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.

Dear friends and supporters of midwifery

As many of you know, the Midwifery Bill, now known as An Act Relative to
Certified Professional Midwives (House Bill 2368 and Senate Bill 1133; same
text) is being heard on Beacon Hill by the MA Joint Committee for Public
Health next Tuesday, 7/19/2011. This bill, when passed, will recognize and
regulate the practice of Certified Professional Midwives (CPMs). A link to
the text for this bill follows later in this post. As always, a few
prominent medical interest groups (most notably the American Congress of
Obstetricians and Gynecologists (ACOG) and the Massachusetts Medical Society
(MMS) are actively trying to kill this midwifery bill, so we need many
citizens to voice their support NOW for midwifery options.

Please call your MA State Rep. and MA Senator TODAY, next week, or at any
point before next Tuesday, 7/19, letting him/her know that this bill is
important to you. and to urge its passage. With legislators, the squeaky
wheel gets the oil so it’s important that you and any friends and colleagues
you know call in support of this bill. If you only have a minute and don’t
have time to look up your Senator’s or Representative’s direct line, you can
call the main number at the State House and ask to be forwarded to him/her.
The main number at the State House is 617.722.2000.

You can find the name and contact information for your MA Senator and Rep.
as the following link:

http://www.wheredoivotema.com/bal/myelectioninfo.php

Bill text (now known as House Bill 2368 and Senate Bill 1133) is available
by clicking here:
http://www.malegislature.gov/Bills/187/Senate/S01133

It’s especially important to call if your Representative or Senator is on
the Joint Committee for Public Health. Committee members and their districts
are listed below:

Sen. Chandler (Senate Vice-Chair of Public Health Comm.):

1st Worcester: Berlin, Boylston, Clinton (Pcts. 3-4), Holden, Northborough,
Paxton, Princeton, West Boylston, Worcester (Wds. 1-4, 9-10)

Rep. Lewis (House Vice-Chair of Public Health Comm.)
31st Middlesex: Stoneham (Pcts. 1-2, 4-7), Winchester

Sen. Timilty

Bristol & Norfolk: Attleboro (Wd. 3, Pct B; Wds 4-6), Dover, Foxboro,
Mansfield, Medfield, Norton, Rehoboth, Seekonk, Sharon (Pcts, 1, 4, 5),
Walpole

Sen. Clark

Middlesex & Essex: Lynnfield, Malden, Melrose (Wds. 1-5), Reading, Stoneham,
Wakefield

Rep. Fallon

33rd Middlesex: Malden (Wd. 2; Wd. 3, Pct 1; Wds. 4-6; Wd 8)

Rep. Balser (bill cosponsor)

12th Middlesex: Newton (Wd. 5, Pcts. 1-3; Wd. 6; Wd 7, Pcts 1, 3-4; Wd 8)

Rep. Sciortino (bill cosponsor)

34th Middlesex: Medford (Wds 4-5; Wd. 7, Pct. 1; Wd. 8, Pct. 2), Somerville
(Wd. 4, Pcts 1-2; Wd. 7)

Rep. Garlick (also on Health Care Financing Committee)

13th Norfolk: Dover, Medfield (Pcts. 1-2), Needham

Rep. Mahoney

13th Worcester: Paxton, Worcester (Wd. 1, Pcts 1-4; Wd. 9; Wd 10, Pct 3)

Rep. Adams

17th Essex: Andover (Pcts. 2-6,9), Lawrence(Wd. D, Pcts. 1-2; Wd E, Pcts. 1,
4), Tewksbury (Pcts. 3, 3A)

Rep. George Ross

2nd Bristol: Attleboro (Wds. 1-2; Wd. 3, Pct. A; Wds. 4-6)

It takes only a minute or two to call, and this will make a big difference.

Here’s a sample script:

Hello! My name is XXX. I’m a constituent of XXXX’s. I’m calling today to
request that Sen./Rep. XXX support An Act Relative to Certified Professional
Midwives (House Bill 2368 and Senate Bill 1133). This bill is being heard
before the Joint Committee for Public Health on July 19th. Thank you for
your support of this important legislation.

(You may be asked for your name again, as well as for your address and/or
phone number).

It’s that simple!

Please call today and help make good birth choices available to all MA women
and their families.

Thanks so much for your support!

Ann Sweeney

Mass. Friends of Midwives

http://www.facebook.com/#!/home.php?sk=group_41256021750

A happy accident?

