Waterbirth has a long history spanning more than 200 years in written record. The earliest record of a waterbirth in the western world was in France in 1803 when a woman, after 48 hours of labor, was encouraged to enter a bath by her physician (Gondinet, 1804). Fifteen minutes after immersion, the woman delivered a healthy newborn into water without interventions or complications (Bertram, 2000; Gondinet, 1804). In the early 1960s, waterbirth became popular in the Soviet Union where Igor Charkovsky began experimenting with waterbirth and neonatal adaptations to water (Church, 1989). In the early 1980s, intrapartum hydrotherapy spread throughout Europe spearheaded by French obstetrician Michel Odent and Belgian obstetrician Herman Ponette (Bertram, 2000; Mackey, 2001; Odent, 1983; Ponette, 1996).
Laura J. Valle, DNP, APRN-CNM
The earliest records of waterbirth and neonatal outcomes are from Odent and Ponette. Odent (1983) published observational data of the first 100 underwater births he attended and reported no neonatal infections or perinatal deaths. In 1996, Ponette detailed his direct experiences with 1,024 waterbirths from 1989-1995 reporting no neonatal complications in the neonates born into water (Ponette,1996). Over the course of 17 years, Ponette’s hospital in Belgium had 2,500 waterbirths, out of almost 8,000 total births, without a single incident of neonatal infection or death related to waterbirth (Turner & Turner, 2000). These positive outcomes highlight the safety and efficacy of Odent’s and Ponette’s experience with waterbirth.
Intrapartum hydrotherapy moved to the United States and steadily grew towards the end of the 20th century (Bertram, 2000). The first recorded waterbirth in the United States was in 1980 when a woman gave birth underwater to a healthy baby after only 90 minutes of labor (Garland, 2011). In 1989, Church published the first waterbirth article in the United States in the Journal of Nurse-Midwifery. Church (1989) reported the first 483 women to have a waterbirth at The Family Birthing Center in Upland, California between February 1985 and June 1989. There were no neonatal complications in the 483 waterbirths (Church, 1989).
Waterbirth continued to gain popularity around the world and in the United States throughout the end of the 20th century into the 21st century. In 1992, the British House of Commons (1992) Health Committee issued a report on maternity services that recommended all hospitals provide women with “the option of a birth pool where this is practicable” (p. 5). By 1997, 95% of maternity services in the United Kingdom had a birthing tub installed and were offering waterbirth (Burns, Boulton, Cluett, Cornelius, & Smith, 2012). In 2009, there were 229 hospitals in the United States offering waterbirth (Nutter, Meyer, Shaw-Battista, & Marowitz, 2014). While intrapartum hydrotherapy progressed in the United Kingdom under the support of the government and midwifery and medical associations, waterbirth progress in the United States stalled without full support of all of the professional bodies.
My professional experience with hydrotherapy began fourteen years ago in the United States as a labor and delivery nurse. As a registered nurse working with three certified nurse-midwives, I witnessed countless women who labored with ease in the water. Even though our tubs were standard household bathtubs affixed to the wall, women were still able to find pain relief and ease of movement in the water. Waterbirths were not allowed per hospital policy and they, unfortunately, are still not an option for women who birth at that hospital today.
I moved to Germany a few short years after becoming a labor and delivery nurse, and I had the pleasure of working in the Netherlands for a year as the New Parent Support RN for the American military triborder community of Germany, the Netherlands, and Belgium. I provided pre- and postnatal education for women in their home along with labor and delivery support in the local hospitals. Most of the women I attended, delivered their babies in Städtisches Krakenhaus Heinsberg (Heinsberg Hospital) in Heinsberg, Germany. The German midwives were pivotal in my education about hydrotherapy and waterbirths. The Heinsberg Hospital has permanently installed, egg-shaped, spacious, and deep pools that allow for maternal choice of movement along with upright positioning and birth. These types of deep pools also provide safety and protection for the neonate as the newborn is fully immersed at birth and, thus, does not take their first breath until their respiratory reflexes are stimulated as they are brought out of the water (Johnson, 1996).
Less painful, less anxiety
The Heinsberg Hospital’s pools afforded women a choice in how they labored and birthed, and the American clients I worked with enjoyed the option. For my multipara clients, the overall consensus was that their labors in Germany were far easier, less painful, less anxiety or fear ridden, and were quicker than their previous land births. As a healthcare professional, I witnessed the peace, calmness, and autonomy that water provided women during both their labors and births. After a year of working for a U.S. contractor as a New Parent Support RN, I decided I wanted to explore travel nursing in the United Kingdom (U.K.). Excited about the prospect of working within a different culture and healthcare system, I hopped aboard a train and went to work for the National Health Service (NHS).
In the United Kingdom, the RCOG and the RCM fully support a woman’s choice of using a birth tub during their labor and delivery if the woman is healthy and the pregnancy is uncomplicated (Alfirevic & Gould, 2006). Further, they endorse maternal choice in childbirth as a human right and believe that the use of waterbirth encourages a woman-centered approach (Harding, Munro & Jokinen, 2012).
