Tuesday, June 15, 2010

Is water birth safe?

(Trying out our birth pool a week before my home birth.  
I labored in the water, but delivered on my bed.)

I realized several weeks ago that there was a fairly important gap in my personal research on the subject of water birth.  While I have read a lot about it in books, heard rave reviews from friends, and seen countless water birth YouTube videos, I hadn't personally delved into the scientific literature about water birth.  Anecdotal and second-hand evidence can be very helpful, but I wanted to see the nitty-gritty facts myself.  Especially after I did a google search and found an OB's blogpost slamming water birth and all its dangerousness.

What I found was that most of the scientific journal articles that come up through a water birth Google search were anecdotal reports and/or case studies of individual cases where doctors suspected that a water delivery contributed to a child's death or poor health.  The general sentiment among doctors is fairly well summed-up in this concluding statement (from an article in the journal Pediatrics) penned jointly by a pediatrician, nurse, and obstetrician:
After reviewing the literature, we stop to ponder: what evidence of harm would be enough to convince us to stop the practice? Should the report of a single drowning be enough? Apparently, it was not. At this point, we are convinced there is no evidence to support any benefit of underwater birth for the neonate, and plenty of evidence to suggest harm. (source)
Another doctor was so bold as to say:  "Water births currently provide no apparent benefit in childbirth" (source).  The introductory paragraph of his article had me chuckling to myself:
Despite an absence of supporting evidence, proponents of water births claim benefits and disregard concerns while continuing to fail to subject this approach to the rigors of scientific inquiry. This desire to ignore the facts may be particularly prevalent among individuals who prefer nontraditional delivery techniques.
I'm not about to suggest that water birth was the norm among our ancestors, but I would hardly call stirrups+hospital bed the "traditional" delivery technique.  Women have only been giving birth strapped to beds for a tiny portion of human existence.  And I won't waste my time addressing his claim that ignoring the facts is prevalent among those who prefer to deliver in "nontraditional" ways.

It can be frustrating and confusing trying to find the facts when it comes to water birth.  The most comprehensive review of the water birth research (that I'm aware of) is the Cochrane review.  Here's what the Cochrane researchers concluded in 2004:
There is evidence that water immersion during the first stage of labour reduces the use of analgesia and reported maternal pain, without adverse outcomes on labour duration, operative delivery or neonatal outcomes. The effects of immersion in water during pregnancy or in the third stage are unclear. One trial explores birth in water, but is too small to determine the outcomes for women or neonates.
So, basically, what we know from the scientific literature is that immersion in water can make labor less painful, but apparently we don't have rigorous enough scientific evidence to demonstrate the relative safety of water deliveries when compared with land deliveries. 

There are other studies demonstrating many benefits of water birth (though I can't personally vouch for the level of scientific scrutiny used by the researchers).  While these studies seem to have been primarily ignored or dismissed by the medical community, they can still be helpful as we strive to explore all the evidence. Here are some of them:

Waterbirths: a comparative study. A prospective study on more than 2,000 waterbirths.

Experience with water births: a prospective longitudinal study of 9 years with almost 4,000 water births

A retrospective comparison of water births and conventional vaginal deliveries.

Effects of water birth on maternal and neonatal outcomes.

Midwife Ronnie Falcao's website also contains a wealth of information on water birth safety.

I think it's helpful to keep in mind that adverse outcomes can occur regardless of mode/location of delivery, and that many modern obstetric practices have been shown by scientific study to be risky or questionable.  So I'm a little baffled by some doctors' outrage about water birth and their claims that it shouldn't be allowed to continue without rigorous scientific support.  If only they required the same standards for their own practices.  Back in April 2009, I quoted Jennifer Block from Pushed:  "A recent ACOG survey found that in 43% of malpractice suits involving neurologically impaired babies, Pitocin was to blame" (p. 137), and again: "Even Williams Obstetrics offers a sobering history: 'Oxytocin is a powerful drug, and it has killed or maimed mothers through rupture of the uterus and even more babies through hypoxia from markedly hypertonic uterine contractions'" (p. 138).  Yet many doctors still pump women full of Pitocin, often with little or no medical necessity.  Given that the percentage of women giving birth underwater is miniscule compared to the number of women being routinely administered Pitocin (a powerful drug with known and frightening side effects), I think tackling the Pitocin problem is far more urgent.

