Immersion in water during labour and birth

Elizabeth R Cluett; Ethel Burns; Anna Cuthbert

doi:10.1002/14651858.CD000111.pub4

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Figure 1

Study flow diagram.

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Figure 2

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 1 Mode of birth (spontaneous vaginal birth).

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Analysis 1.2

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 2 Mode of birth (instrumental vaginal births).

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Analysis 1.3

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 3 Mode of birth (caesarean section).

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Analysis 1.4

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 4 Use of analgesia (regional).

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Analysis 1.5

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 5 Perineal trauma (third‐ or fourth‐degree tears).

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Analysis 1.6

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 6 Admission to neonatal intensive care unit.

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Analysis 1.7

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 7 Neonatal infection.

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Analysis 1.8

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 8 Neonate temperature.

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Analysis 1.9

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 9 Estimated blood loss (mL).

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Analysis 1.10

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 10 Postpartum haemorrhage.

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Analysis 1.11

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 11 Use of analgesia (pharmacological ‐ pethidine/narcotic).

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Analysis 1.12

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 12 Use of any analgesia.

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Analysis 1.13

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 13 Use of analgesia (pharmacological ‐ any).

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Analysis 1.14

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 14 Maternal infection during labour/postnatal period (perineal, systemic, uterine or increase in temperature).

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Analysis 1.15

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 15 Artificial rupture of membranes.

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Analysis 1.16

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 16 Use of oxytocin for augmentation of labour.

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Analysis 1.17

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 17 Use of non‐pharmacological analgesia (transcutaneous nerve stimulation (TENS).

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Analysis 1.18

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 18 Duration of first stage (minutes).

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Analysis 1.19

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 19 Duration of second stage (minutes).

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Analysis 1.20

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 20 Duration of third stage (minutes).

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Analysis 1.21

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 21 Duration of total labour (all three stages minutes).

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Analysis 1.22

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 22 Perineal trauma (intact).

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Analysis 1.23

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 23 Perineal trauma (second‐degree tears).

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Analysis 1.24

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 24 Perineal trauma (episiotomy).

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Analysis 1.25

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 25 Self reports pain score on visual analogue scale of 0‐10.

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Analysis 1.26

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 26 Pain intensity (experience of moderate to severe pain).

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Analysis 1.27

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 27 Systolic blood pressure.

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Analysis 1.28

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 28 Diastolic blood pressure.

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Analysis 1.29

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 29 Mean arterial blood pressure.

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Analysis 1.30

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 30 Preference for care in subsequent labour (Does not wish to use bath with next labour/birth).

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Analysis 1.31

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 31 Postpartum depression (EPDS more than 11).

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Analysis 1.32

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 32 Abnormal fetal heart rate patterns.

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Analysis 1.33

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 33 Presence of meconium‐stained liquor.

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Analysis 1.34

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 34 Apgar score less than seven at five minutes.

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Analysis 1.35

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 35 Apgar score at five minutes.

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Analysis 1.36

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 36 Umbilical artery pH less than 7.20.

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Analysis 1.37

Comparison 1 Immersion in water versus no immersion during first stage of labour, Outcome 37 Breastfeeding ‐ not breastfeeding after six weeks post birth.

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Analysis 2.1

Comparison 2 Immersion in water versus no immersion during second stage of labour, Outcome 1 Mode of birth (spontaneous vaginal birth).

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Analysis 2.2

Comparison 2 Immersion in water versus no immersion during second stage of labour, Outcome 2 Mode of birth (instrumental vaginal births).

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Analysis 2.3

Comparison 2 Immersion in water versus no immersion during second stage of labour, Outcome 3 Mode of birth (caesarean section).

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Analysis 2.4

Comparison 2 Immersion in water versus no immersion during second stage of labour, Outcome 4 Perinatal deaths.

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Analysis 2.5

Comparison 2 Immersion in water versus no immersion during second stage of labour, Outcome 5 Admission to neonatal intensive care unit.

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Analysis 2.6

Comparison 2 Immersion in water versus no immersion during second stage of labour, Outcome 6 Neonate temperature.

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Analysis 2.7

Comparison 2 Immersion in water versus no immersion during second stage of labour, Outcome 7 Fever reported in first week.

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Analysis 2.8

Comparison 2 Immersion in water versus no immersion during second stage of labour, Outcome 8 Postpartum haemorrhage more than 500 mL.

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Analysis 2.9

Comparison 2 Immersion in water versus no immersion during second stage of labour, Outcome 9 Duration of second stage (minutes).

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Analysis 2.10

Comparison 2 Immersion in water versus no immersion during second stage of labour, Outcome 10 Perineal trauma (episiotomy).

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Analysis 2.11

Comparison 2 Immersion in water versus no immersion during second stage of labour, Outcome 11 Perineal trauma (second degree tear).

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Analysis 2.12

Comparison 2 Immersion in water versus no immersion during second stage of labour, Outcome 12 Experience of moderate to severe pain.

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Analysis 2.13

Comparison 2 Immersion in water versus no immersion during second stage of labour, Outcome 13 Preference for care in subsequent labour (Does not wish to use bath next birth).

