 I have the great pleasure now in presenting the next speaker who is Mary Updato. She's a registered midwife since 2016. After working for two years in her home country of Italy she moved to Ireland where she started working at the Coombs Women and Infants University Hospital. She's always had an interest in clinical research and advanced practice and for that reason decided to undertake her master's degree in midwifery practice and leadership which she completed in 2020 at Trinity College in Dublin. So I'm going to switch over and give her presentation rights. Feel free to write your comments in the chat box otherwise we'll ask for questions at the end of her presentation. Over to you. Good morning, good evening or whatever you are at the moment. Everybody have international day to everybody and thanks to these for introducing me. I'm just going to switch off my camera just for just for internet issue but I just wanted to welcome everybody and thank you for having me here today. So the topic that we're going to talk about today is women experience of water immersion during childbirth and in a hospital setting in Ireland and this is a qualitative study that I undertaken for my master's degree. So really the first thing to look at is the evidence around waterbirth and should we start with two questions which are why should low risk women opt for waterbirth and why should maternity units facilitate waterbirth. So we know that research on the use of heterotherapy in a maternity setting has been ongoing since 1916 and is still ongoing but why? Childbirth experience can largely impact on the future health of women and of women and children and families and from users point of view water immersion during childbirth is associated with a sense of control, autonomy, empowerment, privacy and an overall positive childbirth experience. Obviously all of that can lead to women's well-being, increase the bonding and the self-esteem that we know are fundamental indicators of quality of maternity care. From the organization point of view as well water immersion it's a safe care option for low risk women because it's a natural pain relief and of course increased mobility, it reduced the need for pharmacologic and pain relief, increased the chance to have a normal burn and a birth and to reduce the risk of intervention. It also facilitates skin-to-skin contact and increased the breast feeding. So it's also potentially cost effective care option that can be implemented in the countries to reduce intervention, to give more option to women and especially in Ireland to implement the national maternity strategy that was released in 2016. So let's look a little bit at the background and what's the situation at the moment in the Republic of Ireland in regards of water birth. So water birds and water immersion and the use of birthing poles are an established care option for labouring women in many countries. Let's look at the UK for example where more than three quarters of maternity units facilitate water births. In Ireland the situation is a little bit more complicated and this can be associated with a tragic event that occurred in 2006 where a tragic death of a baby occurred after a water bird. So the HSC imposed a ban on water bird that was actually removed in 2009 but regardless the the ban was lifted it's been very difficult to kind of recover from this initial ban and this recovery remains very difficult nowadays. Moreover the medical model of care is still the predominant one in Ireland and only seven of Ireland 19 modernity units have a pool in place and only one of these facilitate water birds. So you can see how difficult has been the recovery from this ban. Regardless the predominant consultant model of care anyway the HSC published in 2016 the national maternity strategy which is a document that was published to place increased emphasis on promoting physiological birth by offering women choices during labour and birth including birding aids such as birthing pool for example. So given that this relative limited use of birding pools in Ireland and also there's no really studied that look at women experience of water immersion in Ireland but even worldwide there's a lack of information on the qualitative aspect of the research. It was considered timely and critical to explore women experience of using water immersion during childbirth in the context of the Irish modernity setting and care. Women experience of this care option in the context of the of the current availability and use in Ireland it was expected to give a greater understanding from women perspective that could actually inform policies and inform practice and that's why I decided to continue with this topic and to look at women experiences of water immersion during labour and childbirth in a hospital setting in Ireland. So let's look a little bit at the methodology. Given that the purpose of the study was to investigate women experience of experience of water immersion during childbirth and so together a better understanding of the process it was a qualitative descriptive approach was the study design that was considered appropriate. The sample were nine women, lorries women, the gate birding water between 20 and 19. Did you come with patience? Did you come with patience? They came with a bus. Hey she's our own. Sorry. So the sample was nine lorries women who gave birth in between February 2019 and November 2019 in the CUMB hospital. So the study population were women who gave birth in water within 12 months previously prior to the study. And