Guideline saying women should not birth in water sparks backlash

By Michele Munz, St. Louis Post-Dispatch
McClatchy-Tribune Information Services

July 24--Belinda Haschke-Green did not plan to give birth in the water. She thought she would use the tub at a birth center in O'Fallon, Mo., whenever she needed comfort during her labor.

After about 13 hours of contractions, she couldn't handle the pain. She wanted to give up on her natural birth plan, head to the hospital and get drugs. But the midwife told her the baby was coming too quickly for that. "If I am going to do this any more, it has to be in the tub," Haschke-Green said, sobbing.

After a few more contractions, Haschke-Green brought her baby out of the water and saw her take her first breath, thankful to have given birth without anesthesia or other medical interventions she had wanted to avoid.

Four months ago, the nation's associations of obstetricians and pediatricians issued an opinion denouncing water birth and sparking a backlash from water birth providers and mothers such as Haschke-Green.

The doctor groups wrote that giving birth in water "has not been associated with maternal or fetal benefit" and should be considered an experimental procedure. The opinion, which serves to guide the practices of hospitals and physicians and inform patients, said water birth should be provided to women only as part of a clinical study.

No hospitals in Missouri allow water births, but a growing number across the country do. Several have suspended their water births in response to the opinion.

Haschke-Green believes women should be able to choose a water birth.

"For someone going through the pain of childbirth, who is choosing not to have an epidural, to deny that option to a woman ... To me, that is just beyond cruel," said Haschke-Green, 34, who traveled to the Birth and Wellness Center in O'Fallon from House Springs in Jefferson County.

Birth centers are staffed by midwives and serve healthy women seeking a natural birth. At the Birth and Wellness Center, which opened more than two years ago as the state's only accredited birth center, almost 65 percent of the nearly 200 mothers served chose to give birth in the water.

Midwives and birth centers are among the most vocal critics of the doctors' opinion.

The national associations of nurse midwives in the United States and in the United Kingdom, as well as the American Association of Birth Centers, released statements saying the opinion by the doctors' groups was an incomplete and inaccurate review of the research.

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"Consequently, the document has the potential to introduce inappropriate fear about the safety of water birth" for those making decisions, the statement said.

The opinion prompted nurse researcher and founder of the popular Evidence Based Birth website, Rebecca Dekker, to take on water birth. Her 52-page article, released last week, concluded the opinion "contained major scientific errors," which she also outlined in a letter to the presidents of the American College of Obstetricians and the American Academy of Pediatrics.

"It's clear that research had nothing to do with this opinion statement that's affecting women all over the country," Dekker said.

The doctors groups' opinion states that while immersion in water during early stages of labor may help decrease pain or use of anesthesia, safety and benefits of immersion during pushing and birth have not been shown. The opinion refers to a dozen reports of rare but serious problems with babies, including infections from contaminated water, drownings and near drownings from inhaling water and umbilical cord rupture from lifting the newborn too quickly to the surface.

The opinion was written by Dr. George Macones, chair of the obstetrics department at Washington University School of Medicine, while he served as chair of the obstetrician group's obstetric practice committee.

Macones said evidence shows that giving birth in water is no better than giving birth out of the water. "If it's not good for the baby and it has any perceivable risks, which there surely are, then you shouldn't be doing it outside of a study," he said.

Dekker found at least 19 studies on water birth done in the past 20 years, only six of which were mentioned in the opinion. The doctors' opinion relies heavily on the case reports, Dekker wrote, but the reports lacked crucial information, included possible intentional drownings and babies who fully recovered.

The birth center association said it studied more than 15,500 births reported by its member birth centers between 2007 and 2010, nearly 4,000 of them water births. Health outcomes were the same, the association found, with no reports of infection, ruptured umbilical cords or newborns breathing water.

The American College of Nurse Midwives says the growing body of evidence indicates women with uncomplicated pregnancies and labors cared for by trained attendants have comparable outcomes whether they give birth in water or out.

"Women should be given the opportunity to remain immersed during labor and birth if they wish do so," no matter their geographic location, insurance status or birth setting, the nurse midwives opinion says.

An analysis published two months ago by the American College of Nurse Midwives of more than 31,000 water births in 11 countries, mostly outside the United States, found water birth was associated with high maternal satisfaction, decreased chances of an episiotomy and severe tearing around the vagina and less likelihood of dangerous heavy bleeding in mothers. Data showed no difference in infection rates, neonatal deaths or intensive care admissions.

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While some look at the research and say there's no reason to conclude that water birth is dangerous, Macones says there's no reason to conclude it's safe.

"The bottom line is that these (studies) in no way can be considered reliable data ... I think it's absolutely misleading to present this sort of information to a layperson as 'science' that supports efficacy and safety," Macones wrote in an email.

Water immersion during labor gained popularity in the 1980s as women shared stories of pain relief, easier movement and holistic experiences. By 1994, doctors and midwives in the United Kingdom endorsed water birth. In the United States, pediatricians first denounced water birth in 2005, and the most recent opinion was the first time obstetricians weighed in on the issue.

Barbara Harper, who founded Waterbirth International in 1987, estimated more than 300 hospitals in the U.S. provide water birth, including several large teaching hospitals.

Laura Collinsworth, 26, of Corinth, Ky., was 34 weeks pregnant with her second child when Clark Regional Medical Center in Winchester, Ky., stopped providing water birth. Because of the positive experience she had with her first child at Clark Regional, she said she badly wanted that option again. So she gave birth in a tub at home.

The experiences of women who have given birth in water and water birth providers should be considered by policymakers, said Jenna Shaw-Battista, a nurse midwife at the University of California, San Francisco, who studies water birth. Women say they feel more in control and less stressed as they push, which promotes a safer and easier birth. They also feel more empowered and capable as new mothers, improving breast-feeding and warding off postpartum depression.

St. Louis-area women say they chose water births because they saw it as a way to help avoid risky medical interventions. "Once I got in the tub, I didn't want to get out. It was like a relief," said Julie Culbertson, 32, of St. Louis, who had a water birth March 9 at the birth center. "It just felt like I was where I was supposed to be. Being enclosed in the water gave me a sense of ease and security that I could do it on my own right there."

Melissa Revisky, 30, of Crestwood, has experienced the gamut: two hospital births with an epidural, a natural birth in the hospital and a water birth at the birth center. Under anesthesia, her tissue tore because she couldn't control her pushing, she said. She felt rushed and lacked the freedom to move during the extremely painful natural birth.

But in the water, she felt calm and relaxed. "It was the most important factor to a successful delivery," Revisky said. "I barely even felt the contractions."

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The disagreements over the safety and benefits of water birth has one positive result -- support to conduct quality research, said Harper of Waterbirth International. Eager to resume their water birth practices, hospitals have hired Harper to review their policies and train staff; and they are enrolling in studies to meet the doctors groups' guidelines.

Harper has launched the first nationwide study where participants submit monthly data on their water births. It's open to any hospital in the U.S. that wants to participate.

The science will give more women such as Haschke-Green an informed choice as they face the pain of childbirth.

"If I decide to have a baby again, I would want water to be available, without a doubt," Haschke-Green said. "I would drive however far and stay in a hotel. I would not have my baby in a hospital that doesn't offer it, now that I have been through that."

Michele Munz is a health reporter at the Post-Dispatch. Follow the health news on twitter at #STLhealth


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