BRIEF REPORTS

Perceptions and Practice of Waterbirth: A

Survey of Georgia Midwives
Shaunette L. Meyer, MA, Christopher M. Weible, PhD, and Kate Woeber, CNM, MPH

This study investigated the experience and perceptions of Georgia certified nurse-midwives about
waterbirth and their level of support for establishing waterbirth in their work setting. A survey was
distributed to a conve-nience sample of 119 certified nurse-midwives from the American College of Nurse
Midwives, Georgia chapter; 45% of those surveyed responded. The majority of midwives had some
exposure to waterbirth through self-education or through clinical practice. More than half supported the
incorporation of waterbirth in their workplace setting. Maternal relaxation and reduced use of analgesia
were perceived as the greatest benefit of waterbirth. Of 11 items related to disadvantages of waterbirth,
certified nurse-midwives were moderately to severely concerned about none. The most concerning factors,
with a mean of 2.4 to 2.5 on a scale of 1 (no worry) to 5 (severe worry), were maintenance of water
temperature, physical stress on the midwife, and inability to see the perineum. Midwives’ support for
waterbirth focused mostly on the perceived benefits to the mother with little worry about the risks. J
Midwifery Womens Health 2010;55:55–59 2010 by the Amer-ican College of Nurse-Midwives.
keywords: water aspiration, birth, hydrotherapy, midwife, opinion, survey

INTRODUCTION syndrome. Contrasting evidence suggests, however, the

The culture of birth in the United States has changed dra-
matically in recent years. Birth has shifted from homes to
hospitals, and advanced technology has emerged to mon-
itor mothers and babies throughout labor and delivery.
Since the 1980s, delivering underwater began to attract at-
1
tention as an alternative to land birth. Waterbirth has been
promoted as providing a safe and effective pain manage-
ment option, especially for women desiring a delivery with
2
less medical intervention. Waterbirth has also at-tracted
skepticism, especially with respect to the lack of
randomized controlled trials to support its perceived
3,4
benefits.
Waterbirth advocates and skeptics have both focused on a
method of delivery that is uncommon in the United States.
5 Although a good deal of research has focused on
Only 10% of hospitals offer waterbirth. When offered,
1,5–7
waterbirth tends to be managed by midwives. For mid-
wives, waterbirth represents a birthing method congruent
with their philosophy, emphasizing holistic practice, little
or no intervention, and woman empowerment.
Since the 1980s, several studies have investigated the
risks and benefits of waterbirth compared with land birth
6,8–13
and found mixed results. Possibly the most publicly
3,14,15
salient risk of waterbirth is water aspiration. These
studies argue that infants, who have inadequate
oxygenation during birth, may gasp for air, causing
water intoxication, hyponatremia, or respiratory distress
Address correspondence to Shaunette L. Meyer, MA, and Christopher
Wei-ble, PhD, UC Denver School of Public Affairs, 1380 Lawrence St.,
Suite 500, Denver, CO 80217. E-mail: Shaunette.Meyer@ucdenver.edu
risk of aspiration is not increased with babies born in
water, due to the inherent diving reflex that newborns
demonstrate.8,10–12
Among the benefits of waterbirth, studies have found
a decrease in the use of analgesia for women delivering in
6,8,10,11,16
water. By using less analgesia, the risk of neo-
natal respiratory depression and maternal decrease in con-
6 10
sciousness is reduced. In addition, Geissbuehler et al.
11
and Thoeni et al. found that waterbirth decreases the
number of episiotomies and perineal lacerations. In rela-
tion to neonatal outcomes, one study showed a significant
increase in neonatal arterial blood pH and an increased
10
Apgar score ; however, three other studies showed no
9,11,13
differences in either.
examin-ing the risks and benefits of waterbirth compared
with other delivery options, less research has focused on
certified nurse-midwives (CNMs) and certified midwives
(CMs) and their experience and perceptions with
waterbirth. Most survey-based research involving CNMs
and CMs empha-sizes issues of malpractice, salary, work
schedules, research utilization, and details of practice.
17–20
Rarely do these studies mention waterbirth. Exceptions
21
include one study that found 20% of a Connecticut
sample of CNMs perform waterbirths.
This brief report focuses on the perceptions, exposure
to, and experience of a sample of Georgia CNMs with
waterbirth. Three questions are pursued: 1) What are
CNMs exposure to and experience with waterbirth? 2)
What are their perceptions of the benefits and
limitations of waterbirth? 3) Do CNMs support a greater
emphasis on waterbirth in their place of practice?