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Analysis 2.14

Comparison 2 Immersion in water versus no immersion during second stage of labour, Outcome 14 Satisfied with labour.

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Analysis 2.15

Comparison 2 Immersion in water versus no immersion during second stage of labour, Outcome 15 Presence of meconium‐stained liquor.

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Analysis 2.16

Comparison 2 Immersion in water versus no immersion during second stage of labour, Outcome 16 Apgar score less than seven (five minutes).

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Analysis 2.17

Comparison 2 Immersion in water versus no immersion during second stage of labour, Outcome 17 Mean Apgar at five minutes.

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Analysis 2.18

Comparison 2 Immersion in water versus no immersion during second stage of labour, Outcome 18 Umbilical artery pH less than 7.20.

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Analysis 3.1

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 1 Mode of birth (spontaneous vaginal birth).

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Analysis 3.2

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 2 Mode of birth (instrumental vaginal births).

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Analysis 3.3

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 3 Mode of birth (caesarean section).

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Analysis 3.4

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 4 Use of analgesia (regional).

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Analysis 3.5

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 5 Perineal trauma (third‐ or fourth‐degree tears).

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Analysis 3.6

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 6 Perinatal deaths.

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Analysis 3.7

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 7 Admission to neonatal intensive care unit.

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Analysis 3.8

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 8 Neonatal infection.

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Analysis 3.9

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 9 Neonate temperature.

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Analysis 3.10

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 10 Fever reported in first week.

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Analysis 3.11

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 11 Antibiotics given to neonate.

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Analysis 3.12

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 12 Estimated blood loss (mL).

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Analysis 3.13

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 13 Postpartum haemorrhage.

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Analysis 3.14

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 14 Use of analgesia (pharmacological ‐ pethidine/narcotic).

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Analysis 3.15

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 15 Use of analgesia (pharmacological ‐ any).

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Analysis 3.16

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 16 Use of any analgesia.

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Analysis 3.17

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 17 Maternal infection during labour/postnatal period (perineal, systemic, uterine or increase in temperature).

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Analysis 3.18

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 18 Artificial rupture of membranes.

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Analysis 3.19

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 19 Use of oxytocin for augmentation of labour.

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Analysis 3.20

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 20 Use of non‐pharmacological analgesia (transcutaneous nerve stimulation (TENS)).

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Analysis 3.21

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 21 Duration of first stage (minutes).

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Analysis 3.22

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 22 Duration of second stage (minutes).

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Analysis 3.23

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 23 Duration of third stage (minutes).

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Analysis 3.24

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 24 Duration of total labour (all three stages).

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Analysis 3.25

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 25 Perineal trauma (none‐ intact).

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Analysis 3.26

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 26 Perineal trauma (first‐ and second‐degree tears).

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Analysis 3.27

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 27 Perineal trauma (episiotomy).

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Analysis 3.28

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 28 Self reports pain score on visual analogue scale of 0‐10.

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Analysis 3.29

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 29 Pain intensity (experience of moderate to severe pain).

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Analysis 3.30

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 30 Maternal temperature.

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Analysis 3.31

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 31 Systolic blood pressure.

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Analysis 3.32

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 32 Diastolic blood pressure.

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Analysis 3.33

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 33 Mean arterial blood pressure.

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Analysis 3.34

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 34 Preference for care in subsequent labour (Does not wish to use bath with next labour/birth).

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Analysis 3.35

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 35 Satisfied with labour.

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Analysis 3.36

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 36 Satisfied with labour on scale.

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Analysis 3.37

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 37 Postpartum depression (EPDS more than 11).

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Analysis 3.38

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 38 Abnormal fetal heart rate patterns.

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Analysis 3.39

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 39 Presence of meconium‐stained liquor.

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Analysis 3.40

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 40 Apgar score less than seven at five minutes.

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Analysis 3.41

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 41 Apgar score at five minutes.

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Analysis 3.42

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 42 Umbilical artery pH less than 7.20.

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Analysis 3.43

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 43 Breastfeeding.

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Analysis 3.44

Comparison 3 Immersion in water versus no immersion during any stage of labour, Outcome 44 Not breastfeeding after six weeks post birth.

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Analysis 4.1

Comparison 4 Early versus late immersion in water, Outcome 1 Use of pharmacological analgesia (epidural/spinal analgesia/paracervical block).

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Analysis 4.2

Comparison 4 Early versus late immersion in water, Outcome 2 Neonatal infection.

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Analysis 4.3

Comparison 4 Early versus late immersion in water, Outcome 3 Use of oxytocin.

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Analysis 4.4

Comparison 4 Early versus late immersion in water, Outcome 4 Abnormal fetal heart rate patterns.

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Analysis 4.5

Comparison 4 Early versus late immersion in water, Outcome 5 Apgar score less than seven at one minute.

