Neonatal outcomes with water birth: A systematic review and meta-analysis

Epidural or water immersion? A prospective cohort study of maternal and neonatal outcomes in a tertiary hospital

BACKGROUND

Providing evidence-based information on maternal and neonatal outcomes of epidural analgesia (EA) and water immersion (WI) is crucial for informed decision-making.

OBJECTIVE

To compare process outcomes, obstetric interventions, and maternal and neonatal outcomes in medium low-risk women based on their choice of analgesia: EA or WI.

METHODS

This prospective observational cohort study analysed 643 women from June 2020 to February 2023. Sociodemographic data, birth process characteristics, and outcomes were collected to compare 284 women who used EA and 319 who used WI (with 82.4% waterbirths). Additionally, 40 cases of women who switched from WI to EA were descriptively analysed. Propensity Score (PS) was applied to reduce selection bias in the comparative analysis.

FINDINGS

WI was associated with a higher probability of spontaneous vaginal birth (18.7%, E:0.187; SE:0.025; p < 0.001 95% CI 0.138,0.235), shorter first stage (-259.532 min; SE:13.592; p < 0.00195%, 95% CI -286.171, -232.892), shorter second stage of labour (-17.829 min; SE:4.665; p < 0.001 95% CI -26.973,-8.686) In terms of neonatal outcomes WI (with 82.4% of waterbirths) was associated with less neonatal ventilatory support (1.6%vs 9.5% p<0.001,RR 0.028 95% CI 0.11-0.56), less birth distress (0.9%vs 7.7% p<0.001,RR 0.22 95% CI 0.06-0.52), lower probability of neonatal admission rates (E:-0.102; SE 0.033, p=0.002, 95% CI -0.166, -0.088), and higher probability of exclusive breastfeeding at discharge especially for multiparous women (E:0.114; SE 0.045 p=0.01 95% CI 0.027, 0.202).

CONCLUSION AND IMPLICATION FOR PRACTICE

Water immersion for low-risk women emerges as a valid, evidence-based approach to supporting physiological childbirth and reducing unnecessary interventions. This study highlights the need to reinforce its availability in maternity care and to ensure women's informed decision-making.

An intelligent adverse delivery outcomes prediction model based on the fusion of multiple obstetric clinical data

Adverse delivery outcomes is a major re-productive health problem that affects the physical and mental health of pregnant women. Obviously, obstetric clinical data has periodically time series characteristics. This paper proposed a three stage adverse delivery outcomes prediction model via the fusion of multiple time series clinical data. The first stage is data aggregation, in which the data set is collected from the obstetric clinical data and divided based on time series features. In the second stage, a multi-channel gated cycle unit is used to solve the calculation error caused by irregular sampling of time series data. The hidden layer feature vector is connected with the fully connected layer, reshaped into a new one-dimensional feature, and fused with the non-time series data into a new data set. The third stage is the prediction stage of adverse delivery outcomes. By connecting the multi-channel gated cycle unit with the extreme gradient lift, the data transmitted in the corresponding channel is used in the feature extraction stage, in which the weighted entropy-based feature extraction is adopted. With the help of the extracted features, a hybrid artificial neural network architecture (MGRU-XGB) was developed to predict adverse delivery outcomes. The experimental results showed that the hybrid model had the best prediction performance for adverse delivery outcomes compared with other single models in terms of sensitivity, specificity, AUC and other evaluation indexes.

Effects of Water Immersion Versus Epidural as Analgesic Methods during Labor among Low-Risk Women: A 10-Year Retrospective Cohort Study

BACKGROUND

Adequate pain relief during childbirth is a very important issue for women and healthcare providers. This study investigates the effects on maternal and neonatal outcomes of two analgesic methods during labor: water immersion and epidural analgesia.

METHODS

In this retrospective observational cohort study at a first-level hospital, in Spain, from 2009 to 2019, 1134 women, low-risk singleton and at term pregnancy, were selected. Among them, 567 women used water immersion; 567 women used epidural analgesia for pain control. Maternal outcomes included mode of birth and perineum condition. Neonatal outcomes included 5 min Apgar score, umbilical cord arterial pH, and Neonatal Intensive Care Unit admissions. Chi-square tests and Mann-Whitney U tests, together with their effect sizes (Cramer's V, odds ratio, and Cohen's d) were used to test the main hypotheses.

RESULTS

Spontaneous vaginal birth was almost 17 times more likely in the water immersion group (OR = 16.866 [6.540, 43.480], p < 0.001), whereas the odds of having a cesarean birth were almost 40 times higher in the epidural group (OR = 39.346 [3.610, 429.120], p < 0.001). The odds of having an intact perineum were more than two times higher for the water immersion group (OR = 2.606 [1.290, 5.250], p = 0.007), whereas having an episiotomy was more than eight times more likely for the epidural group (OR = 8.307 [2.800, 24.610], p < 0.001). Newborns in the water immersion group showed a better 5 min Apgar score and umbilical cord arterial pH and lower rates in admissions at the Neonatal Intensive Care Unit.

CONCLUSIONS

Women choosing water immersion as an analgesic method were no more likely to experience adverse outcomes and presented better results than women choosing epidural analgesia.

Effects of Hydrotherapy on the Management of Childbirth and Its Outcomes-A Retrospective Cohort Study

The use of hydrotherapy during childbirth has gained relevance due to the demand for natural childbirth and greater respect for the woman's choice. Studies have shown benefits such as less use of epidural analgesia, increased ability to cope with pain, shorter labor, and a better overall birth experience.

OBJECTIVE

The main objective of this study was to generate further evidence on maternal and birth outcomes associated with the use of hydrotherapy during labor, specifically aiming to describe the effects of water immersion during all stages of labor (first, second, and third) on women.