the CUMB hospital is a study site that was there is a centre that provides care to 8 000 women per year. Data was collected by semi-structure interviews with open-ended questions and interviews were conducted between February 2020 and March 2020. Because obviously the COVID happened and the strict rules I had to stop the interviews but the sample was considered enough anyway for the data that I get at the time. Data were analyzed by using inductive thematic analysis. I use a software that is in vivo to store, classify and code the data. The data were transcribed verbatim, all the information and all the interviews were transcribed verbatim and from there coded and then three main teams and subteam were identified. This was the whole process and the three sub themes. So water bird keep it normal in a hospital setting which includes two sub themes which are trust in the body and intimate experience and the gentle transition and then the second theme which is intimate experience and the third team which is unknown underestimated resource. So let's look a little bit at the sample characteristic if you can see as you can see here six women out of nine were Irish women. Three of them were European, one Spanish, Lithuanian and Scottish and from the sample 33% of them were multiverse and 67% were nulliverse. So the first team is water bird keep it normal in a hospital setting. This team encapsulates the women perception and describes the women perception of keeping bird in a natural way even though in a hospital setting. As you can read here women describe water immersion as the best thing ever no guts no nothing the best thing ever relaxation. Relaxation in fact was the high level of relaxation was one of the main topic that raised from all women stories and these helped them to not really cope with the pain and as well being active was central for the management of the pain in relation to women's satisfaction with the experience as well. All the multiverse spontaneously compared their water birds with the Pidura for example describing water birds as more natural and satisfied because they could be in control and because they could be active they were actually leading their experience. Also the second stage the majority of the women describe it as quick and easy they were able to follow their instincts and they had the perception to avoid of being caught or having an unnecessary intervention. Overall women describe this experience as amazing lovely unbelievable life changing and wonderful because your experience to give birth to your baby. Two negative aspects also raised one was the tight space that can obviously depend from obviously the even the BMI of the woman or also the fact that we just have one pool in place and we can give more option to the women and also to be rushed out of the pool. This one also can be linked to the fact that the pool is in the delivery suite of these big mother and duty center that provides care to 8,000 women so it's not like a midwifery alongside unit so the workload is continuously like the same so that was probably the reason why. All women indicated overall that the work for they put hopes for a water bird in the future and they use this phrase as like for example would not change a thing cannot imagine being in any other place and after this experience I would only want the pool. The first sub-team is trusting the body and empowering experience. All women reported that being the water idling their experience of being in control of their body perception of being charged was announced by different aspects primarily by not using medication for pain management or women linked not using medication with the perception of being powered as they were able to give birth without any help they use phrases for example as being privileged to be a woman and you know what to do even don't know body tell you. This suggests obviously that water birds can have an impact of women perception of self-affirmation that is a very important indicator of the quality of maternity care as we saw at the beginning of this presentation. Another important aspect that influences woman perception of being in control of and feeling empowered was the hands-off care that they received. Women reported that mid-wise gives them the belief that they could actually do that without any issue and stated that being the water help them avoid unnecessary intervention. The second sub-team is the gentle transition. Women described giving birth in the pool as a non-traumatic experience for them but also for their baby. They all see the birth of their baby as a peaceful way to give birth to the baby and all the birds in all the birds the baby was free to flow out and flow up into the water and this was described as a precious moment for them also to realize what was happening and to look at the baby swimming into the pool was a very relaxing and very stress-free way of seeing the baby being born. The second team is an intimate experience. So this team encapsulates women's perception of having a private and intimate experience. Being covered by the water made them feel safe and comfortable and also very much less exposed and this was quite crucial because all women reported having a perception of being in their own space which was also described as one of the reason why they decided to hop for water birds. For example one of the women that was one of the women that was interviewed she was suffering of hemorrhoids and varicose veins that she's and she reported that being covered by the water give her a sense