 Our wonderful presenters today are from my home state of Georgia. We have them from Emory University. We have Dr. Jennifer Vandalan, who's an instructor and maternal health researcher in the Atlanta. And she investigates health services on maternal outcomes. Her interest in hydrotherapy as a low-cost method to promote for pain management in labor for physiologic relief is her one of her main interests. Jennifer is working to produce the evidence necessary to identify best practices for hydrotherapy and water birth. And with her, we also have Dr. Priscilla Hall, who is also a nursing instructor and midwife researcher at Emory. She investigates the emotional aspects of physiologic birth as this relates to empowerment. In collaboration with Dr. Jennifer, she began to research the health effects of water birth as a non-medical strategy for pain management. The purpose of these studies is to enhance safety and increase access so that women have greater freedoms and choice in their labor care. Jennifer and Priscilla, you have the microphone. Thank you, Pandora. Now, this is Dr. Jennifer Vandalan. I began this project shortly after the American College of Obstetricians and Gynecologists published some clinical guidance in 2014 stating that there was a lack of evidence of safety with hydrotherapy during second stage labor, also known as water birth. My goal was to synthesize the available evidence on neonatal safety to see if we did have any evidence of poor neonatal outcomes. And if I found evidence of poor outcomes, I wanted to use that synthesis to help identify the best practices for water birth. So in this way, the synthesis could provide evidence for writing policies and protocols. I'm Dr. Priscilla Hall. I'm also a PhD trained midwife at Emory. And I trained midwives and research women's agency in Chilburne. I became involved in this project because of my interest in physiologic work in hydrotherapy and water birth of many women who are laboring women. They decreased the duration of labor and the need for augmentation and a decreased need for pharmacological pain management. And I knew that these benefits were not translating into practice mostly because of concerns about safety of the neonates. So I was interested in identifying what practices related to water birth are the safest. Because the experience of agency, which I study, pivots on safe choices being available, my goal was to increase the understanding of safety of water birth. So providers would feel more comfortable with the practice and more confident about counseling women about the risks and benefits. If we could improve the information that providers have about water birth, the choice becomes more available to women. So I thought that we should begin by explaining how a meta-analysis works. A meta-analysis is a systematic and reproducible synthesis of the existing evidence. So systematic means that we have a system for finding and including studies about water birth that we did not know existed. And this prevented us from drawing conclusions based on what we already knew and already believed about water birth. Now our paper, which is published in midwifery, lists the search terms we used and our selection criteria so another research team could reproduce the study and we could compare results. When we began our search, we found 638 studies that could potentially provide information about neonatal outcomes with water birth. We reviewed every study and reduced that list to 39 that reported on at least one neonatal outcome and compared water birth to conventional delivery. Some of the studies provided results in a format that allowed us to use a statistical method to group the studies and find an overall result. That's the part that's called a meta-analysis. And then once we had the results for each outcome, we were also able to track how the findings for that outcome changed over time as more studies became available. This is called a cumulative meta-analysis. It allows us to identify how stable the results are and that means how likely or unlikely it is that additional research on the topic would change our findings. If it's unlikely that additional research would change the results, we can be more confident that the information that we found is accurate. Most of the studies we found were observational studies rather than experimental studies. This makes sense because most of the early research on water birth were retrospective reports of practice outcomes. That just means they did 100 water births and they counted how they turned out. As water birth practice expanded and the research to expand and we started to see more prospective designs. So you'll notice that there were only a few randomized controlled trials. Six out of the 39 studies use this design. Now, this is important on the one hand because a randomized design has a better ability to prevent certain kinds of bias than an observational design. And it can't control for all forms of bias. And their ability to prevent bias is reduced in water birth for a couple different reasons. The first problem is despite randomizing women, you can't upline the study. And that means that everyone from the laboring woman to the provider catching the baby to the provider taking care of the baby later knows if the woman is in the water or not. And people making decisions about other cares that the woman and the baby receive may be biased in one way or another based on some of their assumptions they make about how water affects maternal and neonatal well-being. So for example, women delivering in the water don't really, you don't have the capacity to do an apesiaotomy. Even if