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International Journal of Nursing Practice 2015; 21 (Suppl. 2), 58–66
RESEARCH PAPER
Iranian mothers’ perceptions of the impact of the environment on psychological birth trauma: A qualitative study Ziba Taghizadeh MSc Assistant Professor of Nursing and Midwifery Care Research Center, Nursing and Midwifery School, Tehran University of Medical Sciences, Tehran, Iran PhD Candidate in Reproductive Health, Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
Mohammad Arbabi Associate Professor of Psychiatry, Psychiatry and Psychology Research Center, Tehran University of Medical Sciences, Tehran, Iran
Anoshirvan Kazemnejad Professor, Biostatistics Department, Tarbiat Modares University, Tehran, Iran
Alireza Irajpour PhD Assistant Professor, Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
Violeta Lopez RN PhD FRCNA Professor and Director, Research Centre for Nursing and Midwifery Practice, Medical School, Australian National University Woden, Australian Capital Territory, Australia
Accepted for publication August 2013 Taghizadeh Z, Arbabi M, Kazemnejad A, Irajpour A, Lopez V. International Journal of Nursing Practice 2015; 21 (Suppl. 2): 58–66 Iranian mothers’ perceptions of the impact of the environment on psychological birth trauma: A qualitative study Childbirth is a unique experience in women’s life. Various factors including human and non-human environment are involved in shaping the experience of childbirth.This study investigated the role of the environment on the psychological birth trauma from the perceptions of Iranian mothers. A qualitative descriptive study was conducted from September 2011 to February 2012, using audiotaped interviews with 23 Iranian women recruited from Tehran and Isfahan. The interviews were transcribed verbatim and analysed using the content analysis. Two themes were extracted from the data: human and non-human environment; and several categories also emerged from the data, which are communication with mother, awareness of mother’s needs, support for mother, medical clinical competence, professional responsibility, hospital’s physical structure, hospital’s equipment, routine care in hospital and rules governing the hospital’s environment,
Correspondence: Alireza Irajpour, Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Hezar Jarib Street, Isfahan 8174673461, Iran. Email: [email protected] © 2014 Wiley Publishing Asia Pty Ltd
doi:10.1111/ijn.12286
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respectively. Considering the significant role of environment in psychological birth trauma of the mother, an appropriate intervention must be developed to enhance both human and non-human environment in order to reduce the psychological birth trauma. Key words: childbirth, environment, Iranian mothers, psychological trauma, qualitative study.
INTRODUCTION In the past, women gave birth at home sheltered by their mothers, aunts or close friends. The home provides a quiet and safe environment for childbearing mother, whereas accompaniers provide the necessary psychological support to her.1,2 For many women, the superiority of delivering at home emanates from the feeling of privacy and being surrounded by family members and significant others,3 and the homely environment during childbirth supported their normal lifestyle.4,5 With the recent changes in birthing place, the care of mothers during childbirth is gradually devolved to the medical teams. The women had to leave their own community to deliver their babies in the hospital with unfamiliar staff.6 In this process, women need to be supported additionally by their husbands, friends and caregivers.7 In the 1980s, to promote the humane individualized care, the ‘one to one’ model of care became the standard model in labour and childbirth,8 and each woman received ‘one to one’ care by a trained midwife or physician.9 Also in the last century, major changes in obstetric care and use of technology in hospitals have led to a decline to the threatening risks to mothers.10,11 However, despite the fact that communication is a keystone of good clinical practice,12 the relationship between midwives and mothers has witnessed a gradual decrease.8 Additionally, the lack of care and support of medical teams in hospitals have become one of the factors for mothers to suffer from psychological birth trauma.9,13 To abate this problem, a number of studies reported the benefits of providing support and reassurance to help women to maintain control of childbirth.14–20 In addition, it was recommended that health-care services should provide an environment as a supportive cornerstone for childbearing women to promote effective care and optimize health outcomes.12,15,20 With regard to non-human environment, scholars recognized the importance of the interaction between human and the built environment21,22; several studies explored relationship between hospital design and patient health.4,23,24 A study by Beake et al. (2010) found that the physical environment where the parturient women could
get rest was uncomfortable and the set-up was not prepared according to their needs. Thus, the quality of maternal health has been internationally described as a ‘neglected’ agenda.25 Stokols21 voiced his concern about the way which the pregnant and labouring women were treated in the hospital setting. Verbal abuse and threats which have been experienced by the childbearing women were the other forms of traumatic birth experiences.26 The pressure of pregnancy and childbirth were reported to result in psychological birth trauma.7,27 Psychological birth trauma occurs when the mother feels serious threats and death for herself or her baby,28–30 and affects one in every three mothers.9 Following the trauma, women experience losing control over the events. They experience depression and anxiety31 which could jeopardize maternal and child health, as well as family relationships.32 In Iran, about 1.5 million women are admitted in hospitals for childbirth annually,33 and more than 95% of births take place in the public and private hospitals.33–35 Based on the Iranian cultural values, men do not attend in the labour and birth room as a father or a doctor. Usually, the mothers accompany the daughter in the ward during labour and childbirth as the midwives were often busy doing other tasks besides attending to mothers who are in need of their care. In such busy hospital environment with limited personnel, supporting mothers was not possible. Thus, Iranian mothers often experience excessive fear and anxiety during the childbirth process. Based on a study in a health-care centre in Karaj (a town 50 km west of Tehran), 46.5%, 12.1% and 11.1% of mothers experience psychological trauma, anxiety and depression, respectively, 4–6 weeks after birth.36 Therefore, the aim of this study was to further explore the impact of the current environment that contributed to Iranian mothers’ psychological birth trauma.
