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Respect to Women’s Autonomy in Childbirth: A Qualitative Study

AUTHORS

Firoozeh Mirzaee Rabor 1 , Ali Taghipour 2 , Khadigeh Mirzaii Najmabadi 3 , * , Seyed Hosein Fattahi Masoum 4 , Masoud Fazilat Pour 5

1 Department of Midwifery, Kerman Nursing Research Center, Kerman University of Medical Sciences, Kerman, Iran

2 Department of Epidemiology, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran

3 Department of Nursing and Midwifery, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, IR Iran

4 Department of Thoracic Surgery, School of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran

5 Department of Psychology, School of Letters, Shahid Bahoonar University of Kerman, Kerman, IR Iran

How to Cite: Mirzaee Rabor F, Taghipour A, Mirzaii Najmabadi K, Fattahi Masoum S H, Fazilat Pour M. Respect to Women’s Autonomy in Childbirth: A Qualitative Study, Iran Red Crescent Med J. 2017 ; 19(12):e64817. doi: 10.5812/ircmj.29344.

ARTICLE INFORMATION

Iranian Red Crescent Medical Journal: 19 (12); e64817
Published Online: August 20, 2016
Article Type: Research Article
Received: April 18, 2015
Revised: May 10, 2015
Accepted: May 31, 2015
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Abstract

Background: Respect to women’s autonomy in vaginal child birth is a key factor of maternity care. Engaging women in decision-making in vaginal delivery helps women have a positive experience of delivery.

Objectives: In this content analysis of qualitative study we explored experiences of mothers and midwives in women’s role in normal vaginal childbirth.

Methods: This study was conducted in 2013 - 2014 in Iran. Overall 23 women and midwives were evaluated in this study. Data collected from 12 women and 11 midwives via in-depth semi structured interviews. Participants were selected from governmental and private hospitals in Mashhad and Kerman, Iran. Data analysis was performed using conventional content analysis with MAXqda software (version, 2007).

Results: Mothers’ and midwives’ experiences about women’s role in vaginal childbirth could be organized and categorized in one theme, referred to “Empowerment of women in vaginal childbirth”. This theme consists of two subthemes: “attempts to exhibit self-assertion” and “quest for information” and four categories of compromise with the labor process, cooperation with midwife, finding delivery sources during pregnancy and seeking delivery information in labor.

Conclusions: Attention to women active role in vaginal child birth could improve women experience of vaginal delivery.

Keywords

Vaginal Childbirth Women’s Role Qualitative Study Content Analysis

Copyright © 2016, Iranian Red Crescent Medical Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Background

Childbirth is a key experience for a woman; it influences her dignity for many years (1).

Positive experience of childbirth improves breastfeeding rate, woman’s communication with her family and leads to fewer complications (2). Enabling women to make aware decisions is an important factor to have a positive childbirth experience (3).

Decision-making should be made considering woman’s rights. The necessity for relevant information is the main facture for participation in decision-making (4). Women should be given adequate information by skilled persons to conserve their dignity. If a woman does not agree to a special treatment, there should be a substitute treatment modality for her (5).

Expectations of childbirth are diverse among women; therefore, coping with childbirth varies among women (6). Women should be patronizing to adopt accountability for their parturition and be effective in decision-making throughout maternity care (7). Midwives have a main role in vaginal childbirth (8); therefore, midwives should respect mothers’ decisions by providing required information (9).

Mother’s autonomy in childbirth means that the mother can get participated in decisions (10). The principle of autonomy entails respect for maternal needs and demands (11). International Medical Association (IMA) presented that patient right is to achieve essential medical information; moreover, they should have access to suitable treatment choices (12).

Many studies have emphasized the significance of control and requirement of information given as main keys for women to have an active role in childbirth (13). Sociologists expressed that processes of decision-making are the outcome of balance of authority among obstetricians, women and midwives (14). For all women, availability of secure modes of childbirth appropriate for their social and private conditions is vital for their autonomy. These conditions enable them to actively participate in birth process (15). In short, both quantitative and qualitative studies have the same judgment about the role of birth professionals, critical to both birth consequences and birth experiences (16).

