Water birth
I've always wondered about the place of water birth in the homebirth movement. One of the cornerstones of the homebirth movement seems to be the feeling that natural is "best" and that birth should occur the way nature intended. So where does water birth fit in? It is emphatically not natural! Human babies are not supposed to be born underwater. No primates give birth underwater. How can this completely artificial (and apparently dangerous) way of giving birth be reconciled with the homebirth movement?
Labels: water birth
31 Old Comments:
Ok, I'll bite. Go ahead and share your evidence for the "and apparently dangerous" way of giving birth (as in waterbirth).
Let me ask this however, is it all that unusual? Gee, I live in a rather large city where every hospital offers tubs for comfort during labor and 3 of 5 support waterbirth. It isn't offered just for homebirth.
I am a midwife and I kinda felt the same way til I went to a waterbirth conference and met doctors from around the world that had historical proof that waterbirths have occurred for years. That women gyrated to water for comfort and that peoples in differce places delivered in it, it isn't a fad, nor is it for everyone but it is a fantastic pain reliever.
Anonymous:
Here's just one example of a paper about waterbirth safety:
Ngyen, Kuschel, et al., Water Birth - A Near Drowning Experience, PEDIATRICS Vol. 110 No. 2 August 2002, pp. 411-413.
My question, though, is not about safety. It's about how a waterbirth could be part of the homebirth movement since it is emphatically not natural.
Ollie Hamilton:
"doctors from around the world that had historical proof that waterbirths have occurred for years"
As far as I know, there is no evidence for this. Do you perhaps remember in what cultures and what time frame this took place? I'd like to look into it, if possible.
"it is a fantastic pain reliever"
Maybe so, although if it were a great pain reliever it would be used to relieve other types of pain. In any event, it is not natural. Epidurals are an even more effective pain reliever and they are shunned by the natural childbirth movement precisely because they are not natural.
INgyen, Kuschel, et al., Water Birth - A Near Drowning Experience, PEDIATRICS Vol. 110 No. 2 August 2002, pp. 411-413.
Please share more than that as you're attempting to engage the general public and practitioners who do not have access to full-text journal studies in debate.
Here's the link:
Water Birth - A Near Drowning Experience
By the way, most scientific references are available on the Web. It is easiest to find them using Google Scholar. Just go to Google and click on "more" at the top. You can choose Google Scholar from the list of options.
I'm not sure I see how the births in this study are examples of "near drowning." In all four cases, the 1-minute Apgar was 7 or above. Surely a baby who had just "nearly drowned" would not be that vigorous only one minute later...?
I would be interested to see a comparison of rates of respiratory distress in infants that were and were not born in water. To me, this one sounds like the studies that "prove" that sleeping with your baby is unsafe by citing examples of babies who died in their parents' beds. Somehow, they always fail to mention the number of babies who die in their cribs. How many land-born babies have *exactly the same* respiratory problems as these water-born ones?
BTW, to answer your original question:
"So where does water birth fit in? It is emphatically not natural! Human babies are not supposed to be born underwater. No primates give birth underwater."
No other primates wear clothes, cook their food, or live in houses, either. Does that mean it's "unnatural" for us to do so?
Humans are similar to other primates in many ways, but we have greater brain capacity than any other animal. It is natural for us, as humans, to use our brains to find solutions to problems. To the problem of labor pain, many of us through the ages have found a low-tech and low-risk solution in waterbirth.
When birth advocates talk about "natural" birth, we mean many different things. Some believe that the only "natural" birth is done in solitude, with no assistance or intervention from anyone else. Others consider any vaginal birth to be a natural one, regardless of drugs or interventions - if it wasn't a C-section, it was "natural."
I fall somewhere in between, defining a natural birth as one that's accomplished without pain medication.
Waterbirth certainly falls into many of the categories that we assign to the word "natural." No, it may not be done by other primates (as far as I know), but it could easily be - it doesn't require any drugs, machines or advanced training.
