Perception and knowledge of Saudi women about water birth: A cross-sectional study

Background

Cold or warm water was used in labor processes for maternal relaxation and anesthesia for a long time. Water birth started in the 18th century as hydrotherapy. It was used by Egyptian, Roman, and Greek physicians (Brooks, 2018). The first water birth was conducted in France in 1805. Few physicians claimed that a woman with prolonged labor (almost 48 hours) gave her birth immediately after water submerging. In 1960, a gynecologist from Russia detected the impact of water birth on improving newborn findings. Later, a researcher reported his intervention with 100 water births. He advocated that there was no risk associated with water birth and that water immersion reduced the need for interventions and analgesia during labor (Lim et al., 2016). In this regard, 150,000 water deliveries were done between 1985 and 1999, according to Rosales et al. (2017).

In India, the first water birth was conducted in 2007; however, it was not recommended because of the lack of skills and safety for the mother and her newborn (Dular & Jyoti, 2019). Nevertheless, in several parts of the world, the water delivery rate during labor is remarkably growing (Darsareh et al., 2018).

Water birth involves complete immersion of the mother’s abdomen in a pool of water that allows her to change her position freely during labor (Darsareh et al., 2018). Various positions can be used underwater, such as squatting, kneeling, and sitting while putting a head on a pillow while resting on the side of the pool. In addition, pregnant women can be immersed in warm water when their cervix is dilated by around 5 cm (Dular & Jyoti, 2019). There are criteria for pregnant women to have a safe water birth as gestational age of above 37 weeks, singleton pregnancy, normal labor, vertex presentation, normal blood pressure, normal fetus, and clear amniotic fluid. In contrast, contraindications for water birth are BMI of more than 25, medical health problems, unstable fetal heart rate, intrauterine growth retardation (IUGR), antepartum hemorrhage, herpes simplex infection, and administration of pethidine analgesia in labor (Dular & Jyoti, 2019).

Water birth has been considered an efficient non-pharmacological modality with numerous maternal and neonatal benefits. Regarding the maternal benefits, water birth increased maternal satisfaction and reduced the sensation of heaviness and pain during labor (Brooks, 2018; Cooper & Warland, 2019; Reyhan, 2019). In addition, according to a previous study, water birth increased maternal comfort during childbirth and decreased stress and anxiety (Brooks, 2018; Walls, 2017).

Furthermore, other studies reported reasons to choose water birth as a delivery method, including being non-pharmacological or natural, increased maternal focus, and control during labor (Brooks, 2018; Cooper & Warland, 2019). Moreover, water birth has an analgesic effect, reducing the need for epidural analgesia (Brooks, 2018). Further, water birth decreases the rate of perineal laceration, cesarean section delivery, and prolonged second and third stages of labor, as well as the need for medical interventions such as episiotomy (Brooks, 2018; Kavosi et al., 2015; Szymkowiak et al., 2017). In this regard, women who had water birth expressed the feeling of safety, protection, and security and recommended water birth for others (Akhlaghi et al., 2017; Cooper & Warland, 2019). Physiologically, water birth has been reported to increase endorphin level and pelvic diameter and decrease blood pressure and the duration of the first and second stages of labor (Brooks, 2018; Dular & Jyoti, 2019; Walls, 2017). Moreover, it improves uterine perfusion and labor progress. Also, it decreases catecholamine, stretches the vagina, and facilitates the delivery of the fetus (Dykes, 2017). Further, it increases the elasticity of the perineum, oxygen, blood supply to the fetus, and endogenous oxytocin production (Brooks, 2018; Cooper & Warland, 2019; Kavosi et al., 2015).

Regarding neonatal effects, there is no evidence of increased complications associated with water birth, in addition to the rarely reported side effects (Lim et al., 2016). On the other hand, water birth has been reported to improve bonding and skin-to-skin contact, according to Walls (2017), decrease the risk of respiratory distress syndrome and hypoxia, as reported by Szymkowiak et al. (2017) and regulate body temperature (Darsareh et al., 2018; Dykes, 2017).

Findings of previous studies suggested that water birth has non-significant maternal or neonatal complications. However, water aspirations, postpartum hemorrhage, severe stages of perineal tears, maternal or newborn infection, and retained placenta were observed among some water birth parturients (Brooks, 2018; Cooper & Warland, 2019; Lim et al., 2016). In this regard, attention should be paid to the risk of umbilical cord avulsion at water births (Ulfsdottir et al., 2018). On the other hand, another study showed no maternal or neonatal complications related to water birth (de Camargo et al., 2022; Dykes, 2017; Reyhan, 2019; Walls, 2017). Further, a retrospective cohort study conducted in Sweden showed that water birth did not increase the number of admissions to the NICU or cause a difference in neonatal Apgar scores (Ulfsdottir et al., 2018).