I would love to see a huge randomized controlled trial exploring water birth.  I would love to see this matter rigorously addressed.  In the meantime, what can we do?  I suppose each of us must use whatever tools available to us to determine what is best and safest for our individual circumstances.  For me, that includes my own intuition and Spiritual guidance from my Creator who knows the birth process and my body better than any other being.  I may not be able to determine, with certainty, that water birth is safe for you or anyone else.  But I feel confident I will be able to determine down the road whether it's right for me.

I'd appreciate any wisdom, stories, and insights you might have.


Missy said...

Random question, but where did you get that pool? I am looking for a kiddie pool like that one to labor in and I'm wondering what stores carry the 3 ring deeper ones. Thanks!

Buscando la Luz said...

I just got it in the birth kit from my midwives. I'm not sure where they got it. I could ask them, if you'd like.

Robyn said...

www.yourwaterbith.com sells this type of pool

I rented an aquadoula for my last birth and it was nice but not really necessary. I have friends who felt the pool above was great and very reasonably priced.

Robyn said...

oops, I misspelled the website:

Cherylyn said...

Thank you so much for this informative post! I find it difficult trying to navigate research and studies on birth options such as this. There are conflicting viewpoints without any real supportive evidence, and it can be very frustrating.

With that said, I tend to rely heavily on prayer and personal inspiration when it comes to making such decisions. I want to share my own home water birth experience with you.

I wanted a water birth for my 5th baby, and because of hospital restrictions I decided it would be best to plan a home birth. I'd done research as part of my doula training, but most important was that when I prayed about it I felt an overwhelming, resounding PEACE. I prayed often throughout the pregnancy, and that peace stayed with me the whole time. I never questioned my decision because of that. I had no idea why, but I knew that for whatever reason my baby needed to be born at home and I wanted him to be born in the water.

My baby was a surprise frank breech, which we discovered as I was pushing in the birth tub (provided by my midwife). As I pushed, his bottom came out followed by one leg, and then the other. His torso came out, then one arm, followed by the other arm. At some point the midwife commented to the other midwife that the baby was kicking in the water and was doing "just fine" as she put it. He was able to move freely in the near weightlessness of the water. As I was pushing to get his head out, my baby put his own hands and feet against my body and actually helped push his own head out! I feel it was important for him to be in the water to be able to manipulate his own body and assist in getting himself out.

I also know that had I been in the hospital with my breech baby (my other 4 children were all hospital births) I would have had a c-section. I now understand why it was best for me to plan a home water birth, and I count it a great blessing from Heavenly Father that I was inspired and open to do it.

If you want to read the full birth story, it's on here on my blog: http://mamasandbabies.blogspot.com/2009/07/home-water-birth-breech-delivery-of.html

I want to tell you that I enjoy your blog so much. I love your sometimes rambling thoughts about pregnancy and birth because I have similar thought processes. Your ideas are interesting and spark my own thoughts on the subject. I also enjoy the spiritual approach you have to everything you do, as I also strive to be spiritually in tune with everything I do.

Buscando la Luz said...

What an incredible story. Thank you so much for sharing it! And for your kind words. I will definitely click over and read the full account. :-)

Erika Obert said...

Check out Barbara Harper's work. Barb founded Waterbirth International. She is awesome. http://www.waterbirth.org/mc/page.do;jsessionid=B63DF2843C3E0FD3AA1ED495222923B7.mc0?sitePageId=38425

And for what it's worth, although anecdotal, 4 of my 5 were born in water at home.


Missy said...

Thanks for that link Robyn:) They have exactly what I'm looking for!

Sarah said...

