Background
Methods
Study design
Sampling and recruitment
Site A | Site B | Site C | ||||
---|---|---|---|---|---|---|
MU | OU | MU | OU | MU | OU | |
Births per year (circa) | 400 | 5000 | 1000 | 4000 | 600 | 4000 |
Birth rooms | 3 | 12 | 4 | 12 | 5 | 12 |
Pools | 2 | 2 | 4 | 1 | 3 | 1 |
Waterbirth rate (circa) | 61% | 5% | 30% | 1% | 28% | 0.5% |
Data collection
Data analysis
Results
Site A | Site B | Site C | ||||
---|---|---|---|---|---|---|
OU | MU | OU | MU | OU | MU | |
Band 5–6 midwives | 6 | 3 | 4 | 4 | 5 | 3 |
Band 7–8 (senior) midwives | 6 | 4 | 1 | 2 | 2 | 1 |
Student midwives | 1 | 4 | 2 | 2 | 2 | 1 |
Maternity care assistants | 2 | 3 | 1 | 1 | – | – |
Postnatal women | 1 | 1 | 4 | 6 | 5 | 4 |
Community midwives | 6 | – | 4 | – | 6 | |
Obstetricians | 4 | – | 4 | |||
Neonatologists/Paediatricians | 2 | – | 2 | |||
Doulas | – | 2 | – |
Similarities across case study units
Limited access to waterbirth training
‘I’ve never seen [a pool] used … actually … I don’t really even know how it would work. It’s not something we get taught about.. like I wouldn’t know what to do if someone had a problem in the pool. I’d just pull the plug out and drain them, or do you get the patient out and then pull the plug? I don’t know’ (Site C, Obstetric unit, Obstetrician, 416)
Sociodemographic differences in pool use
‘I don’t want to say married, you know, nuclear family type professionals, but I do think you see an increased trend [for pool use amongst this group]. The ones who would have gone to the breastfeeding classes, the ones who paid to go to [antenatal] classes’ (Site B, Obstetric unit, Student Midwife, 105)
‘We would like our Asian community to try [the pool] more, but I think it’s just their culture a lot of the time [that stops them]. Probably getting undressed, to be honest … and they tend to have a lot of people with them, you know like sister-in-laws, mother-in-laws’ (Site C, Midwifery unit, Band 6 Midwife, 426)
Issues using waterproof fetal monitoring equipment
‘If you’re high risk and you need to be continuously monitored, we generally say not the pool. But then we do also have the facility for telemetry so we can use it whilst in the pool. Which I’ve actually never seen in my training or since I’ve qualified but I know people do use it’ (Site A, Obstetric unit, Band 5–6 Midwife, 204)
Differences between case study sites
Categories and themes | Barriers | Facilitators |
---|---|---|
Criteria for pool use | ||
Criteria for using the pool | Women must meet specific criteria to use a pool. Lots of exclusion criteria. (Site C) | Few contraindications to pool use mentioned in guidelines; risk factors assessed on an individual basis (Site A) Guidelines specifically mention women with risk factors who can use a pool (Site B) |
Staff training requirements | Midwives required to be trained to support women in water for labour/ birth; otherwise they have to approach their manager before undertaking this (Site C) | No specific training required (other than emergency evacuation training); midwives required to have the necessary competences and skills (Sites A & B) |
Criteria for entering the pool | Women should be in established labour (4–5 cm) (Sites B & C) | No fixed cervical dilation required; pool can be used for prolonged latent phase (Site A) |
Use of equipment and resources | ||
Allocation of pool rooms | Women usually automatically allocated a non-pool room (Site B, Obstetric unit) Pool room used for non-water births so is rarely empty (Site C, Obstetric unit) Women not using the pool would not be moved out of the pool room during labour (Site C, Obstetric unit) | Low risk women asked at triage if they would like to use a pool (Site A, Obstetric unit) Some midwives will ask women to switch rooms to free up the pool room (Site A, Obstetric unit) |
Filling pool | Pool is usually filled after women arrive (Sites B & C, Midwifery unit) | Pool is automatically run when women are on their way (Site A, Midwifery unit) |
Pool room environment | Pool rooms less popular than other rooms (Sites B & C, Obstetric unit) | Considered ‘nicer’ than general birth rooms; one pool room located near midwives’ station (Site A, Obstetric unit) |
Emergency procedures | Emergency evacuation not well-practised; some midwives not confident in emergency procedures (Site C, Obstetric unit) | Midwives confident in ability to cope with emergencies in the pool (Sites A & B, Obstetric unit) |
Home birth pool use | Cost can be a barrier to pool hire (Sites A & B) Women have to source their own pool (Sites A & B) | Pools, liners and water pumps provided for women wanting to use a pool at home (Site C) |
Support for natural birth | ||
