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 perfect birth: a content analysis of midwives' posts about birth on Instagram.

BACKGROUND: There is limited research into how midwives use social media within their professional role. Small pilot studies have explored the introduction of social media into maternity practice and teaching but there is little evidence around how midwives use social media professionally. This is important as 89% of pregnant women turn to social media for advice during pregnancy, and how midwives use social media could be influencing women, their perception of birth and their decision making. METHODS: AIM: To analyse how popular midwives portray birth on the social media platform Instagram. This is an observational mixed methods study using content analysis. Five 'popular' midwives from each country (UK, New Zealand, USA and Australia) were identified and their posts about birth collated from a one-year period (2020-21). Images/videos were then coded. Descriptive statistics enabled comparison of the posts by country. Categorisation was used to analyse and understand the content. RESULTS: The study identified 917 posts from the 20 midwives' accounts, containing 1216 images/videos, with most coming from USA (n = 466), and UK (n = 239), Australia (n = 205) and New Zealand (n = 7) respectively. Images/videos were categorised into 'Birth Positivity', 'Humour', 'Education', 'Birth Story' and 'Advertisement'. Midwives' portrayals of birth represented a greater proportion of vaginal births, waterbirths and homebirths than known national birth statistics. The most popular midwives identified mainly had private businesses (n = 17). Both the midwives and women portrayed in images were primarily white, demonstrating a disproportionate representation. CONCLUSION: There is a small midwifery presence on Instagram that is not representative of the broader profession, or the current picture of midwifery care. This paper is the first study to explore how midwives are using the popular social media platform Instagram to portray birth. It provides insight into how midwives post an un-medicalised, low risk representation of birth. Further research is recommended to explore midwives' motivation behind their posts, and how pregnant and postnatal women engage with social media.

A prospective cohort study comparing neonatal outcomes of waterbirth and land birth in an Australian tertiary maternity unit.

BACKGROUND: Maternal preference for warm water immersion (WWI) and waterbirth is increasing, but adoption into obstetric guidelines and clinical practice remains limited. Concerns regarding safety and a paucity of evidence have been cited as reasons for the limited adoption and uptake. AIM: The aim was to investigate maternal and neonatal outcomes after WWI and/or waterbirth compared with land birth. MATERIALS AND METHODS: A prospective cohort study was conducted in an Australian public maternity hospital between 2019 and 2020. Maternal and neonatal outcomes for 1665 women who had a vaginal birth were studied. Primary outcome was admission to the neonatal unit (NNU). Secondary outcomes included neonatal antibiotic administration, maternal intrapartum fever, epidural use and perineal injury. Multivariate logistical regression analyses compared the outcomes between three groups: waterbirth, WWI only and land birth. RESULTS: NNU admissions for a suspected infectious condition were significantly higher in the land birth group (P = 0.035). After accounting for labour duration, epidural use and previous birth mode, no significant difference was detected between groups in the odds of NNU admission (P = 0.167). No babies were admitted to NNU with water inhalation or drowning. Women birthing on land were more likely to be febrile (2 vs 0%; P = 0.007); obstetric anal sphincter injury and postpartum haemorrhage were similar between groups. Regional analgesia use was significantly lower in the WWI group compared to the land birth group (21.02 vs 38.58%; P = <0.001). There was one cord avulsion in the waterbirth group (0.41%). CONCLUSION: Maternal and neonatal outcomes were similar between groups, with no increased risk evident in the waterbirth and WWI groups.

Spiritual Experiences of Portuguese Women Who had a Water Birth.

This study aimed to understand the significance of spirituality to Portuguese women who had a water birth. In-depth interviews, using a semi-structured questionnaire, were conducted with 24 women who experienced water birth at the hospital or home. Results were analyzed from a narrative interpretation perspective. Three spirituality-related categories emerged: (1) Beliefs and connections with the body; (2) Spirituality: integration of being a woman and transformation during birth; and (3) Spirituality as wisdom, intuition, or the sixth sense. Spirituality was perceived in women's faith and beliefs in a superior being that helped them manage the unpredictability and uncontrollability of giving birth.

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.

Mindful awareness as a mechanism of change for natural childbirth in pregnant women with high fear of childbirth: a randomised controlled trial.

