Iranian Kurdish women's experiences of childbirth: A qualitative study

Abstract

Background:

The experience of labor and birth, referred to as childbirth, is complex, multidimensional, and subjective, relating to both the outcome and the process that is experienced by an individual woman. The aim of this study was to describe the experience of childbirth among Kurdish women giving birth at Besat Hospital in Sanandaj, Iran.

Materials and Methods:

A qualitative study was conducted using phenomenological approach. Women eligible for the study were recruited from the postpartum ward. Inclusion criteria were being an Iranian Kurdish woman, being nulliparous, and having vaginal childbirth. Data collection was performed between 2010 and 2011. Women were interviewed by the first researcher 6–12 weeks after they had given birth to their first child.

Results:

All participants had spontaneous vaginal births without their husbands present. None of them received any analgesia or anesthesia during labor and birth. The findings are described under the following four themes: Feeling empowered, changing life, importance of being supported during labor, and the spiritual dimensions of giving birth.

Conclusions:

Women communicate through telling stories and create meaning as they articulate their feelings about pivotal life events such as childbirth. The findings of this study provide a useful first step toward the identification of aspects of Kurdish women's experience of giving birth. The women in this study identified that the presence or absence of effective support had a significant effect on their experience of labor and birth. It is important for midwives and other professionals to understand the benefits of support given for women during childbirth.

INTRODUCTION

The concept of the experience of childbirth has received increasing attention from various disciplines. The experience of labor and birth, referred to as childbirth, is complex, multidimensional, and subjective, relating to both the outcome and the process that is experienced by an individual woman.[1]

Birth is a universal experience for women, and many similarities in their birthing are documented in studies of childbearing women living in many countries. The significance of the physical, emotional, and spiritual dimensions of giving birth is universal.[2] A positive birth experience is associated with long-lasting benefits, an affirmative relationship with the baby, and a positive attitude toward motherhood that contributes to the woman's self-esteem.[3] A negative birth experience may define or alter future pregnancies by affecting a woman's future reproductive decisions.[4] Hug et al. mentioned that maternal experience may have an impact on their attitudes toward the mode of future birth and on cesarean section rates.[5]

Many studies have explored women's experiences of childbirth and have identified that there are many variables that may influence the meaning of childbirth for an individual woman, including maternal age, education, and socioeconomic class.[6] According to Lundgren, pregnancy-related factors, complications, expectations, pain, and the form of organization care all influence women's experience of childbirth.[7]

A woman's previous experience of childbirth may influence her perception of the childbirth experience, for example, first-time mothers were found to be significantly less satisfied with their birth experience and more negative in their description of the baby than were women who had previously given birth.[8] Melender showed that negative stories told by others cause anxiety before childbirth and negative birth experiences.[6] The environment of birth influences both the physiological and psychological aspects of childbirth. A calm, quiet, and caring birthing environment can promote a faster, easier labor and a more positive childbirth experience.[9] The support and care given by midwives and other staff was found to contribute to a woman's birth experience.[10,11]

Over 1,170,000 women give birth in Iran every year and more than 95% of births takes place in hospitals.[12] Due to Iranian religious and cultural values, men do not attend labor and birth. Usually, pregnant women accompanied by females arrive in the labor ward and stay with other laboring women in the same room during labor. Midwives are the women's only source of support in labor and birth.[13]

In Kurdish society, women have to fulfill their familial roles as daughters, wives, and mothers. Kurdish women have a certain intrinsic value in that they represent the originators of the next generation. Pregnancy and childbirth are generally considered positive life events in the Kurdish society, especially when parents have planned and prepared for the beginning of a new life. During pregnancy, women get greater intimacy, closeness, protectiveness, and kindness from their husband and relatives. During their first pregnancy, the woman's family usually buys and prepares clothes and furniture for baby. Postnatally, women often stay at home for 40 days to recuperate during which time they rest and are cared for by their family. They are also expected to eat special foods with their meals which are believed to help restore the energy lost by the mother during childbirth.[14]

Although childbirth is a universal phenomenon, women's experiences are subjective, personal, and particular; hence, childbirth is experienced by women in different ways.[15] Therefore, the aim of this study was to describe the experience of childbirth of Kurdish women giving birth at Besat hospital in Sanandaj.

