Aquabirths Research Review: Women’s experience of Waterbirth

Photo of Aquabirths birth pool to illustrate the article on women's experience of waterbirth

Aquabirths Research Review: 

Title: “A systematic meta‐thematic synthesis to examine the views and experiences of women following water immersion during labour and waterbirth.”

Authors: Claire Feeley, Megan Cooper and Ethel Burns

Published in the Journal of Advanced Nursing (Link)

Review by Emma Ashworth

Background
A common complaint about research into midwifery and obstetric interventions is that they seldom include the views and lived experiences of the women and people who have them. The evaluation of outcomes are usually limited to physical outcomes, not psychological ones, which reflects the dominant culture of prioritising physical injury over psychological injury and the common adage, “at least you and your baby are healthy”. There is also often a prioritisation of the physical health of the baby over the physical and psychological health of the mother or birthing person, which can leave them feeling like they are of less or little importance, or simply a vessel to grow a baby.

It is therefore very refreshing to read this paper, which has gathered together what information we do have on how women feel about waterbirth into one place. Waterbirth is safe for babies, as has been shown time and again (see our blog for more research reviews) and now we have a wonderful collation of the data on the psychological safety and benefits of waterbirth to the birthing woman or person: Women’s experience of waterbirth.

What did the paper look at?
This particular piece of research has gathered together women’s experience of waterbirth under three main themes which they describe as: Liberation and Self‐Emancipation, Synergy, transcendence and demarcation and Transformative birth and beyond.

What were their findings?

  • Pain relief
    Firstly they looked at the effectiveness of water as pain relief. They note that, “While the experience of pain is subjective and influenced by several factors, the provision of adequate pain relief in a timely manner to suit the needs of women is a hallmark of respectful maternity care”. It is also a legal requirement, under the European Convention on Human Rights as well as International Law. No one should be left in pain when suitable pain relief is available, and refusing a large bath but offering opiates is clearly unlikely to be the safest option for many women and people.

The paper discussed the fact that the sense of pain during labour can be increased if a woman feels anxiety or fear. Warm water is a natural relaxant for most people, and this increase in relaxation is thought to be instrumental in reducing anxiety, and therefore pain. The paper states, “Both the water and pool itself facilitated women’s physical and psychological needs during labour and/or birth, including offering effective analgesia.”

While the birth pool may not have taken away all the pain, women explained that it “softened the intensity” of pain, supporting women’s self-belief in their ability to cope with labour.

Key takeaway: Birth pools offer safe and effective pain relief without the side effects that come with pharmaceuticals. Birth pools support the physical and psychological needs of birthing women and people.

  • The protection of the birth space
    The paper describes the experiences of women who gave laboured and/or gave birth in a birth pool as, “liberating and transformative experiences” and that women felt “empowered, liberated, and satisfied”.

An important benefit to the birthing woman or person was the “demarcation” of their space, creating a “safe haven” and a “cocoon”.

“…the pool itself […] provided a physical demarcation of the women’s space in the birthing environment/room. The birthing pool offered a safe and private enclosure in which women were able to let go of inhibitions, physically and psychologically separate themselves from the outside world while also facilitating their ability to go in – flowing ‘with’ labour rather than fighting against it. In turn, this enabled them to transcend into an altered state of consciousness where time and place lost their meaning, indicative of a deep internal connection to ‘being’ rather than doing.”

Key takeaway: The physical presence of the birth pool meant that women felt safe and protected, and supported them to work with their bodies, facilitating a higher chance of physiological birth.

  • The transformative effect of a positive birth
    The sense of achievement that women felt was a very strong theme in all of the research that was summarised in this paper. It describes, “… vivid feelings of empowerment, ‘victory’ women ‘claimed’ their birth’, rather than ‘being delivered’ of their baby.”

Catching one’s own baby in the water was hugely empowering for many women, but even when this didn’t happen the sense of achievement was profound, with many women stating that they wanted to do it all again and that a birth pool would be imperative at their next birth.

This sense of achievement went beyond the birth, and led to a transformation that continued into the postnatal period, showing that women’s experience of waterbirth has far more value than ‘a nice birth experience’.