Support for natural birth | Obstetric consultants sometimes block women from accessing the midwifery unit (Site C) | Obstetric consultants are supportive of the midwifery unit and facilitate women going there (Sites A & B) Support for natural birth at all levels of management (Site A) |
Women’s awareness of and attitudes towards pool use | ||
Tours of the unit | No tours of the midwifery or obstetric unit; virtual tour available online (Site B) | Women are invited to have a tour of the midwifery unit (Sites A & C) |
Antenatal classes | Antenatal classes are over-subscribed, so not all women have the chance to attend (Sites A & B) | Antenatal classes are available for all women and pool use is discussed at length (Site C) |
Sociodemographic differences | Large Asian population who are perceived as less likely to want to use the pool (Site C) | Women in the area are well-informed and aware of their options (Sites A & B) |
Criteria for pool use
I think if people followed the guidelines on who can use the pool a bit more, then they would be helpful. Like … up on the high-risk unit now, if they thought about who could actually labour in the pool … But … it’s not really offered, even to the women who can use it’ (Site B, Midwifery unit, Student Midwife, 109)
‘It varies from consultant to consultant as to how woman centred they’re prepared to be. So you might find that somebody will agree something in advance … and then the consultant on the day is just not comfortable with it, the risk will have always been the same. What changes is the consultant who is there’ (Site B, Doula, 127)
Use of equipment and resources
‘If women get out of the pool and want an epidural, we try and change the rooms, so that we can get the room cleaned and have it available for someone else, rather than have them sort of blocking the room’ (Site A, Obstetric unit, Band 5–6 Midwife, 214)
‘You’ll hear the coordinator when she takes a phone call from triage … the question always is does she want to use the pool?’ (Site A, Obstetric unit, Band 7–8 Midwife, 202)
‘I think there is a culture of it’s kind of not the right place for waterbirths … it’s not facilitated for that reason, so if they’ve got somebody else in that room who doesn’t need it they wouldn’t swap them round for it’ (Site C, Obstetric unit, Band 5–6 Midwife, 405)
‘They’ve got the choice, but we run the pool when they phone, it is ready and warmed up when they get here, and it just feels like a natural progression. Quite often they don’t even ask, or we don’t say do you want a waterbirth, they just get in’ (Site A, Midwifery unit, Band 7–8 Midwife, 305)
‘Hauling a woman out of the pool, when she’s wet and slippery … I’ve not had the training to use [the nets], so if I was in that situation I’d, I’d be unprepared … I haven’t looked after a woman in the pool. And I don’t think I’d want to … I wouldn’t feel equipped’ (Site C, Obstetric unit, Band 5–6 Midwife, 409)
‘I don’t think I’ve ever had a woman who’s really wanted a [home] waterbirth who’s not had the chance to have one’ (Site C, Community Midwife, 435)
Senior staff support for natural birth
‘[Doctors are] definitely advocating birth centres more and more, which in turn then obviously does promote waterbirth essentially’ (Site A, Midwifery unit, Band 7–8 Midwife, 310)
‘They suspected that I had a blood condition … [but] when the bloods came back, they were … normal … every time and there was no reason for me to be induced [on the obstetric unit]. But the doctors were adamant. So they would say like, “She’s at risk of stillbirth” and stuff and things like that … But … the midwives were very, very helpful, they gave me the confidence to just carry on … ’ (Site C, Midwifery unit, Woman, 434)
‘What it tends to end up as if you’re low risk you can use the pool, if you’re high risk you tend not to be able to, even if you would be suitable … any woman that ends up on labour ward tends not to end up in a pool, and in the birth centre it would be routine’ (Site C, Obstetric unit, Obstetrician, 401)
Women’s awareness of and attitudes towards pool use
‘We’re lucky with the facilities at the birth centre, and everybody knowing about being able to come for a tour … Because then that prompts discussion about the pool, because people don’t usually expect the birth centre to be as nice as it is, because it’s gorgeous’ (Site C, Community Midwife, 420)
‘When I fell pregnant I was straight away thinking epidural in hospital, but … I thought actually the birth centre was a much calmer, nicer place to give birth if I could’ (Site A, Midwifery unit, Woman, 319)
‘We don’t have [the] chance to discuss [pools] with every single woman … but everyone is told that they can come to the antenatal classes, and if they choose to come to them … then [pool use] … will be discussed with them at length’ (Site C, Community Midwife, 420)