the woman needs one, she has to get out of the water. So she's no longer a water birth. Another example is in the ways that the provider that's examining the baby might make assumptions about how water affects the newborn. So a baby might have their apgar's, the apgar's might be a little different or the decision to institute some form of care because they have a little transient to get me on. Or two examples of the way that knowing the form of birth might affect the outcome. The other problem is that a portion of women randomized to water will not deliver in the water. They might be asked to get out of that tub because of emerald fetal heart rate or meconium or something like that. Now, when you're looking at a control group, the control group doesn't have to change their form of care whether they need an apesiaotomy or not, whether they have emerald fetal heart tones or not, their form of care is exactly the same. So that contributes to two types of bias. The first one is attrition bias where women in one group leave the study at different rates than women in the other group. And then again, there is misclassification bias where women are categorized in the wrong exposure. In this case, being called a water birth when they actually didn't give birth in the water. So when you look at that, it's understandable that most of the studies about water birth are not from randomized control trials, but rather just look at outcomes from a sample size of water birth and compare them to a control group that's similar. So knowing that there's these limitations of preventing bias in water birth research, we wanted to be really careful about interpreting the results of our studies. So we wanted to show you this graph that we produced as part of our study. This is our risk of bias graph. And as you look at this graph, you're gonna notice that there's large yellow sections, large green sections, and large red sections. The green sections are where there was a low risk of bias, yellow is, we couldn't assess, and the red is where there's a high risk of bias. So what are these areas we looked for? We looked at seven specific areas where there could be bias. We looked at seven domains, confounding, selection bias, measurement bias, attrition bias, missing data, outcome measurement, and reporting bias. I'm gonna tell you what all of those need, but I wanna address those large yellow portions first. See the size of the yellow bar is the proportion of studies that didn't give us the information we needed to assess the potential for bias. This is because we cast a wide net in our search for studies. If there was any evidence of pornunatal outcomes with water birth, we wanted to find it. This means we included studies that were only available to us as an abstract, such as presentations at conferences. We included studies that were in different languages and used Google Translate to ensure we have the right numbers for the right data, but we thought Google Translate would be an unreliable method to try to score a risk of bias. And some of our studies were published nearly 40 years ago. Reporting standards were different at those times, and so the authors didn't give us the information needed to address the issues. So what confounding did we find? What did we address in those red areas? Well, the first one confounding, that's a special problem that happens in some studies when something that's not measured is associated with both the intervention and the outcome. In our case, anything that may affect a woman's access to water birth and may also affect an infant status after delivery was a potential confounder. Most studies address the issue of confounding by restricting the sample to low risk pregnancies and demonstrating that the two groups had similar maternal and gestational age. Some demonstrated similar birth weights. We identified risk of confounding when studies did not provide evidence of similar groups. Selection bias is a problem that happens when the method that you use to select people for the study creates unequal groups. This was our most common risk of bias because it was a problem for studies that looked retrospectively at medical records to select women who had a water birth and then made a control group of low risk women. It was a risk because giving birth in water, as Priscilla explained, requires not only that the woman be low risk, but that she also not experienced any water birth exclusion criteria during her labor. Anything like unusual fetal heart tones or meconium stain fluid would mean that a woman was removed from the water and therefore not included in the water birth group. But none of the studies reported applying these same exclusion criteria to the control group. So this means that there's a risk that the studies were comparing the group of the best water birth labors to normal labors of low risk women. Measurement bias is an interesting one for water birth because measurement bias occurs when a study doesn't do a good job of sorting people into the experimental and control groups. This may seem unnecessary in water birth studies because it's pretty obvious who delivered in water. But we counted risk for measurement bias when the study gave no explanation why the control group included women who used hydrotherapy during labor but then didn't deliver in water. When the explanation was missing, we were concerned that the study may be putting all women who experienced water birth exclusion criteria into the control group. And if this happened, a study would be biased in favor of water birth. Attrition bias is the problem that Priscilla explained earlier when you have uneven