The specific aim of this WA study was to assess Midwifery Group Practice (MGP) and Community Midwifery Program (CMP) midwives’ experience of their education, knowledge and practice around immersion in water for labour or birth. This mixed method study was performed in two sequential phases. Phase one incorporated a cross sectional design and examined midwives' perceptions of education, knowledge and practice around immersion in water for labour or birth through a questionnaire; 34 midwives were invited to participate. Phase two employed a qualitative descriptive design to explore what midwives enjoyed about caring for women who labour or birth in water and the challenges midwives experienced with waterbirth; two focus groups were held.
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
Phase one
Midwives were invited to participate in the study through an information letter and in-house designed questionnaire (Additional file 1), both of which were sent to their workplace mobile phone. Midwives who did not want to complete the online questionnaire were given the option to complete a hard copy and return it to the research team by placing it in a locked box situated in the FBC. Returning a completed questionnaire was deemed implied consent. Ethics approval was gained from the Women and Newborn Health Service Ethics Committee (Approval Number 2016103QK) at the study centre.
The questionnaire was validated through a review process with an expert panel involving a midwifery educator and three midwives who had experience caring for women who had birthed in water. Feedback from the panel resulted in changes to questions around being competent to facilitate water immersion for labour or birth and actively promoting this birth choice for labour and birth. This question was divided into two questions, one focused upon labour and another concerning birth.
The aim of the questionnaire was to examine midwives' perceptions of education, knowledge and practice around immersion in water for labour. Midwives were asked about: their employment status (if they worked in the MGP or CMP and how long they had been working as a midwife and facilitating water immersion for labour or birth); their education (training undertaken to facilitate immersion in water for labour or birth and number of births required to develop waterbirth confidence); their practice (two factors they would discuss with women in relation to water immersion for labour or birth); their confidence caring for women immersed in water for labour and birth (in the first, second and third stages of labour); their enjoyment facilitating immersion in water for labour and birth; whether they actively promote water immersion for labour and birth; and their interpretation of four scenarios around antenatal, early labour, birth and third stage clinical care. The scenarios required a written response, were scored and were based on information relating to the state-wide clinical waterbirth guidelines [16]. It was decided to give midwives completing the questionnaire a website link to the state-wide guidelines [16], in the information letter accompanying the questionnaire. By providing a website link to this guidance, we were examining how midwives interpreted and applied the guidance in their clinical practice. In relation to confidence and enjoyment, midwives were asked to place a cross on a 10 cm line (where zero was ‘not confident’ or ‘does not enjoy’ and 10 was ‘very confident’ or ‘enjoys’), to quantify their perceptions on the continuum from zero to ten.
Phase two
An item was included at the end of the questionnaire (phase one) inviting midwives to participate in a focus group to discuss their experiences around immersion in water for labour or birth. The first author conducted the two focus groups. Observations were documented by the fourth author in the form of field notes. Each focus group lasted approximately 45 min. The focus groups were held at the study centre in an interview room that was convenient to all interested midwives. Prior to commencing the focus group, midwives were reminded that their privacy would be maintained by issuing each of them a unique identifier; the discussions linked to an individual’s identity should ‘remain in the room’; and that the focus group would be audio recorded. All midwives verbally consented to these conditions.
The final questions for the focus groups (Additional file 2) were based around the results from phase one, with two questions being developed: question one asked ‘What contributes to your enjoyment of waterbirth?’ Two prompts were utilised for this question. The first one addressed the promotion of natural birth and the second was around supporting women’s choice. Question two asked ‘Are there any issues with waterbirth?’ One prompt was utilised around the issue of exploring which stage of labour midwives found most challenging.
Data analysis
Phase one: Quantitative data
Each of the four clinical scenarios was allocated a maximum score according to whether a midwife correctly identified key aspects of clinical practice based on the state-wide clinical waterbirth guidelines [16]. Four members of the research team independently scored each scenario. The team then met to compare scores. Any disagreement in relation to the scores was discussed and a consensus reached by referring back to the data.
Means, and interquartile ranges were used to summarise continuous data (such as the scores for each scenario). Frequency distributions were used to summarise categorical data (such as feeling equipped to facilitate waterbirth following training). Statistical software (SPSS version 22) was used for analysis.
Phase two: Qualitative data
Transcribed focus groups were subjected to thematic analysis [20] by five members of the research team, who analysed a cross-section of transcripts and field notes ensuring each data source was reviewed by at least two members [21]. Analysis required the research team to become submerged in the data. Transcripts and field notes were deconstructed enabling the research team to identify patterns, similarities and themes from the midwives’ words or sentences [13, 20, 21]. The team met weekly over three months to negotiate, clarify and refine the themes. Any disagreements on interpretation were negotiated by referring back to the data. All the researchers were clinical or academic midwives, with varying experiences of facilitating immersion in water for labour or birth. As a process of member checking, preliminary themes were presented to five midwife participants who confirmed agreement with the themes.