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Neonatal Outcomes After Delivery in Water. OBJECTIVE: To assess neonatal intensive care unit (NICU) admissions and neonatal outcomes after water birth or land birth in an alternative birthing center. METHODS: We conducted a prospective observational study of preselected low-risk parturients separated into three groups depending on their location for labor and delivery: land-land, water-land, and water-water. Delivery outcomes, labor length, maternal pain assessment, need for newborn resuscitation, and NICU admission and diagnoses were collected. The primary outcome was admission to the NICU. RESULTS: There were 2,077 total deliveries from April 2015 to December 2019, consisting of 458 land-land deliveries, 730 water-land deliveries, and 889 water-water deliveries. The rate of NICU admission was 2.8% (95% CI 1.5-4.8%) for land-land deliveries, 4.1% (2.8-5.8%) for water-land deliveries, and 2.0% (1.2-3.2%) for water-water deliveries. A post hoc power analysis revealed a 70% power to detect a 2.1% difference in NICU admissions between the water-land and water-water groups. CONCLUSION: In this cohort of low-risk pregnant women, births in water and on land were associated with similar rates of admission to the NICU.