Charkovsky, Odent and Leboyer

For millennia, women lucky enough to live near suitable springs or tropical seas, have sat in warm water to ease their labour pains. But they mostly got out for the birth. This makes sense. Humans are land mammals; as the uterus empties, placental oxygen transfer falls and the baby needs to breathe quickly. Drowning, or short of that, inhaling hypotonic or infected water are both possible. The first doctor to advise a woman to actually give birth underwater was taking a risk.

He was also a charlatan. In the 1960’s a self-publicising Russian healer, Igor Charkovsky – he had a doctorate in yoga but no medical training – began to popularise birth underwater. Some say his original idea was to protect the baby from the shock of emerging from the fluid filled womb into gravity, but it seems he also wanted to toughen babies and mothers up. He advocated birth in icy water, and a technique he called baby yoga, tossing the baby in the air, swinging it by its legs and immersing it under water (click here or here). Sensitive Westerners may find parts hard to watch. At 29 minutes in the second clip, while onlookers stand around in the snow wearing fur hats, a few weeks old naked screaming baby is swung about by his legs a few times and then dunked repeatedly in a freezing pond.

His disciples, of which a few remain, film themselves giving birth in warm tropical seas with soft music accompaniment, and blather on about birthing with dolphins (click here). The sea is big, and dolphins swim in it, so I guess they’re right about that.

But sensible supporters of natural birth, like the late Sheila Kitzinger, condemned Charkovsky’s methods, the authorities caught up with him, and soon he was forced to flee Russia. He ended up in the US, where he was accused of sexually assaulting his adult female disciples (click here).

The next pioneer was more reputable.  Michel Odent, a French surgeon, who also ran the maternity unit in Pithiviers, a small town south of Paris, was a disciple of Frederick Leboyer, who in a famous 1975 book, Birth Without Violence, had advocated labouring (not birthing) in warm water with soft lights and music in the birth room. Odent put Leboyer’s principles into practice in Pithivers, and installed deep and roomy birth pools. Most women got out for the birth but a few didn’t, and by 1983 he had collected 100 cases where the mother had birthed underwater (Odent Lancet 1983). One baby had breathing difficulties and another died suddenly some weeks later. Neither, according to Odent, related to the birth underwater.

Odent left Pithiviers two years later, moved to London, and founded the Primal Health Research Centre to promote his ideas (click here for the Primal Health Research Database and here for a related website Wombecology).  So far as I can see he published no more original research on waterbirth, although he continued to advocate it. Instead he produced reviews and opinion pieces, and about 15 books on various aspects of childbirth, and became one of the fathers of the natural childbirth movement. Some of his ideas are a bit nutty, but few would argue with his general efforts to promote a calm environment for childbirth.  Even I have to admit to a scintilla of sympathy for his “Two sets of commandments for obstetricians” (J Med Ethics 1985 click here).

Leboyer meanwhile, who died last month, also continued to advocate tranquillity in the birth room, and lived to see many of his ideas enter mainstream practice. He continued to encourage warm baths during the long hours of labour, but to the end of his life argued that birth underwater was dangerous: “Waterbirth is completely wrong. To give birth, you need to be on dry land.” (click here).

I think we can all agree that Charkovsky was a dangerous child abuser and con artist.  But what about Odent and Leboyer?  Who was right about birth underwater?

I’m with Leboyer. For humans, birth underwater is a treatment like amniotomy, or oxytocin. It may have benefits, but it also has risks, and should only be offered outside well conducted trials if there is good evidence that the benefits outweigh the harms. There is no such evidence yet (click here for the Cochrane review).

Enthusiasts often rightly point to other interventions in obstetrics, such as the two above, for which the evidence base even now is relatively weak, but which are in widespread use.  Why discourage water birth but not those two?

Answer; we should discourage them too. They are both overused. Amniotomy and oxytocin should be limited to situations where the mother wants labour speeded up, there is evidence to support that (click here and here), and is prepared to take the risk of unintended side effects.

Labouring in a warm bath should be encouraged; it’s a useful method of pain relief. But women should be advised either to get out for the actual birth or for the bath to be drained. A few Odent disciples may want to give birth underwater, and take the risks. I guess they should be free to do so, but there’s no need to encourage them. Gently point them to Frederick Leboyer and Birth Without Violence instead.

Jim Thornton