dropout from a study between the control and experimental groups. We were worried about attrition bias in a couple of studies because they never told us the number of women who started in the study. And since we didn't know the starting size of their sample, there was no way for us to determine if unequal attrition occurred. But attrition bias is gonna favor whichever side had the highest attrition. So there's no way to make assumptions about that from the data we had. Missing data causes bias because there's often important reasons why data is missing and the reasons are important for interpreting the results. Missing data was rarely a problem because for the most part, the studies were relying on standard medical record data that's recorded for every newborn. But we did have a few studies that told us there were no differences between groups without giving us the numbers of people included in each outcome. So we couldn't tell if there was any missing data. Outcome measurement bias happens when the person evaluating the outcome can influence how the outcome is counted. For most studies, again, this wasn't a risk because we're dealing with standard medical record data. But there were a few studies that were testing water birth as something new at their facility. And we assumed that when water birth was new, there's a possibility that the medical team may have a lower threshold for intervention for babies born into water. And this could lead to measurement bias in favor of conventional delivery. And finally, reporting bias happens when a researcher decides only to publish the significant results. This didn't appear to be a problem for most of the studies because the outcomes were, again, basic medical record neonatal assessments. And nearly all the studies declared their outcomes in the methods section and then were faked reporting the outcomes. We know there's a risk that some of the studies may have a sample that pushes our estimate in favor of water birth. And so there's something that we did to explore how much this potential bias would change our results. It's called a sensitivity analysis. And we reuse that to see if the results we find are stable when we remove the studies that are at the highest risk of bias. If we find that the results are different in the sensitivity analysis, we assume that the truth is somewhere between what we got in the main analysis and the sensitivity analysis. Important thing that we wanted to point out before we move on to the results was that we compared water birth to conventional delivery across a wide, it was wide geographically and it was wide over time. So the studies that we looked at were conducted all over the world and throughout about 30 years of practice changes. Now that affects the studies compared water birth to different groups of women. And so when you're trying to add them all together and make some conclusions about what they're saying, you have to be careful to interpret what you're reading with the understanding that the control groups might not be the same. We didn't put restrictions on what water birth practice entailed. In fact, many of the papers that we looked at, we had a hard time figuring out what was considered part of water birth practice because the authors gave us so few details on who was eligible, what was the same or different from standard practice who was included in the control group, some of these kind of details. While it may seem obvious what a water birth is, there were authors that had variation in what they considered to be necessary for a woman to be eligible for water birth and what excluded women. And this introduced a more complex question that we're wrestling with and that we plan to use as a basis for future research is are there practices with water birth that are different from standard practice that are, we could call them a package of care for water birth that we should define and use as a basis for writing policy for doing research and for identifying how do we make water birth safest as safe as possible. So as we present the findings, I do wanna remind you that you can get a copy of the paper and all of these graphs that we're going to show you in the journal Midwifery. The first outcome that we looked at is the one minute Apgar. 15 studies provide results on the one minute Apgar but we had a problem with this synthesis. The results of the individual studies had more variation between them than we would expect if every study was measuring the same thing as a one minute Apgar. This variation is called heterogeneity. We used some statistical methods to try to reduce the heterogeneity by dividing the studies on different characteristics like how long they said the baby could stay under water or whether the control group received epidurals. But nothing we tried reduced the heterogeneity. So we had to conclude that there was too much variation in the reporting of one minute Apgar to synthesize the studies as if one minute Apgar was something that was consistently measured. So because of this, we used a more appropriate statistical model. It's called a random effects model and we got an estimate that there was no difference in one minute Apgar between water birth and conventional delivery. And then we chose not to perform further calculations on the outcome because of the unusual nature of it. For a five minute Apgar, this was the most commonly reported outcome. 