I agree with you that waterbirth is not "natural", as far as what evolution has made integral to the birth process. Neither are many other things some homebirthers do, like use herbs (some of which are very effective and less risky than their pharmaceutical counterparts,) or the management and monitoring of birth in itself.
I feel the same when I hear hospital-birthers talking about their "natural" births that include pitocin augmentation, episiotomy, coached pushing, etc. What they mean, of course, is that the births are *vaginal*. So there are clearly different definitions of "natural".
My own birth was uncommonly spontaneous and instinctive, and I think if anyone can say her birth was "natural", it is me. But I did give birth in a house, with candles lit, and my husband putting pressure on my back. None of that is integral to the birth process either, and in that sense it was all "unnatural".
But so what? If someone does something that someone else defines as "unnatural", it doesn't necessarily follow that it's dangerous or counterproductive. And for someone to choose an "unnatural" thing to be a part of her birth experience doesn't invalidate the reasons behind avoiding other unnatural (and inherently risky) choices, like epidurals.
Jen McFar:
"This is a fantastic idea for debating homebirth, thank you for setting this up!"
I'm glad that you like it. I hope it will provide many different points of view in one place.
"Actually, water is used to combat pain in other fields. Just do a search on hydrotherapy and you will see how it is used for arthitis sufferers, etc. to help with pain management."
In that setting, hydrotherapy is used as an adjunct to medical therapy with anti-inflammatory agents and pain relievers. Furthermore, arthritis is a chronic condition known to respond to various types of physical therapy.
Labor, on the other hand, is an acute condition. I'd be more impressed with the pain relieving property of water if it were used to treat patients with kidney stones.
"a waterbirth is not so foreign, as the baby is going from one watery environment into another before transitioning to the air."
Nonetheless, it is not natural because babies are not supposed to transition through a watery environment. Studies of the physiology of vaginal delivery suggest that the newborn is primed to breathe immediately upon being born. It is interesting to me that the same people who express horror at the thought of TTN (a mild form of respiratory difficulty) after a C-section could embrace a procedure that is explicitly not natural.
Thank you for the historical references. I am going to check them. However, I think you would have to agree that those are specific cultural practices and don't have much to do with the way that the vast majority of women gave birth before the advent of medical practitioners.
Anne:
"I would be interested to see a comparison of rates of respiratory distress in infants that were and were not born in water."
I bet you could find such information. Try a search on Google Scholar.
"No other primates wear clothes, cook their food, or live in houses, either. Does that mean it's "unnatural" for us to do so?"
Actually, it does. These are all cultural practices and they vary dramatically from culture to culture. There is no physiologic need to wear clothes, for example.
If you are trying to put waterbirth in the same category as clothing or home building, then you are talking about a cultural practice. When I refer to the concept of "natural" childbirth, I mean childbirth as it happened for virtually all women over the course of human existence.
"for someone to choose an "unnatural" thing to be a part of her birth experience doesn't invalidate the reasons behind avoiding other unnatural choices"
No, it doesn't, but it does invalidate her claim that she is having a "natural" childbirth since she has introduced a totally made up practice, that may be harmful and certainly is not intended to be part of birth.
Once you start introducing "non-natural" practices, why should waterbirth be privileged above having an epidural. I know it is axiomatic in the natural childbirth movement that epidurals are harmful. However, I have yet to see the evidence that this is anything more than wishful thinking on the part of those who promote completely "natural" birth.
Amy Tuteur wrote:
"I bet you could find such information. Try a search on Google Scholar."
You're right - this was a great source. I found a nine-year study comparing neonatal and maternal morbidity and mortality in 3,617 water births and 5,901 land births. Tears, blood loss, and analgesic use were significantly lower in the waterbirths; infection rates were the same for both groups; and land-born babies were more likely to have complications and be transferred to NICU.
I'd be interested to hear of any comparable, large-scale studies that concluded that waterbirth is in some way unsafe.
