Experience of Water Birth Delivery in Iran

Arch Iranian Med 2009; 12 (5): 468 – 471

Original Article





Experience of Water Birth Delivery in Iran

Shahla Chaichian MD•*, Ali Akhlaghi MD*, Firouzeh Rousta PhD*,
Mahboobeh Safavi PhD*


Background: Having considered the physiologic challenges during pregnancy, scientists have
searched for different delivery methods with minimal medical intervention. The use of water
immersion by women for relaxing during labor is being used worldwide. We aimed to evaluate the
controversies surrounding water birth and to find out the interest of Iranian women in this delivery
method.
Methods: In a randomized clinical trial, 106 pregnant women were assigned to control and
experimental groups. The experimental group underwent the labor and delivery in standardized
warm water pools. The control group gave birth by conventional delivery method at the hospital. A
questionnaire was completed during the labor for women in both control and experimental groups
including the method of delivery; labor length; use of different drugs such as analgesics, opiates,
antispasmodic, and oxytocin; use of episiotomy, and newborn’s Apgar score and weight.
Results: Totally, 53 cases and 53 controls with the mean age of 26.4±5.9 and 27.1±5.9 years,
respectively, completed the study. Women in the control group required oxytocin, antispasmodics,
opiates, and analgesics more frequently than those in the experimental group (P<0.001).
Meanwhile, the active phase and the third stage of labor were shorter experimental group by 72
and 1.3 minutes, respectively (P<0.004, and P<0.04). All the participants in the experimental group
gave birth naturally, whereas only 79.2% of the controls had normal vaginal delivery.
Conclusion: Our results revealed the advantage of water birth delivery. Those who gave water
birth experienced less pain and completed the delivery sooner. Meanwhile, normal vaginal delivery
was accomplished more frequently with this group. These all lead to a decreased necessity for
medical interventions as well as an increased socioeconomic advantage for the society.

Archives of Iranian Medicine, Volume 12, Number 5, 2009: 468 – 471.

Keywords: Cesarean section • complementary medicine in obstetrics • normal vaginal delivery •
obstetrical complications • physiologic delivery




Introduction
Furthermore, it places a financial burden on the

family and society.1,2 In 2001, the American
onsidering the physiologic challenges
College of Obstetrics and Gynecology (ACOG)
associated with delivery, scientists have
recommended the implementation of a 10%
Csearched for different delivery methods decrease in cesarean deliveries over a decade in the
with minimal medical intervention and lower
United States [15.5% for 2010].3 Similarly,
complications for mother and newborn.1 One of the
statistics released by the Department of Medical
most prevalent medical interventions is cesarean
Education of the Iranian Ministry of Health reveals
section. In addition to the risks associated with
a frequency of 41.9% for cesarean section in most
surgery and anesthesia, cesarean section has a
cities in Iran and 50% in Tehran.4 On the other
longer hospital stay and recovery time.
hand, it is the goal of insurance companies and the
Iranian Ministry of Health to reduce the rate of
cesarean section by 25%.4
Authors' affiliation: *Department of Obstetrics and Gynecology,
Islamic Azad University, Tehran Medical Unit, Tehran, Iran.
Several alternatives to cesarean surgery are
•Corresponding author and reprints: Shahla Chaichian MD,
exercised in obstetrics. These methods encompass
Department of Obstetrics and Gynecology, Islamic Azad
advantages and disadvantages, among which water
University, Tehran Medical Unit, Tehran, Iran.
Tel: +98-216-650-9283, E-mail: drchaichian@yahoo.com
birth that activates peripheral neurologic receptors
Accepted for publication: 6 May 2009
468 Archives of Iranian Medicine, Volume 12, Number 5, September 2009

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S. Chaichian, A. Akhlaghi, F. Rousta, et al.
is more attractive. The weightless condition
negative history of previous cesarean section,
created in water equalizes the pressure throughout
intact gestational sac, absence of placental
the body and leads to energy conservation. In
abruption or placenta previa, no malpresentation,
addition, water induces relaxation by release of
and suitable results of fetal wellbeing tests. The
endogenous opioid peptides. Both these situations
participants were not selected if their pregnancy
lead to reduced pain sensation.1,2,5–7 The
was the result of assisted reproductive technology.
advantages of this method include reduced pain,
After primary screening, they were randomly
increased functional diameter of true pelvis,
assigned to control and experimental groups. The
increased quality of contractions, increased release
women in the experimental group underwent the
of endorphins, decreased need for opiates,
labor and delivery in standardized warm water
increased movement for the mother, as well as
pools. Those in the control group gave birth by
improved positioning in different stages of labor.
conventional delivery method at the hospital.
Several studies have reported the disadvantages
A second questionnaire was completed during
associated with water birth. These include maternal
the labor and delivery for the participants in both
and neonatal infections, as well as the possibility
groups including the method of delivery; labor
for respiratory problems for the newborn.5,7
length; use of different drugs such as analgesics,
Although these complications increase the rate of
opiates, antispasmodics, and oxytocin; use of
medical intervention in the newborn, none of them
episiotomy; and the newborn’s APGAR score and
leave a long-term unwanted effect. Despite its
weight.
popularity, there are far less water births than
The data were analyzed using SPSS software
conventional deliveries.
(version 11.5, SPSS Inc., USA). Student t- and
The aim of this study was to evaluate the
Chi-square tests were used for data analysis, when
controversies surrounding water birth, and to find
appropriate.
out the interest of Iranian women in this delivery

method. Therefore, we conducted a pilot study on
Results
water delivery at Shaheed Akbarabadi Hospital in

