Original Title: Inmersión en agua durante el parto

Authors' objectives: • To analyse the scientific evidence available on the safety and efficacy of water immersion during childbirth for the mother and the infant. • To describe the experiences, values and preferences of women regarding water immersion during childbirth identified in the evidence. • To identify the most important outcomes for mothers during childbirth. • To describe the situation regarding the use of water immersion during childbirth in hospitals of the Spanish National Health System across Spanish Autonomous Regions and Cities.

Authors' results and conclusions: The systematic search for studies on efficacy and safety, as well as on values and preferences, finally retrieved 18 articles, including 4 systematic reviews, 1 randomised clinical trial and 13 qualitative studies. Regarding the evidence on the efficacy and safety of water immersion during the first stage of labour, no statistically significant differences were found in the rates of normal vaginal birth (moderate quality), or those of third- or fourth-degree tears, episiotomy, or haemorrhage (low quality) among women who gave birth in water, compared to those who did not. On the other hand, water immersion at this stage was associated with less use of regional anaesthesia (low quality) and lower pain scores 60 minutes after the initial assessment (low quality). Regarding the infants, no differences were found in the number of newborns admitted to the ICU or in the cases of neonatal infection (low to very low quality) in the water immersion group compared to the non-water immersion group. Regarding water immersion during the second stage of childbirth, no differences were found in the percentage of vaginal births, episiotomy or second-degree tears in the women who delivered in water compared to those who did not, although the evidence was of very low quality. On the other hand, the percentage of women who were satisfied with labour was greater among those who delivered in water than those who had conventional deliveries (very low quality). Regarding the infants, no differences were observed in the rates of ICU admission or cases of meconium in the amniotic fluid (very low quality) between the study groups. Women who participated in the assessment of the importance of the outcomes of interest in childbirth classified the following variables as critical and of greatest importance: maternal outcomes related to mortality, delivery-related and postpartum infection, blood loss during childbirth (more than half a litre), type of delivery (normal vaginal delivery, instrumental vaginal delivery or caesarean section) and perineal injury (degree 3 or 4). All neonatal outcomes were classified as critical, except for umbilical cord pH immediately after childbirth (arterial or venous blood) which was classified as important. All the outcomes related to the experiences, values and preferences of women were classified as critical. In the qualitative studies included, women associated water birth with a sense of autonomy and control over labour, and a lower level of associated pain. Further, a water birth was considered a positive experience. Regarding the status of water birth in Spain, the availability of the option of water birth varies across hospitals of the National Health System. Forty-six hospitals in 13 autonomous regions indicated that they had birthing pools on their delivery wards. Among these hospitals, 20% reported having more than 10 years of experience in water births, 45% between 5 and 10 years and 35% less than 5 years. Conclusions • The evidence on the efficacy and safety of water immersion during childbirth indicates that, in women with low-risk pregnancies, water immersion during the first stage of labour probably has a small effect in terms of increasing the rate of normal vaginal births or decreasing the percentage of perineal injury (moderate quality), but it does significantly reduce the use of regional anaesthesia or pain (low quality). Concerning its use during the second stage of labour, no differences were detected in the rates of vaginal delivery or perineal injury, newborns admitted to the ICU or meconium in the amniotic fluid (very low quality); the exception was regarding women’s satisfaction with the birth, which was greater among those who delivered in water than those with conventional deliveries (very low quality). • The evidence from qualitative studies indicates that women note benefits associated with water birth. From the point of view of midwives, to make water births safe, there is a need for adequate resources, as well as rigorous standardised protocols, midwife training and a unit culture, that is, support for this type of birth from midwives and all the team of professionals caring for mothers and infants. • The women who participated in the assessment of the importance of outcomes during childbirth classified the following outcomes as critical: maternal mortality, delivery-related and postpartum infection, blood loss during childbirth (more than half a litre), type of delivery (normal vaginal birth, instrumental vaginal birth and caesarean section) and perineal injury (degree 3 or 4). All foetal/ neonatal outcomes considered were classified as critical, except for umbilical cord pH immediately after birth (arterial and venous blood) which was considered important. The outcomes related to women’s experiences, values and preferences were classified as critical. • The availability of the option of water birth varies in hospitals across the Spanish National System. All the hospitals that have birthing pools offer them in the first stage of labour (dilation), while 32% also use them in the pushing stage and 15% during delivery of the placenta. • It would be advisable to have standardized protocols and training to ensure the possibility that all pregnant women, regardless of their place of residence, can safely opt for water immersion during childbirth with satisfactory results.

Authors' methods: A systematic review was carried out to assess: 1) the efficacy, effectiveness and safety of water immersion during childbirth; and 2) the values and preferences of women who have given birth in water. The quality of the individual studies on the efficacy, effectiveness and safety was assessed using the FLC critical appraisal tools, while the quality of the evidence was assessed using the outcome of interest following the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. To identify the most important outcomes for women during labour and delivery —with or without water immersion—, a list of possible outcomes identified in the literature was drawn up and their importance was assessed by five women who had already had children. The studies identified on the values and preferences of women were assessed with the Spanish version of the Critical Appraisal Skills Programme (CASPe) tool and using a narrative summary. This information was complemented by the topics that emerged during the open discussion with the women who participated in the assessment of the importance of the outcomes of interest. In addition, a questionnaire was produced to assess the use of water immersion on maternity wards of National Health System hospitals. The results of the questionnaire are described narratively in the report. The final report was reviewed by several categories of health professionals that care for mothers and infants, as well as the women who participated in the assessment of the importance of the outcomes of interest in childbirth.

Project Status: Completed

Year Published: 2022

URL for published report: https://www.euskadi.eus/contenidos/informacion/osteba_publicacion/eu_def/adjuntos/D9-2019-OSTEBA-inmersion-agua-parto.pdf

English language abstract: An English language summary is available

Publication Type: Rapid Review

Country: Spain

Organisation Name: Basque Office for Health Technology Assessment

Contact Address: C/ Donostia – San Sebastián, 1 (Edificio Lakua II, 4ª planta) 01010 Vitoria - Gasteiz

Contact Name: Lorea Galnares-Cordero

Contact Email: lgalnares@bioef.eus

Copyright: <p>Osteba (Basque Office for Health Technology Assessment) Health Department of the Basque Government</p>