METHODS Study design A qualitative descriptive approach was adopted to uncover the women’s perceptions of the impact of the environment in the psychological birth trauma. Content analysis © 2014 Wiley Publishing Asia Pty Ltd
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with a long history is used in many studies related to nursing.37 In conventional content analysis used in the study, coding categories are derived directly from the mothers’ transcript.38
Setting and sample The study included a convenience sample of 23 mothers participating in the study. The natural setting as the source of data was used in a qualitative research,39 so the participants were from the academic health centres, public and private hospitals in Isfahan and Tehran, as well as the homes and workplaces of the participants or researcher. The age, educational level, economic, social and cultural and employment status, number of pregnancies and the mode of delivery were considered to achieve maximum variation of participants. Based on the research questions, the researcher actively selects the most productive sample,40 who were experiencing psychological birth trauma assessed using the revised fourth edition of the standard psychiatric questionnaire. As Moyzakitis emphasized, the childbirth experience is embedded in the mothers’ memories forever.41 Following 24 h after birth, mothers were able to participate in this study, although women participated within 30 years after delivery. Psychological birth trauma is a situation in which the mother suffered thoughts about death or severe morbidity for herself and her baby; this feeling might lead to traumatic condition, with a prolonged psychological effect.41
Data collection procedures Ethical considerations Approval to conduct the study was obtained from the institution’s ethics committee of Isfahan University of Medical Sciences (No: 389293). Sampling permission was obtained from the relevant university and hospital. Participants, from different settings, were provided with an Information Sheet that explained the purpose and nature of the study. They were informed that the interview will be tape-recorded and will take about 60 min. They were assured about their privacy and that withdrawal from the study would not affect their care; also, the signed informed consent was obtained. The interviews were conducted at a time and place convenient to the participants using an interview guideline. Interviews were conducted until saturation was achieved, when any new information was not achieved. The sampling process lasted from September 2011 to February 2012. © 2014 Wiley Publishing Asia Pty Ltd
Data analysis Tape-recorded interviews were transcribed verbatim. The transcripts were read word by word to get a general sense of what the participants were saying,42 and tried to find the main concept of the entire individual transcript, and identify any codes.43 So, the initial codes from the interviews were extracted using content analysis. The codes were reviewed several times and categorized based on their similarities. In the next stage, the categories were grouped according to themes.42 The themes described the lived experience of mothers in association with environment role in psychological birth trauma.43
Trustworthiness Data credibility was established by face-to-face discussions with any participants and through prolonged engagement. Considering the long-term communication with the mothers, the researcher made effort to better understand participants’ perception. To ensure that no data were lost in the analysis process, three academic staff took part as peer reviewers. A diverse range of participants were covered in two big cities of Iran (Tehran and Isfahan), but due to the nature of the qualitative research method, the findings could not be generalized to the other cultures.
RESULTS Twenty-three (n = 23) participants aged between 18 and 50 years consented to participate in the study. Their educational status ranged from secondary school to PhD degree, and the majority of them were housewives. None had a history of smoking or psychiatric drug use. There were 13 from 24 participants who were multiparous; almost half of them had a history of infertility. Most of the pregnancies were complicated ones, and some gave birth by Caesarean section in public hospitals.
Unprepared environment for mothers in childbirth Childbirth is a unique experience in women’s life. Various environmental factors which are out of the mother’s control are involved in shaping her childbearing experience. Two themes which described the impact of the environment on psychological birth trauma among Iranian women were extracted from the data: human and nonhuman environment as an unprepared environment for childbearing mothers (Table 1).
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Table 1 Themes and categories of unprepared environment and psychological birth trauma Unites
Category
Theme
‘No one could have seen my crying at all, and nobody knows the reason why I was crying. It means no one understood the feeling of fear and sadness that I was experiencing and no one was there for me and consoled me.’ ‘I recognized it since about the tenth day of delivery but it was wonderful that the people close to me as well as my husband were failed to understand the changes in my psychological behaviors.’ ‘The night before the delivery, my husband began to complain that it was your mother who did it and. . . . since I was unable to fight back, I began to cry and went to bath and started crying since 12 o’clock at night until 2 in the morning. Yet he went to bed and didn’t care how hurtful his speech was.’ ‘I could see that the people in the surgery room pay no attention to her dress in terms of moral code. When she becomes unconscious, they do not observe human morals.’ ‘It beats me, when they sent me to the surgery room for caesarian with a signature by my husband, while they didn’t explain it to me or even talk to me.’ ‘The room is scary by day, it looks like a tunnel, I never saw a morgue, but I don’t know why I feel the room looks like that.’ ‘Doctors gleaned information on my diseases. However, I wanted them to finish it soon and anaesthetize me, so that I couldn’t see the equipment. Seeing hospital equipment causes me to feel fear more.’ ‘Since my doctor arrived so late, then she saw my baby head is on the perineum for long time, she just said “excuse me” for giving you episiotomy without analgesia. You can imagine how much pain I felt. Indeed, I was slaughtered, does it suggest care?’ ‘I entered the delivery room under stress because they didn’t allow my attendants to enter the delivery room or even the Labor. But the fear I harbored didn’t matter to anyone. There is no specific rule in favor of mothers, at all.’
