The effect of waterbirth on neonatal mortality and morbidity: a systematic review protocol

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Abstract

Review question/objective

The objective of this research is to systematically review the evidence regarding the effect of waterbirth, in comparison to land birth, on the mortality and morbidity of neonates born to low risk women.

Background

Waterbirth and water immersion in labor are two distinct phenomena; however they are often confounded. Some women use water immersion in labor as a strategy to manage their labor pain but leave the bath prior to the birth of their baby. As the name implies, however, waterbirth occurs when a baby is born underwater. This can happen either intentionally or accidentally, for example when a woman uses water immersion during labor and remains in the water to birth her baby.

Background

Although the definitions of waterbirth and water immersion are simple to separate, descriptions of their use during a woman's labor are often merged.1, 2 Given this, it is not surprising that research attempting to describe the benefits and risks of both water immersion and waterbirth is interwoven In many instances, discussion of waterbirth is confused by focusing on the benefits of water immersion for the woman and the risks of waterbirth to the neonate, two separate issues.

Background

Water immersion in labor

Background

Water immersion in labor has been used by many generations of women and is common practice in many birthing suites.3 Current research describes benefits for women using water immersion in labor including: increased relaxation4, pain relief5, 6, maximized maternal satisfaction7, reduced length of labor2, 3, 5, 8, 9, reduced intervention3, 10, 11, increased spontaneous birth12, 13 and reduced first and second degree perineal tears.13, 14 The buoyancy enabled by the water allows women to move easier during labor and potentially optimizes labor progress.3, 6 Water immersion may also be associated with improved uterine perfusion, less painful contractions and a shorter labor.3, 15, 16 A Cochrane systematic review of eight trials comparing water immersion in labor with controls showed that water immersion resulted in a significant reduction in epidural analgesia use (478/1254 versus 529/1245; risk ratio [RR] 0.90; 95% [Confidence Interval [CI] 0.82 to 0.99, six trials]), a reduction in duration of the first stage of labor (mean difference -32.4 minutes; 95% CI -58.7 to -6.13, seven trials) with no difference in assisted vaginal birth (RR 0.86; 95% CI 0.71 to 1.05, seven trials), caesarean sections (RR 1.21; 95% CI 0.87 to 1.68, eight trials), use of oxytocin infusion (RR 0.64; 95%CI 0.32 to 1.28, five trials), perineal trauma (intact perineum, 236/678 versus 200/659, RR 1.16, 95% CI 0.99 to 1.35, five trials) or maternal infection (15/647 versus 15/648, RR 0.99, 95% CI 0.50 to 1.96, five trials).5 There have been no studies that have identified any adverse effects of water immersion in labor for the woman or the neonate.

Background

Waterbirth

Background

The benefits to women of using water immersion in labor are evident. However, the practice of birth underwater remains controversial and the debate polarized, with research providing conflicting information and mixed results. As a result of this confusion, many birthing units in Australia provide water immersion in labor as an option for women; however, implementing waterbirth policies remains a slow and complex process.17,18

Background

The trend of waterbirth

Background

The first recorded waterbirth occurred in France in 1803.19 After laboring for 48 hours, an exhausted woman used a warm bath and birthed a healthy baby.1 In the early 1980s, waterbirths became more popular as water immersion was promoted to help women relax and cope with their labor.20,21 Currently, few women birth their baby underwater; however water immersion in labor is commonly available.20 Baths and birthing pools were integrated into the United Kingdom's mainstream maternity units in 1992 after the House of Commons Health Committee recommended that all women have access to water for labor and birth.12 Their national practice guidelines also support the use of baths and birthing pools in labor.22 Within Australia, 14 of 19 birthing centres provide bath facilities.23 Further, waterbirth tends to be supported by midwives as it represents a birthing option congruent with midwifery philosophy.7,24

Background

Concerns about waterbirth

Background

In an uncomplicated pregnancy, water immersion is unlikely to harm the woman or her baby.5 Given this, many birthing units will restrict water immersion in labor to women with a low risk pregnancy. Regarding waterbirth, commentators have developed a list of contraindications; however, due to a paucity of research in this area, this is based largely on opinion.18 Even so, the option to waterbirth remains restricted to women with a low risk pregnancy. Individual birthing units develop specific waterbirth protocols suiting their own circumstances and existing policy.