My sister just gave girth to her fourth little boy yesterday, in England. She has always wanted a water birth and in England they are pretty agreeable to it, as long as you are not anemic. She was anemic early in her pregnancy and her midwives knew she wanted a water birth so they started her on extra iron early. Water births are fairly common in the UK, and epidurals are not the norm like they are here.
Their concern with a water birth is that you don't know exactly how much blood a mother is losing in the water so if the mother is anemic already than a water birth can be a problem. That being said, they knew my sister's desire for a water birth, because they had been there for her three other births, and did something to improve the situation.
My sister labored in the water but she relaxed so much that labor stalled. She felt strongly that she needed to get up and move around to continue to progress and when she got up and moved things progressed so quickly that she didn't have time to get back in the pool. She had her 9 lbs baby (her biggest yet by almost a pound) with his hand and arm wrapped around his head. She did not get her water birth but she did get to use the birthing pool and could have had a water birth she just didn't make it back into the water.
The best part is she was back home with all four of her sons ages 6,4,2, and newborn) six hours after her baby was born!

Marsha M said...

Good post. I always wanted a water birth because it sounded so much less painful. However, after I read an article about the baby that died after a water birth in England I couldn't justify it as a natural way to deliver. Labor yes, but not delivering for me.

The baby had gotten stuck or something in the birth canal and had prematurely started breathing and inhaled water which was given as the cause of his death. This is my understanding which could be completely wrong but made me re-evaluate my definition of natural and water birth no longer fits. But I wouldn't call water birth unsafe because this example seems like a freak occurrence and not a normal outcome.

I would certainly choose water birth over pitocin for levels of safety!

Ginger Harvey said...

A midwife friend of mine promotes water for laboring but not for delivery. She will do a water delivery, but doesn't think it's the best. She says
1 - it makes it more difficult to judge how much a mom bleeds postpartum, and the thought of moving out of the pool in order to deliver the placenta and judge that blood loss better isn't what mama wants to be doing just after delivery of her child
2 - makes it difficult for the midwife to judge without dunking her head (which she has had to do due to shoulder dystocia)if the baby is in distress at all (hands, elbows, and shoulder dystocia, cord entanglement are all easier handled on dry ground with a firm surface for support rather than floating and fighting against buoyancy)
3- she says that watching the baby crowning and the baby's facial expressions helps her to know when to keep her hands off and when the baby needs help (such as being able to see the color of the baby and how quickly s/he needs to be delivered)
4 - mama and baby can be easily chilled when switching from warm water to dry air, both bodies are lacking in temperature regulating abilities just after birth, getting chilled and having difficulty warming up is common even for moms who aren't in water, but it's made worse due to a water birth.

She admits that there are pro's to water birth, but suggests water laboring and dry land delivery as the preferred method.

That said, I labored in water last time and plan to do so again. Perhaps this time actually in a pool or tub rather than just having the water poured over my lower back. I'm not yet sure if I'd deliver in the water, or have the tub or pool drained during the pushing stage of labor.

Just thought I'd share a few comments that I hadn't thought of before they were pointed out to me!

Kate said...

There is one risk of water birth that you never read about, and that is what if shoulder dystocia occurs. My first (and only) child was born at home in a birthing tub but he experienced shoulder dystocia. Because of the size of the tub - a typical birthing tub - the flexible nature of the tub rim and the general slipperiness of the tub, some positions that could help resolve shoulder dystocia are not available to you. The midwife is in a very difficult position, typically, and any interventions that would require reaching in and manually rotating the baby are also not generally possible. Sadly, she was left with pretty much no option other than to pull and twist on his head to get him out. His brachial plexus (nerves to his left arm) was permanently injured and he has permanent partial paralysis of his arm. So if you do choose a birthing tub, please make sure that your midwife or practitioner has a well -practiced plan for dealing with shoulder dystocia if it occurs. If we had had a sturdy chair or other support right outside of the tub, or helpers ready to steady me if I needed to stand up and change positions or get out of the tub very quickly, things might have been different. I have no doubt that the injury my child had could have been very much worse if it had been a medicalized birth, on my back with an epidural. But it kills me that it could still have been prevented with a more prepared midwife.

Cooley said...

all of my births have been waterbirths and all of them have been safe.