2006 – 2007.
Totally, 53 women in the experimental group

and 53 controls with the mean age of 26.4±5.9 and
Materials and Methods
27.1±5.9 years, respectively, completed the study.

Most of the participants in both groups were para
In a randomized clinical trial, the interview and
2, gravida 2 followed by para 1, gravida 1.
observation techniques were used to study 106
Although the number of individuals with para 3
pregnant women who were admitted to Shaheed
was higher in the experimental group, the
Akbarabadi Hospital, affiliated to Iran University
difference was not statistically significant (Table
of Medical Sciences, between June 2006 and
1).
September 2007. The participants were given
The use of drugs such as oxytocin, anti-
comprehensive information on water birth before
spasmodics, opiates, and analgesics was
they consented to participate in the study. They
significantly between the groups. As shown in
were primarily screened by completing a
Table 2, nearly all the women in the control group
questionnaire, which contained demographic
used these drugs whereas the women in the
information as well as the inclusion criteria for the
experimental group took them less frequently.
study.
The study revealed that active phase of the first
The following inclusion criteria were applied at
stage and the third stage of labor were shorter in
baseline: gestational age between 37 – 42 weeks,
the experimental group by 72 and 1.3 minutes,
Table 1. Characteristics of the participants in experimental and control groups.

Experimental group (water birth)
Controls (conventional delivery)
P value
(n=53)
(n=53)
Age (years)
26.4±5.9
27.1±5.9
0.7
Gravidity ?3 20(37.7%)
19(35.8%)
0.7
Parity ?2 18(33.9%)
17(32.1%)
0.66
Previous abortion
5(9.4%)
3(5.7%)
0.3
PROM 1(1.9%)
0
0.5
History of ART
1(1.9%)
2(3.8%)
0.5
PROM=premature rupture of membrane; ART=assisted reproductive technique
Archives of Iranian Medicine, Volume 12, Number 5, September 2009 469

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Water birth delivery in Iran
Table 2. Use of drugs during labor in experimental and control groups.

Case (water birth)
Control (conventional delivery)
P value
n (%)
n (%)
Oxytocin 0
50(94.3)
0.001
Antispasmodic 2(3.8)
53(100)
0.001
Analgesic 2(3.8)
53(100)
0.001
respectively. However, the second stage was the
experimental group compared with the controls by
same in both groups, as depicted in Table 3.
72 and 1.3 minutes, respectively. In contrary to
Our results revealed that all participants in the
ours, Cammu et al. and Schorn et al. did not
experimental group gave birth naturally, whereas
observe any difference in the duration of different
only 79.2% of the controls had normal vaginal
phases of labor.8,11 Nevertheless, Harper believes
delivery. There was 23% higher episiotomy rate
that the hydrokinetic effect of water stimulates
among the controls compared with the
release of oxytocin from the nipples that in turn
experimental group. Conversely, the perineal
shortens the labor and delivery times.12 Pellantova
laceration rate was 12% higher in the experimental
and co-workers conducted a long-term study and
group; however, most of these lacerations were
concluded that the decreased labor time was
minimal. No statistically significant difference was
characteristic of the second phase only.13
observed between the two groups in any of the
Analysis of different studies related to water
following measures: maternal level of education,
birth and its effect on pain and labor time further
newborns' weight, height, head and chest
qualifies the importance of this area of research in
circumferences, sex, APGAR score at the first and
Iran where other resources are limited. It is
fifth minutes, and initial breastfeeding episode.
noteworthy that all women using water birth in our

study gave birth naturally whereas only 79.2% of
Discussion
those using conventional delivery had normal