Background

In a review of the evidence on waterbirth, Young and Kruske (2013) identified five main areas of concern: a perceived risk of neonatal water aspiration, neonatal and maternal infection, neonatal and maternal thermo-regulation, skills of attending midwives and emergency procedures in the event of maternal collapse. They concluded there was no evidence supporting these concerns.25

Background

Although the practice of waterbirth has been linked to increased risk to the neonate1, 26-28 there is no high level evidence available to support this issue.20, 29 The association between waterbirth and adverse neonatal outcomes comes largely from case reports.28, 30, 31 These highlight the potential risks to the neonate from waterbirth, including: neonatal respiratory distress, neonatal infection, umbilical cord avulsion, hyponatremia, hypoxic ischemic encephalopathy, fetal thermoregulation and water embolism.1, 26, 28, 32, 33 There are also numerous articles providing commentary about a perceived lack of adequate research and potential disregard for adverse neonatal outcomes following waterbirth.18, 32, 34-36 Both case studies and commentary are at risk of author bias and represent a low level of evidence upon which to build waterbirth policy and protocol.

Background

The above neonatal outcomes, as described within the literature, will form the basis of the reviewers search and discussion concerning potential neonatal outcomes following waterbirth.

Background

Current evidence and policy

Background

Simpson (2013)37 conducted a systematic review of neonatal outcomes following waterbirth; however, only two randomized controlled trials (RCT), two systematic reviews and case reports were reviewed. A number of observational studies have been conducted on waterbirth but these were not included.37 Also, no meta-analysis was conducted. The Cochrane systematic review by Cluett and Burns (2009) was similarly limited to RCTs.5 Another systematic review, conducted in 2004, searched for complications that could be associated with waterbirth and was not limited to RCTs.1 They reviewed 16 articles and concluded that waterbirth may be associated with complications that are not seen with land birth, however, outcomes from water immersion and waterbirth are confounded.1 The quality and rigor of this review has also been called into question.35

Background

There are two known RCTs comparing outcomes after waterbirth and land birth: an Iranian study of 106 women38 and a pilot study conducted in the UK.29 Both trials are small and therefore offer limited evidence. Woodward and Kelly (2009) reported that a larger RCT is possible and acceptable to women; however no further trial has been conducted hence raising concerns over feasibility.29

Background

Published guidelines for health practitioners argue that there is insufficient evidence to guide waterbirth practice. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists offer a cautious review, suggesting that there is little evidence of waterbirth offering any benefits and advise caution when interpreting any current studies due to small sample sizes.39 The American College of Obstetricians and Gynecologists (2014) state that waterbirth “should be considered an experimental procedure that should only be performed within the context of an appropriately designed clinical trial with informed consent”40(p.914). However, it is unlikely that a RCT could ethically be conducted on this practice.

Background

Other protocols agree that there may be no benefit, but argue that there is also no adverse effects directly attributed to waterbirth. A joint statement released by the Royal College of Obstetrics and Gynaecology (RCOG) and the Royal College of Midwives (RCM) support women laboring in water while acknowledging the lack of evidence supporting waterbirth and the rarity of complications.41 The Queensland Normal Birth guidelines also discuss waterbirth stating there is no evidence of increased adverse effects for the woman or fetus; however they acknowledge there is inadequate evidence to either support or not support, a woman's choice to birth underwater.42 Young and Kruske (2012) confirm that Australia's individual state policies lack contemporary, high quality evidence and do not encourage or provide guidance for women or their health care providers.43

Background

The current state of opinion and evidence of the benefits and risks of waterbirth for the neonate requires a thorough systematic review to be conducted. Current evidence is contradictory and the lack of robust systematic evidence regarding waterbirth allows the growth of conflicting opinion about its safety. Given the scarcity of reliable evidence, anecdotal shared experiences and personal observation has influenced policy and practice.20 A review of current literature focusing on high level evidence and maintaining clear and thorough search guidelines is needed to advance our understanding of the effect of waterbirth on neonatal outcomes.

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