Journal of Midwifery & Women’s Health www.jmwh.org 55

2010 by the American College of Nurse- 1526-9523/10/$36.00 doi:10.1016/j.jmwh.2009.01.008

Midwives Issued by Elsevier Inc.
METHODS
The target population was currently or recently active CNMs
in Georgia. The convenience sample used the mem-bership e-
mail list of the American College of Nurse Mid-wives
(ACNM), Georgia chapter, which was provided by, and used
with the permission of, the chapter president. All 119 CNMs
on the membership e-mail list were invited to take part in the
study; the list represents approximately one quarter of the 411
22
licensed CNMs in Georgia. Many of the rural CNMs do not
attend the Atlanta-based meetings, and therefore their names
were not included on the email list.
The survey questionnaire was developed by the authors
in consultation with CNM faculty at Emory University. To
assess its face and content validity, the content was re-
viewed by four CNMs as well as a childbirth education ex-
pert who worked in the only facility in metropolitan
Atlanta that currently performs waterbirths. It is unknown
how many other facilities perform waterbirth in Georgia.
The survey contained the following sections: 1) demo-
graphic information, 2) exposure to and experience with
waterbirth, 3) the hospital environment related to water-
birth, 4) personal effectiveness in shaping policy in their
place of practice, 5) views of research on waterbirth, 6)
support for waterbirth, and 7) advantages and disadvan-
tages of waterbirth. This brief report focuses upon the de-
mographic information, exposure to and experience with
waterbirth, perceived advantages and disadvantages of
waterbirth, and support for waterbirth.
A secure and encrypted internet software, Survey Mon-
key, was used to administer the questionnaire. The ques-
tionnaire administration followed Dillman’s method for
23
internet surveys. Members received an advance-notice e-
mail, followed within 1 week by a link to the survey. One
week later, members received an e-mail thanking them for
responding and requesting a response from those who had
not yet responded. Two weeks later, a link to the survey
was sent a second time to those members who had not
responded, followed again by a reminder e-mail 1 week
later. The survey remained online for respondents to
participate for approximately 6 weeks, from early Jan-uary
and into February, 2008. At this point, data were
downloaded into a secure deidentified file and analyzed
using SPSS version 15 (SPSS, Inc., Chicago, IL). This re-
search project was administered with institutional review
board approval at Emory University. Informed consent
Shaunette L. Meyer, MA, completed this research study during her nursing
degree at Emory University, Atlanta, GA. She is currently attending the Uni-
versity of Colorado at Denver to receive her MS in Midwifery.
Christopher M. Weible, PhD, is a professor at the School of Public Affairs
of the University of Colorado at Denver.
Kate Woeber, CNM, MPH, is a clinical instructor at Emory University,
Atlanta, GA.
56
was obtained on an internet cover letter before the
respon-dent had access to the survey.
RESULTS
Fifty-three of 119 midwives from the Georgia chapter e-
mail list responded to the survey, for a response rate of
45%. Of the 53 respondents, 40% were aged younger than
40, 47% were aged between 40 and 59, and 11% were
older than 59. Three quarters of respondents reported
practicing midwifery for less than 20 years. Nearly half
(45%) acknowledged not currently practicing in the metro-
politan Atlanta area, with 20% working less than 10 years
and 35% working more than 10 years in the metro Atlanta
area. More than 80% of respondents worked in a hospital
setting for at least part of their practice, with the remaining
respondents working in community clinics or academia. Of
the 53 responding midwives, 39 had given birth, 12 said
they had not, and one did not respond. All respondents
were CNMs (n = 52), with one unknown; there were no
CMs in the sample.
Eleven different measures evaluated the respondents’
exposure to and experience with waterbirth. Figure 1
shows the frequency distributions of yes and no responses.
One nonresponse for the measures was not included.
Nearly all respondents had exposure to waterbirth by
reading an article, receiving a question about waterbirth
from a patient, and watching a video about it. One third to
one half of the respondents had experience with water-birth
in activities such as learning about waterbirth in their
midwifery program, witnessing a waterbirth, and helping
deliver a baby in water. Finally, it was very rare for any of
the midwives in the sample to have given birth in water.
Respondents were asked to rate their concern on 11 is-
sue categories that may be experienced during a waterbirth
on a scale of 1 to 5, with 1 being ‘‘no worry’’ and 5 being
‘‘severe worry.’’ Table 1 presents the frequency distribu-
tions of the categories along the five-point scale and the
mean for each category. The categories are ordered by
means from most worry to least worry.
The majority of categories have responses clustered near
the low end of the scale, suggesting little worry about
waterbirth among this sample of CNMs. No more than two
CNMs responded to a category with severe worry at the
top end of the scale. Showing the most worry were main-
tenance of water temperature, physical stress on the mid-
wife, and difficulty seeing the vagina. The areas of least
concern were infection of the midwife and infection of the
newborn. Table 1 also shows that CNMs do not con-sider
aspiration and infection as top worry items.
Respondents were asked about the perceived benefits of
waterbirth on a five-point scale, with 1 being ‘‘not a bene-
fit’’ to 5 being a ‘‘major benefit’’ (Table 2). Except for ma-
ternal blood loss, the overall rankings for these categories
cluster near the high end of the scale. CNMs perceived the
most benefits for mothers being more relaxed, a decreased
Volume 55, No. 1, January/February 2010
 Figure 1. Certified nurse-midwives’ exposure to and experience with waterbirths (N = 53).

