During the final year of the Bachelor of Midwifery at Griffith University, midwifery students are asked to write an opinion piece focussed on normal birth that could be published. Dr Jyai Allen convenes this course and supported the students to complete this work. Several of these were of such good quality that we offered students the option of having them published here. This is the first of five articles in a series. The author of this article preferred to publish anonymously.
Access to water immersion for labour and birth during the pandemic: an opinion piece
There is no denying that COVID-19 has completely changed the world (United Nations Children’s Fund, 2020). Many populations have been unequally disadvantaged by the global pandemic, including childbearing women (Gausman & Langer, 2020). It has been a period of heightened anxiety as new policies aimed at flattening the curve have limited women’s birth preferences and choices (Australian College of Midwives [ACM], 2020a). This includes the Royal Australian and New Zealand College of Obstetrics and Gynecology (RANZCOG) recommendation to suspend the use of water immersion for all labouring women within COVID-19 hotspots (ACM, 2020a). Whilst staunchly opposed by ACM (2020a), this position statement has been adopted by health services across the nation including the Department of Health and Human Services [DHHS] in Victoria (2020). The topic is controversial as the suspension of access to water immersion is not supported by evidence (Centres for Disease Control [CDC], 2020a) and devalues a woman’s autonomy and right to self-determination.
Midwives have a professional obligation to advocate for evidence-based practices that empower women and promote normal birth. Water immersion during labour is associated with positive outcomes and should be available to all low-risk women who are presumed or confirmed COVID-19 negative.
Arguments for the suspension
Let us consider the evidence for suspending water immersion in the context of a woman with a confirmed positive COVID-19 test result. The rationale behind RANZCOGs recommendation was the protection of healthcare workers (ACM, 2020a; 2020b). Concerns have been raised regarding the level of protection provided by personal protective equipment when immersed in water (DHHS, 2020; Royal College of Midwives [RCM], 2020). It was also believed the moist atmosphere of the birth pool room could increase the risk of droplet transmission (RCM, 2020).
Some evidence contradicts this viewpoint, however, finding the virus is less likely to be transmitted in humid environments (Qi et al., 2020). Given that COVID-19 is not a waterborne virus, it is believed that liquid may dilute contamination and therefore reduce the potential risk of transmission (ACM, 2020a). Another potential benefit from water immersion is that the birth pool aids in physical distancing by providing a barrier between women and care providers (Burns et al., 2020; Ulfsdottir et al., 2018).
Another concern that was raised was faecal-oral transmission of COVID-19 within a birth pool. While some studies suggest the virus can be transmitted through faeces (Wang et al., 2020; Zhang et al., 2020a), there has been no evidence of faecal-oral transmission to date (World Health Organization, 2020). Some argued that if faeces were highly contagious for COVID-19, healthcare workers would be at greater risk during land birth as the particles are not diluted (ACM, 2020a). So while water immersion has been framed as posing a risk to clinical staff, women and babies; there is limited evidence to suggest it is easily spread to humans through birth pools (CDC, 2020a).
Benefits of water immersion
It is important to recognise the known benefits of water immersion during labour and for birth. Water immersion facilitates positive birth experiences (Cooper & Warland, 2019; Lathrop et al., 2018; Neiman et al., 2019). When immersed in water during labour, women have increased feelings of empowerment and experience a greater sense of privacy, safety, control and focus (Fair et al., 2020; Ulfsdottir et al., 2018). It is also an effective pain management method which can help to avoid a cascade of intervention and therefore promotes normal birth practices (Cluett et al., 2018). Women who were prevented from accessing water immersion as a consequence of their COVID-19 status would not access these benefits. The arbitrary decision to suspend water immersion for all labouring women is consistent with historical practices in maternity care that value subjectivity over evidence-based recommendations (Cooper et al., 2017).