Communication with mother
Human environment
Theme 1: Human environment Human environment referred mainly to the interactions between the mothers and the health-care professionals during labour and childbirth, and was reported as a major factor that resulted among mothers who suffered from psychological birth trauma. The mothers reported that health-care professionals did not communicate with them and were not aware of their needs in the childbirth process, when they mostly needed their support. The mothers perceived that the health-care professionals, both the midwives and doctors, did not have enough interpersonal skills to communicate effectively with them, which they believe is one of their important professional responsibilities. The mothers expressed their concerns as: No one asked me why I was crying. A midwife who approached me later told me that I should not be behaving like this.
Awareness of mother’s needs Support for mother
Medical clinical competence Professional responsibility Hospital’s physical structure Hospital’s equipment
Non-human environment
Routine care in hospital
Rules governing the hospital’s environment
Childbirth is a normal event and that I should be happy that it is all over. No one understood that I am afraid and I don’t know what to do. This is my first baby. I need somebody to assure me that I am doing the right thing. No one was there to help me. Another mother said: Doctors often come along and stay a minute, help with the birth of the child and then go. There was no attempt to talk to me and even ask how I was doing. The mothers believed that the doctors were only interested in their physical health and not interested in understanding their mental needs. The doctors were just content in doing their routine jobs. One of the needs the women reported was alleviating their pain during labour, as one mother said: © 2014 Wiley Publishing Asia Pty Ltd
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I was in pain and I was left alone and ignored. No one bothered to come and check up on me. I was expecting that somebody will be there to comfort me but . . .’ Another mother said: ‘If nurses do not have enough time to support mothers, hospital manager should hire new nurses. If it is impossible, allow us to have an accompanier. At least she could talk to us and give some peace. Most of the mothers also indicated that the lack of understanding and knowledge of mothers’ needs does not only relate to the health professionals in the labour and delivery room, but also to the people close to them like their husbands who were unaware of their needs, as one mother recounted: I need the human connection from people close to me. My husband failed to understand my needs. They don’t understand that childbearing women are vulnerable to suffer from psychological anxiety during pregnancy and they fail to support or console us. One of the participants complained: I gave birth about three years ago, but I have not talked to anyone until now; nobody asks me about my concern. Today by taking with you, I am feeling calm and mental peace.
Theme 2: Non-human environment The hospital environment in general, and in particular, the labour and delivery room, also impacted on the women’s psychological birth trauma. The non-human environment included the instruments and equipment used in delivery as well as the hospital routines. They all agreed that the hospital is not a good place to give birth to a child. Majority of the mothers found the first moment when they arrived at the hospital to give birth as the worst moment in their delivery: The worst moment is when I stepped into the delivery room and saw the midwives rushing and saying to the others to prepare this and that. The environment terrified me. Another mothers said: As I entered the room, I noticed the walls were tiled and I said to myself—My goodness, how unfriendly and unpleasant this room is. It reminded me of death. It looks like a mortuary. Seeing hospital instruments was also frightening for the mothers, as one mother said: © 2014 Wiley Publishing Asia Pty Ltd
Doctors just wanted to do their job as quickly as they can without even bothering to explain. However, I wanted them to finish it soon and anaesthetize me so that I couldn’t see the instruments. Seeing hospital instruments causes you to feel fear more. In most instances, mothers felt that doctors just used instruments to hasten the process of labour and delivery without explaining why this was necessary. The mothers thought major violations of their rights due to unnecessary procedures by physicians. The mothers reported their experience as: The doctors were abusing us with their power and not with their competence as caring obstetricians. We felt violated. One of the mothers who was a midwife said: All of my family and my physician emphasized on C-section, but I wish to have a normal delivery. When my water bag was ruptured and the baby had a stool, they said me; you are responsible, if the baby getting any trouble! Nobody could understand me. I was in need of support, but there was nothing. Routine hospital cares were also not welcomed by the mothers. The rules included not allowing anybody to accompany the mothers in the labour and delivery rooms. One of mothers stated that: I entered the delivery room under stress because they didn’t allow my family to enter the labour and delivery room. The fear I harboured didn’t matter to anyone. There is no specific rule in favour of mothers at all’. One of mothers who suffered pain and loneliness said: ‘I had killer pain, but due to lack of attention, I did not say anything. Nobody could understand me. I was alone and just cry; No one did accompany me.