use of analgesia by mothers, and mothers having a more
positive birth experience. The areas of least benefit were
a decrease in maternal blood loss, decrease in pitocin
aug-mentation, and lower incidence of perineal trauma.
Comparing the limitations in Table 1 and benefits in
Table 2, CNMs in this sample rated the benefits higher
than the limitations. The overall mean for only one
benefit question (decrease in maternal blood loss) was
lower than all of the limitation questions. CNMs,
however, varied more in their opinions about the
benefits than the limita-tions of waterbirth.
Respondents were asked the following question: ‘‘To
what extent do you oppose or support the introduction or a
greater emphasis of waterbirth in the facility where you
practice, or most recently practiced?’’ The mean re-sponse
was 3.7 on a scale of 1 to 5, with 1 being ‘‘strongly
oppose’’ to 5 being ‘‘strongly support.’’ A majority of
respondents supported a greater emphasis of waterbirth in
their practice. Of the 53 respondents, 34 (64%) recorded
Table 2. Frequency of Responses and Means for Benefits
of Waterbirth, N = 53

Table 1. Frequency of Responses and Means for Frequency of Responses

Limitations of Waterbirth, N = 53
Not a Major
Frequency of Responses Benefit Benefit
No Severe Response 1 2 3 4 5 Mean
Worry Worry Mothers are more relaxed 1 1 7 17 27 4.3
Response 1 2 3 4 5 Mean Decreased use of analgesia 1 4 7 20 21 4.1
by mothers
Maintenance of water temperature 9 18 18 6 2 2.5 Mothers have a more positive 1 2 15 11 23 4.0
Physical stress on CNM 12 19 11 8 2 2.4 birth experience
Difficult to see vagina 14 15 17 5 2 2.4 Maternal relief from back pain 1 3 13 17 18 3.9
Difficult to estimate blood loss 8 26 15 3 1 2.3 Newborns are calmer/more 3 8 17 9 14 3.5
Aspiration of newborn 11 26 11 2 2 2.2 peaceful
Hypothermia of newborn 15 23 11 2 2 2.1 Quicker labor 7 7 8 14 14 3.4
Inconvenience of CNM getting wet 19 19 10 3 2 2.1 Newborns are more alert 3 9 15 16 9 3.4
Infection of mother 25 11 11 4 2 2.0 Lower incidence of perineal 6 11 21 7 7 3.0
Infection of newborn 24 15 8 4 2 2.0 trauma
Infection of CNM 26 18 4 5 0 1.8 Decrease in pitocin 11 11 11 11 9 2.9
Inconvenience of CNM wearing 28 18 6 1 0 1.6 augmentation
shoulder-length gloves Decrease in maternal 30 4 15 2 1 1.8
blood loss
CNM = certified nurse-midwife.

