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Comment and Controversy

Review of data on water birth was biased

December 2009 · Vol. 21, No. 12
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I found the summary of the evidence of the dangers and safety of water birth to be purposely skewed toward findings of dangers, while ignoring the wealth of evidence supporting its safety. The author quoted the 2009 Cochrane review and accurately included the conclusion that water immersion during labor reduces the use of analgesia, but skipped right over the evidence of lack of danger to the newborn. That evidence includes no differences in Apgar score, NICU admission, or neonatal infection rate between infants born in water and those born on land. 1

The author then goes on to focus on the opinion of a nonpracticing ObGyn blogger who has some very strong opinions on controversial topics who touts an obscure article about culturing the water in birth pools before delivery. Conveniently omitted is the fact that the researchers were actually supportive of water labor.

She took the ObGyn blogger’s opinion at face value and distorted the conclusions of the researchers. This kind of editorializing is misleading to your reading public and is also dishonest and unethical. Even a cursory glance at the articles available on PubMed reveals that numerous observational studies have demonstrated the safety and efficacy of water immersion during labor and birth. See, for example, Geissbuehler and associates 2,3 and Cluett and colleagues. 4

The “review” was biased and uninformed; the purpose of the article was clearly to cast water immersion during labor and birth as a dirty and dangerous practice.

Samantha McCormick, CNM, ARNP
Cape Coral, Fla


1. Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database Syst Rev. 2009;(2):CD000111.-

2. Geissbuehler V, Stein S, Eberhard J. Waterbirths compared with landbirths: an observational study of nine years. J Perinat Med. 2004;32:308-314.

3. Geissbuehler V, Eberhard J. Waterbirths: a comparative study. A prospective study on more than 2,000 waterbirths. Fetal Diagn Ther. 2000;15:291-300.

4. Cluett ER, Pickering RM, Getliffe K, St. George Saunders NJ. Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labour. BMJ. 2004;328:314.-

Ms. Yates responds: Lack of randomized trials means safety of water birth has not been proved

In assessing the published data, I faced an insurmountable challenge: the lack of any randomized, controlled trials of birth in water (though there have been a couple of labor in water). That leaves a fairly sizeable collection of case reports and other observational data. I chose not to skip over the risks described in this literature, assuming that the reader would prefer to be informed of their possibility rather than falsely reassured of the absolute safety of water birth.

The Cochrane review 1 that I cited was able to confirm the safety of water immersion only during the first stage of labor, as I stated. In regard to actual birth in water, it pointed to a lack of data, noting the fact that only two trials have evaluated immersion of women in water during the second stage of labor, and none during the third stage. It further observed: “A lack of data for some comparisons prevented robust conclusions.” After these equivocations, the reviewers stated that there is “no evidence of increased adverse effects to the fetus/neonate or woman from labouring in water or waterbirth.” That is hardly a wholesale endorsement of the practice of water birth. In fact, the review also observed: “The fact that use of water immersion in labour and birth is now a widely available care option for women threatens the feasibility of a large, multicentre randomized controlled trial.”

The “blogger” whom Ms. McCormick mentions is Amy Tuteur, MD. She served as a clinical instructor of obstetrics and gynecology at Harvard Medical School and is the author of How Your Baby is Born (Ziff-Davis, 1994). Her interpretation of published data, therefore, merited discussion.


1. Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database Syst Rev. 2009;(2):CD000111.-

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