Nevertheless, a comparative study between water birth and spontaneous vaginal delivery conducted in Iran showed that the mean Apgar score in the water birth group was higher than the conventional birth group with no neonatal aspirations underwater, need for prolonged hospitalization, or NICU admission. Moreover, maternal complications such as infection, postpartum hemorrhage, or readmission were not seen in women who gave birth in both groups (Akhlaghi et al., 2017). A recent meta-analysis showed that NICU admission and dystocia rates were reduced among neonates born underwater than neonates born conventionally (Zhang & Yang, 2022).

Most women lack knowledge about giving birth underwater or find it difficult to access the information about it and struggle to identify healthcare professionals willing to support their options. Therefore, healthcare providers should provide the needed information to increase the knowledge of pregnant women and their peers, explain the benefits and barriers of hydrotherapy, and follow the recommended protocols for potential candidates regarding thermoregulation of water and infection control (Dykes, 2017). In this regard, nurses and midwives have a crucial role in increasing the knowledge of pregnant women about water birth to be ready physically and mentally (Dular & Jyoti, 2019).

Previous research in Turkey showed that 39.5 % of the participants preferred water delivery. However, the percentage increased to 63.1% after watching visual media. Moreover, 70.9% of participants had insufficient information about water birth (Reyhan, 2019). In the same perspective, a study aimed to explore the perception and knowledge of women who had or did not have a water birth showed that 31% of the women who had water birth reported that their primary reasons for planning a water birth were pain relief and having a natural birth in a relaxing environment. Moreover, 69% of the women who did not have water birth reported previous obstetric complications (Lewis et al., 2018).

In summary, water birth is considered a widely available option for delivery worldwide (Milosevic et al., 2019). Unfortunately, there are few implementations of water delivery in some private hospitals in Jeddah, Saudi Arabia (Al Masoud, 2020). Further, few studies assessed water birth knowledge among medical students, staff nurses, and midwives. However, no studies evaluated public females' knowledge and perception regarding water birth in Saudi Arabia (Al Masoud, 2020; Nazir et al., 2020). Therefore, based on the limited studies and implementations, there is a knowledge and comprehension gap about water birth among women in Saudi Arabia.

Consequently, this study is pursued to shed light on the perception and knowledge level of Saudi women regarding water birth and enhance future advancements in the rate of water delivery. Furthermore, it is to determine what are the contributing factors to their knowledge level and how this can affect their decision in the future if they want a water birth. Therefore, the purpose of this research was to evaluate the perception and knowledge of Saudi women regarding water birth.

Methods

Results

The mean age of the participants was 34.91 ± 8.851, with 83.2% being highly educated. Nearly half of them, 52.1%, were housewives, while 13.6% were working in health-related jobs. More than half of the participants lived in Jeddah, 58.2%, and 41.8% were from other regions. Over one-third of the participants, 35.1%, had a monthly income between 5000 – 10,000 S.R with a mean of 2.03 ± 0.807 (Table 1).

It was determined that the mean number of deliveries was 3.36 ± 2.167, with 60% having no history of abortion, 97.9% delivering in hospitals, 65.5% having a normal vaginal delivery, and 25.8% having a cesarean section. Furthermore, it was found that 42.8% of the participants received education on pregnancy and delivery, with 27.7% of them having their education sessions in a hospital setting and 36.1% receiving information on water birth. Furthermore, most of the participants, 84%, have heard about water birth, with 74.8% have listened on the internet (Table 2).

Concerning knowledge of the participants on water birth, nearly half of them identified that water birth reduces birth pain and allows the mother to move into various positions for the relaxation. Also, the presence of the husband during water birth affects women positively (56.2%, 49.7% & 47.4%, respectively). On the other hand, nearly one-third of them reported that water birth increases labor duration, perineal tears, and maternal tension (30.7%, 30.7% & 41.2%, respectively) (Table 3). Figure 1 illustrates the distribution of women's knowledge of water birth based on the scoring scale; 96.4% had a fair level, and 3.6% had a good level.

Regarding the perception of the participants of water birth, 42.8% thought that water birth is not performed in Saudi Arabia, whereas 40.5% wanted water birth to be a common birth method in the country. Moreover, 40.2% of the women wanted to give birth in water, with 31.7% of them preferred their spouses to be their birth partners. Two-thirds of the participants, 64.4%, perceived that obstetricians and nurses should conduct water birth, and 75.3% wanted to have more information on water birth (Table 4).

Regarding the contributing factors to the participants’ knowledge of water birth, the age of women was found to be significantly related to their knowledge of water birth, as the mean age of women with good knowledge was 39.7 compared to 34.7 for women with fair knowledge. In contrast, other sociodemographic data of the participants had no significant relation to their knowledge level of water delivery (Table 5).

Furthermore, the majority of the participants who had fair knowledge received educational courses by midwives/nurses and perceived that water birth should be conducted by both the obstetrician and midwife with statistically significant relationships (95%, 97.2%; p = 0.048, 0.030 respectively) (Table 6 & Table 7).