Many studies showed that supporting women during labor improves delivery consequences. Attention to women’s role in delivery would lead to a positive experience of women labor and delivery. For example, Hunter et al. mentioned this issue in their study (17). Bruggemann et al. (18) showed that women’s role in labor and delivery is important and affects delivery outcomes; but there is lack of data how to form women role in vaginal delivery in studies.

Despite many studies on delivery process, only a few evaluated women’s role in vaginal childbirth.

Child birth is a complex phenomenon and women’s role is an important factor for vaginal childbirth. It has many different meanings in cultures. There is no study in Iran to women’s role in normal childbirth. Therefore, it is important to know how women play a role. To respond this subject, qualitative inquiry is the best method. Therefore, we interviewed a group of women and midwives to specify their viewpoints about this issue.

2. Objectives

To recognize facilitating factors for women’s role in childbirth, we aimed to provide a broad description of women’s role in childbirth in Iran, based on women's and midwives perspectives.

3. Methods

3.1. Study Location and Participants

The current study was performed from March 2013 to April 2014 in labor wards of two private and three governmental hospitals and participant’s homes in Kerman and Mashhad, the capitals of Khorasan Razavi and Kerman provinces, respectively, Iran. Kerman is a traditional city and Mashhad is a religious city. Kerman and Mashhad have around 534441 and 3009295 inhabitants, respectively, based on latest national census.

Women and midwives are key informants in normal childbirth, so we interviewed them for their opinion and experiences about women’s role in vaginal child birth.

3.2. Study Design

A qualitative approach was used in this study. Conventional content analysis was used in the current study with a purpose to find out, explain and describe women’s role in vaginal childbirth. Qualitative interview empowers researcher to preserve centralization on the subject and comfort settlement (19, 20).

3.3. Study Procedures

Written informed consents to conduct interviews were obtained from women and midwives. They were assured that all their information would be confidential. In this study, participants suggested date and site of interview. Women and midwives were interviewed by one interviewer (FM). She was a member of the research team with complete perception about qualitative research and good experience of working with pregnant women and childbirth settings.

Semi-structured in-depth interviews were performed in this study. Inclusion criteria for women in this study were as follows: 1) giving birth at a governmental or private hospital; 2) experience of vaginal delivery; 3) having a low-risk pregnancy and childbirth and 4) speaking in Farsi and for midwives were: 1) having job experience at a governmental or private hospital and 2) having at least one year of job experience.

Women with high-risk pregnancies or childbirths (e.g. preeclampsia, diabetes, preterm labor and complicated childbirth) and midwives with less than one year job experience were excluded from this study. Fourteen women and twelve midwives were invited in the study; two women were excluded because of complicated childbirth and one midwife withdrew from the study due to time restriction. The participants were chosen from different parities, ages, educational levels and socio-economic status due to adopt maximum variation.

Data collection method was face to face. The interviews from women and midwives were performed in hospitals and subject’s home; each interview lasted between 45 and 60 minutes. At first women and midwives were asked their opinion about childbirth, then the initial question from each mother was ‘Can you explain about the experience of your role during labor and delivery?’ and the first question from each midwife was ‘Can you describe the experiences of women’s role during labor and delivery?’ The participants were patronized to explain all their experiences by probe questions.

Data collection was continued until we reached data saturation in the two groups.

To encourage participants to describe their experience of women’s role in the hospital, written narratives were used. Field notes were written during and after interviews.

3.4. Data Analysis

To analysis data, qualitative content analysis, guided by Graneheim and Ludman, was used (21). A conventional content analysis method that implicates comprehensively understanding of the basic meaning of the text and assembles data without missing its quality was used.

First, all interviews were transcribed for analysis, and then to obtain an overall sense of subject, transcribed text was evaluated for several times. Meaning units, i.e. the main statement in the text, were recognized and determined. Events, explanations, experiences and perceptions were recognized and coded.

Each meaning unit was given a code. MAXqda software (version. 2007) was used for coding data by a one of the research team (FM) who is a midwife researcher with good experience in childbirth setting. Then, subcategories were formed by comparing and arranging codes.

Comparisons were used constantly and united into sub-themes and one comprehensive theme (Table 2). A beginning analysis was fulfilled by FM separately, and then analysis by KM, AT, S H F and MF was repeated. Conflicts and disagreements were resolved by consensus.

