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• How a Belgian daily paper informed its readers about the contents of the review on waterbirth
  Sophie Alexander
  Published on: 27 July 2016
• Re: Water births: adverse events for the baby are rare but devastating
  Alastair Sutcliffe
  Published on: 17 June 2016
• Water births: adverse events for the baby are rare but devastating
  Mark W Davies
  Published on: 17 June 2016

• Published on: 27 July 2016

  How a Belgian daily paper informed its readers about the contents of the review on waterbirth

  • Sophie Alexander, Obstetrician

  Le Soir, one of Belgium's leading French language newspapers (1), headlined the front page of its 23 May 2016 edition with "Birth in water: a dangerous new fashion." Page 6 was devoted to the review by Taylor et al; the subtitle said "New study underlines the dangers of drowning and pulmonary infection for babies; no benefit from this fashionable birthing technique". I was asked that afternoon, in my capacity of advise...

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  Le Soir, one of Belgium's leading French language newspapers (1), headlined the front page of its 23 May 2016 edition with "Birth in water: a dangerous new fashion." Page 6 was devoted to the review by Taylor et al; the subtitle said "New study underlines the dangers of drowning and pulmonary infection for babies; no benefit from this fashionable birthing technique". I was asked that afternoon, in my capacity of adviser to the Belgian French-speaking maternal and child welfare agency "ONE" (2) to provide an answer to a parliamentary question on ONE's response to women about the reported risks of waterbirths. My answer to the parliamentary question was that "no, there is no new evidence that waterbirths present an increased risk to babies." However important questions remain about how a serious newspaper arrived at such a distortion of the content of the review by Taylor et al. I offer three possible causes:

  - Translation issues: the paper in ADC-FN said that "no definitive evidence" was found. This scientific statement was translated as "the study underlines the dangers of [...]" - The British RCOG and RCM have clearly established standard procedures for waterbirths whereas in the US ACOG recommends that waterbirths are limited to experimental cases. It may be that Belgian obstetricians are more familiar with US guidelines. - It is possible that the wording of the Reuters press release, quoting an email from one of the authors "[...] my advice is to wait until there is more convincing evidence of safety before having the actual delivery in water," contributed to the biased representation of the paper in Le Soir (3). Waterbirths are not in fact a new fashion or fad in Belgium. There is a pioneering hospital in Ostend which has been doing it for over 30 years (4).

  Answering the parliamentary question accurately and with a fast turn- around was made possible thanks to the efficiency of JISCMAIL (the academic midwifery list) and I would like to thank them here for their help.

  (1) Le Soir (Belgian daily newspaper http://journal.lesoir.be/ accessed 15/6/16 (2) Office de la Naissance et de l'Enfance http://www.one.be/ accessed 15/6/16 (3) Reuters press release http://www.reuters.com/article/us-health- pregnancy-water-birth-idUSKCN0XW1QT accessed 15/6/16 (4) Sint Jan hospital in Ostend http://www.azsintjan.be/materniteit- hs/bevallen/bevalling/onderwaterbevalling.aspx accessed 15/6/16

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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• Published on: 17 June 2016

  Re: Water births: adverse events for the baby are rare but devastating

  • Alastair Sutcliffe, Professor
  • Other Contributors:
    • Henry Taylor, Ira Kleine, Susan Bewley, Eva Loucaides

  We are grateful for the interest in our paper and the opportunity to refute the suggestion that it is falsely reassuring. Our paper provides a fair and accurate representation of the best available data; it concludes that "this systematic review and meta-analysis did not identify definitive evidence that waterbirth causes harm to neonates ... However, there is currently insufficient evidence to conclude that there are no...

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  We are grateful for the interest in our paper and the opportunity to refute the suggestion that it is falsely reassuring. Our paper provides a fair and accurate representation of the best available data; it concludes that "this systematic review and meta-analysis did not identify definitive evidence that waterbirth causes harm to neonates ... However, there is currently insufficient evidence to conclude that there are no additional risks or benefits for neonates".

  It does indeed state that "existing evidence is not strong enough to examine the relative risk of rare and potentially devastating adverse events" as well as citing the risk of aspiration in a compromised baby who was born gasping (paragraph 8).

  It is incorrect to suggest that the susceptibility to bias of different study designs was ignored and that results are reliant on poor quality retrospective studies. The entire meta-analysis was repeated, for every outcome, using data only from randomised controlled trials. These results were entirely consistent with the primary analysis and are available to view in supplementary file D.

  There are a number of ways to examine safety and capture rare, serious adverse events. The merits and drawbacks of each approach must be carefully considered before any future study. We recognise the limitations of prospective cohort studies and agree that a large, adequately powered RCT would be ideal to determine the safety of waterbirth. However, there are significant ethical and practical issues with randomising enough women. In one UK pilot, of 40 women randomised to water birth, only 10 delivered in water.[1] The National Institute for Health Research recently called for an observational study to address this question and stated the design 'should not involve randomisation given the rarity of adverse events'.[2]

  [1] Woodward J, Kelly SM. A pilot study for a randomised controlled trial of waterbirth versus land birth. BJOG: an international journal of obstetrics & gynaecology. 2004 Jun 1;111(6):537-45.

  [2] National Institute for Health Research (NIHR). HTA commissioned funding opportunities, call 15_157 'Delivering babies in or out of water'. http://www.nets.nihr.ac.uk/funding/hta-commissioned

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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• Published on: 17 June 2016

  Water births: adverse events for the baby are rare but devastating

  • Mark W Davies, Neonatologist

  The overall tone of this systematic review is to reassure the reader that waterbirths are safe; this is not justified by the results which rely almost exclusively on extremely poor quality retrospective cohort studies. Different study designs have significant differences in their susceptibility to bias and the authors have largely ignored this issue. Larger, non-randomised studies, more prone to bias, carry more weight ; n...

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  The overall tone of this systematic review is to reassure the reader that waterbirths are safe; this is not justified by the results which rely almost exclusively on extremely poor quality retrospective cohort studies. Different study designs have significant differences in their susceptibility to bias and the authors have largely ignored this issue. Larger, non-randomised studies, more prone to bias, carry more weight ; no meta-analysis should have been done with these data.

  In contrast to the use of immersion in the first stage of labour, waterbirth confers no benefit to the mother or baby and puts the baby at unacceptable risk; current trials are too small to rule this out. Adverse events for the baby are rare but devastating. A hypoxic-ischaemic fetus will aspirate water when gasping while immersed.

  The authors have deemed that a large, prospective, cohort study is an acceptable approach to determining the benefit/harm ratio for waterbirth. Such non-randomised studies are prone to significant bias. The control group would be fundamentally different to the waterbirth group, and such differences would undermine the major principle that both groups should be as similar as possible with respect all other factors that may be related to treatment and outcomes except for the intervention. With non-random assignment in a cohort study, equally eligible women with different risks for adverse outcomes will be assigned the intervention group (consciously or unconsciously) based on how the women themselves or their caregivers perceive the risk of adverse outcome -large numbers of women enrolled in this way will seriously imbalance the treatment groups with regard to factors affecting outcomes.

  An appropriately sized, good quality RCT with longterm follow-up remains the only reliable way to assess both the efficacy and the safety of waterbirths.

  Conflict of Interest:

  I was a peer reviewer for this paper.

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  Conflict of Interest:
  None declared.

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