vaginal delivery. Rush and colleagues observed a
The current study indicates that women who
more prevalent use of medical interventions such
underwent water birth delivery received less anti-
as forceps and vacuum in women using
spasmodic drugs, opiates, analgesics, and oxytocin
conventional delivery than those using water
during labor. Cammu and co-workers showed that
birth.9 However, they did not observe a significant
water causes body relaxation that in turn leads to
difference in the number of cesarean section cases
decreased pain between contractions.8
between the two methods of delivery. It is
Consequently, taking antispasmodic drugs, opiates,
important to note that the total number of cesarean
and analgesics were substantially reduced among
sections reported in the Rush et al's. study was less
women with water birth compared with those
than the average annual cases reported by the
undergoing conventional delivery. Rush et al. also
center where the study was conducted (8.9% vs.
reported a similar finding in their study.9
16.6%).9 Eberhard and Geissbuhler were able to
Additionally, Richmond observed that the amount
establish a positive relationship between the
of drug consumption among women using water
decreased rate of cesarean sections and water
birth delivery method was significantly lower.1
births.10 This is in agreement with ours.
Conversely, Eberhard and colleagues believe that
The current study showed a lower episiotomy
water birth is not less painful than conventional
rate among women with water birth delivery.
delivery.10 They assert that the comfort associated
While the perineal laceration rate was 12% higher
with water delivery elevates the pain threshold and
in women in the experimental group, the difference
pain acceptance in the mother.
was not statistically significant. The lacerations in
Our study revealed that the active phase of the
women with water birth delivery were less severe
first and third stages of labor were shorter in the
than those in conventional delivery. Harper
Table 3. Different stages of labor in experimental and control groups.

Experimental group
Control group
P value
(water birth)
(conventional delivery)
Active phase of the first stage
114.4±93.6 186±132.5
0.004
(minute)
Second stage (minute)
20.9±20.5
20.6±22.2
0.9
Third stage (minute)
6.0±2.3
7.3±3.4
0.04
470 Archives of Iranian Medicine, Volume 12, Number 5, September 2009

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S. Chaichian, A. Akhlaghi, F. Rousta, et al.
believes that water hydrothermal characteristics
Gynecology of Shaheed Akbarabadi Hospital.
lead to perineal, vaginal, and uterine relaxation

that, in turn, shorten the labor and delivery time.12
References
Rush and co-workers revealed that there were less

1
Richmond H. Women's experience of waterbirth. Pract
perineal lacerations in water birth method than
Midwife. 2003; 6: 26 – 31.
conventional delivery.9 Additionally, Pellantova
2
Gilbert RE, Tookey PA. Perinatal mortality and
and colleagues observed fewer number of perineal
morbidity among babies delivered in water: surveillance
lacerations associated with water birth, they were
study and postal survey. BMJ. 1999; 319: 483 – 487.
at most, first degree lacerations.13 Therefore, it can
3
Harer WB Jr. A look back at women's health and ACOG,
a look forward to the challenges of the future. The
be concluded that water birth protects pelvic
American College of Obstetricians and Gynecologists.
muscles. Pellantova and co-workers claim that the
Obstet Gynecol. 2001; 97: 1 – 4.
transitional (temporary) bruise in newborns
4
Department of Health and Statistics, Ministry of Health,
delivered in water is not caused by fetal hypoxia.
Treatment, and Medical Education, Iran. Population and
health in Islamic Republic of Iran; 2000: 52.
They believe that it is caused by fetal circulatory
5
Rawal J, Shah A, Stirk F, Mehtar S. Water birth and
transformation that is routinely seen in
infection in babies. BMJ. 1994; 309: 511.
conventional delivery when the umbilical cord
6
Woodward J, Kelly SM. A pilot study for a randomized
remains connected for longer than expected time.13
controlled trial of waterbirth versus land birth. BJOG.
Harper asserts that newborns who are delivered by
2004; 111: 537 – 545.
7
Geissbühler V, Eberhard J. Experience with water births:
water birth method have a better score because of
a prospective longitudinal study of 9 years with almost
better nutrition and oxygenation from placenta12;
4,000 water births. Gynakol Geburtshilfliche Rundsch.
however, Rush et al. did not observe a better fetal
2003; 43: 8 – 12.
condition in such newborns.9
8
Cammu H, Clasen K, van Wettere L, Derde MP. 'To
bathe or not to bathe' during the first stage of labor. Acta
In conclusion, this study points out several
Obstet Gynecol Scand. 1994; 73: 468 – 472.
advantages of water birth delivery. Those women
9
Rush J, Burlock S, Lambert K, Loosley-Millman M,
who used this method experienced less pain and
Hutchison B, Enkin M. The effects of whirlpools baths in
completed the delivery sooner. Meanwhile, natural
labor: a randomized, controlled trial. Birth. 1996; 23:
vaginal delivery was accomplished more
136 – 143.
10 Eberhard J, Geissbuhler V. Pain intensity and need for
frequently with this group. These all lead to a
analgesics with waterbirth and land birth. Geburtsh
decreased necessity for medical interventions as
Frauenheilk. 2005; 65: 482 – 487.
well as an increased socioeconomic advantage for
11 Schorn MN, McAllister JL, Blanco JD. Water immersion
the society.
and the effect on labor. J Nurse Midwifery. 1993; 38:
336 – 342.

12 Harper B. Waterbirth basics. From newborn breathing to
Acknowledgment
hospital protocols. Midwifery Today Int Midwife. 2000;

(54): 9 – 15, 68.
13 Pellantová S, Vebera Z, P?cek P. Water delivery; a 5-
We would like to express our special thanks to
year retrospective study. Ceska Gynekol. 2003; 68:
all the staff of Department of Obstetrics and
175 – 179.












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