Waterbirth Works

Objectives: The objective of this review was to systematically synthesize the best available evidence regarding the effect of waterbirth, compared to landbirth, on the mortality and morbidity of neonates born to low risk women.

Inclusion criteria: This review considered studies that included low risk, well, pregnant women who labor and birth spontaneously, at term (37-42 weeks), with a single baby in a cephalic presentation. Low risk pregnancies are defined as pregnancies with an absence of co-morbidity or obstetric complication, such as maternal diabetes, previous cesarean section, high blood pressure or other illness. Women may be experiencing their first or subsequent pregnancy. The fetus must also be well and without any co-morbidity or complication.The intervention of interest is waterbirth. The comparator is landbirth. Women and their babies must be cared for by qualified maternity healthcare providers throughout their labor and birth. The birth setting must be clearly described but can include home, hospital or birth center, either freestanding or attached to a hospital.This review considered randomized controlled trials, quasi-experimental studies and observational prospective and retrospective cohort studies.

Results: The meta-analyses of 12 studies showed that for the majority of outcomes measured in this review there is little difference between waterbirth and landbirth groups. Meta-analysis was not conducted for mortality within 24 days of birth. Heterogeneity was significant between studies for APGAR (Appearance, Pulse, Grimace, Activity, and Respiration). scores ≤7 at one minute and admission to Special Care nursery. Sensitivity analysis for case control studies describing infection found results that were not statistically significant (OR 0.74, 95% CI 0.05-11.06). Results of meta-analysis were also not significant for studies describing resuscitation with oxygen (OR 1.12, 95% CI 0.14-8.79) and Respiratory Distress Syndrome (OR 0.81, 95% CI 0.44-1.49). Results comparing APGAR scores ≤7 at five minutes for waterbirth and landbirth groups results for included RCTs demonstrated results that were not statistically significant (OR 6.4, 95% CI 0.63-64.71). However, results for included cohort studies describing APGAR scores ≤7 at 5 minutes indicate neonates are less likely to have scores ≤7 in the waterbirth group (OR 0.32, 95% 0.15-0.68). Data were not statistically significant for meta-analysis describing admission to NICU (OR 0.51, 95% CI 0.13-1.96) between water and landbirth groups. The differences in arterial (MD 0.02, 95% CI 0.01-0.02) and venous (MD 0.03, 95% CI 0.03-0.03) cord pH, while statistically significant, were clinically negligible.

Conclusions: Analyses of data reporting on a variety of neonatal clinical outcomes comparing land with waterbirth do not suggest that outcomes are worse for babies born following waterbirth. Meta-analysis of results for five-minute APGAR scores ≤7 should be treated with caution due to the different direction of results for meta-analysis of data from randomized controlled trials and cohort studies. Data measuring cord pH (an objective measure of neonatal wellbeing) were robust and showed no difference between groups. Overall this review was limited by heterogeneity between studies and meta-analysis could not be conducted on a number of outcomes. Waterbirth does not appear to be associated with adverse outcomes for the neonate in a population of low risk women.

Implications for practice: There is no evidence to suggest that the practice of waterbirth in a low risk population is harmful to the neonate.

Implications for research: There is a paucity of high level evidence to guide practice in the area of waterbirth. It is unlikely that randomized controlled trials on waterbirth will be acceptable to childbearing women or maternity caregivers. Observational studies are a more appropriate choice for researchers in this field as they offer a more practical and ethical approach.

Davies, R., Davis, D., Pearce, M., & Wong, N. (2015). The effect of waterbirth on neonatal mortality and morbidity: a systematic review and meta-analysis. JBI database of systematic reviews and implementation reports, 13(10), 180–231.

The effect of waterbirth on neonatal mortality and... : JBI Evidence Synthesis surprising that there are few randomized controlled trials available to inform practice. Much of the criticism directed at waterbirth focuses on the potential impact on the neonate. Objectives The objective of this review was to systematically synthesize the best available evidence regarding the eff...

Cristina, T., Mara, T., Arianna, S., Gennaro, S., Rosaria, C., & Pantaleo, G. (2022). Impact of waterbirth on post-partum hemorrhage, ge***al trauma, retained placenta and shoulder dystocia: A systematic review and meta-analysis. European journal of obstetrics, gynecology, and reproductive biology, 276, 26–37. https://doi.org/10.1016/j.ejogrb.2022.06.016

Objectives: To examine different maternal complications of WB compared to standard land birth (LB). The primary outcomes were postpartum hemorrhage and ge***al trauma. The secondary outcome included the risk of retained placenta and shoulder dystocia.

Methods: We searched the electronic databases including PubMed, MEDLINE, Embase, Scopus, EBSCO. In addition, we searched in Google Scholar and ClinicalTrials.gov. The pooled results were used to evaluate the association between WB and obstetric outcomes. This systematic review (SR) was reported according to PRISMA statement 2020. Statistical meta-analyses were performed using Cochrane RevMan version 5.4 software (http://www.cochrane.org).