‘We didn’t get … to do [antenatal classes] … we were late booking them, so we didn’t get a chance to get in there’ (Site B, Midwifery unit, Woman, 121)
Differences between obstetric and midwifery units
Categories and themes | Obstetric units | Midwifery units |
---|---|---|
Physical environment | ||
Pool availability | Pool in 7–17% of birth rooms | Pool in 60–100% of birth rooms |
Pool room environment | Some pool rooms disliked by midwives | Described by women/midwives as relaxing/encouraging of pool use |
Midwives’ intrapersonal factors | ||
Midwives’ attitudes | Some not keen on pool use, often due to lack of confidence | All very positive about pool use |
Midwives’ confidence | Some not confident - frightened of pool use | All confident in supporting pool use |
Autonomy and support of midwives | ||
Senior staff support | Some senior staff unsupportive of pool use | Midwives feel very supported by seniors to support pool use |
Midwives’ autonomy | Some autonomy to offer the pool to ‘low risk’ women | Complete autonomy to offer the pool to all women |
Information and support for women | ||
Women’s awareness | Women don’t necessarily know there is a pool, so don’t ask to use one | Women very aware of pools on the unit; most ask to use one |
Information given to women | Pool use not fully discussed antenatally | Pool use discussed and encouraged antenatally |
Proactive offering of pool | Pool not usually offered - women have to be proactive | Pool offered / promoted to all women |
Support for women to use a pool | Pool use generally discouraged, and in some cases blocked | Women are supported / actively encouraged to use a pool |
Physical environment
‘I have been on a couple of shifts where a lady’s wanted a pool, and they’ve both been taken up, and then she’s obviously had to not have the birth she was envisioning’ (Site A, Obstetric unit, Midwifery Support Worker, 211)
‘In all honesty, there are actually very few women on here who do want to go in [the pool]’ (Site C, Obstetric unit, Band 7–8 Midwife, 408)
‘There’s one pool in the whole [unit] and it is first come first served... I think I had that in my head … just even if I asked for it I probably wouldn’t get it’ (Site B, Obstetric unit, Woman, 117)
‘With all the other rooms they are connected to [the remote monitoring system] so you know that you’ve kind of got eyes on that watching … You’re kind of on your own in the pool room, no one is watching it … ’ (Site B, Obstetric unit, Band 5-6 Midwife, 128)
‘An unspoken thing … is that it’s not a very nice room, just in terms of its setup … It’s a bit more clinical in other rooms, so generally this room isn’t loved by midwives … It is just things are in different places … . I don’t know what’s in those drawers in order. Whereas if I went to any other room I would know’ (Site B, Obstetric unit, Band 5–6 Midwife, 119)
‘When you walk into one of the delivery rooms, the most obvious point of the delivery room is the pool. And no bed. Often people say well where’s the bed?... I think that’s a really good trigger point and they often say oh that looks amazing, to get into a pool’ (Site A, Community Midwife, 302)
Midwives’ intrapersonal factors
‘I love pool births and that’s half the reason I’m here. I think it just gives people immense pain relief, relaxation, and you just instantly see people relax as they get into it’ (Site A, Midwifery unit, Band 5-6 Midwife, 304)
‘I think it’s all ingrained here that we’re very pro water and a lot of the staff will encourage it’ (Site B, Midwifery unit, Band 5–6 Midwife, 107)
‘They wouldn’t offer it … If they’re not keen on pool births, they would go straight to Entonox, paracetamol, codeine, pethidine, epidural, rather than offering the pool’ (Site A, Obstetric unit, Band 5–6 Midwife, 203)
‘Coming across to a unit that [is] quite pro waterbirth it was just a confidence building thing for me and having had a good eight years I would say now of regular exposure to waterbirths, that’s really helped my confidence’ (Site A, Community Midwife, 302)
‘Some midwives are, are frightened … we’ve had midwives in other areas in tears, because they’re frightened of coming on here, haven’t … been witness or participated in a waterbirth, since … they were a student’ (Site C, Midwifery unit, Band 5–6 Midwife, 432)
‘I certainly wouldn’t feel confident enough to be left in charge of a woman … delivering in the pool … I’ve just not got … the competence really … So I, I’d sort of defer and let somebody else … look after her really’ (Site C, Obstetric unit, Band 5–6 Midwife, 409)