Amy also wrote:
"If you are trying to put waterbirth in the same category as clothing or home building, then you are talking about a cultural practice. When I refer to the concept of "natural" childbirth, I mean childbirth as it happened for virtually all women over the course of human existence."
Could you explain further what you mean by this? Exactly how have virtually all women given birth; what do they all have in common?
I'm not asking this to be snarky; I'm really puzzled as to how we can separate birthing women from the cultures they're birthing in. As humans, we *all* live in one culture or another.
You've said that you believe that anyone who "introduces 'non-natural practices'" into her birth has not had a natural birth. You've also said that cultural practices like home building and clothing wearing are not natural.
So by that definition, a birth is not natural if it's attended by a trained care provider, or if the woman wears clothing or glasses, or if she births in water (or on a bed or in a house or building), or if her baby's heart rate is auscultated, or...... I have a hard time imagining any human since we became Homo sapiens who has had a completely "natural" birth.
Again, I'd truly like to know what you consider a natural birth for human beings.
Anne:
"I found a nine-year study comparing neonatal and maternal morbidity and mortality in 3,617 water births and 5,901 land births. Tears, blood loss, and analgesic use were significantly lower in the waterbirths; infection rates were the same for both groups; and land-born babies were more likely to have complications and be transferred to NICU."
The study is Waterbirths Compared with Land Births: an Observational Study of 9 Years, Geissbuhler et al., J Perinatal Med,32(2004)308-314. I had never read the study before, and I had to buy it to read it now.
There's a very serious problem with this study: it compares waterbirths in women with virtually no risk factors to land birth in all women having a vaginal delivery, including those with pregnancy complications.
Here's what the authors themselves say:
"Water- and land births differ significantly in all features and risks ...such as pre-eclampsia (including gestional hypertension), signs of infection ..., meconium stained amniotic fluid and suspicious/pathological fetal heart rate tracings."
So right away, the study is useless. The authors acknowlege that they compared low risk women who had a waterbirth with all women (including all high risk women) who had a land birth.
If that weren't bad enough, the authors acknowledge another serious violation of basic statistical research:
"There were 782 deliveries classified as planned but discontinued waterbirths. After discontinuation, 647 women delivered spontaneously and these women were included in the land birth group."
That means that any woman who experienced a complication while in the tub was pulled out, subtracted from the waterbirth group and added to the land birth group.
You cannot do that in scientific research. You cannot move people from one group to another. If a person starts in one group, they MUST stay in the same group.
It's pretty obvious if you think about it. If a woman in the waterbirth group developed an infection while in the tub and then was pulled out to receive IV antibiotics and delivered outside the tub, she is still in the waterbirth group. Her complication may have even been caused by being in the tub, so it is especially unreasonable to put her in the land birth group.
This is an awful study. Even so, violating two major rules of statistical analysis, the authors only managed to show women who did not have any risk factors and had a waterbirth did as well as a group that contained high risk women, AND women who actually failed waterbirth. That's hardly an endorsement of waterbirth.
Kudos to you for finding the article, but, unfortunately, the article does not prove what it claims.
"Her complication may have even been caused by being in the tub..."
Excuse me? What complication can be caused by laboring in water?
Anonymous:
"Excuse me? What complication can be caused by laboring in water?"
Infection.
I chose homebirth for my third baby not because I wanted everything "natural," but because I wanted an environment that made me feel safe and comfortable.
I did not make waterbirth a goal, but made sure it was an option by having a tub ready if I wanted it. As it happens, I did find being in the water substantially improved my experience and ability to cope, and when the time came I did give birth in the water, as I felt no need to get out at that point.
My goal in avoiding medication was not because it is "unnatural," but because I did not want the side effects and risks associated with the medication unless I had exhausted all other options, and the medication was truly needed.
I didn't want the cascade of interventions that pain medication usually brings--pitocin, continual monitoring, IV, catheter, no option but to push in lithotomy position, etc. My goal was not a "natural" birth, but a safe and gentle birth.