I was just reading this post on Slate’s XX Factor Blog (what ‘Women Really Think’ — or so they claim. In it KJ Dell’Antonia writes her response to Colleen Oakley’s Blog post wondering why she doesn’t get much support when she tells people she’s aiming for an intervention-free birth.

Dell’Antonia–an apparent birthing expert after four babies: one section and one natural birth courtesy of a midwife who “wouldn’t ante up the good stuff”–is amused by the notion of women thinking they can choose their birth experiences much like they order dinner from a restaurant menu.

I’ll grant her that birth can be unpredictable. Prepare as you do, you really don’t know precisely what your child’s entry into the world will be like until it happens. That said, I sure don’t feel like my son’s drug-free birth was based on luck alone. The choices you make during your pregnancy–from selecting your care provider to researching laboring techniques and understanding the huge variety in labor progressions–it all matters when your child’s birth day arrives.

Dell’Antonia professes to be enjoying her hard-earned wisdom. She’s apparently resigned herself to the claim that a healthy baby is all that matters She’s birthed, therefore she knows: prepare for disappointment.

My message to Oakley and women like her is that women who have given birth within our medical system have a lot to be cynical about. But it’s not them failing you by appearing skeptical, it’s the system failing all of us. My message to Dell’Antonia is that all moms value healthy babies above all else. Mom’s who choose to educate themselves know something you don’t: Being your own advocate makes a difference. You are not powerless. Until our healthcare system changes, educating yourself and advocating for yourself is the best birth choice we have.

Talking to friends about birth

I presently have three close friends due with their first child and one cousin due with her second. All have expressed an interest in natural birth and have a various times come to me with questions about my experience, seeking advice on everything from care providers to laboring techniques.

My first advice is always: get a midwife not an OB. After that I find I get tongue tied. I of course have an opinion on everything from how to labor, to the best baby carrier to buy for newborns. But I fear sometimes that I’m so passionate about my birthing opinions that I might come across as almost militantly anti-intervention.

I also think it’s nice to let a new mom explore birth options on their own and come to conclusions that feel right to them. So what I’ve tried to do lately is steer them towards resources I’ve found helpful.

What helped me the very most in terms of preparing to have a baby was reading birth stories. The internet is filled with some fantastic ones and I definitely have my favorites.

Here are my top five birth stories, in no particular order (FYI, most if not all of these links contain birth pictures that may not be safe for work, click with discretion!):

Xan’s UBAC Birth, by Babyslime This story is both heart-wrenching and inspiring. Unassisted birth is definitely not for everyone but it was the right choice for this mom. For me the fact that she’s 5′ 1″ and birthed a 9+ lb baby after a section gave me lots of motivation to trust my body.

If you’ve not read her blog before, definitely worth checking out. She’s a fantastic writer and offers some interesting info on everything from cloth diapering to no poo-ing (that’s no shampoo btw!)

The Birth of Grey Forest Walt: Outdoor, midwife attended VBAC This is the first birth story I remember reading. I re-read it the other day and it reads far more ‘earthy crunchy’ than I remember. Some might find that a turnoff but it’s lovely in all of its detail. It’s also a great illustration of the transformative power of birth for moms.

One Journey to Homebirth after 3 Sections: Slideshow/Video Love, love, love this… makes me cry every time. A beautiful story of a mom taking change, learning to trust herself and enjoy her child’s birth.

Home, midwife assisted water birth from Birth Story Diaries I just discovered a lot of the links to the birth stories on this site are now down but this one is still up and it’s fantastic. Lots of pictures!

Olive’s home/waterbirth video/slideshow This is just a lovely, simple birth experience from a mom who birthed at home with a midwife and her husband.

Does anyone have any others they love to share?

Ruminating on Gisele’s son’s birth

In a fit of utter boredom I spent some time yesterday trolling a celebrity gossip site and came across a post about Gisele Bundchen’s birth where she blissfully declared it “not painful.” The comments that followed were fascinating. They started out remarkably positive, along the lines of “wow, that gives me inspiration, I hope I can have a birth like that.” 700+ comments later the conversation devolved into the usual mud slinging. But a few things really stood out to me about the whole dialogue created by this unusual celebrity birth story.

