–it’s a bit easier on an iPhone. Some quick links related to birth:

• “Workouts May Not Be the Best Time for a Snack” (NYTimes)–discusses eating during marathons, etc. Since labor is often compared to a marathon, but since eating during labor has been shown to be better than not eating, this was interesting and thought-provoking to read. I’m not sure how far to take these parallels, though–I’d say that listening to one’s body is probably the ultimate answer.
• “Do Men Abuse Parental Leave?” (WSJ)–analyzes men’s actions during parental leave (specifically in academia). I happen to be on parental (maternity, obviously) leave from an academic appointment at the moment, and I definitely have been getting some pressure (both from men and from women who seem to have no idea what early motherhood is like) to “be more productive” and “just get things done” related to my research. But you know, this semester isn’t about my research. It’s about my baby. Productive, too, no?
• “17,000,000 Weeping Pregnant Women Can’t Be Wrong” (Slate–where else, with a title like that?)–offers a critical view of a mainstream pregnancy book in the mainstream press. Since, depending on the mama-crowd you run with, What to Expect When You’re Expecting is either reviled or deified, this article is very much worth reading.
• “Cesarean Nation” (Slate again)–reports on the out-of-control c-section rate in China. Very interesting article–it speculates that problems will only start arising once the one-child policy is repealed.

–Christina

Up with the Midwives in MA!

Big year (so far!) for midwives in MA!

The CDC home birth review has good, clear findings on midwife-attended home births, and is co-authored by an MA/Boston scholar and midwife advocate. 

And CNMs in MA no longer must practice under a doctor–wow!

–Christina

Motherhood Museum

I love Phyllis Chesler, feminist, professor, writer, psychologist, scholar, and poet-on-birth extraordinaire (just dip into With Child: A Diary of Motherhood if in doubt on that last point). On her website two months ago–but sadly I’m just seeing it now–she published an amazing review of the brand-new Museum of Motherhood that opened in September in Manhattan. She discusses her own journey to motherhood, her books on the subject, her interview with the museum’s founder, and her fervent hope that this museum manages to get the funding it needs and stay open.

–Christina

Book Review: Viral Mothers

Bernice L. Hausman. Viral Mothers: Breastfeeding in the Age of HIV/AIDS (U Michigan, 2011).

What a great book! It’s academic, for sure, and not for the casual reader, but it’s a great, perceptive look at so many issues surrounding breastfeeding in our culture. Hausman considers the famous pro-breastfeeding ad campaign of a few years ago, which focused on the risks of not breasftfeeding rather than the advantages of breastfeeding, and which garnered such a critical response; she addresses the way that breastfeeding features in media reports about AIDS and West Nile virus; and she offers perceptive, feminist-based criticism of how our society in general marginalizes breastfeeding because it is actually threatening to what she identifies as our underlying cultural values. Really just a smart, thoughtful, and interesting read!

–Christina

Cute preschooler nursing anecdotes

By the time I was 36 weeks pregnant and my son was three years and three months old, Marcus seemed to have forgotten entirely how to latch and suck. He still asked to wa-wa every couple days, but he just couldn’t figure it out. Stubborn little boy, though–when asked, he said yes, he’s still drinking milk there, even though I knew he wasn’t.

My husband had recently started teasing/nagging him about nursing, in part because Marcus said, looking at a picture from Halloween, “That’s my friend G——–. He likes milk.”

Robert asked, “Really? Don’t you like milk?”

Marcus said, “No, I like water, but I get milk from Mommy’s wa-was, and I like that milk.”

Then a couple weeks later my husband was trying to convince Marcus to eat a pudding-like dessert, and he said, “Here, this tastes like milk–like Mommy’s milk,” in an attempt to sell it to him.

Marcus looked at him skeptically, then ran over to me, climbed into my lap, asked to nurse, “latched” on (not really, though), and then popped off and said, “Nope! Mommy’s milk is better!”

My husband rolled his eyes and threw in the towel. He claims I’ve “spoiled” our son for “regular” milk.

So, this is all to say that while Marcus might no longer really be nursing–as in actually getting milk at the breast–he is still very attached to the idea of it.

–Christina

More thoughts on being “post-dates”

I’m 41 weeks pregnant. When I’m out and about and strangers ask me, “When are you due?” and I say, “Last week,” they look terribly shocked. Am I not supposed to leave my house until I have the baby? Clearly, activity is good for my body, and just as clearly, things need to get done–three-year-olds need to get dropped off at preschool, groceries need to be bought, etc. It’s not a bad combination–I stay active and busy and things keep functioning. When this baby is ready, she’ll come out, trust me.

A lot of people don’t think that way, though. I have a large number of friends who were induced at 42, 41, or even 40 weeks exactly for no specific medical concern other than the simple fact of being “post-dates,” and who said/say things like, “Oh, my body just doesn’t know how to go into labor.” Well, that’s possible, but very, very unlikely. The vast, vast, majority of the time, your body will go into labor, and your baby will come out on his/her own.

I have a lovely, caring midwife who came to the house at 40.5 weeks and then again about five days later. She checks up on me by text/email, and tells me to call or text if I have any questions, any different symptoms/sensations, any concerns, any labor signs, etc., but she is not pressuring me at all. The rest of the world? Uh, yeah, not so much.

–Christina