My experience as St. Thomas’ Hospital in London was one of exponential growth and knowledge attainment. The midwifery and nursing models of care in the U.K. are quite different than in the U.S. Midwives are the main providers of low risk, normal maternity care and there are no labor and delivery nurses in the maternity units. Rather, the care for women in labor and birth is one-to-one midwifery care with midwifery assistants or midwifery students assisting. Women are able to labor and birth in the pools at St. Thomas’ Hospital. The pools used when I was there were permanently affixed in the middle of the room, oval in nature, and deep. Women reported that the pools provided them with a sense of privacy, security, and warmth during their labors and deliveries. Women using hydrotherapy during their labors and births were able to change position easily, had fewer interventions, and were easily monitored via handheld, waterproof dopplers.
Waterbirth is prevalent in the United Kingdom due in part to their national evidence-based campaign to normalize birth by reducing unnecessary interventions and increasing spontaneous vaginal birth rates (Burns et al., 2012). As part of the Normality for Labour and Births campaign, water immersion in labor and delivery is promoted as one of the top ten tips for women to use as an active birthing position that increases the chance of having a spontaneous vaginal birth while decreasing the chances of having interventions during birth (Royal College of Midwives, 2014). This was supported in Chaichian and colleagues’ (2009) RCT where they found that all of the women experiencing a waterbirth gave birth spontaneously, while only 79.2% of those who had a conventional birth had a normal spontaneous vaginal delivery.
Waterbirth was introduced in the United Kingdom, as well as the United States, in an effort to swing the pendulum back towards normal vaginal birth (Burns, 2001; Rosenthal, 1996). Waterbirth was utilized to reduce the rising, routine use of obstetric interventions; the rising costs of maternity care related to epidural anesthesia use and cesarean sections; and the increasing rates of instrumental and cesarean births (Chaichian, Akhlaghi, Rousta, & Safavi, 2009; Church, 1989; Cluett & Burns, 2009; Rosenthal, 1996). Waterbirth also provides a safe and private space for women to birth gently without invasive interventions (Akhlaghi et al., 2009; Maude & Foureur, 2007). Both the Royal College of Midwives (RCM) and Royal College of Obstetricians and Gynaecologists (RCOG) continue to support the use of water in labor and birth. The RCM and the RCOG published a joint statement in 2006 in support of autonomy, informed choice, and waterbirth (Alfirevic & Gould, 2006). The RCM and RCOG stated that while there is documentation of rare but serious neonatal complications, their review of the overall neonatal waterbirth data is reassuring, and that women “who make an informed choice to give birth in water should be given every opportunity and assistance to do so by attendants who have appropriate experience” (Alfirevic & Gould, 2006, p. 2).
Childbirth is a life-changing event that can have long lasting physical and emotional effects on a woman and her newborn (National Institute for Health and Care Excellence, 2014). Waterbirth has been shown to increase levels of satisfaction with childbirth and the overall birthing experience (Akhlaghi et al., 2009; Cluett & Burns, 2009). This higher rate of satisfaction has been attributed to women feeling more in control of their body and the birth process while in water (Aird, Luckas, Buckett, & Bousfield, 1997; Akhlaghi et al., 2009; Richmond, 2003). Women were also more satisfied with their birth experiences when their feelings and concerns were listened to, their autonomy was respected, and they had control of the decision making surrounding their birth choices (Akhlaghi et al., 2009; Wu & Chung, 2003). In Brown (1998), a birthing tub was installed within their maternity unit in England in response to women wanting to have a choice in how they birthed, and desiring control over their own birth process. Women who feel in control of their childbirth experience demonstrate long-term satisfaction beyond childbirth and mothering, including feelings of accomplishment and enhanced self-esteem (Green, Coupland, & Kitzinger, 1990; Simkin, 1991). Women also tend to have more positive psychological outcomes in the postpartum period when they feel in control of themselves and their environment (Green, Coupland, & Kitzinger, 1991). A woman’s satisfaction with her childbirth experience has the ability to contribute to long-term health and well-being and is a pivotal event that a woman will remember for the rest of her life (Ferguson, Browne, Taylor, & Davis, 2016; Simkin, 1991).
After working in London, I returned to the United States to complete my Master in Science in Nursing to become a nurse-midwife. Whilst my waterbirth knowledge and experience advanced in Europe, I returned to the U.S. after almost four years to find that no progress had been made at my hospital, or surrounding hospitals, to provide waterbirth as an option for women. In fact, the only option for a waterbirth where I lived was for a woman to have a homebirth. My passion for women centered care, women’s choice in labor, women’s autonomy, and shared decision making have propelled me to finish a Doctor of Nursing Practice degree and to pursue a PhD exploring shared decision making in maternity care. In my research I have found that waterbirth is a safe and viable option for women to exercise control over their birthing experience and experience autonomous choice in mode of delivery. While there is a paucity of level two evidence or randomized controlled trials, large observational studies have shown that waterbirths in low risk women who are attended by trained and experienced professionals are as safe as conventional births with no increased risk to neonates (Bodner et al., 2002; Brown 1998; Davies et al., 2015; Demirel et al., 2013).
Laura J. Valle, DNP, APRN-CNM
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