New Position Statement Compiles Waterbirth Research for Families, Providers

Many families consider waterbirth, but the 2014 American Congress of Obstetricians and Gynecologists/American Academy of Pediatrics (ACOG/AAP) guidelines recommend against this practice. Fortunately, new information and tools that can inform birthing people’s decision-making process were released in the past week. First, the largest research study in the US on waterbirth was published in the Journal of Midwifery and Women’s Health. Last week, a new position paper compiling the findings of this and other waterbirth research, Midwives Alliance and Citizens for Midwifery Position Statement on Water Immersion During Labor and Birth, was released by Citizens for Midwifery and Midwives Alliance, with the goal of informing families, health care providers, and policy makers. Jeanette McCulloch of BirthSwell interviewed the article researchers Marit L. Bovbjerg PhD, Melissa Cheyney PhD, CPM, LDM and Courtney Everson MA, PhD and position paper authors Nasima Pfaffl MA, Jill Breen CPM, CLC and Justine Clegg MS, LM, CPM, to help inform childbirth educators and others on how to interpret the findings and the position paper for their clients. 

Jeanette McCulloch: What were the key findings of the research?

Marit Bovbjerg PhD: We found that being born underwater did not confer any excess risk to the baby. Babies born underwater were no more likely than those not born in water to have a low five-minute Apgar score, or require hospitalization or neonatal intensive care (NICU) admission. We also found no evidence that waterbirth is associated with neonatal death; on the contrary, in our sample of 6,534 babies born in water, there were no cases of death that could be attributed to being born in water. This indicates that, for low-risk mothers whose labors proceed normally, water immersion is generally a safe pain management option.

For the pregnant parent, we found that waterbirth was not associated with infection or hospitalization. Surprisingly, though, we found that mothers in the waterbirth group were slightly (11%) more likely to experience perineal tearing.  This finding is contrary to numerous previously-published studies, most of which reported a lower rate of tearing in mothers choosing waterbirth. The question of trauma (tearing), then, is still unresolved, and any future studies on waterbirth should make this outcome a focus.

However, even if the small, but increased risk of tearing that we reported is replicated in other studies, many individuals may still choose to labor and birth in water for the labor pain relief described in numerous other studies. For those who want to avoid epidurals and other drugs, spending a portion of active labor in a pool or tub may facilitate an unmedicated physiologic birth with all the benefits we know that confers for both mother and baby (ACNM, MANA, and NACPM, 2012; Buckley, 2014)¹  Each childbearing family should weigh the potential benefits (reduction of labor pain) and the potential risks (possible increased risk of tearing), and decide based on their own values and preferences. The main upside of our research is that clients can explore these issues without worrying about whether or not waterbirth will negatively affect their babies. It won’t.

JMc: This research was based on home and birth center births from the MANA Stats dataset.   Are the outcomes applicable to the hospital setting?

Melissa Cheyney PhD, CPM, LDM: As Marit just highlighted, our findings suggest that waterbirth is a reasonably safe option for use in low-risk, low-intervention births, especially when the risks associated with other forms of pharmacologic pain management, like epidural and spinal anesthesia, are considered. Because hospitals that do allow waterbirths generally only provide this option to low-risk women, we believe these results could be applied in other settings. We know that there are several hospitals here in Oregon, for example, that have active waterbirth programs and are currently tracking their outcomes. Their preliminary impressions are that babies born in water are at no greater risk, and that water immersion as a pain management strategy helps to decrease rates of epidural use.  

It is possible that training and experience level of the provider makes a difference in outcomes. In our sample (based on MANA Stats) 35 percent of births occurred under water. This means that many of the midwives who contribute data to MANA Stats are very experienced at monitoring and attending births in the water. While some hospitals do offer waterbirth programs, it is currently unclear how frequently births happen under water in these facilities. One difference between the provider populations represented in our study, who are almost all CPMs and CNM/CMs, and those who might attend waterbirths in the hospital could be variability in exposure to, and experience with, labor and delivery management in the water. 

That said, when we look at the balance of evidence from international studies, our study, and preliminary data from hospitals in the US, we believe that findings are converging around the sentiment that while waterbirth may not confer any particular safety benefit for babies, it almost certainly confers no added risk to the neonate in low-risk pregnancies. Families should be allowed to choose waterbirth from among a range of pain management options. We would like to see waterbirth offered more widely across the US in all birth settings. 

JMc: The MANA and CfM Position Statement on Water Immersion During Labor and Birth brings together peer reviewed evidence and the clinical experience of midwives who provide waterbirth. How can childbirth educators use this document to support clients considering waterbirth?         

Justine Clegg MS, LM, CPM: Because laboring and birthing in water is popular with clients, especially those choosing to birth at home and in birth centers, childbirth educators, doulas, midwives and midwifery educators need to be well versed in the issue to answer consumer questions, and provide the most current information to help families decide what is best for them. 