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Summary of findings for the main comparison. Immersion in water compared to no immersion during first stage of labour in water during labour and birth

Immersion in water compared to no immersion during first stage of labour in water during labour and birth
Patient or population: women in labour Setting: hospital‐based maternity units in the following countries: UK, Canada, Iran, Finland, Australia, USA, Belgium, Brazil, Sweden, South Africa and China. Intervention: immersion in water in the first stage of labour Comparison: no immersion during first stage of labour
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with no immersion during first stage of labour	Risk with immersion in water
Mode of birth (spontaneous vaginal birth)	Study population		RR 1.01 (0.97 to 1.04)	2559 (6 RCTs)	⊕⊕⊕⊝ MODERATE ¹
	822 per 1000	830 per 1000 (797 to 855)
Mode of birth (instrumental vaginal birth)	Study population		RR 0.86 (0.70 to 1.05)	2559 (6 RCTs)	⊕⊕⊝⊝ LOW ^{1 2}
	138 per 1000	119 per 1000 (97 to 1.05)
Mode of birth (caesarean section)	Study population		RR 1.27 (0.91 to 1.79)	2652 (7 RCTs)	⊕⊕⊝⊝ LOW ^{2 3}
	41 per 1000	52 per 1000 (38 to 74)
Use of analgesia (regional)	Study population		RR 0.91 (0.83 to 0.99)	2439 (5 RCTs)	⊕⊕⊕⊝ MODERATE ¹
	429 per 1000	390 per 1000 (356 to 424)
Perineal trauma (third‐ or fourth‐degree tears)	Study population		RR 1.36 (0.85 to 2.18)	2341 (4 RCTs)	⊕⊕⊕⊝ MODERATE ¹
	25 per 1000	33 per 1000 (21 to 54)
Perinatal death	Study population		‐	‐	‐	No trial reported this outcome.
	see comment	see comment
Admission to neonatal intensive care unit	Study population		Average RR 1.30 (0.42 to 3.97)	1511 (2 RCTs)	⊕⊕⊝⊝ LOW ^{2 4}
	58 per 1000	75 per 1000 (24 to 229)
Neonatal infection	Study population		RR 2.00 (0.50 to 7.94)	1295 (5 RCTs)	⊕⊝⊝⊝ VERY LOW ^{1 5}
	5 per 1000	9 per 1000 (2 to 37)
Estimated blood loss (mL)	The mean estimated blood loss with immersion was 265.5 mL	MD 14.33 mL lower without immersion (63.03 mL lower to 34.37 mL higher)	‐	153 (2 RCTs)	⊕⊝⊝⊝ VERY LOW ^{6 7}
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio
GRADE Working Group grades of evidence High certainty: We are very confident that the true effect lies close to that of the estimate of the effect Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹ All trials had design limitations: No trial was blinded, two trials did not randomise adequately, and three did not report all outcomes (‐1) ² Wide confidence intervals that cross the line of no effect (‐1) ³ All trials had design limitations: No trial was blinded, two trials did not randomise adequately, one did not conceal allocation, and three did not report all outcomes (‐1) ⁴ Both trials have design limitations: Neither trial was blinded, one trial did not randomise adequately, and both did not report all outcomes (‐1) ⁵ Few events and wide confidence intervals crossing the line of no effect (‐2) ⁶ Both trials have design limitations: Neither trial was blinded, one trial did not randomise adequately (‐1) ⁷ Small sample size and wide confidence intervals crossing the line of no effect (‐2)

Summary of findings for the main comparison. Immersion in water compared to no immersion during first stage of labour in water during labour and birth

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Summary of findings 2. Immersion in water compared to no immersion during second stage of labour in water during labour and birth

