There has, very understandably, been a huge amount of concern about whether different maternity care practices increase the risk of transfer of Covid-19 between the woman giving birth and those caring for her. In some hospitals, the use of gas and air was stopped for a while, and in many, water births have not been supported for some time.
The two most commonly referred to concerns about Covid-19 and water birth were:
- As virus particles have been found in faeces, could water birth increase the risk of faecal transmission?
- Could water vapour in the pool room transmit virus particles more efficiently than in dry air?
It is also important to look at whether water birth can reduce the transmission of Covid-19. Does birthing in water reduce the risk of transmitting Covid-19 between birthing mother and midwife?
Consideration of theoretical risks of water birth with Covid-19
Let’s first look at the possible risks. According to the WHO1, Covid-19 is transmitted through a) droplets in the air (created by sneezes, coughs, breathing and so on) which can be breathed in by other people, and b) by the droplets landing on a surface which are then picked up, eg by someone putting their hand on them, followed by them transferring the virus particles to the face, allowing entry through the eyes, nose or mouth.
Although, according to WHO, there may be Covid-19 virus particles in faeces, only one study has been able to culture it and there have been no reports of faecal-oral transmission.2 Furthermore, faeces passed in the pool is immediately in contact with the chlorinated tap water and enveloped viruses such as Covid-19 are not able to survive for long in chlorinated water. It’s not clear from this WHO data how long it might survive in chlorinated water (it only refers to de-chlorinated water), nor how chlorinated the water needs to be (as the tap water’s chlorine does evaporate over time). However, even without this data it seems that provided that normal care is taken with the water and hand and body hygiene, there is a much lower chance of a midwife contracting Covid-19 from a birthing woman through the water compared to through the air. Furthermore, when the baby is born in the presence of faeces (which, of course, is a very common occurrence), the effect of dilution and washing of the mother’s genitals by the water may decrease the chance of transmission at the point of birth from woman to baby, but to date there is no evidence on this point. However there is evidence that rates of the newborn contracting other infections such as staphyloccus and e-coli are no different in land and water births. This does not mean that Covid-19 would be the same, but the effect of dilution in the water is likely to be an important protective mechanism.3
The second question was whether Covid-19 could be more easily transmitted through the air within the possibly more humid environment of the pool room. The research on this, as with so much around Covid-19, is very minimal and contradictory. It also tends to look at humidity in terms of weather, not humidity inside a room. There is some evidence that increased humidity may make the virus harder to transmit, but other research says that this is not the case – but social distancing, natural when a woman is labouring in a pool of water, PPE and hand hygiene might have far more impact anyway.
Consideration of theoretical benefits of water birth with Covid-19
We have already considered that it is likely that if there is any possible faecal-oral transmission route, water birth will reduce the chance of this. In addition, we believe that there are other possible benefits to water birth in terms of reduction of potential transmission of Covid-19 between mother and midwives.
The birth pool, by its nature, means that for many labour positions there is a greater distance between the birthing woman and the midwife, which could help to reduce the chance of cross infection. The water surface is a large part of the space within the room, and virus landing on the water would not be a possible route for surface to face infection, unlike a maternity bed.
Using bed birth as a comparator it is possible to see water birth as being as safe as a land birth. In summary, when looking at the safety of water birth in the context of Covid-19, we must not lose sight of the benefits as well as the possible risks – and not take away this vital form of pain relief as a knee jerk reaction rather than thinking through the comparative risks of land and water birth, physiological and medicalised birth.
- WHO: Water, sanitation, hygiene and waste management for the COVID-19 virus: https://apps.who.int/iris/bitstream/handle/10665/331305/WHO-2019-NcOV-IPC_WASH-2020.1-eng.pdf
- WHO on faecal-oral transmission: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/q-a-coronaviruses
- Fehervary et al, 2004, Water Birth: Microbiological Colonisation of the Newborn, Neonatal and Maternal Infection Rate in Comparison to Conventional Bed Deliveries: https://pubmed.ncbi.nlm.nih.gov/12955529/