If the circumstances of my labor changed so that I needed more medical intervention, I would have gone to the hospital to receive it. If exhaustion made me unable to cope with the pain, I would have received pain medication. I'm glad that I didn't need it, and I'm glad that the environment I chose to birth in helped me reach that goal.
Amy wrote, quoting Anonymous:
"'Excuse me? What complication can be caused by laboring in water?'
"Infection."
Actually, it's been proven again and again that waterbirth does not increase the chances of maternal or infant infection. Bathwater does not enter the vagina. Please see this bibliography.
Still curious about your definition of natural birth!
Anne:
You can't submit a bibliography as evidence. You don't even know what any of these papers say. For all you know, they could show precisely the opposite. You need to read the papers before you can claim that they support your point.
"Still curious about your definition of natural birth!"
My definition of natural birth would birth as it took place from about 100,000 years ago until about 500 years ago.
<< My definition of natural birth would birth as it took place from about 100,000 years ago until about 500 years ago >>
Which, in multiple other posts, Dr. Amy has said do NOT count in our modern debate over this or that, because they happened before the advent of modern medicine. Which does not make much sense to me.
To me, who has read all the evidence (http://www.waterbirth.org/store/catalog/images/Documents/Bibliography2004.pdf) I believe waterbirth to be safe. For me, who has attended a hundred or more waterbirths, I believe it to be safe.
Dr. Amy, you might be interested to know: waterborn babies do not cry much. But they are the PINKEST babies you ever saw. And tears hardly ever happen.
But here's my devils-advocate question: even if a mother accepts any risk associated with waterbirth (or homebirth, for that matter) -- do you think it is HER RIGHT to accept any given (potential) risk, or do you think the choice of a mother is not important in this discussion?
Oh, and believe me, I do know what the articles in that bibliography say. Why, Dr. Amy, do you assume that we are less professional or less thorough in our work preparation than you? Seriously?
Basically, I believe 'natural birth' is a birth that occurs without drugs. I feel that we should trust our instincts regarding birth space, our bodies and natural environment- they're there to guide us. Some women are instinctively drawn toward water, and if they follow that instinct, that to me is natural. Birth can occur on land or in water, they're both natural elements, so to me there is nothing 'not natural' about water births in my opinion.
As for the safety of waterbirths, drownings are extremely rare, but there's another aspect to remember. In water, the chance of intervention is greatly reduced, therefore lessening the likelihood of birth trauma. Many women who suffer overly-'managed' births, (the cascade of interventions) go on to experience Post Traumatic Stress Disorder. A symptom of this is suicidal tendencies. Some women who have suffered birth trauma have taken their own lives, and those of their babies. This to me is a safety factor we need to consider.
Water births are often gentler births. There is less interference, less checking of dilation, less chance of episiotomy, less hands and instruments entering the vagina, less chance of birthrape. Therefore the woman has a positive experience, and her chances of PTSD are reduced, meaning healthy happy bonding and fewer lives lost.
Maribeth, CNM:
"even if a mother accepts any risk associated with waterbirth (or homebirth, for that matter) -- do you think it is HER RIGHT to accept any given (potential) risk
Of course, it is the mother's right to choose whatever she thinks is best for her. However, it is also her right to have accurate information. When a midwife tells a patient that water birth is as safe as "land" birth, she is giving FALSE information. How can a woman make an informed decision if the information she is given isn't true?
"do you think the choice of a mother is not important in this discussion?"
As I have said before, homebirth is ENTIRELY about the choice and experience of the mother. It is perfectly legitimate for a woman to make her choice based on her needs, wants and desires. Just don't tell me that it's for the good of the baby when there is significant evidence that shows it puts the baby at risk.
Back to your original question:
"So where does water birth fit in? It is emphatically not natural!"
This is a straw man argument. Advocates of natural birth are not by default advocates of natural to the exclusion of everything else - a rough but much more true definition of natural birth would be "without the use of pain medication". Water birth fits nicely into this definition.
The use of good logic prohibits your question and assertions. Why misrepresent an idea and then attack the misrepresentation? Obviously your questions are not addressing what we home- and water-birthers are encouraging.