BACKGROUND: Mindfulness-Based Childbirth and Parenting (MBCP) is effective in increasing natural childbirth in pregnant women with high fear of childbirth (FOC) as compared to enhanced care as usual (ECAU). We aimed to examine through which pathway of action MBCP reaches this effect, based on a model of approaching or avoiding the challenges related to childbirth. METHODS: One hundred eleven pregnant women with high FOC were measured pre- and post-intervention on FOC (emotion pathway), catastrophic beliefs about labour pain (cognition pathway) and mindful awareness (attention pathway). A multiple mediation model was used to examine through which pathway the mechanism of change operated in relation to approach (i.e., natural childbirth) versus avoidance (i.e., self-requested caesarean section). RESULTS: It was found that greater mindful awareness (18% R2 = 0.18, F[1107] = 22.77, p < 0.0001) was the only significant mechanism of change operating through the attentional pathway leading to natural childbirth. More specifically, nonreactivity to inner experience (a facet of mindful awareness) showed to be the strongest mechanism of change. More extensive meditation practice was positively associated with natural childbirth; however, the number of completed MBCP sessions was not associated with the outcome. CONCLUSIONS: An increase in mindful awareness was the strongest mechanism of change for better adaptation to the challenges of childbirth. Decreases in neither FOC nor catastrophic beliefs about labour pain were identified as mechanisms of change. Additionally, the more one meditated, the more one was inclined towards a natural childbirth. MBCP enhances adaptation to the challenges of childbirth and less use of obstetric interventions in the presence of high FOC. TRIAL REGISTRATION: The Netherlands Trial Register (NTR; 4302 ).

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.

Waterbirths were associated with low pain relief during delivery, high breastfeeding success and healthy newborn infants.

AIM: Our aim was to compare the outcomes of waterbirths and conventional births in a Finnish hospital setting for the first time. METHODS: This retrospective study compared waterbirths with conventional low-risk deliveries from September 2018 to March 2021 at a level-two hospital in Finland. Cases and controls were collected from the patient records database. RESULTS: The study comprised 78 waterbirths and 1623 matched conventional births. Mothers in the waterbirth group only required a quarter of the amount of pain medication required by those in the control group. Babies born in water had slightly lower birth temperatures than those born conventionally (36.6 versus 36.8°C). Umbilical cord artery and vein pH were slightly higher in the waterbirth group than in the control group (artery 7.31 versus 7.28 and vein 7.38 versus 7.35). The Apgar scores did not differ. Hospital stays were shorter in the waterbirth group than in the conventional birth group (1.90 versus 2.33 days). Babies in the waterbirth group were significantly less likely to require formula than those in the conventional birth group during their hospital stay. CONCLUSION: Waterbirth decreased the requirement for maternal pain medication and favoured greater breastfeeding and earlier discharge. Prospective studies must confirm these findings.

Effect of lubricant gel on the length of the first stage of labour and perineal trauma in primiparous women.

The objective of this study was to investigate the effects of obstetric gel application on the length of the first stage of labour and perineal trauma in primiparous women. This randomised controlled trial included 110 primiparous women. Women were randomly assigned to the two groups: lubricant gel group and control group. In the intervention group, during cervical dilatation of 4 cm until complete cervical dilatation, 5 ml of water-soluble lubricant gel was used at each vaginal examination. In the control group, routine care was performed. Mean duration of the total length (p = .025), the first (p = .012), and second stage (p = .022) of labour was significantly shorter in the obstetric gel group than control group. Perineal health was significantly better in the gel-applied pregnant women (p < .001). Using obstetric gel at the beginning of the first stage could shorten the total length, the first and the second stage of labour and could protect perineal health.IMPACT STATEMENTWhat is already known on this subject? Prolonged labour and perineal injuries are a major problem in natural childbirth for primiparous mothers.What the results of this study add? The first (p = .012), and second stage (p = .022) of labour was significantly shorter in the obstetric gel group than in the control group. Perineal health was significantly better in gel-applied pregnant women (p < .001). Using obstetric gel at the beginning of the first stage could shorten the total length, the first and the second stage of labour and could protect against perineal injury.What the implications are of these findings for clinical practice and/or further research? Obstetrical gel lubricant usage in the first stage of labour during the active phase of nulliparous women could shorten the total length, the first and the second stage of labour and could protect perineal health.

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.

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.

Sexuality and childbirth: a qualitative analysis of women who had a waterbirth.

