Understanding the barriers and facilitators related to birthing pool use from organisational and multi-professional perspectives: a mixed-methods systematic review

Aims To identify and synthesize the evidence regarding the facilitators and barriers relating to birthing pool use from organizational and multi-professional perspectives. Design A systematic integrated mixed methods review was conducted. Data sources MEDLINE, CINAHL, PsychINFO, EMCARE, PROQUEST and Web of Science databases were searched in April 2021, March 2022 and April 2024. We cross-referenced with Google Scholar and undertook reference list searches. Review methods Data were extracted from studies meeting the inclusion criteria. Barriers and facilitators to birthing pool use were mapped and integrated into descriptive statements further synthesized to develop overarching themes. Results Thirty seven articles (29 studies) were included—quantitative (12), qualitative (8), mixed methods (7), and audits (2), from 12 countries. These included the views of 9,082 multi-professionals (midwives, nurses, obstetricians, neonatologists, students, physicians, maternity support workers, doulas and childbirth educators). Additionally, 285 institutional policies or guidelines were included over 9 papers and 1 economic evaluation. Five themes were generated: The paradox of prescriptiveness, The experienced but elusive practitioner, Advocacy and tensions, Trust or Trepidation and It’s your choice, but only if it is a choice. These revealed when personal, contextual, and infrastructural factors were aligned and directed towards the support of birth pool use, birthing pool use was a genuine option. Conversely, the more barriers that women and midwives experienced, the less likely it was a viable option, reducing choice and access to safe analgesia. Conclusion The findings demonstrated a paradoxical reality of water immersion with each of the five themes detailing how the “swing” within these factors directly affected whether birthing pool use was facilitated or inhibited. Supplementary Information The online version contains supplementary material available at 10.1186/s12978-023-01690-0.

that encourages buoyancy and the freedom to move.The warm water can also offer comfort, relaxation and pain relief.Extensive studies have demonstrated birthing pool use during childbirth is safe for mothers and babies.It is associated with reduced medical interventions (e.g.speeding up labour and cuts to the perineum), improved outcomes (e.g.satisfaction, less pain or excessive bleeding after birth).Given these positive outcomes, we wanted to explore any barriers or facilitators for birthing women and people accessing birthing pools so we could help improve access for those wishing to use one.We gathered and assessed the literature to explore these aspects.We included quantitative and qualitative studies exploring the perspectives of different maternity professionals and those of organisations.We reviewed 37 studies from 12 countries (from 2004 to 2020).We found that birthing pool use was a viable option when all maternity professional groups and their organisational guidelines or policies valued and supported its use.Conversely, in other organisations, multiple barriers prevented the use of birthing pools as an equally viable option to medication pain relief options.These barriers were influenced by the beliefs of different maternity professional groups, organisational guidelines or policies (where some were highly restrictive) whether midwives were supported to offer care in birthing pools or whether the midwives had the confidence to do so.Keywords Analgesia, Birth pool, Childbirth, Guidelines, Maternity care, Midwifery, Physiological birth, Policies, Water immersion, Water birth, Obstetrics, Anesthesiology, Neonatology