Discussion

Considering the educational level of the participants, it was determined in the current study that the majority of the females who had a fair level of knowledge regarding water delivery had a university education with no statistically significant relationship. This may reflect that water birth is not adequately covered in the educational field, either in hospitals or schools/universities. In contrast, a study by Reyhan (2019) to identify the knowledge level regarding giving birth in the water among pregnant women showed a statistically significant correlation between women’s knowledge of water birth and a high level of education.

The location of residence was another variable that did not show any significant association with women’s knowledge. It was found that most women who lived in Jeddah had a fair knowledge of water birth, while most of the females who lived in other regions had a fair level of knowledge. This indicates that the place of residence does not affect women’s knowledge level, which may be attributed to the similarity of information resources. On the other hand, Reyhan (2019) reported a high knowledge level related to water birth among pregnant mothers whose residency is in the center of the city with a significant statistical correlation. This can be attributed to the availability of health care services and educational classes in city centers.

The age of the women in the present study was found to be significantly correlated with their knowledge about water birth. Similarly, Reyhan (2019) found a significant statistical correlation between the age of the participants and their level of knowledge of water delivery. On the other hand, no significant relationships were found between employment status, income, and women’s level of knowledge on water delivery. Similarly, Reyhan (2019) reported that the highest level of knowledge regarding water delivery was observed among employed pregnant women and those with a good family income with no statistically significant relationship.

It was found that most of the women who received educational courses on labor and delivery had a fair knowledge level about water birth with a statistically significant relationship. This finding was agreed by Reyhan (2019), who found that women with a good knowledge level about water delivery had received information and health education on water birth during their pregnancy with a statistically significant relationship.

Based on the used scoring system to determine the level of knowledge on water birth among Saudi females, it has been found that the majority of the participants had a fair level. This may reflect the importance of disseminating more information and arranging educational programs on birth modalities, including water birth. In the same regard, Reyhan (2019) reported that nearly three-quarters of the participants had insufficient information on water birth. Additionally, Carlsson and Ulfsdottir (2020) conducted a study to explore the retrospective experiences of women who had a water birth in Sweden; they reported that respondents had a lack of general and specific information related to waterbirths.

In the current research, more than half of the women reported that water birth reduces birth pain and allows the mother to move into various positions for the relaxation. Similarly, other studies revealed numerous maternal benefits of water birth as an efficient non-pharmacological modality that alleviated the sensation of pain (Brooks, 2018; Carlsson & Ulfsdottir, 2020; Cooper & Warland, 2019; Reyhan, 2019), noninvasive birth experience (Estuardo et al., 2021; Reyhan, 2019), a peaceful, calm, and relaxing method for delivery, an effective way to relieve labor discomforts (Carlsson & Ulfsdottir, 2020; Cooper & Warland, 2019) and promote labor progress (Carlsson & Ulfsdottir, 2020).

Previous studies suggested maternal complications such as infection, perineal laceration, NICU admission, and postpartum hemorrhage were less observed in women who gave birth in water (Akhlaghi et al., 2017; Sidebottom et al., 2020). Further, a retrospective study was conducted to compare water birth with a traditional delivery method in Mexico and determine both approaches’ obstetric and newborn outcomes and related complications. The authors reported no difference between the groups regarding the incidence of postpartum hemorrhage and advanced stages of perineal tears. Moreover, water birth has non-significant maternal or neonatal adverse effects (Estuardo et al., 2021). Alternatively, water aspirations, postpartum hemorrhage, advanced stages of perineal tears, maternal or newborn infection, and retained placenta were observed among water birth parturients in other studies (Brooks, 2018; Cooper & Warland, 2019; Lim et al., 2016). In the current study, it had been reported by the women that water birth does not increase the rate of perineal tears, the risk of maternal infection, and postpartum hemorrhage. Furthermore, the participants mentioned that the risk of neonatal infection is the same as normal vaginal birth, there is no possibility of neonatal aspiration or drowning, and water delivery does not raise the risk of trauma or injury to the mother or the newborn.

In the current study, less than one-third of the women thought that water birth was performed in Saudi Arabia, and more than one-third wanted water birth to be a common birth method performed for every Saudi woman. Moreover, three-quarters of the participants desired more information on water birth, and more than one-third wanted to deliver in water. Similarly, it was found that 39.5% of pregnant mothers wanted a water birth as an option for delivery (Reyhan, 2019). Another study reported that 38% of the women planned for water birth as the first choice for delivery (Lewis et al., 2018). These findings may indicate that Saudi women need to be more aware of water delivery as one of the options. Besides, nearly one-third of the participants reported that they preferred their spouses as birth companions throughout water birth. In the same line, it was reported that a considerable number of pregnant women preferred that their spouses be available throughout the moment of water birth (Reyhan, 2019). Further, the presence of the partners was described by the participants as a positive experience, and the couples became more united and intimate with the growth of genuine, humanistic, encouraging, and trustworthy relationship of care because of this presence (de Camargo et al., 2022).

Conclusion

Based on the findings of the current study, it can be concluded that most Saudi women had a fair knowledge level of water birth; however, they wanted to have more information on it. Furthermore, the knowledge level of women had increased with age and receiving educational courses on labor and delivery.