As you are a doctor, you understand the use of certain methods where the advantages outweigh the risks, such as cesarean for a baby in distress. Do you disagree that the benefits of using water for labor and birth greatly outweigh any risks to mother and baby?
maribeth, cnmj said...
Oh, and believe me, I do know what the articles in that bibliography say. Why, Dr. Amy, do you assume that we are less professional or less thorough in our work preparation than you? Seriously?
Probably because people keep posting study abstracts which "prove" their point about home birth, without talking about (or reading, apparently) the details of the studies... and then, when the study is actually read, it doesn't "prove" their point at all.
See, for example, Anne's comment.
If you do this enough times, people start to get suspicious.
Other fun examples might include citing an opinion piece as "evidence". Or a bibliography. Not even the author of the bibliography would use it alone as support for a position!
To me, who has read all the evidence (http://www.waterbirth.org/store/catalog/images/Documents/Bibliography2004.pdf) I believe waterbirth to be safe. For me, who has attended a hundred or more waterbirths, I believe it to be safe.
Great! Does that mean we can cite a collection of evidence from our own personal sites, and you won't claim bias? Can Dr. Amy, who has attended thousands of births, "outrank" you?
If you want to play the "my site wins" or the "my anecdote wins" game, it works BOTH WAYS. And it not especially valid either way.
Dee Dibal said...
I've done several waterbirths and have had NO complications. I am NOT sure what is perceived as being dangerous about them. I am much more familiar with many more hospital generated injuries perpetrated on infants, i.e., facial lacerations during C/S (elective and/or emergent),
This is an interesting opportunity to make a point. An emergency C/S which results in a facial laceration is NOT necessarily a bad outcome. In fact, it's an EXCELLENT outcome if the infant would otherwise have died absent the C/S. If you're counting this in the "hospitals are bad" section (which it seems you are), you're missing something.
So, if neonatal injury is the yardstick, the hospital is much more dangerous and certainly NOT historical-except for the last 150 years or so.
Except that this ISN'T the yardstick. We've generally been talking about death as a yardstick.
Anonymous said:
Do you disagree that the benefits of using water for labor and birth greatly outweigh any risks to mother and baby?
First, I might point out that you don't need "many" problems caused by water birth, or "many" drownings, for it to radically change the safety analysis. 2 per thousand makes a BIG difference.
But yes: this is what we're disagreeing on.
Babies delivered in water: perinatal mortality is no higher
Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey
Ruth E Gilbert and Pat A Tookey
BMJ 1999 319: 483-487
Hmm. I don't seem to be able to find a full text link to that article. Can you provide one? What's your opinion on the details of the study?
I can't fully comment on the article without reading the study details. It may be an outstanding and accurate study which supports water birth, or it may not. Send me a full text link and I'll take a look.
I would be REALLY interested to see a water birth advocate discuss the study details, and explain why it's a good study in support of their position. It would be even better if someone could do this in advance of Dr. Amy doing so.
I wasn't able to use the Jacuzzi at the hospital where I gave birth to my son due to PROM but I am definitely hoping to use it if I have another baby. How could it not help? Just taking a shower helps me with a host of ills -- anxiety, nausea, general malaise, sore muscles after a good workout. And going for a swim is even better!
Cherrie said...
I think it's a mistake to use only mortality of baby as the yardstick, which Amy is quite bent on doing. I think the other side is using mortality and morbidity of both mother and baby as the yardstick.
The "other side" has been using mortality but also argiung morbidity whenever thay start losing on the mortality front.
The reason people are focusing on mortality is that this is ALREADY extremely complex and difficult to study. Some might say it's nearly impossible to study it well. Given that, it doesn't make much sense to vastly increase the study parameters.
I think we'd all agree on this point (better alive than dead). The part where it becomes muddy, however, is that 29% (latest c-section rate in US) of babies wouldn't otherwise have died without the C.
You are undoubtedly correct.