32 studies reported results. We were able to synthesize the results of 17 studies and found there was no difference between water birth and conventional delivery. This finding is supported by an additional 15 studies that reported there was no difference but they didn't give us the data that we needed to include them in the meta analysis. The results were consistent at no difference when we removed the studies with the highest risk of bias. So it's unlikely that the finding of no differences due to bias. And we performed a cumulative meta analysis and we found that the result of no difference in five minute Apgar has been stable since 1995 which is a pretty good indication. We don't need to study this outcome anymore. We looked at need for resuscitation. Six studies provided data on this outcome. We found there was no difference in need for resuscitation between water birth and conventional delivery. The result was consistent at no difference when we removed the studies with the highest risk of bias. So it's unlikely that the finding of no differences due to bias. We performed the cumulative meta analysis and found that the result of no difference in need for neonatal resuscitation has been stable since the first time it was reported in 1999. Seven studies provided data for us on the synthesis of umbilical pH. We found that there was no difference in umbilical pH between water birth and conventional delivery. The finding is supported by two additional studies that reported there was no difference but did not provide data for inclusion in the meta analysis. And the results are consistent at no difference when we remove the studies with the highest risk of bias. So it's unlikely that this finding is due to bias. We performed a cumulative meta analysis and found that the result of no difference in umbilical pH has again been stable since it was first reported in 1997. The finding of no difference in respiratory rate, rate of respiratory distress is important. There were a number of case reports. I want to stop here and talk a minute about these ABGARs. So the ABGARs, the need for resuscitation and umbilical pH, they tell us about the transition to life outside the uterus and any problems related to these outcomes would be more likely associated with problems that are caused for the fetus because the woman is in the water. So we took a look at studies with just looking at immersion to see if there was any evidence that that might be the case. We didn't identify any evidence that a woman being and just simply being in warm water would negatively affect the fetus. There is a little bit of a concern that if the water is too cool, the baby may be stimulated to take his first breath before being removed from the water. So there is a recommendation to keep the water at about body temperature but not higher than 101 degrees Fahrenheit. But only a total of 16 of the studies required that this there was a reporting requirement for water temperature. Okay, so we also had five studies that reported synthesis or that reported odds of respiratory distress. And the synthesis for respiratory distress favored water birth, but one large study was responsible for nearly half the weight of the analysis, meaning that this study had as much effect on the results as all the other studies combined. And because this study was in favor of water birth, we tested the analysis without the study to see how stable the result would be. When the study was removed, the outcome was no difference. The results were also no difference when we removed the studies with the highest risk of bias. So it's likely there's no difference in odds of respiratory distress. Because the main analysis and sensitivity analysis differed, we didn't include the studies with the highest risk of bias in our cumulative meta-analysis. With a cumulative meta-analysis, we found that there's never been evidence of a difference of odds of respiratory distress between water birth and conventional delivery. But there were too few studies included in the cumulative meta-analysis to determine the stability of the finding. This finding of no difference in respiratory distress is important because in a number of the case reports on poor outcomes with water birth that are not associated with infection, the initial symptom was respiratory distress or at the very least, it was transient tachypnea that could occur even hours after delivery. And this was a big concern to pediatricians who were writing and submitting case reports of babies that were becoming ill. So in these cases, it appears that delivery in water can result in the aspiration of water, at least theoretically. And the authors believed that it should be considered a possibility. So we identified that the meta-analysis results really showed that there was really no difference in respiratory distress when you compare water birth babies to conventional deliveries. In fact, the raw analysis was that the risk of was lower in water birth. And this likely has to do with the eligibility and exclusion criteria that are used to decide which women can deliver under water. Okay, moving on to neonatal hypothermia. There we go. Four studies provided data for us on neonatal hypothermia. We found that the results did favor water birth over conventional delivery, but this appears to be due to the sample size and the small difference in temperatures rather than a clinical difference in odds of hypothermia because the mean neonatal temperature was within normal range for every water birth and control group in all the studies that reported it. In the sensitivity analysis, when we removed the studies with the highest risk of bias, the result was no difference. So though bias may push the estimate toward favoring water birth, it doesn't appear to hide a higher risk for hypothermia. And there were too few studies that reported temperature outcome to do a