Improving Birth believes that women need more, not fewer, evidence-based options for birth. In fact, we believe these options cannot ethically be withheld from informed and consenting consumers.
Water birth is one such option.
>> Why Now?
In April, mothers and midwives were dismayed when a committee opinion was released jointly by the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP), calling into question the safety of water birth and citing “reported concerns” like drowning or near drowning and seizure. The authors essentially stated that water birth should be treated as an experimental procedure because its safety had not been established, but serious risks of harm existed.
Within days of the release of this opinion, Improving Birth began to receive reports from women around the country, upset that their hospitals were removing or reconsidering the option of water birth. One Minnesota childbirth educator said:
Sadly, another unintended consequence we are seeing is that since it was primarily midwives doing the bulk of the waterbirth in the [local hospital] system, what that means is that these mamas are leaving the excellent care of some really great providers, and the midwifery practices are losing patients. It’s so unfortunate that these families are being forced by the system to leave established care, often late in their pregnancy, because this choice has been taken away from them. And ultimately, it seems like a bad business decision for Allina since there are 10 other metro-area hospitals that offer waterbirth in addition to three freestanding out-of-hospital birth centers and all home birth. We are so lucky here in the Minneapolis/St. Paul Metro Area to have a vibrant, thriving birth-friendly community with lots of doulas, independent childbirth education options, and varied birth choices available to families. But I’m sure in the end these families would have rather stayed with their originally chosen provider.
Jess Helle-Morrissey, doula and Lamaze-Certified Childbirth Educator
We received reports that almost two dozen hospitals have taken action to remove water birth, leaving in the lurch many pregnant women – some of whom felt so strongly about water birth that they stated they would simply give birth at home if the hospital would not allow that option.
Please note that opinions such as these—issued by membership organizations for certain types of care providers—are not legally binding on hospitals or providers. However, these organizations yield great influence over practice, and their issuance does have the potential to expose a hospital or provider to liability for offering an option considered “experimental” by certain professionals in the field.
> So, What?
As consumer advocates, we believe that women deserve the best information with which to make important healthcare decisions like how to give birth. Unfortunately, the opinion statement that so dramatically impacted how some women would give birth contained numerous errors and factual inaccuracies. It strongly influenced hospital policy in a way that does not represent the wants or needs of women giving birth—without an evidence basis.
For one thing, a small number of doctors cite “no maternal benefit” to water birth, despite qualitative research studies that demonstrate maternal benefit, and the fact that water birth exists because of the demand of consumers who are evidently deriving some benefit. At the same time, the potential risks of the alternative, a hospital land birth and the associated complications, don’t seem to be treated as legitimate by those making sweeping decisions about how women should give birth. You might even say that American childbirth is defined by its complications, and in light of that, how can we ethically withhold options that help women and babies avoid common injuries and interventions?
In making such statements about maternal benefits, why isn’t anyone listening to the women actually giving birth? We believe that out of everyone involved, the women experiencing waterbirth first-hand are best qualified to speak about its benefits.
Here, for example, are a few of the 133 comments made by women on our Facebook page in less than two days about “why they loved it”:
To compare the water births to non-water is like comparing apples to oranges! After my first water birth I could not see why I waited SO long to come to water!! It takes the edge off labor ~ the feeling of anxiousness; the “fight or fly” feeling is alleviated. Muscles are relaxed; all tension released….
Water allowed me to never once feel like I needed drugs. The thought never even crossed my mind. I was so relaxed that my labor was about 4 hours start to finish. My little bundle was birthed out into the water with her eyes open and staring straight at me. Focused. When I pulled her up from the water it was by far the greastest and most serene feeling I’ve ever felt.
I had two water births… I loved them both because I felt weightless and supported. It made each contraction feel more like an embrace than labor. I’d never do it any other way.
I found the water especially helpful with my youngest, who was born posterior after a long labor. The warm water was a wonderful relief from the back labor I had been experiencing. It also allowed me to move around freely and easily. I was able to listen to my body and get in to a position (on my knees, leaning over the side of the tub) that allowed me to more easily move my baby through the pelvis.
It was SUCH an amazing experience, the water helped [me] stay literally pain free until I was pushing her shoulders out. Every time I had to get out of the water to re heat it, I was so uncomfortable working through those contractions. As soon as I got back in the pool, it was like it all melted away. The water is magical.