‘When midwives are really confident in high risk … their high-risk care, starts to drip into the midwifery-led [unit], transfer rates go up, intervention rates start to go up. Whereas if you see it the other way, their normal care starts to get infiltrated into the women [on the obstetric unit]. So you see a peak in the pool being used [on the obstetric unit], because it’s a midwife that’s really confident with waterbirth’ (Site B, Band 7–8 Midwife, 102)
‘Some midwives don’t like working in the midwifery-led unit, they’re not midwifery-led midwives, they’ll call themselves high risk midwives … they will be then the midwives that are highly skilled in looking after that diabetic mother, or you know, all of those kind of things, and their knowledge in a different area will be absolutely superb and much more superior to somebody else, but switch their roles, and they both feel really uncomfortable and out of their comfort zone’ (Site B, Band 7–8 Midwife, 102)
Autonomy and support of midwives
‘I had a lady that asked for a waterbirth and was told no. Even though I kind of said but she is low risk … I was told categorically no … A lot of the time because I know certain staff [are] on … I wouldn’t offer [the pool because I know] they wouldn’t allow it … which is sad really’ (Site C, Obstetric unit, Band 5–6 Midwife, 405)
‘We fought hard to get a pool on the labour ward … I think some of the consultants wanted twelve high risk rooms’ (Site C, Midwifery unit, Band 7–8 Midwife, 428)
‘I think [a pool is] something that birth centres should have. I am not sure about it being on labour ward because we get the more complicated people, and you want to monitor them more’ (Site C, Obstetric unit, Obstetrician, 416)
‘Everybody’s happy if the outcome is good, but if [it’s not] … they go back and back and back … and then they’ll start looking and saying so you know, her blood pressure was up once, so why did you put her in the pool? So that is sometimes the issue … It’s not quite as black and white up here to put somebody in the pool as it is on the midwifery-led unit’ (Site B, Obstetric unit, Band 7–8 Midwife, 133)
‘I can think of … a waterbirth and the baby was six hours old. Everything was nice and straightforward until we noticed that the baby was grunting … actually we weren’t overly concerned … [But] the paediatrician … said it was because it was a waterbirth … actually there’s no research that supports that’ (Site A, Midwifery unit, Band 7–8 Midwife, 310)
‘Women are down here because things are normal so you can just say “Fine” and turn the taps on … you don’t have to, you might update your, your senior but at that point you can make the decision’ (Site B, Midwifery unit, Band 5–6 Midwife, 106)
‘I think [on the obstetric unit] you [need to check with senior staff] because the women’s cases are complex … If I compare to my [midwifery-led] placement … [it] was just a standard thing, oh you can have the pool. Up here … well as much as you are autonomous you are and you’re not really. You’re forever double checking nearly every decision you make … So I don’t feel like really with anybody that I would just say yeah let’s go and use the pool’ (Site B, Obstetric unit, Band 5–6 Midwife, 130)
Information and support for women
‘When I first found out that I was pregnant, [waterbirth] was something that I … didn’t want to consider, I didn’t want to be in water and be wet … but once I’d been to the antenatal … it was something that changed my mind and something I would definitely want to do’ (Site C, Midwifery unit, Woman 404)
‘Once I was told I was moved to being consultant-led, I was under the impression that a waterbirth wouldn’t necessarily be something that I could consider … . As the pregnancy went on it just became something I thought is probably not going to happen’ (Site B, Obstetric unit, Woman, 117)
‘I think if it’s high risk, I don’t think [pool use is] discussed … it just gets dropped … and I don’t think it is given as a valid, potential option … If your obstetric staff are not keen on it, it won’t be promoted via them, they’ll actually try and put women off, and if the midwives are not experienced in it, then they won’t promote it either’ (Site C, Obstetric unit, Band 7–8 Midwife, 402)
‘It seems to me … that [the pools are] not always offered … even if they are available, as a first line. If you were in the birthing centre they’d be filling the pool practically before you got there. Whereas [on the obstetric unit] … it’s an afterthought’ (Site A, Community Midwife, 217)
‘I’ve never seen it be offered … The only time I’ve ever seen a woman in the pool [on the obstetric unit] was because she requested it’ (Site B, Midwifery unit, Student Midwife, 109)
‘In the hospital you … hear people telling [women] that a pool is not available because they don’t want to use them’ (Site A, Midwifery unit, Band 5–6 Midwife, 304)