“The next day I was sitting, suckling my daughter, with an oversized aura, super proud of me, my experience, and all that. And I think it’s fundamental to have a positive birth experience.”

“The difference in me mentally was unbelievable; I was definitely a lot mentally safer this time. I honestly believe [the water VBAC] turned me into supermum.”

Key takeaway: A positive birth leads to safer women and babies, both during the birth and afterwards. It can transform how women and people feel about themselves, and their relationship with their babies.

Summary
This important paper gives us yet more invaluable information on the importance of ensuring that every woman or person who wants to labour and/or birth in water is supported to do so. It clearly describes the powerful and positive effect of water on physiological birth, and on the psychological well-being of mothers and birthing people. The paper concludes that, “We recommend maternity professionals and services offer water immersion as a standard method of pain relief during labour/birth.” Aquabirths completely agrees!

High BMI & Guidelines for Hospital Birth Pools

water birth in birth pool, woman with high bmiHow can Trusts ensure that their guidelines for hospital birth pools support women with a high BMI?

The benefits of using a birth pool for labour and birth are well documented, and yet there is a group of women who are regularly denied the chance to use this powerful form of pain relief and comfort when giving birth to their babies: women with a high BMI.

The most common reason given by Trusts for the denial of access to a birth pool for women with a high BMI is that if she were to collapse, she’d be harder to get out of the pool. Another reason is that women of high BMI might be less flexible, and less able to step out of the pool themselves. A recent article by AIMS clearly debunks both of these considerations. (See here: https://www.aims.org.uk/journal/item/waterbirth-high-bmi)

But what if women with a high BMI collapse in the birth pool?
The term “BMI” does not mean “weight”. A short women who is overweight might weigh less than a tall, slim woman, and yet the short woman may be classed as “high BMI”, and the tall woman “normal BMI”. The heavier woman would be permitted access to the hospital birth pool, whereas the shorter, lighter woman might not. This is clearly illogical as the taller woman would be heavier, and harder to lift out of the pool, despite her lower BMI.

Any woman may need to be lifted out of the birth pool, irrespective of her weight or BMI, and so appropriate equipment and guidelines should be available at all times for every person using the pool.  This should not need to be weight limited. For instance, slings which support people of all weights are commonly available through hospital suppliers.

Methods to help women out of the blow-up birth pools used at home which do NOT include slashing the pool are well known. Slashing the pool will flood the floor, and nearby electrical items, with water, and the women will “flow” out with the water in an uncontrolled way. Instead, supporting the woman to remain above the water (birth partners are always going to help with this!) while a managed removal happens is much safer. A fast deflation of the centre ring will lower the sides while containing the water and retaining the structure of the birth pool.

Women with a high BMI and mobility issues
Another reason commonly given to deny women with a high BMI access to a hospital birth pool is that these women may be less likely to be able to leave the pool without assistance. In other words, the assumption is made that larger women will have reduced mobility. Any woman may have mobility issues, so this should be a separate consideration, no matter her BMI. That said, women who may find moving on land harder, for any reason, may find that the supportive effect of water in a birth pool can help them to remain more mobile in labour, thus leading to a higher chance of a positive, straightforward birth. It therefore makes sense to do what we can to support women to access the water, even if they are limited in their ability to jump out of the pool themselves – and this has nothing to do with BMI.

There are many different considerations for Trusts when they are writing their guidelines for women who wish to labour and/or birth in water. Using BMI as a barrier to access, however, needs urgent reconsideration, in order to ensure that all women are given the opportunity to birth in the way that is right for them – and which has many benefits for the Trust as well, as a low-cost way to support normal birth and better birth outcomes.

For a full and detailed report on the issue of access to a birth pool and BMI, please read the AIMS Journal article here: https://www.aims.org.uk/journal/item/waterbirth-high-bmi

 

Organising safe and sustainable care in Alongside Midwifery Units: A Review

Oldham Midwifery Unit with Aquabirths birth poolAlongside midwifery units are defined as midwife-led units which are on the same premises as an obstetric unit (OU). They are usually next to the OU and may have come about following restructuring of the OU.

