Factors influencing the use of birth pools for labour and birth in the United Kingdom

This chapter is an adapatation of material from published articles and has been reproduced with permission from Milosevic et al.44,45 These are Open Access articles distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) licence, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text.

Background

Research on use of water immersion during labour and birth in the UK is limited, but international studies have identified several barriers to its widespread adoption. Negative attitudes from medical staff, often stemming from a lack of experience and safety concerns, have been frequently reported,46–49 along with insufficient knowledge and education among other healthcare professionals.47,49 Water immersion policies and guidelines have been found to be restrictive,47 and inadequate staffing levels,46,48 poor information provision50 and stigma from friends and family51 also affect birth pool use.

In the UK, birth options include OUs, alongside midwifery units (AMUs), freestanding midwifery units (FMUs) and home births, although many services do not offer all options. However, women planning to give birth in OUs, even those without risk factors, tend to have significantly lower rates of pool use compared to those in freestanding or AMUs. As found internationally, negative staff attitudes have been identified as a key barrier to water immersion during labour and waterbirths in the UK.52,53

To address gaps in understanding the factors influencing birth pool use in the UK, we conducted a two-stage qualitative study. Stage 1 comprised online discussions and interviews with women, midwives, neonatologists and obstetricians to explore their attitudes and experiences related to birth pool use for labour and birth. Stage 2 comprised in-depth case studies of OUs and midwifery units.

Methods and findings are summarised here, but these are described in detail in two publications.44,45

Stage 1: online discussion groups and interviews

Methods

Between October and December 2018, separate online discussion groups were set up for midwives, women who were pregnant or had given birth within the previous year, and neonatologists/paediatricians and obstetricians. The aim was to explore experiences, attitudes and beliefs in relation to the use of birth pools during labour and birth. This method was selected to engage geographically diverse participants and to encourage open expression of views via an anonymous forum. The online discussion groups were advertised via professional and parenting networks. Due to the difficulty in recruiting medical staff to participate in online discussions, between December 2018 and February 2019, we offered brief semistructured interviews to capture the views and experiences of this group. All midwives and medical staff worked in NHS settings in the UK.

Findings

The study revealed a range of factors influencing birth pool use in the UK, which were grouped into three main categories: Resources, unit culture and guidelines, and staff endorsement.

Resources

Availability of birth pools was a significant factor affecting pool use. Some women and midwives reported a shortage of pools, leading to limited access; the lack of availability of waterproof CTG equipment also restricted pool use for women with risk factors. Midwives suggested that a shortage of pools affected their ability to accommodate women’s choices in labour and created a reluctance to offer a pool, which in turn impacted on women’s awareness and midwives’ experience of intrapartum water immersion and waterbirth. Time taken for filling and cleaning pools between uses and inefficient allocation of birthing rooms were also highlighted. In obstetric-led units, where pool availability was particularly scarce, some women, who wanted to use a pool, were unable to.

Women described using strategies to ensure access to a pool, such as selecting a maternity unit with sufficient pools, contacting several units around their due date to assess occupancy, requesting a pool when telephoning the unit in labour or planning a home birth (which as women identified, due to cost, would not be accessible for all).

When planning my second delivery, I chose the unit based on how likely I was to get in the pool. The one I chose had the pool in a small internal room with no natural light; they were clear that it was only ever used for pool deliveries. The other potential unit … stated that the pool room was the largest room they had and was a lovely environment, so it often got used for normal deliveries just because it was one of the nicest rooms. I was shocked that they would allow the pool to be blocked in this way.

Unit culture and guidelines

Hospital guidelines were perceived as rigid and arbitrary by participants, making it challenging for women with risk factors to access intrapartum water immersion. Some participants mentioned that birth was often overmedicalised, especially in obstetric-led units, which led to pool use being viewed as unusual, and thus constrained, in contrast to the experience of women labouring in MLUs who generally described pool access as easy.

