Water birth: pregnant women’s decision-making and interaction with health professionalsABSTRACT
Objective to explore pregnant women’s decision-making process regarding water birth, based on their personal experiences.
Methods this study employs qualitative research and thematic data analysis using the “Four Models of the Physician–Patient Relationship” framework as its theoretical and analytical foundation.
Results A total of 61 women from four Brazilian regions participated in the study. Among them, 52.5% gave birth in a hospital or birth center, whereas 47.5% opted for a home birth. Among the 83.6% who had planned their birth, 57.4% received guidance from obstetric nurses/midwives. Two thematic categories emerged: “Determinant factors in the decision-making process for water birth” and “Water birth planning: possibilities and limitations”, comprising four and three subcategories, respectively.
Final considerations and practical implications pain relief, physical comfort, and the baby’s well-being, together with a smooth transition and respect for the natural process were key factors influencing the birth method choice. The study acknowledged the use of Google Forms for online data collection as a limitation, as it potentially excluded participants without internet access or electronic devices. Respecting the birth plan was crucial for ensuring humanized care, fostering a collaborative relationship between pregnant women and healthcare professionals. This interaction facilitated knowledge sharing, provided professional prenatal support, contributed to a positive birth experience, and enhanced overall birth safety.
Keywords:
Obstetric Nurses; Pregnant Women; Water Birth; Planning; Decision-Making
RESUMO
Objetivo analisar a tomada de decisão sobre o parto na água por gestantes, a partir de suas vivências.
Métodos pesquisa qualitativa, com análise temática dos dados, baseada no referencial teórico-analítico “Quatro modelos da relação médico-paciente”.
Resultados participaram 61 mulheres de quatro regiões brasileiras, destas 52,5% tiveram parto em hospital ou casa de parto, enquanto 47,5% escolheram o domicílio. Das 83,6% mulheres que planejaram o parto, 57,4% receberam orientações de enfermeiras obstetras/obstetrizes. Emergiram duas categorias temáticas: “Determinantes no processo de tomada de decisão pelo parto na água” e “Planejamento do parto na água: possibilidades e limites”, com quatro subcategorias e três subcategorias respectivamente.
Considerações finais e implicações para a prática o alívio da dor, conforto físico e bem-estar do bebê, aliados a uma transição suave e ao respeito pela naturalidade do processo, foram fatores determinantes para a tomada de decisão pela modalidade de parto. A pesquisa destacou, como limitação o Google Forms como modalidade on-line, restringindo a participação de indivíduos que não dispõem de acesso à internet e dispositivos eletrônicos. O respeito ao plano de parto foi fundamental para assistência humanizada associada à interação gestantes/profissionais para aquisição de conhecimento; ao suporte profissional pré-natalista, à experiência positiva e à segurança do parto.
Palavras-chave:
Enfermeiras Obstétricas; Gestantes; Parto na Água; Planejamento; Tomada de Decisões
RESUMEN
Objetivo analizar la toma de decisiones sobre el parto en el agua por parte de las gestantes, a partir de sus experiencias.
Métodos investigación cualitativa, con análisis temático de los datos, basada en el marco teórico-analítico «Cuatro modelos de la relación médico-paciente».
Resultados participaron 61 mujeres de cuatro regiones brasileñas, de las cuales el 52,5% dio a luz en un hospital o en una casa de partos, mientras que el 47,5% eligió el domicilio. De las 83,6% de mujeres que planificaron el parto, el 57,4% recibió orientación de enfermeras obstetras/parteras. Surgieron dos categorías temáticas: «Determinantes en el proceso de toma de decisión sobre el parto en el agua» y «Planificación del parto en el agua: posibilidades y límites», con cuatro subcategorías y tres subcategorías respectivamente.
