Waterbirth - Time to Move Forward

By Beverley Lawrence Beech

AIMS Journal, Summer 2000, Volume 12 No. 2

AIMS Chair Beverley Beech believes that it's time we started taking labour and birth in water more seriously.

During the 1980s water birth in the UK became popular. It was encouraged by pictures of women in France giving birth or labouring in water after Michel Odent had installed a pool in the hospital at Pithivier 1977. The pool was initially used for pain relief, but over time more and more women were giving birth in the water.

At a time when women were expressing concern about the effects of birth on the baby and wanting a gentle birth for their babies the use of water seemed the answer. Interest continued to grow and in April 1995 myself, Janet Balaskas, Jayn Ingrey and Sheila Kitzinger organised the First International Water Birth Conference at Wembley. It was attended by 1,500 midwives, doctors and parents from all over the world. During the conference those who had been helping women to labour and birth in water presented their findings and statistics (Beech, 1996).

One of the huge advantages of water is that it has no side effects and it gives the woman a sense of space, safety, peace and tranquillity. It also has the advantage of removing women from medical interference. A midwife recalled saying to a woman in her care "I would like to give you an internal now to check your progress" and the woman said "Oh no you don't!" gave a push with her feet and floated over to the other side of the pool.

In response to parents' requests for water pools many hospitals installed their own, often too shallow to be of much use. This development also brought with it hospital protocols to ensure the staff had full control of who went into the pool and when they should enter. Few of these protocols were based on scientific evidence. Having inveigled women into hospital with siren calls of beautiful pools many of the staff developed tactics for ensuring that few women ever used them.

It was not uncommon for women to be told: "there are no other midwives qualified to attend a women in water, so if 'Jane' is not on duty you will not be allowed to use the pool"; or, "someone is already using the pool"; or, "the electrical supply has to be checked by a safety officer"; or, "the pool has not been cleaned since the last person used it"; or, "health and safety are concerned about injury to the midwives' backs and have banned the use of a pool without a lifting hoist being in place".

By 1993 seventy British hospitals claimed to have water pools available but that did not mean that many women were able either to use the pools for pain relief or give birth in them. AIMS members were so concerned about midwives claiming that water birth was outside their sphere of practice so they could not attend a woman who wanted a water birth, that we lobbied the Midwifery Committee of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) to make a statement.

In October 1994 they produced a Position Statement on Waterbirths in which they stated:

"The Council recognises that waterbirth is preferred by some women as their chosen method for delivery of their babies. Waterbirth should, therefore, be viewed as an alternative method of care and management in labour and as one which must, therefore, fall within the duty of care and normal sphere of the practice of a midwife. Waterbirth is not considered to be a 'treatment'." (UKCC, 1994)

From the beginning obstetricians employed a variety of tactics to dissuade people from adopting this new development ranging from hysteria to sarcasm, none of it based on any scientific evidence. Those doctors who disapproved of this new development used every opportunity to denigrate or sneer at waterbirth enthusiasts:

"Another threat they (the midwives) face is the kinky exhibitionist partner." (Frank Loeffler, consultant obstetrician)

"UCS (under water caesarean section) is no sillier than normal delivery under water." (JO Drife, 1993)

As recently as January this year the Royal College of Obstetricians and Gynaecologists published on their web site Guidelines for Birth in Water. The focus of these Guidelines was not based on available research evidence but centred instead on 'potential problems associated with birth in water'. As a result of AIMS and other consumer groups' criticisms, the College has withdrawn these guidelines. Following discussion with interested lay groups and individuals I suggested that it was time that lay people published their own guidelines. Sheila Kitzinger offered to co-ordinate this and suggested that we should involve the Royal College of Midwives and those water birth experts who are already recognised as experts in this field. We anticipate that these guidelines will be issued shortly.

Over time, anxieties about possible complications were refuted e.g. the potential for the baby to inhale water, potential risk of infections, potential effects of the water temperature. In August 1999 the British Medical Journal published a research study showing that between April 1994 and March 1996 4032 babies were born in water (Gilbert RE and Tookey PA, 1999). The study concluded: "perinatal mortality is not substantially higher among babies delivered in water than those born to low risk women who delivered conventionally".

It was undertaken by researchers who wrote to 1500 consultant paediatricians asking them to report 'whether or not they knew of any births that met the case definition of "perinatal death or admission for special care within 48 hours of birth following labour or delivery in water". This is an extraordinary approach which, as far as we know, has never been applied to any other study of obstetric technology or practices. We are now looking forward to studies of electronic fetal monitoring, ultrasound or epidural anaesthesia asking a similar question.

In 1996 Sally Marchant sent a questionnaire about the use of water in labour and/or birth in water. She found that 195 of the 219 maternity units reported using a birthing pool or a conventional bath. Women need to be very cautious when told that their local unit has a birth pool. Ideally, a pool will be deep enough to cover a woman's abdomen while sitting upright. Baths usually require the woman to lie horizontal, which is not the ideal position when in labour or giving birth.

At the recent AIMS conference Midwifery Models for Excellence Jane Walker revealed that it has been estimated that 15% of all water births in the UK take place at the Edgware Birth Centre (which has approximately 240 women birthing there each year). The most recent figures from the Birth Centre show that 80% of the women using this midwifery unit now use the pool at some point during their labours and 65-70% give birth in the water. So, why are water pools (and midwives trained to use them) not available in every hospital?

We have found that few hospitals actively promote and support labour or birth in water. Any woman wanting a water birth needs to ask some fundamental questions to establish just how likely it is her wishes will be respected and supported. It is fine having a pool, but if less than 10% of women get anywhere near it what experience are the midwives gaining, and what chance do women really have of using this highly effective form of pain relief?

It is quite astonishing that on the one hand so many obstetric units are unwilling to encourage a form of pain relief which has no side effects and has been shown to be wanted by many women, whilst on the other the staff are only too keen to subject women to a wide range of drugs despite the evidence that exposure in utero to barbiturates and narcotics increases by 4.7 times the risk of drug addiction in teenage years (Jacobson B, 1990). Huge amounts of money are being spent on drug addiction programmes, but neither the government, the Department of Health, nor individual medical practitioners are willing consider the potential origins of the problem. Nor are they willing to follow-up Jacobson's research by conducting other large-scale studies.

Perhaps they fear that the results will tell them something they don't want to know?

What mothers should ask

Any woman considering a waterbirth should get as much information from her hospital midwives as possible. Here are some basic questions which need to be answered before a woman can make an informed decision and judge the likelihood of actually achieving her goal:

• How many pools are available in your unit?
• Are these pools (i.e. deep enough to cover my abdomen when I sit in a vertical position) or are they baths (in which I will have to lie horizontal in order for the water to cover my abdomen)?
• Do you have a rolling education programme for all the midwives in your unit? Is water labour/water birth part of such training?
• Are all the midwives confident to attend a woman using a pool? If not how many on any one shift have the skill and confidence to facilitate labour/birth in water?
• How many women give birth in your unit each year?
• How many women have used the pool for pain relief in the last two years?
• How many babies have been born in water?
• May I bring a hired pool into the unit?

If the answer to any of these questions barely reaches double figures you can be certain that there is little support for the use of water for labour or birth and you are likely to encounter problems of one sort or another unless you are very determined.

Note: We would like to hear from women about the ease or difficulties they encounter when they wish to book a water labour or birth.