What the suspension really represents
It can be assumed that broader socio-cultural factors have influenced RANZCOGs recommendation. RANZCOG is an obstetric organisation that aligns itself with the technocratic model of care and values surveillance, intervention, and hierarchy (Davis-Floyd, 2001). This is demonstrated by their staunch and public opposition to practices such as homebirth – which is discussed in the context of obstetric outcomes and perinatal mortality (Licqurish & Evans, 2015).
RANZCOGs position statement on water immersion is similar. By standardising institutional practices and banning all women from using water immersion, the individual needs of women are deemed unimportant. Consequently, these clinicians retain their position at the top of the organisation’s hierarchy (Davis-Floyd, 2001). The recommendation represents authority and responsibility inherent in the healthcare provider, not the woman – as the woman’s personal preferences are disregarded by the institution (Davis-Floyd, 2001).
Loss of choice and failing to make decisions in partnership with women may also add to women’s feelings of stress and anxiety (Jago et al., 2020). This further impacts normal birth outcomes as women are passive in decision-making and do not challenge recommended practices (Carolan- Olah et al., 2015). The prohibition of water immersion also fails to demonstrate a holistic approach to care as the social and emotional needs of women are neglected (Jago et al., 2020) during a period in history that has elevated anxiety and depression amongst pregnant women (Lebel et al., 2020).
Medicalisation of childbirth also likely influenced the decision to suspend water immersion. An obstetric approach views water immersion as inherently risky and therefore requires medical management (Licqurish & Evans, 2016; Milosevic et al., 2019). This is demonstrated by RANZCOGs recommendations for water immersion statement (2017) which focuses on rigorous protocols, exclusion criteria, and obstetric emergency drills. Their value of a medicalised approach is also apparent when considering that they have not recommended suspending the use of nitrous oxide for all labouring women (RANZCOG, 2020c), despite posing a higher risk of contracting COVID-19 through droplet or aerosol transmission (ACM, 2020a; CDC, 2020b).
The influence of medicalisation is even more obvious in the recommendation to site an epidural early in labour, in case an emergency caesarean section becomes ‘indicated’ (DHHS, 2020). This practice has been adopted by Barwon Health, along with the recommendation of continuous fetal heart rate monitoring, should a woman be suspected of COVID-19 (2020). Normal birth outcomes then become even more difficult to achieve as interventions such as instrumental birth are increased (Alfirevic et al., 2017).
To affect any sort of change, it is important for midwives to gain confidence in water immersion (Plint & Davis, 2016). Lack of training creates a workplace culture where water immersion is feared (Klein et al., 2011). Consequently, medicalised approaches are promoted as midwives do not feel confident advocating for normal birth practices.
The media also plays a pivotal role in the depiction of childbirth, often shaping public opinion irrespective of evidence (Petrovska et al., 2017). Normal birth practices are vastly underrepresented, with childbirth often portrayed as medicalised and risky (Luce et al., 2016). Commonly associated with fear, pain and intervention, high-impact dramatic stories are more often depicted in the media rather than calm, normal births (Maclean, 2014). Media portrayals will influence women’s perceptions of water immersion given that two out of three women source information from the media instead of their healthcare provider (Carlsson & Ulfsdottir, 2020). Combined with media coverage on COVID-19, it is no wonder water immersion is scarcely supported. As women become fearful of childbirth, they are disempowered to advocate for normal birth practices (Plint & Davis, 2020). It is imperative for midwives to support women in making informed choices to ensure their decisions are not influenced by fear perpetuated by the media
(Jago et al., 2020).
How do we move forward?
Maintaining the health and safety of women, babies, and healthcare workers is paramount.
Measures can be taken to minimise the potential risk of COVID-19 transmission whilst still promoting normal birth practices. Screening women for COVID-19 and fast-track testing will inform care management more accurately (RCM, 2020). Individualised risk assessments should be undertaken and midwives should demonstrate effective clinical decision making (RCM, 2020). Being up-to-date with infection control practices would be supportive (Liang & Archarya, 2020; Public Health England, 2020) along with access to appropriate personal protective equipment (RCM, 2020). Burns et al. (2020) found wearing long gauntlet gloves that are one size too small can improve the seal when immersed in water. Maintaining proper cleaning and hygiene practices reduces the risk of transmission (ACM, 2020a) as well as removing faecal matter should it contaminate the water (Gu et al., 2020).