DISCUSSION The study attempted to interview women with different demographic and reproductive characteristics to achieve maximum variation. Indeed, in this study, researchers attempted to engage deeply in the research subject through interviewing mothers with different characteristics. According to Sandelowski, to have access to demographically varied cases, maximum variation sampling can be used.44 In this study, both young and middle-aged mothers experienced psychological birth trauma; due to the nature
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of this qualitative study, the researchers could not be able to detect the relationship between age and the main variable. Although, a cross-sectional study among 30 480 pregnant women found that young age was one of the risk factors for fear of childbirth.45 In regard with level of literacy, participants with different levels of education have been included in the study. The findings showed that probably a high level of education would not guarantee a childbirth process without psychological trauma. Another study accentuated the significant relationship between unspecified educational status and childbirth fear.45 Despite educational status, the degree of awareness regarding a childbirth process might be beneficial for the prevention of psychological birth trauma. Bryanton et al.’s findings are in line with the results of this study, in which he emphasized that degree of awareness about childbirth events can be considered as one the most important predictors of childbirth experiences. In fact, the awareness could lead mothers to be more active in the childbirth process. As a result, they might feel less frightened.46 In this study, majority of the mothers gave birth by C-section, and only a small portion of them had normal delivery, but based on the findings all of them experienced psychological birth trauma. It seems that this kind of trauma was not related to vaginal birth exclusively. Another study was in the same viewpoint about the lack of relationship between the mode of birth and the psychological trauma.47 The time between delivery and interview with the mother was another important aspect in this research. As a representative case, the first interview was conducted 24 h after childbirth; however, mothers who had labour many years ago were included in the study. The finding of this study is consistent with Moyzakitis’ who believed that the childbirth experience will be engraved in the mothers’ memory forever.41 Iranian mothers participating in this study left their homes to take shelter in hospitals with the hope of a pleasant and safe delivery. However, due to environmental factors such as not receiving enough support from human and non-human environment, they experienced psychological birth trauma. The results concurred with other studies.48 External conditions of the pregnancy itself and the birth-giving environment were found to be strong predictors of psychological birth trauma.13 All mothers in our study experienced fear in connection with the physical structure of the delivery or operation rooms as they per-
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ceived these rooms similar to mortuaries for dead people. Misago et al. reported that women give birth their babies was cold, dehumanized the atmosphere where and their social and cultural needs were ignored there.6 In another study, where women had to share the labour room, they found that the room was noisy, with ambient temperature and inappropriate mattresses.49 Our results are in contrast to other settings where the women were provided with physically and emotionally friendly environment, with access to fully equipped labour and delivery suites, joyful pink or green colours, and were spacious50; our women perceived that the rooms caused them to become more stressed. One of the strict rules was the lack of permission for any of the mother’s husband, family or ‘Doula’ to accompany them during labour and delivery of the baby. Evidence shows that the presence of other close persons during labour and delivery, who could provide coaching and support, has physical and psychological benefits.20,51 In some countries, many mothers choose a ‘Doula’ to provide support during childbirth, which enhances the mothers’ sense of security and improves maternal health outcomes.51–53 ‘Doula’ is an experienced woman who offers emotional and practical support to a woman (or couple) during childbirth. A doula believes in ‘mothering the mother’.54 The presence of Nepali women’s husbands during childbirth gave the comfort, physical and emotional support that reduced the women’s psychological distress.55,56 Mayberry et al. emphasized that cultural values, which construct assumptions, knowledge and meanings, have a significant role in the health-care system.57 Unfortunately, due to cultural limitations, the presence of the husband and mother in the labour room is not common in Iran, so cultural restructure is recommended. Aside from the participants not experiencing any peace in hospitals, they faced some painful interventions as well. Also, mothers felt that some of these interventions, which are non-humanistic, could not keep their health. Fear of interventions and repeated examinations at hospitals were the concern of 71.9% of the women who preferred home delivery.3 Hodges reported that medical practices are rarely diagnosed as a violence and abuse against women in the hospitals; some unnecessary interventions for the mother were performed as a medical treatment which violates the mothers’ rights.26,50 This situation is a systematic problem similar to what existed in hospital settings in the decades between 1950 and 1960, and it seems that special attention to this issue is necessary. © 2014 Wiley Publishing Asia Pty Ltd
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The most favourable environment for childbirth is a familiar environment without any extra intervention, with support from the midwives and medical teams and which encourages mothers to express their needs freely.58 As the study of Sapountzi-Krepia et al. showed, the behaviour of the medical team has an important role in shaping mothers’ experiences in the childbirth process.59 Mothers in our study suffered from lack of support, care and understanding from the medical staff. During pregnancy, they were unable to establish good communication with their doctors resulting, to mothers’ feelings of fear and lack of trust in the obstetric staff. In a study of 329 Finnish women, leaving the mother alone, lack of parental involvement in decision-making and medical teams’ unfriendly behaviour were the reasons for most of the mothers’ fears and concerns during childbirth.13,59 One study also showed that many health-care providers do not establish effective communication with mothers during childbirth that caused them distress.60 Most of the mothers stated that lack of trust in health-care teams was the reason for their fear during childbirth, which concurred with the study of Beake et al.49 Our study has limitations in that the results were not representative of all Iranian mothers due to the nature of the qualitative research. The purpose of most qualitative studies is not to generalize, but rather to provide a deep perception of some aspects of human experience.61 However, the results of our study provided evidence of the impact of the environment on labouring mother on developing psychological birth trauma that could have been easily overcome.
Conclusions Based on our findings it seems that delivery and operation rooms should be redesigned, in a way that they make mothers feel more relaxed. Moreover, perhaps the presence of doula or partner can be considered as an effective support for women in childbirth. Thus, accompanying mother in labour could be addressed in future national health priority. Updating the regulations of maternity units and mother care plans, according to mothers need, seems to be necessary.