Immersion in water compared to no immersion during second stage of labour in water during labour and birth
Patient or population: women in labour Setting: hospital‐based maternity units in the following countries: UK, Canada, Iran, Finland, Australia, USA, Belgium, Brazil, Sweden, South Africa and China Intervention: immersion in water in the second stage of labour Comparison: no immersion during second stage of labour
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with no immersion during second stage of labour	Risk with immersion in water
Mode of birth (spontaneous vaginal birth)	Study population		RR 1.02 (0.96 to 1.08)	120 (1 RCT)	⊕⊕⊝⊝ LOW ^{1 2}
	967 per 1000	986 per 1000 (928 to 1000)
Mode of birth (instrumental vaginal birth)	Study population		RR 1.00 (0.06 to 15.62)	120 (1 RCT)	⊕⊝⊝⊝ VERY LOW ^{1 3}
	17 per 1000	17 per 1000 (1 to 260)
Mode of birth (caesarean section)	Study population		RR 0.33 (0.01 to 8.02)	120 (1 RCT)	⊕⊝⊝⊝ VERY LOW ^{1 3}
	17 per 1000	6 per 1000 (0 to 134)
Use of analgesia (regional)	Study population		‐	‐	‐	This outcome was not reported as it is not applicable to the second stage of labour.
	see comment	see comment
Perineal trauma (third‐ or fourth‐degree tears)	Study population		‐	‐	‐	No trial reported this outcome
	see comment	see comment
Perinatal death	Study population		RR 3.00 (0.12 to 72.20)	120 (1 RCT)	⊕⊝⊝⊝ VERY LOW ^{1 3}	1 death occurred in the immersion group in this trial. The infant was born alive to a woman with HIV who was treated 2 weeks previous to birth for vaginal infection. The infant died at 2.5 hours after birth. After investigation the cause of death was determined to be intrauterine infection.
	0 per 1000	0 per 1000 (0 to 0)
Admission to neonatal intensive care unit	Study population		RR 0.78 (0.38 to 1.59)	291 (2 RCTs)	⊕⊝⊝⊝ VERY LOW ^{1 3}
	108 per 1000	84 per 1000 (41 to 172)
Neonatal infection, including markers of infection such as pyrexia and raised white cell count: Neonatal temperature less than 36.2^oC at birth	Study population		RR 0.98 (0.30 to 3.20)	109 (1 RCT)	⊕⊝⊝⊝ VERY LOW ^{1 3}	Number of neonatal infections was not reported, but temperature was included as a marker of infection.
	93 per 1000	91 per 1000 (28 to 296)
Neonatal infection, including markers of infection such as pyrexia and raised white cell count: Neonatal temperature greater than 37.5^oC at birth	Study population		RR 2.62 (0.73 to 9.35)	109 (1 RCT)	⊕⊝⊝⊝ VERY LOW ^{1 3}	Number of neonatal infections was not reported, but temperature was included as a marker of infection.
	56 per 1000	146 per 1000 (41 to 519)
Neonatal infection, including markers of infection such as pyrexia and raised white cell count: Fever reported in first week	Study population		RR 0.53 (0.10 to 2.82)	171 (1 RCT)	⊕⊝⊝⊝ VERY LOW ^{3 4}	Number of neonatal infections was not reported, but fever was included as a marker of infection.
	45 per 1000	24 per 1000 (5 to 128)
Estimated blood loss (mL)	Study population		‐	‐	‐	No trial reported this outcome
	see comment	see comment
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio
GRADE Working Group grades of evidence High certainty: We are very confident that the true effect lies close to that of the estimate of the effect Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹ Data from one study with design limitations: trial was not blinded, and did not randomise adequately (‐1) ² Small sample size (‐1) ³ Small sample size, few events, and wide confidence intervals crossing the line of no effect (‐2) ⁴ Data from one study with design limitations: trial was not blinded, did not report all outcomes, and was at unclear risk of bias in most domains (‐1)

Summary of findings 2. Immersion in water compared to no immersion during second stage of labour in water during labour and birth

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Comparison 1. Immersion in water versus no immersion during first stage of labour

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mode of birth (spontaneous vaginal birth) Show forest plot	6	2559	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.97, 1.04]

2 Mode of birth (instrumental vaginal births) Show forest plot	6	2559	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.70, 1.05]

3 Mode of birth (caesarean section) Show forest plot	7	2652	Risk Ratio (M‐H, Fixed, 95% CI)	1.27 [0.91, 1.79]

4 Use of analgesia (regional) Show forest plot	5	2439	Risk Ratio (M‐H, Fixed, 95% CI)	0.91 [0.83, 0.99]

5 Perineal trauma (third‐ or fourth‐degree tears) Show forest plot	4	2341	Risk Ratio (M‐H, Fixed, 95% CI)	1.36 [0.85, 2.18]

6 Admission to neonatal intensive care unit Show forest plot	2	1511	Risk Ratio (M‐H, Random, 95% CI)	1.30 [0.42, 3.97]

7 Neonatal infection Show forest plot	5	1295	Risk Ratio (M‐H, Fixed, 95% CI)	2.00 [0.50, 7.94]

8 Neonate temperature Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

8.1 Temperature greater than 37.8 degrees C as an indicator for infection	1	274	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.06, 15.83]
9 Estimated blood loss (mL) Show forest plot	2	153	Mean Difference (IV, Fixed, 95% CI)	‐14.33 [‐63.03, 34.37]

10 Postpartum haemorrhage Show forest plot	1	274	Risk Ratio (M‐H, Fixed, 95% CI)	1.58 [0.80, 3.13]

11 Use of analgesia (pharmacological ‐ pethidine/narcotic) Show forest plot	3	1180	Risk Ratio (M‐H, Random, 95% CI)	1.08 [0.59, 1.96]

12 Use of any analgesia Show forest plot	3	487	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.88, 1.12]

13 Use of analgesia (pharmacological ‐ any) Show forest plot	2	394	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.80, 1.39]

14 Maternal infection during labour/postnatal period (perineal, systemic, uterine or increase in temperature) Show forest plot	5	1295	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.50, 1.96]

15 Artificial rupture of membranes Show forest plot	3	926	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.90, 1.16]

16 Use of oxytocin for augmentation of labour Show forest plot	4	1019	Risk Ratio (M‐H, Fixed, 95% CI)	0.91 [0.72, 1.15]

17 Use of non‐pharmacological analgesia (transcutaneous nerve stimulation (TENS) Show forest plot	1	785	Risk Ratio (M‐H, Fixed, 95% CI)	1.25 [0.34, 4.61]

