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I appreciate the comments of King and Carr in regards to my commentary on water birth.1 It is regrettable that they illustrate the points of my commentary by missing them entirely. The discerning reader will note that their comments reflect little of my commentary or its intent. They change the focus away from my invitation to provide legitimacy to alternative birthing practices that currently do not enjoy it. They did not provide substantive examples of what I may have missed or how my concern for a lack of evidence to support the claims of water-birth proponents may be misguided.
To understand the unique position and perspective that medical and midwifery providers of alternative birthing practices fill, it is important to place it in the context in which it dwells. The series of articles that appeared in the Journal of Nurse-Midwifery in 1989,2 describing alternative birthing practices and the attitudes of their practitioners, provide precisely that, in their own words. This "dated" information remains as relevant today as it did then and does not suffer from having aged. It is the environment from which King and Carr write, and it is that milieu that I think threatens to fail them and their constituency in regards to immersion in childbirth.
The review from the Cochrane Library entitled "Immersion in Water in Pregnancy, Labour and Birth" (an update of the review cited by King and Carr) was not available to me as I wrote my commentary.3 Closer examination of this review gives pause to any claim of clinical significance. Although the conclusion of the meta-analysis is encouraging, the insurmountable limitations they note bar any certainty in claim to the truth on immersion. The review's authors note the same methodologic issues as I did. They note that the nature of the processes of immersion in labor and birth prevent equipoise. Eight trials conducted between 1993 and 2001 were eligible for review in this update, a pooled cohort of 2939 women. Only 1 trial evaluated immersion in the second stage of labor. It was too small to determine outcomes. Trials were not consistent in their definitions of water immersion or their procedures for conducting them. Compliance with determined procedures within the individual studies they reviewed was variable, and crossover was common. These factors combined to "limit comparisons across trials and the validity of the trial findings," which is the point of meta-analysis. When one reviews the individual findings from which statistical significance is met, the clinical significance is not evident, and selection and reporting bias remains a thorn precluding confidence in these determinations. For example, a primary finding of the review is a statistically significant reduction in the use of medical anesthesia and analgesia among women in the pooled immersion cohort during the first stage of labor, compared with those not immersed in water; this conclusion is based on a 4% reduction (471 of 1196 vs 521 of 1210, respectively). It is difficult to call this clinically significant. Additionally, immersion was not found to reduce the incidence of assisted or operative delivery or of perineal trauma or episiotomy. The reviewers conclude that "there is insufficient information to support or not support the use of immersion," particularly in the second and third stages of labor. This meta-analysis is an important step toward organizing the diaspora of water-labor and water-birth research, such as it is, but one hesitates to call it "state of the science" supporting immersion practices or associated claims of benefit.
King and Carr did not offer other significant references, in large part because remarkably few exist. A Medline search reveals little substantial published research since my commentary. Pinette et al4 performed a retrospective review of available literature on risks associated with water birth and found obstacles similar to those encountered by Cluett et al.3 They found that there are significant risks of morbidity and mortality unique to water. Although these adverse outcomes may be rare, lack of sound data precludes a well-defined conclusion on prevalence. In a study separate from her Cochrane review, Cluett et al5 provide an effort examining water labor in the management of dystocia in 99 women. The associated commentaries reflect the difficulties that these studies present.6,7 Their approach is remarkable in that it does not attempt to answer all the questions at once. They take 1 part and evaluate it. Still, this study suffers from lack of clinical significance despite their conclusions. There was no difference between immersion and nonimmersion in operative deliveries, confidence intervals for analgesia were very wide, and there was significant crossover from immersion to augmentation. Six infants in the immersion group were admitted to the NICU, whereas none from the standard-therapy group were. Despite a lack of evidence to support it, they conclude that "[l]aboring in water under midwifery care may be an option for slow progress of labor, reducing the need for obstetric intervention and offering an alternative pain management strategy." A more compelling step forward is made by Woodward and Kelly8 in their pilot study comparing "land and waterbirth." The fact that they are conducting a pilot study reflects their goal of overcoming methodologic flaws, and they looked at obstacles in conducting immersion studies. Unfortunately, their study is replete with them. In an interesting design, 60 women were randomized, and 20 additional women were entered in a "preference" arm for immersion or nonimmersion. Of the 60 randomized women, 40% randomized to immersion never entered the water, and 32.5% left in the first stage of labor and did not return to the water for the birth. Therefore, 72.5% of those randomized to water birth did not deliver in water (many for exclusions, illustrating a laudable concern for the well-being of the mothers and their infants). Despite this, the authors conclude that such a trial is feasible. These are hardly rousing advances in immersion research. It is difficult to take such an emotionally driven practice that cannot be blinded and subject it to critical review. The importance of this bias is that there are few practices more deserving of blinding in a study in which it could not be more impossible to do so. As more work is completed in a quality publishable in seminal journals, proponents hopefully will become less tolerant of methodologic error and bias and become more objective, organized, and germane.
It is clear that, as I state in my original commentary, not everything we do will avail itself to the sine qua non of evidence-based medicine: the randomized, controlled trial.9 It is just as certain that medical practice must be based on purposefully collected data that are organized and evaluated with integrity. The evolution of our practice of medicine is that of our history with the scientific method moving asymptotically toward perfection. We assail medical claims without foundation, an aversion to the snake oils of our time. We have learned that there are those practices that are unexpectedly without merit and abandon or modify them, just as we have adopted those proven efficacious and yet continue to review them. In those areas lacking such evidence, or after discovering breaches in integrity of the work, the best of providers proceed with care and trepidation, and only when necessary. The measure is risk versus benefit. Rather than take invitations to provide legitimacy to alternative practices as derision, their practitioners should take on the challenge of providing the necessary and useful evidence. Obstetrical providers have recognized the serious need to reign in the pendulum of medicalized childbirth. Providers offering alternative birthing practices need to work with those offering "mainstream" practices, and vice versa, to ensure that we find the valid middle ground that serves our patients best, in a collegial manner. Having abundant proven, safe, and efficacious options and variations will most effectively meet the needs of the broad variety of laboring mothers and their families and bring us the best that both perspectives have to offer.
The American College of Nurse-Midwives and the Journal of Midwifery & Women's Health are uniquely positioned to establish the culture, traditions, and tone of these interactions. Review of articles published in the past few years in the Journal of Midwifery & Women's Health reflect a concerted effort to develop evidence-based practice and nurture a philosophy of midwifery-oriented research. This important orientation should also be applied to immersion research. These organizations must encourage work toward international consensus to establish evidence-based immersion standards that can be tracked, studied, and modified in a prospective fashion. Rather than throw "stones in glass houses," gather them together and build a foundation for purposeful progress. Work to establish the legitimacy of the body of alternatives offered so that the necessary role filled by alternative practitioners prospers and truly empowers mothers and families. Work toward critical introspection as to purpose, setting aside agendas that do not place mother and infant first. Continue to turn away from the model offered by Elder; seek instead to pioneer proven alternative approaches and not tolerate claim to benefits that cannot be supported.
I look forward to seeing all that such collaboration can accomplish. I remain willing to change my understanding as we learn. Until then, while hopeful that recent efforts to improve the body of immersion literature progresses, I remain skeptical, because evidence is still lacking to support the claims used by proponents of water labor and birth. Immersion, particularly water births, remains a source of avoidable morbidity and mortality without benefit. Water birth and water labor represent "medical practice" under false pretenses of safety and efficacy. Their continued practice outside organized study with informed consent should be considered malpractice. Immersion as a standard of care remains a naked emperor.
REFERENCES
Related articles in Pediatrics:
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