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evidence based medicine, pregnancy

A water birth isn’t natural it’s an intervention

The joint statement on laboring in water and delivering in water (the latter also known as immersion births) from the American Academy Pediatrics (AAP) and the American Congress of Obstetricians and Gynecologists (ACOG) is making the rounds. I’ve linked to the full statement above, but in essence it says that some women find laboring in water helpful for pain relief (in the first stage of labor it reduces the need for epidurals) and is safe, but that giving birth in water (immersion birth) has not been adequately studied and furthermore there are case reports of poor outcomes for some babies.

It is important to remember that we did not evolve to give birth in water. If giving birth in water were integral to reproduction no tribe would ever have migrated away from a major water source. Ever. However, according to the United Nations 85% of the world’s population lives in the direst half of the planet. Then there is also the task of getting and keeping the water warm (a challenge for anyone without running water and electricity) and the issue of an adequate supply of clean water (meaning non feculent and  parasite free), which is still a dream for close to a billion people.

As delivering in water is not part of our biology then it is an intervention. An intervention that was apparently introduced relatively recently. This does not make it bad (although it may throw a wrench in how some people advertise it), it just means that like all interventions it should be evaluated appropriately. Every intervention has one of the three possible outcomes: 1) make things better 2) no effect 3) make things worse. Studies tell us that the diving reflex (what proponents of immersion births claim protects babies) is over ridden with a compromised baby. This isn’t just some hypothetical potential for badness because bad outcomes have been reported in the literature. To recommend an immersion birth we would have to know what it offers with an appropriately designed prospective study (some examples might be reduced pain scores, shortened 2nd stage of labor, or reduction in lacerations) and the risk of complications (such as neonatal pneumonia or cord avulsion). However, we don’t have that data.

An immersion birth is not some long-practiced delivery technique based on physiology that modern obstetrics has hidden from women since the advent of maternity institutions, but rather an inadequately studied intervention introduced around 1991. Delivering in water may very well offer benefits and it may not. We know it has risks, some catastrophic, but how common they are is also unknown. Whether the rate of serious complications is 1% or 0.001% matters. It is also possible that the complications that have been reported are all from unskilled practitioners who either don’t understand the technique or can’t recognize when a baby is compromised and is no longer a candidate for an immersion birth. Without appropriate studies you don’t know much at all.

The ACOG/AAP statement doesn’t say that immersion births are bad or evil, it points out that this is an inadequately studied intervention and because there are several reports of catastrophic complications the practice requires study. It shouldn’t be hard to do the study, so it really behooves the proponents of immersion births to design a trial and produce the data.

I’m all about reproductive choice, and that includes where you deliver, but you need data to make an informed choice so you can assess what the risks and the benefits mean to you. I can quote someone the data on the effect of an epidural on the length of labor, the c-section rate, and the complication rate of the procedure, but I don’t have that data on immersion births.

Just because it’s water it shouldn’t get a free ride.

 

 

 

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Discussion

6 thoughts on “A water birth isn’t natural it’s an intervention

  1. Pretty asinine, if you ask me. Interventions in labor are designed to augment the process OF labor. Laboring and birthing in water is designed to give mom comfort, not augment labor. Also? As our c-section rates continue to rise and we have such an insanely high rate of maternal mortality, shouldn’t we spend research dollars finding out how to LOWER those numbers, instead of research dollars being thrown at a technique that rarely causes the death of an infant or mother? This is simply the medical community further trying to push women back into hospitals with yet more fear-mongering. ACOG and the AAP obviously aren’t in women’s best interests if they’re focusing on the “dangers” of water birth instead of why we are sectioning moms for failure to progress after only hours of labor that’s already been ARTIFICIALLY INDUCED.

    Posted by hrm517 | March 27, 2014, 11:22 am
    • The post isn’t about c-sections rates or labor induction. Changing the topic doesn’t make water birth safe or unsafe and is a debate technique that typically used to bolster a weak argument.

      “Rarely causes the death of an infant or mother?” If that infant was yours, you would care I suppose. I had a baby die in a rare situation and it doesn’t make it any easier when you pick up the ashes at the funeral home. However, you are wrong when you say “rare;y” as we don’t know the true rate since the studies are poor/non existent. We can’t quote people the statistics and a neonatal death rate of 0.001% versus 1% matters greatly. It should matter to midwives who offer immersion births. If it doesn’t that’s a far bigger issue and concern. Wouldn’t you want to prove that your technique was as safe for your patient as you think?

      Research dollars and resources are obviously spent studying many subjects at a time, so your implication that looking at water births somehow diverts previous resources from elsewhere is ridiculous.

      As we did not evolve to give birth in water and it is a relatively new intervention with reports of complications and there appears to be a lack of understanding about the diving reflex among some who practice/promote water births it deserves study. To insinuate otherwise is wrong both medically and ethically.

      Posted by Dr. Jen Gunter | April 2, 2014, 6:45 am
  2. Since I do not wish to re-invent the wheel, I am leaving a post to ACNM’s position statement, which clarifies some of the research available on hydrotherapy in labor and birth. I hope this helps aid in the discussion a bit. Thanks-

    http://www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000286/Hydrotherapy-During-Labor-and-Birth-April-2014.pdf

    Posted by Amy | May 14, 2014, 2:06 pm

Trackbacks/Pingbacks

  1. Pingback: An Update on Water Immersion During Labor and Delivery – JumpSeek - March 28, 2014

  2. Pingback: Roundup: What Top Pelvic Health Bloggers are Talking About - Pelvic Health and Rehabilitation Center - April 30, 2014

  3. Pingback: Why is the “natural” birth movement so afraid of epidurals? | Dr. Jen Gunter - May 14, 2014

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