Water birth

Water birth is a method of giving birth, which involves immersion in warm water. Proponents believe this method is safe and provides many benefits for both mother and infant, including pain relief and a less traumatic birth experience for the baby. However, critics argue that the procedure introduces unnecessary risks to the infant such as infection and water inhalation.

History
The use of warm-water pools for labor and childbirth is a relatively recent phenomenon in Western societies. During the 1960s, Russian researcher Igor Charkovsky undertook considerable research into the safety and possible benefits of water birth in the Soviet Union. In the late 1960s, French obstetrician Frederick Leboyer developed the practice of immersing newly-born infants in warm water to help ease the transition from the womb to the outside world, and to mitigate the effects of any possible birth trauma.

Another French obstetrician, Michel Odent, took Leboyer's work further, using the warm-water birth pool for pain relief for the mother, and as a way to normalize the birth process. When some women refused to get out of the water to finish giving birth, Odent started researching the possible benefits for the baby of being born under water, as well as the potential problems in such births. By the late 1990s, thousands of women had given birth at Odent's birthing center at Pithiviers, and the notion of water birth had spread to many other Western countries.

Water birth first came to the United States through couples giving birth at home, but soon was introduced into the medical environment of hospitals and free-standing birth centers by obstetricians and certified nurse midwives. In 1991, Monadnock Community Hospital in Peterborough, New Hampshire became the first hospital to create a protocol for giving birth in water. By 2005, there were over 300 hospitals in the US that had adopted such protocols. More than three-quarters of all National Health Service hospitals in the UK provide this option for laboring women.

Research
Considerable research has been undertaken into the safety of water birth. Two of the most prolific researchers have been Michel Odent and the American obstetrician Michael Rosenthal. Dianne Garland, a midwife in the UK, has focused on gathering research through the National Health Service system, and has published a book called, Waterbirth: An Attitude to Care. In the US, Barbara Harper, a nurse and childbirth educator, has explored waterbirth throughout the world, and chronicled the history and current use of waterbirth in dozens of countries in her book, Gentle Birth Choices. Harper has compiled an extensive bibliography of research on the subject, which can be seen at the website for Waterbirth International. 

For the baby
Childbirth can be a strenuous experience for the baby. Properly heated water helps to ease the transition from the birth canal to the outside world because the warm liquid resembles the familiar intra-uterine environment, and softens light, colors and noises.

Pain Management
Harper reports that water birth is an effective form of pain management during labor and delivery (Harper 2000). Water birth is a form of hydrotherapy which, in studies, has been shown to be an effective form of pain management for a variety of conditions especially lower back pain (a common complaint of women in labor). In an appraisal of 17 randomized trials, two controlled studies, 12 cohort studies, and two case reports, it was concluded that there was a definite "benefit from hydrotherapy in pain, function, self-efficacy and affect, joint mobility, strength, and balance, particularly among older adults, subjects with rheumatic conditions and chronic low back pain," (Geytenbeek 2002). When compared with conventional pain management techniques for labor and delivery (e.g. anaesthesia and narcotics) hydrotherapy is also possibly a safer alternative. In studies, epidural anaesthesia (EDA), is correlated with an increased rate of instrumental (e.g. forceps in childbirth) delivery rates and also cesarean section rates (Ros et al. 2007). Full immersion in water promotes physiological responses in the mother that reduce pain including a redistribution of blood volume, which stimulates the release of oxytocin and vasopressin (Katz 1990), the latter which also increases oxytocin blood levels (Odent 1998). The Cochrane Database of Systematic Reviews has found that "the statistically significant reduction in maternal perception of pain and in the rate of epidural analgesia suggest that water immersion during the first stage of labour is beneficial for some women. No evidence was found that this benefit was associated with poorer outcomes for babies or longer labours."

Intact perineum/Decreased Episiotomy
Support from the water slows crowning of the infant's head and offers perineal support (Garland 2000), which decreases the risk of tearing and reduces the need for episiotomies. Indeed, there is a zero episiotomy rate in the waterbirth literature (Harper 2000). Moroever, "perineal trauma is reported to be generally less severe, with more intact perineums for multips, but in some literature about the same frequency of tears for pimips in or out of the water," (Harper 2000; also see Burn 1993 and Garland 1997).

