By Birth & Baby University · Last updated: October 2026 · 4 min read
Warm water is a familiar part of comfort support, and many clients ask about it. Evidence for water immersion in the first stage is reasonably consistent. Evidence and professional opinion about giving birth in water are less settled. This article lays out both and where the sources diverge.
Key takeaways
- A Cochrane review of 15 trials found that immersion in the first stage probably has little effect on mode of birth and may slightly reduce use of regional analgesia, with no evidence of increased adverse effects.
- A 2022 meta-analysis of mostly observational studies reported fewer interventions and higher satisfaction with immersion, but its design is more prone to bias than the Cochrane review’s.
- ACOG’s 2016 opinion supports first-stage immersion for healthy low-risk pregnancies at term and recommends birth occur on land, citing insufficient data for the second stage.
- Whether a person can use a tub depends on the facility’s protocols, medical status and monitoring needs.
What the research says
Randomized evidence
The 2018 Cochrane review included 15 trials with 3,663 women, all conducted in hospital labor wards between 1990 and 2015, none in a midwifery-led setting. For first stage immersion versus no immersion there was probably little or no difference in spontaneous vaginal birth (RR 1.01, 95% CI 0.97 to 1.04) and little difference in instrumental birth or cesarean, though cesarean estimates were imprecise (RR 1.27, 95% CI 0.91 to 1.79). The risk of regional analgesia fell slightly from 43% to 39% (RR 0.91, 95% CI 0.83 to 0.99). For second stage the evidence rested on one or two small trials and showed no clear differences, and no evidence of increased adverse effects to babies or women was found, though evidence was limited by clinical variability and heterogeneity.
A larger but less controlled picture
A 2022 meta-analysis of 36 studies and 157,546 participants reported that immersion was associated with fewer epidurals (OR 0.17), injected opioids, episiotomies and lower maternal pain, along with higher satisfaction, more intact perineums and lower postpartum hemorrhage (OR 0.69, 95% CI 0.51 to 0.95). Waterbirth was associated with higher odds of cord avulsion (OR 1.94, 95% CI 1.30 to 2.88), although the absolute risk was low (4.3 per 1,000 versus 1.3 per 1,000). The authors note that most included studies were in obstetric units, and that factors like parity, care model and birth setting shape results. Because many of those studies compare people who chose water with those who did not, their results may reflect who chooses water as much as water itself.
Professional guidance
ACOG Committee Opinion 679 (2016) says immersion during the first stage may be associated with shorter labor and less spinal and epidural analgesia and may be offered to healthy women with uncomplicated pregnancies between 37 0/7 and 41 6/7 weeks. It finds insufficient data to draw conclusions about the second stage and recommends that birth occur on land, but says a person who requests water birth should be told the benefits and risks have not been studied enough to either support or discourage the request. Facilities should have protocols for candidate selection, cleaning, infection control, monitoring and getting people out of the tub if concerns arise. Check ACOG’s current position, since opinions are periodically revised.
Where the sources differ
The Cochrane review and the 2022 meta-analysis agree that no excess harm was found. They differ on how much benefit, with the larger review reporting more benefits than the randomized evidence supports. ACOG is more cautious about birth in water than the 2022 authors. Readers should weigh randomized trial results more heavily for effects, while recognizing that rare harms are hard to detect in any of these datasets.
What this means for doulas
- Offer water as a comfort option. The evidence supports it as reasonable for suitable low-risk labors, with a modest effect on analgesia use.
- Know the facility’s rules. Ask early about tubs, intermittent monitoring and eligibility. Hospitals differ.
- Be honest about water birth. Professional bodies differ in their stance and rare risks are poorly measured, so provide the sources and let the client discuss it with their provider.
- Prioritize safety. Help clients get out of the water if staff ask. Keep an eye on hydration and temperature comfort without making clinical calls.
Putting the evidence into practice
- Include “tub or shower available?” in prenatal birth setting questions.
- Explain that a tub may not be available if monitoring needs change, and that a shower is a reasonable alternative.
- If a client plans a water birth at a facility that allows it, help them read the facility’s own criteria and written protocol.
- After birth, avoid attributing outcomes to water or its absence.
The bottom line
For healthy people at term, first-stage water immersion looks safe in the evidence reviewed and may reduce analgesia use. Birth in water is where sources part ways. Doulas can offer water as comfort, know local rules and keep conversations honest about what remains unknown.
This article is for professional education. It is not medical, legal or tax advice. Check the standards of your certifying organization and the rules where you work.
Sources and further reading
- Cluett ER, et al. Immersion in water during labour and birth. Cochrane Database of Systematic Reviews 2018. Read the source
- Burns E, et al. Systematic review and meta-analysis to examine intrapartum interventions, and maternal and neonatal outcomes following immersion in water during labour and waterbirth. BMJ Open 2022. Read the source
- American College of Obstetricians and Gynecologists. Committee Opinion No. 679: Immersion in Water During Labor and Delivery. Obstetrics & Gynecology 2016. Read the source
Supporting clients in the tub or shower is one of many practical skills in doula preparation. See the training options on the For Doulas page.
More for professionals: the Professionals Blog.
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