Empowering women to guide their babies into the world while immersed in water facilitates physical distancing practices (RCM, 2020). This would be supported by antenatal education as it instills confidence and allows women to engage in their care (ACM, 2020a; Milosevic et al., 2019; Plint & Davis, 2016). Arguably the most important factor, is that midwives must be trained in water immersion. This will ensure competence and develop a workplace culture that supports normal birth practices (Nicholls et al., 2016). Midwives should also engage in respectful conversations that promote midwifery care by challenging practices that are deemed unnecessary or not based on evidence.
Midwives have a professional obligation to protect choices for women and promote normal birth practices (ACM, 2020b). Water immersion should be available to all women. RANZCOGs recommendation is not based on evidence and has been influenced by technocratic ideologies. As gatekeepers to normal birth, midwives are in a powerful position to influence maternity reform and must continually advocate for evidence-based practices to ensure women are supported throughout their childbearing journey (McIntyre et al., 2012).
Alfirevic, Z., Gyte, G., Cuthbert, A., & Devane, D. (2017). Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews, (5), 1-141. https://dx.doi.org/10.1002/14651858.CD006066.pub3
Australian College of Midwives. (2020a). ACM’s updated position on use of water in labour. https://www.midwives.org.au/news/acm-s-updated-position-use-water-labour
Australian College of Midwives. (2020b). Midwifery philosophy and values. https://www.midwives.org.au/midwifery-philosophy-values
Barwon Health. (2020). COVID-19 (coronavirus) and pregnancy.
Burns, E., Cooper, M., Feeley, C., Hall, P., Roehr, C., & Venderlaan. (2020). Coronavirus COVID-19: Supporting healthy pregnant women to safely give birth. https://www.brookes.ac.uk/WorkArea/DownloadAsset.aspx?id=2147622699
Carlsson, T., & Ulfsdottir, H. (2020). Waterbirth in low‐risk pregnancy: An exploration of women’s experiences. Journal of Advanced Nursing, 76(5), 1221-1231. https://dx.doi.org/10.1111/jan.14336
Carolan-Olah, M., Kruger, G., & Garvey-Graham, A. (2015). Midwives׳ experiences of the factors that facilitate normal birth among low risk women at a public hospital in Australia. Midwifery, 31(1), 112-121. https://dx.doi.org/10.1016/j.midw.2014.07.003
Center for Disease Control. (2020a). Coronavirus Disease 2019 (COVID-19) [Topic: Pools, Hot Tubs, and Water Playgrounds]. https://www.cdc.gov/coronavirus/2019- ncov/faq.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2 019-ncov%2Fphp%2Fwater.html#COVID-19-and-Water
Center for Disease Control. (2020b). How COVID-19 Spreads. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid- spreads.html
Cluett, E., Burns, E., & Cuthbert, A. (2018). Immersion in water during labour and birth. Cochrane Database of Systematic Reviews, (6), 1-171. https://dx.doi.org/10.1002/14651858.cd000111.pub4
Cooper, M., McCutcheon, H., & Warland, J. (2017). A critical analysis of Australian policies and guidelines for water immersion during labour and birth. Women and Birth, 30(5), 431-441. https://dx.doi.org/10.1016/j.wombi.2017.04.001
Cooper, M., & Warland, J. (2019). What are the benefits? Are they concerned? Women’s experiences of water immersion for labor and birth. Midwifery, 79, 102541-102551. https://dx.doi.org/10.1016/j.midw.2019.102541
Davis-Floyd, R. (2001). The technocratic, humanistic, and holistic paradigms of childbirth. International Journal of Gynecology and Obstetrics, 75(1), 5-23. https://dx.doi.org/10.1016/S0020-7292(01)00510-0