cumulative meta-analysis. This finding is particularly interesting because there is a theoretical risk of hypothermia when the baby will be wet longer and may stay in the water. But we found that didn't happen. We looked at two different types of infection. We divided analysis into pneumonia and non-pneumonia infections because of the difference in theoretical risk for infection with water birth. The risk for inhalation of water would increase the risk of pneumonia, but there's a potential that dilution of bacteria by the water may decrease the risk for topical infections. For pneumonia, we found that there was no difference in the odds of pneumonia between water birth and conventional delivery, though again, we found that a single study was responsible for nearly half the weight of the analysis. And without this study, there was no difference. We have too few studies to perform a sensitivity analysis or a cumulative meta-analysis, but we have no evidence that would make us be concerned that there was a higher rate of pneumonia. 13 studies provided data for non-pneumonia infections. We found there was lower odds of non-pneumonia infections with water birth compared to conventional delivery. This was different from the two additional studies that reported no results but didn't give us the data we needed to include them in the meta-analysis. And the result was no difference when we removed the studies with the highest risk of bias. These results need further study to determine if water birth does reduce the odds of non-pneumonia infections, but we can conclude there's no increased risk of non-pneumonia infections. We also looked at NICU admissions. 17 studies provided data on this. We found that the main analysis favored water birth to additional studies reported no difference in NICU admission but didn't provide the data to be included in the meta-analysis. When we removed the studies with the highest risk of bias, we found there was no difference in odds of NICU admission. So this means that while bias may push the results in favor of water birth, bias doesn't appear to be obscuring any increased risk of NICU admission. We performed a cumulative meta-analysis and found that the results moved from no difference to favoring water birth in 2001 and they've been stable there ever since. Now neonatal death is a rare outcome, which means you need a very large sample. We only had four studies that looked at this, but with those four studies, we found that there was no difference in odds of neonatal death between water birth and conventional delivery. There were too few studies to perform a sensitivity analysis and though technically we did a cumulative meta-analysis and it indicated that there's never been evidence of a statistically significant difference. Four studies is really too few to make any serious conclusions about a cumulative meta-analysis. Shoulder dystocia provides a different challenge because while the studies counted the incidence of it, they didn't really count successful management, meaning delivery without injury. Four studies told us how frequent they had shoulder dystocia and we found there was no difference in the frequency of shoulder dystocia between water birth and conventional delivery, but four studies again, that's too few to perform a sensitivity analysis. We did a cumulative meta-analysis. The finding has been stable at no difference, but with four studies, we don't wanna make any conclusions about how stable it is over time. And we did attempt to synthesize the evidence for cord evulsion given concern for this outcome in the literature, but we only found one paper that included cord evulsion as an outcome and it found that there was no difference in the frequency of this occurring. There was one additional type of bias that we examined, publication bias. It's a term that we use when we think only certain findings are being published. There's a concern that researchers may only be sharing their results when the outcome is in favor of water birth, but our study found evidence that there is no publication bias in favor of water birth. In fact, in at least one outcome, it looks as though studies with held findings in favor of water birth. So at this point, we know that there is no reason from the published evidence to suspect poor neonatal outcomes occur more frequently with water birth than with conventional delivery. This doesn't mean that poor outcomes don't happen. Just that they're no more frequent than we see with conventional delivery. Our next question was about who can and cannot use hydrotherapy and how this decision was being made. We wondered if there was any evidence in the studies that could help us identify which women we could all agree were safe or safest to be in the water. This turned out to be more difficult than we expected. This is a chart of the eligibility criteria for the 17 studies that provided us with the most detailed information. And you can see there was very wide variation in their definitions of what was normal, what was healthy. There were some standard items. For example, most studies limited hydrotherapy to women with singleton term pregnancies that were cephalic. And these are standards that we're seeing in the policy documents that we're reviewing. We have evidence to support the gestational age requirement because we want the dive reflex of the baby to be functioning. That's the reflex that prevents the baby from breathing in the water. The specific evidence for whether for a singleton or a cephalic baby, we don't really have. Although from a logistical perspective, it would just seem to be prudent to have those as