After my first birth- an attempted natural birth in a conventional hospital setting which resulted in ARM, [Pitocin] drip, and eventual epidural, episiotomy, and displaced coccyx- I’m sold on water birth. It was so gentle and serene laboring in the tub with just my partner there. And delivering in the dimly lit bathroom with only our midwife and nurse attending (versus on a hospital bed surrounded by strangers and machines) was incredible. Overall it was an empowering and beautiful experience which we hope to recapture with our next birth!
I had peace, support and physical control of my body. No one could reach a hand or hold up my leg. I got to do it myself.
> A Call for Better Science
But while the opinion statement did not paint a complete, current, or accurate picture on water birth, we weren’t aware of any literature review that did. Luckily, Rebecca Dekker, PhD, RN, APRN, of Evidence Based Birth (and IB.org advisory board member) was in the process of creating just that. When we saw her preliminary findings, we agreed to write directly to ACOG and the AAP to request that the opinion be suspended until a full scientific review of the literature could be completed. We enclosed a letter from Dr. Dekker outlining some of the major errors and omissions in the opinion.
The president of ACOG graciously responded that same day, and we were notified that our letter and Rebecca’s letter would be discussed at an internal meeting sometime in mid-June. As of today, July 10, we have not received any further response.
> Use Your Voice!
The claim that there are “no maternal benefits” to water birth is contrary to the evidence and to what many women say who have actually experienced it. If you had a water birth and found it beneficial, please comment below! We may publish selected statements from women in the future.
Below, we’ve attached our letter to ACOG and AAP, and Dr. Dekker’s comprehensive article can be found here. If you agree that hospital policy should be based on good science, and all policy should respect the right of women to informed consent about how they give birth, please plan to take that message to your local hospital. Dr. Dekker has created some incredible resources for you to use, including a 52-page printer-friendly PDF of the article itself, a 4-page “To whom it may concern” letter summarizing her critique of the ACOG/AAP statement, and (coming later this week) an 80-page annotated bibliography of all the research studies ever published on waterbirth.
> Want a behind-the-scenes look?
Tonight, Rebecca Dekker of Evidence Based Birth and Cristen Pascucci of Improving Birth will host a LIVE VIDEO CALL to give you the inside scoop on how we wrote letter to ACOG and the AAP about their water birth opinion statement. We’ll cover:
Join us at 9 p.m. on July 10, right here: BEHIND THE SCENES with Rebecca and Cristen
> Improving Birth’s letter to ACOG and AAP re: Committee Opinion No. 594, Immersion in Water During Labor and Delivery
April 24, 2014
Jeanne Conry, MD, PhD
President, Executive Board
American College of Obstetricians and Gynecologists
P.O. Box 70620
Washington, DC 20024
James Perrin, MD, FAAP
President, Executive Committee
American Academy of Pediatrics
141 NW Point Boulevard
Elk Grove Village, IL 60007
Re: Committee Opinion No. 594
Dear Dr. Conry and Dr. Perrin,
We would like to introduce ourselves as consumer advocates for evidence-based maternity care, and hope this year allows us an opportunity to work with you towards a common goal of high-quality, patient-centered practice for women in the U.S. We also would like to offer ourselves to you as ears on the ground, as we are in contact with thousands of mothers around the country about what they are experiencing in their maternity care.
Today, we are writing to share our concerns about Opinion No. 594, “Immersion in Water during Labor and Delivery,” released jointly by ACOG’s Committee on Obstetric Practice and the American Academy of Pediatrics (AAP) earlier this month. We were surprised by the conclusions reached by the authors of the statement, and have been dismayed to see the effects on women around the country seeking water birth in hospitals.
The result of the statement, which we understand was meant to discourage home birth, has been the suspension or elimination of water birth in hospitals around the country. In the past week, women have reported to us that over twenty hospitals in nine states have taken such steps. Please note, we have not confirmed this information with the hospitals; this is based on reports in the media and from women living in those communities. Nevertheless, we have real concerns about the effect the opinion is having and will have.
Some of the women who have lost this option are currently pregnant and planning water births. Many of these women have said they will give birth at home if this option is not reinstated in their hospitals. As women, in general, continue to seek more low-intervention, evidence-based options for birth, we have seen time and again that they will avail themselves of those options regardless of location. Discouraging safe and patient-friendly practices will only lead more women to seek care outside of hospitals.
Please see the enclosed letter from Rebecca Dekker, PhD, RN, APRN, detailing concerns about the evidence upon which the Committee Opinion was based. It seems the authors’ conclusions are based on a few case studies and case reports, failing to include several important pieces of evidence, including at least four large prospective studies and the findings of the American Association of Birth Centers with respect to 3,998 recent water births,1 all of which showed no adverse outcomes for either mothers or babies. Also, we believe it is critical that analyses such as these make the critical distinction between the evidence-based practice of water birth and all practice of water birth.