Journal of Midwifery & Women’s Health

www.jmwh.org 57
moderate to strong support (4 or 5 on the scale). Only five
(10%) respondents said they opposed an emphasis on
waterbirth. Twenty-five percent indicated neither strong
support nor opposition to waterbirth. A Kruskal-Wallis rank
test found no statistically significant difference in
supporting waterbirth in their place of practice between
those working in hospitals or outside of hospitals (P > .10).
DISCUSSION
The majority of the sampled Georgia CNMs have some
exposure to waterbirth via reading an article or watching a
video, yet fewer have experience with witnessing a
waterbirth or delivering a baby in water. Nonetheless, the
current sample of Georgia CNMs is slightly more likely to
help deliver a baby in water (34%) than the 20% of
sampled CNMs in Connecticut who performed
21
waterbirths. In addition, although most waterbirths in the
4
United States are supervised by CNMs, only 30% of the
CNMs in this sample received education in their midwifery
program about waterbirth. These findings sug-gest a
possible need for education programs to provide
opportunities for direct experience with waterbirth.
A majority of CNMs support waterbirth in their
facility, regardless of the facility type. The respondents’
general support for waterbirth is consistent with their
opinions about the perceived benefits and limitations.
All but one category of benefits had higher means (>2.9)
than the lim-itations (<2.5), the exception being the
benefit of reduced maternal blood loss (mean = 1.8).
This latter perception conflicts with one descriptive
research study that found that delivering in water
10
decreases the amount of maternal blood loss.
Midwives perceived the benefits of waterbirth as includ-
ing pain reduction and relaxation of the mother, positive
birth experiences, and quicker labor, all of which are con-
6,8,10,11,16
sistent with the extant research. For example, the
perceptions of midwives in this study parallel the findings
11
in Thoeni et al., who found a decrease in the duration of
labor with waterbirth. Additionally, the findings in this
study support existing research showing that women who
have waterbirths have reported their experiences
as more ‘‘wonderful’’ or ‘‘pleasurable’’ when compared
with women who choose land births.1,7,16
Neonatal and maternal infections are frequently dis-
3,15,24
cussed as risks of waterbirth. In this study, the
CNMs’ concerns about waterbirth included maintaining
water temperature and the physical stress on the CNM. The
concern about maternal and newborn infection was near the
bottom of the list of limitations; this is consistent with
research that finds no difference in infection rates
among infants or mothers who chose to deliver using
9,10,11,13
waterbirth. Although worry about aspiration is
3,15
a risk of waterbirth often mentioned in the literature, it
is not a major concern among respondents in this study.
58
This study had several limitations that may affect inter-
pretation and generalizability of the results. This survey
was distributed to all members of the Georgia chapter of
ACNM. The response rate of 45% may not be representa-
tive of the ACNM community or CNMs in Georgia; it may
reflect a bias toward Atlanta-based CNMs and CNMs with
strong opinions about waterbirth. To some extent, general-
ization arguments can be made assuming that CNMs, re-
gardless of their geographic residence and place of work,
25
share a common professional philosophy. In addition,
respondents suggested the authors should have included a
question on whether their current facility performs water-
birth. Such information may have helped sort out whether
CNMs who work in such a facility support waterbirth or
not. Despite a limited sample and survey instrument, how-
ever, this study is one of the few investigations of CNMs
and their perceptions of waterbirth.
CONCLUSION
The future of waterbirth will depend on the beliefs and ex-
perience of the people involved in the birthing process, in-
cluding CNMs, pediatricians, labor and delivery nurses,
obstetricians, hospital administrators, and patients. The re-
sults from a sample of Georgia CNMs show that a large
majority have exposure to waterbirth and generally sup-
port the expansion of waterbirth in their place of practice.