Background
The pain of childbirth is unique.It is both expected and purposeful, unlike other forms of pain.Many women seek interventions to ease the discomfort.While some will opt for pharmacological methods that attempt to eliminate pain, such as epidural analgesia, other women will choose non-pharmacological options that buffer the pain and may increase the likelihood of a physiological birth [1].Water immersion for labour and/or birth in an appropriately sized birthing pool, is a low-tech, nonpharmacological pain relief option.As an effective tool to optimize the physiology of labour and the release of endogenous endorphins and oxytocin [2], water immersion is associated with several benefits: reduced labour duration [3], transfer from midwifery-led settings [4], episiotomy, postpartum hemorrhage, [5] and carries no increased risk of obstetric anal sphincter injury (OASI) [5].Furthermore, birth pool use is associated with an increased likelihood of spontaneous vaginal births [6], intact perineum [7] and high maternal satisfaction [8].Importantly it can reduce intervention in the obstetric unit setting [3,5,9], particularly for nulliparae.
For neonates, systematic reviews have not found an association with waterbirth and poor neonate outcomes [5,10].While more cord avulsions have been reported for waterbirths, the incidence is widely variable indicating care practices such as undue traction may be more relevant than birth in water [5].Moreover, cord avulsion can be quickly and easily managed with no consequences for the newborn [10].Despite these benefits and with no long-term adverse outcomes for neonates-as identified in multiple systematic reviews [10][11][12], barriers to birthing pool use remain [13][14][15].There have been calls for a large-scale randomised controlled trial (RCT) to determine the safety profile.However, as an intervention, the birth pool precludes blinding, which presents a major RCT limitation and a recent feasibility study (N = 1260) found only 15% (n = 118) of participants would consent to randomisation in a future waterbirth trial, indicating that an RCT is unlikely to be feasible [16], or ethical in a healthcare climate that respects and supports maternal choice.Therefore, an understanding of these barriers, along with potential facilitators for birthing pool use is important for care providers and maternity services to ensure equitable and improved access.
With all the benefits water immersion offers birthing women and people, demand for birth pool access and use has increased.Use in high-income countries has grown steadily since the 1990s [12], prompting the development of numerous policies and guidelines regarding birthing pool use [17,18].However, evidence from the UK and Australia suggests that birth pool usage is dependent upon the setting, staffing and infrastructure [17,19,20].For example, the UK Birthplace study found that comparable healthy women planning to birth in obstetric units (OU) were significantly less likely to use water immersion compared to women who birth in midwifery-led settings [21].For example, only 13.3% of nulliparae used immersion birthing pool in an OU versus 53.7% in a freestanding midwifery unit (FMU), with a similar disparity amongst multiparae [21].
In other high incomes countries, uptake of water immersion also varies by setting [22].In Australia, there is a significant disparity across States and territories and within and across local health networks with the highest birth pool use in midwifery-led settings and continuity of care models.It is estimated that around 60-80% of women birthing at home in Australia use water immersion for labour and/ or birth compared with rates between 1 and 10% in hospital settings [23,24].These statistics highlight the known association between birthing pool use and midwifery-led care and settings [6]; suggesting birth pool access may be inhibited/less supported in the obstetric unit (OU) setting [21].Given that the majority of birthing women and people in high-income countries birth in OU's [25], where they are cared for by multi-professional teams (midwives, obstetricians, anaesthetists, and paediatricians), exploration of the perspectives from all maternity professionals and a review of organisational evidence (i.e. policy and/or guideline analysis) would yield a comprehensive overview of barriers and facilitators regarding birth pool use.As such, this mixed methods evidence synthesis, the first to date was undertaken to examine the organisational and multi-professional perspectives of water immersion to uncover both the facilitators and barriers to birth pool use.

Aim
The aim of this mixed-methods evidence synthesis was to source, synthesize and interpret the evidence relating to birthing pool use from organisational (policies and guidelines analyses) and multi-professional perspectives to examine the barriers and facilitators to birth pool use.

Design
We used a systematic integrated mixed-methods design.This deviated from the original published protocol (PROS-PERO 2019 CRD42019146998) whereby we originally intended to carry out a qualitative meta-thematic synthesis exploring maternity multi-professionals' views and experiences regarding birthing pool use during labour and birth.Our initial scoping searches identified less qualitative studies than anticipated but did yield surveys and papers related to organizational perspectives of birthing pool use.Therefore, we expanded our research questions and amended our research design and search strategy to secure a fuller, more comprehensive review to answer our research questions.We adopted a mixed methods integrated review design, as per Noyes, Booth, Moore, Flemming, Tunçalp and Shakibazadeh [26].This involved using both quantitative and qualitative data which were gathered, analysed and integrated to answer the research question: 'What are the barriers and facilitators, from organisational and multiprofessional perspectives, for birthing pool use for labour and/or birth?' .

Reflexivity
Reflexivity is an integral part of quality research; researchers convey their positioning in relation to the research to enhance the trustworthiness of the study [27].In brief all authors are midwives.CF, AM and EB have extensive experience of facilitating water immersion for labour and birth across all birth settings (home, birth centre, and hospital), and MC has extensive experience of facilitating birth pool use in the OU setting.All believe water immersion is a feasible low-cost, low-tech form of pain relief with benefits for women.Additionally, all believe access to water immersion needs to be improved to ensure equitable pain relief options are available.By referring back to or reflecting on our prior positioning throughout the research process, potential blind spots or biases were challenged [27].Furthermore, three authors have been involved in water immersion research in various capacities with MC directly involved in 5 of the included papers in this review.Therefore, to ensure impartial assessment of quality, a fourth researcher AM reviewed these papers who was unknown to MC at the time of assessment, with CF.