ACKNOWLEDGEMENTS The authors would like to thank the women who willingly shared their childbirth experiences with the research team. We also thank Isfahan University for their support to the study. © 2014 Wiley Publishing Asia Pty Ltd
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International Journal of Nursing Practice 2015; 21 (Suppl. 2), 58–66
RESEARCH PAPER
Iranian mothers’ perceptions of the impact of the environment on psychological birth trauma: A qualitative study Ziba Taghizadeh MSc Assistant Professor of Nursing and Midwifery Care Research Center, Nursing and Midwifery School, Tehran University of Medical Sciences, Tehran, Iran PhD Candidate in Reproductive Health, Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
Mohammad Arbabi Associate Professor of Psychiatry, Psychiatry and Psychology Research Center, Tehran University of Medical Sciences, Tehran, Iran
Anoshirvan Kazemnejad Professor, Biostatistics Department, Tarbiat Modares University, Tehran, Iran
Alireza Irajpour PhD Assistant Professor, Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
Violeta Lopez RN PhD FRCNA Professor and Director, Research Centre for Nursing and Midwifery Practice, Medical School, Australian National University Woden, Australian Capital Territory, Australia
Accepted for publication August 2013 Taghizadeh Z, Arbabi M, Kazemnejad A, Irajpour A, Lopez V. International Journal of Nursing Practice 2015; 21 (Suppl. 2): 58–66 Iranian mothers’ perceptions of the impact of the environment on psychological birth trauma: A qualitative study Childbirth is a unique experience in women’s life. Various factors including human and non-human environment are involved in shaping the experience of childbirth.This study investigated the role of the environment on the psychological birth trauma from the perceptions of Iranian mothers. A qualitative descriptive study was conducted from September 2011 to February 2012, using audiotaped interviews with 23 Iranian women recruited from Tehran and Isfahan. The interviews were transcribed verbatim and analysed using the content analysis. Two themes were extracted from the data: human and non-human environment; and several categories also emerged from the data, which are communication with mother, awareness of mother’s needs, support for mother, medical clinical competence, professional responsibility, hospital’s physical structure, hospital’s equipment, routine care in hospital and rules governing the hospital’s environment,
Correspondence: Alireza Irajpour, Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Hezar Jarib Street, Isfahan 8174673461, Iran. Email: [email protected] © 2014 Wiley Publishing Asia Pty Ltd
doi:10.1111/ijn.12286
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respectively. Considering the significant role of environment in psychological birth trauma of the mother, an appropriate intervention must be developed to enhance both human and non-human environment in order to reduce the psychological birth trauma. Key words: childbirth, environment, Iranian mothers, psychological trauma, qualitative study.
INTRODUCTION In the past, women gave birth at home sheltered by their mothers, aunts or close friends. The home provides a quiet and safe environment for childbearing mother, whereas accompaniers provide the necessary psychological support to her.1,2 For many women, the superiority of delivering at home emanates from the feeling of privacy and being surrounded by family members and significant others,3 and the homely environment during childbirth supported their normal lifestyle.4,5 With the recent changes in birthing place, the care of mothers during childbirth is gradually devolved to the medical teams. The women had to leave their own community to deliver their babies in the hospital with unfamiliar staff.6 In this process, women need to be supported additionally by their husbands, friends and caregivers.7 In the 1980s, to promote the humane individualized care, the ‘one to one’ model of care became the standard model in labour and childbirth,8 and each woman received ‘one to one’ care by a trained midwife or physician.9 Also in the last century, major changes in obstetric care and use of technology in hospitals have led to a decline to the threatening risks to mothers.10,11 However, despite the fact that communication is a keystone of good clinical practice,12 the relationship between midwives and mothers has witnessed a gradual decrease.8 Additionally, the lack of care and support of medical teams in hospitals have become one of the factors for mothers to suffer from psychological birth trauma.9,13 To abate this problem, a number of studies reported the benefits of providing support and reassurance to help women to maintain control of childbirth.14–20 In addition, it was recommended that health-care services should provide an environment as a supportive cornerstone for childbearing women to promote effective care and optimize health outcomes.12,15,20 With regard to non-human environment, scholars recognized the importance of the interaction between human and the built environment21,22; several studies explored relationship between hospital design and patient health.4,23,24 A study by Beake et al. (2010) found that the physical environment where the parturient women could
get rest was uncomfortable and the set-up was not prepared according to their needs. Thus, the quality of maternal health has been internationally described as a ‘neglected’ agenda.25 Stokols21 voiced his concern about the way which the pregnant and labouring women were treated in the hospital setting. Verbal abuse and threats which have been experienced by the childbearing women were the other forms of traumatic birth experiences.26 The pressure of pregnancy and childbirth were reported to result in psychological birth trauma.7,27 Psychological birth trauma occurs when the mother feels serious threats and death for herself or her baby,28–30 and affects one in every three mothers.9 Following the trauma, women experience losing control over the events. They experience depression and anxiety31 which could jeopardize maternal and child health, as well as family relationships.32 In Iran, about 1.5 million women are admitted in hospitals for childbirth annually,33 and more than 95% of births take place in the public and private hospitals.33–35 Based on the Iranian cultural values, men do not attend in the labour and birth room as a father or a doctor. Usually, the mothers accompany the daughter in the ward during labour and childbirth as the midwives were often busy doing other tasks besides attending to mothers who are in need of their care. In such busy hospital environment with limited personnel, supporting mothers was not possible. Thus, Iranian mothers often experience excessive fear and anxiety during the childbirth process. Based on a study in a health-care centre in Karaj (a town 50 km west of Tehran), 46.5%, 12.1% and 11.1% of mothers experience psychological trauma, anxiety and depression, respectively, 4–6 weeks after birth.36 Therefore, the aim of this study was to further explore the impact of the current environment that contributed to Iranian mothers’ psychological birth trauma.