MATERIALS AND METHODS

This study was performed at the governmental Besat hospital in Sanandaj, a center of Kurdistan province in the western part of Iran. This hospital is a referral center and there are about 6000 childbirths taking place annually with a cesarean section rate of 42%. This study was approved by the ethics committee of the Kurdistan University of Medical Sciences. Women eligible for the study were recruited from the postpartum ward. Inclusion criteria were being an Iranian Kurdish woman, being nulliparous, and having vaginal childbirth.

Phenomenological approach was used in the study. Phenomenology describes the subjective meaning of the lived experience and is particularly appropriate in seeking a rich description of significant life events, such as childbirth, in the voices of the women themselves.[16] Descriptions of the mothers’ experiences in the present study were obtained through in-depth interviews. A purposive sample was used. Sample size was not predetermined, but was determined when interviewing reached saturation.[17,18]

The sample number was restricted to 15, as no new data was generated after the 14^th interview. When a participant expressed interest in the study and permission to approach was obtained, the participating woman was asked for the contact information. Participants were given oral and written information about the study. They were also told that they could ask any question about their participation. The purpose of the study was explained to the participants, followed by recording of demographic and contact information. Women were also notified about the time needed for the interview. They were informed that their participation in the study was voluntary and that their names would remain confidential.

Written consent, which included permission to be interviewed for a second time, was also received. The date of interview was fixed to suit the participant. To give confidentiality, participants were given pseudonyms and their real names were kept confidential by the first researcher. They were reassured that their care would not be affected if they chose not to participate in the study. Moreover, they could withdraw from the study at any stage without giving any explanation. The interviews were conducted at the woman's home and lasted between 80 and 120 min.

Data collection took place between 2010 and 2011 using semi-structured, audiotaped, face-to-face interviews, which allowed flexibility and made it possible for the researcher to follow the interests and thoughts of the participants. Women were interviewed by the first researcher (RSh) 6–12 weeks after they had given birth to their first child. The timing was set to allow maximum time for recovery from birth, while still being close to the experience.

The initial question was, “Can you tell me about the experience of childbirth?” The women were encouraged to describe all their feelings and experiences. The researcher attempted to convey the attitude, “teach me,” “tell me about your birth,” and the women were more than willing to share their perspectives and birth stories. Simple and clear grammatical sentence constructions were used to enhance understanding. One of the mothers said she did not understand some of the questions; so, the questions were rephrased to facilitate understanding. Careful and subtle probing was done in order to clarify what the participant was attempting to say. The researcher also used validating reflective statements as the participants responded; therefore, participants knew the researcher understood what they were trying to say.

All interviews were transcribed verbatim in the Kurdish language by the first researcher.

Transcription accuracy was checked by a colleague who read randomly chosen transcripts while listening to the audiotape. The analysis was also undertaken with the Kurdish transcripts, and only verbatim quotations presented in the writing for publication were translated into English. The researcher has attempted to translate the women's descriptions to correspond closely with their meaning in Kurdish, while making them grammatically correct for English readers.

In data analysis for phenomenological enquiry, the researcher aims to uncover and produce an accurate description of the phenomena being studied as experienced by the individual.[19] Content analysis of the data including the generation of themes was performed using Van Manen's method.[20]

Data were analyzed concurrently with data collection, and trustworthiness of the data was established by saturation of categories as data were gathered. Findings were verified through member checks, with the principal investigator discussing the data collected with the participants to verify that the data accurately described their experiences.