Search strategy
We carried out two pilot searches in MEDLINE and Cumulative Index of Nursing and Allied Health Literature (CINAHL) and found that using a simplified search string yielded the best balance between comprehensive searching and specificity.See Table 1 for the final search terms.All searches can be found in Additional file 1.
A second search was carried out using the identified key words in Cumulative Index of Nursing and Allied Health Literature (CINAHL), MEDLINE (Ovid), PsychInfo, Embase, Emcare, Proquest and Web of Science.These searches were then cross-checked with Google Scholar.Reference/citation checking of all identified papers was undertaken.Details of all search results are provided in Additional file 1. Database searches were saved to EndNote and duplicates then removed.
Inclusion and exclusion criteria were adapted to reflect the expanded review.Accordingly, we focused on the views, opinions, perspectives and experiences of all maternity staff (midwives, obstetricians, anesthetists, neonatologists) regarding birthing pool use.Additionally, we sought policy and/or guideline analyses, economic evaluations or audits to reflect organizational perspectives.It is also important to note differences between countries in their use of clinical policies and/or guidelines.For example, in the UK birthing pool use sits within guidelines-flexible recommendations for care provision.Whereas in Australia, birthing pool use sits within policies (mandatory expectations of clinical care provision) and guidelines (flexible recommendations of care).While we recognise these differences, in reality, guidelines are often viewed as mandatory policies [28] so for the purposes of this review we have kept them closely aligned and representative of organisational perspectives.We also included any published study, thesis or audits related to the research questions e.g., quantitative, qualitative, mixed-methods or policy/guideline analysis.No date restrictions were set.No language caveat other than studies that could be translated via Google Translate.No time restrictions were applied but papers were excluded if they could not be translated and if they related to either the views and experiences of women using birthing pools or those related to maternal-neonatal outcomes following birthing pool use.

Quality appraisal
Quality assessment of cross-sectional surveys was carried out using a critical appraisal checklist [29].Quality assessment of qualitative papers was carried out using criteria from Walsh and Downe [30].Quality assessment of economic evaluations were carried out using the adapted CASP tool by Drummond, Sculpher, Claxton, Stoddart and Torrance [31].Quality assessment of mixed methods papers was carried out using the Mixed Methods Appraisal Tool (MMAT) tool [32] where they reported both elements of the mixed methods in one paper.However, for mixed method studies reporting discrete phases across different papers, they were quality assessed against the framework suited to the research design identified in the paper and not with the MMAT tool.For example, Russell [20] and Russell, Walsh, Scott and McIntosh [33] were publications arising from one overarching mixed methods action research study.Russell [20] reported the qualitative component comprising of interview and focus group data and was quality assessed against the Walsh and Downe [30] framework.Russell, Walsh, Scott and McIntosh [33] reported the distinct quantitative component comprising of a survey following an educational workshop and was quality assessed against the BMJ Publishing Group Ltd. [29] survey quality framework.Audits were not quality assessed but all other studies were graded A-D by discussion between two reviewers (CF/AM), where A: No, or few flaws; the study credibility, transferability, dependability, and confirmability is high, and D: Significant flaws that are very likely to affect the credibility, transferability, dependability, and/or confirmability of the study [30].A detailed exposition of the quality assessments can be found in Additional file 2.

Data analysis and synthesis
Data analysis was undertaken in stages (an exposition of the full analysis found in Additional file 1).First, study characteristics of the included papers were collected on a data extraction form: author and date, title, resource setting, country, study design, setting, population, participants, methods.Second, a data-based convergent synthesis as per Noyes, Booth, Moore, Flemming, Tunçalp and Shakibazadeh [26] was carried out.This involved MC reading and re-reading each text 'line by line' and extracting the findings from the papers in short relevant sections that were tabulated, colour coded and applied with a code word or phrase.Where studies also included women's views, data only pertaining to staff views was extracted.CF cross-checked at this stage of the process to ensure accuracy and trustworthiness of the analysis.Third, the codes were then reviewed and grouped together which generated 10 descriptive categories reflecting five sets of opposing statements related to the key barriers and facilitators to birthing pool use.Finally, these opposing statements were further synthesized interpretatively into five themes, reviewed by the whole research team.

