Factors influencing water immersion during labour: qualitative case studies of six maternity units in the United Kingdom

Abstract

Background Water immersion during labour can provide benefits including reduced need for regional analgesia and a shorter labour. However, in the United Kingdom a minority of women use a pool for labour or birth, with pool use particularly uncommon in obstetric-led settings. Maternity unit culture has been identified as an important influence on pool use, but this and other possible factors have not been explored in-depth. Therefore, the aim of this study was to identify factors influencing pool use through qualitative case studies of three obstetric units and three midwifery units in the UK. Methods Case study units with a range of waterbirth rates and representing geographically diverse locations were selected. Data collection methods comprised semi-structured interviews, collation of service documentation and public-facing information, and observations of the unit environment. There were 111 interview participants, purposively sampled to include midwives, postnatal women, obstetricians, neonatologists, midwifery support workers and doulas. A framework approach was used to analyse all case study data. Results Obstetric unit culture was a key factor restricting pool use. We found substantial differences between obstetric and midwifery units in terms of equipment and resources, staff attitudes and confidence, senior staff support and women’s awareness of water immersion. Generic factors influencing use of pools across all units included limited access to waterbirth training, sociodemographic differences in desire for pool use and issues using waterproof fetal monitoring equipment. Conclusions Case study findings provide new insights into the influence of maternity unit culture on waterbirth rates. Access to pool use could be improved through midwives based in obstetric units having more experience of waterbirth, providing obstetricians and neonatologists with information on the practicalities of pool use and improving accessibility of antenatal information. In terms of resources, recommendations include increasing pool provision, ensuring birth room allocation maximises the use of unit resources, and providing pool room environments that are acceptable to midwives.

Seeking safe harbour: Water immersion for women with complex pregnancy

“…Currently there is no evidence or research to support the biomedical stance of a lack of safety for women with complexity using water immersion and this would be a more honest and accurate place to initiate the conversation regarding water immersion in labour in this context. Women and health professionals recognise that the eligibility requirements for water immersion are subjective rather than evidence-based and the commonly raised concerns against water immersion are not supported by the research (Milosevic et al, 2020). What research has demonstrated is that water immersion has been shown to have no negative impacts for women or babies and is associated with a range of positive outcomes such as feeling more in control, being more active and experiencing less pain in labour.…”

“…Within biomedically dominant institutions it can be challenging to change the rhetoric around water immersion and the positioning of water birth as an unsafe practice. For all health practitioners the literature consistently demonstrates that a lack of familiarity and confidence with water immersion is associated with increased fear, increased beliefs around the risks of water immersion and a reduced willingness to support water immersion (Plint & Davis, 2016;Milosevic et al, 2020;Stark & Miller, 2010). Pools for water immersion are less available within obstetric birth settings which maintains this lack of familiarity and confidence for staff and the literature supports that hospital staff, both midwives and obstetricians, operate as gate keepers to pool use (Milosevic et al, 2020;Russell, 2011).…”

“…For all health practitioners the literature consistently demonstrates that a lack of familiarity and confidence with water immersion is associated with increased fear, increased beliefs around the risks of water immersion and a reduced willingness to support water immersion (Plint & Davis, 2016;Milosevic et al, 2020;Stark & Miller, 2010). Pools for water immersion are less available within obstetric birth settings which maintains this lack of familiarity and confidence for staff and the literature supports that hospital staff, both midwives and obstetricians, operate as gate keepers to pool use (Milosevic et al, 2020;Russell, 2011). While some birthing suite midwives have indicated that they believe water immersion has an important role within obstetric birth settings this belief was not held by obstetricians who did not want to and were not confident in providing care for women using water immersion (Orrantia & Petrick, 2021;Plint & Davis, 2016).…”

“…Midwives have identified that in high-tech birthing environments the discomfort of many practitioners with pool use meant that adverse outcomes were quickly attributed to being due to water immersion (Milosevic et al, 2020). This increased the sense of blame for individual midwives if they had supported the women in her desire for water immersion.…”

“…Within the obstetric birth environment, the socialisation of midwives and ward culture had a significant impact on midwifery decision making (Russell, 2011). Midwives working within an obstetric setting were less likely to feel they were able to make an autonomous decision to support water immersion than midwives who were working in a midwifery-led setting (Milosevic, 2020). Additionally, water immersion within an obstetric setting was often viewed as time consuming, requiring an investment in one-on-one care which was viewed as a 'luxury' and 'selfish' of the midwife (Russell, 2011).…”