On 17 June 2014 Public Health England (PHE) and NHS England temporarily advised against the home use of birthing pools with built-in heaters and recirculation pumps, potentially filled up to 2 weeks in advance of the birth. This followed a case of Legionnaires’ disease identified in a baby born in this specific type of birthing pool at home.
The temporary advice was issued as a precautionary measure while further investigations were carried out into the provision of these pools by a number of companies, including the advice given by the companies on pool filling and on controlling risks from exposure to legionella.
Further investigations have been carried out and based on an assessment of the available evidence, PHE has now confirmed the provisional advice issued on 17 June 2014.
This means that PHE recommends that heated birthing pools (incorporating both a re-circulation pump and heater), filled in advance of labour, should no longer used for labour or birth, in the home setting.
The majority of birthing pools used at home are filled from domestic hot water systems at the time of labour - these birthing pools do not pose the same risk and are excluded from this alert, as long as pumps are used solely to empty the pool and not for recirculation of warm water.
Professor Nick Phin, PHE’s head of Legionnaires’ disease, said:
Further investigation into this incident has confirmed that the type of legionella bacteria found in the birthing pool is the same strain which caused the baby to become ill with Legionnaires’ disease.
As part of the investigation, PHE has been working with local authorities to investigate the provision of these pools by a number of companies, including the advice given by the companies on pool filling and on controlling risks from exposure to legionella.
This final recommendation is based on the difficulty, in the home setting, of preventing legionella growth in re-circulated warm water over a period of days or weeks. For this reason, PHE has confirmed its earlier precautionary advice and is recommending that this type of pre-filled, heated birthing pool is no longer used at all at home.
Louise Silverton director for midwifery at the Royal College of Midwives, said:
Women planning birth at home using a traditional pool that is filled when the woman is in labour or using a fixed pool in an NHS unit are not affected by this alert and should not be concerned. Birthing pools in hospitals are subject to stringent infection control procedures and monitoring. Home birthing pools filled during labour come with disposable liners and are only in place for a relatively short time period, reducing opportunity for bacterial growth.
Any women with concerns about using home birthing pools should contact their midwife or local maternity unit.
Notes to editors
- This is the first reported case of Legionnaires’ disease linked to a birthing pool in England, although there have been 2 cases reported internationally some years ago.
- The baby diagnosed with Legionnaires’ disease remains very poorly in hospital.
- A briefing note confirming the original advice has been issued by PHE via the Chartered Institute of Environmental Health (CIEH) to local authorities and to all PHE Centres across the country.
- The Patient Safety Alert (PSA) issued by NHS England on 17 June 2014 remains in place. The PSA notified the healthcare system – and specifically midwives – to the possible risks associated with the use of these heated birthing pools at home. The alert recommends that heated birthing pools, filled in advance of labour and where the temperature is maintained by use of a heater and pump, are not used for labour or birth.
- Key messages:
- the majority of birthing pools used at home are filled from domestic hot water systems at the time of labour
- these types of pool do not present the same risk as long as pumps are used solely to empty the pool and not for recirculation of warm water
- this new advice relates to the importance of women not labouring or giving birth in a heated birthing pool which has been filled prior to the onset of labour and where the temperature has been maintained by the use of a heater and pump
- The heated pools from the supplier involved in this incident have been recalled. Currently there are at least 6 companies known to hire out heated birthing pools, with a total of 60 to 70 pools made available for hire. The majority of these pools have been recalled and all known companies have been advised.
- The pools were usually delivered around 2 weeks before the expected delivery date, filled from the domestic hot water supply, and the temperature maintained via a pump and heater until labour and delivery. Various disinfection regimes are recommended by the companies. It is unclear whether or not legionella risk assessments have been undertaken by the companies.
- Legionella is a commonly occurring bacteria and can be found in around 10 to 20% of domestic hot water systems. Legionnaires’ disease is a severe pneumonia caused by the Legionella bacteria. There are 350 to 400 cases a year reported in England and Wales, mainly in older adults. More information about Legionnaires’ disease.
- Legionnaire’s disease is extremely rare in childhood, with only one case in children aged 0 to 9 years reported in England between 1990 to 2011.The infection does not spread from person-to-person – people become infected with the bacteria through inhalation of contaminated water droplets.
- There are 2 international reports of legionella infection after birth in birthing pools, both from the late 1990s, in Italy and Japan:
- ‘Legionella pneumophila Pneumonia in a Newborn after Water Birth: A New Mode of Transmission’ (available from the CID website)
- ‘Neonatal Sudden Death Due to Legionella Pneumonia Associated with Water Birth in a Domestic Spa Bath’ (available from the NCBI website)
- Public Health England’s mission is to protect and improve the nation’s health and to address inequalities through working with national and local government, the NHS, industry and the voluntary and community sector. PHE is an operationally autonomous executive agency of the Department of Health.
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Image by Centers for Disease Control and Prevention