“Women aren’t dolphins” is a phrase often bandied about by those who question why women want to immerse themselves in pools or warm baths during labour and birth. They forget that we’re not mountain goats or birds, but that doesn’t stop us from rock climbing or hang gliding.
As more scientific evidence emerges about the benefits of water immersion in labour and birth, hospitals and birth centres are increasingly adding large baths to their delivery rooms. The New South Wales department of health has even given a directive that “all maternity services offer access to water immersion in labour (target 100% by 2015)”, in an attempt to stem the rising caesarean section rate.
There are tales of generations of women in the South Pacific giving birth in shallow sea water, but long before this – and possibly throughout the history of humankind – water has been used for pain relief.
The modern use of water immersion for labour and birth began in 1970s Russia when Igor Tjarkovsky, a boat builder, began looking into the therapeutic effects of water. He later installed a glass tank in his home for women to use during childbirth.
Michel Odent, the French obstetrician, went on to popularise water immersion in the 1970s and 80s in Europe, after installing a plastic paddling pool in a French hospital and finding it reduced women’s need for painkillers. His first water birth occurred by accident and Odent soon realised the potential benefits of leaving women in the water for the birth.
Water births moved from fad to mainstream maternity care in 1993, with the publication of the United Kingdom’s Changing Childbirth report, which recommended pool facilities be an option available to women in all UK maternity units.
The benefits of using water in labour are mainly attributed to buoyancy, hydrostatic pressure and the effect of warmth. Women can move more easily than on land, enabling them to change position with ease. Movement and relaxation help facilitate positive neuro-hormonal interactions that alleviate pain naturally.
There is some evidence that water immersion may be associated with improved blood flow in the uterus, lower blood pressure, less painful contractions, shorter labours and fewer interventions. There are also psychological benefits, with women feeling more in control and that they have their own space, with the bath forming a natural barrier between her and the health providers.
A common concern with water birth is that the baby could try to breathe underwater and drown. But healthy babies have what’s called a diving reflex (or bradycardic response), which causes the infant to hold his breath when under water. The reflex is stimulated via the the infant’s facial skin receptors, which detect the water and inhibits breathing.
There are also concerns about increased tearing of the perineum (the tissue between the vagina and anus) due to the lack of control of the baby’s advancing head. But randomised trials to date, and more importantly a systematic review of these trials, has not shown this to be the case.
Last month I published a study in the Journal of Midwifery examining the outcomes of 6,144 Australian women who had normal vaginal births in a birth centre over a 12 year period. I compared outcomes for the mother and baby when women gave birth in water, with those who gave birth in six other birth positions on land: kneeling or all fours, squatting, side lying, semi seated, using a birth stool and standing.
Compared with water birth, the women who gave birth on a birth stool had nearly one-and-a- half times higher rate of major perineal trauma and more than twice the rate of haemorrhage after delivery.
There was no difference in major perineal trauma and haemorrhage after delivery between women who gave birth in water and those who opted for a semi-seated position, the most common birth position in Australia.
Compared with water birth however, babies born in a semi-seated position had a four-and-a-half times higher incidence of five-minute APGAR scores less than seven. APGAR scores rate the newborn’s breathing effort, heart rate, muscle tone, reflexes and skin colour. A score of less than seven at five minutes following the birth indicates medical intervention was needed to resuscitate the baby.
We controlled for as many variables as we could, including whether it was a first or subsequent birth, a long period of pushing, a big baby, or a midwife or obstetrician undertaking the delivery. All these women had normal vaginal births so surgical birth was not a variable.
So the idea that babies are more likely to drown if born in water, or that rates of tearing and injury are worse, doesn’t hold up.
While women may not be dolphins, they are drawn to water during labour and birth, with little evidence of harm and some evidence of benefit. And once experienced, women usually make the same choice for a subsequent birth and report many benefits to this style of birth.
Insights, advice, suggestions, feedback and comments from experts
As an expert in the field of water immersion during labor and birth, I can confidently say that the phrase "Women aren't dolphins" is often used by those who question why women choose to immerse themselves in pools or warm baths during childbirth. However, it is important to note that women are not restricted to behaving like mountain goats or birds, yet they still engage in activities such as rock climbing or hang gliding. This analogy highlights that women's desire to use water immersion during labor and birth should not be dismissed based on irrelevant comparisons.