of dignity instead of being exposed to everybody. Most of the women talked about their satisfaction with the care and the care that they received also in relation of the midwifery care that they received. Women described midwives to be very discreet with them and they all appreciated the fact that the body was really encroaching their space and this announced a perception of feeling in a private and a home-like space. Also another important aspect was the part and role. Getting the part and prepared for the labor for the labor was a very recurrent team and aspect. All women reported how highly they valued the fact that the the partner was playing an active role in their birds. They said that the partner were more involved in the decision making even during the pregnancies they couldn't make without the partner getting the environment ready and they felt very protected and safe because they had the partner right in front of them looking in the eyes instead of turning the head while they were in the bed. Also the partner had the chance to start bonding with the newborns because for example as you can read here when baby came out he picked up the baby up and put the baby on my chest. So the partner in some of the stories was also the first person catching the baby. The third and the last team is an unknown underestimated research. This team encapsulates the lack of information and the access that all the women mention in regards of water birds in Ireland. So if we look a little bit at the numbers two women out of nine directly were directly informed by this care option in the hospital. Most of the women decided to have a water bird because they were informed, they educated themselves or because somebody has experiences. Also six women considered water birds to achieve a normal bird and all the new leopards, all the multi-paras considered water birds because they had a traumatic experience. So really as a healing experience for them now women felt that they did not receive the right information and they would feel very anxious, worried and very lucky that they actually made it to achieve a water bird. And this is one of the phrases that one of the women said you shouldn't have to fight to have a water bird or whatever kind of bird you want. I would choose the comb poorly for the pool. I'd be open to consider home bird to guarantee to have a water bird and these women actually had a home bird with the second baby and she had a pool bird at home. So strength and limitation just to conclude. Strength, we are providing new knowledge on water birds in the harsh context from women's point of view and this is the first study that is looking at this and we and this can inform policies and improve midwifery practice. Limitation wise we're considering this considering the time frame chosen for the study record cannot be excluded. As I said women were interviewed between the 12 months prior after their birth experience so this can be it's a limitation for the study and then the voluntary sampling. So women with positive water experience might have decided to attend the study and participate in the study but women that did not have a good experience that probably didn't decide to didn't want to participate. So to conclude water can promote positive empowering bird experience to women led to a shift of focus from high risk to low risk midwifery can which contributes to a reduction of necessary intervention even in a high medicalized hospital setting. Preserve physiological process of bird even in a high medicalized settings and in Irish maternity hospital and to ensure that obviously water birds is a valuable realistic option for women in Ireland we should engage and educate more regarding water birds. Thank you everybody for listening and for being here today. Thank you very much and I think that last quote is very apt that birth isn't only about making other babies it's about making mothers who are strong competent capable who trust themselves and know their inner strength which after birthing they most certainly do. Just going to take presentation back from you so this now comes to question time. So we've got comments on here first so let's go back to that slide because it's pretty good to look at. Catherine has written here that she loves your accompanying pictorials so your pictures are beautiful throughout your presentation. Thank you so much it is actually a woman that was included in the study this last picture here. Oh that's brilliant. Yes yes and that's the pool. Yes. So can I go for it? No no no when we were looking up for example the the tight space the negative aspect is as you can see this pool is quite long because it's the only pool that is present in the hospital and we don't have different options and option and size for example as you can see this might have been like obviously a negative aspect and that's the pool that we were talking about and that's one of the women that attended and that had a waterproof. So is that steps at the front of her that she can climb in and out of? Say again sorry. Are those the steps of the pool in front of her? Yes yes the steps are besides like on the side there is a some movement and some position that we would explain or midwives are trained on how to get the woman out of the pool quickly if it needed but the stairs on are on the side there is actually a pole there is on the side of the pool where the woman can hold herself and then she can step out of the pool by using this little stairs. Oh and I apologize for mispronouncing people's names but