The Position Paper is a great educational tool that gives concise access to the research and the wisdom of experience that documents the safety, benefits, and recommendations for success. 

Jill Breen CPM, CLC: First, I think the research we cite will help to dispel some of the publicized concerns (drowning, cord avulsion, respiratory distress) about safety to the baby since no deaths in over 6500 waterbirths were attributable to being in the water.  

The position paper also makes it clear that the experience level of the practitioner may be an important factor in the safety of waterbirth. Childbirth educators can help clients identify experienced practitioners in their area or help families develop questions that they can ask to choose a site and practitioner for their planned waterbirth. 

In the position paper, Jennie Joseph LM, CPM identifies another potential outcome important to raise with some clients. Because waterbirth may reduce stress and promote physiologic birth, thereby reducing the likelihood of unnecessary procedures and disruptions of the newborn transition and parent/infant attachment, access to waterbirth may be an important tool to address disparities in outcomes for families of color.

JMc: What role should consumer choice and shared decision making play in waterbirth? 

Nasima Pfaffl MA: Just as in all birth choices, shared decision making is key. 

One of the primary tenants of the Midwives Model of Care is individualized counseling and education. For all birthing decisions, a midwife and the birthing family can explore the available evidence, the client’s needs, values and preferences, and the midwives experience, comfort level and clinical recommendations during shared decision making.

For example, let’s look at the conflicting findings across all waterbirth literature for vaginal tearing. The small increased risk of perineal trauma could be a deciding factor for some clients, but a small concern for those who place greater emphasis on the research findings that show overall high rates of satisfaction with waterbirth. The warmth, mobility, comfort, privacy and pain relieving attributes of laboring and birthing in water may be a deciding factor for others. 

For families who  want a waterbirth, I recommend when possible, choosing a practitioner with a high degree of comfort, knowledge, and experience with waterbirth. A knowledgeable practitioner will be familiar and comfortable with the differences between water and air birth (such as evaluating blood loss in water) and should be able to discuss these with their client. 

JMc: How do findings from the recently released paper on waterbirth compare to the current ACOG/AAP guidelines?

Courtney Everson MA, PhD: The ACOG/AAP guidelines (Committee Opinion No. 594), released in April 2014, were a primary impetus for this study. In those guidelines, ACOG and AAP acknowledge the safety and potential benefits (i.e., pain management) of laboring in water, but also state that the safety of birthing in water has not yet been established and, thus, waterbirth is not recommended.  

At the time the guidelines were written, many small- to medium-sized cohort studies from Europe were published suggesting that waterbirth was safe. However, the ACOG/AAP guidelines did not include this evidence, and cited instead primarily case series and case reports. Case series/reports are not studies; rather, they are a description of what happened to a few patients (laboring women/newborns, in this scenario). There is no comparison group and the results are based on a very small sample, which means that robust conclusions about the exposure (in this scenario, waterbirth) cannot be drawn. Knowing, for example, that one baby ended up in the NICU from the case group of 10 waterbirths is not helpful unless you also know how many babies went to the NICU from a similar group of non-waterbirths.  

In the guidelines, ACOG and AAP recognize the limitations of available research, stating, “Before examining available evidence concerning immersion during childbirth, it is important to recognize limitations of studies and evidence in this area” (ACOG/AAP, 2014, 1). We believe that our research has addressed these limitations, and now offers good evidence for the safety of waterbirth. 

Our sample of 6,521 women (6,534 neonates), with a comparison group of 10,252 women (10,290 neonates) who did not choose waterbirth, makes this the largest study on waterbirth to-date. Additionally, this is the first large waterbirth study in a US population, which is important because of the acknowledged uniqueness of both the US healthcare system and the US population. 

With this publication, there is now a study in a US population examining neonatal and maternal outcomes for more than 6500 waterbirths. Contrary to conclusions drawn in the ACOG/AAP guidelines, findings from this study demonstrate that waterbirth confers no additional risk for babies. Future position statements and clinical guidelines should reflect the balance of evidence on waterbirth to-date, which suggests that birth in the water is a safe and viable option for low-risk pregnancies and, accordingly, should be offered as an option to childbearing families. 

¹ACNM, MANA, NACPM. (2012). Supporting healthy and normal physiologic childbirth: A consensus statement by the American College of Nurse-Midwives, Midwives Alliance of North America, and the National Association of Certified Professional Midwives. Journal of Midwifery & Women’s Health, 57(5), 529–532. http://doi.org/10.1111/j.1542-2011.2012.00218.x

Buckley, S. (2015). Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity. Washington, D.C.: Childbirth Connection Programs, National Partnership for Women & Families.

Photo credit: Megan Hannon Photography courtesy Izabella de Barbaro