criteria. Most of the studies did list conditions under which women would be asked to leave the water. And the most common for these were maternal fever, meconium stain fluid and any unusual or non-resuring cartons. Although we all know there's some variability in the definition of non-resuring cartons as well. There were ambiguous definitions about who was not eligible to use the water. The most common exclusion criteria was that the women not have any pregnancy complications, but these were not defined clearly. So what exactly counts as a pregnancy complication? And where does that leave women who are at the border of normal, such as essentially healthy women who say, for example, might have a higher BMI? There were pregnancy complications that were defined that mostly those related to specific infections, such as HIV or other really significant contagious diseases. Then there were studies that excluded pregnancy complications and pre-existing conditions. Presumably those are related to chronic health issues, but they didn't define what those are. So we don't know what women were they considering to have at pre-existing conditions or not. Now, the reason this matters is because in most settings women take care of, middle-aged take care of patients, of women who are essentially healthy, but there are settings where women take care, middle-aged take care of pregnant women who do have health conditions in a collaborative team. And that is one of the models of care in the United States. So a caseload may include women with moderate and or more serious health problems. The other thing we wanted to point out is there were a lot of restrictions of water birth around women who had a previous cesarean. And we think that this is an important issue to really take a good look at. Vaginal births are psychologically very important to women with a previous cesarean birth. And sometimes they feel like the choice and agency were compromised in the birth that was a serine birth. So water birth can enhance the chance of a vaginal birth by reducing the length of labor and the need for pharmacological pain management. We know that hydrotherapy is associated with increased odds of spontaneous delivery. So we think that hydrotherapy can really help women to be a successful VBAC, but the eligibility criteria for VBAC with are very similar to the eligibility criteria for hydrotherapy. So women must be at low risk without a clear definition of risk, which results in some encircular reasoning and probably water birth being restricted from VBACs more than it really does need to be because of the... So I told you at the beginning that one of my interests was finding if we could provide evidence for writing protocols. So we wanted to know if these criteria that we were using actually mattered. But the problem was we couldn't compare the studies that did and did not have the criteria because with few exceptions, the studies only told us if they had the requirement. When the requirement was not listed, we were left to guess if the authors didn't list the requirement because it didn't apply or because they assumed that it was understood, of course that was part of their limitations. So we did another sensitivity analysis. We performed the analysis again only for studies that specifically told us that they used an exclusion criteria, the theory being if we see an improvement in where water birth looks better when we use this, when we limit it only to studies that use a criteria, we would know that the criteria were improving the outcomes. But we were unable to find any exclusion or eligibility criteria that resulted in improved outcomes. So we're not really sure if this means that our eligibility and exclusion criteria are too tight or if this means that everybody was doing it and they just didn't tell us. So we can't tell from the data that we have, we need more research to determine the best criteria for eligibility and exclusion from water birth. We had one more thing we wanted to test and that was if the control group made a difference. Remember we said the studies were conducted all over the world and over almost 40 years. So there was wide variation. So we wanted to test if differences in control groups might be biasing some of our outcomes. So what you're looking at right now, this is a chart of the distribution of the use of analgesics for the 11 studies that told us how many people in each group used an analgesic. The dark area shows the proportion of women in the conventional group and the light is the proportion in the water birth group. You'll notice, yes, analgesics were used in water birth groups. Most commonly this was nitrous oxide and you can clearly see that the use of pharmacological cane management occurs at a higher rate in the conventional delivery group that's often cited as a benefit for water birth. And we found when we compared this, when we did a sensitivity analysis looking only at the studies that had the highest difference in use of analgesics, we didn't change any of our results. So having women in the control group using analgesics when women in the water birth group didn't is not biasing our results. We did the same thing with the use of uterotonics. Most frequently this was pitocin. You'll notice again that in the light area, studies had much lower use of use of uterotonics when the women were in the water. Again, that's cited as a benefit of water birth, which we found in our studies. But again, when we limited it to the studies that had the biggest differences in use between uterotonics in the conventional and water birth groups, again, we didn't see that this had been biasing the