Thursday, March 27, 2014

Wait, I thought we were discussing waterbirth

This last week, the American Academy of Pediatrics and the American College of Obstetrics and Gynecology jointly published a position statement regarding waterbirth.

Immersion in Water During Labor and Delivery

In short, it states that immersion in water during labor poses little risk of harm and appears to have some benefit, but that safety of delivering a baby underwater "has not been established."

OK - so midwives - of all stripes - are up in arms over this rather bland, cautionary statement. Apparently midwives believe waterbirth is their exclusive purview, and are taking this statement as an attack on midwifery.

The resounding tack is to change the subject by proclaiming that obstetricians have no right to scrutinize waterbirth when obstetrics is rife with non-evidence based practices.

From MANA's Facebook page:

An excerpt from an email to ACNM membership:

Wait, I thought we were discussing waterbirth...

The question comes up - why are midwives so loathe to engage in any self-reflection? Why are midwives afraid to examine their practices and critically evaluate them for safety and effectiveness? Why are midwives changing the subject when their own practices are being scrutinized?

If midwifery is what it says it is - safe, effective care for low-risk women -and does what it says it does: provides high-quality, personalized maternity care - why the defensiveness? Why change the subject? Safe and sound practices should hold up to scrutiny.

Why aren't midwives clamoring to answer these questions:
Is there evidence of increased risk of aspiration at waterbirth?
Is there evidence of increased rates of neonatal infection at waterbirth?
Is there evidence of increased rates of difficult management of complications (ie shoulder dystocia) during waterbirth?
Is there evidence of increased rates of umbilical cord avulsion during waterbirth? 
What are the safest parameters for waterbirth?
When is waterbirth contraindicated?

And will the ACNM include in their position statement recommendations about the following practices that are currently offered to women under midwifery care in the US:

These are "controversial contraindications" to water birth according to water birth 'expert' Barbara Harper of Waterbirth International:

Meconium staining "meconium washes off the baby in the water"
Maternal HIV, Hepatitis A, B, C infection "HIV is susceptible to warm water and cannot live in that environment"
Maternal GBS colonization "There is no evidence that GBS positive cases should be asked to leave the water."
Maternal herpes outbreak during labor "it is safer to deliver in the water due to the dilution effect of the water."
Breech vaginal birth "a perfect environment for a hands free vaginal birth"
Multiple birth "labor in water for multiples is well documented and recommended."
VBAC  women attempting VBAC in water "have a much higher success rate in giving birth vaginally"
Shoulder dystocia: "there is mounting evidence that providers find it easier to assist a shoulder dystocia in the water."
Placental delivery in water: "there is no reason not to allow the birth of the placenta in the water"

~ Barbara Harper (c) 2006 Guideline for a Safe Water Birth

To be clear, Barbara Harper is stating that the above indications are NOT contraindications to underwater birth and, in some cases, is asserting the superiority of water birth in these higher-risk circumstances.

If these things are being recommended by a "water birth expert" you can bet they're happening with midwives at planned deliveries in the US. Spend a minute Googling, and you'll find ample photographic evidence of these practices.

So no, ACNM, now is not the time to examine what OB/GYNs are or are not doing in hospitals with regard to c-sections, epidurals and whatever-all-else is happening that doesn't fit into the midwives' ideal model of care. It's time to examine what midwives are doing, and to address some of the reckless and negligent practices being promoted as "safe" and "evidence-based" without supporting scientific evidence.

We're looking forward to that position statement.

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