Results: This systematic review included 22 studies (20 observational studies and 2 RCT). The pooled results showed lower risk of major PPH compared to the LB group (OR = 0.76, 95% CI: 0.66-0.89), no significant difference (OR: 0.94, 95% CI: 0.50-1.78) in the incidence of minor PPH (500-1000 mL blood loss) between WB and LB, no significant difference in the rate of third- and fourth-degree lacerations (OR = 0.87, 95% CI: 0.71-1.07) and in the incidence of retained placenta (OR = 1.30, 95% CI: 0.50-3,35), fewer shoulder dystocia for WB (OR = 0.42, 95% CI: 0.35-0.50). However, compared with the LB group, the rate of first-second-degree tears in the WB group increased by 45% (OR = 1.45, 95% CI: 1.16-1.81).

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Clews, C., Church, S., & Ekberg, M. (2020). Women and waterbirth: A systematic meta-synthesis of qualitative studies. Women and birth : journal of the Australian College of Midwives, 33(6), 566–573. https://doi.org/10.1016/j.wombi.2019.11.007

Aim: To undertake a review of qualitative studies exploring women's experiences of waterbirth. This understanding is pertinent when supporting women who birth in water.

Methods: A literature search was conducted in databases British Nursing Index, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, Maternity and Infant Care, Medline, Applied Social Sciences Index and Abstracts and Web of Science, using search terms waterbirth, labour/labor, childbirth, women, mothers, experience, perception and maternity care. Five primary research articles published between 2003 and 2018 which explored the views of women who had birthed in water were selected for inclusion. Using meta-ethnography, qualitative research studies were analysed and synthesised using the method of 'reciprocal translational analysis' identifying themes relating to women's experiences of birthing in water.

Findings: Four themes were identified: women's knowledge of waterbirth; women's perception of physiological birth; water, autonomy and control; and waterbirth: easing the transition.

Conclusion: Despite the paucity of qualitative studies exploring women's experiences of waterbirth, meta-synthesis of those that do exist suggested women identify positively with the choice. The experience of birthing in water appears to enhance a woman's sense of autonomy and control during childbirth suggesting waterbirth can be an empowering experience for women who choose it.

Redirecting

Aughey, H., Jardine, J., Moitt, N., Fearon, K., Hawdon, J., Pasupathy, D., Urganci, I., NMPA Project Team, & Harris, T. (2021). Waterbirth: a national retrospective cohort study of factors associated with its use among women in England. BMC pregnancy and childbirth, 21(1), 256.

Waterbirth: a national retrospective cohort study of factors associated with its use among women in England - BMC Pregnancy and Childbirth Background Waterbirth is widely available in English maternity settings for women who are not at increased risk of complications during labour. Immersion in water during labour is associated with a number of maternal benefits. However for birth in water the situation is less clear, with conclusive e...

Allen, J., Gao, Y., Dahlen, H., Reynolds, M., Beckmann, M., Cooper, C., & Kildea, S. (2022). Is a randomized controlled trial of waterbirth possible? An Australian feasibility study. Birth (Berkeley, Calif.), 49(4), 697–708. https://doi.org/10.1111/birt.12635

Background: The safety of waterbirth is contested because of the lack of evidence from randomized trials and conflicting results. This research assessed the feasibility of a prospective study of waterbirth (trial or cohort).

Methods: We conducted a prospective cohort study at an Australian maternity hospital. Eligible women with uncomplicated pregnancies at 36 weeks of gestation were recruited and surveyed about their willingness for randomization. The primary midwife assessed waterbirth eligibility and intention on admission in labor, and onset of second stage. Primary outcomes measured feasibility. Intention-to-treat analysis, and per-protocol analysis, compared clinical outcomes of women and their babies who intended waterbirth and nonwaterbirth at onset of second stage.

Results: 1260 participants were recruited; 15% (n = 188) agreed to randomization in a future trial. 550 women were analyzed by intention-to-treat analysis: 351 (waterbirth) and 199 (nonwaterbirth). In per-protocol analysis, 14% (n = 48) were excluded. Women in the waterbirth group were less likely to have amniotomy and more likely to have water immersion and physiological third stage. There were no differences in other measures of maternal morbidity. There were no significant differences between groups for serious neonatal morbidity; four cord avulsions occurred in the waterbirth group with none in the landbirth group. An RCT would need approximately 6000 women to be approached at onset of second stage.

Conclusions: A randomized trial of waterbirth compared with nonwaterbirth, powered to detect a difference in serious neonatal morbidity, is unlikely to be feasible. A powered prospective study with intention-to-treat analysis at onset of second stage is feasible.