METHODOLOGY

A retrospective cohort study was carried out on a random sample of women who gave birth at the Costa del Sol Hospital between January 2010 and December 2020. The calculated sample size was 377 women and the data were extracted from their partograms. After data extraction, two groups were formed: one group used hydrotherapy during childbirth (n = 124), while the other group included women who did not use hydrotherapy during the childbirth process (n = 253).

RESULTS

The results highlight significant differences in pain perception, analgesia use, types of labor, and delivery times between the two groups. Women who did not use hydrotherapy reported higher pain perception, with a median (IQR) of 8 (7-9) on a numerical scale, compared to a median (IQR) of 6 (5-7) for the hydrotherapy group. Furthermore, the group without hydrotherapy required epidural analgesia in 40% of cases, while in the hydrotherapy group, it was only necessary in 20%. In terms of the type of delivery, the hydrotherapy group had more spontaneous vaginal deliveries compared to the non-hydrotherapy group, which had more operative vaginal deliveries. The overall duration of labor was longer in the hydrotherapy group, especially in women who arrived at the hospital late in labor.

CONCLUSIONS

Hydrotherapy is associated with a longer time to delivery. Women with a higher pain tolerance tend to opt for hydrotherapy instead of epidural analgesia.

Water birth: a systematic review and meta-analysis of maternal and neonatal outcomes

OBJECTIVE

This systematic review and meta-analysis aimed to conduct a thorough and contemporary assessment of maternal and neonatal outcomes associated with water birth in comparison with land-based birth.

DATA SOURCES

We conducted a comprehensive search of PubMed, EMBASE, CINAHL, and gray literature sources, from inception to February 28, 2023.

STUDY ELIGIBILITY CRITERIA

We included randomized and nonrandomized studies that assessed maternal and neonatal outcomes in patients who delivered either conventionally or while submerged in water.

METHODS

Pooled unadjusted odds ratios with 95% confidence intervals were calculated using a random-effects model (restricted maximum likelihood method). We assessed the 95% prediction intervals to estimate the likely range of future study results. To evaluate the robustness of the results, we calculated fragility indices. Maternal infection was designated as the primary outcome, whereas postpartum hemorrhage, perineal lacerations, obstetrical anal sphincter injury, umbilical cord avulsion, low Apgar scores, neonatal aspiration requiring resuscitation, neonatal infection, neonatal mortality within 30 days of birth, and neonatal intensive care unit admission were considered secondary outcomes.

RESULTS

Of the 20,642 articles identified, 52 were included in the meta-analyses. Based on data from observational studies, water birth was not associated with increased probability of maternal infection compared with land birth (10 articles, 113,395 pregnancies; odds ratio, 0.93; 95% confidence interval, 0.76-1.14). Patients undergoing water birth had decreased odds of postpartum hemorrhage (21 articles, 149,732 pregnancies; odds ratio, 0.80; 95% confidence interval, 0.68-0.94). Neonates delivered while submerged in water had increased odds of cord avulsion (10 articles, 91,504 pregnancies; odds ratio, 1.75; 95% confidence interval, 1.38-2.24) and decreased odds of low Apgar scores (21 articles, 165,917 pregnancies; odds ratio, 0.69; 95% confidence interval, 0.58-0.82), neonatal infection (15 articles, 53,635 pregnancies; odds ratio, 0.64; 95% confidence interval, 0.42-0.97), neonatal aspiration requiring resuscitation (19 articles, 181,001 pregnancies; odds ratio, 0.60; 95% confidence interval, 0.43-0.84), and neonatal intensive care unit admission (30 articles, 287,698 pregnancies; odds ratio, 0.56; 95% confidence interval, 0.45-0.70).

CONCLUSION

When compared with land birth, water birth does not appear to increase the risk of most maternal and neonatal complications. Like any other delivery method, water birth has its unique considerations and potential risks, which health care providers and expectant parents should evaluate thoroughly. However, with proper precautions in place, water birth can be a reasonable choice for mothers and newborns, in facilities equipped to conduct water births safely.

The use of hydrotherapy in the first stage of labour: A systematic review and meta-analysis

AIM

To explore the effect of hydrotherapy applied in the first stage of labour on the health of mother and newborn.

METHODS

This systematic review and meta-analysis was carried out by following PRISMA. The studies were obtained by scanning EBSCO, PubMed, Science Direct, Ovid, Web of Science and Scopus electronic databases. Twenty studies published between 2013 and 2023 were included.

RESULTS

The total sample size of the studies was 8254 (hydrotherapy: 2953, control: 5301). Meta-analyses showed that the perception of pain decreased, comfort level and vaginal birth rate were higher and assisted vaginal birth rate and APGAR scores in the first minute were lower in women who underwent hydrotherapy. There was no difference between groups in terms of the duration of the first and second stage of labour, episiotomy, perineal trauma, intrapartum and postpartum bleeding amounts, use of pain medication and labour augmentations, APGAR scores in the fifth minute, positive neonatal bacterial culture and neonatal intensive care unit need.

CONCLUSION

This study revealed that the results that hydrotherapy decreased the perception of pain and assisted birth, increased the rate of vaginal birth and comfort level and did not adversely affect the health of the mother and baby during the birth process.

Neonatal outcomes after water birth: A retrospective cohort study

OBJECTIVE

To compare neonatal outcomes between water births, births with immersion only during labour, and births in which immersion was never used.

METHODS

A retrospective cohort study was performed including mother-baby dyads attended between 2009 and 2019 at the Hospital do Salnés regional hospital (Pontevedra, Spain). These women were categorised into 3 groups: water birth; immersion only during dilation; and women who never used immersion. Several sociodemographic-obstetric variables were studied and the main outcome was the admission of the neonate to the intensive care unit (NICU). Permission was obtained from the responsible provincial ethics committee. Descriptive statistics were used and between-group comparisons were performed using variance for continuous variables and chi-square for categorical variables. Multivariate analysis was performed with backward stepwise logistic regression and incidence risk ratios with 95%CI were calculated for each independent variable. Data were analysed using IBM SPSS® statistical software.