The principal investigator (RSh) established an audit trail by keeping a journal of impressions associated with data collection and analysis.[21] The investigator also worked with the co-investigators in analyzing the data. A draft copy of the findings of the research was given to each participant for verification and to ensure that the participants did not feel that they were identified.

RESULTS

Participants’ profiles

The final sample consisted of 15 women aged between 23 and 29 years. All women were born and residing in Sanandaj. Most participants described themselves as housewives (60%). The women differed in educational qualification, ranging from diploma to university degree. All participants were married and first-time mothers. All participants had spontaneous vaginal births without their husbands present. None of them received any analgesia or anesthesia during labor and birth. The findings are described under the following four themes: Feeling empowered, changing life, importance of being supported during labor, and the spiritual dimensions of giving birth. The women's quotes are used to illustrate the text where appropriate.

Feeling empowered

In the interviews, women continuously described that they were feeling empowered by the experience of becoming a mother.

“I am capable of doing a delivery and I am capable of being mother.” #6

“I feel I have grown up … I feel proud because now I am a mother.” #10

For these women, becoming a mother was a pivotal transition that brought changes in their perspectives and priorities.

“Only if you are a mother can you understand how hard it was to give birth to you.” #10

The women discovered inner power during the extreme experience of giving birth.

“I have a lot of strength; I didn’t know I had it.” #12

For these women, pain was an expected part of childbirth and motherhood. One participant said,

“Although it is painful, it is also easy because women have been having babies for thousands of years and became mothers.” #6

The reward of this pain was the joy and happiness most of these women felt when they saw their babies for the first time.

“Birth of my baby is most joyful time for me.” #8

“I am very proud of myself because I’m a mother. I am proud that I have a baby and I am very happy. I can’t imagine myself without my baby.” #5

A new child becomes a part of the woman's life and a part of themselves. For these mothers, the moment when they first saw and touched their newborns was the positive and most emotional aspect of giving birth.

“When I heard the voice of the child, I was happy. I did not know if it was a boy or girl.” #5

The findings of this study show that women can have increased satisfaction with their childbirth when there is increased amount of emotional support.

“With this baby, I think we have a strong family relationship, we can care for each other and love each other.” #9

Changing life

The findings of this study reveal that the women experienced various changes that were associated with their childbirth. These changes included increased patience, understanding, experiences, and feeling more responsible.

“It is an experience without words. There are no words to describe. Perhaps only a mother's heart can feel it.” #6

“I don’t find the right words to express how I felt. I think without having children, life would be empty worth nothing.” #6

Women spoke of how childbirth had brought them closer to both their mothers and spouses. One mother said,

“You are not able to appreciate your parents if you don’t have your own child. Having my own child gives me a new understanding of my relationship with my parents.” #3

“The child's development is a result of the parent's hard work, I realize now.” #1

“Of course there is certainly a change after giving birth, now my husband and I are much closer. We love each other more.” #6

Giving birth provided them with feelings of completeness and changed their view of the world.

The women expressed a sense of self-actualization. The women discovered inner power during the extreme experience of giving birth.

“I think I have gained a lot of experience with this birth. I am quite different from my past.” #2

One participant mentioned:

“Things appear in a different perspective now. I feel very differently and the past is viewed very differently now as well.” #9

Importance of being supported during labor

Interaction with midwives was considered an essential part of experience of giving birth. The participants described a need for the midwives to provide emotional support and encouragement.

“She told me something that nobody else had done. She explains about childbirth and the reason of pain. Then I felt that I could tell her that I need to help.” #11

The experience of not being seen and being ignored in the long first phase of childbirth overshadowed the whole childbirth experience in negative terms for some women.

“They didn’t talk to me and my contractions were very violent.” #7

The environment of labor ward had negative impact on attitudes toward the future pregnancies.

“I don’t want to have pregnancy at all because I have had bad experience; the midwives had very bad behavior, they didn’t care about me and my baby. They were very impolite.” #3

Participants mentioned that they needed support of their husband and family during labor and childbirth. They believed that their presence can influence their perception of the childbirth and help them to have an enjoyable experience.