I was blocked (from using a pool) without genuine evidence-based rationale – it was a blanket policy they have of not letting any woman with any level of GD (gestational diabetes) use the birth centre … Postcode lottery comes into play as other areas would let a GD mother use a pool, which tells me that the risk cited by some clinicians is debatable and not evidence based.

Staff endorsement

Women receiving midwifery-led care generally felt supported in their choice to use a pool for labour and birth. Some midwives identified that a lack of confidence due to limited experience may underpin staff resistance to offering water immersion during labour and birth. Lack of support from obstetricians and senior midwives was also cited as a barrier to pool use, particularly in OUs.

Medical staff considered water immersion during the first stage of labour to be generally safe, but they raised concerns about potential risks of waterbirths, such as delayed recognition of complications, meconium aspiration, infection due to unclean water, increased perineal trauma and difficulties with fetal monitoring. Neonatologists, in particular, did not see any benefits of waterbirth for the baby and expressed concerns about potential harm, while obstetricians believed that pools provided effective analgesia for the first stage of labour but were less suitable for birth. It was suggested that some midwives preferred a ‘hands-on’ approach for the birth due to concerns about perineal tearing and would therefore encourage women to leave the pool before birth. Medical staff highlighted the difficulty of establishing the relative risks (RRs) of waterbirths due to lack of evidence and suggested that their perception of the safety of waterbirth might be biased due to their involvement in complicated births.

I do think there is still some resistance to (waterbirth) in the obstetric field. So better information wouldn’t be a bad thing … people are worried about infections … aspirations, pneumonia in babies. So yeah there are obstetricians who take a long time to change their views.

Conclusions from online discussion groups and interviews

This work identified various factors influencing the use of birth pools and rates of waterbirths in the UK and emphasised the need to address issues related to resource availability, including midwives with experience of caring for women in a pool, unit culture and guidelines, and staff endorsement. Demand for intrapartum water immersion and waterbirth was perceived to vary across the UK and across different socioeconomic groups: health professionals suggested that greater promotion of the options by maternity unit staff could increase awareness among women. Proactive support for waterbirth in obstetric-led units was seen as lacking. Obstetricians and neonatologists and some midwives held differing views towards water immersion during the first and second stages of labour. Those expressing concerns about birth in water generally expressed some acceptance of the potential analgesic benefits of water immersion during the first stage of labour, but they had concerns about the safety of birth in water for mothers and their babies. Other midwives, who were experienced and confident with caring for women in water during labour and birth, did not make this separation when talking about pool use.

Stage 2: case studies

Stage 2 of the qualitative work was designed to gain a deeper understanding of the factors influencing water immersion practices in selected maternity units. Data collection took place between July 2019 and March 2020 and included semistructured interviews, collating service documents and public-facing information, and observations of the unit environment.

Sampling and recruitment

Three case study sites were selected from NHS Trusts or Health Boards participating in the wider POOL Study, each with a MLU and an OU and at least one birth pool. The selection of sites aimed to ensure geographical diversity and varying waterbirth rates, as shown in Table 24.

Participants111 interviews were conducted across the six case study units (Table 25).

Case study findings

We identified similarities and differences across the case study units that influenced the rates of pool use for labour or birth.

Some of the key similarities were:

• Limited access to training: Most midwives had received no formal training in caring for women during intrapartum water immersion or during waterbirth. Training was considered as a ‘luxury’ due to time constraints. Student midwives had mixed exposure to intrapartum water immersion and waterbirth during their training, and obstetricians also had limited knowledge. Midwives felt that greater awareness of the benefits of water immersion among doctors would support their practice.
• Sociodemographic differences in pool use: Midwives observed that ‘White, middle-class women’ who were well-informed about their options were more likely to use a birth pool. Women from ethnic minority communities, particularly Asian women, were perceived as less likely to use a pool for labour or birth due to unfamiliarity or cultural reasons. Midwives suggested that providing comprehensive information to all women during the antenatal period could help reduce sociodemographic differences in pool use.
• Issues using waterproof fetal monitoring equipment: Units had waterproof equipment for continuous fetal monitoring, but it was not widely used, and some midwives or consultants were unaware of its availability. The equipment was not always charged, was sometimes not working or not synchronised to centralised fetal monitoring systems and was described as awkward to use in the pool. Midwives’ reluctance to facilitate continuous fetal monitoring in water meant that women who were recommended to have this were usually prevented from accessing water immersion.

