Throughout human existence, women have typically given birth to their offspring on land. Over the last 25 years, however, underwater birth has become more popular in certain parts of the world despite a paucity of data demonstrating that it is either beneficial or safe.1–22 Underwater birth occurs either intentionally or accidentally after water immersion for labor, a procedure promoted primarily as a means of decreasing maternal discomfort. A review of the available literature indicates that the risks of underwater birth to the newborn seem to outweigh the benefits, and caution is urged before widespread implementation.
Although there is no suggested benefit of underwater birth to the newborn, morbidities identified in clinical reports have raised concerns that this mode of delivery may not be safe. In 1983, Odent1 reported his experience with 100 consecutive deliveries. All mothers used water immersion during labor, but only a limited and unspecified number of births occurred under water. Two infants required positive-pressure support, but little additional data were provided. In 1995, Alderdice et al2 performed a retrospective survey of 4494 underwater deliveries by midwives in England and Wales. They reported 12 stillbirths or neonatal deaths, 51 cases of neonatal morbidity (respiratory or infectious), 33 serious maternal complications (postpartum hemorrhage, perineal trauma), and 7 cases of back injuries among staff members. In a subsequent survey of 4032 underwater births in England and Wales,3 the perinatal mortality rate was 1.2 per 1000 live births (95% confidence interval [CI]: 0.4–2.9) and the rate of admission to a special care nursery was 8.4 per 1000 live births (95% CI: 5.8–11.8). The author of this survey suggested that these rates may be higher than expected for a term, low-risk, vaginally delivered population.4 In 1996, a retrospective review of ∼19000 underwater births from around the world5 noted that underwater birth (after water immersion for labor) was associated with a decrease in instrumented or operative delivery, a reduction in the need for pain medication, and no increased morbidity or mortality in the neonates. However, these data were largely anecdotal and compared with historical controls. A prospective observational study compared underwater birth with births using Maia-birthing stools and beds.6 Although underwater birth was associated with a decreased need for episiotomies and pain medication as well as higher Apgar scores and less cord blood acidosis in newborns, the birthing method was determined by maternal preference, and potential confounding variables were not analyzed. Over the last several years, numerous case reports have associated underwater birth with respiratory distress,3,7,8 hyponatremia,8 infections,3,8–11 hypoxic ischemic encephalopathy,3,7 ruptured umbilical cords,3 seizures,7,8 tachycardia and fever12 (related to water temperature of the bath), and near drownings3,7 in newborns or fetuses.
There is only 1 report of a randomized, controlled trial (RCT) of underwater birth, but it has not been published in a peer-reviewed journal.13 This study showed no difference in the number of neonates admitted to a NICU; however, it was not sufficiently powered to evaluate important morbidities (n = 120). There have been 6 published RCTs of water immersion during labor14–19 (only 1 in the United States16). A Cochrane systematic review20 of 3 of theses trials,14–16 involving 988 mothers, found no benefits for pain relief, the course of labor, or perineal trauma for the mother and no differences in neonatal outcomes. The authors concluded that there were insufficient data to evaluate water immersion for labor. Subsequently, an RCT of water immersion for labor of 274 Australian women also found no benefit for pain relief, the length of labor, perineal trauma, or mode of delivery.17 However, more neonates born to mothers who labored underwater required oxygen or positive-pressure ventilation in the delivery room compared with the control group (49% vs 35%; relative risk: 1.41; 95% CI: 1.06–1.89). A Swedish study of 1237 women found no benefit or harm to mothers or infants after water immersion for labor.18 Cluett et al,19 from England, reported the results of an RCT in 99 women, comparing water immersion versus augmentation (amniotomy and oxytocin) for the subset of patients with labor dystocia. There were no differences between groups in the use of epidural analgesia, operative delivery, or duration of labor. Although women in the water-immersion group were less likely to receive augmentation than the routine-care group (relative risk: 0.74; 95% CI: 0.59–0.88) and generally had lower pain scores, 12% of neonates born to mothers who labored underwater were admitted to the NICU, compared with none in the augmentation group (P = .013). A second Cochrane systematic review of water immersion for labor by the same authors as the first was published recently.21 This report included the previously mentioned studies but also relied on unpublished data, personal communications, and data not published in peer-reviewed journals. The authors concluded that water immersion resulted in a reduction in the use of analgesia/anesthesia for mothers (odds ratio [OR]: 0.87; 95% CI: 0.71–0.99), but differences in vaginal operative deliveries (OR: 0.83; 95% CI: 0.66–1.05) and cesarean sections (OR: 1.33; 95% CI 0.92–1.91) did not reach statistical significance. The differences in the incidence of low Apgar scores (OR: 1.57; 95% CI: 0.63–4.01), admissions to a NICU (OR: 1.05; 95% CI: 0.68–1.61), and neonatal infections (OR: 2.01; 95% CI: 0.50–8.07) also did not reach statistical significance.