Results
The initial literature search was undertaken in April 2021 by MC and updated in March 2022.CF carried a further search update April 2023 (no further studies were found).A total of 5788 records were sourced from the databases and through Google Scholar and citation checking (see Fig. 1 for PRISMA flow diagram).Duplicates were removed.Paper titles and abstracts were screened against the inclusion criteria by MC and irrelevant records were excluded yielding 93 records in total.Full text versions of 11 papers could not be sourced therefore, were excluded prior to full-text screening.Thereafter, full text screening of 82 records was performed separately by MC and CF and a consensus reached about each paper yielding a total of 44 papers that met the inclusion criteria.However, of these, seven records were later excluded as the results of four theses were included as published papers (already included), while another two theses were excluded as they were not written in English and were too large for Google Translate, and finally, one was excluded as it was not research or audit.Therefore, the total sample included was 37 papers, but 29 studies-5 authors utilized either mixed-methods or reported on different aspects of the same overarching study [13,14,17,19,[33][34][35][36][37][38][39][40][41].

Findings
The ten descriptive statements derived from the dataset can be found in Table 3.
Five interpretative themes arose from the data analysis-see
Several midwives reported policies and guidelines assisted their decision-making and reduced their fear of working outside their scope of practice or the parameters of their workplace [34,46].In turn, this assured guideline-developers that midwives would be accountable should they not be working in line with the guidance [17].Moreover, in some studies, policies and guidelines were valued as tools with clearly documented benefits and risks that could be shared with birthing women or people to facilitate informed decision making [45,48].Additionally, they informed risk assessments assisting midwives to identify potential deviations from normal and as such, deliver appropriate and timely action [45,48].This was found to promote practitioner confidence and where confidence improved, practitioners were more likely to facilitate water immersion: "I wanted to make sure that what we did was robust and would stand up and actually support midwifery practice for birth through water.So I wanted to have a strong educational framework to support it.Because ... I'm sure eventually there would be some kind of adverse outcome and we need to be able to show that we've got some rigor behind what we're doing and why we're doing it" Clinical Midwifery Consultant [34].
Conversely, multiple studies reported policies and guidelines restricted women and midwives' autonomy [13,17,19,35,37,38,48].For example, the information was either too scant or overly cumbersome, inhibiting greater uptake of the option [19,38,39,48].Others reported that policies and guidelines were excessively risk-focused and that much of the content was focused

Review finding Theme
Policies and guidelines can be facilitative and prompt implementation of birth pool use Policies and guidelines are often risk averse and do not reflect women's experiences The paradox of prescriptiveness Education, training, mentorship, and experience leads to knowledge, competence, and confidence in facilitating birth pool use The elusive experienced practitioner The experienced but elusive practitioner Water immersion is a midwifery option in demand that facilitates physical and psychological benefits and physiological birth Resistance stems from fear, lack of experience and support and the view that labour and birth are inherently risky Trust or trepidation

Midwifery champions
The importance of medical and organisational support

Advocacy and tensions
Women must actively seek and request water immersion Infrastructure, cost, and concerns inhibit implementation and accessibility It's your choice, but only if it is a choice on minimizing "potential" or "possible" risks, and rather than supporting individualized care for each woman [17, 19, 35, 37-39, 44, 48, 49].Where blanket statements about risk or medical history were included as contraindications [19], midwives interpreted this to be a major barrier whereby the slightest deviation often precluded women from choosing water immersion [17, 35-37, 48, 49]: "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" Obstetrician [36].

The experienced but elusive practitioner
This theme exemplified a common requirement of practitioners to undertake additional education or training to facilitate birth pool use while also exposing the barriers to becoming experienced enough to do so.In some cases, excessive demands on midwives to achieve waterbirth competencies (that were not required to facilitate pharmacological pain relief ) and to become 'experienced'-loosely defined, was a significant barrier to providing birthing pools as an option.For example, multiple studies highlighted that water immersion was not always included in midwifery programs and therefore, some midwives sought out water immersion education packages or courses to upskill [13,34,44,45,48].While some midwives felt formal education was important [44,45], others believed it was simply physiological birth and therefore within the scope of a midwife [15,42,45]; as such, extensive and prescriptive accreditation requirements or credentialing were not required [34].Midwives in the study by Woodward [45] suggested that these additional training requirements might deter midwives from facilitating and/or discussing water immersion with women.
"…training should not be seen as 'any big deal as that will put midwives off waterbirth if it is thought to be so different.' Midwife [45].
Furthermore, two studies [36,45] discussed that water immersion training and education was not given the same weight as other procedures.Midwives resented a lack of training during their education once they experienced the benefits water immersion afforded women [42,45].This was exacerbated where women sought water immersion but were denied access because an experienced practitioner was not available [19,34,38].The need for accreditation or formal training, particularly in Australia, was identified as a major barrier [19,34,35,39,44].