Bigum has in Turkey only a maximum of seven or eight public hospitals have water birth units if you want water birthing you can take this service from private hospital and sadly costs a lot of money and I think that's the same almost everywhere if a woman has money she can have less pay and she has more choice. Megan Cooper's giving you hands up on applause. Jane's agreeing with what Bigum has said. Diane thank you so much for sharing your research it is uplifting bravo. Catherine has asked how expensive is it to set up a water birthing unit in dollars or sterlings? I don't really know about dollars and standards sterling or to set up a birthing to set up a birthing unit. It is quite expensive but the problem in Ireland it's not more about the money it's about the the model of care the predominant ones there is still a short care between GP and the consultant and the hospital so the reason mainly is not because there is a lack of money or there's no money to invest on that but it's because obviously it's a very medicalised maternity care at the time at this moment. We still didn't step out of the all the induction induction of labor's process and stuff like this there's women usually go to consultant instead of going to midwives. So we're making step by step there is a few midwifery led units in Ireland unfortunately there's none in Dublin and probably in the not very far future even Ireland will have the possibility to have a midwifery led unit but I don't know how much could be in dollars of sterling but definitely it's not there it's not a money issue here in Ireland. You can change the system before you can think about that but as Jane has put her comment as well it's about integration of normal on how we kind of go about that. Megan has written in excellent work confirms so much of the research we've already done I would love to work with you as a challenge as you mentioned a common across the globe. Megan's currently working with they agree absolutely amazing Claire Freely on a scoping review that looks at facilitators and challenges in more depth so much work to do. Bogum Turkey's minimum wage is 4,250 lira and water birth starts at 2,000 lira yeah and this is when we look at social justice and the importance of social justice to midwifery care and to making sure people have the options all options and it's not just about money almost a conversation happening down here. Jane Houston another person for you to connect up with Maripa she's did her doctorate in water immersion so as long as you get the buy-in it's simple but need motivated people lots of chats are going to happen offline I think by the looks of this and Megan from the Australian perspective two two and a half to three thousand dollars to get started using a portable pool and then you've got to do your occupational health and safety and draining after that. Does anyone else want to ask any other questions either ask them verbally or type in other questions? I was going to ask one more people thinking about what has changed in Ireland but you've kind of answered that that it's well first of all yeah well it's been complicated especially after the Covid so it was already complicated to have Waterbird starting in Ireland it was needed as a quantitative study that was actually carried out from one of the assistant director of midwifery in the comb hospital the publish one study on just in 2020 comparing outcomes between standard care and Waterbird this actually gave the possibility to the hospital because there was a study going on to start with Waterbirds from there actually things didn't really change too much but that's because the Covid then it so because of the Covid and because it's not like an established care option in Ireland most of the hospital decided just to stop Waterbirds and well the comb stopped Waterbirds first of all because there was no staff and we had very high waves of obviously women hospitalized for Covid so the staff level wasn't enough to even look after women in the water and because we didn't know anything about also from a perspective of hygiene and how to you know sharing the virus by using the pool and stuff like this so they stopped and they actually start again Waterbirds have started again in March the problem is that they have been stopped for two years almost so that's that's very wasn't very good aspect but the thing is that there is actually a new unit that put the pool in place which is the Rotunda hospital which is the other big maternity units in Dublin so the hospital are starting slowly starting to provide this care option to women even though it's not established care option quite yet and we do need lots of work from a mid-wise point of view that they don't feel enough confident and comfortable in assisting women given birth in the water but also from medical point of view because doctors are not really involved in this care option and they should in terms of being not because they need to to be present obviously if it's a low risk women we're talking about but because they need to be aware that this is a care option that is safe for women low risk and these and they need to provide information to women that attended their clinic for example so you know there is a little bit of work to do still as you can say before as you said before mentality first but slowly we can see a little bit of progress from this point of view. Covid has a lot to answer for Jane do you want to ask your questions using your microphone or do you want to type your question with your score question about sample