Consideraciones finales e implicaciones para la práctica El alivio del dolor, el confort físico y el bienestar del bebé, junto con una transición suave y el respeto por la naturalidad del proceso, fueron factores determinantes para la toma de decisión sobre la modalidad de parto. La investigación destacó como limitación el uso de Google Forms como modalidad en línea, lo que restringió la participación de personas que no tienen acceso a Internet ni a dispositivos electrónicos. El respeto al plan de parto fue fundamental para la asistencia humanizada asociada a la interacción entre las gestantes y los profesionales para la adquisición de conocimientos; el apoyo profesional prenatal, la experiencia positiva y la seguridad del parto.
Palabras clave:
Enfermeras obstétricas; Gestantes; Parto en el agua; Planificación; Toma de decisiones
INTRODUCTION
Water birth refers to deliveries in which fetal expulsion occurs underwater, regardless of where and how the subsequent stages of labor take place. This modality has generated both favorable and unfavorable arguments, which vary considerably according to the obstetric care model adopted. These perspectives directly influence the clinical practice of health professionals and the experience of pregnant women and their families, affecting both accessibility and the actual freedom to choose water birth.1
Despite the conjectures surrounding water birth, evidence indicates that experiencing labor in water leads to a positive, satisfying, and empowering experience,2,3 with no indication that immersion in water during labor or birth increases risks of adverse events for the fetus, neonate, or woman.4,5
Interaction with health professionals plays an essential role in ensuring that pregnant women and their families have access to accurate information on water birth.6 In this regard, educational activities conducted during prenatal care by perinatal educators, such as nurse-midwives, midwives, and doulas, can be decisive for enabling informed and conscious decision-making in birth planning. It is particularly important for pregnant women to have access to clear and detailed information on different birth modalities, possible scenarios, settings, and outcomes. With such knowledge, they can prepare a structured and participatory birth plan, supported by their chosen companion.
Furthermore, during birth planning, women need to understand that both they and the professionals responsible for their care may revise the birth plan based on labor progress, making it essential that the document includes alternatives for circumstances that deviate from the original plan.7
Water birth may facilitate a shift of focus within obstetric care, fostering respectful, woman-centered care grounded in scientific evidence, which enhances the potential for normalizing childbirth while ensuring a positive experience.2,3,8 For this reason, among others, many women have sought information about water birth through the internet, acquaintances, or perinatal educators, who have been instrumental in supporting informed and conscious decision-making regarding this modality of birth.3,9
Reports on the benefits of water birth have served to empower and encourage other women to consider this form of delivery.8,9 Moreover, studies1,2,4 have found no evidence of adverse effects for neonates or women who deliver in water, although findings remain inconclusive regarding any benefits. Currently, guidelines from the National Institute for Health and Care Excellence (NICE) endorse water immersion during labor but recommend that women be informed that high-quality evidence is still insufficient to support or discourage water birth.10
This study used the ethical interaction model between healthcare professionals and women as its theoretical framework. This model suggests that interactions among these actors be examined through four ethical approaches: paternalistic, deliberative, interpretive, and informative.11 As a result, it became possible to examine how shared decision-making was integrated into obstetric care during water birth. In turn, social representation theory, which views knowledge as a unique form developed through behavioral and communicative processes among individuals,12,13 provided a deeper understanding and framework for discussing how women, within a specific sociocultural context, shaped their experiences with water birth.
Therefore, this study focuses on two main aspects: water birth planning and key factors identified by those who experienced it, influencing their decision-making process. The study aimed to examine the decision-making process of pregnant women regarding water birth, drawing on their personal experiences.
METHOD
This is an exploratory-descriptive qualitative study. The theoretical and analytical frameworks adopted in this research were the following: “Four Models of the Physician-Patient Relationship” — ethical interaction models between healthcare professionals and patients to understand their decision-making process11 — and the Social Representation Theory approach.13
The study adhered to the guidelines outlined by the Consolidated Criteria for Reporting Qualitative Research (COREQ)14 to ensure high-quality reporting.
Participants were selected using the snowball sampling technique and contacted through digital invitations sent via email and/or social media accounts with open profiles. Inclusion criteria required having experienced a water birth within the Brazilian healthcare system, regardless of gestational age or birth setting, whether in an institutional facility or at home. Participants under 18 years old were excluded to ensure compliance with research ethics guidelines, due to challenges in obtaining consent from legal guardians in the virtual environment.