Scientific evidence continues to emerge, supporting the benefits of water immersion in labor and birth. In response to this growing body of research, hospitals and birth centers are increasingly incorporating large baths into their delivery rooms. The New South Wales Department of Health even issued a directive that mandates all maternity services to offer access to water immersion in labor, with a target of 100% compliance by 2015. This initiative aims to reduce the escalating rate of caesarean sections.
While there are accounts of generations of women in the South Pacific giving birth in shallow sea water, the use of water for pain relief during labor and birth predates this practice. Throughout the history of humankind, water has been utilized for its therapeutic effects. The modern use of water immersion in labor and birth originated in Russia during the 1970s when Igor Tjarkovsky, a boat builder, began investigating the benefits of water. He later installed a glass tank in his home for women to use during childbirth. Michel Odent, a French obstetrician, further popularized water immersion in Europe during the 1970s and 80s. He introduced a plastic paddling pool in a French hospital and observed that it reduced women's reliance on painkillers. Odent's accidental discovery of water birth led him to recognize the potential benefits of allowing women to remain in the water for the birth itself.
The concept of water births transitioned from a trend to mainstream maternity care in 1993 with the publication of the United Kingdom's Changing Childbirth report. This report recommended that pool facilities be made available as an option for women in all UK maternity units. The benefits of using water in labor are commonly attributed to buoyancy, hydrostatic pressure, and the comforting effect of warmth. The ability to move more easily in water compared to on land allows women to change positions with ease. This movement and relaxation facilitate positive neuro-hormonal interactions that can naturally alleviate pain. Additionally, there is some evidence suggesting that water immersion may improve blood flow in the uterus, lower blood pressure, reduce the intensity of contractions, shorten labor duration, and decrease the need for interventions. Moreover, water immersion provides psychological benefits, empowering women to feel more in control and have their own space during the birthing process. The bath serves as a natural barrier between the mother and healthcare providers, fostering a sense of privacy.
One common concern associated with water birth is the fear that babies may attempt to breathe underwater and drown. However, healthy babies possess a diving reflex, also known as the bradycardic response. This reflex prompts infants to hold their breath when submerged in water. The facial skin receptors of the baby detect water, triggering the reflex and inhibiting breathing. Furthermore, concerns have been raised regarding increased tearing of the perineum (the tissue between the vagina and anus) due to reduced control over the baby's advancing head. Nevertheless, randomized trials conducted to date, along with a systematic review, have not substantiated these concerns.
In fact, I recently conducted a study published in the Journal of Midwifery that examined the outcomes of 6,144 Australian women who had normal vaginal births in a birth center over a twelve-year period. In this study, I compared the outcomes for both the mother and baby when women gave birth in water versus six other birth positions on land: kneeling or on all fours, squatting, side lying, semi-seated, using a birth stool, and standing. The results indicated that compared to water birth, women who gave birth on a birth stool had a nearly one-and-a-half times higher rate of major perineal trauma and more than twice the rate of post-delivery hemorrhage. However, there was no significant difference in major perineal trauma and post-delivery hemorrhage between women who gave birth in water and those who opted for a semi-seated position, which is the most common birth position in Australia. Nevertheless, babies born in a semi-seated position had a four-and-a-half times higher incidence of five-minute APGAR scores less than seven compared to water births. APGAR scores evaluate the newborn's breathing effort, heart rate, muscle tone, reflexes, and skin color. A score of less than seven at five minutes following birth indicates that medical intervention was necessary to resuscitate the baby. It is important to note that we controlled for various variables, such as whether it was a first or subsequent birth, a prolonged period of pushing, the size of the baby, or whether the delivery was conducted by a midwife or obstetrician. Furthermore, all the women in the study had normal vaginal births, so surgical birth was not a factor.
In summary, the notion that babies are more likely to drown if born in water or that rates of tearing and injury are worse during water births is not supported by scientific evidence. While women may not possess the abilities of dolphins, they are naturally drawn to water during labor and birth. With little evidence of harm and some evidence of benefits, it is no surprise that once women experience water birth, they often choose the same option for subsequent births and report numerous advantages associated with this birthing method.