results, the results remained no difference. So there are some things that we still don't know. Priscilla, tell them about them. If any of you is really interested in collecting data or being involved in this research, I think we're really interested in people to collaborate with us. But one of the things we thought that came out of this was we wanna identify what are the best eligibility criteria for water birth? And are we restricting too many women from being in the water? One of the things that happens if we're excluding too many women is that it decreases the demand for tubs and affects the cost of their use and the resources the hospital must allocate to support the program. So one of the other issues that we wanna take a look at is what is the cost of a water birth program to the facilities in the United States and in other parts of the world? Because we can only implement this widely if we can demonstrate to facilities that it's cost effective. We want to know what are the issues related to a trial of labor for women with a previous Assyrian? How does it affect their emotional wellbeing? How does it affect the outcomes of labor? We wanna clearly define the specific conditions that really restrict a woman from using water during labor because we need to be able to counsel women about these and address the risk and benefit balance with confidence. We don't know a lot about the optimal management of water birth emergencies. So certainly that is something that needs to be explored shoulder dystocia, quadrivulgen, hemorrhage. We also wanna identify what are the essential elements of the package of care for water birth and how those influence water birth safety. There are things that go together with water birth that always go together and we need to study them as a whole rather than just say, well, this is just about getting in the tub. Well, there's a collection of elements that goes together. We need to understand the demand for water birth. The evidence is anywhere from 5% to 60% of women wanting to use tubs and the numbers are not meaningful for hospitals to be able to plan. And then finally, we really would like to identify implementation projects that will describe training for any healthcare personnel involved in water birth. And that includes midwives, physicians, nurses, and other supportive personnel. Part of the reluctance of some providers have with water birth is a lack of knowledge about how to manage challenging births in the water and training and emergency simulations with water birth can increase provider comfort and confidence. So thank you so much for listening to our presentation. Again, we want to direct you to the Journal Midwifery if you want to get any of the data from this study. Pandora, do we have time for any questions? I'm not hearing Pandora. And I... Sorry, can you hear me then? Can you hear me, Jennifer? Yes, yes. It's Linda here. Yes, we have five minutes for questions. Perfect. I don't know why Pandora might be in the other room. No, she won't be in the other room. I'll just not do the next one. Here we go. I've not got my headphones on either. Oh, is that you? Yes. We've lost one of our computers, so I'm going to unplug my headset so that we can use... We can both be answering questions at the same time. So if this makes any noise, I'm very sorry. I'm going to unplug it right now. Yeah, Sheila actually has written, typed in a very wonderful question about the distinguishment between hydrotherapy for labor and water birth, that the clinical exclusions might fall away if water labor only was being considered. Are you able to speak to that? Because you did mention what are the questions having to do with demand and the cost-benefit analysis for this. I'm sorry, we missed the first part of the question because our computer was switching from the headset to the main... If you can look on the chat box, Sheila asked a question about the distinguishing between water labor and water birth. You had mentioned the cost-benefit concerns and the demand drivers in facilities for this, and she had indicated that clinical exclusions could fall away if water labor only was being considered. Is that something you could speak to briefly? And also the question about women's refusal to listen to any medical risk factors that they might be a candidate for water birth if women still wish to. Thank you. We can see both of those questions. So in our study, we made sure that we only looked at outcomes that were related to delivery in water. So every study used delivery in water, not every study used labor in water. Laboring in water actually has a much broader set of research. And if you pull up the Cochrane review, I think the last one was at 2012 was when it was published. They actually go into water labor very clearly, but I don't know that they've ever done an examination of what the criteria are. We have the problem with water birth that here we are 30 years plus after the introduction, still trying to prove that it's safe. We never moved into the research we need on implementation on how do we expand its use? How do we best implement it? How do we make it available to the most women possible? I agree that when we use only water labor and not water birth, that there should be some relaxing of the criteria. We don't see that happen in the United States. Thank you. Any other questions from anyone? There's one from Celine that she put in the chat box. She wants to know if there's a difference between planned water birth and spontaneous water birth and does it count for research? I don't know that anybody doing research on water birth is having spontaneous water birth. If