Participant selection was concluded once theoretical data saturation was achieved, indicating that no new relevant information was emerging from the data. This process involved continuous, collaborative data analysis, critically conducted by multiple researchers, ensuring that data collection continued until no new insights emerged. Thus, the study included 61 participants. The snowball sampling technique helped identify women interested in participating in the research, whether through their connection to the topic or their experience with water birth, resulting in no refusals or dropouts.
Data collection took place from August 2020 to February 2021 via self-administered questionnaires conducted online through the Google Forms platform. The reasons for conducting the research were outlined in the consent form, which also highlighted the principal researcher’s personal interests.
It is noteworthy that data collection was conducted virtually, complying with the social distancing recommendations established during the COVID-19 pandemic, particularly considering postpartum women as a group with greater vulnerability to aggravations caused by the disease.
The self-administered questionnaires were previously tested in a pilot study. The pilot results were not included in the sample of the main research. No field notes were recorded during the study, as the information obtained through the questionnaires was sufficient to contextualize the participants. The transcripts of the data were not returned to the participants for review; however, the documents remained available for consultation throughout the entire research process and after its completion.
The methodological approach adopted was content analysis, based on the thematic-categorical technique.15 The information collected in written form was automatically transferred to spreadsheets in Microsoft Excel®, where sample characterization was performed; subsequently, they were inserted into Microsoft Word® to compose the textual corpus. After the exploratory phase of the data, inferential analysis was carried out, considering the relevance of the narrative content to the study objectives, as well as sociodemographic characteristics. The aim was to identify similarities and differences among the results obtained in order to address the study’s objective.16,17
To ensure confidentiality and anonymity, the women’s quotations are presented with alphanumeric identifiers corresponding to the sequence of participants (P1, P2, P3…). This research followed the recommendations and regulations established by the Brazilian National Health Council and was approved by the Research Ethics Committee involving Human Subjects of the School of Arts, Sciences, and Humanities of the University of São Paulo, approval number 4.167.612.
RESULTS
The study included 61 women who responded to the questionnaire on water birth. Participants were from four different regions of Brazil, with the majority (52.1%) residing in the Southeast. The average age was 32.3 years; 75.4% identified as white; 93.4% had higher education; 83.6% were employed; and 95.0% had a partner. Among them, 32 (52.5%) gave birth in a hospital setting, distributed across Natural Birth Centers, Obstetric Centers, and Birthing Houses, while 29 (47.5%) had home births.
Water birth was planned by 83.6% of these women. Obstetric nurses or midwives provided guidance on this type of birth in 57.4% of cases. A birth plan was developed by 80.3% of the participants. Regarding parity, 85.2% were first-time mothers having their first water birth. A large majority (95.1%) stated that, if given another opportunity, they would choose water birth again.
The qualitative results are presented in Chart 1, featuring two thematic categories: Determinant factors in the decision-making process for water birth and Water birth planning: possibilities and limitations. Four subcategories emerged from the first category, and three subcategories arose from the second (as detailed in Chart 1).
DISCUSSION
When analyzing the decision-making process of the study participants regarding water birth, it was observed that some chose this mode of delivery in pursuit of a positive childbirth experience, while others experienced water birth without prior planning but in accordance with their sensations and desires at the moment of birth. The participants’ narratives revealed two broad categories representing their decision-making process concerning water birth: “Determinants in the decision-making process for water birth” and “Planning water birth: possibilities and limits”.
In the category “Determinants in the decision-making process for water birth,” pain relief, physical comfort, naturalness, and respect for the birth process were benefits expressed in the participants’ narratives, which align with other studies reporting pain relief, greater control of fear and anxiety during the expulsive phase of labor,18 as well as reduced use of epidural analgesia.1,4,18,19
Other research identified pain relief as a main motivation for choosing water birth, along with the pursuit of a more natural birthing experience, a relaxing and welcoming environment, confidence in the body’s ability to give birth, aversion to excessive medicalization, past birth experiences, and trust in the professional attending the water birth.8,9 Similar results were observed in the present study, reinforcing the decision for water birth.