Having a c-section raises Mama's mortality risk 4%. How many babies actually needed that C to avoid death? Add that to how many Mamas died as a result of 29% C rate.
I think you're getting a little off track here. When a given person enters a hospital, she is in full control of whether she, personally, is willing to get a C-section. The vast increase in VOLUNTARY sections--which I think are nuts--is a decent indicator of that.
The sheer number of sections is not evidence of much, exactly. It might be a good starting point if you explained how many sections you think should happen. Zero? 27%?
Furthermore, how many subsequent babies miscarried, or abrupted, or caused morbidity for Mama due to accreta, etc? The risks of a high C rate aren't limited to the baby being born today. It's all subsequent pregnancys as well.
You might be able to figure this out through proper study, though I don't really know. But because you don't know either I'm not sure what you're getting at.
Reciting a laundry list of potential harms and trying to raise fears about risk isn't really evidence. It's not expecially persuasive. And--it turns out--it's often wrong.
That's why we DO statistical studies: to show that CS are (or are not) helpful, absent any belief one way or another.
I honestly can't get into this kind of debate, whether home birth or hospital birth is actually better and whether or not studies can support someone's specific stance. There are risks and benefits to everything, and whether you give birth in the hospital, in the OR, or on your kitchen floor, I just hope that you're comfortable and everyone is healthy by the end.
To say that pain medication has no effect on the baby is an outright lie. But they have been determined to be relatively safe. Cesareans are more risky but still they go well more often than not.
The truth is that birth is resilient enough to withstand these interventions and it generally turns out well no matter the method used. The rest - home or hospital, medicated or natural, land or water - is really just preference. That is why this discussion is never going to go anywhere.
The best thing we can do to improve our statistics is not confine all women to the hospital for birth. It's prenatal care. Women who take good care of themselves and have good health coverage have fewer complications during birth. Their births go well. Their babies are healthier. Plain and simple.
Cherrie:
"I think it's a mistake to use only mortality of baby as the yardstick, which Amy is quite bent on doing. I think the other side is using mortality and morbidity of both mother and baby as the yardstick."
That would certainly be a valid way to analyze the problem, particularly if the morbidities are serious and have long lasting consequences. Why not look into this and let us know if homebirths are superior to hospital birth in terms of morbidity?
Cherrie:
"But first, I'd like to hear how YOU THINK I think the morbidity rates compare."
I would think that the morbidities would be very different in the two groups. For example, the hospital group would contain iatrogenic morbidities. The homebirth group might contain morbidities related to delayed transfer to the hospital (infection, etc.). That would entail looking into what happened to the patients who transferred to the hospital after an attempted homebirth.
Of course, you'd have to make sure that the two groups were comparable to begin with in order to make a valid comparison.
There are some things that I imagine would be difficult to assess. For example, it is probably difficult to get good data about the amount of stitches that a woman might have needed at a homebirth to make an assessment of whether an episiotomy or stitching of tears caused greater morbidity.
More infection in the homebirth group than the hospital group, ha!
Amy do you know about the epidural - fetal fever link?
You really, truly think neither epidurals nore narcs have bad effects on babies??!!
I can't say it is necessarily part of a true human natural birth, but I have had one hospital birth ,three homebirths and two were in water. The water births were short and sweet. Neither of my babes had any respiratory problems. The one child that I have that has been hospitalized for athsma is the one who was hospital born. I would like to see more of proff that it is unsafe vs safe. Show me some true statistics.
As far as why shun an epidural and not water if both are unnatural is simlpy because one is a sytemic drug. It affects the ability of the mother to push properly and feel the contractions. Other pain medications drug the baby as well as the mother. Water is not a drug,it relaxes, is not invasive and allows a smooth birth. Babies are in water(amniotic fluid) before the birth. They breathe it in to excercise the lungs. The transition from the birth canal to the tub to air is more gradual. The baby gets oxygen from the pulsing red cord,as long as the placenta has not yet separated. My water birthed babies never cried when they were born.
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