RESULTS

A total of 1191 cases were included. 404 births without immersions; 397 immersions only during the first stage of labor; and 390 waterbirths were included. No differences were found in the need to transfer new-borns to a NICU (p = .735). In the waterbirth cohort, neonatal resuscitation (p < .001, OR: 0,1), as well as respiratory distress (p = .005, OR: 0,2) or neonatal problems during admission (p < .001, OR: 0,2), were lower. In the immersion only during labor cohort, less neonatal resuscitation (p = .003; OR: 0,4) and respiratory distress (p = .019; OR: 0,4) were found. The probability of not breastfeeding upon discharge was higher for the land birth cohort (p < .001, OR: 0,4).

CONCLUSIONS

The results of this study indicated that water birth did not influence the need for NICU admission, but was associated with fewer adverse neonatal outcomes, such as resuscitation, respiratory distress, or problems during admission.

Content Analysis of Water Birth Policies With Implications for Practice and Research

OBJECTIVE

To identify areas of agreement and variation in clinical guidance documents (protocols, policies, or guidelines) that direct water birth care.

DESIGN

Qualitative descriptive.

SETTING

The clinical guidance documents studied covered water birth in home and hospital settings.

SAMPLE

The sample included 22 water birth guidance documents in English from six countries. The documents were obtained by request and resulting snowball sampling.

MEASUREMENTS

The framework method was adapted as an analytic tool, and a structured matrix output was used to organize and support the method of qualitative content analysis using a general inductive approach. Areas of general agreement and variations in practice guidelines for water birth were identified.

RESULTS

Criteria for a term, singleton, and cephalic presentation with reassuring maternal and fetal status were the most consistent for inclusion. The reliance on "low-risk" status was strongly present but without a uniform definition. A history of previous cesarean birth, body mass index, use of opioid pain medication, adequate labor progress, and vaginal bleeding were found to vary in directed care, and scarce supporting evidence was offered. Meconium-stained fluid variably excluded water birth in most documents, but this was not supported by evidence. The inconsistent findings from this study are cohesive in the evidence they provide for needed research in areas that affect access to water birth. The findings also provide nurses and birth providers with evidence-based guidelines for water birth care.

CONCLUSION

There was variation across guidance documents, demonstrating that water immersion is a flexible intervention that can be implemented in different settings and locations while following individual facility protocols for processes for care. An identified area of concern comes from examples of overly restrictive policies for water birth based on opinion or perceived risk rather than evidence from research.

Is a randomized controlled trial of waterbirth possible? An Australian feasibility study

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.

Women's preferences for water immersion during labor and birth: Results from a discrete choice experiment

BACKGROUND AND AIM

No discrete choice experiment study has been conducted to elicit women's preferences for water immersion during labor and birth.

METHODS

An online survey including sociodemographic questions and choice cards was conducted to explore women's preferences (i.e., factors that may influence their decision). Each participant responded to 12 choice cards with 6 attributes/factors (i.e., birth mode, duration of the labor phase, pain sensation, risk of severe perineal tears, risk of death of the newborn, and newborn general condition). Utilities were estimated using logit, latent class, and hierarchical Bayesian analyses.

FINDINGS

A total of 1088 subjects completed the survey in 2019. The risk of death of the newborn was given high priority by women in all but one analyses, while the risk of severe perineal tears was always considered the least important attribute. The latent class analysis clearly revealed three classes of women. The largest class including 52.9% of women was interested in water birth if it could reduce pain and would be risk-free for the newborn. The second class included 30.8% of women interested in water immersion but only during the labor phase. Finally, the third class (16.2%) did not want to consider water immersion during labor and birth, regardless of its risks and benefits. Follow-up questions revealed that many women were interested in water birth only if they could be assured that there would be no risk for the newborn.

DISCUSSION AND CONCLUSION

This study provided insights in favor of water immersion during labor and birth contingent upon the safety of the procedure for the newborn.

STATEMENT OF SIGNIFICANCE

No discrete choice experiment on women's preference for water immersion during childbirth was previously conducted. Six attributes/factors were used for the discrete choice experiment. Water immersion is poorly used in Quebec with only 49 (7.9%) women over 621 with childbirth experience reporting such immersion. A majority of women (70-80%) were in favor of water immersion.

Systematic review and meta-analysis to examine intrapartum interventions, and maternal and neonatal outcomes following immersion in water during labour and waterbirth

OBJECTIVES

Water immersion during labour using a birth pool to achieve relaxation and pain relief during the first and possibly part of the second stage of labour is an increasingly popular care option in several countries. It is used particularly by healthy women who experience a straightforward pregnancy, labour spontaneously at term gestation and plan to give birth in a midwifery led care setting. More women are also choosing to give birth in water. There is debate about the safety of intrapartum water immersion, particularly waterbirth. We synthesised the evidence that compared the effect of water immersion during labour or waterbirth on intrapartum interventions and outcomes to standard care with no water immersion. A secondary objective was to synthesise data relating to clinical care practices and birth settings that women experience who immerse in water and women who do not.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

A search was conducted using CINAHL, Medline, Embase, BioMed Central and PsycINFO during March 2020 and was replicated in May 2021.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Primary quantitative studies published in 2000 or later, examining maternal or neonatal interventions and outcomes using the birthing pool for labour and/or birth.

