Making Waves – Consumers vs The Hospital

By Jodie Miller

Warm water – the cheapest, safest, most effective natural therapy in existence – has become this year's leading consumer debate at the Royal Brisbane and Women's Hospital.

With the completion of the new Ned Hanlon wing for the Royal Women's Hospital (RWH) in 2000, maternity services consumers were excited to see the 10 rooms of the mainstream Birth Suite had been fitted with tubs. But almost 5 years later the tubs have not seen a day of use. Despite the availability of the baths and a number of waterbirth credentialed midwives, the tubs are still a “no-go zone” for all but the privileged Birth Centre clients of Royal Brisbane and Women's Hospital (RBWH).

What's the big issue? Warm water immersion in labour and water birth has been conducted at the Royal Women's Hospital Birth Centre since it first opened in 1995. With the installation of its first purpose built birth pool in 1999 came the Warm Water Immersion Policy for Labour and Birth which is still in place at the Birth Centre today. In the mainstream Birth Suite there continues to be a consumer demand for water immersion, stimulated, quite ironically, by the very existence of the banned tubs.

In September 2003 a multi-disciplinary water immersion policy review committee was appointed to discuss the various risks and benefits of extending the waterbirth policy to the team midwifery projects in RWH mainstream Birth Suite. The committee decided that consumers were capable of evaluating the risks and benefits of water immersion for themselves. It would appear that the hospital executives disagreed, despite paving a road to change via the appointed policy review committee. Clearly the hospital executives were not prepared for this eventuality.

In August this year, after many months of procrastination, District Manager, Professor Richard Olley of the RBWH personally overturned his committee's decision to extend waterbirth practices to the mainstream Birth Suite. In September a press release from the RBWH Media and Communications clarified:

Extension of Waterbirth practice will only be considered if a multi-centred Randomised Control Trial is conducted and finds that the practice of Waterbirth is safe and beneficial in different practice settings.

The Royal Brisbane and Women's Hospital currently has no plans to begin a multi-centred Randomised Control Trial in the foreseeable future.

Multicentred randomised control trials (RCTs) are a cumbersome undertaking. It would take years to collect a large enough sample of birthing women to be statistically valid. Consumer group Friends of the Birth Centre fundraise to purchase “non-standard” active birth equipment such as birthstools and beanbags for the Birth Centre. If the hospital can't afford a birthstool then a multi-centred randomised control trial for water immersion would most certainly break the bank!

To break down the definition of an RCT:

Multicentred: Across a number of hospitals/institutions. Selangor Private Hospital near Nambour and John Flynn Private Hospital at the Gold Coast also perform waterbirths and share their data with the Royal Women's Hospital Birth Centre.

Randomised: Women are randomly allocated the use of water immersion. This reduces women's control of their own labours, which may adversely affect outcomes and the integrity of the study. The controversial Term Breech Trial* is an example of this faulty research design. It's the childbirth equivalent of Schrödinger’s cat.

Control Trial: Groups being compared are controlled to ensure that both groups are as similar as possible.

So with that media statement, extending the water immersion policy beyond the RWH Birth Centre has reached an impasse. The very suggestion that a multi-centred RCT is the only means of knowing that waterbirth is safe and beneficial in different practice settings is a smoke screen. Such international research does already exist.

In 2004 the prestigious Cochrane Review published a meta-analysis of eight randomised control trials of labour in water which found that:
1. there was a significant decrease in the use of pharmacological pain relief in the women who used a birth pool in labour;
2. women who used water immersion during the first stage of labour reported experiencing a statistically significant measure of pain relief compared to those who laboured without water;
3. there were no significant differences in outcomes for babies over a range of measures.

This reinforces the RBWH Birth Centre's own data analysis which showed a significantly different rate of operative deliveries (6.2% vs 17.7%) between women who used water immersion in labour and those who did not. To date, no water born baby has been admitted to the intensive or special care nursery. For those babies who have been admitted to intensive or special care nursery whose mothers used water immersion only for labour pain, no relationship to the use of water could be identified.

In the last two years, the RWH has joined the Oxford Centre for Health Research (OCHRAD) data base correlated by the Oxford Brookes University UK. This database is collecting information about the use of water in labour and birth worldwide. Results for this research project will be available in 2005.

There is nothing new about soaking in deep warm water in childbirth. Since warm baths for labouring women were given Parliamentary support in Britain in 1992, they have become almost universally available in British public hospitals.

It's time the executives of RWH caught up with the times and acknowledged that women know what they want and are capable of evaluating the risks and benefits for themselves. By offering the information and the decision-making power to birthing women it's quite possible there will be observable improvements to outcomes across all maternity services as women develop greater ownership of their own birthing concerns. Surely this is to be encouraged, whether water birth is embraced by the general public or not?


*The Term Breech Trial was a randomised multicentre trial for planned caesarean section versus planned vaginal birth for breech presentation at term. It was stopped in 2000 before the trial was complete because results clearly favoured caesarean delivery. Later analysis draws attention to the high degree of obstetric intervention in the vaginal birth group, the low degree of expertise at vaginal breech birth for birth attendants and the observation that dictating how a woman should birth interferes with the normal process of labour.

Bibliography

Cluett ER, Nikodem VC, McCandlish RE, Burns EE, (Cochrane Review, Issue 3, 2004)

Cochran, M, Media & Communications RBWH Health Service District, Queensland Health, (Response to Use of Waterbirth Practices, 10 Sept, 2004)

Marshall K, (Audit and Evaluation – Use of water in labour and birth. Birth Centre Royal Women's Hospital Brisbane 2003)