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Stock photo.
Doctor examining a pregnant woman.

Health officials have issued new guidelines for water births after two babies born at home in Arizona contracted Legionnaire's disease. The infants recovered, but obstetricians who discourage underwater birth say the cases highlight the risks of this type of delivery. Those risks include drowning, infection and cord rupture.

The nation's leading group of obstetricians says pregnant women can undergo labor safely in water, and that doing so provides benefits, including diminished pain and a reduced chance of a cesarean section. But the group recommends that mothers come out of the water for the delivery.

Proponents of underwater delivery — also known as hydrobirth — say it provides a less traumatic entry for babies who spent the last nine months floating in amniotic fluid.

Here’s a look at why water births are making headlines again, and what couples considering one should know.

Legionella in Arizona

In January 2016, a mother in Maricopa County, Arizona, gave birth to an infant at home, in a tub that had been cleaned with vinegar and tap water, then filled with tap water. Five minutes after the delivery, the midwife gave the baby a score of 9 out of 10 on the APGAR, the common test of how well a child is doing at one and five minutes after birth.

The next day, however, the parents took the baby to the emergency room, where the infant was diagnosed with Legionnaire’s disease and a congenital heart problem.

Legionnaire’s is a form of pneumonia spread through water droplets. The bacteria that cause the disease are called Legionella, and they are commonly found in natural bodies of water, but they make people sick when they infiltrate plumbing and cooling systems, such as air-conditioning units, hot tubs and public fountains. People are infected when they inhale tiny drops of water, or if they accidentally take water into their windpipe and lungs instead of their digestive system. The illness is not contagious.

Most healthy people exposed to Legionella bacteria don’t get sick, but infants are susceptible since their immune systems have not fully developed.

Four months after the Maricopa County infant was diagnosed, another Arizona baby born at home was brought to the emergency room suffering from a high fever. Tests determined that this infant, too, had Legionnaire's disease. The baby had been delivered underwater in a rented Jacuzzi.

In a report issued June 9, the Centers for Disease Control and Prevention said both cases might have been prevented had certain sanitary precautions been taken.

“Although the tub for delivery in the first case was filled immediately before the birth, tap water is not sterile, and Legionella can grow and spread in man-made water systems, such as plumbing systems,” the CDC report said.

In the second case, the tub had been filled a week before the delivery, and the water maintained 98 degrees Fahrenheit, providing a perfect climate for Legionella to grow. The bacteria thrive at temperatures between 77 and 108 degrees Fahrenheit, the CDC said.

Although Legionnaire’s can be fatal in about 1 out of 10 cases, both infants were treated with antibiotics and recovered. However, a 3-week-old baby died from a Legionella infection after a water delivery in Texas in 2014.

New guidelines for home births

In the wake of the infants' infections, the Arizona Department of Health issued new guidelines for water births at home. While the agency warned that the risk of Legionnaire's cannot be obliterated completely, the risk can be reduced by running hot water through the hose used to fill up to the tub for three minutes before filling the tub. Doing this clears the hose and pipes of stagnant water and sediment.

This is also good advice for anyone with old pipes in their home, regardless of whether they're having a baby. The Environmental Protection Agency encourages people at risk of lead in their water to let tap water run anywhere from five seconds to two minutes before filling a pot or a glass, depending on how long it's been since the water has been run.

Arizona's guidelines also say that women should use only a tub or pool made specifically for giving birth and water should not be left in the tub or pool for more than six hours.

But unlike the American College of Obstetricians and Gynecologists, Arizona health officials did not discourage water birth if the mother is considered at low risk for complications.

"Benefits of water immersion include increased relaxation, mobility and pain relief. The safety of water immersion during labor has been established by research, and does not result in reduced APGAR scores, increased neonatal or maternal infections, or increased (intensive care) admissions," the Arizona guidelines say, noting research that has found no increase in risk to mother or baby if a licensed medical provider is involved with the birth.

By land, not by sea

While some hospitals, including the University of Utah, offer water births as an option, most occur at home. The number of women who choose water births is not known because the information is not noted on birth certificates, according to a 2016 report by the American College of Obstetricians and Gynecologists.

The group says that there is evidence that laboring in water for the first stages of labor may help reduce pain and the need for anesthetics in pregnant women, but says there is not enough research to establish the safety of the mother and infant at the end of labor and during childbirth itself.

"Therefore, until such data are available, it is the recommendation of the American College of Obstetricians and Gynecologists that birth occur on land, not in water," the group says.

The group notes, however, that Royal College of Obstetricians and Gynaecologists in the United Kingdom and the American College of Nurse–Midwives support water birth for healthy women with low-risk pregnancies.

And Rebecca Dekker, a nurse who advocates for water births on her website Evidence Based Birth, challenges the American college's arguments, saying that more than 28,000 water births have been examined in studies over the past 20 years with few complications unrelated to sanitary lapses or high-risk pregnancies.

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