18 Duration of first stage (minutes) Show forest plot	5	1295	Mean Difference (IV, Fixed, 95% CI)	‐11.53 [‐45.42, 22.36]

19 Duration of second stage (minutes) Show forest plot	6	1403	Mean Difference (IV, Random, 95% CI)	1.12 [‐5.23, 7.48]

20 Duration of third stage (minutes) Show forest plot	2	1059	Mean Difference (IV, Fixed, 95% CI)	0.25 [‐1.10, 1.60]

21 Duration of total labour (all three stages minutes) Show forest plot	1	120	Mean Difference (IV, Fixed, 95% CI)	‐27.5 [‐133.05, 78.05]

22 Perineal trauma (intact) Show forest plot	4	1277	Risk Ratio (M‐H, Fixed, 95% CI)	1.17 [1.01, 1.37]

23 Perineal trauma (second‐degree tears) Show forest plot	4	1212	Risk Ratio (M‐H, Fixed, 95% CI)	0.94 [0.74, 1.20]

24 Perineal trauma (episiotomy) Show forest plot	4	1212	Risk Ratio (M‐H, Fixed, 95% CI)	0.94 [0.80, 1.09]

25 Self reports pain score on visual analogue scale of 0‐10 Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only

25.1 Pain score at start of assessment period (time zero)	2	141	Mean Difference (IV, Random, 95% CI)	0.15 [‐0.79, 1.08]
25.2 Pain score up to 60 minutes later	2	141	Mean Difference (IV, Random, 95% CI)	‐0.81 [‐1.34, ‐0.28]
26 Pain intensity (experience of moderate to severe pain) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

26.1 Ordinal description as moderate to severe, 30 mins after randomisation	1	120	Risk Ratio (M‐H, Fixed, 95% CI)	0.75 [0.62, 0.91]
26.2 VAS scale 8 to 10, 30 mins after randomisation	1	120	Risk Ratio (M‐H, Fixed, 95% CI)	0.72 [0.58, 0.90]
26.3 Ordinal scale pain faces 4 to 5, 30 mins after randomisation	1	120	Risk Ratio (M‐H, Fixed, 95% CI)	0.67 [0.51, 0.90]
26.4 Ordinal description as moderate to severe, 1 hr after randomisation	1	117	Risk Ratio (M‐H, Fixed, 95% CI)	0.76 [0.63, 0.91]
26.5 VAS scale 8 to 10, 1 hr after randomisation	1	117	Risk Ratio (M‐H, Fixed, 95% CI)	1.21 [0.69, 2.11]
26.6 Ordinal scale pain faces 4 to 5, 1 hr after randomisation	1	117	Risk Ratio (M‐H, Fixed, 95% CI)	0.68 [0.53, 0.86]
26.7 Ordinal description as moderate to severe, 2 hrs after randomisation	1	57	Risk Ratio (M‐H, Fixed, 95% CI)	0.76 [0.59, 0.98]
26.8 VAS scale 8 to 10, 2 hrs after randomisation	1	57	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.66, 1.05]
26.9 Ordinal scale pain faces 4 to 5, 2 hrs after randomisation	1	57	Risk Ratio (M‐H, Fixed, 95% CI)	0.72 [0.52, 0.98]
26.10 Ordinal description as moderate to severe, 3 hrs after randomisation	1	32	Risk Ratio (M‐H, Fixed, 95% CI)	0.52 [0.23, 1.16]
26.11 VAS scale 8 to 10, 3 hrs after randomisation	1	32	Risk Ratio (M‐H, Fixed, 95% CI)	0.69 [0.39, 1.23]
26.12 Ordinal scale pain faces 4 to 5, 3 hrs after randomisation	1	32	Risk Ratio (M‐H, Fixed, 95% CI)	0.57 [0.25, 1.27]
26.13 Ordinal description as moderate to severe, 24 hrs after randomisation	1	119	Risk Ratio (M‐H, Fixed, 95% CI)	0.64 [0.50, 0.82]
26.14 VAS scale 8 to 10, 24 hrs after randomisation	1	119	Risk Ratio (M‐H, Fixed, 95% CI)	0.62 [0.49, 0.80]
26.15 Ordinal scale pain faces 4 to 5, 24 hrs after randomisation	1	119	Risk Ratio (M‐H, Fixed, 95% CI)	0.69 [0.54, 0.87]
27 Systolic blood pressure Show forest plot	1	120	Mean Difference (IV, Fixed, 95% CI)	‐7.20 [‐13.12, ‐1.28]

28 Diastolic blood pressure Show forest plot	1	120	Mean Difference (IV, Fixed, 95% CI)	‐10.20 [‐13.70, ‐6.70]

29 Mean arterial blood pressure Show forest plot	1	120	Mean Difference (IV, Fixed, 95% CI)	‐10.5 [‐14.68, ‐6.32]

30 Preference for care in subsequent labour (Does not wish to use bath with next labour/birth) Show forest plot	1	119	Risk Ratio (M‐H, Fixed, 95% CI)	0.38 [0.14, 0.98]