METHODS Study design A qualitative descriptive approach was adopted to uncover the women’s perceptions of the impact of the environment in the psychological birth trauma. Content analysis © 2014 Wiley Publishing Asia Pty Ltd
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with a long history is used in many studies related to nursing.37 In conventional content analysis used in the study, coding categories are derived directly from the mothers’ transcript.38
Setting and sample The study included a convenience sample of 23 mothers participating in the study. The natural setting as the source of data was used in a qualitative research,39 so the participants were from the academic health centres, public and private hospitals in Isfahan and Tehran, as well as the homes and workplaces of the participants or researcher. The age, educational level, economic, social and cultural and employment status, number of pregnancies and the mode of delivery were considered to achieve maximum variation of participants. Based on the research questions, the researcher actively selects the most productive sample,40 who were experiencing psychological birth trauma assessed using the revised fourth edition of the standard psychiatric questionnaire. As Moyzakitis emphasized, the childbirth experience is embedded in the mothers’ memories forever.41 Following 24 h after birth, mothers were able to participate in this study, although women participated within 30 years after delivery. Psychological birth trauma is a situation in which the mother suffered thoughts about death or severe morbidity for herself and her baby; this feeling might lead to traumatic condition, with a prolonged psychological effect.41
Data collection procedures Ethical considerations Approval to conduct the study was obtained from the institution’s ethics committee of Isfahan University of Medical Sciences (No: 389293). Sampling permission was obtained from the relevant university and hospital. Participants, from different settings, were provided with an Information Sheet that explained the purpose and nature of the study. They were informed that the interview will be tape-recorded and will take about 60 min. They were assured about their privacy and that withdrawal from the study would not affect their care; also, the signed informed consent was obtained. The interviews were conducted at a time and place convenient to the participants using an interview guideline. Interviews were conducted until saturation was achieved, when any new information was not achieved. The sampling process lasted from September 2011 to February 2012. © 2014 Wiley Publishing Asia Pty Ltd
Data analysis Tape-recorded interviews were transcribed verbatim. The transcripts were read word by word to get a general sense of what the participants were saying,42 and tried to find the main concept of the entire individual transcript, and identify any codes.43 So, the initial codes from the interviews were extracted using content analysis. The codes were reviewed several times and categorized based on their similarities. In the next stage, the categories were grouped according to themes.42 The themes described the lived experience of mothers in association with environment role in psychological birth trauma.43
Trustworthiness Data credibility was established by face-to-face discussions with any participants and through prolonged engagement. Considering the long-term communication with the mothers, the researcher made effort to better understand participants’ perception. To ensure that no data were lost in the analysis process, three academic staff took part as peer reviewers. A diverse range of participants were covered in two big cities of Iran (Tehran and Isfahan), but due to the nature of the qualitative research method, the findings could not be generalized to the other cultures.
RESULTS Twenty-three (n = 23) participants aged between 18 and 50 years consented to participate in the study. Their educational status ranged from secondary school to PhD degree, and the majority of them were housewives. None had a history of smoking or psychiatric drug use. There were 13 from 24 participants who were multiparous; almost half of them had a history of infertility. Most of the pregnancies were complicated ones, and some gave birth by Caesarean section in public hospitals.
Unprepared environment for mothers in childbirth Childbirth is a unique experience in women’s life. Various environmental factors which are out of the mother’s control are involved in shaping her childbearing experience. Two themes which described the impact of the environment on psychological birth trauma among Iranian women were extracted from the data: human and nonhuman environment as an unprepared environment for childbearing mothers (Table 1).
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Table 1 Themes and categories of unprepared environment and psychological birth trauma Unites
Category
Theme
‘No one could have seen my crying at all, and nobody knows the reason why I was crying. It means no one understood the feeling of fear and sadness that I was experiencing and no one was there for me and consoled me.’ ‘I recognized it since about the tenth day of delivery but it was wonderful that the people close to me as well as my husband were failed to understand the changes in my psychological behaviors.’ ‘The night before the delivery, my husband began to complain that it was your mother who did it and. . . . since I was unable to fight back, I began to cry and went to bath and started crying since 12 o’clock at night until 2 in the morning. Yet he went to bed and didn’t care how hurtful his speech was.’ ‘I could see that the people in the surgery room pay no attention to her dress in terms of moral code. When she becomes unconscious, they do not observe human morals.’ ‘It beats me, when they sent me to the surgery room for caesarian with a signature by my husband, while they didn’t explain it to me or even talk to me.’ ‘The room is scary by day, it looks like a tunnel, I never saw a morgue, but I don’t know why I feel the room looks like that.’ ‘Doctors gleaned information on my diseases. However, I wanted them to finish it soon and anaesthetize me, so that I couldn’t see the equipment. Seeing hospital equipment causes me to feel fear more.’ ‘Since my doctor arrived so late, then she saw my baby head is on the perineum for long time, she just said “excuse me” for giving you episiotomy without analgesia. You can imagine how much pain I felt. Indeed, I was slaughtered, does it suggest care?’ ‘I entered the delivery room under stress because they didn’t allow my attendants to enter the delivery room or even the Labor. But the fear I harbored didn’t matter to anyone. There is no specific rule in favor of mothers, at all.’