"All women have the opportunity to have water immersion in labour however staff in birth suite
are not all accredited for water births hence water immersion is not used as freely due to the "risk" of unplanned water births, hence all staff need to be accredited with water immersion/water birth as the two go hand in hand." Midwife [35].
In one study, the policies and guidelines specified a set number of water immersion competency requirements [48].This was also detailed in other studies however, these requirements were not based on high quality evidence as reflected by the inconsistencies from venue to venue [19,34].In some cases, midwives who had been facilitating water immersion for decades were expected to undertake training packages when moving from one hospital to another in order to prove their competency [13,34].Therefore, policies and guidelines could inhibit birthing women or people's access to birthing pools through creating elusive expectations of midwives, notably not required for pharmacological pain relief methods.
Additional education and/or training, while not always viewed by midwives as essential, was identified as a facilitator of water immersion [17,34,42,47,50].The literature revealed that midwives and other health care providers involved in caring for women using water not only felt more confident after engaging in workshops and study days but were also more likely to promote and advocate for its use [42,47,51].This was particularly the case for emergencies including evacuating a woman from the bath/pool in the event they collapsed [48].
Midwives wishing to support women in the pool raised the importance of having an experienced midwife mentor to facilitate confidence and competence [36,[42][43][44][45]].An experienced mentor provided reassurance and safety, especially for those who were just starting out as they could explore their feelings and fear and gain vital skills [45].Confidence and competence grew with each positive water immersion experience, building experiential evidence to counteract negative views held by other clinicians and counteract opinions based on cultural influences [17,35,43]: "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" Community Midwife [36].
Clinicians who were experienced, competent and confident were more likely to discuss water immersion with women and facilitate access [35,43,45].However, prior experience and contextual factors were found to be highly influential over the accessibility of water immersion.
"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" Midwife [36].
Conversely, midwives who were mentored by practitioners (including midwives) averse to water immersion expressed a negative experience and a lack of confidence even where they wished to offer the option to women [20,37,45].

