By Barbara Harper, RN, CLD, CCE, DEM, CKC, CCCE

The American College of Obstetricians and Gynecologists (ACOG) Committee Opinion No. 679, "Immersion in water during labor and delivery," was released at the end of October[1] and replaces the previous opinion published in April 2014[2]. The opinions of ACOG do carry weight with the obstetric community worldwide, however, the very first sentence before the opinion states, "The information (in this opinion) should not be construed as dictating an exclusive course of treatment or procedure to be followed." Opinion papers reflect the sentiment of the authors who sometimes review the available research and then use it exactly the way they want to support their opinions.

I was actually encouraged by this opinion, as well as the previous one. The previous statement warned of more dire consequences for newborns and stated that births in water should only be done as part of a clinical trials. That sparked the creation of many prospective studies and retrospective analyses of waterbirth data from various hospitals around the US. The current opinion reflects a new look at some of the available research that was not examined in the 2014 opinion. They even looked at two meta-analyses published in 2015[3] and 2016,[4] both of which concluded that birth in water posed no risk for babies born to low risk women, stating that there is largely reassuring data on newborns and that there is no difference in neonatal morbidity or mortality. When statistics between the two groups of babies are compared (bed and bath) the bath group experiences fewer NICU admissions, respiratory issues and infections and have better five minute Apgar scores.[5] I'm excited to anticipate the publication of another waterbirth meta-analysis from Jennifer Vanderlaan, CNM, MPH, PhD candidate (Emory) next year.

ACOG draws a distinction between water immersion in the first stage of labor, which is acknowledged as being useful for decreasing pain, lowering intervention rates, and shortening labor duration and birth in water.[6],[7],[8] They state fears about no evidence of benefit for mothers or babies in both opinions. What is different about this opinion are the recommendations for practice, which acknowledge that waterbirth does take place in hospitals in the US.

The most frequent questions Waterbirth International receive daily are, "where can I go to have a waterbirth" or "can you help me get waterbirth started at my hospital?"" There are hospitals in the US that offer waterbirth and more are starting every day. ACOG suggests that if a woman asks to give birth in water she should be informed that "the benefits and risks of this choice have not been studied sufficiently to either support or discourage her request."" Women can review the literature themselves and make an informed choice.

ACOG acknowledges that hospitals are offering waterbirth and will continue to offer waterbirth. They bullet point this suggestion: "Facilities that plan to offer immersion during labor and delivery need to establish rigorous protocols for candidate selection; maintenance and cleaning of tubs and pools; infection control procedures, including standard precautions and personal protective equipment for health care personnel; monitoring of women and fetuses at appropriate intervals while immersed; and moving women from tubs if urgent maternal or fetal concerns or complications develop."" Every hospital that works with Waterbirth International either before starting a waterbirth program or after one begins, receives detailed instructions on how to create all the policies and procedures that are necessary to safely conduct waterbirth and training for the entire staff.[9]

Perhaps ACOG should talk to the women who have experienced waterbirth. The current global estimate of births in water since 1978 are more than half a million. Women vote with their feet. When waterbirth is not offered in a particular hospital many of those women go to birth centers or stay at home. The 2016 publication of Midwives Alliance of North America Statistic Project, 2004-2009 Cohort,[10] revealed 6534 waterbirths took place out of hospital and concluded that, "Our results are congruent with findings from studies in other settings, and contrary to the recently published ACOG/AAP clinical guidelines, suggest that waterbirth is a reasonably safe option for use in low-risk, low-intervention births."

Water is a benefit to women and babies. Waterbirth is safe when providers are educated, experienced and confident. There is something that ACOG will never acknowledge and that is the healing and mind-altering effects of laboring and giving birth in water. Marine biologist, Wallace Nichols, writes and talks about the impact of water in his book, "Blue Mind: How Being Near, On, In or Underwater Changes Your Brain."[11] Water is the medium of consciousness. I believe the introduction of water into clinical settings, which is what I do daily in all parts of the planet, changes the way we see birth. It teaches us to be patient, observant, calm and it changes our consciousness at the same time. It's here to stay.

References

[1] Immersion in water during labor and delivery. Committee Opinion No. 679. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;128:e231-6.

[2] Immersion in water during labor and delivery. Committee Opinion No. 594. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:912-5

[3] Davies R, Davis D, Pearce M, Wong N. The effect of waterbirth on neonatal mortality and morbidity: a systematic review and meta-analysis. JBI Database System Rev Implement Rep 2015;13:180-231

[4] Taylor H, Kleine I, Bewley S, Loucaides E, Sutcliffe A. Neonatal outcomes of waterbirth: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2016;101:F357-65.

[5] Geissbuehler V, Stein S, Eberhard J. Waterbirths compared with landbirths: an observational study of nine years. J Perinat Med 2004;32:308-14.

[6] Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD000111. DOI: 10.1002/14651858.CD000111.pub3.

[7] Henderson J, Burns EE, Regalia AL, Casarico G, Boulton MG, Smith LA. Labouring women who used a birthing pool in obstetric units in Italy: prospective observational study. BMC Pregnancy Childbirth 2014;14:17.

[8] Liu Y, Liu Y, Huang X, Du C, Peng J, Huang P, et al. A comparison of maternal and neonatal outcomes between water immersion during labor and conventional labor and delivery. BMC Pregnancy Childbirth 2014;14:160

[9] Harper, B (2014). Birth, Bath and Beyond: The Science and Safety of Water Immersion During Labor and Birth. Journal of Perinatal Education Summer , Volume 23, Number 3

[10] Bovbjerg ML, Cheyney M, Everson C. Maternal and newborn outcomes following waterbirth: the Midwives Alliance of North America statistics project, 2004 to 2009 cohort. J Midwifery Womens Health 2016;61:11-20.

[11] Nichols, W. J., (2014) Blue Mind: The Surprising Science That Shows How Being Near, In, On, or Under Water Can Make You Happier, Healthier, More Connected, and Better at What You Do. Little Brown & Co., New York, NY.

About Barbara Harper

Barbara Harper, RN, CLD, CCE, DEM, CKC, CCCE, loves babies and has been a childbirth reform activist since her first day at nursing school over 42 years ago. She is an internationally recognized expert on waterbirth, a published author and she founded Waterbirth International in 1988, with one goal in mind - to insure that waterbirth is an available option for all women. During the past four decades, Barbara has worked as a pediatric nurse, a childbirth educator, home birth midwife, midwifery and doula instructor and has used her vast experience to develop unique seminars which she teaches within hospitals, nursing schools, midwifery and medical schools and community groups worldwide. She was recognized in 2002 by Lamaze International for her contributions in promoting normal birth on an international level. Her best selling book and DVD, Gentle Birth Choices has been translated into nine languages so far. Her next book Birth, Bath & Beyond: A Practical Guide for Parents and Providers, will be ready for publication in 2017. Barbara has dedicated her life to changing the way we welcome babies into the world. She considers her greatest achievement, though, her three adult children, two of whom were born at home in water. She lives in Boca Raton, Florida, where she is active in her Jewish community as a volunteer and as a local midwifery and doula mentor and teacher. Barbara can be reached through her website, Waterbirth International.

photo credit: Alberto Perra and Angela Giusti

flickr photo by U.S. Army Alaska https://flickr.com/photos/usarak/12976615034 shared under a Creative Commons (BY) license

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