Table 3 Descriptive statements

Education, training, mentorship, and experience leads to knowledge, competence, and confidence in facilitating water immersion

Limited opportunities for education both during training and as midwives

[1, 7, 11, 25, 34, 37]

Training and experience improved competence and competence

[1, 4, 9,10,11, 15, 16, 19, 25, 26, 28, 32]

Additional training is not needed

[12, 37]

Mentorship is key

[1, 4, 25, 35, 37]

Midwifery-led spaces promote greater confidence

[2, 16, 20, 21, 28, 30, 32]

Water immersion is a midwifery option in demand that facilitates physical and psychological benefits and normal physiological birth

Facilitates normal birth

[9, 16, 25, 35,36,37]

Reduces intervention and adverse events

[9, 16, 19, 25, 37]

Promotes comfort, protection, relaxation, and a more positive birth experience

[4, 9, 11, 16, 19, 20, 26, 37]

Decreased use of analgesia

[4, 11, 19, 26, 28, 35, 37]

Promotes empowerment and control

[16, 26, 37]

Demand

[4, 11, 17, 21, 26]

Midwifery option

[8, 26, 37]

Policies and guidelines can be facilitative and prompt implementation of water immersion

Ensure safety for the woman and midwife

[9, 11,12,13, 25, 37]

Alleviate practitioner concerns and promotes confidence

[9, 25]

Improved accessibility and availability

[1, 4, 10, 11, 20, 28, 37]

Prompt information provision

[7, 13, 20, 36]

Participation in development

[1, 11, 31, 36]

The importance of medical and organisational support

Easier process

[5, 18, 21, 28, 36]

As long as guidelines/policies followed, and information provided

[15]

Organisational support and leadership are essential

[1]

Midwifery champions

Midwives promote and support water immersion

[1, 4, 5, 11, 14, 15, 17, 19,20,21,22,23, 26, 28, 35, 36]

Champions are needed

[4, 5, 10, 37]

Midwives offer water immersion as an option

[1, 3, 11, 15, 37]

Policies and guidelines are often risk averse and do not reflect women's experiences

Focus on risk and safety

[7,8,9,10, 15, 31]

Precludes high risk, only low risk

[7, 8, 10, 20, 21, 31]

Inconsistencies in guidance and contraindications with little underpinning evidence

[7, 8]

Authoritative, prescriptive, restrictive, did not include women's views

[7,8,9,10,11, 14, 21, 23, 36, 37]

Not reflective of contemporaneous evidence

[1, 7,8,9,10, 15, 16, 20,21,22,23]

Normalise intervention

[23]

Resistance stems from fear, lack of experience and support and the view that labour and birth are inherently risky

Obstetricians lack training and experience

[10, 20, 21, 28]

No support from obstetricians and/or seniors

[1, 5, 6, 8,9,10, 15, 18, 20, 21, 25, 28, 29, 35,36,37]

Legal and insurance barriers

[1, 10]

Midwives’ resistance or lack of experience

[21, 29, 37]

Infrastructure, cost, and concerns inhibit implementation and accessibility

Resources, few or no pools or the room blocked

[1, 5, 7,8,9,10,11, 14, 16, 19,20,21,22, 24, 29, 31, 37]

Maternal collapse and evacuation

[11, 18, 20, 26, 29, 36, 37]

Culture

[7, 20]

Staffing

[5, 11, 28, 29, 37]

Midwives discomfort

[14, 19, 20, 28, 36, 37]

Paperwork

[23]

Cost

[1, 21, 27, 29]

Safety of the baby e.g., drowning

[26, 28, 35, 37]

Personal concerns

[32]

Waterproof CTG

[20, 21]

Women must actively seek and request water immersion

Policies not woman-centred

[8, 9, 11, 24]

No information antenatally

[8, 11, 20, 21, 23, 29]

Women must ask

[1, 8, 20,21,22, 24, 29, 37]

Midwives influence women’s access

[1, 3, 8, 11, 20, 23, 25, 28, 29, 37]

If women don’t ask, there must be no demand

[23, 29]

Not a primary option compared to other options

[20, 23, 24]

The illusive experienced practitioner

Option removed because experienced/accredited practitioner not available

[7, 8, 10, 12, 23]

Accreditation or extra training required

[1, 8, 10, 12, 23]

'adequately' and 'appropriately' 'experienced', 'qualified', 'registered', responsible', 'competent', 'educated' practitioner

[8, 12]