3.5. Trustworthiness of Study

Credibility, dependability, confirmability and transferability, explain rigidity in qualitative research, according to Guba and Lincoln evaluative criteria. Member checking is used for achieving credibility. We took the last description to women and midwives and asked them whether they perceived that findings were a true and correct reflectance of their terms and words. Their explanation and assertions were applied to complete the results. By peer check methods dependability was evaluated. Moreover, confirmability was obtained by leaving a verification sequence and asking a colleague to trail the way and statement on the results. Trans-ferability of this study was achieved as the results were clear and rational for two women and two midwives apart from ones participated in the research (22).

3.6. Ethical Considerations

This study was verified by ethics committee of Mashhad University of Medical Sciences University, Mashhad, Iran [code: 920487]. All women and midwives were aware of the goal of study, privacy of their interviews and their right to take part and leave any time they desired. Ethical issues about anonymity of participants were considered.

4. Results

Participants of this study were 12 women aged 18 - 43 years and 11 midwives aged 22 - 53 years with job experiences from 1 to 34 years. The participants’ characteristics are presented in Table 1. Quotes are shown in italics. Subjects are identified with P quotations.

Table 1. Characteristics of Participantsa
CharacteristicsValues
Women
Age, y
18 >2 (16.67)
18 ≤10 (83.33)
Parity
Primiparous7 (58.33)
Multiparous5 (41.67)
Educational level
Elementary2 (16.67)
Secondary4 (33.33)
Post- secondary3 (25.0)
Postgraduate3 (25.0)
Hospital of childbirth
Governmental7 (58.33)
Private5 (41.67)
Midwives
Educational level
BA degrees7 (63.63)
MA degrees3 (27.27)
PhD degrees1 (9.1)
Job experience, y
10 >5 (45.45)
10 ≤6 (54.55)
Type of hospital
Governmental8 (72.73)
Private3 (27.27)

aValues are expressed as No. (%).

Table 2. “Empowerment of Women in Vaginal Delivery” a Theme on Active Role of Women in Vaginal Childbirth
ThemeSub-ThemeCategorySubcategory
Empowerment of women in vaginal childbirthAttempts to exhibit self-assertion-Coping with pain
-Coping with stress
compromise with the labor process-Coping with frequent vaginal examinations
-Coping with devices connected to monitors
-Attention to specific midwifery positions
Cooperation with midwife-Knowledge about effective midwifery breathing techniques
-Knowledge about useful non-pharmacological midwifery methods of pain relief
Quest for informationFinding delivery sources during pregnancy-Reading books related to childbirth during pregnancy
-Previously heard explanations and experiences of other women
-Using the internet
-Questions about the delivery process
Seeking delivery information in labor-Asking about how their labor progresses
-Questions about fetus health
-Asking about mother’s health

4.1. A theme on “Empowerment of Women in Vaginal Childbirth”

The theme “Empowerment of women in vaginal childbirth” consists of two sub-themes from midwives’ and women’s experiences about women’s role during labor and childbirth. Each sub-theme describes different perspectives in the process of women’s role. “attempts to exhibit self-assertion” refers to women’s and midwives’ descriptions about women’s efforts during labor for self-assertiveness, whilst the sub-theme “quest for information” points to women’s and midwives’ experiences about women’s efforts to find answers for questions about labor and delivery. Emergence of the theme “Empowerment of women in vaginal childbirth” is shown in Table 2.

4.1.1. Attempts to Exhibit Self-Assertion

Women and midwives explained that women wish to show their self-assertion in childbirth, which is shown by two acts: 1) compromise with the labor process; women attempt to exhibit self-assertion through agreement with labor process, such as pain, its length, not eating and drinking.

2) Cooperation with midwife; women and midwives stated that women attempt to exhibit self-assertion through cooperation with midwives such as listening and understandings breathing techniques, non-pharmacological midwifery methods of pain relief and other techniques for improvement of labor process.

4.2. Compromise With the Labor Process

The women and midwives in this study knew that coping with labor pain is one of the ways to comply with childbirth process. Also, pain experience was accepted as part of delivery experience so, they knew how to bear that and tried to cope with that. They knew labor pain was a way to achieve baby.

