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New recommendations from the American College of Obstetricians and Gynecologists (ACOG) say women should not give birth immersed in water because of a lack of good evidence showing whether it is safe and beneficial. But going through the first stages of labour in a birthing pool may help with pain relief and could speed labour up, according to the new guidelines.

Being immersed in water during labour and delivery, often referred to collectively as a "water birth," has become more mainstream in recent years, in part because of greater accessibility to midwives and alternative birthing centres and more options in hospitals. Many midwives support immersion either during labour, delivery or both as a way to reduce pain and improve the overall birthing experience.

It's a controversial topic with few simple answers. For starters, it can be difficult to study the effectiveness of water immersion because other factors, such as the woman's setting, the type of care provider she is using and her desire for pain-relieving drugs, could affect the results. And the decision over how to give birth is often personal and emotional to the individual involved, not clinical or based on a set of statistics.

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So how should those considering a water birth interpret these new guidelines?

Background

This isn't the first time ACOG has waded into the debate over immersion during delivery and birth. In 2014, the association published a similar set of recommendations, warning that while labouring in water can be beneficial, it's better to give birth outside the water because of the scarcity of evidence.

The response was swift. Groups like the American College of Nurse-Midwives came out with statements supporting the use of water during labour and delivery, depending on a mother's overall health and risk factors.

There hasn't been any groundbreaking update in the medical literature since the last guidelines were published. The major difference is that they aim to be "less prescriptive, more permissive" than before, said Joseph Wax, chair of the committee on obstetrics practice at ACOG who developed the new guideline.

That means that, instead of telling women not to have a water birth, ACOG now says they should be informed about the current state of evidence so they can make an informed decision.

"We still recommend against it, but again recognize that some women may prefer to go that route despite the recommendation," Dr. Wax said.

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What does the evidence say?

The lack of comprehensive, high-quality data looking at the safety and effectiveness of water births has been a major stumbling block.

But one piece of research provides some important insights. According to a 2009 Cochrane review – in which researchers look at the best available evidence on a given topic to draw conclusions – immersion in water during labour does seem to help with pain, reduce the need for epidurals and even speed the process of labour. Overall, the review found a lack of good evidence looking at giving birth in the water, but did cite one study that found women who did were more satisfied with the birth experience.

The ACOG recommendations mention a number of case studies where babies died because they were immersed in the water too long, as well as other problems, such as infections in the infant.

But case studies aren't applicable to wide swaths of the population. And a lack of evidence doesn't mean there is no evidence. In other words, the water-birth debate remains vulnerable to individual opinions and interpretation of the research, said Nicholas Leyland, professor and chair of the department of obstetrics and gynecology at McMaster University's Michael G. DeGroote School of Medicine.

In Canada, few, if any, medical organizations have official position statements on the safety of water births. In general, Dr. Leyland said, he and his colleagues tend to favour the case in Britain, where recommendations support water births for healthy women with uncomplicated pregnancies.

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There is one aspect of the debate that Dr. Leyland takes issue with: the idea that it is somehow more natural to give birth in the water. "Human beings, for as far back as we know, have never delivered that way."

The bottom line?

Water therapy isn't for all women and it's clear that more research is needed, but with careful consideration and input from health-care professionals, it can certainly be an option for those women who want it.

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