We identified differences in criteria for pool use, equipment and resources, senior staff support and women’s awareness and attitudes towards intrapartum water immersion and waterbirth among the case study sites. These differences are summarised in Table 26.

Criteria in all units were generally seen as appropriate and supportive of intrapartum water immersion and waterbirth by midwives. However, guidelines were inconsistently applied, depending on individual clinicians’ knowledge and attitudes. For instance, some midwives had mixed views on whether women should use a pool in early labour, and cervical dilation requirements sometimes prevented pool use when women declined vaginal examinations.

On OUs, women were found often not to be offered with the option of water immersion even when they met the unit criteria for doing so.

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.

Use of equipment and resources varied across the sites. In site A, pool rooms on the OU were allocated efficiently, encouraging maximum pool use; however, this was not the case in sites B and C.

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 (the pool) they wouldn’t swap them round for it.

Senior staff support for ‘physiological birth’ played a significant role in influencing pool use during labour and birth. In sites A and B, obstetric consultants supported midwifery-led care, leading to increased access to water immersion and rates of waterbirths. However, in site C, obstetricians tended to discourage women from accessing the midwifery unit, impacting intrapartum pool use.

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 OU). But the doctors were adamant. So, they would say like, ‘She’s at risk of stillbirth’ and … things like that….

Women’s awareness and attitudes towards intrapartum pool use were influenced by factors such as unit tours and antenatal classes. In sites A and C, unit tours and pool room visits encouraged the consideration of their use during labour. Antenatal classes were also useful in raising awareness, although the availability was limited in sites A and B.

When I fell pregnant I was straight away thinking epidural in hospital, but (after visiting) I thought actually the birth centre was a much calmer, nicer place to give birth if I could.

Differences between OUs and midwifery units within each site were more substantial than those between the same type of units across the sites. Differences fell into four main categories: physical environment, midwives’ intrapersonal factors, autonomy and support of midwives, and information and support for women (Table 27).

The physical environment of maternity units, particularly the availability and location of pools, considerably influenced the numbers of women using pools. Some midwives suggested that the low number of pools available in OUs suited the low level of demand from women. However, others proposed that the limited availability itself affected requests to use a pool. Women felt discouraged from requesting to use a pool in OUs due to their perceived scarcity, and the nature of the rooms themselves made them less popular with some midwives (e.g. described as being located at the furthest point from the midwives’ station, set up differently to other birth rooms or not connected to the unit’s central fetal monitoring systems).

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.

Midwives’ attitudes and confidence played a crucial role in facilitating water immersion and waterbirths. Midwives in MLUs were more positive and experienced in water immersion and facilitating waterbirth, while those in OUs had varying attitudes and experience, with some expressing fear or reluctance. Midwives proposed that they and their colleagues fitted into one of two categories: ‘low-risk’ midwives who are confident in low-risk settings, and ‘high-risk’ midwives who are skilled at supporting higher-risk women but less comfortable with low-risk births.

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.

Autonomy and support for midwives were also important factors. Midwives in MLUs felt fully supported and encouraged to offer water immersion and waterbirths to women. By contrast, midwives in OUs often had to seek approval from senior staff, fearing they could be blamed for adverse outcomes if they supported pool use.

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 … 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.

The information provided to women about intrapartum water immersion and waterbirths during antenatal care appeared to influence their choices. In MLUs, pool use was actively promoted and routinely offered to women. In OUs, pool use was not discussed as frequently, leading to a reliance on women actively requesting the option, resulting in lower utilisation.

