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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. Plain English Summary: During childbirth, most women wish to use a pain management technique; some prefer to use medications and others prefer non-medication methods. Another option is to use a birthing pool, larger than a typical bath, 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. [ABSTRACT FROM AUTHOR]

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. Plain English Summary: During childbirth, most women wish to use a pain management technique; some prefer to use medications and others prefer non-medication methods. Another option is to use a birthing pool, larger than a typical bath, 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. [ABSTRACT FROM AUTHOR]

Introduction: A key component of achieving respectful maternal and newborn care is labor companionship. Despite important health benefits for the woman and baby, there are critical gaps in implementing labor companionship for all women globally. The paper aims to present the perceptions and experiences of pregnant women, postpartum women, and health care providers regarding companionship during labor and childbirth, and to identify barriers and facilitating factors to the implementation of labor companionship in Burkina Faso. Methods: This is a formative study to inform the "Appropriate use of cesarean section through QUALIty DECision-making by women and providers" (QUALI-DEC) study, to design, adapt and implement a strategy to optimize the use of the cesarean section, including labor companionship. We use in-depth interviews (women, potential companions, and health workers) and health facility readiness assessments in eight hospitals across Burkina Faso. We use a thematic analysis approach for interviews, and narrative summaries to describe facility readiness assessment. Results: In all, 77 qualitative interviews and eight readiness assessments are included in this analysis. The findings showed that all participants acknowledged an existing traditional companionship model, which allowed companions to support women only in the hospital waiting room and post-natal room. Despite recognizing clear benefits, participants were not familiar with companionship during labor and childbirth in the hospital as recommended by WHO. Key barriers to implementing companionship throughout labor and birth include limited space in labor and delivery wards, no private rooms for women, hospital rules preventing companionship, and social norms preventing the choice of a companion by the woman. Conclusion: Labor companionship was considered highly acceptable in Burkina Faso, but more work is needed to adapt to the hospital environment. Revisions to hospital policies to allow companions during labor and childbirth are needed as well as changes to provide private space for women. Training potential companions about their roles and encouraging women's rights to choose their companions may help to facilitate effective implementation. Plain Language Summary: A labor companion is a person who supports a woman throughout labor and birth, typically a woman's spouse/partner, family member, or friend. We were interested to explore if a labor companion throughout labor and birth was acceptable to women and health workers, and feasible to start doing for women in Burkina Faso. To achieve this objective, we interviewed 77 women, companions, and health workers about their beliefs and opinions about labor companions, and what might help or be a challenge to having companions. We also visited eight hospitals to understand what the labor ward looks like, and any policies about companions. We found that hospitals were allowing a 'traditional model' of companionship, allowing companions to accompany women only in the waiting and postnatal rooms (not during labor or birth). Both women and health workers believed that companionship during labor and birth would be helpful and desired, which might help to make it a reality for all women. We also identified some challenges, due to crowded labor rooms with limited privacy, and hospital rules that did not allow companionship. We found that sometimes a woman's family would choose the companion, instead of the woman herself, which may mean the woman does not want this person present. We plan to use these findings to help us to develop a program that allows any woman to have a companion present during labor and birth, in a way that ensures that she chooses the companion, and the companion can support her well. [ABSTRACT FROM AUTHOR]

Background: The World Health Organization (WHO) Labour Care Guide (LCG) is a paper-based labour monitoring tool designed to facilitate the implementation of WHO's latest guidelines for effective, respectful care during labour and childbirth. Implementing the LCG into routine intrapartum care requires a strategy that improves healthcare provider practices during labour and childbirth. Such a strategy might optimize the use of Caesarean section (CS), along with potential benefits on the use of other obstetric interventions, maternal and perinatal health outcomes, and women's experience of care. However, the effects of a strategy to implement the LCG have not been evaluated in a randomised trial. This study aims to: (1) develop and optimise a strategy for implementing the LCG (formative phase); and (2) To evaluate the implementation of the LCG strategy compared with usual care (trial phase). Methods: In the formative phase, we will co-design the LCG strategy with key stakeholders informed by facility assessments and provider surveys, which will be field tested in one hospital. The LCG strategy includes a LCG training program, ongoing supportive supervision from senior clinical staff, and audit and feedback using the Robson Classification. We will then conduct a stepped-wedge, cluster-randomized pilot trial in four public hospitals in India, to evaluate the effect of the LCG strategy intervention compared to usual care (simplified WHO partograph). The primary outcome is the CS rate in nulliparous women with singleton, term, cephalic pregnancies in spontaneous labour (Robson Group 1). Secondary outcomes include clinical and process of care outcomes, as well as women's experience of care outcomes. We will also conduct a process evaluation during the trial, using standardized facility assessments, in-depth interviews and surveys with providers, audits of completed LCGs, labour ward observations and document reviews. An economic evaluation will consider implementation costs and cost-effectiveness. Discussion: Findings of this trial will guide clinicians, administrators and policymakers on how to effectively implement the LCG, and what (if any) effects the LCG strategy has on process of care, health and experience outcomes. The trial findings will inform the rollout of LCG internationally. Trial registration: CTRI/2021/01/030695 (Protocol version 1.4, 25 April 2022). Plain language summary: The new WHO Labour Care Guide (LCG) is an innovative partograph that emphasises women-centred, evidence-based care during labour and childbirth. Together with clinicians working at four hospitals in India, we will develop and test a strategy to implement the LCG into routine care in labour wards of these hospitals. We will use a randomised trial design where this LCG strategy is introduced sequentially in each of the four hospitals, in a random order. We will collect data on all women giving birth and their newborns during this period and analyse whether the LCG strategy has any effects on the use of Caesarean section, women's and newborn's health outcomes, and women's experiences during labour and childbirth. While the trial is being conducted, we will also collect qualitative and quantitative data from doctors, nurses and midwives working in these hospitals, to understand their perspectives and experiences of using the LCG in their day-to-day work. In addition, we will collect economic data to understand how much the LCG strategy costs, and how much money it might save if it is effective. Through this study, our international collaboration will generate critical evidence and innovative tools to support implementation of the LCG in other countries. [ABSTRACT FROM AUTHOR]