ACOG and the AAP have an incredible opportunity to impact policy in positive ways, and we urge you to take steps to protect the informed decisions made by these mothers about how and where to give birth. It would be most commendable if Committee Opinion No. 594 were suspended until it is subject to a full scientific review of the literature, to provide mothers and practitioners a high-quality evidence basis for making care decisions, and to allow hospitals to respect informed consent for women being served by their facilities. We urge the College and Academy to do this as soon as possible, before more women lose this excellent option in hospitals.
Please let us know how your organizations intend to proceed. We welcome the opportunity to engage in further discussion, and would like to extend an offer for ongoing communication (especially, with ACOG), to provide continuing consumer input on issues that have such profound effects on mothers and families.
Thank you for taking the time to seriously consider our requests, and to review the enclosed letter from Dr. Dekker. We look forward to working with you towards evidence-based care for all women and babies.
President, Board of Directors
Vice President, Board of Directors
Heather Thompson, PhD
Secretary, Board of Directors
Amanda Hardy Hillman, PhD
Member, Board of Directors
Encl: Letter from Rebecca Dekker, PhD, RN, APRN (Confidential)
cc: Executive Committee Board Members, AAP
Executive Board Members, ACOG
Clinical Practice Department, ACOG
Quality Improvement Department, ACOG
Celeste G. Milton MPH, BSN, RN, Joint Commission
Christa Billings, International Cesarean Awareness Network
Cheryl Gates, BirthNetwork National
Ginger Breedlove, CNM, PhD, APRN, FACNM, American College of Nurse Midwives
1. “AABC Position Statement: Immersion in Water during Labor and Birth.” American Association of Birth Centers. N.p., 1 Apr. 2014. Web. 23 Apr. 2014. <http://www.birthcenters.org/about-aabc/position-statements/immersion-in-water>.
Author Cristen Pascucci is the former Vice President of ImprovingBirth and is the founder of Birth Monopoly, co-creator of the Exposing the Silence Project, and executive producer of Mother May I?, a documentary film on birth trauma and obstetric violence. She is dedicated to promoting the rights of women in childbirth.
For all moms who could not have the birth they wanted, I wanted to share my amazing home birth experience. I hope that one day all women will be able to choose to have a similar experience for themselves.
I was blessed to have water birth with my firstborn. My husband and I planned on home birth before we even conceived. That was the best decision in my life. The second best was that I decided to have water birth. 30 hours of back labor were excruciating. Warm water was about the only thing that helped to relieve that pain a little. It also helped my body to be more relaxed and more elastic. It was the best experience, save the pain, that I could have had. I was in the comfort of my home, with people who truly cared about me and my child (my husband, two seasoned midwives and their apprentice). I am planning for my next pregnancy and know that it will be home WATER birth again.
My first birth was a primary c-section, which was a very bad experience for me, partly because I did not want a c-section and partly because I was not treated well by the hospital staff.
My second birth was a homebirth VBAC. For most of my labour I used a bathtub and the effect of the water was wonderful. I could relax, the warm water was very soothing, and the contractions hurt less in the water than they did on land. I laboured in water until I felt that I’d give birth in a few minutes. The bathtub did not feel big enough to give birth in, so I climbed out and gave birth kneeling in front of the bathtub. All was fine! The only thing I’d change was that I wished I had had a proper birth pool with more space compared to the bathtub.
As a midwife I have also attended many waterbirth. From my experience, I’d say about 9 out of 10 women who try labouring in water love it and use it at least for a certain time of their labour. And about 5 out of 10 women actually give birth in water. Many women say that the water helped them tremendously with relaxation and pain relief.
Waterbirth definitely should be an option for all those who want to try it, including women with so-called risk factors. Why should they be denied a natural safe method of pain relief, which waterbirth clearly is? For example, I have made very good experience with women with elevated blood pressure labouring and birthing in water. Women-of-size also seem to benefit a lot, as they can move more easily around in water and maybe also are less self-conscious. Water also seems to offer a certain protection, like a shield from the surrounding environment, so can be very beneficial for victims of abuse and trauma (e.g. sexual abuse or a traumatic previous birth experience).
After two waterbirths of my own, I must say that there is no greater way to empower mothers than to let them birth in whatever way they choose. Telling a woman she cannot birth in water is no different than saying she has to birth in a hospital bed. Denying her options does her no benefit.