The World Health Organization (WHO) guideline on intrapartum and childbirth care for a positive childbirth experience20 supports all pregnant women and their newborns in receiving high-quality care grounded in scientific evidence.
This guideline20 outlines best practices for labor and childbirth to ensure a safe birth in a clinically and psychologically secure environment with the presence of a chosen companion. A similar approach is found in the humanized model21 which endorses the woman’s decision-making process as an individual entitled to the presence of the father or another meaningful companion during childbirth, the non-separation of the newborn, and the continued presence of family and friends throughout labor and delivery. In this study, choosing water birth aligns both with WHO guidelines20,22 and the Humanization model.21
Another study9 investigated the decision-making process of women who planned water birth and sought information through digital sources, such as the internet and social media, intending to limit medical interventions during delivery. Support from doulas and nurse-midwives or midwives proved fundamental in this process, helping pregnant women cope with resistance from family members, friends, colleagues, and opponents. The authors reported that women who experienced water birth described it as both positive and empowering, offering inspiration and encouragement for other women interested in this modality and strengthening their desire to experience it again in future births. In this study, 95.1% of participants stated they would choose water birth again.
The involvement of technically competent professionals providing high-quality and safe care in an organized manner while maintaining dignity, privacy, and confidentiality is recommended to ensure a respectful birth free of harm or mistreatment.23,24 Informed choice in this context contributes to maternal satisfaction, promoting self-fulfillment and a sense of control through participation in decision-making, even when medical interventions become necessary.20
A review on women’s experiences with water birth highlighted that their decision stemmed from autonomy, self-control, empowering experience, and smooth extrauterine transition for the newborn.3 Similarly, these aspects were evident in the present study, as shown in Chart 1. The maternal desire for autonomy and individualized care, fundamental to the holistic model and valued during childbirth, is unique and incomparable, allowing women to experience freedom of movement, eating, drinking, and delivering in the position they prefer, guided by intuition.21
In the category “Planning water birth: possibilities and limits”, participants adopted strategies aimed at ensuring a positive outcome. However, some women’s narratives suggested that the team responsible for assisting the birth may not have had a well-established protocol regarding the role of each person involved.
The women emphasized physical, psychological, and emotional preparation as essential strategies for planning water birth, enabling them to experience this process even before pregnancy.
In relation to physical preparation, the women mentioned various body movement practices as strategies to succeed in planning for water birth. According to the holistic model of care,21 individuals possess the inherent authority and responsibility to assume accountability for their own health and well-being, meaning they must consciously engage in their healing process to achieve meaningful results. This was evident in the participants’ narratives about their physical, psychological, and emotional preparation for childbirth. Similarly, a systematic review with meta-analysis,3 supports the findings of this study by indicating that water birth led to positive choices and emotional well-being among women.
Decision-making in any circumstance requires prior knowledge about the subject. In this study, fundamental strategies for planning water birth were linked to seeking information and knowledge, mainly through contact with professionals from the birth team, as well as testimonials from other women, videos, and documentaries. Comparable results were observed in previous studies.3,9
The role of health professionals in ensuring the woman’s dignity, privacy, and confidentiality must be emphasized, as protection from harm or mistreatment depends on providing clear information and continuous support throughout labor and birth. It is crucial to recognize that women seek self-fulfillment and control over the birthing process, requiring active, collaborative, and respectful engagement of professionals in decision-making.25,26
Therefore, achieving a positive birth experience requires valuing women’s beliefs, expectations, environments, and decision-making involving their families.20,25,26 This approach aligns with the ethical model of interaction,11 in which professional responsibilities include those enumerated in the informative model, where the health professional serves as a provider of technical knowledge, granting the healthcare user the means to exercise control. However, this model also demands the professional’s participation in a joint process of understanding, allowing the healthcare user to gain clarity about personal identity and how different care or treatment options may affect it.
