Response to joint ACOG and AAP Committee’s opinion regarding birthing pool use

K.D.Brainin Founder & Director
Blog: 15.11.2016

May 2014

Response to joint American College of Obstetricians and Gynecologists (ACOG), and American Academy of Pediatrics (AAP) Committee’s opinion regarding birthing pool use during labour and waterbirth

A recent publication, ‘Immersion in water during labor and delivery’, by the US Committee on Obstetric Practice representing the American College of Obstetricians and Gynecologists and American Academy of Pediatrics, recommended that waterbirth should be ’considered an experimental procedure’ and only performed in the context of a randomised controlled trial 1.

Whilst this committee’s opinion accurately highlighted the lack of definitive randomised controlled trial (RCT) evidence (level 1) for waterbirth, citing the Cochrane review 2, its reignition of the debate about the ‘safety and efficacy’ of waterbirth was disappointingly biased, and partially incorrect. For example, it concludes that waterbirth ‘has not been associated with maternal or fetal benefit’, yet there is no evidence to suggest that it presents a greater risk than land birth for women who experience a straightforward pregnancy, or their newborn.

The committee opinion also indicated that most of the literature in support of waterbirth comprises ‘retrospective reviews of a single center experience, observational studies using historical controls [….] often in publications that are not peer reviewed’ 1. Geissbuehler and Eberard’s observational study, which included 3,617 waterbirths was in fact prospective and published in a peer reviewed journal 3.

Moreover, the committee made no mention of two additional prospective observational studies: one involving a UK sample of 8,924 women, which included 5,192 waterbirths 4, and the second study involving an Italian sample of 2,505 women, of whom 1,519 had a waterbirth 5. These studies were also published in peer reviewed journals.

There is reliable level 2 evidence showing an association between waterbirth and positive outcomes for women and their newborn. The UK study found that women, particularly nulliparae who had a waterbirth were more likely to experience a normal birth compared with women who used a birthing pool only during the first stage of their labour 4.

Normal birth is a composite outcome defined as including a spontaneous labour onset, no epidural and a spontaneous vaginal birth with no episiotomy 6, and its incidence has been identified as a marker of quality care 7.

This is an important finding in the context of a global initiative to reduce the overuse of intrapartum interventions and operative delivery.

Safety outcomes for women at low risk of childbirth complication showed no increase in the incidence of infection, or primary postpartum haemorrhage, and a reduction in operative delivery 3-5, 8. Findings of a reduced incidence of intrapartum interventions such as requirement for augmentation, pharmacological analgesia, and episiotomy indicate that waterbirth is also efficacious 3-5.

Results for neonates born in water to women at low risk of childbirth complication show no associated risk of increased morbidity or mortality in relation to infection, resuscitation, or NICU admission compared to land birth 3-5, 8. The committee opinion paper cited a small number of case studies that reported newborn ‘near-drownings’ following waterbirth.

This term has been used to describe a phenomenon whereby some babies born in water present with respiratory distress in the hours following birth; a condition that may self-resolve or require admission to NICU for oxygen therapy. In the term infant, this is usually caused by delayed lung aeration, and known as transient tachypnoea of the newborn (TTN) 9.

The large prospective observational studies, and a paediatric survey of 4,032 waterbirths found no increase in the incidence of transient tachypnoea of the newborn compared with land birth 3-5, 10.

Waterbirth studies have reported a low incidence of umbilical cord snap during waterbirth 4, 10, 11. However, data have not been collected for this complication during land birth, which currently precludes making comparisons.

As with all aspects of childbirth, and irrespective of high quality care provision, unforeseen adverse events shall always occur, and waterbirth is no exception.

It is incumbent upon caregivers to ascertain that it poses no added risk, or harm. Birthing pool use has gained in popularity among women and midwives in several countries, particularly among those working in midwifery led care settings. Further level 1 research is required to examine a number of factors in more detail.

For example, we need to explore further if waterbirth has the potential to facilitate normal birth. It is also necessary to compare the incidence of umbilical cord snap at, and transient tachypnoea of the newborn following waterbirth versus land birth. Another important area that we need to know more about is the acceptability of waterbirth to women and midwives.

Available level 2 evidence for waterbirth provides an important basis to inform pertinent outcome measures for a future randomised controlled trial.

In the meantime however, there is no reliable available evidence to indicate that waterbirth presents an increased risk factor compared with land birth for women who experience a straightforward pregnancy. There is therefore no reason to deny them the choice of using a birthing pool during the first or second stage of their labour in their planned place of birth.

Maternal choice in childbirth is a human right 12.

The right for women to choose is endorsed by the UK’s position statement regarding birthing pool use during labour and waterbirth 13, as reiterated in a recent BMJ news item in response to this Committee Opinion from the US 14.


1.      American College of Obstetricians and Gynecologists, American Academy of Pediatrics. Immersion in water during labor and delivery. Committee opinion Number 594, April

2014  [cited 2014 26th March]; Available from:

2.      Cluett E, Burns E. Immersion in water in labour and birth Cochrane Database Syst Rev  2009 22nd October 2009 [cited 2013 20th January ]; CD000111.pub3.]. Available from:

3.      Geissbuehler V, Stein S, Eberhard J. Waterbirths compared with landbirths: an observational study of nine years. Journal of Perinatal Medicine. 2004; 32(4): 308-14.

4.      Burns EE, Boulton MG, Cluett E, Cornelius VR, Smith LA. Characteristics, Interventions, and Outcomes of Women Who Used a Birthing Pool: A Prospective Observational Study Birth. 2012; 39(3,): 192-202.

5.      Henderson J, Burns EE, Regalia AL, Casarico G, Boulton MG, Smith LA. Labouring women who used a birthing pool in obsteric units in Italy: prospective observational study. BMC Pregnancy Childbirth. 2014; 14(1): 17.

6.      Maternity Care Working Party, Royal College of Obstetricians and Gynaecologists, Royal College of Midwives. Making normal birth a reality; consensus statement.  2007  [cited 2011 9th September]; Available from:

7.      Dodwell M. Normal birth as a measure of the quality of care.  2010  [cited 2011 20th February]; Available from:

8.      Thoeni A, Zech N, Moroder L, Ploner F. Review of 1600 water births. Does water birth increase the risk of neonatal infection? J Matern Fetal Neonatal Med. 2005; 17(5): 357-61.

9.      Carpenter L, Weston P. Neonatal respiratory consequences from water birth. J Paediatr Child Health. 2012; 48(5): 419-23.

10.     Gilbert R, Tookey P. Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. British Medical Journal. 1999; 319(7208): 483-7.

11.     Cro S, Preston J. Cord snapping at waterbirth delivery. British Journal of Midwifery. 2002; 10(8): 494-7.

12.     Birthrights. Human rights in maternity care.  2014  [cited 2014 10th April]; Available from:

13.     Royal College of Obstetricians and Gynaecologists, Royal College of Midwives. Immersion in water during labour and birth, Joint statement No.1.  2006  [cited 2014 10th April]; Available from:

14.     McCarthy M. Underwater births should be limited to clinical trials, says US pediatric and obstetrics panel. .  2014  [cited 2014 27th March]; 348:[Available from:


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