they're all planned. Yes. And there was another question further up. What was the second? I can't make it go up. Yes, and Linda says in the UK, they offer water birth all the time. I know you do, Linda. We are so unusual in the United States. Oh yeah. I don't know. I don't know why. I don't know why. I don't know. It's really, it's because our system is so medically driven and physicians are uncomfortable with this form of care. They don't like it. It's messy. It's not, it's not medical and they're not used to it. And we don't, you know, they're just, it's not part of their paradigm. So it limits it. Yes, Cindy. Yes, definitely email us at Emory. We'd love to talk about that. Oh yeah. Yes, and Pandora, you're right. So Pandora, that's one of the limitations we have studying water birth is this problem that just because a woman plans a water birth, it doesn't mean she's going to have a water birth. When we were looking at some of the data from a hospital practice, I think almost 50% of women who were eligible for the tub and use the tub in labor and could have given birth in the tub, got out of the tub. So some of them, they had an exclusion criteria. Some of them had to go to the bathroom and decided they were just more comfortable walking around. Things happen and you can't force a woman to give birth in the tub just because you want to find out what the outcomes are going to be if she does. Celine made the comment that we should offer water to all but not necessarily water birth. And I think that's an interesting, it's an important question. The issue is like, how do we get women to get out of the water? And as they approach birth or as they get close to second stage, like there's some ethical considerations there about trying to negotiate with a person that's sort of moved into sort of a nonverbal, non-mobile state where getting out of the water would be very, very hard. Any other questions? I think Celine's question also speaks to midwives going beyond just looking at the water birth itself, but us getting involved in the committees that are looking at hospital planning and structure because I have been in many practices where even midwives want to offer water but the facilities are already built. The facilities have not accommodated for a tub, for a shower, for the space, for the floor weight that comes with a tub. So this is a call for all of us. In the United States, we have the problem that even if your nurses and your obstetricians are interested unless you can prove to the administration that putting in tubs is going to be cost effective or bring in more patients to the hospital, you can't get it. Oh, AFGAR and research. Yeah. We did run into that problem with the one minute answer. Sheila made a comment about the use of AFGAR as in research in general. I think that this is a really big problem. I don't think that it's just an idiosyncrasy with water birth that our one minute AFGARs were so unable to be used. But how telling is it that when we looked to see if analgesics or uterotonics, or we looked specifically for epidurals because they're used very commonly in the United States or uterotonics would possibly confound the study, we only found they looked at one in five minute AFGARs and they looked at NICU admission. That's it in the in the Cochrane systematic reviews. Those are the only outcomes they provided us with. So we don't know these other outcomes. We don't know how it might affect it. But that's okay for epidural that allows our American physicians and pediatricians to be okay with women getting epidurals but they won't let them get in the water. It's very frustrating to us. Well, and even you think about that the incidence of epidural fever and the septic work the septic workup for the baby including sometimes a spinal tap and then sometimes if that particular baby develops a little bit of TTN they get antibiotics thrown at them. But that is sort of it. No one ever like looks at that as a risk factor for an epidural but TTN with water birth is a big deal. Yeah. And there was a question can this type of birth only be done in a hospital setting? No, in fact in the United States it's more frequent to be done in a birth center or at home but our interest in writing this was because the only resistance we get in the United States is in hospitals. So we limited our evidence. These studies that we used for this meta-analysis were limited to water birth in a hospital setting. So you can take this to your hospital administration and say look these were hospital births and with hospital births there was no increased risk. Well, Jennifer and Priscilla thank you for a wonderful, wonderful presentation. Wow. I think we have all learned something that can be applied wherever we are. And then the question about access to the article would you be able to facilitate that if the participants were to email you for a PDF copy of that? Yeah, yes we can. If you can just like text in your email addresses and because I know sometimes access to different journals can be a challenge particularly when one is not always affiliated with a university setting. The other thing that we have is I put together a annotated bibliography for people who are trying to get water birth or hydrotherapy in their hospital. It's a list of studies that you should know about to help navigate this discussion with administration and infection control and pediatrics. Anybody you might have to negotiate with to get water birth or hydrotherapy in your hospital. Thank you so much. Thank you to all of you who are out there listening. Have a wonderful rest of your international day of the midwife wherever you are.