Challenges related to the childbirth experience involved both logistical aspects of organizing physical space and resource availability, complications during birth, and the respect demonstrated by the team. Logistical challenges included preparing the team for proper management of water immersion. A couple’s account of difficulties encountered when filling the birthing pool mirrors findings from another study,27 which reported that 68% of Brazilian obstetric teams lack specific training for water births. This supports participants’ accounts suggesting that the team was not adequately prepared to help couples fully experience the benefits of immersion in warm water, such as reduced pain perception and greater maternal satisfaction.28
The freedom of movement promoted by the birthing pool, along with the intimacy, connection, and privacy shared by the couple in the aquatic setting, contributes to creating a welcoming environment with dim lighting, essential oils, candles, and curated music. When the couple experiences this privacy in the water, they can help establish a safe environment as well,29 which favors a positive experience, as indicated by another participant.
In this context, the birth team must plan and prepare in advance to align with best care practices, ensuring that the family’s expectations are fulfilled. Therefore, the birth team must include a technically competent nurse midwife or midwife,22-24 ensuring that childbirth is carried out respectfully and safely, making it a memorable experience for the woman in labor and her family.20,22,28,29
Regarding these same aspects, logistics, organization, resources, and possible complications during childbirth, the narratives in this study align with what is outlined in the paternalistic model,11 in which the professional acts as a guardian of the parturient woman, prioritizing her interests above his or her own, as well as in the interpretive11 and humanized,21 models, which emphasize the professional’s role in helping women clarify their expectations concerning available care options. In these models, the woman and professional make decisions together, which is essential for preparing the home birth environment. It is understood that a technically competent and experienced team takes responsibility for the entire logistics of water birth, such as planning the filling and draining of the pool, the latter being of crucial importance due to biosafety considerations essential to home birth care.
To date, systematic reviews have found no evidence of adverse maternal or neonatal effects associated with water birth.1,2-4,18,19,30 On the contrary, outcomes have been positive, providing pregnant women and their families with a safe alternative for giving birth marked by autonomy and self-control over the childbirth process, fostering an empowering experience.3
Ensuring a positive experience in water birth requires a technically skilled team.20,23,24 Considering that 47.5% of the study participants chose domestic water birth, careful planning is essential to guarantee both the safety of the birth and a positive experience for the woman in labor.
FINAL CONSIDERATIONS AND PRACTICE IMPLICATIONS
Pain relief, physical comfort, and the baby’s well-being, along with smooth transition and respect for the natural course of birth, were determining factors influencing the decision to choose this mode of delivery.
As for study limitations, using Google Forms for data collection allowed access to a considerable number of participants from various geographical locations, thereby broadening sample diversity in terms of geographic and cultural differences. However, this online data collection method limited participation among socially disadvantaged individuals without internet access, electronic devices, or digital literacy. Additionally, the self-reported and online nature of the instrument may have influenced the depth of responses, occasionally restricting them to objective information due to lack of time or difficulty with written expression. This limitation may have affected the exploration of deeper and symbolic aspects of the participants’ experiences.
In terms of practice implications, respecting the birth plan was essential to promoting humanized care associated with pregnant women’s interaction with professionals for knowledge acquisition, professional prenatal support, positive childbirth experience, and safety.
ACKNOWLEDGMENTS
The authors thank colleagues who contributed to the conception of this project: Professor Dr. Rosemeire Sartori de Albuquerque (School of Arts, Sciences, and Humanities of the University of São Paulo), Professor Dr. Nágela Cristine Pinheiros Santos (Universidade Federal de Minas Gerais), and Master Pamela Vicente Nakazone (School of Nursing of the Universidade de São Paulo). Gratitude is also extended to all individuals who voluntarily participated in the survey.
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FINANCIAL SUPPORT
None.
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DATA AVAILABILITY RESEARCH
The data underlying this research are included in the article.
References
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Edited by
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ASSOCIATED EDITOR
Candida Primo https://orcid.org/0000-0001-5141-2898
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SCIENTIFIC EDITOR
Marcelle Miranda da Silva https://orcid.org/0000-0003-4872-7252
The data underlying this research are included in the article.