Waterbirth is associated with a less painful childbirth, enhanced couples' intimacy, and positive feelings toward women's bodies and sexuality. In a qualitative, descriptive case study involving 21 participants, we examined the sexual experiences-during childbirth and postpartum-of women who had a waterbirth in a hospital environment. Women discussed their sexuality in the intrapartum and postpartum period after having a waterbirth in public or private hospitals. Two main themes were developed from the data analysis: 'women's sexual pleasure during waterbirth' and 'sexuality after childbirth'. Experiences included transcendence during waterbirth, a feeling that it represented a unique experience, and couples' more positive feelings about intimacy. The shared representations of women suggest that waterbirth can be a calming, joyful event for couples. During this process, they felt that it was a loving, shared event. In addition, after childbirth women experienced positive feelings toward their bodies and sexuality (including orgasm), as well as closer intimacy with their partners.

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.

Perineal skin tear repair following vaginal birth; skin adhesive versus conventional suture - a randomised controlled trial.

This was a prospective randomised controlled trial comparing the effects of first-degree perineal tear repair using adhesive glue versus conventional suturing in terms of pain score, wound complication and patient's satisfaction. One hundred and twenty one women were randomised. The skin adhesive group had a significantly lower pain score at rest as well as during sitting, walking and micturition during the first week of delivery compared to the suture group. The time taken to become pain free was significantly shorter in the tissue adhesive group (3.18 vs. 8.65 days, p < .001). Only two patients who had skin glue experienced wound gaping. No significant difference was observed in the level of satisfaction between the adhesive and suture groups. Tissue adhesive is better than subcuticular suture for repairing first-degree perineal tear as it causes less pain and has shorter recovery time.Impact statementWhat is already known on this subject. First- and second-degree tears following vaginal delivery are common and involved a third of women. Suturing of these tears is advocated to avoid wound gaping and poor healing.What the results of this study add. For first-degree tear repair, tissue adhesive is better than conventional suture in terms of pain reduction and recovery time.What the implications are of these findings for clinical practice and/or further research. Skin adhesive is an ideal method for first-degree perineal tear repair especially in out of hospital settings such as home birth or midwifery-led centre. A larger scale study is needed to establish its feasibility for second- and third-degree tears repair.

In water or on land? Evaluation of perinatal and neonatal outcomes of water births in low-risk women.

OBJECTIVE: Evaluate perinatal and neonatal outcomes comparing a water birth to regular childbirth in low-risk women. File and methods: Retrospective analysis of a set of childbirths that took place over a given period of time in the hospital and health center of Havířov. We compared a set of low-risk women that had given a water birth to a selected control group of low-risk women that had given regular childbirth. We evaluated statistical comparability, as well as perinatal and neonatal outcomes in both sets. RESULTS: From 1. 1. 2020 to 28. 2. 2021, 1,083 women gave birth in the delivery department of Havířov hospital; from this set 122 were water births (11.3%). In our study, we only included 101 water deliveries (we designed our study to monitor low-risk births in order to be able to statistically correlate our findings; 21 water deliveries were excluded from our study due to perinatal risk factors - gestational diabetes and induced deliveries). We selected 60 low-risk women for our control group. Both sets of women were compared and we ruled out any statistically significant differences in age, education, body mass index, number of births given, gestation week at time of labor, number of smokers, premature rupture of membranes, women with previous history of one cesarean section, becoming pregnant by in vitro fertilization, presence of streptokoka skupiny B, and fetal weight. Water birth does not affect the Apgar score, neonatal adaptation to extra-uterine life, umbilical blood pH decrease, complications of infection, need of intensive care, and neonatal mortality. In the water birth set, we found increased occurrence of non-infectious conjunctivitis, treatable by regular eye drops without antibio-tics. We have not observed the effect of water birth on duration of the first and second stage of labor, total amount of uterotonics used, blood loss determined by the obstetrician, and uterine hypotonia. In the water birth group, we observed a prolonged third stage of delivery, lesser need for pharmacological stimulation (augmentation) of labor, notably lower use of analgesics, lower occurrence of birth injuries, shorter in-patient time, and more frequent bonding. CONCLUSIONS: We discovered that water birth does not increase the risk for mother and neonate in low-risk women. Despite initial concerns, our outcomes and mother satisfaction have clearly shown that water births are not only a temporary whim, but probably a new integral part of our obstetric care.

Predictors of obstetric anal sphincter injury during waterbirth: a secondary analysis of a prospective observational study.