 

A follow on study from Birthplace 2011 investigated the way that alongside midwifery units are organised, staffed and managed, as well as the experiences of the women who use them and the staff who work in them.

 

The researchers looked at 4 different alongside midwifery units. They interviewed midwifery staff and service users, and also those in a management and organisational role. What became clear from the study was the fact that midwives working in alongside midwifery units were able to practice more autonomously, using their own clinical judgement. This is how all midwives, who are all autonomous practitioners, should be able to work, but obstetric units often discourage or reject this aspect of the midwifery role. Midwives also reported how they valued the work environment and culture, although the study did acknowledge that there was a need to ensure that midwives were supported to continue to develop their confidence, which is not a surprise as so many would have been trained in a far more repressive environment.

 

Another challenge for the sustainability of the alongside midwifery units was the fact that of all of the women who were considered to be good candidates to birth there, only a third ended up doing so. This study does not look at why this might be, but we know from feedback from women that very often they are simply not made aware of the midwife led unit in their area, so they did not have the opportunity to consider it for their baby’s birth.

 

Ultimately, Aquabirths would like to see the facilities which are commonplace within a midwife led unit such as birth pools, birth couches, mats and birthing balls, as well as the environment which is designed for calm, and to promote oxytocin, available as standard within all types of units, including obstetric units. There is no reason why these facilities could not be used by far more women, and we strongly believe that if a better birth environment was available to all, that more women would birth their babies with fewer unnecessary interventions. We hope that more research like this will encourage designers of all types of maternity units to create spaces which support both women and midwives to work together for better births.

 

Waterbirth : Part of a World Movement

Revisiting WaterbirthBarbara Harper, founder/director of Waterbirth International reviews the second edition of Dianne Garland’s textbook ‘Revisiting Waterbirth: An Attitude to Care’ in the context of waterbirth practice around the world.

It is no secret that water is healing and that the use of water is an effective medium to facilitate changes in actual brain wiring. It is with excitement and great pleasure that I welcome the publication of the second edition of Revisiting Waterbirth: An Attitude to Care. Dianne Garland has continued to provide waterbirth education and training not only throughout the UK, but around the world. Our mutual passion brought us together for conferences, workshops and presentations many times. It has been my privilege to work closely with Dianne as a teaching partner in China, Spain, the Czech Republic, Israel, India and the United States. Her excitement about demystifying waterbirth is contagious, and the reader, whether midwife, doctor or mother, will experience that enthusiasm within the pages of this book.

There has never been a time in our combined history when the message and knowledge within Revisiting Waterbirth: An Attitude to Care has been more necessary. The misinformation surrounding waterbirth that Dianne and I have witnessed in different parts of the world is sometimes distressing and occasionally humorous. This book gives every practitioner an effective, informative guide to start a waterbirth practice and integrate that practice into any clinical setting. It also provides concrete examples and stories from those with whom Dianne and I have worked. The inclusion of detailed stories from practitioners and parents is a wonderful supplement to the new edition of Revisiting Waterbirth.

The use of water for labour and birth has increased exponentially since Dianne and I first started writing letters to one another in 1989. When we finally met in person 26 years ago in Kobe, Japan, at the International Confederation of Midwives conference, we excitedly shared documentation of the efficacy and safety of waterbirth. The demand for accurate, useful information and descriptions of experiences has also increased. When we first started our collaboration, waterbirth was referred to as a fad or a trend that would soon be gone. Women seeking the ease and comfort of water will continue to increase in every part of the world. Waterbirth is part of a world movement that seeks a more humane and gentler approach to childbearing.

The use of warm water immersion has long been seen as an aid for labour, making it easier for the mother to enter into and remain in a state of hormonal bliss. Today, there are well-designed studies that prove the efficacy of water for labour and the safety of water for the birth of the baby. Dianne’s experience as a hands-on midwife attending waterbirths, as well as her design and documentation of research, makes her the perfect person to lay the foundation of education for those who want to incorporate the use of water into maternity care settings. This book is also a guide for those who have already started waterbirth practice to improve their experience.