DATA EXTRACTION AND SYNTHESIS

Full-text screening was undertaken independently against inclusion/exclusion criteria in two pairs. Risk of bias assessment included review of seven domains based on the Robbins-I Risk of Bias Tool. All outcomes were summarised using an OR and 95% CI. All calculations were conducted in Comprehensive Meta-Analysis V.3, using the inverse variance method. Results of individual studies were converted to log OR and SE for synthesis. Fixed effects models were used when I2 was less than 50%, otherwise random effects models were used. The fail-safe N estimates were calculated to determine the number of studies necessary to change the estimates. Begg's test and Egger's regression risk assessed risk of bias across studies. Trim-and-fill analysis was used to estimate the magnitude of effect of the bias. Meta-regression was completed when at least 10 studies provided data for an outcome.

RESULTS

We included 36 studies in the review, (N=157 546 participants). Thirty-one studies were conducted in an obstetric unit setting (n=70 393), four studies were conducted in midwife led settings (n=61 385) and one study was a mixed setting (OU and homebirth) (n=25 768). Midwife led settings included planned home and freestanding midwifery unit (k=1), alongside midwifery units (k=1), planned homebirth (k=1), a freestanding midwifery unit and an alongside midwifery unit (k=1) and an alongside midwifery unit (k=1). For water immersion, 25 studies involved women who planned to have/had a waterbirth (n=151 742), seven involved water immersion for labour only (1901), three studies reported on water immersion during labour and waterbirth (n=3688) and one study was unclear about the timing of water immersion (n=215).Water immersion significantly reduced use of epidural (k=7, n=10 993; OR 0.17 95% CI 0.05 to 0.56), injected opioids (k=8, n=27 391; OR 0.22 95% CI 0.13 to 0.38), episiotomy (k=15, n=36 558; OR 0.16; 95% CI 0.10 to 0.27), maternal pain (k=8, n=1200; OR 0.24 95% CI 0.12 to 0.51) and postpartum haemorrhage (k=15, n=63 891; OR 0.69 95% CI 0.51 to 0.95). There was an increase in maternal satisfaction (k=6, n=4144; OR 1.95 95% CI 1.28 to 2.96) and odds of an intact perineum (k=17, n=59 070; OR 1.48; 95% CI 1.21 to 1.79) with water immersion. Waterbirth was associated with increased odds of cord avulsion (OR 1.94 95% CI 1.30 to 2.88), although the absolute risk remained low (4.3 per 1000 vs 1.3 per 1000). There were no differences in any other identified neonatal outcomes.

CONCLUSIONS

This review endorses previous reviews showing clear benefits resulting from intrapartum water immersion for healthy women and their newborns. While most included studies were conducted in obstetric units, to enable the identification of best practice regarding water immersion, future birthing pool research should integrate factors that are known to influence intrapartum interventions and outcomes. These include maternal parity, the care model, care practices and birth setting.

PROSPERO REGISTRATION NUMBER

CRD42019147001.

Comparative Efficacy of Water and Conventional Delivery during Labour: A Systematic Review and Meta-Analysis

In many maternal settings, water delivery is widely available for women who do not have an increased risk of complications during childbirth. Soaking in water during labor has been associated with a number of maternal benefits. However, the situation of water birth is not well known, there is lack of hard evidence on safety, and little is known about the characteristics of women who give birth in water. In this paper, we have explored the effects of water delivery compared to the conventional delivery on the health of mothers and babies. For this purpose, clinical trials were conducted including women in labor, in which participants were treated with water labor or conventional labor, respectively, in the experimental and control group. In this analysis, we have selected 17 eligible studies which included 175654 participants. Compared to the conventional birth group, the risk of Apgar score <7 at 5 min of age in the water birth group dropped by 28% (OR = 0.72, 95% CI: 0.52-1.00, I 2 = 25%, P=0.05). Also, the duration of labor was shorter the in water birth group whatever the labor stage was. The patients who underwent water birth showed an obviously lower rate of neonatal intensive care unit (NICU) admission (OR = 0.58, 95% CI: 0.39-0.86, I 2 = 53%, P=0.007). In this meta-analysis, it was seen that water delivery has clinical significance in alleviating the pain of mothers, promoting the safety of mothers and infants, and reducing postpartum complications.

Maternal and neonatal outcomes following waterbirth: a cohort study of 17 530 waterbirths and 17 530 propensity score-matched land births

OBJECTIVE

Investigate maternal and neonatal outcomes following waterbirth.

DESIGN

Retrospective cohort study, with propensity score matching to address confounding.

SETTING

Community births, United States.

SAMPLE

Medical records-based registry data from low-risk births were used to create waterbirth and land birth groups (n = 17 530 each), propensity score-matched on >80 demographic and pregnancy risk covariables.

METHODS

Logistic regression models compared outcomes between the matched waterbirth and land birth groups.

MAIN OUTCOME MEASURES

Maternal: immediate postpartum transfer to a hospital, any genital tract trauma, severe (3rd/4th degree) trauma, haemorrhage >1000 mL, diagnosed haemorrhage regardless of estimated blood loss, uterine infection, uterine infection requiring hospitalisation, any hospitalisation in the first 6 weeks. Neonatal: umbilical cord avulsion; immediate neonatal transfer to a hospital; respiratory distress syndrome; any hospitalisation, neonatal intensive care unit (NICU) admission, or neonatal infection in the first 6 weeks; and neonatal death.

RESULTS

Waterbirth was associated with improved or no difference in outcomes for most measures, including neonatal death (adjusted odds ratio [aOR] 0.56, 95% CI 0.31-1.0), and maternal or neonatal hospitalisation in the first 6 weeks (aOR 0.87, 95% CI 0.81-0.92 and aOR 0.95, 95% CI 0.90-0.99, respectively). Increased morbidity in the waterbirth group was observed for two outcomes only: uterine infection (aOR 1.25, 95% CI 1.05-1.48) (but not hospitalisation for infection) and umbilical cord avulsion (aOR 1.57, 95% CI 1.37-1.82). Our results are concordant with other studies: waterbirth is neither as harmful as some current guidelines suggest, nor as benign as some proponents claim.