INTRODUCTION AND HYPOTHESIS: Obstetric anal sphincter injury (OASI) during childbirth is associated with urino-genital pain and dysfunction. Waterbirth is a popular birth choice for women, but controversy remains around the risk of OASI during waterbirth. This study reports on the incidence of OASI, and factors associated with OASI, for a cohort of women who gave birth in water. METHODS: This secondary analysis used prospectively collected data from 2,908 women who gave birth in water in a hospital setting. The incidence of OASI was calculated. Univariable and multivariable logistic regression analysis evaluated factors associated with OASI. RESULTS: The incidence of OASI was 1.9% (95% confidence interval (CI) 1.4, 2.4) for all women. In nulliparae it was higher (3.2%, 95% CI 2.3, 4.3) than in multiparae (0.9%, 95% CI 0.5, 1.4). In the multivariable analysis, two variables were associated with OASI; multiparity was negatively associated with OASI (adjusted odds ratio [aOR] 0.24, 95% CI 0.12, 0.50, p < 0.001), and birth weight was positively associated with OASI (aOR 1.001, 95% CI 1.000, 1.002, p = 0.02). A "hands-on" technique was used during only 13% of births. A birth position supporting a flexible sacrum did not influence OASI risk. CONCLUSIONS: A low incidence of OASI was found for this cohort of women. The low proportion of midwives using a hands-on technique suggests that it may not be required in waterbirth.

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.

A retrospective comparison of waterbirth outcomes in two United States hospital settings.

BACKGROUND: Water immersion during labor is an effective comfort measure; however, outcomes for waterbirth in the hospital setting have not been well documented. Our objective was to report the outcomes from two nurse-midwifery services that provide waterbirth within a tertiary care hospital setting in the United States. METHODS: This study is a retrospective, observational, matched comparison design. Data were collected from two large midwifery practices in tertiary care centers using information recorded at the time of birth for quality assurance purposes. Land birth cases were excluded if events would have precluded them from waterbirth (epidural, meconium stained fluid, chorioamnionitis, estimated gestational age < 37 weeks, or body mass index > 40). Neonatal outcomes included Apgar score and admission to the neonatal intensive care unit. Maternal outcomes included perineal lacerations and postpartum hemorrhage. RESULTS: A total of 397 waterbirths and 2025 land births were included in the analysis. There were no differences in outcomes between waterbirth and land birth for Apgar scores or neonatal intensive care admissions (1.8% vs 2.5%). Women in the waterbirth group were less likely to sustain a first- or second-degree laceration. Postpartum hemorrhage rates were similar for both groups. Similar results were obtained using a land birth subset matched on insurance, hospital location, and parity using propensity scores. DISCUSSION: In this study, waterbirth was not associated with increased risk to neonates, extensive perineal lacerations, or postpartum hemorrhage. Fewer women in the waterbirth group sustained first- or second-degree lacerations requiring sutures.

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.

Waterbirth in low-risk pregnancy: An exploration of women's experiences.

AIMS: To explore retrospective descriptions about benefits, negative experiences and preparatory information related to waterbirths. DESIGN: A qualitative study. METHODS: Women who gave birth in water with healthy pregnancies and low-risk births were consecutively recruited between December 2015-October 2018 from two birthing units in Sweden. All who gave birth in water during the recruitment period were included (N = 155) and 111 responded to the survey. Women were emailed a web-based survey six weeks postpartum. Open-ended questions were analysed with qualitative content analysis. RESULTS: Two themes were identified related to benefits: (a) physical benefits: the water eases labour progression while offering buoyancy and pain relief; and (b) psychological benefits: improved relaxation and control in a demedicalized and safe setting. Two themes were identified related to negative experiences: (a) equipment-related issues due to the construction of the tub and issues related to being immersed in water; and (b) fears and worries related to waterbirth. In regard to preparatory information, respondents reported a lack of general and specific information related to waterbirths, even after they contacted birthing units to ask questions. Supplemental web-based information was sought, but the trustworthiness of these sources was questioned and a need for trustworthy web-based information was articulated. CONCLUSION: Women who give birth in water experience physical and psychological benefits, but need better equipment and sufficient information. There is room for improvement with regard to prenatal and intrapartum care of women who give birth in water. IMPACT: Judging from women's recounts, midwives and nurses should continue advocating waterbirth in low-risk pregnancies. The lack of adequate equipment in Swedish birthing units articulated by women challenge current routines and resources. The findings illustrate unfulfilled needs for preparatory information about waterbirth, further strengthening that midwives should discuss the possibility of waterbirth when meeting expectant parents in the antenatal setting.