For example a woman (P2, 37 years old, first delivery) in this regard indicated:

“Well, childbirth means tolerating pain I had a lot of pain, but I knew I had to bear it to have natural delivery.”

The midwives and women described how reducing stress about labor enhances coping with labor process. The expression of one of the women (P7, 20 years old, first delivery) reveals this point:

“I was so nervous when I came for labor. I feared, but I tried to overcome my stress; I comforted myself.”

The women and midwives knew that copping with frequent vaginal examinations was the main factor to get along with the labor process. Although vaginal examinations are unpleasant, women endured them, for midwives knowledge of delivery time and they knew vaginal examinations were necessary for them. The following expression reveals this concept:

“During delivery I underwent multiple vaginal examinations; I was so tired and furious. But the midwife said the examinations were necessary to make sure about delivery progress” (P5, 35 years old, second delivery).

Coping with devices connected to monitors is one of the ways for mothers to comply with the delivery process. Connecting to devices restricts women’s movement. The women bearded this restriction to have a safer delivery process.

A midwife (P3, 27 years old, with 3 years of work experience) in this regard said:

“When the sonication device is attached to women, they should lie down on their back so that we can connect the probe to their abdomen; they should not move; otherwise, the device stops functioning.”

4.3. Cooperation With Midwife

The women and midwives underscored the importance of women’s attention to specific midwifery positions for cooperation with midwives. For instance, a mother (P6, 23 years old, first delivery) said:

“When I had pain, they (midwives) asked me to lie down on my left side; during delivery, they told me what to do; I accepted their advice and it was useful for me.”

The women and midwives knew that midwifery breathing techniques are useful for progression of delivery process. The following expression of one of the women (P9, 29 years old, first delivery) reveals this concept:

“My midwife taught me how to breathe when I had pain and told me to breathe deeply when I had labor pain; when I did it, the labor pain decreased.”

The women and midwives explained that non-pharmacological methods of pain relief in midwifery care are useful for women; such as massage, hot water bag, acupressure, reflexology and etc. These methods help reduce labor pain and improve delivery process.

A mother (P3, 37 years old, second delivery) said:

“She (midwife) massaged my ankle for one minute and said it would relieve the labor pain. This massage affected the pain severity, and I felt less labor pain.”

4.4. Quest for Information

Two factors are related to quest for information: (i) finding delivery sources during pregnancy; (ii) seeking delivery information in labor.

4.5. Finding Delivery Sources During Pregnancy

Women and midwives believed that women read books related to childbirth during pregnancy to gain information about delivery. This information induces women active roles in decision making of delivery process. The following expression reveals this concept:

“I studied several books related to labor pain and delivery during my pregnancy. I was interested in the nature of labor pain and delivery, and I became somewhat familiar with labor pain and delivery.” (P11, 27 years old, first delivery,)

What women have previously heard and experiences of other women are some sources for women’s familiarity with delivery; for example, a mother (P8, 40 years old, third delivery) said: “I had experienced two deliveries in the past; therefore, I was almost familiar with pregnancy and labor pain; I knew how long the labor pain would continue and how severe it would be.”

The internet facilitates access of mothers to information on childbirth and internet could be a good resource for women availability to delivery information. Women availability to internet is easier than other sources. A woman (P9, 29 years old, first delivery) in this regard indicated:

“I was curious about the nature of delivery and labor pain; so I used the internet and searched it. I got some information from the internet.”

4.6. Seeking Delivery Information in Labor

Questions about the delivery process are common questions of woman about labor. For example, a mother (P12, 31 years old, third delivery) said:

“When she (midwife) examined me and said that my cervix had widened three centimeters, I wanted to know how much it should be for a delivery, and how long it takes.”

Women frequently ask midwives questions about how the labor process proceeds. This question is one of the most important questions that women ask. The following expression reveals this concept:

“When I perform vaginal examinations during labor, they ask me about their examination and delivery progress.” (P8, 42 years old, with 18 years of work experience).

Women and midwives explained in this study that fetus health was very important for women, so they asked midwives questions about it; for instance a woman (P8, 40 years old, third delivery) said:

“I was worried about the fetus health; I was afraid a problem might arise. I asked her (midwife) about the fetus health. She made me confident that the fetus was in good health.”