TWEETABLE ABSTRACT

New study demonstrates #waterbirth is neither as harmful as some current guidelines suggest, nor as benign as some proponents claim. @TheUpliftLab @BovbjergMarit @31415926abc @NICHD_NIH.

Neonatal Outcomes After Delivery in Water

OBJECTIVE

To assess neonatal intensive care unit (NICU) admissions and neonatal outcomes after water birth or land birth in an alternative birthing center.

METHODS

We conducted a prospective observational study of preselected low-risk parturients separated into three groups depending on their location for labor and delivery: land-land, water-land, and water-water. Delivery outcomes, labor length, maternal pain assessment, need for newborn resuscitation, and NICU admission and diagnoses were collected. The primary outcome was admission to the NICU.

RESULTS

There were 2,077 total deliveries from April 2015 to December 2019, consisting of 458 land-land deliveries, 730 water-land deliveries, and 889 water-water deliveries. The rate of NICU admission was 2.8% (95% CI 1.5-4.8%) for land-land deliveries, 4.1% (2.8-5.8%) for water-land deliveries, and 2.0% (1.2-3.2%) for water-water deliveries. A post hoc power analysis revealed a 70% power to detect a 2.1% difference in NICU admissions between the water-land and water-water groups.

CONCLUSION

In this cohort of low-risk pregnant women, births in water and on land were associated with similar rates of admission to the NICU.

Feature Article—Continuing Education Module—International Water-Birth Practices With Recommendations During a Global Pandemic

The number of hospitals globally that offer water birth has increased exponentially during the past 10 years. This article examines some of the reasons for this increase as well as the objections to water birth by The American College of Obstetricians and Gynecologists, raised in their 2014 and 2016 opinion statements. The amount of research has also increased as more hospitals are keeping track of their data and publishing both prospective studies and retrospective analyses. The effects of water birth on the neonate are discussed through three meta-analyses from 2015, 2016, and 2018. The challenges and recommendations on continuing the use of water during labor and birth as a nonpharmacologic comfort measure even during a global pandemic are highlighted and supported by the best available evidence.

Effect of hot shower application on pain anxiety and comfort in the first stage of labor: A randomized controlled study

We conducted a randomized controlled study of the effects of a hot shower on pain, anxiety, and comfort during the first stage of labor. Our sample included 104 primigravidas. There was no statistically significant difference between the groups in terms of duration of labor, yet the transition phase time of the experimental group was lower compared to the control group. Also, the pain and scores of the experimental group were significantly lower than the control group in 4, 5-7, and 8-10 cm dilatation. In addition, the total comfort score of the experimental group was higher than the control group. We determined that the application of a hot shower in the first stage of labor reduces pain and anxiety has a positive effect on birth comfort and shortens the transition phase time.

Waterbirth: a national retrospective cohort study of factors associated with its use among women in England

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 evidence on safety lacking and little known about the characteristics of women who give birth in water.

This retrospective cohort study uses electronic data routinely collected in the course of maternity care in England in 2015–16 to describe the proportion of births recorded as having occurred in water, the characteristics of women who experienced waterbirth and the odds of key maternal and neonatal complications associated with giving birth in water.

Methods

Data were obtained from three population level electronic datasets linked together for the purposes of a national audit of maternity care. The study cohort included women who had no risk factors requiring them to give birth in an obstetric unit according to national guidelines. Multivariate logistic regression models were used to examine maternal (postpartum haemorrhage of 1500mls or more, obstetric anal sphincter injury (OASI)) and neonatal (Apgar score less than 7, neonatal unit admission) outcomes associated with waterbirth.

Results

46,088 low and intermediate risk singleton term spontaneous vaginal births in 35 NHS Trusts in England were included in the analysis cohort. Of these 6264 (13.6%) were recorded as having occurred in water. Waterbirth was more likely in older women up to the age of 40 (adjusted odds ratio (adjOR) for age group 35–39 1.27, 95% confidence interval (1.15,1.41)) and less common in women under 25 (adjOR 18–24 0.76 (0.70, 0.82)), those of higher parity (parity ≥3 adjOR 0.56 (0.47,0.66)) or who were obese (BMI 30–34.9 adjOR 0.77 (0.70,0.85)). Waterbirth was also less likely in black (adjOR 0.42 (0.36, 0.51)) and Asian (adjOR 0.26 (0.23,0.30)) women and in those from areas of increased socioeconomic deprivation (most affluent versus least affluent areas adjOR 0.47 (0.43, 0.52)).

There was no association between delivery in water and low Apgar score (adjOR 0.95 (0.66,1.36)) or incidence of OASI (adjOR 1.00 (0.86,1.16)). There was an association between waterbirth and reduced incidence of postpartum haemorrhage (adjOR 0.68 (0.51,0.90)) and neonatal unit admission (adjOR 0.65 (0.53,0.78)).

Conclusions

In this large observational cohort study, there was no association between waterbirth and specific adverse outcomes for either the mother or the baby. There was evidence that white women from higher socioeconomic backgrounds were more likely to be recorded as giving birth in water. Maternity services should focus on ensuring equitable access to waterbirth.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03724-6.

A systematic meta-thematic synthesis to examine the views and experiences of women following water immersion during labour and waterbirth

AIMS

To gather, quality assess, synthesize and interpret the views, feeling, and experiences of women who used water immersion during labour and/or birth.

DESIGN

A systematic meta-thematic synthesis and GRADE-CERQual.

