Bringing new understanding to water immersion for labour and birth

Dr Ethel Burns

Research by Dr Ethel Burns, Senior Lecturer in Midwifery, has led to greater understanding of how being immersed in water offers key benefits to women and their babies during childbirth. It has also sparked the development of a new training resource to support midwives using birthing pools.

Uptake of birthing pools is growing. In 2019, the UK Care Quality Commission survey found that more than 1 in 10 (11%) of births take place in water. This is likely to be an underestimate given that just 50% of units took part in the survey, and the statistics don’t include women who were in labour, but did not give birth in water.

Throughout her career as a clinical midwife and researcher, Ethel has focused on water immersion as an important option for women during childbirth. In 1990 she played a central role in introducing the first plumbed-in birthing pool in an NHS maternity unit. She has carried out both national and international reviews on birthing pool use, including evidence-based Cochrane Reviews (in 2009 and 2018) which brought together all the evidence-based research at the time.

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The value of using a birthing pool

Between 2021 and 2023 Ethel continued her research, coordinating three key systematic reviews. In 2021, her review of women’s experiences of using a birthing pool found that water immersion encouraged buoyancy and the freedom to move during labour and birth, offering comfort, relaxation and pain relief. The research also showed that birthing pool use is an increasingly popular care option in midwifery-led units in the UK, Australia and New Zealand, and is gaining popularity in several other countries. 

In 2022, her review of more than 157,000 mothers and babies demonstrated the safety of using a birthing pool, leading to  fewer medical interventions and improved outcomes for mothers.

Ethel’s third review, published in 2023, uncovered the barriers that can prevent the use of birthing pools where more medicalised options for pain relief are used instead. These barriers included insufficient preparation for midwives and an institutionalised lack of clarity from other medical staff, where women were often moved out of birthing pools unnecessarily. 

Through Ethel’s research, water immersion for labour and birth is becoming more widely understood and supported by service providers, with several maternity units in the UK and elsewhere, including Australia and Italy, now supporting water births. Her findings have been shared by the American Congress of Obstetricians and Gynaecologists on the American TV network CNN, across social media platforms by the International Childbirth Education Association, and by midwifery professionals.

On the 6th June 2024, Oxford Brookes University in collaboration with King’s College London are delighted to host SPLASH, an exciting one-day international conference focusing on research for birthing pool use during labour and birth.

estiMATE – delivering an essential core skill for midwives

Ethel’s research also identified a need to develop ways of helping midwives to accurately estimate blood loss during water births. Working alongside two of her PhD students, she supervised the development of an online training package ‘estiMATE’. Featuring short video simulations with live models in a birthing pool, its aim is to build the skills of midwifery professionals in visually estimating blood loss during waterbirths. Feedback from midwives has been positive with many noting that it boosted their knowledge and confidence, offering essential learning to secure safe, skilled practice in water births. 

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Future steps

In December 2023, estiMATE was launched on All4 Birth, an open access platform provided by All4Maternity, a leading international midwifery training provider. The platform, with language translation options, ensures significant global reach, available to midwives worldwide.

Within the UK, advancing skills and knowledge of water births continues to be essential. Clinical midwives are required by NHS employers and the Nursing and Midwifery Council to undertake annual learning updates. And, as recommended by NICE 2023, every maternity and midwifery unit in UK hospitals has a birthing pool, together with community-based midwifery units. Water birth is popular too among women who choose to have a home birth. 

Going forward, it is hoped that Ethel’s research findings will inform national guidance and policy for the future use of birthing pools. 

Ethel is now collaborating with colleagues internationally, with the aim of advancing knowledge and understanding about the safety and scope of water immersion as a low-tech, non-pharmacological, nuanced intervention, with global relevance.

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