Comparing the 2014 and 2016 ACOG and AAP Statements about Waterbirth

by | Mar 14, 2019

In April 2014, waterbirth—an alternative method for pain relief in which a person gives birth in a tub of warm water—made national headlines. The event that pushed waterbirth safety into the spotlight was a joint Opinion Statement from the American Congress of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP), denouncing the practice.

In their opinion statement, ACOG and the AAP firmly stated that waterbirth should be considered an untested practice. They said that it should only occur in the context of a clinical research study. Their conclusion, which echoed a previous AAP Opinion Statement from 2005, was based on their opinion that waterbirth does not have any benefits and may pose dangers for the newborn.

Differing opinions on waterbirth

In response, the American College of Nurse Midwives (ACNM), the American Association of Birth Centers (AABC), and the Royal College of Midwives (RCM) all released statements endorsing waterbirth as a safe, evidence-based option.

Meanwhile, the AABC released early data from nearly 4,000 waterbirths that occurred in birth centers all over the United States (U.S.). These findings supported waterbirth as safe for mothers and infants. Despite the response from midwifery groups and the AABC, hospitals all over the U.S. began suspending or shutting down their waterbirth programs. At St. Elizabeth’s Regional Medical Center in Lincoln, Nebraska, mothers and families organized rallies and started a petition to bring waterbirth back.

Since that time, ACOG and the AAP have released a new statement, in which they softened their stance. In this article, we will answer the following questions:

  • Was the 2014 ACOG/AAP statement based on a complete and accurate review of the literature?
  • How has the 2016 ACOG/AAP statement changed since the 2014 version?

What Kind of Evidence Did ACOG and the AAP Rely on in Their 2014 Opinion Statement on Waterbirth?

When discussing the reported complications from waterbirth, ACOG/AAP relied heavily on case reports instead of higher levels of evidence that was available from observational studies and retrospective surveys (ACOG, 2014). For the original Evidence Based Birth® article on waterbirth, I easily identified at least seven recent studies—five of which were very high quality prospective studies—that were not mentioned in the 2014 opinion statement. This raised the question as to whether the authors conducted a thorough literature review before forming their opinion.

In addition, the ACOG/AAP Opinion Statement contained several major errors, including references to studies that had nothing to do with waterbirth and misrepresentation of study findings. In one case, they led the reader to think that there were waterbirth drownings in a study when there were actually none (Personal correspondence, Alderdice, 2014). They left out important details from the included case studies and relied heavily on the findings of a single article (Pinette et al. 2004) that did not meet basic standards for scientific rigor.

How Has the 2016 ACOG Opinion Statement Changed from the 2014 Opinion Statement?

The 2016 ACOG Opinion Statement (endorsed by the AAP) on water immersion during labor and birth replaces the 2014 Opinion Statement (ACOG, 2016). The new statement shows a strengthening of support for water immersion during labor and a softening on waterbirth. Here are some of the key differences between the old and new opinion statements:

Water Immersion May Be Offered

  • New: “Water immersion may be offered to healthy women with uncomplicated pregnancies between 37 0/7 weeks and 41 6/7 weeks of gestation”
  • Old:    No suggestion that pregnant people be offered water immersion during labor

Water Immersion Is Increasing in Popularity

  • New: “In the U.K., 1.5% of hospital deliveries include a period of immersion and 58% of births in a freestanding midwifery unit”
  • Old:    “1% of births in the U.K. include a period of immersion”

Water Immersion During Labor and Birth Is Supported by Some Professional Organizations

  • New:  “Several professional organizations, including the Royal College of Obstetricians and Gynaecologists and the American College of Nurse–Midwives, support healthy women with uncomplicated pregnancies laboring and giving birth in water” [These organizations have been supporting healthy people giving birth in water since before 2014, the authors just didn’t mention it in the 2014 statement]
  • Old:    “The Royal College of Obstetricians and Gynaecologists and Royal College of Midwives support immersion in water during labor for healthy women with uncomplicated pregnancies”

The Language Applied to Water Immersion During Labor Is More Affirming, Less Skeptical 

  • New:  “Benefits Associated With Immersion During Labor and Delivery”
  • Old:    Proposed Benefits From Immersion During Labor and Delivery”;” There have been claims”; “Some advocates argue”; “May be appealing to some; however…”

Informed Consent Is Appropriate for Waterbirth

  • New:  “A woman who requests to give birth while submerged in water should be informed that the maternal and perinatal benefits and risks of this choice have not been studied enough to either support or discourage her request” 
  • Old:    No mention of informed consent with pregnant people requesting waterbirth

New Mention of Benefits to Waterbirth

  • New:  “Individual prospective observational and retrospective studies report associated benefits of immersion during the second stage of labor [including delivery] to include fewer episiotomies and less use of pharmacologic analgesia” [Note that all sources were available to the authors of the 2014 statement but were not included]
  • Old:    “Immersion in water during the second stage of labor has not been associated with maternal or fetal benefit”

New Attention to Mother’s Satisfaction with the Childbirth Experience

  • New:  Includes data from interviews with birthing people that found high satisfaction with immersion during labor and birth [Again, note that all sources were available to the authors of the 2014 statement but were not included]
  • Old:    No mention of qualitative studies that looked at mothers’ experiences with water immersion during labor or birth

Language Careful to Not Discourage Prospective Studies

In prospective studies, researchers enroll people while they are still pregnant and follow them until after their babies are born, collecting data all along the way.