Trust or trepidation
There was a generalized trust in water immersion from midwives included in the studies reviewed, especially from those who had facilitated the option.Water immersion was viewed as a means of supporting women and birthing people to achieve a physiological birth such that it had been associated with reduced intervention and improved outcomes [13,19,42,[51][52][53][54].This view was informed by the wider research and the midwives' own experiences of witnessing the comfort, protection and relaxation that birth pool use afforded women [13,17,50,53,54].Midwives also discussed a deep trust in labour and birth as physiological processes and more so, in women's bodies to achieve and navigate the intricate but intimate experience [52].They articulated the demarcation of the birth pool instilled control in, and empowered the woman to work with their body to birth without interference [17,51]: "You absolutely see the hormones that promote labour take over.You know labour progresses better and the woman relaxes into labour."Midwife [51].
Conversely, obstetricians and other medical professionals in the studies were reported as unlikely to have been trained in, or to have witnessed labour and/or birth in water-this was associated with fear or misunderstanding [36,37,50,[55][56][57].In some situations, this manifested as "fear mongering", sabotage, threats, or other obstructive mechanisms [36,56].Some information leaflets included explicit statements suggesting that doctors "will not support water births" [50,56]: "Our doctors are the stumbling block regarding birth in water.We do have support for labour in water.If we have an inadvertent water birth an [incident report] has to be completed and follow up is usually punitive despite the fact that there have been no negative outcomes and a high level of satisfaction from clients-they have actually refused to get out of the bath and have progressed to wonderful births.My own compromise at the moment is to have women get out of the bath late and continue water by means of the shower.Clients have an understanding of the lack of medical support and are ok with this compromise.Seems a ridiculous opposition to something that is actually an endorsed protocol for our unit."Midwife [35].Some midwives expected opposition from their medical colleagues [17,45].They put this down to ignorance and lack of understanding around the practice of water immersion and selective use and interpretations of the evidence base [17,35,56].Midwives perceived that medical professionals primarily focused on the safety of the baby and argued the commonly held medical view that there remained insufficient high quality, empirical evidence to support water immersion and especially, for birth [19,35,37,45,47,50,56].This was noted in the greater support for water immersion during labour compared to birthing in water [15,37,47] and was further supported by studies that suggested medical professionals and especially, paediatricians and neonatologists commonly challenged the notion that water immersion was a natural way to give birth [35,37,57]: "I think the idea of waterbirth is mis-sold to women [as] a physiological way to deliver babies.When actually the only mammal that deliver under water are whales, and even they don't actually deliver under water…all the whales circle round and create a sort of bubble raft in order to make it more safe" Neonatologist [37].
Newnham et al. [38] explored the way this aversion translated to policies, guidelines and associated information leaflets and compared these with the equivalent for epidural use.Their findings highlighted that epidural was much more acceptable and readily promoted.They argued that epidural constituted "acceptable risk" while water immersion was a step too far, highlighting pharmacological methods of pain relief were more readily supported and available when compared to water immersion [19,38].Thus, reflecting the contradictory nature of the risk averse culture of maternity care [35,38,39].
In the defense of medical professionals, midwives related their aversion to a lack of experience and engagement with water immersion [35][36][37]: "… some of the senior staff 's thinking… Just things like water births.There's a lot of fear around the staff who have never seen a baby born in water or who just trust in the process of normal birth… I feel for those people and for the doctors as well because … you only see them when things are going wrong so I understand it's very difficult for them to trust in the process when they only ever see the process go wrong… they become very obstructive about making that happen… I think maybe there's a lot of ego stuff that goes on as well…" Junior Midwife [52].
Some midwives discussed how they had held similar negative views about the practice before they have witnessed women using water [37].However, negative views were not unique to medical professionals with some midwives still expressing uneasiness about water immersion [37,45,52].Where these midwives held senior roles, this often inhibited access and therefore women's choice [37,52].Therefore, birthing pool use was influenced by the prevailing care culture.

Advocacy and tensions
This theme reflects the opposing views and perceptions of water immersion and how this manifested in environments that were either facilitative or inhibitive of birthing pool uptake.Midwives looked to midwifery champions for support and guidance to overcome their personal fears and concerns and to advocate for continued access and protection of the use of birth pools [36,42,45].One midwife in Bayes, Juggins, Whitehead and De Leo's [56] study stated, "if you don't have …a leader with vision, then you don't have anything."Water immersion champions were the most important enabler and their presence and persistent advocacy ensured that challenges and barriers were not only managed but kept to a minimum [35,44,45,50].These leaders were described as good communicators-they could articulate the benefits while mitigating against risks [45].They were well versed and well-read and utilized evidence to gain the support of their medical counterparts.
The opposite was also true.In the absence of a midwifery water immersion champion or leader, conflicts between midwives and their managers could occur [45].With a lack of leadership or 'champion' midwives were left to navigate restrictive birthing pool policies/guidelines individually-using "subtle and covert" mechanisms to navigate the challenges and barriers when supporting women's informed choices [35,38].In some situations, this extended to "deliberate, accidental water births" where midwives would intentionally not ask the woman to leave the bath despite their local policy stating that water births were not supported [17].Such behaviours risk furthering tensions and conflicts between maternity professionals and the endangering the water immersion service.
While midwifery champions were essential to the success of water immersion implementation, the lack of support from medical colleagues was often a "stumbling block" [15,35,36,50].Even where obstetricians, neonatologists and pediatricians supported water immersion for labour, there was a general view that waterbirth was associated with greater risk than traditional births [37,50].Midwives commonly felt that their clinical decision making and judgement with respect to the woman's suitability were diminished and as such, their autonomy constrained due to medical aversion within their setting [19,35].A doula in Milosevic, Channon, Hughes, Hunter, Nolan, Milton and Sanders' [36] study discussed that this was often dependent on the doctor or consultant: "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" Doula [36].
Midwives described the lack of support from medical professionals as burdensome in that if anything were to go wrong, they would be held personally responsible.They referred to this as being "on your own" and "if anything goes wrong, it's on your shoulders" [37].