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.

Discussion of qualitative work

Stage 1 of the qualitative research identified factors influencing the use of birth pools for labour and birth by exploring the attitudes and experiences of key stakeholders, and it was the first UK study to encompass the perspectives of women, midwives and medical staff. Overarching categories were resources, unit culture and guidelines, and staff endorsement. Obstetricians and neonatologists generally expressed safety concerns around births in water, which were shared by some midwives. Midwives who were supportive of waterbirths regarded a lack of opportunity for training, experience and confidence of individual midwives as factors limiting pool use, particularly in OUs. Stage 2 of the research provided new insights into the influence of maternity unit culture on pool use through examination of the differences between six UK maternity units with varying waterbirth rates. Consistent with UK pool use statistics, the greatest differences were between OUs and midwifery units within case study sites rather than between the sites themselves. Criteria for intrapartum pool use, equipment and resources, staff attitudes and confidence, senior staff support for colleagues and endorsement of physiological birth were identified as key, alongside information provided to and encouragement for women to use a pool for labour or birth.

In both stages of the research, we found that pool availability had a broad impact, affecting women’s choice of maternity unit, requests for water immersion during labour, midwives’ ability to offer the pool and confidence in relation to pool use. Although limited pool availability acted to reduce the demand for water immersion and waterbirth, low demand was often cited as a reason for limiting the number of pools available, creating a vicious circle in which pool provision remained low. As found by Russell,52,53 birth room allocation practices in case study maternity units were a key influence on pool access, and it appeared to reflect the extent to which pool use was supported by the maternity unit. The timing of filling the pool also influenced the extent to which women were encouraged or enabled to use water immersion or have a waterbirth.

Examination of the UK context highlighted the differences between MLUs and obstetric-led maternity units. Women participating in stage 1 of the research generally perceived MLUs as supportive of pool use and waterbirths, but they described obstetric-led units as an overmedicalised environment in which pool use was seen as unusual and therefore restricted. Exploring the perspectives of medical staff facilitated understanding of the reasons behind these differences in culture, building on previous quantitative research.48 For example, obstetricians and neonatologists, although supportive of water immersion as analgesia during the first stage of labour, acknowledged that there was hypervigilance around birth in water, attributing this to a lack of evidence on the safety of waterbirth for mothers and babies and skewed perceptions of risk due to experiences being confined to complicated births.

The pool room environment was also found to influence the use of water immersion during labour, with midwifery units at case study sites providing welcoming pool rooms, while OU pool rooms had barriers to use, such as poorer monitoring facilities. Although several studies54–56 show that the birth room environment positively influences labour experience and outcomes, how this occurs, and the implicit messages conveyed by environment, have not been fully explored.

The relationship between midwives’ attitudes to water immersion and waterbirths, their confidence in offering the pool to women and the setting is a complex one. In terms of encouraging water immersion, in the midwifery units midwives were confident and experienced, with easier access to facilities and supported by senior staff.. Conversely, in the OUs, midwives were often fearful of facilitating pool use, had fewer opportunities to gain experience and worked with senior staff who themselves did not support water immersion or promote the pool as an option. In stage 2 of this research, midwives highlighted fundamental differences in the beliefs and competences of those working in the different settings. It is not possible to elicit the causal chain in this situation: whether midwives are attracted to a certain type of setting due to previous preference, or whether finding themselves in a particular setting, they develop the beliefs, competences and confidence to match, conforming to the norm for that setting. These differences and this interplay of factors have the potential to impact considerably on the way care is delivered and thus merit further exploration.

Lack of training and unfamiliarity with equipment were both given as reasons for midwives based in OUs being unable or reluctant to care for women in a pool. Such attitudes would not be tolerated towards other equipment on OUs, suggesting an acceptance among all levels of staff that the option for women to use a pool on an OU is an optional luxury rather than an essential midwifery skill.

