Evaluating technology

AIMS Journal 2014, Vol 26, No 1

Jo Dagustun offers a geographical appraisal of the birth pool

Current western culture has become brilliant at 'denormalising birth'. The sheer possibility of the physiological process of birth actually working is eroded, it seems, at every turn. This leads to women seeking increasingly inventive ways to preserve normality whilst birth culture looks for ways to turn those self-help measures into interventions.

These inventive ways that support the physiology of birth are frequently taken over by systems and then used to control rather than support women.

In some areas of the UK water has become a taken-forgranted part of the repertoire of birthing mothers and midwives oriented towards achieving normal birth, and new possibilities are opened up by this new type of birthing space. In other areas there is resistance to the use of birth pools.

So many birthing technologies are introduced without good quality, or even any, evaluation. Research on the use of birth pools shows positive outcomes,¹ but some would argue that high quality evidence is still needed.^2,3

From a purely biological perspective, despite some speculative work done around our mammalian links to underwater birthing practices as exemplified by dolphins, there is nothing to suggest that humans giving birth in water is 'normal'. However, babies have long been born in baths after their mothers spending part of labour in a nice hot tub of soothing water.

The practice of labouring and/or giving birth in water regularly crops up in the context of the promotion of 'normal' labour and birth: in journals and magazines aimed at researchers, professionals and pregnant women; at antenatal classes and homebirth support groups; at academic conferences. In parts of the UK it is rapidly becoming part of the 'working with pain' tool-kit of midwives oriented towards supporting normal birth, and for women seeking to avoid pharmacological pain relief, wherever they are planning to give birth. However, in many places women are not getting information and there are still unfounded concerns about things such as babies drowning. All too often women are advised against using water unless their pregnancy and labour fit a very narrow range of normality.

In some places medical resistance to this particular initiative has been fairly muted; in others (particularly Ireland and the US) there has been vociferous and sustained obstruction to using birth pools. Paediatricians have raised some concerns about possible negative consequences of water births on neonatal lung function, but research evidence on that and other fears has been inconclusive. Other research shows that labouring in water does indeed provide pain relief and reduces the numbers of women having epidurals.²

While practical debates continue about how to resolve some key barriers to the practice, the notion of 'allowing' women to labour in water has finally been accepted in most areas of Britain, although even where it has been accepted there is not always whole-hearted support for actually birthing in water. Remaining barriers to the widespread availability of birthing pools include: cost and space; training needs for staff in supporting the use of a pool; local health and safety clearance for the use of a pool in the labour suite; debate around some detailed protocols for the 'intervention', such as who is and isn't eligible to use the birthing pool; at what stage of her labour should a woman be 'allowed' to access the pool; what are the indicators that suggest the need to get a woman out of the pool. Practical and control issues aside, in places we can see that the installation of birth pools on the labour ward is now a mainstream part of any well-funded refurbishment project, with birth pool equipment businesses flourishing and projects to support access to birthing pools for use at home widespread.

It has become clear that the use of birthing pools in labour and for birth represents the introduction of a significant new and unique kind of birthing space.

As a geographer investigating contemporary UK childbirth culture, I'm extremely interested in the growth of the birth pool phenomenon. Yes, the birth may still be taking place within the walls of a traditional birth setting, but whether this is on the consultant-led maternity ward, in a midwifery-led birth centre or at home, such a new waterbased space has potentially far-reaching consequences for the performance of birth itself.

Women are often drawn to water because it affords them more privacy, it creates focus, it increases mobility, eases strong sensations and aids relaxation. The water both represents and physically ensures a barrier. Very few medical professionals don their swimsuits and get into the water with the mum-to-be.

By situating herself within the birthing pool environment, the labouring woman immediately distances her body from those outside the pool. In doing so, a new boundary, border or space of exclusion is constructed, within which the woman can be alone with her body, and move freely, and rapidly perhaps, to avoid unwanted touch, much more effectively than might be possible on land. This must surely focus the mind of all those involved, if they are open to such ways of thinking, on which hands-on interventions really are important to the well-being of mum and baby.

