Strengths and limitations
This is the first study of its kind to include women utilising WWI and
waterbirth whilst using CEFM. These women represent a ‘moderate risk’
rather than the usual ‘low risk’ cohort that has dominated the
literature until now. The safety and efficacy of WWI for labour and
birth in low-risk women is well established (6, 8).
This study adds to the current literature but also highlights that this
practice is a safe option for some women with clearly defined, moderate
risk factors who require CEFM in labour.
This is a large sample size relative to other studies, with 400 women
using WWI during their labour and/or birth. The groups had similar
baseline characteristics and the subgroup analysis allowed for the
control of confounding factors. Our data was prospectively collected and
inputted into the perinatal database at the time of birth thereby
increasing the reliability of our findings.
Due to the nature of the intervention, patients self-select
Waterbirth/WWI which may be a source of bias. A randomised controlled
trial would reduce bias but would be challenging given it removes choice
around pool access and birth setting. Despite the larger sample size,
some secondary outcomes are relatively rare (i.e. cord avulsion), and
the nonsignificant findings should be interpreted within the context of
limited statistical power.
Our department has a clear, well-defined policy surrounding
WWI/Waterbirth and an established midwifery education programme
facilitating training of accoucheurs in waterbirth. The findings from
this study may not be generalisable to water immersion protocols at
sites whereby the policies and education surrounding WWI/Waterbirth are
less established or differ significantly from our study site.