Midwives’ experience of their education, knowledge and practice around immersion in water for labour or birth

Design

Mixed methods were utilised to provide in-depth knowledge [13, 14] relating to the education, knowledge and practice around immersion in water for labour or birth. This methodology offers researchers using quantitative methods the opportunity to utilise qualitative research to gain deeper understanding of the investigated phenomenon [15]. Utilising this two phase mixed methodology provided a more informative, constructive and thorough integration of the research results, building on the links between methods rather than within methods [15]. We envisaged being able to utilise both numbers and words would give greater insight into the bigger picture around midwives' experience of their education, knowledge and practice around immersion in water for labour or birth.

Participants and setting

The study was performed at the sole tertiary public maternity hospital in WA, which has approximately 5200 births annually. Women can labour and birth in the tertiary maternity hospital’s Labour Ward and Birth Suite or the Family Birth Centre (an adjacent building within the hospital grounds).

Perinatal data collected in 2016, by King Edward Memorial Hospital (KEMH) in WA confirmed that 5% (228 of 4402) of infants ≥37 weeks gestation were born immersed in water. Currently WA and South Australia are the only Australian states with state-wide policies and guidance supporting immersion in water for labour and birth, although waterbirth is available in every state and territory [16, 17]. In WA midwives are guided by state-wide clinical waterbirth guidelines [16]. Between August and November 2016 we invited the 34 midwives who provided care for women who opted to use water for labour and/or birth to participate. Throughout the study, women choosing to labour and/or birth in water were cared for by midwives working within two publically funded services: the MGP and CMP. These low risk continuity of care models [18] are ideally suited to provide care for women who labour and/or birth in water, as this model facilitates a shift from high risk obstetric-led care to low risk midwifery-led care [18, 19]. Both the MGP and CMP operate their services (antenatal, intrapartum and postnatal care) from the Family Birth Centre (FBC) with the CMP also providing antenatal, intrapartum and postnatal care to women in their homes and local community clinics. In these midwifery care models, a primary midwife is supported by a small team of midwives who provide continuity of care 24 h a day throughout pregnancy, birth and up to two weeks post birth. Perinatal data collected in 2016 at KEMH confirmed MGP and CMP midwives birthed 16% (813 of 5189) of all women at KEMH. Although, no women received immersion in water for labour and birth in the tertiary maternity hospital’s Labour Ward and Birth Suite throughout the duration of the study, in the last two weeks of the study the tertiary maternity hospital agreed that immersion in water for labour and birth could be facilitated in their main Labour and Birth Suite.

Recruitment and data collection

Data analysis

Phase one

Table 1 summarises the midwives’ perception of their education, knowledge and practice around immersion in water for labour and birth. A total of 29 (85%) out of a potential 34 midwives returned a questionnaire. The mean time midwives were qualified was 162 months (13 years and 5 months), with the mean time midwives had been facilitating waterbirth being 83 months (eight years and 9 months). Most (59%; n = 17) midwives worked in the MGP. The majority (93%; n = 27) of midwives used the WA state-wide clinical guidelines for waterbirth [16] for their education and training, with 90% (n = 26) accessing the E-learning package developed by the study hospital’s education department. Following waterbirth training, 93% (n = 27) felt equipped to facilitate waterbirth with the mean number of waterbirths required to facilitate confidence being seven.

Phase two

Two focus groups comprising of seven and five midwives were performed. Findings are presented with supportive quotes in italics from the midwives. For confidentiality a pseudo-name was allocated to each midwife.

Instinctive birthing

Jasmine agreed with Kate’s sentiments: ‘Because you can’t see as the vagina is submerged, the first sign she needs to push is she’s pushing’ whilst Anna summarised her experience was that ‘They’re more likely to reach down and lift the baby up themselves’.

Woman-centred atmosphere

The theme ‘woman-centred atmosphere’ described a labour and birth environment which was woman centred, calm, peaceful and relaxed. Initially midwives discussed how labouring and birthing in water empowered women. Jacquie noted ‘I feel women have more control’. Anna agreed suggesting she thought it was to do with power stating ‘The woman holds more of the power in labour’. Noreen continued the discussion ‘the thing is society brings up pictures of women with somebody doing it [the birth] for them, there is a cultural thing of having somebody delivering the baby whilst [with water] there is themselves and their body’. Bonnie reflected on Noreen’s comments suggesting water promoted a change in the woman’s demeanour ‘You can see the change in the woman’s face and in her body when she gets in the water, it’s nice and relaxed’. Beth agreed water ‘Promotes the environment to be quiet and peaceful’. Jacquie thought this may be because ‘The space between contractions is very different from a land birth, they are very much more focused on their breathing and calmer’. Whilst Noreen shared how a woman’s relaxed state affected the care she gave ‘You know it’s all relaxed and you can concentrate more on the signs, the natural signs of a woman giving birth’. Sophie agreed ‘It’s so calming for the women. I think it relaxes them which then relaxes us’.