31 Postpartum depression (EPDS more than 11) Show forest plot	2	370	Risk Ratio (M‐H, Fixed, 95% CI)	1.38 [0.85, 2.24]

32 Abnormal fetal heart rate patterns Show forest plot	3	487	Risk Ratio (M‐H, Random, 95% CI)	0.75 [0.34, 1.67]

33 Presence of meconium‐stained liquor Show forest plot	4	1200	Risk Ratio (M‐H, Random, 95% CI)	0.92 [0.64, 1.33]

34 Apgar score less than seven at five minutes Show forest plot	5	1834	Risk Ratio (M‐H, Fixed, 95% CI)	1.58 [0.63, 3.93]

35 Apgar score at five minutes Show forest plot	2	893	Mean Difference (IV, Fixed, 95% CI)	‐0.03 [‐0.11, 0.06]

36 Umbilical artery pH less than 7.20 Show forest plot	1	110	Risk Ratio (M‐H, Fixed, 95% CI)	5.18 [0.25, 105.51]

37 Breastfeeding ‐ not breastfeeding after six weeks post birth Show forest plot	2	363	Risk Ratio (M‐H, Fixed, 95% CI)	1.17 [0.64, 2.15]

Comparison 1. Immersion in water versus no immersion during first stage of labour

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Comparison 2. Immersion in water versus no immersion during second stage of labour

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mode of birth (spontaneous vaginal birth) Show forest plot	1	120	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.96, 1.08]

2 Mode of birth (instrumental vaginal births) Show forest plot	1	120	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.06, 15.62]

3 Mode of birth (caesarean section) Show forest plot	1	120	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 8.02]

4 Perinatal deaths Show forest plot	1	120	Risk Ratio (M‐H, Fixed, 95% CI)	3.0 [0.12, 72.20]

5 Admission to neonatal intensive care unit Show forest plot	2	291	Risk Ratio (M‐H, Fixed, 95% CI)	0.78 [0.38, 1.59]

6 Neonate temperature Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

6.1 Temperature less than 36.2 degrees C at birth	1	109	Risk Ratio (M‐H, Fixed, 95% CI)	0.98 [0.30, 3.20]
6.2 Temperature greater than 37.5 degrees C at birth	1	109	Risk Ratio (M‐H, Fixed, 95% CI)	2.62 [0.73, 9.35]
7 Fever reported in first week Show forest plot	1	171	Risk Ratio (M‐H, Fixed, 95% CI)	0.53 [0.10, 2.82]

8 Postpartum haemorrhage more than 500 mL Show forest plot	1	120	Risk Ratio (M‐H, Fixed, 95% CI)	0.14 [0.01, 2.71]

9 Duration of second stage (minutes) Show forest plot	2	291	Mean Difference (IV, Fixed, 95% CI)	‐1.83 [‐8.18, 4.52]

10 Perineal trauma (episiotomy) Show forest plot	1	119	Risk Ratio (M‐H, Fixed, 95% CI)	0.74 [0.17, 3.15]

11 Perineal trauma (second degree tear) Show forest plot	1	119	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.57, 2.38]

12 Experience of moderate to severe pain Show forest plot	1	117	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [0.73, 1.53]

12.1 Ordinal description as moderate to severe	1	117	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [0.73, 1.53]
13 Preference for care in subsequent labour (Does not wish to use bath next birth) Show forest plot	1	117	Risk Ratio (M‐H, Fixed, 95% CI)	0.57 [0.22, 1.47]

14 Satisfied with labour Show forest plot	1	117	Risk Ratio (M‐H, Fixed, 95% CI)	0.24 [0.07, 0.80]

14.1 Little or not satisfied with coping experience	1	117	Risk Ratio (M‐H, Fixed, 95% CI)	0.24 [0.07, 0.80]
15 Presence of meconium‐stained liquor Show forest plot	1	120	Risk Ratio (M‐H, Fixed, 95% CI)	1.4 [0.47, 4.17]

16 Apgar score less than seven (five minutes) Show forest plot	1	119	Risk Ratio (M‐H, Fixed, 95% CI)	4.92 [0.24, 100.31]

17 Mean Apgar at five minutes Show forest plot	1	171	Mean Difference (IV, Fixed, 95% CI)	‐0.10 [‐0.22, 0.02]

18 Umbilical artery pH less than 7.20 Show forest plot	1	116	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.45, 1.75]

Comparison 2. Immersion in water versus no immersion during second stage of labour

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Comparison 3. Immersion in water versus no immersion during any stage of labour

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mode of birth (spontaneous vaginal birth) Show forest plot	9	2845	Risk Ratio (M‐H, Random, 95% CI)	1.03 [0.99, 1.09]

2 Mode of birth (instrumental vaginal births) Show forest plot	8	2739	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.70, 1.04]

3 Mode of birth (caesarean section) Show forest plot	9	2832	Risk Ratio (M‐H, Fixed, 95% CI)	1.19 [0.86, 1.65]

4 Use of analgesia (regional) Show forest plot	6	2499	Risk Ratio (M‐H, Fixed, 95% CI)	0.90 [0.82, 0.98]

5 Perineal trauma (third‐ or fourth‐degree tears) Show forest plot	5	2401	Risk Ratio (M‐H, Fixed, 95% CI)	1.37 [0.86, 2.17]

6 Perinatal deaths Show forest plot	1	120	Risk Ratio (M‐H, Fixed, 95% CI)	3.0 [0.12, 72.20]

7 Admission to neonatal intensive care unit Show forest plot	5	1862	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.70, 1.39]