Department of Health and Human Services. (2020). Maternity and neonatal care during coronavirus (COVID-19). https://www.dhhs.vic.gov.au/covid-19-maternity-and-neonatal- care-during-coronavirus
Fair, C., Crawford, A., Houpt, B., & Latham, V. (2020). “After having a waterbirth, I feel like it’s the only way people should deliver babies”: The decision-making process of women who plan a waterbirth. Midwifery, 82, 102622-102628. https://dx.doi.org/10.1016/j.midw.2019.102622
Gausman, J., & Langer, A. (2020). Sex and gender disparities in the COVID-19 pandemic. Journal of Women’s Health, 29(4), 465–466. https://dx.doi.org/10.1089/jwh.2020.8472
Gu, J., Han, B., & Wang, J. (2020). COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology, 158(6), 518-519. https://dx.doi.org/10.1053/j.gastro.2020.02.054
Jago, C., Singh, S., & Moretti, F. (2020). Coronavirus disease 2019 (COVID-19) and pregnancy: Combating isolation to improve outcomes. Obstetrics and Gynecology, 136(1), 33-36. https://dx.doi.org/10.1097/AOG.0000000000003946
Klein, M., Liston, R., Fraser, W., Baradaran, N., Hearps, S., Tomkinson, J., Kaczorowski, J., & Brant, R. (2011). Attitudes of the new generation of Canadian obstetricians: How do they differ from their predecessors? Birth, 38(2), 129-139. https://dx.doi.org/10.1111/j.1523- 536x.2010.00462.x
Lathrop, A., Bonsack, C., & Haas, D. (2018). Women’s experiences with water birth: A matched groups prospective study. Birth, 45(4), 416-423. https://dx.doi.org/10.1111/birt.12362
Lebel, C., MacKinnon, A., Bagshawe, M., Tomfohr-Madsen, L., & Giesbrecht, G. (2020). Elevated depression and anxiety symptoms among pregnant individuals during the COVID-19 pandemic. Journal of Affective Disorders, 277, 5-13. https://dx.doi.org/10.1016/j.jad.2020.07.126
Liang, H., & Acharya, G. (2020). Novel coronavirus disease (COVID‐19) in pregnancy: What clinical recommendations to follow? Acta Obstetricia et Gynecologica Scandinavica, 99(4), 439-442. https://dx.doi.org/10.1111/aogs.13836
Licqurish, S., & Evans, A. (2016). ‘Risk or Right’: A discourse analysis of midwifery and obstetric colleges’ homebirth position statements. Nursing Inquiry, 23(1), 86-94. https://dx.doi.org/10.1111/nin.12111
Luce, A., Cash, M., Hundley, V., Cheyne, H., van Teijlingen, E., & Angell, C. (2016). “Is it realistic?” the portrayal of pregnancy and childbirth in the media. BMC Pregnancy and Childbirth, 16(1), 40. https://dx.doi.org/10.1186/s12884-016-0827-x
Maclean, E. (2014). What to expect when you’re expecting? Representations of birth in British newspapers. British Journal of Midwifery, 22(8), 580-588. https://dx.doi.org/10.12968/bjom.2014.22.8.580
McIntyre, M., Francis, K., & Chapsman, Y. (2012). Primary maternity care reform: Whose influence is driving the change?. Midwifery, 28(5), 705-711. https://dx.doi.org/10.1016/j.midw.2011.08.004
Milosevic, S., Channon, S., Hunter, B., Nolan, M., Hughes, J., Barlow, C., Milton, R., & Sanders, J. (2019). Factors influencing the use of birth pools in the United Kingdom: Perspectives of women, midwives and medical staff. Midwifery, 79, 102554-102561. https://dx.doi.org/10.1016/j.midw.2019.102554
Neiman, E., Austin, E., Tan, A., Anderson, C., & Chipps, E. (2019). Outcomes of waterbirth in a US hospital‐based midwifery practice: A retrospective cohort study of water immersion during labor and birth. Journal of Midwifery & Women’s Health, 65(2), 216-223. https://dx.doi.org/10.1111/jmwh.13033