and midwifery education on water immersion? Why did you ask? Is it okay if I use the microphone? Absolutely go for it Jane. As I was called in the last session I'm an aged midwife so my typing is rather slow so um yeah my question I mean it seems self-defeating in Ireland we're telling women that this should be an option yet there's there's not availability for younger folks to receive the education and the training and for my analysis a lot of the staff including midwives nurses etc I mean to be honest it is more work you know to to to provide options such as water birth I mean it's great I mean I totally I'm on board I think everyone should have a home birth with a water birth but my question so two full questions how are we going to actually educate the newer folks in Hyatt and big shout out to the students here if no one's got the experience now and then was your sample I'm sorry I missed at the beginning was it folks that had births within the hospital setting or was there was there a mixture and would it be the same midwives or is there a mixture there I'm not familiar I've worked in a lot of places but not Ireland is there mostly the same health service midwives or would there be private and public midwives that were offering these options thank you and really great good work and very impressed congratulations thank you so much Jane for your questions so I'm gonna start with the easiest one so the sample it's so these were women that gave birth in the pool in a hospital setting yes as I said unfortunately in Ireland in Dublin specifically we don't have midwifery let units and we wanted to look at how it is to provide careful low risk women in a medicalized setting so in a hospital setting so these were women that were low risk that they met all the criteria the inclusion criteria to you know assessed actually even during the labor and they attended the hospital they some of them attended the domino clinic which is the community midwife service in the hospital and they came to the hospital at the time obviously of the labor and they were able to use the pool in the delivery switch so this pool is actually placed into the delivery switch and the midwives were midwives there was no private midwives but just the midwives that were on duty that day so the facilitating water birth can also as you said depend from who is the midwife like if there is enough experienced midwife to provide care to women in labor in the water and I connect with the second question which is yes the one about the education because as you said as you said it's very important to educate midwives in promoting and to and actually look after women in labor in the water midwives in Ireland are very well educated regarding and very skilled on especially on emergencies and on high risk settings but because there's very little regarding low risk and especially perting pools they might feel not confident on that now there is a lot of study days that are going on since the pool started in the Kumbh there is a lot of we are including all the students for example in the Kumbh hospital in our master class on water births and I am a clinical skill facilitator myself working in the labor world so if I have new stuff I will work with them and provide them education while looking after women in the water but as you said it should be like much more included even in the university and even in the program on the university for the student midwives just to make them to make everybody confident and comfortable in providing this care option to women I don't know if I answer that sounded good to me so hopefully Jane's happy I need to just say why did you have seven in your sample that's just been answered as well yeah sorry it was actually nine in my sample I had nine because I started so women were recruited by the gatekeeper this gatekeeper is actually the research midwife that I was talking about before the data study a quantitative study before this study before my qualitative and she sent them she sent all the women that gave birth between the 12 months prior my study a letter so the woman voluntarily replied me back to decide whether or not to attend the study so none of them decided to attend the study to voluntarily sampling like they decided to to participate in the study but then unfortunately COVID hit so at the time I have nine women and I could have also sent more information leaflet and more letter recruit letter to other women but because of the COVID and we couldn't do any one-to-one interviews because obviously the restrictions and because the data were actually enough to explain women women experiences I decided just with my supervisor at the time that the sample was was a good sample also in qualitative study the sample doesn't have to be representative because we're talking about experiences and a nine women sample was considered enough for the purpose of the party and especially at that stage of COVID we had no idea what was hitting us so a lot of kind of restrictions stopped a lot of things and also the workforce demand suddenly hit through the roof as well so Dana's just saying as we're kind of wrapping up this session so Dana said that she's Irish working in France and the changes have been amazing since she left 20 years ago the big change is the voice of the women in the last 25 years and Rhonda's agreeing it's progress but we still need more we will always need more and the women's voice absolutely I think that's an international thing that as the women's voice grows louder more things are going to change