I have been blessed by two natural births at and area hospital with one child born on land and one born under water. My first birth was a dramatic experience filled with an unfamiliar doctor and continual options for interventions I did not require or request just because that was how “it was done”.
I insisted on trying the tub and it might have worked, but I was uncomfortable in its size and so I resorted to the shower. The warm water helped with the back pain, but when I was told I would have to leave the water and assume the correct position on the the bed for the doctor to deliver the baby I was broken. After a long pushing phase, my baby was born healthy and I was torn extensively, but I was happy to have my baby.
With the birth of my second child things changed and I came prepared. My midwife was present and granted me more control of the situation. We were also allowed to bring in and use our own inflatable pool with padded floor. My husband monitored the water temperature and during transition all the stress and pain melted into the calm warm waters. We labored briefly in the water from 7 cm on, and the pushing phase floated by. An hour felt like fifteen minutes as time passed, and my second child was born into the water and brought to the surface by my midwife. Still sleeping peacefully she was placed on my chest and warmed with towels. The following moments of peace were remarkable and really she didn’t start screeching until a few rough towels dried her off a bit too briskly.
Now as I approach the birth of my third child, the hospital I have used twice has revoked all water birth privileges because of the new corporate policies influenced by the ACOG/AAP position. I am seeking to change their policy or maybe even change hospitals if I have to. I too am considering home birth, as I must have water as an option during the birth of my child. Luckily my midwife is working with me as much as she is able, and I am hoping many voices together can help things change.
Waterbirth is a reasonably safe mode of birth and should be treated as such and offered to women in all labor settings. I was not offered the option to use waterbith in the hospital setting and so I sought care elsewhere. I’m so glad that I did because the pain relief in my waterbirth was divine and I can’t imagine birthing without the option to labor or birth in the tub/pool if that is medically appropriate at the time.
With my second daughter, I did experience what was noted in the studies of a lower APGAR rating at 1 minute since I’d been in labor more than 24 hours after SROM. She perked up extremely well without too much encouragement necessary and is now a healthy 10 month old who loves the water.
I had positive experiences with both of my waterbirths. I had minimal tearing and I’ve read the evidence that this is not rare among women who birth in the water. The freedom to move while in late labor, due to buoyancy in the birth pool, was a huge benefit to me. I was moving just as I needed to when I would have otherwise been too fatigued to change position and that was extremely important in getting my baby to descend quickly and be born in reasonable time. I pushed for about 30 minutes with both births.
I firmly believe that I was able to get into pushing positions that were helpful for increasing the comfort and maximizing effectiveness of pushing without being overly tiring to me. Had I been restricted in my movement I’m convinced that I would had required more intervention in my birth and my personal satisfaction with the experience would have been diminished.
I had a home water birth in the UK. It was quick, easy, empowering, wonderful and brilliant. I had sever PGP throughout my pregnancy and the water helped me to find comfortable positions and birth easily. Catching my baby was the single most important and wondrous moment of my life. Please don’t deny women this amazing resource.
Both of my children were born in water at home , the most recent being less than a year ago. He was posterior and I’m convinced there’s no way I would have made it in the hospital and without the water. The freedom of movement is such a huge part of why I love it. It makes doing what comes natural so much easier, and much less painful.
I have firsthand experience of what happens when this option is denied. I was planning a waterbirth in a hospital based birth center 11 years ago and was denied without any evidence based reason. I was physically damaged by the standard lithotomy birth position and still suffer incontinence and sexual dysfunction. My baby almost died from the cytotec forced upon me to augment labor. If I had been allowed to relax in the tub as I planned, I would remember joy instead of horrific unnatural pain. There is no excuse to ignore a mother’s needs.
I was able to use water during my labor with both of my children. In my first birth of my son, it was helpful in easing the pain or labor. With my second birth of my daughter, I delivered shortly after getting out of the water. My body pushed her out with no effort from me. I attribute the ease of delivery to water – it naturally encourages the body to relax, soothe, and soften. I strongly believe that women need and deserve this option to support and facilitate birth!
I am so fortunate to have experienced two water births. Well actually I labored with the first in the water for several hours and had a very peaceful, blissful experience. My midwife felt it best I change my location and position and within 5 minutes of doing that my son was born out of the water. I am so grateful for having been able to labor most of the time in the water. It is what got me through.
With my second son, I labored in the water and again wouldn’t have done it any other way. He was born in the water and came out alert, pink and hungry.
I couldn’t imagine getting through labor any other way. I am so grateful for having had the option to birth in water. Every women should have the option to experience birthing in water. It definitely takes the edge off without the use of medication which is best for mom and baby and much more cost effective.