1. Positive role models can produce positive results: It was lovely to see how just the mere acknowledgment that childbirth can be a pleasurable experience led some woman to shift their own thinking. I know this reflects my own experience with a mom and siblings who always spoke of the virtues of natural birth and clued me in to the reality of intervention heavy births. It allowed me to see births in film and on TV for what they really were: fiction intended to create drama.

2. How pervasive the negative image of birth is: Despite the comments starting out positive, it didn’t take long before Gisele was accused of lying about her birth experience. So many posters could not accept that it was possible for birth to be anything other than painful and horrible. The most common reason I saw: “My (mom, sister, friend) said childbirth was the worst pain ever. They were cut, the baby’s head was huge, they were in labor for three weeks, etc..” See point one.

3. That many view being sliced open via surgical birth as preferable to the possibility of tearing from vaginal birth: This never stops surprising me. I hear it all the time. It’s as though they’ve blocked out the reality that in order to surgically deliver a child an OB needs to cut through your entire abdominal cavity and then sew you back up. How is this better or less painful than even a larger tear? As if that’s even a foregone conclusion… (shakes head).

In related news:
A new California state report concludes that the number of woman dying from childbirth has tripled in the last decade. And guess what? The usual scapegoats (obesity, maternal age and fertility treatments) were ruled out as likely causes. What could not be ruled out? (wait for it) C-sections and inductions. Shocking, right?

-Christine

Not too posh…

What do you know, apparently Gisele Bundchen had a homebirth!
Source
-Christine

The ‘no need to be a super hero’ comments..

A close friend is 14 weeks pregnant with her first child and is very excited and inspired by her pursuit of a natural, midwife attended birth. I’ve shared with her all of my favorite books and she’s presently really enjoying reading about hypnobirthing. She also recently watched “A Business of Being Born” with her husband and now feels fantastic about her choice of care providers and honestly seems to be looking forward to the birthing experience, not fearing it.

Sounds lovely, no?

Then she goes home to visit her family and gets the–sadly almost inevitable–‘take the drugs! Don’t try to be a super hero’ comments from a relative. The comments made her furious, as I remember them making me. I’m not even sure what is the most anger triggering, the vague implication from sometimes total strangers that you can’t hack child birth? The dismissive nature of one’s birth choices that were made, in many cases, after ample research? I guess the bottom line is it just seems completely inappropriate to vocalize such a negative experience onto someone who’s not even yet had the opportunity to go through it for themselves. But beyond just ‘raining on her parade,’ the comments towards my friend felt like the same kind of negative propaganda birth always gets: “It sucks, it’s painful, make it as easy on yourself as possible and do what your doctor tells you to do. But above all, TAKE THE DRUGS!”

What do you say to this? I’m pretty sure initially she did what I did, which was basically to nod and ignore. Then she moved on to, “how about we discuss this after I give birth?” But the subject left us wondering: what is the deal with this variety of comments that you get EVERYWHERE (even from our doctors as was depicted in Knocked Up)? At the end of the day, it’s only you and your baby experiencing that particular birth so why it matters to anyone else how you choose to prepare is beyond me. But is there any way to turn the conversation towards the positive so that it doesn’t feel like a weird birth-based competition?

We both assumed the root of these comments was some kind of failure insecurity. The mom is question had apparently aimed for a natural birth herself and somehow fell short and now resents the idea. And I’ve run into this many times myself – this resentment of the quest for natural birth. In some cases it comes from a mom who is using natural to mean vaginal birth, but regardless these moms feel very justified in telling you, aiming for a natural birth is not worth the effort.

Obviously there are plenty of women who have had natural births that feel differently. You can certainly just attempt to surround yourself with their stories instead. But I sometimes wonder if the whole ‘don’t be a super hero’ thing isn’t scaring a lot of natural birthers into the closet. I mean, who wants to cheapen a wonderful personal experience by feeling put into a position of having to defend it? Or having it made to be something that was somehow selfish, and about what the mom wants alone?

On the flip side, much like I hate being told ‘take the drugs’ I have no interest in forcing my birth choices on other women like a natural birth vigilante either. It just would be nice to get a constructive conversation out of assumptions.

Am I being too idealistic? Probably..

-Christine

Going unassisted…

I’ve been pretty fascinated with the idea of birthing unassisted, but not to the point of considering it for myself. I love having the reassurance I felt from having my midwife there as well as my husband and mother (who acted as my doula).