DATA SOURCES

We searched MEDLINE, CINHAL, PsychINFO, AMED, EMBASE (MIDIRS only), LILACS, AJOL. Additional searches were carried out using Ethos (thesis database), cross-referencing against Google Scholar and citation chasing. Searches were carried out in August 2019, updated February 2020.

METHODS

Studies that met the selection criteria were appraised for quality. Data were extracted from the studies using meta-thematic analytical techniques; coding, descriptive findings, and analytical findings. The descriptive findings were subjected to confidence assessments using GRADE-CERQual.

RESULTS

Seven studies met the inclusion criteria. Nine key statements of findings were generated - one had high confidence, three moderate, three low and one very low confidence in the findings. The analytical findings generated three main themes: Liberation and Self-Emancipation, Synergy, transcendence and demarcation and Transformative birth and beyond. Overall, women experienced warm water immersion during labour and/or birth positively. Both the water and pool itself, facilitated women's physical and psychological needs during labour and/or birth, including offering effective analgesia. Our findings indicated that birthing pools are versatile tools that provide for a space that women can adapt and influence to best suit their individual needs.

CONCLUSION

Women who used warm water immersion for labour and/or birth describe liberating and transformative experiences of welcoming their babies into the world. They were empowered, liberated, and satisfied. We recommend maternity professionals and services offer water immersion as a standard method of pain relief during labour/birth.

IMPACT

Understanding women's experiences of labour and birth will inform future clinical practice. Midwives are optimally positioned to enhance women's access to water immersion. These findings have implications for education, guideline, and policy development as well as clinical practice.

Maternal and Neonatal Outcomes in Hospital-Based Deliveries With Water Immersion

Hospital-based deliveries with second-stage water immersion had no higher risk of neonatal intensive care or special care nursery admissions than a clinically comparable population.

OBJECTIVE:

To compare neonatal intensive care unit (NICU) or special care nursery admission for deliveries with water immersion compared with deliveries in the matched control group without water immersion. Secondary outcomes included adverse neonatal diagnoses, maternal infections, and perineal lacerations.

METHODS:

We conducted a retrospective study using electronic health record data (2014–2018) from two health systems (eight hospitals), with similar clinical eligibility, associated with low risks of intrapartum complications, and implementation policies for waterbirth. The water immersion group included women intending waterbirth. Water immersion was recorded prospectively during delivery. The comparison population were women who met the clinical eligibility criteria for waterbirth but did not experience water immersion during labor. Comparison cases were matched (1:1) using propensity scores. Outcomes were compared using Fischer's exact tests and logistic regression with stratification by stage of water immersion.

RESULTS:

Of the 583 women with water immersion, 34.1% (199) experienced first-stage water immersion only, 65.9% (384) experienced second-stage immersion, of whom 12.0% (70) exited during second stage, and 53.9% (314) completed delivery in the water. Neonatal intensive care unit or special care nursery admissions were lower for second-stage water immersion deliveries than deliveries in the control group (odds ratio [OR] 0.3, 95% CI 0.2–0.7). Lacerations were lower in the second-stage immersion group (OR 0.5, 95% CI 0.4–0.7). Neonatal intensive care unit or special care nursery admissions and lacerations were not different between the first-stage immersion group and their matched comparisons. Cord avulsions occurred for 0.8% of second-stage water immersion deliveries compared with none in the control groups. Five-minute Apgar score (less than 7), maternal infections, and other adverse outcomes were not significantly different between either the first- or second-stage water immersion groups and their control group.

CONCLUSION:

Hospital-based deliveries with second-stage water immersion had lower risk of NICU or special care nursery admission and perineal lacerations than matched deliveries in the control group without water immersion.

Factors influencing water immersion during labour: qualitative case studies of six maternity units in the United Kingdom

BACKGROUND

Water immersion during labour can provide benefits including reduced need for regional analgesia and a shorter labour. However, in the United Kingdom a minority of women use a pool for labour or birth, with pool use particularly uncommon in obstetric-led settings. Maternity unit culture has been identified as an important influence on pool use, but this and other possible factors have not been explored in-depth. Therefore, the aim of this study was to identify factors influencing pool use through qualitative case studies of three obstetric units and three midwifery units in the UK.

METHODS

Case study units with a range of waterbirth rates and representing geographically diverse locations were selected. Data collection methods comprised semi-structured interviews, collation of service documentation and public-facing information, and observations of the unit environment. There were 111 interview participants, purposively sampled to include midwives, postnatal women, obstetricians, neonatologists, midwifery support workers and doulas. A framework approach was used to analyse all case study data.

RESULTS

Obstetric unit culture was a key factor restricting pool use. We found substantial differences between obstetric and midwifery units in terms of equipment and resources, staff attitudes and confidence, senior staff support and women's awareness of water immersion. Generic factors influencing use of pools across all units included limited access to waterbirth training, sociodemographic differences in desire for pool use and issues using waterproof fetal monitoring equipment.

CONCLUSIONS

Case study findings provide new insights into the influence of maternity unit culture on waterbirth rates. Access to pool use could be improved through midwives based in obstetric units having more experience of waterbirth, providing obstetricians and neonatologists with information on the practicalities of pool use and improving accessibility of antenatal information. In terms of resources, recommendations include increasing pool provision, ensuring birth room allocation maximises the use of unit resources, and providing pool room environments that are acceptable to midwives.

Beliefs and Perspectives of Women and Obstetrical Providers in Northern Ontario on Water Births

OBJECTIVE

This study sought to understand the beliefs and perspectives of women in northern Ontario and their obstetrical providers with respect to water birthing as access to this service is limited in this region METHODS: All midwives, family physicians (FPs), and obstetricians providing labour and delivery services in northern Ontario were surveyed, as were a sample of labour and delivery nurses in the region and convenience samples of regional women.