Certified nurse-midwives were not moderately or severely
worried about any of the disadvantages of waterbirth. What
worry CNMs did have dealt less with the risks of the
birthing technique and more about the extra stress placed
on CNMs in implementing the approach.
We would like to recognize the support of Dr. Rebecca Gary, honors research
faculty at Emory University, and Dr. Joyce King, nurse-midwifery faculty at
Emory University and ACNM Georgia Chapter President for their consultation
throughout the project. In addition, we would like to thank Dr. Kenneth Hepburn,
Associate Dean for Research, for his financial contribution for the online
software subscription.
REFERENCES
1. Wu C, Chung U. The decision-making experience of
mothers selecting waterbirth. J Nursing Research 2003;11:261–7.
2. Hess S, Batton D, Lucey JF. Strong opinions versus science
in water-birth controversy. Pediatrics 2005;116:522–3.
3. Bowden K, Kessler D, Pinette M, Wilson E. Underwater
birth: Missing the evidence or missing the point? Pediatrics 2003;
112:972–3.
4. Schroeter K. Water births: A naked emperor. Pediatrics 2004;
114:855–8.
5. Garland D. Waterbirth—an international overview. Int Mid-
wifery 2006;19:24–5.
6. Eberhard J, Stein S, Geissbuehler V. Experience of pain and
analgesia with water and land births. J Psychosom Obstet
Gynecol 2005;26:127–33.
Volume 55, No. 1, January/February 2010
 7. Richmond H. Women’s experience of waterbirth. The Pract
Midwife 2003;6:26–31.
8. Cluett ER, Nikodem VC, McCandlish RE, Burns EE.
Immer-sion in water in pregnancy, labour and birth. Cochrane
Database Syst Rev 2004;(2):CD000111.
9. Fehervary P, Lauinger-Lorsch E, Hof H, Meichert F, Bauer
L, Zeiger W. Water birth: Microbiological colonization of the
new-born, neonatal and maternal infection rate in comparison to
conven-tional bed deliveries. Arch Gynecol Obstet 2004;270:6–9.
10. Geissbuehler V, Stein S, Eberhard J. Waterbirths compared
with landbirths: An observational study of nine years. J Perinatal
Med 2004;32:308–14.
11. Thoeni A, Zech N, Moroder L, Ploner F. Review of 1600
wa-ter births. Does water birth increase the risk of neonatal
infection? J Matern Fetal Neonatal Med 2005;17:357–61.
12. Woodward J, Kelly SM. A pilot study for a randomized con-
trolled trial of waterbirth versus land birth. Br J Obstet Gynecol
2004;111:537–45.
13. Zanetti-Dallenbach R, Lapaire O, Maertens A, Frei R, Holzgreve
W, Hosli I. Water birth: Is the water an additional reservoir for group B
streptococcus? Arch Gynecol Obstet 2006;273:236–8.
14. Kassim Z, Sellars M, Greenough A. Underwater birth and
neonatal respiratory distress. BMJ 2005;330:1071–2.
15. Pinette MG, Wax J, Wilson E. The risks of underwater birth.
Am J Obstet Gynecol 2003;190:1211–5.
16. Cluett ER, Pickering RM, Getliffe K, Saunders NJ. Rando-
mised controlled trial of labouring in water compared with standard
Journal of Midwifery & Women’s Health
www.jmwh.org
of augmentation for management of dystocia in first stage of labour.
BMJ 2004;328:314–8.
17. Jevitt C, Schuiling KD, Summers L. The national
practitioner data bank: Information for and about midwifery. J
Midwifery Womens Health 2005;50:525–30.
18. Kennedy HP, Rousseau AL, Low LK. An exploratory meta-
synthesis of midwifery practice in the United States. Midwifery
2003;19:203–14.
19. Lange G, Kennedy HP. Student perceptions of ideal and
actual midwifery practice. J Midwifery Womens Health 2006;
51:71–7.
20. Oshio S, Johnson P, Fullerton J. The 1999-2000 task
analysis of American nurse–midwifery/midwifery practice. J
Midwifery Womens Health 2002;47:35–41.
21. Holland ML, Holland ES. Survey of Connecticut nurse-
midwives. J Midwifery Womens Health 2007;52:106–15.
22. Active licensees. Georgia Board of Nursing. Available
from: www.sos.georgia.gov/plb/rn/ [Accessed June 25, 2008].
23. Dillman DA. Mail and Internet Surveys: The Tailored
Design Method: with New Internet, Visual, and Mixed-Mode
Guide, 2nd edition. Hoboken, NJ: John Wiley & Sons Inc., 2007.
24. Nagai T, Sobajima H, Iwasa M, Tsuzuki T, Kura F,
Amemura-Maekawa J, et al. Neonatal sudden death due to legion-
ella pneumonia associated with water birth in a domestic spa
bath. J Clin Microbiol 2003;41:2227–9.
25. Kennedy HP. A model of exemplary midwifery practice: Results of
a Delphi study. J Midwifery and Womens Health 2000;45:4–19.
59