It's your choice, but only if it is a choice
Thirteen studies highlighted the conflict/paradoxical positioning of 'choice' for women seeking to use a birth pool.In two studies, antenatal discussions around water immersion were limited and here, women had to proactively seek out information as it was not readily offered or discussed [19,36].Newnham, McKellar and Pincombe [39] reported that for women requesting to use the water, consent forms were required (in some cases, more than one) to be signed antenatally.While midwives mentioned that this prompted staff to talk about water immersion, they also described that this offered false reassurance as access to the pool/bath could not be guaranteed: "Three rooms have a bath…but you must have a signed consent form, have done all the paperwork before you come in, and not only do you need to meet all of the criteria, but there needs to be midwife on who is accredited, and there needs to be a bath free" Midwife [39].
Moreover, even where a pool or bath was in place, infrastructural issues including access to a hot water supply, lifting equipment for evacuation, non-slip floors, a plug (in the case of fixed pools) and appropriate means of draining pools (for portable versions) were inhibitory [13,44,49,51,58].In some cases, plugs were not available or were locked away, rendering baths useless and women or birthing people unable to access water immersion [35,49].Where infrastructural issues were overcome, other challenges were common.This included limited access to a suitably credentialed or qualified midwife-either they were not available, or staffing did not permit [19,34,45,50,56].Where policies and guidelines required a midwife to be with women at all times while in the pool [45,48], this could not be facilitated [20,45].In the absence of an experienced or waterbirth accredited midwife, women were precluded from accessing water immersion [56].These issues often inhibited water use even before women were assessed or risked-out against prescriptive and rigid inclusion and exclusion criteria.
"If the ward's busy, they know that if that midwife goes in that room, (pool room) they've lost her...She doesn't come out again, so that's taken a member of staff away, whereas if we've got somebody on a bed with an epidural and a CTG (fetal monitor), you can come out occasionally and admit somebody else." Midwife [20].
Additional issues were also described.In some units, limited resources (i.e., more than one birth pool, sufficient hot water, etc.) often denied women the option [20,36,37,45]."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" Woman [36].
Midwives also described that the pools (particularly those that were fixed) were not conducive to their comfort and limited access to the woman and baby where indicated [17,45,50,58].

"Because of the height of the bath I can't sit down because I can't see. So I'm standing, leaning on my knees as a lever on the bath, leaning over, holding
the torch with my left hand, holding the mirror with my right -it hurts.I've got a really sore back."Midwife [58].
In a minority of cases, water immersion was seen as a costly option in terms of the initial outlay of installed birthing pools [37,59] but were seen as cost-effective over the longer term.For example, Pagano et al. [59] identified it was a cost-effective intervention due to the reduced perineal trauma from water immersion.