In stage 1 of the research, strict eligibility criteria for intrapartum pool use (as found by Newnham et al. in 201557 and 201758) were found to have a clear impact on the accessibility of the option during labour and birth. In line with previous studies,47 both women and medical staff suggested that eligibility assessment was subjective rather than evidence-based. The existence of guidelines should have the potential to support midwives’ confidence and autonomy. However, we found that inconsistent implementation across case study sites meant that some women were prevented from using a pool when trust/health board policy would have supported them to do so. Pool use guidelines at all three sites had relaxed in recent times, with a general shift towards assessing suitability on an individualised basis; for example, increasing cut-off BMIs, removing cervical dilation requirements for pool entry and supporting women who are carriers of GBS and who require intravenous antibiotic prophylaxis to use a pool. Midwives generally welcomed this increased flexibility; however, not all were aware of the changes.

In support of Russell’s findings,53 participants suggested that water immersion tended not to be actively offered as an option, therefore there was a reliance on women themselves requesting to use a pool. This is contrary to the NICEguidance,59 which states that women should be offered the opportunity to use a pool during labour. Evidence suggests that antenatal information plays a vital role in enabling women to make an informed choice about water immersion.50,60,61 This is particularly important in starting to democratise pool use and break down some of the barriers, either real or assumed, faced by women from different backgrounds accessing waterbirth.

Recommendations for practice based on qualitative work

Midwives, doctors and managers working within obstetric-led care need to be aware of the potential barriers to intrapartum water immersion and waterbirth, so they can act to reduce these and support use of pools where appropriate. Increasing exposure to care of women using pools during labour and birth for student midwives and midwives in OUs may enhance confidence and be instrumental in changing unit culture. Strong midwifery leadership, for example through ensuring the presence of a consultant midwife in all settings (as recommended by the Royal College of Obstetricians and Gynaecologists62), is also key to ensuring a culture that safely supports uncomplicated labour and births.

Providing obstetricians and neonatologists with information on, and exposure to, waterbirths could increase support for pool use, reduce the risk of adverse events erroneously being attributed to birth in water and increase confidence in responding to emergencies in the pool. Applying local guidelines consistently will help to ensure that women who can safely use a pool are enabled to do so.

Even in areas with perceived low demand for water immersion, increasing the provision of pools in birth rooms can enhance midwives’ experience and confidence, enable water immersion to be offered more frequently and encourage women to request to use a pool. Birth room allocation practices should also be considered to facilitate more effective use of unit resources. Thought should be given to the birth room environment to ensure that all birth rooms are attractive to both women and midwives and that the layout of pool rooms encourages use of the pool. Filling the pool ready for a woman’s arrival may also facilitate this.

More importantly, it is vital that, in the antenatal period, women are provided with information to enable an informed choice about water immersion during labour and birth. Time constraints may make it difficult to discuss this in routine antenatal appointments, so it is important that antenatal information and/or maternity unit tours are available for all. At an organisational level, support for MLUs and home birth can help to increase access to these settings, and in turn, pool use.

Conclusions from qualitative work

The context of care in maternity units has a substantial influence on pool use during labour and birth. We found considerable differences between OUs and midwifery units in relation to equipment and resources, staff attitudes and confidence, senior staff support and women’s awareness of intrapartum water immersion. Findings have several implications for practice: increased exposure to care of women during intrapartum water immersion for labour and birth is vital to improve the confidence of midwives, particularly those working in OUs; sharing of information with for obstetricians and neonatologists on the practicalities and outcomes of pool use could increase support for waterbirth; and improved access to antenatal information would help increase awareness of the option to use a pool. We recommend that OUs increase pool provision, ensure birth room allocation, maximise the use of unit resources, design pool room environments that encourage use and ensure that all midwives take the responsibility for being familiar with water immersion equipment and unit guidance.