Communication with mother
Human environment
Theme 1: Human environment Human environment referred mainly to the interactions between the mothers and the health-care professionals during labour and childbirth, and was reported as a major factor that resulted among mothers who suffered from psychological birth trauma. The mothers reported that health-care professionals did not communicate with them and were not aware of their needs in the childbirth process, when they mostly needed their support. The mothers perceived that the health-care professionals, both the midwives and doctors, did not have enough interpersonal skills to communicate effectively with them, which they believe is one of their important professional responsibilities. The mothers expressed their concerns as: No one asked me why I was crying. A midwife who approached me later told me that I should not be behaving like this.
Awareness of mother’s needs Support for mother
Medical clinical competence Professional responsibility Hospital’s physical structure Hospital’s equipment
Non-human environment
Routine care in hospital
Rules governing the hospital’s environment
Childbirth is a normal event and that I should be happy that it is all over. No one understood that I am afraid and I don’t know what to do. This is my first baby. I need somebody to assure me that I am doing the right thing. No one was there to help me. Another mother said: Doctors often come along and stay a minute, help with the birth of the child and then go. There was no attempt to talk to me and even ask how I was doing. The mothers believed that the doctors were only interested in their physical health and not interested in understanding their mental needs. The doctors were just content in doing their routine jobs. One of the needs the women reported was alleviating their pain during labour, as one mother said: © 2014 Wiley Publishing Asia Pty Ltd
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I was in pain and I was left alone and ignored. No one bothered to come and check up on me. I was expecting that somebody will be there to comfort me but . . .’ Another mother said: ‘If nurses do not have enough time to support mothers, hospital manager should hire new nurses. If it is impossible, allow us to have an accompanier. At least she could talk to us and give some peace. Most of the mothers also indicated that the lack of understanding and knowledge of mothers’ needs does not only relate to the health professionals in the labour and delivery room, but also to the people close to them like their husbands who were unaware of their needs, as one mother recounted: I need the human connection from people close to me. My husband failed to understand my needs. They don’t understand that childbearing women are vulnerable to suffer from psychological anxiety during pregnancy and they fail to support or console us. One of the participants complained: I gave birth about three years ago, but I have not talked to anyone until now; nobody asks me about my concern. Today by taking with you, I am feeling calm and mental peace.
Theme 2: Non-human environment The hospital environment in general, and in particular, the labour and delivery room, also impacted on the women’s psychological birth trauma. The non-human environment included the instruments and equipment used in delivery as well as the hospital routines. They all agreed that the hospital is not a good place to give birth to a child. Majority of the mothers found the first moment when they arrived at the hospital to give birth as the worst moment in their delivery: The worst moment is when I stepped into the delivery room and saw the midwives rushing and saying to the others to prepare this and that. The environment terrified me. Another mothers said: As I entered the room, I noticed the walls were tiled and I said to myself—My goodness, how unfriendly and unpleasant this room is. It reminded me of death. It looks like a mortuary. Seeing hospital instruments was also frightening for the mothers, as one mother said: © 2014 Wiley Publishing Asia Pty Ltd
Doctors just wanted to do their job as quickly as they can without even bothering to explain. However, I wanted them to finish it soon and anaesthetize me so that I couldn’t see the instruments. Seeing hospital instruments causes you to feel fear more. In most instances, mothers felt that doctors just used instruments to hasten the process of labour and delivery without explaining why this was necessary. The mothers thought major violations of their rights due to unnecessary procedures by physicians. The mothers reported their experience as: The doctors were abusing us with their power and not with their competence as caring obstetricians. We felt violated. One of the mothers who was a midwife said: All of my family and my physician emphasized on C-section, but I wish to have a normal delivery. When my water bag was ruptured and the baby had a stool, they said me; you are responsible, if the baby getting any trouble! Nobody could understand me. I was in need of support, but there was nothing. Routine hospital cares were also not welcomed by the mothers. The rules included not allowing anybody to accompany the mothers in the labour and delivery rooms. One of mothers stated that: I entered the delivery room under stress because they didn’t allow my family to enter the labour and delivery room. The fear I harboured didn’t matter to anyone. There is no specific rule in favour of mothers at all’. One of mothers who suffered pain and loneliness said: ‘I had killer pain, but due to lack of attention, I did not say anything. Nobody could understand me. I was alone and just cry; No one did accompany me.