“I think if my husband or my mother was there, all things were different and I had better experience.” #6

The spiritual dimensions of giving birth

In this study, a strong sense of the spiritual dimensions of giving birth with women's religious beliefs was identified. These women continuously described the need for reliance on Allah as they gave birth and revealed a strong sense of the spiritual dimension of the childbirth experience.

“You need Allah more than ever when you are in the delivery ward.” #5

“Our Allah made it easy for me … I am thankful to Allah because He sent me a marvellous blessing.” #3

“Before I went to hospital, I read Holy Quran and during contraction, I tried to read Holy Quran by heart. I think they helped me tolerate that pain.” #7

Some women reported taking religious icons with them to keep under their pillows during labor.

DISCUSSION

A potential limitation of this study is that all participants were Kurdish pregnant women in Sanandaj; the findings might have been somewhat different if urban and rural Kurdish women from other countries had been included. Furthermore, findings may be quite different in a multiparous woman. Moreover, it must be taken into consideration that a qualitative study implies interaction between researchers and participants, and that the researcher's pre-conceptions might influence interpretation of the material.[22]

The overall purpose of the present study was to investigate the experience of childbirth among Kurdish women giving birth in Iran. Semi-structured interviews proved a very useful tool for the purpose of data collection in this study. The women were free to talk about the experiences that were important to them personally.

In this study about the perspectives of Kurdish childbearing women, their experiences are described in their own words. However, participants of this study are not representative of all Kurdish childbearing women; there are some lessons which can be learnt.

The main finding of this study was that participants described childbirth as the meaning of motherhood. Participants believed that childbirth changed their views about themselves and how they were viewed by others. This finding is consistent with previous studies[7,11,23,24,25] that showed women after childbirth have a sense of self-actualization and self-understanding. The data from the participants’ interviews affirmed that they found giving birth to be enriched by and to enrich their role in their society.

The participants also identified the midwife as an essential part of the birth experience. This view is supported by other studies and shows that the midwife is an important source of support.[11] In addition, it has been identified in a number of research studies that effective support during childbirth reduces the need for interventions and, therefore, increases women's chances of experiencing normal births.[26,27]

The findings of this study suggested that the support of woman's husband or one of her family members during labor and birth had an important role in the experience of childbirth. Although there is an increased amount of literature about the presence of fathers during childbirth, due to Iranian religious and cultural values, men do not attend labor and birth. In a study where women in birth clinics were asked to rank their support during birth, the women often ranked the support from the partner higher than the professional support received.[7]

Maternal experience may have an impact on the attitudes toward the mode of future birth and the cesarean section rates and the maternal role.[5] Therefore, it is important for midwives to see beyond the process of labor and understand the importance of a woman's experience of her birth, because it is this that the women will remember and that will affect their future. Furthermore, having an understanding of a woman's labor and delivery experience allows midwives to continue to improve the quality of maternity care. Therefore, all midwives can do something to help change the environment in which they work and to improve the care they offer to women. Laboring women who feel safe and who have had the opportunity to build a relationship with their midwife have a positive experience. It is evident that effective support during childbirth is a vital aspect of intrapartum care.[28] It is important for midwives and other health professionals to understand the benefits of giving continuous support to women during childbirth.

According to Melender, the childbirth experience has the potential to affect positively or negatively a woman's interaction with her infant.[6] Therefore, midwives who have the responsibility of preparing a woman for childbirth or caring for her during childbirth should be aware of all the variables that can influence a woman's experience of childbirth.

This study adds richly descriptive data to the body of literature on Kurdish childbearing women. Women communicate through telling stories and create meaning as they articulate their feelings about pivotal life events such as childbirth.[29] The findings of this study provide a useful first step toward the identification of aspects of Kurdish women's experience of giving birth. Further exploration of women's experience regarding childbirth is required.