The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) released a joint statement on laboring and birthing in water, Committee Opinion #594: Immersion in Water During Labor and Delivery.  You can read the whole opinion here.  While they concede that laboring in water reduces pain, reduces use of epidurals and other pharmaceutical pain relief, and shortens labor, they come down against birthing in water. Their arguments are a little odd.

First, they make no universal recommendations that water submersion be available to laboring women.  The benefits are obvious–there are no side effects from water as pain relief, women like it, and it shortens labors without increasing risk or pain (as Pitocin augmentation does when it is used to shorten labor).  As both epidurals and Pitocin augmentation are ubiquitous at births attended by obstetricians, even though both carry risks, why would they not recommend that water submersion be available to all women as an alternative?

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Their statement against birthing in water is based on what are called “case reports.”  These are generally considered the lowest form of scientific evidence–if you could even call them scientific.  A case report is essentially a statement that someone saw something happen, but with no scientific comparison or exploration of alternative explanations.  Thus, if a baby had a bad outcome after a water birth that could be attributed to the water birth, a case report may assume it is attributable to the water birth.  This is a bit like saying, “My Aunt Myrtle went out walking in a blue hat and she fell down, so wearing blue hats must make people fall down,” or “My friends didn’t vaccinate their kids and the kids have not died of whooping cough.”

Ultimately, the opinion concludes,

The safety and efficacy of immersion in water during the second stage of labor have not been established, and immersion in water during the second stage of labor has not been associated with maternal or fetal benefit. (emphasis mine)

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But immersion in water during birth has been associated with multiple benefits during the birth (not just labor).  These include:

I am not sure why these would not be considered evidence of benefit.

The committee opinion itself says,

[T]he only difference in maternal outcomes from immersion during the second stage was an improvement in satisfaction among those allocated to immersion in one trial.

Apparently, women’s satisfaction with their birth experience is not worthy of consideration as a benefit.

This dismissal of women’s experience is mirrored in other recommendations.  For instance, ACOG’s recommendation on management of labor states,

Patients should be counseled that walking during labor does not enhance or improve progress in labor nor is it harmful.

Why bother telling the patient anything if this is the case?  Why not “counsel” her to do whatever makes her feel most comfortable?

ACOG’s Practice Bulletin on labor induction makes no note of maternal pain or preferences, except in cases of fetal demise, where it indicates that “patient preference” may be a consideration.  The only mention of “discomfort” is in reference to membrane stripping, but it is not indicated that potential discomfort should be a consideration when deciding whether or not to do the procedure.

So who benefits if water birth is prohibited?  The AGOG/AAP opinion indicates a number of potential harms to the infant, including drownings, near drownings, and respiratory distress.  However, they also note that the Cochrane Review on water birth did not come to the same conclusion:

Morbidity and mortality, including respiratory complications, suggested in case series were not seen in the 2009 Cochrane synthesis of RCTs, which concluded that, “there is no evidence of increased adverse effects to the fetus/neonate or woman from laboring in water or water birth.”

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They suggest however, that the randomized control trials (RCTs) were not large enough to pick up on “rare but potentially serious outcomes.”  This is the same reasoning given by the the chief of obstetrics at Massachussetts General Hospital, Michael Greene, for ignoring the results of a large randomized control trial that showed the safety of planned vaginal birth for twins.  Basically, he said, he wanted to keep practicing the way he always had and saw no compelling reason to change.

It is frustrating to see physicians making bold statements against something women want when not only is there no scientific evidence to support their view, the most rigorous evidence that exists actually comes to the opposite conclusion.  Both doctors and midwives in the United Kingdom endorse water birth, stating that basic safety should be practiced and that the people attending the birth should be properly trained:

Both the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives support labouring in water for healthy women with uncomplicated pregnancies. The evidence to support underwater birth is less clear but complications are seemingly rare. If good practice guidelines are followed in relation to infection control, management of cord rupture and strict adherence to eligibility criteria, these complications should be further reduced.

The United Kingdom has better birth outcomes than the U.S.  Though water birth itself likely has nothing to do with that, it does seem like an American focus on a process that has, as ACOG and AAP acknowledge, no scientific evidence of harm, is misplaced.

This leads to the consideration of who does benefit from a policy of banning water birth.  Most doctors have not been trained in how to perform water births and may have never seen one.  Nancy Shute writes on NPR’s health news site,

[I]t’s hard not to get the sense that this also may be a bit of a battle for control over the birthing process.

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Barbara Harper, founder of Waterbirth International,  teaches all over the world. This is her official response to the ACOG/AAP opinion:

There are no bad outcomes, nothing that would lead ACOG to issue this statement at this time. Doctors see that women want options that are out of their comfort zone, educational scope and experience and it pushes the envelope for freedom of choice and human rights. It is a basic human right to birth without drugs or intervention or interference of any kind. If that can be integrated into a hospital setting, great. But, it still makes doctors nervous because their training demands that they ‘do’ something at a birth instead of sit by and knit or take the photos. This is why I have titled my new book, ‘Birth, Bath and Beyond.’ Waterbirth gives you the ability to watch birth happen, relax with it, witness the miracle – and it changes the way you approach all other births after you experience it. Waterbirth equates liability in the litigious world that we live in. Waterbirth challenges the conventional ‘security oriented/risk management’ approach to maternity care.  The science behind waterbirth, coupled with the experience of at least a quarter of a million women who have done it, will dictate policy and not the opinion of any organization, even ACOG and the AAP.

As a commenter on the NPR piece, Erin Shetler, says,

There are risks and benefits of every type of birth intervention, including water births. But you don’t see ACOG coming out with news releases about the risks of epidurals (increased C-section rate), vacuum extraction (cephalatoma in a newborn’s brain), induction (increased risk of uterine rupture and fetal distress), episiotomy (increased likelihood of third- or fourth- degree tearing) and other common practices because these are risks they feel comfortable taking. The risk of infection increases with every pelvic exam during labor, but that doesn’t stop most doctors from doing several. Some of the drugs used for induction are very commonly used “off-label,” meaning that their use is not approved by the FDA. Look up the facts. No matter what kind of birth you like or endorse, coming out against water births because they have a few risks while staying mum and/or endorsing other interventions is disingenuous at best.

It’s worth noting that there are doctors and hospitals that do support water births, so this committee opinion is not universal.

If ACOG wants to develop a committee opinion that is truly in the interests of women’s health and not the physician’s bottom line or comfort zone, they might issue strongly worded opinions against practices with no scientifically established benefits and well established harms, such as pregnancy bed rest.

Plus, women don’t like bed rest.  Perhaps that should be worthy of consideration as well.

 

Updates

Barbara Harper on “Why Pediatricians Fear Waterbirth.”  Her evidence-based review points out misinterpretations and misrepresentations of research in the ACOG/AAP statement.

American Association of Birth Centers (AABC) Position Statement on waterbirth.  AABC has a long record of conducting waterbirths safely.

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