One of the women wished to achieve information about their own health; women and midwives talked about it in this study. Women afraid of problems such as bleeding, too much pain, lack of labor progress and other problems threatening their healthy.

A midwife (P7, 38 years old, with 13 years of work experience) in this regard said:

“Women are worried about their own health in addition to fetus health and we should reassure them that there is no problem and everything is under our control.”

5. Discussion

This study highlighted how women’s role is formed during vaginal delivery. The findings of this study showed that in traditional and religious cities, active role of mother in childbirth is shaped by “Empowerment of women in vaginal childbirth”.

In multifaceted healthcare system nowadays, respect for autonomy with opposing principles is very complicated because of the growing number of choices for screening, diagnosis and treatment (23).

One of fulminations to midwifery care has been the rising practice of using midwives instead of physicians, which might cooperation the adequate processes inherent to midwifery care. For instance, advocacy for women during labor and patients’ education might be limited due to time restrictions in care management. In addition, midwife might rush to attain the traditional medical components of care and contain or leave some dimensions of midwifery care to be integrated by other healthcare professionals. As care is transmitted from one care provider to other, necessary components may be lost or left crude, which might lead to permanent injure; whereas, women request to be involved in their labor, especially to have possession of their childbirth, which leads to a potent feeling of manageability and meaningfulness (24).

It has been revealed that women want a feeling of safety and be involved in interventions during childbirth process (25, 26). There is a complication to provide sufficient support during childbirth. Therefore, support from social network (27-30) and health providers is important (31).

Women’s role in vaginal childbirth is affected by managerial policies that could become effective on moral subjects with consideration for patients.

During interview in this study, women stated that their information is from experiences of other women. This result was also shown by Sercekus et al. (32).

According to the findings of this study, active role of women in childbirth is crucial for women’s ability to follow the labor process and achieve a positive experience.

WHO affirmed that a woman in labor should not be neglected; midwife should supply finest potential support. It is essential to let adequate time for mother to become familiar with midwife, to sense confidence that midwife had sufficient time for mother and for midwife to be taught to the woman’s requirements (33).

Waldenström et al. observed that first-time mothers often have a positive birth experience when they feel involved in decisions, which lead to truth, that they can manage the situation better than they attend before giving birth. In some obstetric status, immediate decisions are sometimes necessary by professionals; for example, changing the delivery position might influence the baby’s heartbeat. In these situations, it may be complex to give the women information, and they may consider that they are not involved.

Goodman et al. (2) described that first-time mothers’ self-confidence is increased by a positive childbirth experiences. This issue leads to affirmative prospect for next parturient experiences.

In this study, informants explained that compliance with labor process is an attempt to show self-assertion for women in labor. The same results were achieved in Fisher et al. (34) study. They noted that pain is a symptom of disease, but pain in childbirth is the expense to become a mother.

In many centers there are inadequate midwives with time restriction and it is an obstacle to provide appropriate information to women’s questions. Besides, Akhavan and Lundgren (35) in their study stated that midwifery is difficult because of high requests and time limits. They should care for numerous mothers in the same time.

Furthermore, midwives in this study required better education on importance of women’s role in delivery.

Ekstrom et al. (36, 37) reported that a process-oriented education for professionals involved in pregnancy, childbirth and infancy changes health professionals’ attitudes and behavior in a positive method. Aune and Ammundsen (38) explained that reciprocal empowerment of woman and midwife is essential.

This study was one of the firsts to shed light on women’s role in childbirth in Iran. The main strength of this study was to apply a qualitative methodology to hear women’s requirements and preferences in vaginal childbirth. Moreover, performing the study in two cities with diverse cultural and religious background allowed the researchers to compare the results. The findings were same in two cities.

One of the limitations of this study was inability to generalize findings to other populations, but the findings of this study can be useful in countries with same socio-cultural context. Also in this study, we attended on women and midwives perceptions. To achieve a more comprehensive perception of women’s role in childbirth, viewpoints of obstetrician should be evaluated in future studies.

5.1. Conclusion

The findings of this study showed the importance of women’s role in vaginal delivery. Women’s active role in vaginal delivery induces a positive experience. Abortions and cesarean section rate can be reduced by this experience in future pregnancies.

Acknowledgements

Footnotes

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