Nicholls, S., Hauck, Y., Bayes, S., & Butt, J. (2016). Exploring midwives’ perception of confidence around facilitating water birth in Western Australia: A qualitative descriptive study. Midwifery, 33, 73-81. https://dx.doi.org/10.1016/j.midw.2015.10.010
Petrovska, K., Sheehan, A., & Homer, C. (2017). Media representations of breech birth: A prospective analysis of web‐based news reports. Journal of Midwifery & Women’s Health, 62(4), 434-441. https://dx.doi.org/10.1111/jmwh.12609
Plint, E., & Davis, D. (2016). Sink or Swim: Water immersion for labor and birth in a tertiary maternity unit in Australia. International Journal of Childbirth, 6(4), 206-222. https://dx.doi.org/10.1891/2156-5218.104.22.168
Public Health England. (2020). COVID-19: infection prevention control guidance. https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection- prevention-and-control
Qi, H., Xiao, S., Shi, R., Ward, M., Chen, Y., Tu, W., Su, Q., Wang, W., Wang, X., & Zhang, Z. (2020). COVID-19 transmission in Mainland China is associated with temperature and humidity: A time-series analysis. Science of the Total Environment, 728, 138778. https://dx.doi.org/10.1016/j.scitotenv.2020.138778
Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2017). Warm water immersion during labour and birth. https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG- MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical- Obstetrics/Warm-water-immersion-during-labour-and-birth-(C-Obs-24)-Review-July- 2017.pdf?ext=.pdf
Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2020a). COVID-19: Protection of midwives and doctors in the birth unit. https://ranzcog.edu.au/news/covid-19-protection-of-midwives-and-doctors-in-th
Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2020b). RANZCOG statement. https://ranzcog.edu.au/news/ranzcog-statement
Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2020c). A message for pregnant women and their families. https://ranzcog.edu.au/statements- guidelines/covid-19-statement/information-for-pregnant-women
Royal College of Midwives. (2020). RCM Professional briefing on waterbirths for women without symptoms during the COVID-19 pandemic. https://www.rcm.org.uk/media/4034/rcm-professional-briefing-on-waterbirth-in-the- time-of-covid-v-3-7-may-2020.pdf
Ulfsdottir, H., Saltvedt, S., Ekborn, M., & Georgsson, S. (2018). Like an empowering micro- home: A qualitative study of women’s experience of giving birth in water. Midwifery, 67, 26-31. https://dx.doi.org/10.1016/j.midw.2018.09.004
United Nations Children’s Fund. (2020). How COVID-19 is changing the world. https://data.unicef.org/resources/how-covid-19-is-changing-the-world-a-statistical-perspective/#
Wang, J., Tang, K., Feng, K.,; Li, X., Lv, W., Chen, K., & Wang, F. (2020). High temperature and high humidity reduce the transmission of COVID-19. Centre for Evidence- Based Medicine. https://www.cebm.net/study/covid-19-high-temperature-and-high- humidity-reduce-the-transmission-of-covid-19/
World Health Organization. (2020). Modes of transmission of virus causing COVID-19: Implications for IPC precautions and recommendations. https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus- causing-covid-19-implications-for-ipc-precaution-recommendations
Zhang, Y., Chen,C., Zhu, S., Shu, C., Wang, D., Song, J., Song, Y., Zhen, W., Feng, Z., Wu, G., Xu, J., & Xu, W. (2020). Isolation of 2019-nCoV from a stool specimen of a laboratory- confirmed case of the coronavirus disease 2019 (COVID-19). China CDC Weekly, 2(8), 123-124. http://weekly.chinacdc.cn/en/article/doi/10.46234/ccdcw2020.033