Undisturbed space

The theme ‘undisturbed space’, described how water creates an undisturbed space where access to the woman is mediated by the water. Jasmine noted that ‘If you’re in the bath people knock and they stay out, they leave you alone. As far as society is concerned, it’s not acceptable to walk into the room when someone’s in the bath. If someone’s in lithotomy, fine’. Kerry reflected it also had an impact on how safe the woman felt. ‘Especially for the women who have a sexual abuse history, they feel safer in the water, they feel like you can’t get at them’. The topic of safety led to a discussion around privacy with Olivia commenting that ‘It’s [‘water] their ‘own space and you have to really reach into their space, rather than them being poked and prodded [with a land birth]’. Dorothy agreed stating ‘It’s more undisturbed’. Kerry continued ‘Even though you can see beneath the water and everything, I think for them it just feels, more private under the water’. Kate reflected on her experiences by recounting a scenario ‘A woman that came back to the waterbirth study day and spoke about when she got in [the pool] there was a real sense of privacy, even though she had nothing on, the water was like a veil’. Baily also remarked on how the ‘dynamics’ of a labour in water effects the partner ‘I get a sense they quite like it too, because they are able to just sit and observe and hold that silent still place…my experience is that even men feel quite comfortable in that space’.

The challenges midwives experienced with waterbirth

Analysis of the focus group transcripts exploring the question ‘are there any issues with waterbirth’ revealed that issues highlighted by the midwives were perceived as challenges. Two themes were identified: learning through reflection and facilities required to support waterbirth.

Learning through reflection

The theme ‘learning through reflection’ illustrates how midwives learnt by documenting and then reflecting on the clinical challenges encountered during their day to day clinical practice around water immersion for labour and birth. Kerry shared ‘I didn’t used to but since we’ve been doing group practice… when you look at your records you can see most of them are waterbirths’. Olivia continued ‘I don’t remember all of the waterbirths…I’ve got a little book that I just pop them in’. Kate reflected on her colleagues comments sharing she did not keep records of each waterbirth and that her confidence caring for women in water ‘took a long time. I’ve probably done, I don’t know over 150 now’. Kate went on to explain why ‘You had to flex the head and then move the hand and then sweep the perineum, it was really hands on. But that’s how we were taught. So to move to totally hands off [waterbirth] where you’re not even poised is challenging’. Olivia agreed with Kate’s sentiments describing a waterbirth scenario where ‘I remember taking over from somebody else and it was a hypno-birth and so there was no talking…it was a good learning experience’.

To illustrate, the topic of learning through clinical experience led to a discussion around placental cord snapping. Bonnie shared ‘I’ve had a few cord snaps now. Like quite a few issues, but it hasn’t changed my feeling of how to perform waterbirth because I know it’s going to be fine and we just deal with it as it comes’. Kerry empathised, supporting Bonnie by acknowledging ‘I think a lot of midwives get anxious even though they may pretend they don’t get anxious about waterbirths. They want to get the baby out as fast as possible. But I think if you make them [the women] aware you don’t just yank it [the baby up]…you need to check how long it [the cord] is before you can go yanking’.

Facilities required to support waterbirth

Sophie was also concerned by the rollout of waterbirths to the main hospital but her frustration was around the referral process. ‘When waterbith was approved in the main hospital…I had a patient come over and say ‘I want a waterbirth but they [the main hospital] won’t facilitate one for me over there and they’ve told me to come to the Birth Centre and I was quite surprised’. Whilst Kate’s sentiments concerned the content of the waterbirth guidelines. ‘When it [the waterbirth guideline] was first developed we didn’t have telemetry and now we do. So I think waterbirth telemetry needs to be incorporated into the guideline’. Other midwives did not appear sure of how often in-service needed to be provided in relation to emergency management, pool evacuation and assessment of blood loss. There was debate between midwives in relation to how often these drills should be performed. Dorothy confirmed ‘In the CMP we have to do like a quiz, you know we put the blood in the water every six months and estimate it’. Whilst Jacquie confirmed ‘We do up a calendar [of available professional development sessions]’ and it was up to individuals to ensure their development was up to date.

Strengths and limitations

Although the quantitative methods employed provided limited scope to explore the wide range of experiences midwives in our study encountered caring for women who laboured and/or birthed in water, they did provide the research team with an objective starting point for further exploration of specific aspects of the questionnaire [21, 30]. For example, utilising a question for the focus groups gleaned from a phase one question asking midwives to score their enjoyment facilitating immersion in water for labour and birth, gave us the opportunity to contextualise what they enjoyed; providing a connection between the quantitative and qualitative components that could not be answered by mono-methods alone. By utilising both numbers and words to explore this topic [14, 15], the qualitative and quantitative components became cohesively integrated, producing research findings around midwives enjoyment which were greater than the sum of individual parts of the research [31]. This approach exposed the importance of instinctive birthing; woman-centred atmosphere; and undisturbed space.

Midwives in this study were self-selected from the MGP and CMP midwives based within the sole tertiary public maternity hospital in WA. Providing midwives with a website link to the WA state-wide waterbirth guidelines may have influenced their responses. This was a self-assessment of competence which is a subjective aptitude. The research would have been strengthened by comparing the midwives responses to their actions. Participating midwives may have been motivated and confident in their waterbirth practice. The sample of midwives included in phase one was small and may not be representative of all midwives who provide care for women who labour and/or birth in water. We acknowledge these factors could have had an impact in relation to the findings and should be considered when interpreting transferability of the findings to other settings.