RESULTS

Of the 362 women who completed the survey (a 90.5% response rate), 81.8% (95% CI 77.5-85.4) believed water births to be safe, 40.9% (95% CI 35.9-46) were interested in having a water birth, and 76.5% (95% CI 71.8-80.5) wanted to have the option of a hospital-based water birth. Perceptions of water birth safety varied significantly by provider type (χ²P < 0.001) with 100% (95% CI 89.6-100) of midwives but 0% (95% CI 52.3-94.9) of obstetricians considering them to be safe. Perceptions of the specific risks and benefits of water birth also varied significantly by provider type, as did understanding of consumer interest. Reflecting these perceptions, 97.1% (95% CI 85.1-99.5) of midwives and 0% (95% CI 0-27.8) of obstetricians would consider assisting in or providing hospital-based water births.

CONCLUSIONS

Women in northern Ontario are interested in water birth and in having this service available in hospitals. However, given the widely divergent views of the professional groups providing labour and delivery care in the region, hospitals should be strongly encouraged to explore interprofessional development opportunities to enable patient-centred care in this context.

The Experience of Land and Water Birth Within the American Association of Birth Centers Perinatal Data Registry, 2012-2017

Consumer demand for water birth has grown within an environment of professional controversy. Access to nonpharmacologic pain relief through water immersion is limited within hospital settings across the United States due to concerns over safety. The study is a secondary analysis of prospective observational Perinatal Data Registry (PDR) used by American Association of Birth Center members (AABC PDR). All births occurring between 2012 and 2017 in the community setting (home and birth center) were included in the analysis. Descriptive, correlational, and relative risk statistics were used to compare maternal and neonatal outcomes. Of 26 684 women, those giving birth in water had more favorable outcomes including fewer prolonged first- or second-stage labors, fetal heart rate abnormalities, shoulder dystocias, genital lacerations, episiotomies, hemorrhage, or postpartum transfers. Cord avulsion occurred rarely, but it was more common among water births. Newborns born in water were less likely to require transfer to a higher level of care, be admitted to a neonatal intensive care unit, or experience respiratory complication. Among childbearing women of low medical risk, personal preference should drive utilization of nonpharmacologic care practices including water birth. Both land and water births have similar good outcomes within the community setting.

Systematic Review of Case Reports of Poor Neonatal Outcomes With Water Immersion During Labor and Birth

Water immersion is a valuable comfort measure in labor, that can be used during the first or second stage of labor. Case reports of adverse outcomes create suspicion about water birth safety, which restricts the availability of water birth in the United States. The objective of this study was to synthesize the information from case reports of adverse water birth events to identify practices associated with these outcomes, and to identify patterns of negative outcomes. The research team conducted a systematic search for cases reports of poor neonatal outcomes with water immersion. Eligible manuscripts reported any adverse neonatal outcome with immersion during labor or birth; or excluded if no adverse outcome was reported or the birth reported was unattended. A qualitative narrative synthesis was conducted to identify patterns in the reports. There were 47 cases of adverse outcomes from 35 articles included in the analysis. There was a pattern of cases of Pseudomonas and Legionella, but other infections were uncommon. There were cases of unexplained neonatal hyponatremia following water birth that need further investigation to determine the mechanism that contributes to this complication. The synthesis was limited by reporting information of interest to pediatricians with little information about water birth immersion practices. These data did not support concerns of water aspiration or cord rupture, but did identify other potential risks. Water immersion guidelines need to address infection risk, optimal management of compromised water-born infants, and the potential association between immersion practice and hyponatremia.

Water Birth and Perinatal Outcomes in British Columbia: A Retrospective Cohort Study

OBJECTIVE

This study aimed to quantify adverse neonatal outcomes in a cohort of registered midwife (RM)-attended conventional and water births in British Columbia.

METHODS

The study included all term singleton births in British Columbia between January 1, 2005 and March 31, 2016 attended by RMs. Births were allocated to a conventional birth cohort or a water birth cohort according to where the actual birth of the neonate took place. The primary outcome was a composite adverse neonatal outcome (Apgar <7 at 5 minutes, resuscitation need, neonatal intensive care unit admission). Secondary outcomes included individual components of the primary outcome, maternal length of labour, and degree of perineal laceration (Canadian Task Force Classification Level II-2).

RESULTS

The population included 25 798 births. Of these, 23 201 were conventional, and 2567 were water births. The rate of the composite adverse neonatal outcome was not higher in water births compared with conventional births (hospital conventional, 5.0%; hospital water, 4.2%; home conventional, 3.4%; and home water, 2.9%). Rates of individual components of the composite adverse neonatal score were not greater in the water birth cohort. Maternal outcomes included statistically shorter labours in the water birth cohort and no difference between the cohorts in incidence of third- and fourth-degree lacerations.

CONCLUSION

Water births attended by RMs in British Columbia are not associated with higher rates of adverse neonatal outcomes than conventional births attended by midwives.

Factors influencing the use of birth pools in the United Kingdom: Perspectives of women, midwives and medical staff

Objective

To identify factors influencing the use of birth pools.

Design

Online discussion groups and semi-structured interviews, analysed thematically.

Setting

United Kingdom.

Participants

85 women and 21 midwives took part in online discussion groups; 14 medical staff participated in interviews.

Findings

Factors influencing the use of birth pools were grouped into three overarching categories: resources, unit culture and guidelines, and staff endorsement. Resources encompassed pool availability, efficiency of pool use and availability of waterproof cardiotocograph equipment. Unit culture and guidelines related to eligibility criteria for pool use, medicalisation of birth and differences between midwifery-led and obstetric-led care. Staff endorsement encompassed attitudes towards pool use.