But when I was researching birth stories in preparation for my son’s birth, I confess i found reading unassisted birth stories pretty inspiring. There are some beautiful ones online that very much present the birthing moms as extraordinarily knowledgeable and capable of making good judgement calls—even if it means transferring to a hospital. (An example of one I loved reading.)

Then there are those unplanned, unassisted births…the kind you see on “I didn’t know I was pregnant,” that new (bizarre) series on TLC. Not what I would call empowering by any stretch. Although it does sometimes leave me thinking, “wow, look at all of these babies born perfectly healthy despite a lack of outside care.” Of course they always present the situation like a bullet was dodged. And certainly, good prenatal care and a midwife to assist with the birth are (I think) pretty important safety measures. But it’s also tough not to notice how few of these births require any intervention.

Speaking of interventions: This craziness makes me grateful I didn’t birth in Utah.

-Chrisine

Reflecting on my son’s birth, a year later.

It was around this time last year that I was putting the finishing touches on my Juno costume and getting myself ready to give birth to my first child.

As things worked out, my son was delivered on November 6 by my midwife Valaree at Newton Wellesley Hospital. It really couldn’t have gone much better. My water broke spontaneously at 6 a.m. and I labored comfortably at home until around 1 p.m. Driving to the hospital in active labor and laying strapped to monitors in antenatal still isn’t the most relaxing memory of my son’s birth. But I consider myself pretty fortunate as far as hospital births go. I was fully dilated—probably on arrival, although I was never checked—and my son was born healthy at 3:26 p.m. after about an hour of pushing.

When I first learned I was pregnant what I had really wanted was a home birth. But after researching the options and related expenses i backed off of the idea. If my insurance wouldn’t help with the costs, I wasn’t comfortable paying out of pocket when I could give birth at a birth center or hospital for free. Many moms are more than happy to incur this expense to have the birth they want, but I wasn’t one of them. I had thought hospitals or birth centers would give me enough birthing options where I could have a birth experience close to what I was hoping for at home.

But further research proved that’s less, and less true. While Newton Wellesley at least has tubs for laboring you’re not permitted to birth in them. Even having access to the birthing stool was a fight. Inexplicably the padding had been removed, a surprise discovered by my midwife when she requested it for me. I felt well supported by my loved ones and care providers, but not by the institution I was in.

So now as I start thinking about my next child I’ve been wondering whether we would opt for a hospital birth again or further research a home birth. I keep hoping I’ll learn that they’re now covered by my insurance or that a new birthing center has opened. So far it’s hard to gage whether the tide is changing in support of home birth or against. It seems even Moms in the UK continue to fight for the option. I won’t say I have regrets about my son’s birth, I don’t, but if anything it validated my instincts that homebirth is right for me. If for no other reason than to spare myself the car ride to the hospital.

I have time to decide still so in the meantime I’m throwing my support behind those fighting for more birthing options, including signing this petition. I’m also doing what I can to share what I know about how birth can and should be with friends. The choir needs and many voices as it can get.

-Christine

Improving the outcome for birthing moms

NPR has run a few stories via the BBC news hour about the incredible death rate of African moms during childbirth. Faced with a lack of care, these moms-to-be—particularly in Ethiopia, but also throughout the continent—frequently give birth alone and receive no prenatal or post partum care. One woman dies every minute worldwide, almost all of the deaths are preventable.

It’s been interesting listening to some of the issues being faced in Africa, in comparison to our own system. There, according to the report, malnutrition leads to weak, small moms struggling to birth large babies, apparently laboring for days sometimes and frequently dealing with untreated tearing. Most of the deaths there are the result of haemorrhage (source: Unicef). Here, and in countries with similar healthcare systems, the deaths are far lower and stem from c-sections or reaction to anaesthesia.

At first I found it kind of ironic listening to how much Ethiopian women would benefit from access to c-sections while our death rate here is often blamed on the over use of the surgery. After reading this article, I’m struck by some consistent themes:

Access to adequate care: More midwife-attended births would prevent a lot of unnecessary intervention here and provide much needed aid there.

Nutrition/poor health of the mom: There it’s malnutrition bordering on starvation. Here it’s obesity. In either case the outcome isn’t great for mom or baby.

The real puzzle Even in this country, African women are more likely to die during childbirth than Caucasian women, regardless of wealth or education.

It seems far too easy to fix these issues and yet nothing seems to be changing. Maybe the change needs to start from the top. One thing clear from the NPR report anyway, there have been multiple summits and lots of conversation but sadly, very little action.

-Christine