DISCUSSION The study attempted to interview women with different demographic and reproductive characteristics to achieve maximum variation. Indeed, in this study, researchers attempted to engage deeply in the research subject through interviewing mothers with different characteristics. According to Sandelowski, to have access to demographically varied cases, maximum variation sampling can be used.44 In this study, both young and middle-aged mothers experienced psychological birth trauma; due to the nature
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of this qualitative study, the researchers could not be able to detect the relationship between age and the main variable. Although, a cross-sectional study among 30 480 pregnant women found that young age was one of the risk factors for fear of childbirth.45 In regard with level of literacy, participants with different levels of education have been included in the study. The findings showed that probably a high level of education would not guarantee a childbirth process without psychological trauma. Another study accentuated the significant relationship between unspecified educational status and childbirth fear.45 Despite educational status, the degree of awareness regarding a childbirth process might be beneficial for the prevention of psychological birth trauma. Bryanton et al.’s findings are in line with the results of this study, in which he emphasized that degree of awareness about childbirth events can be considered as one the most important predictors of childbirth experiences. In fact, the awareness could lead mothers to be more active in the childbirth process. As a result, they might feel less frightened.46 In this study, majority of the mothers gave birth by C-section, and only a small portion of them had normal delivery, but based on the findings all of them experienced psychological birth trauma. It seems that this kind of trauma was not related to vaginal birth exclusively. Another study was in the same viewpoint about the lack of relationship between the mode of birth and the psychological trauma.47 The time between delivery and interview with the mother was another important aspect in this research. As a representative case, the first interview was conducted 24 h after childbirth; however, mothers who had labour many years ago were included in the study. The finding of this study is consistent with Moyzakitis’ who believed that the childbirth experience will be engraved in the mothers’ memory forever.41 Iranian mothers participating in this study left their homes to take shelter in hospitals with the hope of a pleasant and safe delivery. However, due to environmental factors such as not receiving enough support from human and non-human environment, they experienced psychological birth trauma. The results concurred with other studies.48 External conditions of the pregnancy itself and the birth-giving environment were found to be strong predictors of psychological birth trauma.13 All mothers in our study experienced fear in connection with the physical structure of the delivery or operation rooms as they per-
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ceived these rooms similar to mortuaries for dead people. Misago et al. reported that women give birth their babies was cold, dehumanized the atmosphere where and their social and cultural needs were ignored there.6 In another study, where women had to share the labour room, they found that the room was noisy, with ambient temperature and inappropriate mattresses.49 Our results are in contrast to other settings where the women were provided with physically and emotionally friendly environment, with access to fully equipped labour and delivery suites, joyful pink or green colours, and were spacious50; our women perceived that the rooms caused them to become more stressed. One of the strict rules was the lack of permission for any of the mother’s husband, family or ‘Doula’ to accompany them during labour and delivery of the baby. Evidence shows that the presence of other close persons during labour and delivery, who could provide coaching and support, has physical and psychological benefits.20,51 In some countries, many mothers choose a ‘Doula’ to provide support during childbirth, which enhances the mothers’ sense of security and improves maternal health outcomes.51–53 ‘Doula’ is an experienced woman who offers emotional and practical support to a woman (or couple) during childbirth. A doula believes in ‘mothering the mother’.54 The presence of Nepali women’s husbands during childbirth gave the comfort, physical and emotional support that reduced the women’s psychological distress.55,56 Mayberry et al. emphasized that cultural values, which construct assumptions, knowledge and meanings, have a significant role in the health-care system.57 Unfortunately, due to cultural limitations, the presence of the husband and mother in the labour room is not common in Iran, so cultural restructure is recommended. Aside from the participants not experiencing any peace in hospitals, they faced some painful interventions as well. Also, mothers felt that some of these interventions, which are non-humanistic, could not keep their health. Fear of interventions and repeated examinations at hospitals were the concern of 71.9% of the women who preferred home delivery.3 Hodges reported that medical practices are rarely diagnosed as a violence and abuse against women in the hospitals; some unnecessary interventions for the mother were performed as a medical treatment which violates the mothers’ rights.26,50 This situation is a systematic problem similar to what existed in hospital settings in the decades between 1950 and 1960, and it seems that special attention to this issue is necessary. © 2014 Wiley Publishing Asia Pty Ltd
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The most favourable environment for childbirth is a familiar environment without any extra intervention, with support from the midwives and medical teams and which encourages mothers to express their needs freely.58 As the study of Sapountzi-Krepia et al. showed, the behaviour of the medical team has an important role in shaping mothers’ experiences in the childbirth process.59 Mothers in our study suffered from lack of support, care and understanding from the medical staff. During pregnancy, they were unable to establish good communication with their doctors resulting, to mothers’ feelings of fear and lack of trust in the obstetric staff. In a study of 329 Finnish women, leaving the mother alone, lack of parental involvement in decision-making and medical teams’ unfriendly behaviour were the reasons for most of the mothers’ fears and concerns during childbirth.13,59 One study also showed that many health-care providers do not establish effective communication with mothers during childbirth that caused them distress.60 Most of the mothers stated that lack of trust in health-care teams was the reason for their fear during childbirth, which concurred with the study of Beake et al.49 Our study has limitations in that the results were not representative of all Iranian mothers due to the nature of the qualitative research. The purpose of most qualitative studies is not to generalize, but rather to provide a deep perception of some aspects of human experience.61 However, the results of our study provided evidence of the impact of the environment on labouring mother on developing psychological birth trauma that could have been easily overcome.
Conclusions Based on our findings it seems that delivery and operation rooms should be redesigned, in a way that they make mothers feel more relaxed. Moreover, perhaps the presence of doula or partner can be considered as an effective support for women in childbirth. Thus, accompanying mother in labour could be addressed in future national health priority. Updating the regulations of maternity units and mother care plans, according to mothers need, seems to be necessary.
ACKNOWLEDGEMENTS The authors would like to thank the women who willingly shared their childbirth experiences with the research team. We also thank Isfahan University for their support to the study. © 2014 Wiley Publishing Asia Pty Ltd
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