The message in this book is simple, straightforward and very hopeful. It is hopeful in the sense that more and more women are asking how to make labour less about ‘enduring the pain’ and more about creating a good, healthy and loving experience of birth for the baby. Women understand that creating a new human being is one of the most important jobs on the planet. The providers who serve those women need the encouragement that this book offers to step out of the routine medical care and become open to the possibilities that water can, indeed, change the course of a labour and should be utilized as a valuable tool for almost all women. The attitude with which professionals view a woman’s ability to give birth can either enhance or detract from her experience.

In 2014, the American Congress of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatricians (AAP) launched a campaign to put doubt about the usefulness of waterbirth into the minds of nurses, doctors, midwives and the public. Some US hospitals paid attention to the published and widely distributed ACOG opinion paper and halted their successful and incident-free waterbirth programs. Dianne and I travelled together to hospitals in Cleveland, Ohio, and Minneapolis, Minnesota, shortly after the article was published, to educate hospital staff and help reinstate waterbirth policies in these facilities. We were welcomed in these places and our efforts were rewarded when the practices were put back into place.

It is my sincere hope and desire that practitioners throughout the world are guided by the message in Revisiting Waterbirth: An Attitude to Care and start implementing protocols in more hospitals. All women should be offered the choice and opportunity to labor in water and birth their babies with the ease, safety and pleasure that water so beautifully provides. I also hope that our tandem careers continue to bring this message to every corner of the globe. As founder and director of Waterbirth International, I have relied on Dianne Garland to provide a multitude of research and documentation from the UK and have used this book in its earlier editions as a teaching tool and recommended reading for nurses, midwives and doctors.

Barbara Harper, RN, CLD, CCCE, CKC, Midwife
Founder/Director of Waterbirth International

Corner Baths

We’ve had a bit of a flurry of requests for corner baths, mainly from export customers, so we thought we’d better write a short blog on them.

The short answer is, ‘yes, we do make them.’ They are an excellent option where space is a bit tight but the hospital still want to give a birthing mum the option of a water birth.  Sometimes, corner baths are avoided as the midwives want to be able to access the woman from as many parts of the bath as possible.

Our Dunoon model birthing bath is ideally suited to being used in a corner.  It is already designed specifically to be compact and fit in smaller rooms but to still give a labouring woman plenty of room to move and keep active during birth.  It does this by virtue of its rounded rectangular shape and by using space wisely so that it still has the capacity of a birth.

The Dunoon can be fitted in any position and doesn’t have to go in a corner but if you let us know when ordering, we can include an extra piece of trim (at no cost) so that you can have a neat finish against the corner walls.

Dunoon compact birth pool

Beautiful Birth Room at Barrow

Best birth bath ever

Though I’m proud of our bath, this article is about Estates Management.

Furness General is part of the Morcambe Bay Trust and includes Lancaster Royal and the Westmorland (Kendal).  Lancaster had a Canberra bath in 2011, and Kendal in early 2014.

All works to the rooms (new flooring, lighting, fittings, etc) have been overseen by their Estate Manager, Paul Coward.  If you are wondering how to go about a refit of a birth room or the installation of a birthing pool, I’d recommend you have a word with Paul as we never have jobs that run smoother than his.

Whilst we offer an installation service, it is possible to hire our expert plumber for consultation, so that he can advise or work alongside your plumber on site.  And now, we also offer training in fitting our birthing pools and Aquabirths accredited plumbers would then be eligible for a 10% discount on our baths.

Bradford Royal Infirmary & the Canberra Birth Bath

Birth Rooms by AQB Pools Ltd A couple more pictures from the opening of the new Birth Centre and Bradford Royal Infirmary.

The hospital now has several of the Canberra model birth baths each in its own beautiful new birth room.  The Canberra birth bath is designed to be universal in that it can fit into most rooms and situations.   It is available on short lead times or from stock and costs well under £5000 (and discounts for 2 or more baths).

The photos came from Lorne Campbell / Guzelian.