8 Neonatal infection Show forest plot	5	1295	Risk Ratio (M‐H, Fixed, 95% CI)	2.00 [0.50, 7.94]

9 Neonate temperature Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

9.1 Temperature greater than 37.8 degrees C as an indicator for infection	1	274	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.06, 15.83]
9.2 Temperature less than 36.2 degrees C at birth	1	109	Risk Ratio (M‐H, Fixed, 95% CI)	0.98 [0.30, 3.20]
9.3 Temperature greater than 37.5 degrees C at birth	1	109	Risk Ratio (M‐H, Fixed, 95% CI)	2.62 [0.73, 9.35]
10 Fever reported in first week Show forest plot	1	171	Risk Ratio (M‐H, Fixed, 95% CI)	0.53 [0.10, 2.82]

11 Antibiotics given to neonate Show forest plot	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	1.5 [0.17, 13.52]

12 Estimated blood loss (mL) Show forest plot	3	273	Mean Difference (IV, Fixed, 95% CI)	‐6.28 [‐13.67, 1.11]

13 Postpartum haemorrhage Show forest plot	2	394	Risk Ratio (M‐H, Random, 95% CI)	0.73 [0.08, 6.90]

14 Use of analgesia (pharmacological ‐ pethidine/narcotic) Show forest plot	4	1240	Risk Ratio (M‐H, Random, 95% CI)	0.85 [0.46, 1.56]

15 Use of analgesia (pharmacological ‐ any) Show forest plot	2	394	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.80, 1.39]

16 Use of any analgesia Show forest plot	5	653	Risk Ratio (M‐H, Random, 95% CI)	0.72 [0.46, 1.12]

17 Maternal infection during labour/postnatal period (perineal, systemic, uterine or increase in temperature) Show forest plot	5	1295	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.50, 1.96]

18 Artificial rupture of membranes Show forest plot	3	926	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.90, 1.16]

19 Use of oxytocin for augmentation of labour Show forest plot	5	1125	Risk Ratio (M‐H, Random, 95% CI)	0.64 [0.32, 1.28]

20 Use of non‐pharmacological analgesia (transcutaneous nerve stimulation (TENS)) Show forest plot	2	845	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.37, 2.94]

21 Duration of first stage (minutes) Show forest plot	8	1561	Mean Difference (IV, Random, 95% CI)	‐42.21 [‐80.93, ‐3.49]

22 Duration of second stage (minutes) Show forest plot	11	1960	Mean Difference (IV, Random, 95% CI)	‐2.85 [‐8.85, 3.16]

23 Duration of third stage (minutes) Show forest plot	3	1165	Mean Difference (IV, Random, 95% CI)	‐0.52 [‐1.84, 0.79]

24 Duration of total labour (all three stages) Show forest plot	2	240	Mean Difference (IV, Fixed, 95% CI)	‐40.83 [‐87.09, 5.43]

25 Perineal trauma (none‐ intact) Show forest plot	5	1337	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.99, 1.35]

26 Perineal trauma (first‐ and second‐degree tears) Show forest plot	7		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

26.1 Second‐degree tear	7	1525	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.71, 1.10]
27 Perineal trauma (episiotomy) Show forest plot	7	1511	Risk Ratio (M‐H, Random, 95% CI)	0.88 [0.67, 1.17]

28 Self reports pain score on visual analogue scale of 0‐10 Show forest plot	3		Mean Difference (IV, Random, 95% CI)	Subtotals only

28.1 Pain score at start of assessment period (time zero)	2	141	Mean Difference (IV, Random, 95% CI)	0.15 [‐0.79, 1.08]
28.2 Pain score up to 60 minutes later	2	141	Mean Difference (IV, Random, 95% CI)	‐0.81 [‐1.34, ‐0.28]
28.3 overall pain score (assessed once post labour)	1	100	Mean Difference (IV, Random, 95% CI)	‐3.43 [‐3.95, ‐2.91]
29 Pain intensity (experience of moderate to severe pain) Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