During the moments when the baby is being born, the water-based venue lends itself well to the mother (or her chosen birth partner) playing a primary role in 'catching' her own baby - something that is far harder to achieve in land-based births.

I am not suggesting that these implications are the explicit goals of the individual women who choose to labour or birth in water: personal goals will be many and varied, as will the nature of the support a woman receives whilst using a birthing pool, but the birth pool creates fundamentally new spaces of birthing. It opens up new possibilities for how the birth performance can be imagined and enacted.

This is a space where healthcare professionals might be supported in developing an increasingly confident hands-off approach to birth, and where a mother may achieve a far greater degree of autonomy over the birth of her baby and how her baby is, quite literally, handled at and immediately after birth. Indeed birthing your own baby in water, even with a midwife in the room, may present a non-disturbed birthing scenario for women who wish to prioritise respect for the body's amazing physiological ability to birth.

So far so good, but I'd like to share two aspects of all this that continue to trouble me. Is there a danger that women will feel obliged to use a pool in order to avoid unwanted interventions, instead of practitioners examining how women can be less disturbed overall?

Is there also a danger that birthing pools morph into yet another in a long line of childbirth technologies which individually and collectively over the years have worked to send a powerful signal that birth is outside the competence of ordinary women; that women's bodies are weak and bound to fail? What if the birthing pool is absorbed into yet another in a long list of interventions that, whilst intended to help a woman cope with pain in labour, actually reinforce the notion that women are not expected or able to work with their bodies' various signals about the ongoing physiological process of birth, sometimes known as pain, in order to achieve a good outcome?

What if the birth pool as a simple and effective tool used by women to gain privacy and autonomy as well as pain relief becomes hijacked by technology and evolves into something too complex for a woman in labour to own or have control over? It is already happening, with pools being designed with cut-away places where a professional can get physically closer to the woman or get a better view of the birth, and pools with numerous mechanical controls and equipment attached. The 'rules' that have already become attached to labour and birth in water serve to prevent a woman having control over her environment rather than encourage it, such as having to reach a certain stage of labour or dilation (diagnosed by some test or standard other than the woman's own need or desire for water).

In the context of the sustained undermining of women's confidence in their abilities to birth, over several generations, this raises the inherent challenge of giving positive messages about birth and women's innate ability to labour and birth while at the same time acknowledging that some practices might help women.

Enthusiastically promoting birth pools, hypnotherapy, TENS, aromatherapy, massage and other means of supporting physiology and normal birth - unless the key message is that women can do birth - can imply that women can only birth by using props.

How can we best retain the incredibly positive practical consequences of birthing pool technology on our own terms? How can we make use of this technology whilst avoiding the reproduction of the powerful cultural messages around women's inability to birth? Those highly influential cultural messages have, I believe, been a problematic part of dominant birth discourse for far too long, and our societal health pays the price. The more we can reflect on our own potential contribution to them, by every one of us in our every day lives, the better chance we may have of dismantling them.

Jo is currently a PhD candidate in the School of Geography, at the University of Leeds. Jo has birthed four babies, none of whom was born in water, although Jo is the owner of a birth pool (aka very large paddling pool - remember the early versions?) and has spent some time over the years labouring in a bath, both at home and in hospital. Jo can be contacted at jdagustun@hotmail.com.

References

1. Burns, E et al (2012) Characteristics, Interventions, and Outcomes of Women Who Used a birthing Pool: A Prospective Observational Study. Birth 39 (3) 192-202.
2. Cluett ER, Burns E (2009) Immersion in water in labour and birth. The Cochrane Library. doi 10.1002/14651858.CD000111.
3. Cooper, M et al (2013) Diving in: a dip in the water of the labour and birth policy debate. Essentially MIDIRS 4 (9) 30-35.