Key conclusions

Accessibility of birth pools was often limited by eligibility criteria. While midwifery-led units were generally supportive of pool use, obstetric-led units were described as an over-medicalised environment in which pool use was restricted and relied on maternal request.

Implications for practice

Midwives can improve women's access to birth pools by providing information antenatally and proactively offering this as an option in labour. Maternity units should work to implement evidence-based guidelines on pool use, increase pool availability (even where there appears to be low demand), and enhance awareness amongst medical staff of the benefits of water immersion.

Outcomes of Waterbirth in a US Hospital-Based Midwifery Practice: A Retrospective Cohort Study of Water Immersion During Labor and Birth

INTRODUCTION

Although the safety of water immersion during labor is largely supported by evidence from research, the risks to women and neonates during waterbirth are not well established. The purpose of this study was to generate evidence regarding maternal and neonatal outcomes related to water immersion in labor and during birth.

METHODS

A retrospective cohort study included a convenience sample of women receiving prenatal care at a nurse-midwifery practice. Participants were categorized into 3 groups: 1) waterbirth, 2) water labor, or 3) neither. Participant characteristics, maternal outcomes, and newborn outcomes were collected at time of birth and health record abstraction. At the 6-week postpartum visit, another maternal outcome, satisfaction with birth, was measured using the Care in Obstetrics: Measure for Testing Satisfaction (COMFORTS) scale. Analysis included effect size, descriptive statistics (sample characteristics), and maternal and neonatal group differences (analysis of variance and chi-square) with a significance level of P < .05.

RESULTS

Women in the waterbirth (n = 58), water labor (n = 61), and neither (n = 111) groups were primarily white, married, and college educated and did not differ by age or education. Women in the waterbirth group were more likely to be multiparous. Nulliparous women who had a waterbirth had a significantly shorter second stage of labor than nulliparous women who did not have a waterbirth (P = .03). The most commonly cited reasons for discontinuation of hydrotherapy were maternal choice (42.6%) and need for pain medication (29.5%). Significantly more women in the waterbirth group experienced a postpartum hemorrhage, compared with water labor or neither (n = 5, n = 3, n = 1, respectively; P = .045); there was no difference in related clinical measures. Neonatal outcomes were not significantly different. Maternal satisfaction was high across all groups.

DISCUSSION

The results of this study suggest that waterbirth, attended by qualified intrapartum care providers in hospital settings in the United States, is a reasonable option for low-risk women and their neonates.

Who Gives Birth in the Water? A Retrospective Cohort Study of Intended versus Completed Waterbirths

INTRODUCTION

Most waterbirth studies have been conducted outside the United States with a primary focus on birth outcomes. Studies to date provide limited information about how often women choosing waterbirth end water immersion before the birth and about the reasons for tub exit. This study examines a cohort of women intending a hospital-based waterbirth and documents the timing and reasons for tub exit. Demographic, clinical, and intrapartum care provider characteristics among women completing waterbirth were compared with those who exited the water prior to birth.

METHODS

This is a collaborative, multisite study from 2 health systems (8 hospitals) using retrospective electronic health records from August 2014 through December 2017.

RESULTS

Of 576 women who entered the waterbirth tub, 48% exited prior to the birth. The primary reasons for exit were maternal choice (50%), medical indication (32%), and provider decision (13%). Women exiting in the first stage did so primarily by choice (57%), whereas medical indication (42%) was the most common reason among women exiting in the second stage. Women who completed waterbirth did not differ from those who exited prior to birth with regard to age, race, ethnicity, country of origin, language, marital status, or intrapartum care provider specialty. Women completing waterbirth were more likely to have previously given birth (72% vs 47%) and to have a provider with more water immersion births during the study period (65% vs 55%).

DISCUSSION

Giving birth in the tub was associated with parity and intrapartum care provider experience. Half of the women intending waterbirth in this study exited the tub, with variation in exit reason by stage and provider type. It is important for women to understand that they or their provider may change the birth plan based on labor progress and maternal experience.

Water Birth Maternal and Neonatal Outcomes Among Midwifery Clients in Alberta, Canada, from 2014 to 2017: A Retrospective Study

OBJECTIVES

This study sought to evaluate retrospectively the maternal and neonatal outcomes of water births (WBs) managed by Registered Midwives in Alberta compared with traditional or "land" vaginal birth outcomes for clinical evidence or knowledge and to assist in health care management planning.

METHODS

This study was a retrospective cohort comparison of maternal and neonatal outcomes of WB (1716) and traditional or land birth (non-WB) (21 320) from selected low-risk maternal cohorts with spontaneous onset of labour and vaginal delivery in Alberta (2014-2017) using Alberta Perinatal Health Program data sets. Anonymized client and patient records linked the Alberta Perinatal Health Program data with inpatient Discharge Abstract Database for newborn and/or maternal personal health number (PHN/ULI) analyzed using SPSS 19.0 software (IBM Corp., Armonk, NY) (Canadian Task Force Classification II-2).

RESULTS

The WB group had fewer and less severe perineal lacerations despite increased macrosomia. The non-WB group had increased maternal factors (age <20 years, third- to fourth-degree perineal tears, excessive blood loss) and neonatal factors (Apgar scores <7 at 5 minutes and neonatal intensive care unit admission). No significant difference was identified between the birth groups for maternal age >35 years, primiparous status, maternal fever, maternal puerperal infection, maternal intensive care unit admission, low birth weight, neonatal resuscitation, and neonatal intensive care unit admission <28 days of life.

CONCLUSIONS

A low-risk maternal cohort of WBs (1716) managed by midwives had equivalent or improved neonatal outcomes compared with a low-risk maternal cohort of land or traditional births (21 320) managed by midwives and other maternity providers.