29.1 Ordinal description as moderate to severe, 30 mins after randomisation	1	120	Risk Ratio (M‐H, Fixed, 95% CI)	0.75 [0.62, 0.91]
29.2 VAS scale 8 to 10, 30 mins after randomisation	1	120	Risk Ratio (M‐H, Fixed, 95% CI)	0.72 [0.58, 0.90]
29.3 Ordinal scale pain faces 4 to 5, 30 mins after randomisation	1	120	Risk Ratio (M‐H, Fixed, 95% CI)	0.67 [0.51, 0.90]
29.4 Ordinal description as moderate to severe, 1 hr after randomisation	1	117	Risk Ratio (M‐H, Fixed, 95% CI)	0.76 [0.63, 0.91]
29.5 VAS scale 8 to 10, 1 hr after randomisation	1	117	Risk Ratio (M‐H, Fixed, 95% CI)	1.21 [0.69, 2.11]
29.6 Ordinal scale pain faces 4 to 5, 1 hr after randomisation	1	117	Risk Ratio (M‐H, Fixed, 95% CI)	0.68 [0.53, 0.86]
29.7 Ordinal description as moderate to severe, 2 hrs after randomisation	1	57	Risk Ratio (M‐H, Fixed, 95% CI)	0.76 [0.59, 0.98]
29.8 VAS scale 8 to 10, 2 hrs after randomisation	1	57	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.66, 1.05]
29.9 Ordinal scale pain faces 4 to 5, 2 hrs after randomisation	1	57	Risk Ratio (M‐H, Fixed, 95% CI)	0.72 [0.52, 0.98]
29.10 Ordinal description as moderate to severe, 3 hrs after randomisation	1	32	Risk Ratio (M‐H, Fixed, 95% CI)	0.52 [0.23, 1.16]
29.11 VAS scale 8 to 10, 3 hrs after randomisation	1	32	Risk Ratio (M‐H, Fixed, 95% CI)	0.69 [0.39, 1.23]
29.12 Ordinal scale pain faces 4 to 5, 3 hrs after randomisation	1	32	Risk Ratio (M‐H, Fixed, 95% CI)	0.57 [0.25, 1.27]
29.13 Ordinal description as moderate to severe, 24 hrs after randomisation	1	119	Risk Ratio (M‐H, Fixed, 95% CI)	0.64 [0.50, 0.82]
29.14 VAS scale 8 to 10, 24 hrs after randomisation	1	119	Risk Ratio (M‐H, Fixed, 95% CI)	0.62 [0.49, 0.80]
29.15 Ordinal scale pain faces 4 to 5, 24 hrs after randomisation	1	119	Risk Ratio (M‐H, Fixed, 95% CI)	0.69 [0.54, 0.87]
29.16 Ordinal description as moderate to severe	1	117	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [0.73, 1.53]
30 Maternal temperature Show forest plot	1	60	Mean Difference (IV, Fixed, 95% CI)	0.20 [‐0.18, 0.58]

31 Systolic blood pressure Show forest plot	1	120	Mean Difference (IV, Fixed, 95% CI)	‐7.20 [‐13.12, ‐1.28]

32 Diastolic blood pressure Show forest plot	1	120	Mean Difference (IV, Fixed, 95% CI)	‐10.20 [‐13.70, ‐6.70]

33 Mean arterial blood pressure Show forest plot	1	120	Mean Difference (IV, Fixed, 95% CI)	‐10.5 [‐14.68, ‐6.32]

34 Preference for care in subsequent labour (Does not wish to use bath with next labour/birth) Show forest plot	2	236	Risk Ratio (M‐H, Fixed, 95% CI)	0.46 [0.24, 0.90]

35 Satisfied with labour Show forest plot	1	117	Risk Ratio (M‐H, Fixed, 95% CI)	0.24 [0.07, 0.80]

35.1 Little or not satisfied with coping experience	1	117	Risk Ratio (M‐H, Fixed, 95% CI)	0.24 [0.07, 0.80]
36 Satisfied with labour on scale Show forest plot	1	60	Mean Difference (IV, Fixed, 95% CI)	0.03 [‐0.64, 0.70]

37 Postpartum depression (EPDS more than 11) Show forest plot	2	370	Risk Ratio (M‐H, Fixed, 95% CI)	1.38 [0.85, 2.24]

38 Abnormal fetal heart rate patterns Show forest plot	3	487	Risk Ratio (M‐H, Random, 95% CI)	0.75 [0.34, 1.67]

39 Presence of meconium‐stained liquor Show forest plot	6	1380	Risk Ratio (M‐H, Fixed, 95% CI)	0.97 [0.78, 1.21]

40 Apgar score less than seven at five minutes Show forest plot	6	1953	Risk Ratio (M‐H, Fixed, 95% CI)	1.79 [0.76, 4.25]

41 Apgar score at five minutes Show forest plot	4	1184	Mean Difference (IV, Fixed, 95% CI)	‐0.04 [‐0.11, 0.02]

42 Umbilical artery pH less than 7.20 Show forest plot	2	226	Risk Ratio (M‐H, Fixed, 95% CI)	1.04 [0.54, 1.98]

43 Breastfeeding Show forest plot	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.69, 1.08]

44 Not breastfeeding after six weeks post birth Show forest plot	2	363	Risk Ratio (M‐H, Fixed, 95% CI)	1.17 [0.64, 2.15]

Comparison 3. Immersion in water versus no immersion during any stage of labour

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Comparison 4. Early versus late immersion in water

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Use of pharmacological analgesia (epidural/spinal analgesia/paracervical block) Show forest plot	1	200	Risk Ratio (M‐H, Fixed, 95% CI)	2.21 [1.39, 3.52]

2 Neonatal infection Show forest plot	1	200	Risk Ratio (M‐H, Fixed, 95% CI)	3.0 [0.12, 72.77]

3 Use of oxytocin Show forest plot	1	200	Risk Ratio (M‐H, Fixed, 95% CI)	1.9 [1.35, 2.68]

4 Abnormal fetal heart rate patterns Show forest plot	1	200	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

5 Apgar score less than seven at one minute Show forest plot	1	200	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 4. Early versus late immersion in water

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