Objectives: Ethical dilemmas at both the individual and structural level are part of the daily work of midwives and gender inequality and injustice can affect women's sexual and reproductive health. Mainstream bioethical theory has been criticized for neglecting women's issues. To ensure women's experiences are addressed, a gender lens on ethics is crucial. Aim: This study develops a theory model by exploring ethical dilemmas related to gender in the context of maternity care from the perspective of midwifery science and feminist ethics. Methods: The research strategy followed a coherent stepwise approach: literature search, thematic analysis, elaboration of a gender ethics protocol, and the integration of various components into a preliminary gender ethics model for midwifery. Findings: A literature search was performed using Scopus and Web of Science to identify ethical dilemmas in maternity care linked to gender and power. The search of articles published between 1996 and 2019 returned 61 abstracts. These abstracts were screened and assigned one of the following themes: The Midwifery Profession, The Rights of the Woman, Fetal Rights Dominate, and Medicalization of Pregnancy and Childbirth. A tentative gender ethics frame was developed and tested on two articles on abortion, one from Denmark and one from Japan. The protocol facilitated the gender analysis of ethical dilemmas related to abortion, which were related to the imbalance of power relations in health care. In the final step, we synthesized the dimensions of gender and power in a gender ethics model for midwifery. Discussion: The gender ethics protocol developed revealed gendered dimensions of ethical dilemmas in midwifery. This gender analysis adds to the understanding of the "do no harm" principle by revealing assumptions and stereotypes that promote unequal power relations. The gender ethics model is an innovative approach that envisions and exposes power imbalance at the micro, meso, and macro levels. Conclusions: The protocol could improve gender competence among researchers, midwives/professionals, and midwifery students throughout the world. Plain Language summary: As gender inequity, gender inequality, and oppression infuse dimensions in all human cultures and societies, not the least in midwifery practice where the layers of injustice affect women during pregnancy and birth in high-, middle-, and low-income countries, the time has come to renew the perspectives of normative ethics. In this study, we explore gender ethical dilemmas unique to maternity care from the perspective of midwifery science and feminist ethics. A literature search uncovered ethical dilemmas in midwifery, and four broad themes were identified: Midwifery Profession, Rights of the Woman, Fetal Rights Dominate, and Medicalization of Pregnancy and Childbirth. Next, we developed a gender ethics protocol suitable for providing gender ethical interpretations of results. The protocol was tested and refined using two articles (one from the Denmark and one from Japan) that address ethical dilemmas of abortion care. The pilot analysis indicates that the autonomy of midwives and their scope of practice might be constrained and that the obstetric medicalized/authoritative knowledge still plays a dominate role in maternity practice. Here, we present an elaborate model, gender ethics model for midwifery (GEMM), developed for midwifery science that can be further refined. The model challenges the views of maternity care and contributes to a deeper understanding of how fluid concepts such as gender and power circulate and influence women's and birthing person's sexual and reproductive health. Statement of significance: Problem or issue Layers of injustice affect women during pregnancy and birth in both high-, middle-, and low-income countries. The time has come to renew the perspectives of normative ethics. What is already known? Globally, ethical dilemmas at both the individual and structural levels pervade the daily work of midwives, but ethical research that includes gender theory in midwifery science is limited. What this paper adds Here, we present a gender ethics protocol and develop an innovative gender theory ethics model for midwifery to improve gender competence among researchers, midwives/professionals, and midwifery students. [ABSTRACT FROM AUTHOR]