Waterbirth: a national retrospective cohort study of factors associated with its use among women in England

Abstract

Background Waterbirth is widely available in English maternity settings for women who are not at increased risk of complications during labour. Immersion in water during labour is associated with a number of maternal benefits. However for birth in water the situation is less clear, with conclusive evidence on safety lacking and little known about the characteristics of women who give birth in water. This retrospective cohort study uses electronic data routinely collected in the course of maternity care in England in 2015–16 to describe the proportion of births recorded as having occurred in water, the characteristics of women who experienced waterbirth and the odds of key maternal and neonatal complications associated with giving birth in water. Methods Data were obtained from three population level electronic datasets linked together for the purposes of a national audit of maternity care. The study cohort included women who had no risk factors requiring them to give birth in an obstetric unit according to national guidelines. Multivariate logistic regression models were used to examine maternal (postpartum haemorrhage of 1500mls or more, obstetric anal sphincter injury (OASI)) and neonatal (Apgar score less than 7, neonatal unit admission) outcomes associated with waterbirth. Results 46,088 low and intermediate risk singleton term spontaneous vaginal births in 35 NHS Trusts in England were included in the analysis cohort. Of these 6264 (13.6%) were recorded as having occurred in water. Waterbirth was more likely in older women up to the age of 40 (adjusted odds ratio (adjOR) for age group 35–39 1.27, 95% confidence interval (1.15,1.41)) and less common in women under 25 (adjOR 18–24 0.76 (0.70, 0.82)), those of higher parity (parity ≥3 adjOR 0.56 (0.47,0.66)) or who were obese (BMI 30–34.9 adjOR 0.77 (0.70,0.85)). Waterbirth was also less likely in black (adjOR 0.42 (0.36, 0.51)) and Asian (adjOR 0.26 (0.23,0.30)) women and in those from areas of increased socioeconomic deprivation (most affluent versus least affluent areas adjOR 0.47 (0.43, 0.52)). There was no association between delivery in water and low Apgar score (adjOR 0.95 (0.66,1.36)) or incidence of OASI (adjOR 1.00 (0.86,1.16)). There was an association between waterbirth and reduced incidence of postpartum haemorrhage (adjOR 0.68 (0.51,0.90)) and neonatal unit admission (adjOR 0.65 (0.53,0.78)). Conclusions In this large observational cohort study, there was no association between waterbirth and specific adverse outcomes for either the mother or the baby. There was evidence that white women from higher socioeconomic backgrounds were more likely to be recorded as giving birth in water. Maternity services should focus on ensuring equitable access to waterbirth.

Comparative Efficacy of Water and Conventional Delivery during Labour: A Systematic Review and Meta-Analysis

“…The baseline characteristics, namely, the author, year, median age, number of participants in the control and experiment group, of the 17 included studies are shown in Table 1 [ 13 – 29 ]. Through keywords search and simply reading abstracts, we found 4417 articles that could be used for further screening.…”

Systematic review and meta-analysis to examine intrapartum interventions, and maternal and neonatal outcomes following immersion in water during labour and waterbirth

“…7 71 72 A significant PPH reduction was another important finding, which is also supported in the literature. 73 In this study, there was no difference in caesarean birth rate between those who used water and those who did not. Interestingly, the caesarean rate in these studies was 3.6%, with all but two studies reporting a caesarean birth rate of less than 10% for the study participants.…”

Seeking safe harbour: Water immersion for women with complex pregnancy

“…There have been mixed findings regarding the incidence of postpartum haemorrhage with water birth with some finding a reduced incidence (Aughey et al, 2021;Nutter et al, 2014), some increased incidence (Barry et al, 2020;Neiman et al, 2020) and some no difference (Bailey et al, 2020;Menakaya et al, 2013) between water immersion and control groups.…”

“…Further, women are less likely to experience perineal trauma (Bailey et al, 2020;Lewis et al, 2018;Nutter et al, 2014;Sidebottom et al, 2020) or obstetric anal sphincter injuries (OASI) (Aughey et al, 2021;Menekaya et al, 2013;Nutter et al, 2014). Some studies identified no increase in perineal damage or OASI with the use of water immersion (Barry et al, 2020;Cluett et al, 2018;Shaw-Battista, 2017) whereas others identified an increased risk of perineal injury (Bovbjerg et al, 2016).…”

“…Adverse neonatal outcomes with water birth, such as asphyxia, infection or neonatal unit admission, are rare and do not occur at higher rates than with conventional land birth practices (Aughey et al, 2021;Bailey et al, 2020;Barry et al, 2020;Bovbjerg et al, 2016;Burns et al, 2012;Cluett et al, 2018;Lathrop et al, 2018;Neiman et al, 2020;Nutter et al, 2014;Shaw-Battista, 2017;Sidebottom et al, 2020;Taylor et al, 2016;Vanderlaan et al, 2018). Umbilical cord snap has been identified as a risk during a water birth (Burns et al, 2012;Henderson et al, 2014).…”