  • New:  “The opinions expressed in this document should not be interpreted in such a manner as to prevent the conduct of well-designed prospective studies of the maternal and perinatal benefits and risks associated with immersion during labor and delivery”
  • Old:    “[Waterbirth] should be considered an experimental procedure that only should be performed within the context of an appropriately designed clinical trial with informed consent”

There May Be Newborn Benefits Not Yet Known

  • New:  The 2016 statement agrees that no benefits to newborns have been found in large meta-analyses (many studies pooled together) and that there is the potential for rare adverse events, but mentions that the existing evidence is insufficient to rule out the possibility of newborn benefits
  • Old:    The 2014 statement concludes that there is no evidence of newborn benefits to water immersion during labor or delivery, only rare but serious adverse effects

Examines More Evidence, Including Observational Studies

  • New: Includes findings from observational studies as well as randomized trials when reporting on the potential benefits and risks for mothers and newborns of water immersion during labor and birth
  • Old:    The studies examined were largely limited to the randomized trials included in the Cluett & Burns (2009) Cochrane review and individual case studies

New Language Around Risks

  • New:  The 2016 statement clarifies that while some newborns experience complications, “most instances [of umbilical cord avulsion (cord ‘snapping’ or cord rupture] were not associated with additional neonatal morbidity” and they express a need for evidence-based guidelines to prevent umbilical cord avulsion
  • Old:    The 2014 statement gives a misleading representation of risk, claiming only that “umbilical cord avulsion and umbilical cord rupture while the newborn infant is lifted or maneuvered through and from the underwater pool at delivery, leads to serious hemorrhage and shock”

What Else Is New in the 2016 Opinion Statement?

The 2016 statement discusses additional risk factors for newborn infection from waterbirth:

  • Not enough pool disinfection
  • Birthing pools which have built-in heaters and recirculation pumps and can be filled well in advance of the birth—all factors that can increase the risk of infection
  • Pool filling long before intended use
  • Using water from an unclean source

What Has Not Changed from the 2014 Opinion Statement?

ACOG/AAP continue to affirm that immersion during the first stage of labor may be associated with increased maternal satisfaction, decreased use of analgesia for pain relief, and decreased duration of the first stage of labor. However, the new statement goes further to promote these findings by recommending that it be offered to healthy people with uncomplicated pregnancies between 37 0/7 weeks and 41 6/7 weeks of gestation.

They re-affirm their recommendations to improve the safety of water immersion, urging that:

“Facilities that plan to offer immersion during labor and delivery need to establish rigorous protocols for candidate selection; maintenance and cleaning of tubs and pools; infection control procedures, including standard precautions and personal protective equipment for health care personnel; monitoring of women and fetuses at appropriate intervals while immersed; and moving women from tubs if urgent maternal or fetal concerns or complications develop.”

Perhaps the most obvious factor that remains the same between the old and new statements is that ACOG and AAP continue to recommend that birth occur on land, not in water. However, the new statement recommends that pregnant people who request to give birth in water should be allowed an informed choice. They should be informed that the benefits and risks of this choice have not been studied enough to either support or discourage the request.

Who or what informs policies and guidelines concerning water immersion during labor and birth?

Researchers in Australia wanted to find out if the clinical practice guidelines in existence were evidence-based or based on subjective opinions. The study included a total of 25 Australian policies and guidelines on water immersion and water birth. They used a type of analysis called ‘critical discourse analysis’, in which language is studied to determine the influence of power or dominance by one social group over another. The analysis revealed that often only lower levels of evidence were cited in the guidelines, such as case reports or expert opinion, and many were out-of-date and did not include the latest research evidence.

The documents were frequently written to suggest that the care provider was in charge and that the birthing person’s choices were restricted from going against their advice. If they chose to remain in the tub against advice, they were met with consent forms that suggested they had no choice but to comply (“I will respect the directions of the midwife and/or Doctor and will abide by their expertise”). The study found that medical dominance limits the decision-making of both the people using water immersion and the providers (often midwives) who facilitate the water immersion, since they are not free to draw on their experience and knowledge but must submit to the guidelines.

The researchers concluded that Australian clinical practice guidelines concerning water immersion and waterbirth were out-of-date and heavily influenced by the subjective expert opinions of the medical authorities, rather than research evidence or the opinions of the parties involved in the practice – the women and their midwives. This study is important for people living outside of Australia as well, because the findings indicate that sometimes clinical guidelines are based more on medical opinion than strictly evidence.

What’s the bottom line?

In conclusion, it appears that the 2016 ACOG/AAP statement on waterbirth relied less on subjective opinions than it has in the past. In the new 2016 statement, these bodies moved towards including more research evidence in their statement on water immersion during labor and birth.


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