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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]