Risks and Concerns
A large-scale study of waterbirth in the UK (1994-1996) showed a decrease in perinatal mortality (1.2 per 1,000 for waterbirth vs. 4 per 1,000 for conventional birth during the same period) (Harper 2000; Gilbert 1999; London: Office for National Statistics 2005). While of the 150,000 recorded waterbirths worldwide between 1985 and 1999, problems comparable to non-water births did arise, "there are no valid reports of infants deaths due to water aspiration or inhalation," (Harper 2000).

A review of the literature on water birth suggests that any controversy in the medical community stems from OBGYN and pre-natal care providers who generally support water birth, on the one hand, and pediatric specialists who criticize water birth, on the other (see Schuman 2006). While this is by no means a universal divide, it appears to correlate with the "do no harm" credo. The American Academy of Pediatrics 2005 statement on water birth explains that because to date there is no adequate randomized controlled study to demonstrate any benefit to the newborn (only concern over possible complications), when parents are informed about water birth, risks (rather than benefits) should be stressed (Schuman 2006). However, on the other hand, studies have shown that labouring in water does offer significant benefits to the mother (as cited above). While as of 2006 the American College of Obstetricians and Gynecologists had not taken an official position on water birth (Schuman 2006), the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives explicitly support, "Immersion in water during labour and birth," (Royal College of Midwives 2006). Studies that are critical of water birth generally object to or cite evidence from "poorly managed" or un-monitored water birth by inexperience care providers (e.g. Zimmermann et al. 1993).

Infection
Another concern is that the water could increase the risk of infection. In a randomized controlled trial of the effects of water labor in Canada, no difference was noted in the low rates of maternal and newborn signs of infection in women with ruptured membranes (Rush 1996). Due to the rigorous protocols for cleaning birthing tubs between labors (especially in hospitals), there is little (if any) risk of transferring bacteria from infant to infant or mother to mother. In a 1999 study of bacterial cultures carried out at the Oregon Health Sciences University Hospital, there were no instances of bacteria cultured from the birth pool itself. While Pseudomonas bacteria (common in tap water) were present, even those infants that tested positive for the bacteria needed no treatment for infections (Harper 2000). These findings confirm those of a British study conducted over a 3-year period (Brown 1998).

Slowed Labor
Due to the documented relaxing effects of water, laboring in water is sometimes associated with a decrease in the intensity of contractions, and is thus thought to slow labor. While water birth experts (e.g. Harper, RN) argue that this must be evaluated on a case-by-case bases, some hospitals have adopted a "5 centimeter" rule, allowing women to enter the tub only once the cervix has already expanded to 5 centimeters (Harper 2000).

Maternal Blood Loss
For care providers who are inexperienced delivery in water, it may be difficult to assess the amount of maternal blood loss. While well-developed methods of determining maternal blood loss in water do exist (Harper 2000), many providers prefer to deliver the placenta "on land" for this reason (e.g. the University of Michigan hospital).

Acceptance
Water birth is accepted and practiced in many parts of the United States, Canada, Australia, and New Zealand, as well as many European countries, including the United Kingdom and Germany, where many maternity clinics have birthing tubs. Many independent birthing centers and many home birth midwives offer water birth services. At present, water birth is often practiced by those who choose to have a home birth, because the majority of hospitals have not yet installed proper birth pools in their maternity wards. In 2006, Waterbirth International listed more than 300 U.S. hospitals that offered such facilities. At least two such hospitals were listed in the 2006 U.S. News and World Report "Honor Roll" of best U.S. hospitals: Barnes-Jewish Hospital in St. Louis, Missouri and the University of Michigan hospital in Ann Arbor, MI.

Resources
Books Films
 * ''New Active Birth — A Concise Guide to Natural Childbirth,' Janet Balaskas, HarperCollins, UK, 1995 ISBN 0-7225-2566-4
 * Gentle Birth Choices, Barbara Harper, Inner Traditions, USA, 2005 ISBN 1-59477-067-0
 * Having a Great Birth in Australia, David Vernon, Australian College of Midwives, Canberra, 2005 ISBN 0-9751674-3-X
 * Water Baby: Experiences of Waterbirth an award-winning documentary by filmmaker Karil Daniels