By Carol A. Kemper, MD, FACP
Fristchel E, et al. Fatal legionellosis after water birth, Texas, USA, 2014. Emerging Infectious Diseases www.cdc.gov/eid. 2015;21(1):130-132.
Despite a lack of thorough statistics, home water births seem to be not only increasingly prevalent in both the US and the UK, but also gaining traction in Australia and Europe. This increase in popularity has heightened the visibility of water births, renewing concerns about midwife training as well as the sanitation and maintenance of equipment used in home water deliveries.
One particularly tragic case is that of a baby boy who died of sepsis and respiratory failure in 2014. Initial cultures failed to detect any of the range of organisms that typically cause post-partum sepsis. Critical care staff, however, were aware of the home water birth and suspected that additional testing would reveal a potential cause. Tracheal aspirates and legionella urinary antigen tests both proved positive for Legionella pneumophila. In spite of a rigorous treatment regimen the baby died 19 days after he was first hospitalized. The duration of the 9-month pregnancy passed without complication. At the time of birth, the newborn was reportedly normal weight and entirely healthy. Texas state health authorities were called in to investigate the incident, and found several concerning factors that could have played a role in the baby’s death. The water used for the birth came from a well, and prior to the delivery was allowed to sit and circulate at around 37 degrees for two weeks. The water was changed two days prior to delivery, but was only treated with enzyme tablets and not chlorine. The tub used was a spa hot tub primarily used for recreation that was exceedingly difficult to appropriately sterilize and is not licensed for use as medical equipment. After delivery the new mother was permitted to hold the baby while in a more standard bathtub that was also filled with well water. By the time the investigation tested the tubs, the spa tub had been disinfected and put into storage, so neither tub yielded evidence of Legionella. Though cases of legionella stemming from hot tubs can occur, cases involving infants are exceedingly rare. It is also documented that inadequate chlorination of spas and hot tubs can allow the proliferation of mycobacteria, fungi and a whole host of other microbial agents. Take, for example, a regional outbreak of non-tuberculous mycobacterial folliculitis. Despite never definitively sourcing the outbreak, the investigation revealed just how dirty and contaminated the pipes and internal jets of hot tubs can be even with regular cleaning.
This was undoubtedly a tragic case, and it has led to more stringent and formal public health recommendations regarding sanitation, maintenance, and midwife care standards — all in an effort to ensure that a case of this nature does not recur.