Saturday, December 19, 2015

Birth Apologetics: Waterbirth- Friend or Foe?

Note: This post is part of a series called "Birth Apologetics". "Apologetics" comes from the Greek and means "to speak in defense". (Often used in relation to defense of a particular idea or viewpoint, such as "Christian Apologetics".) In these posts, I will be taking blog posts and articles that are critical of home birth and natural birth and doing a critical analysis on the data and arguments. The idea is that if natural birth and home birth are safe for most women, arguments against them will have serious flaws.
Case: The American College of Obstetrics and Gynecology released a bulletin in 2014 saying that waterbirth has no known benefits for babies and many potential dangers and should be limited only to controlled studies for research purposes. Full text of the ACOG's bulletin can be found here.
Analysis: The ACOG's position is based on individual case reports and case series of complications, which they acknowledge are not uniformly reported and there fore make it impossible to assess the actual incidence of these complications. The ACOG also bases their position on concerns about possible complications like "...higher risk of maternal and neonatal infections, particularly with ruptured membranes; difficulties in neonatal thermoregulation; umbilical cord avulsion and umbilical cord rupture while the newborn infant is lifted or maneuvered through and from the underwater pool at delivery, which leads to serious hemorrhage and shock; respiratory distress and hyponatremia that results from tub-water aspiration (drowning or near drowning); and seizures and perinatal asphyxia." They also state the they have believe that waterbirth could be potentially dangerous because of the possibility of the baby breathing in water: "Although it has been claimed that neonates delivered into the water do not breathe, gasp, or swallow water because of the protective “diving reflex,” studies in experimental animals and a vast body of literature from meconium aspiration syndrome demonstrate that, in compromised fetuses and neonates, the diving reflex is overridden, which leads potentially to gasping and aspiration of the surrounding fluid."
So let's take a look at these arguments in detail.
  1. Incidence of serious complications: The ACOG states that the information they have is not enough to actually find what the incidence of complications would be on a large scale. However, The United Kingdom provides a nice counterpoint to this. As stated in the ACOG's bulletin, approximately 1% of all birth in the UK have at least a period of water immersion. It should be noted that the United Kingdom has lower rates of neonatal mortality (3 deaths per 1,000 live births) than the United States does (4 deaths per 1,000 live births), so if waterbirth is as dangerous as the ACOG seems to be representing, then the UK would likely have higher rates of neonatal mortality than the United States, but this is not the case. Also, because the usage of waterbirth is not well regulated in the United States, the chance for problems to occur because of ill-informed and untrained attendants could be a significant (but very avoidable) risk factor for complications. Furthermore, the ACOG dismisses studies involving thousands of births which show that with a competent attendant water birth is very safe. One study from England showed that of 4,032 births in water that took place between 1994-1996, there was a mortality rate of 1.2 per 1,000 but none of those deaths were not attributed to waterbirth, but rather other causes. Out of the entire 4,032 births, two babies were admitted to the NICU for possible water aspiration, but recovered.
  2. Concerns over certain conditions: The ACOG very rightly brings up that there are risk factors for waterbirth. However, in the 2006 joint statement from the UK's Royal College of Obstetrics and Gynecology and the Royal College of Midwives, good practice of waterbirth requires taking measures to avoid these problems. For example, the Guidelines from the RCOG and RCM state that all birthing pools and equipment should be sterilized or disposed after use and that the water should be kept free from debris and fecal matter to prevent infection. They also state the need to watch for umbilical cord rupture and plan and prepare for it. Guidelines from Waterbirth International for waterbirth state that sterilization of all supplies and parts of the tub must take place and that no one should allowed in the tub if they have an infection. These guidelines also include recommendations for control of the baby's body temperature by monitoring the temperature of the pool or tub water and keeping the baby in the water with head out and close to the mother initially. The UK's policies for hospital waterbirth (similar to those of UK midwives) state that women who are at least 37 weeks along with an uncomplicated pregnancy and have well-established, spontaneous labor are candidates for water birth or water labor. This reduces many possible complications. One large study from Switzerland (which has a neonatal mortality rate lower than that of the United States at 3 per 1,000 live births) compared waterbirth to maia stool births and bed births for spontaneous, singleton babies in a head down position and found that there was no greater risk of infection with waterbirth. (In fact, out of the natural births, births in bed had a greater risk of infections, primarily in the eyes). They also found that waterbirths had far less complications with bleeding and hemorrhage than other birthing options.
  3. Concerns over drowning: Take note of the language in ACOG's comments on the possibility of drowning: "...in compromised fetuses and neonates, the diving reflex is overridden..." (emphasis mine). So the ACOG acknowledges that the diving reflex which keeps babies from gasping under water does work under normal circumstances. Their concern lies with babies who have been compromised, inhibiting the diving reflex. However, the RCOG and RCM's guidelines state that "If the woman raises herself out of the water and exposes the fetal head to air, once the presenting part is visible, she should be advised to remain out of the water to avoid the risk of premature gasping under water." Guidelines from Waterbirth International state: "The baby should be born completely underwater with no air contact until the head is brought to the surface, as air and temperature change may stimulate breathing and lead to water aspiration. If a change in position during delivery causes the baby to come in contact with air, the birth should be finished in the air." Both organizations advise the monitoring the baby's heart rate with a Doppler heart monitor to watch for problems. So those who are experienced, educated and competent in attending waterbirths acknowledge that the baby's protective diving reflex could be overridden and have guidelines in place to handle such a situation. Also, once the baby has been fully born a competent waterbirth attendant will quickly and gently get the baby's head out of the water and into the air while leaving the body in the warm water, held by the mother.
Conclusion: It is curious that American OB-GYN's have a habit of criticizing the birthing options of countries that have lower rates of neonatal death than that of the United States! Waterbirth is successfully used in many other countries to deliver babies and with competent and educated attendants has a great track record. For the most part, the ACOG's reasons against homebirth surround bad or incompetent usage of this tool. But we can't write something off as dangerous just because it has been used improperly.
Let's take for example, Cytotec (a.k.a. misoprostol). Cytotec is a drug for preventing stomach ulcers caused by non-steroidal anti-inflammatory drugs. However, doctors in America have been using it for about  20 years now to induce pregnant women because it works faster and causes stronger contractions than pitocin. This usage is in opposition to both the FDA and Cytotec's manufacturer Searle. Cytotec is contraindicated for use in pregnant women and not approved by the FDA for labor induction and has been associated with a large number of uterine ruptures and the deaths of many babies and mothers. Cytotec has proven so problematic that its manufacturer Searle issued a letter in August of 2000 warning obstetricians not to use it for labor induction.
Now, just because some doctors have chosen to use Cytotec in a way that it was never designed to work with resulting injuries and deaths does not mean that Cytotec itself is dangerous. Cytotec may be very helpful for someone with stomach ulcers from NSAID's. Cytotec is simply a tool. The results from its use depend upon the discretion of the practitioner. The same can be said of waterbirth. Waterbirth is a tool and while the improper use of it can result in injury or death, when used competently the evidence shows that it can have enormous benefits.

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