Water births should be treated as a medical 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.

Jennifer Gunter is an obstetrician-gynecologist and author of The Preemie Primer. She blogs at her self-titled site, Dr. Jen Gunter.

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