In March of 2014, I wrote a post discussing a joint clinical report on water immersion during labor and delivery published by the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG). To the surprise of nobody who is familiar with the current state of health journalism and the minds of true believers, the internet overflowed with poorly-written news articles and the fallacious logic of waterbirth proponents in response to the new guidelines. You can plunge into my previous post for a deeper dive than will be presented in this update, but for those of you who don’t wish to do more than splash around in the shallow end, the AAP-ACOG report concluded that immersion in water prior to delivery is likely not of much benefit to mother or baby and that delivery in water is potentially extremely dangerous and should be considered an experimental procedure restricted to ethically-run clinical trials.

On October 24th of this year, the ACOG Committee on Obstetric Practice released an updated AAP-endorsed statement titled “Immersion in Water During Labor and Delivery.” The new guidelines, described as “more accepting and less judgemental of the practice of water immersion” by the Chair of the AAP Committee on the Fetus and Newborn, actually aren’t that much different than the 2014 version. The ACOG remains clear on the lack of solid evidence in support of claimed benefits of water immersion during the first stage of labor. And they are still opposed to delivering a baby underwater, but they have inappropriately softened their stance and walked back the part about restricting underwater delivery to proper clinical trials.

Why has ACOG released new recommendations so soon?

While not unheard of, it is a little odd for there to be a release of new guidelines on a topic like this so soon. Although likely increasing in popularity, particularly water immersion during only the first stage of labor, nobody is keeping track in the United States. And the literature on the subject often fails to differentiate between immersion during early labor and underwater delivery. According to the guideline authors, in England, where there is better tracking, as many as 58% of women spend at least some part of the labor process in water in some birthing centers while rates are considerably lower in hospitals.

There also doesn’t appear to have been any game changing new research that would justify an update, with the focus still primarily being on a 2011 Cochrane review that I discussed in detail in my prior post. Sadly, it seems that they are simply reacting to negative responses to the 2014 clinical report from proponents of immersion during labor and waterbirth. Their goal may have been to be kinder and more understanding of different approaches, but this watered down new statement unfortunately may encourage more women to take part in a dangerous practice.

The updated ACOG recommendations

I will provide a brief summary of the new recommendations as well as my concerns with each:

Recommendation: Immersion in water up until complete cervical dilation may reduce labor duration and the need for spinal and epidural anesthesia and may be offered to healthy women with uncomplicated term pregnancies.

They conclude this despite the many flaws in the available literature and the high risk of bias, all of which is discussed in great detail in the ACOG document. There are many variables that go into immersion during the first stage of labor, variables which are rarely discussed in the mostly retrospective, and always unblinded, studies on the subject. And there are numerous potential outcomes that have been looked at. The weak findings on reduced labor duration and the reduced need for spinal and epidural anesthesia may simply be noise in the data or the result of factors other than the immersion in water.

Because nobody is keeping track of immersion during the first stage of labor, even in hospitals and birthing centers, I worry that there are women taking part in this practice who have risk factors or who haven’t reached 37 weeks of gestation. And women who labor in water are almost certainly more likely to deliver in water than women who don’t. Delivering a child underwater is dangerous and the evidence in favor of it is even more shallow.

Recommendation: There is currently not enough data to compare maternal and perinatal risks and benefits of actually delivering a baby underwater so ACOG doesn’t recommend it.

There is a difference between saying that there isn’t enough data to compare risks and benefits and that there is no plausible benefit and proven risk of catastrophic adverse outcomes. This topic is an excellent example of where evidence-based medicine fails and science-based medicine succeeds. This statement misses the point.

There is a reason why the amniotic membrane ruptures at the onset of labor. This is one of the important first steps in a baby’s structural and biochemical preparation to emerge from their fluid environment and to begin breathing air. There is nothing “natural” about being born into a tub full of water, blood, fecal matter, urine, and pathogenic bacteria.

Recommendation: Because of this lack of data, a woman interested in delivering her baby underwater can neither be supported nor discouraged but she should be informed of possible rare but serious neonatal complications.

Because of this lack of plausible benefit and clear risk of neonatal infection, injury, and death, a healthcare provider who practices ethically and based on scientific principles must discourage the delivery of a baby underwater. The patient must be supported in understanding the risks and the lack of benefit so that they might make an informed decision. There, I fixed it.

Recommendation: The ACOG would support prospective clinical trials designed to investigate maternal and perinatal risks and benefits associated with labor and delivery in water.

Labor yes. Delivery I’m not so sure. But if done, it should only be as part of an ethically-designed prospective trial. Frankly I don’t think that this is possible.

Recommendation: Facilities offering labor and delivery in water should have rigorous protocols regarding appropriate candidates, maintenance and cleaning of tubs and pools, infection control, monitoring of maternal and fetal health, and the removal of mothers from the water if maternal or fetal complications occur.

The fact that they don’t already is terrifying.

The bad, the worse, and the drowning babies

So what can go wrong with water immersion during labor and/or delivery? As I did in my 2014 post, I’ll provide a handy list:

  1. Increased risk of infection, especially after rupture of the amniotic membranes that act as a barrier between baby and the outside world
  2. Delay in providing resuscitation or other necessary medical care while transferring an ill or injured baby from the water
  3. Problems with temperature regulation in the baby
  4. Damage to the umbilical cord, or pulling of the cord out of the placenta, leading to severe bleeding complications
  5. Respiratory distress, hyponatremia, seizures, and asphyxia from fresh water drowning

All of the above can result in the death of a child. All of the above can result in long term disability. And all of the above will result in a child requiring admission to a neonatal intensive care unit and separation from their family, which can negatively impact breastfeeding success and interfere with the bonding process. Although these are uncommon outcomes, they must be considered in the context of extremely low plausibility of benefit and no reasonable evidence to say otherwise.

Conclusion: Immersion during labor still has few benefits, significant risks

This new set of AAP-endorsed ACOG guidelines appears to be attempting to fix something that was not broken. Their 2014 position paper covered the subject of water immersion during labor in a thorough and rational manner, pointing out the weak evidence of benefit but acknowledging that it is fairly low risk in most circumstances. And it appropriately concluded that the risks of delivering underwater are such that it should not be taking place unless as part of a proper and ethical clinical study.

Although data is scarce, there are likely tens of thousands of women laboring in water in the United States every year. If even 1% of babies are delivered into water, that is roughly 40,000 per year. Many of these would be born in water regardless of what the ACOG or AAP has to say about it because of the unfortunate worldview of some mothers, and there are far too many irresponsible healthcare professionals and nonprofessional lay practitioners who are quick to condone or promote it. My fear is that the softened language in this new statement may provide a bit more encouragement for those who haven’t yet made up their mind.

Here is a response to the new ACOG statement by the American College of Nurse-Midwives.

Posted by Clay Jones

Clay Jones, M.D. is a pediatrician practicing at Newton-Wellesley Hospital in Newton, MA, and a regular contributor to the Science-Based Medicine blog. He primarily cares for healthy newborns and hospitalized children, and devotes his full time to educating pediatric residents and medical students. Dr. Jones first became aware of and interested in the incursion of pseudoscience into his chosen profession while completing his pediatric residency at Vanderbilt Children’s Hospital a decade ago. He has since focused his efforts on teaching the application of critical thinking and scientific skepticism to the practice of pediatric medicine. Dr. Jones has no conflicts of interest to disclose and no ties to the pharmaceutical industry. He can be found on Twitter as @skepticpedi and is the co-host of The Prism Podcast with fellow SBM contributor Grant Ritchey.