Discussion
This mixed methods systematic review included 37 papers to examine the facilitators and barriers of water immersion for labour and birth from the perspectives of multi-health professionals (midwives, obstetricians, neonatologists, maternity support workers, doulas etc.), revealing a complex interplay of factors.When personal, contextual, and infrastructural factors are aligned and directed towards the support and facilitation of birth pool use, water immersion is made a viable option.On the contrary, the more barriers that women and midwives experienced, the less likely water immersion was an option, reducing women and birthing people's choices and access to a safe form of pain relief that is associated with excellent maternal-neonatal health outcomes.The barriers were multifaceted but weighted by policies and guidelines that were prescriptive and restrictive.These conveyed strict exclusion criteria for those who could access a birthing pool, but with little to no underpinning evidence and were unduly risk focused, starkly different to those policies/guidelines written for pharmacological pain relief options.These issues were reflected in a systematic review of scholarly references exploring publications authored by multi-professionals that focused on water immersion for childbirth [60].For example, authors of obstetric or neonatology water immersion publications were less likely to reference midwives and nurses research in this area, and more, those from the latter were more likely to cite commentaries and case studies, rather than primary research with robust research methodologies.Accordingly, the authors found barriers to the diffusion of midwifery or nursing water immersion research into obstetrics or neonatology [60], which may subsequently limit the composition of evidence that inform water policies/guidelines as we have found in this review.
Compounding this, our review revealed that there was a need for a suitably 'qualified' and experienced clinician to be available and present at the birth.Water immersion was often eliminated as an option where this requirement could not be fulfilled.However, this negates the expertise and role of professional midwives in facilitating physiological land births, whereby these skills can be transferred to care in birthing pools.Many studies in our review identified a lack of exposure to water immersion for labour and birth so midwives' skillsets were underutilised and magnified concerns toward a more risk-focused approach resulting in less, or no birthing pool provision.Our review revealed the challenges that midwives they face in implementing, facilitating, and advocating for this option especially when compared with pharmacological forms of pain relief [1].Even where these barriers were not inhibitive, infrastructural issues including suitable bath/pools and to a sufficient hot water supply meant that women could not access water even where they were deemed suitable.These insights provide important findings as to why women 'struggle to get into a pool room' [13][14][15]40] which is counter to what many women or birthing people want.For example, a systematic meta-thematic synthesis explored women's experiences of water immersion revealed benefits included analgesic properties and beyond-to an improved sense of control and empowerment and an easier transition from labour through birth to the postnatal period [8].Such qualitative insights are strengthened by the maternal health benefits recently captured within a meta-analysis of 157,000 mother-baby dyads [5] (discussed in the background)-therefore, it is unsurprising that there is an increased demand for birthing pool use during childbirth [9].Therefore, it is essential that the barriers to birthing pool use that we have identified in this review are overcome.
The findings of this review offer insight into the paradoxical reality of water immersion with each of the five themes detailing how the "swing" within these factors directly affected whether water immersion was facilitated or inhibited.These themes also provide insight into the work that still needs to be done to ensure that access to water immersion is improved, especially considering the growing evidence base that reflects that water immersion outcomes are equivalent if not, better, than those achieved in traditional births.Policies and guidelines must be informed by the most up to date evidence and evidence reviews must be complete and appropriately translated to these documents.For example, our review also found, converse to the barriers identified, policies and/or guidelines could also be facilitative of birthing pool use, women's choice and midwives' ability to deliver such care.As was the support of medical professionals towards birthing pool use and birthing women or people's bodily autonomy.Where the culture supported water immersion as a viable option, and was driven by a midwifery champion, barriers were removed, and water immersion embraced by the broader multidisciplinary team-pools were sourced, and midwives and medical professionals advertised and discussed water immersion as valid, safe, and effective mode of birth.Thus, revealing insights as to how barriers could be overcome.Future research and clinical quality improvement projects should focus on exploring effective methods to 'swing' organisational cultures from inhibiting birthing pool use to a facilitatory approach.Additionally, such activities must include birthing women and people as part of the multidisciplinary team-those who have used birthing pools and those who wanted to but were denied.In this way, clinical practice and organisational cultural changes embed the principles of woman and person-centred care [61].

Strengths and limitations
Strengths of this study included the use of a mixed methods evidence synthesis to source, collate and synthesize the literature using a systematic approach and we minimised bias through ongoing reflexivity and returning to the literature base to inform our interpretations.The inclusion of survey data.guideline analyses and an economic evaluation, which are often excluded from systematic reviews, strengthened this work and the overall findings.Overall, the strength of this approach meant we included 37 papers with a sample of > 9000 health professionals, from 11 high-income countries and one lower-middle income country, therefore, these findings have transferability to other high-income settings.However, as with all search strategies, there is a risk of missing pertinent studies.We mitigated against this through pilot searching, updating the searches at two time points, included citation chasing and cross referenced against Google Scholar.Additionally, with any interpretative syntheses there is a risk of under or over interpretation.However, we mitigated against this through developing descriptive statements in the first instance, which remained close to the original data, before embarking on an interpretative synthesis.

Conclusion
This mixed methods evidence synthesis has explored the facilitators and barriers of birth pool use from organisational and multi-professional professional perspectives.Our findings revealed the paradoxical nature of water immersion as a practice.While water immersion is best facilitated in clinical contexts where multidisciplinary support is high and infrastructure is appropriate and available, the existence of a facilitative policy or guideline was also viewed as essential.Through a comprehensive search strategy and thorough mapping of the current evidence base, we have revealed the key facilitators and barriers to birth pool use.As such, the findings will be beneficial for directing further research and clinical quality improvement projects to implement and facilitate water immersion for childbirth.

Table 1
Search terms midwife* or midwives or midwifery or obstetri* or nurs* or anaesth*or paediatric* or neonat* AND water birth or water?birth or birthing pool or under water birth or birthing pool or tub or hydrotherapy

Table 4 :
The paradox of prescriptiveness, The experienced but elusive practitioner, Advocacy and aversion, Trust or Trepidation and It's your choice, but only if it is a choice.

Table 2 (
continued) a Same overarching study, different components published as individual papers

Table 3
Descriptive statements