Balaskas on Waterbirth

A new study shows that birth pools can ease the pain of labour.
So why, asks Janet Balaskas, are some women denied access to them?

Wednesday January 28, 2004

The Guardian

In the late 1970s most women labored in large consultant units, semi-reclining in bed, strapped to electronic fetal heart monitors and subject to an avalanche of routine obstetric interventions. Of course, any sensible woman is only too grateful for modern obstetric care when there are problems. But we only have to look at our hospitals today where, in 2002, 22% of babies were born by caesarean section, to see that there remains a complete misunderstanding of the nature of birth physiology and the kind of environment and care women need to support it.

It’s not surprising that women the world over have been moved to rebel against the medical model. When I founded the active birth movement in the 1980s it was about women reclaiming the right to labor and to birth in upright positions in an environment that is more conducive to a natural birth. Gradually, this has been influencing change in the provision of midwifery care and birthing rooms that are designed to facilitate more women being able to be mobile and to have a natural active birth. But there still remains suspicion and misconceptions among some quarters of the medical profession towards waterbirths. Why?

News this week of a study into waterbirths by Southampton General Hospital simply confirms what women and midwives have been saying for two decades. There is no doubt now that immersion in water can provide dramatic relief of discomfort for a high proportion of women, as well as an alternative to the epidural. The Southampton study followed 100 first-time mothers who were making slow progress in labour and revealed that those who used a birth pool progressed better than those getting standard care. Less than half (47%) needed an epidural, compared with 66% of those who did not use a birth pool.

Many women find that the support of the water allows them to relax much more deeply, to feel much more comfortable both during and in between contractions and to have an increased sense of privacy. There is a noticeable calming of stress levels and the ability of the mother to cope with her labour can be transformed. At the same time the water seems to promote more effective contractions, so dilation may progress more rapidly while the mother is relaxing in the pool.

There have long been accounts of women labouring and giving birth in water, mostly among peoples living near a source of shallow, warm water, such as the South Pacific islanders. In New Guinea, Gahuka women gave birth by the river – the sound of the water helping the mothers’ concentration and the flowing movement of the water helping the movement of the baby inside. Some women in Africa are known to squat over steaming hot rocks to soften the perineum. Japanese women in remote fishing villages used to give birth in the sea and Finnish women laboured in steaming saunas.

Waterbirth, as it is known today, was pioneered in the 1960s by the Russian researcher Igor Tjarkovsky. Using a large aquarium he installed a glass tank in his own home in Moscow in which many mothers gave birth. Stunning photographs of these extraordinary births were published in the west and inspired the first waterbirths. These earliest waterbirths took place at home in pools that were often improvised by the couples themselves and attended by independent midwives. The parents created birthing pools using any large waterproof container they could find – including refuse skips, cattle troughs, inflatable paddling pools or garden ponds lined with a plastic sheet.

However, the women who chose this way of birthing, and their attendants, were often regarded as crazy, deluded, or foolhardy. The medical establishment rallied to condemn, or at least call the practice into question, citing theoretical risks of infection and fears of the baby drowning. But in 1999, Ruth Gilbert and Pat Tookey of the Institute of Child Health, London, published a hugely important study in the British Medical Journal that effectively provided the “green light” for labour and delivery in water. It showed that there was no increased risk to health for babies born in water as compared with babies born to other low-risk women on land.

Against this backdrop, the extent of the use of birth pools in the UK increased. Pools are now used in hospitals, independent birth centres, and at home births, with both independent and NHS midwives. The Edgware Birth Centre in North London is an example of a new type of forward-thinking NHS birth unit. It has two pools and typically 70% of women who give birth at the centre use water during labour and 50% give birth in water. This is a model of care that would transform our maternity services if widely adopted.

In 2000, the Royal College of Midwives estimated that 50% of maternity units were providing facilities for labour or birth in water. But the usage of the pools varied between 15% and 60%, which may be an indicator of the significance of the role of the midwife in supporting and encouraging women to consider the use of water. Since then the number of UK hospitals and birth centres with installed pools has risen to closer to 60%.

However, that does not necessarily mean that the pools are being fully or enthusiastically utilised or that the pool is always available. It’s not uncommon for women to be discouraged from using them or to be told that trained midwives are not available. Sometimes stringent protocols around the use of a pool can limit its usefulness and frustrate both mothers and midwives. Women who want to use a pool are often also told that this may not be possible if the pool is already in use.

It is time for such problems to be addressed and for all women to have the possibility of using a birth pool wherever they choose to give birth. Waterbirth is one of the greatest innovations in childbirth of our times and can no longer be regarded as a passing fad.

The use of epidurals today has reached epidemic proportions and contributes significantly to the high caesarean and intervention rate and is also very costly, requiring a high level of expert attendance. The simple expedient of a pool of warm water is now a proven way to confine the use of epidurals to those women who really need them and improve safety and quality of the birth experience.

Janet Balaskas is the founder of the Active Birth Centre (tel: 020 7281 6760, activebirthcentre.com) and author of many books about natural and active births. Her latest book, The Water Birth Book (Thorsons, £14.99), is published this August.