The safety and efficacy of underwater birth for the newborn has not been established. There is no convincing evidence of benefit to the neonate but some concern for serious harm. Therefore, underwater birth should be considered an experimental procedure that should not be performed except within the context of an appropriately designed RCT after informed parental consent.
Dr Batton acknowledges the additional members of the Committee on Fetus and Newborn of the American Academy of Pediatrics for advice and guidance regarding this commentary.
- Accepted September 20, 2004.
- Reprint requests to (D.G.B.) Department of Pediatrics, William Beaumont Hospital, 3601 W 13 Mile Rd, Royal Oak, MI 48073. E-mail:
No conflict of interest declared.
- ↵Odent M. Birth under water. Lancet.1983;2 (8365–8366):1476–1477
- ↵Alderdice F, Renfrew M, Marchant S, et al. Labour and birth in water in England and Wales. BMJ.1995;310 :837
- ↵Gilbert R, Tookey P. Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. BMJ.1999;319 :483– 487
- ↵Gilbert R. Water birth—a near-drowning experience [commentary]. Pediatrics.2002;110 :409
- ↵Beech B. Water birth unplugged. In: Proceedings of the First International Water Birth Conference. Cheshire, England: Book for Midwives Press; 1996
- ↵Nguyen S, Kuschel C, Teele R. Water birth—a near-drowning experience. Pediatrics.2002;110 :411– 413
- ↵Bowden K, Kessler D, Pinette M, Wilson E. Underwater birth: missing the evidence or missing the point [published correction appears in Pediatrics. 2004;113:433]? Pediatrics.2003;112 :972– 973
- Parker P, Boles R. Pseudomonas otitis media and bacteremia following a water birth [letter]. Pediatrics.1997;99 :653– 654
- Rawal J, Shah A, Stirk F, Mehtar S. Water birth and infection in babies. BMJ.1994;309 :511
- ↵Hagadorn J, Guthrie E, Atkins V, DeVine CW, Hamilton L. Neonatal aspiration pneumonitis and endotracheal colonization with Burkholderia pickettii following home water birth. Pediatrics.1997;100(suppl) :506
- ↵Deans A, Steer P. Labour and birth in water. Temperature of pool is important [letter]. BMJ.1995;311 (7001):390–391
- ↵Nikodem VC. The effects of water on birth: a randomized controlled trial. Presented at the 14th Conference in Priorities in Perinatal Care in South Africa; March 7–10, 1995; South Africa
- ↵Cluett ER, Pickering RM, Getliffe K, St George Saunders NJ. Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labour. BMJ.2004;328 :314
- ↵Nikodem V. Immersion in water during pregnancy, labour and birth [Cochrane review]. In: The Cochrane Library. Issue 3. Oxford, United Kingdom: Update Software; 1998
- ↵Cluett ER, Nikodem VC, McCandlish RE, Burns EE. Immersion in water in pregnancy, labour and birth. Cochrane Database Syst Rev.2004;(2):CD000111
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