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ORIGINAL ARTICLE
Year : 2018  |  Volume : 23  |  Issue : 6  |  Page : 465-470

Exploring first-time pregnant women's motivations for planning vaginal delivery: A qualitative study


1 Social Determinants in Health Promotion Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
2 Fertility and Infertility Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran

Date of Web Publication4-Oct-2018

Correspondence Address:
Dr. Teamur Aghamolaei
Social Determinants in Health Promotion Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnmr.IJNMR_175_17

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  Abstract 


Background: In spite of medical indications, preferences for the mode of delivery are influenced by several factors. However, as the literature suggests, the underlying motivation of women choosing vaginal delivery is rarely attended to. The current study aimed to explore first-time pregnant women's motivation for planning vaginal delivery. Materials and Methods: An exploratory design with in-depth interviews was employed from September 2015 to March 2016. Participants were asked key questions about their beliefs about vaginal delivery, perceived outcomes of vaginal delivery, the impact of others perspectives on their decision, and factors that might inhibit or facilitate vaginal delivery. A community advertisement was placed in obstetricians' offices, public health departments, as well as beauty salons throughout the city of Bandar Abbas, Iran, to enroll target participants. All interviews were tape-recorded, transcribed, and subsequently analyzed. Results: Twelve pregnant women within the age range of 19–33 years volunteered to participate. Ninety four initial codes were obtained. These codes were then summed up into three themes as well as six subthemes. The three themes specified were personal beliefs, deliberation and risk assessment, and personal autonomy. Conclusions: A number of key motivating factors such as fast recovery after vaginal delivery, immediate breastfeeding, and powerful bonding were identified, which were influential in choosing vaginal delivery. Awareness of the fact that the provided information shapes women's beliefs and can lead to attitude changes, midwives played a key role in shaping positive and healthy attitudes toward natural birth giving as well as empower them to make autonomous decision.

Keywords: Decision making, Iran, personal autonomy, vaginal birth


How to cite this article:
Darsareh F, Aghamolaei T, Rajaei M, Madani A. Exploring first-time pregnant women's motivations for planning vaginal delivery: A qualitative study. Iranian J Nursing Midwifery Res 2018;23:465-70

How to cite this URL:
Darsareh F, Aghamolaei T, Rajaei M, Madani A. Exploring first-time pregnant women's motivations for planning vaginal delivery: A qualitative study. Iranian J Nursing Midwifery Res [serial online] 2018 [cited 2018 Dec 18];23:465-70. Available from: http://www.ijnmrjournal.net/text.asp?2018/23/6/465/242697




  Introduction Top


Birth of the first child can be considered as an extraordinary event in the life of a woman.[1] There are two birthing options for women, namely vaginal and cesarean delivery. In spite of medical and obstetrical indications, preferences for the mode of delivery are influenced by knowledge of risks and benefits as well as personal, social, and cultural factors.[2] The studies addressing preferences for the mode of delivery have recently focused on cesarean delivery,[3],[4] especially with consideration of dramatic rises in cesarean delivery rate worldwide.[5]

Women have voiced a number of reasons for requesting cesarean delivery such as demographic factors, individuals' expectations of childbirth, previous birth experiences, and concerns over the health and safety of mother and infant.[6] However, as the literature suggests the underlying motivation of women choosing vaginal delivery is rarely attended to. A result of a qualitative study showed that some factors identified by participants facilitated the choice of cesarean section. Vaginal birth was anticipated as a prolonged and painful process.[7] In a study conducted in Iranian context, 22 Kurdish pregnant women in their third trimester were interviewed. The results of that study found that the majority of the women preferred vaginal delivery due to safety of baby and fear of surgery.[8] The result of a study from Sweden showed that negative perceptions of a vaginal delivery lead to requesting a cesarean section by many women.[9] Based on a qualitative study from Australia childbirth fear, issues of control and safety were the main reasons for requesting a cesarean section.[10] An increasing number of surveys have investigated women's reason for a cesarean section without any medical indication, but few studies have solely studied first-time mothers and what motivates them toward a vaginal delivery. A significant gap can be noticed with respect to this specific topic in the literature. A limited number of studies have directly asked first-time pregnant women about their decision to proceed with vaginal delivery. Moreover, studies exploring the decision-making process for vaginal delivery have almost tended to be survey-based.[11],[12] Hence, conducting qualitative studies will play a significant role in specifying women's underlying decision-making processes as well as the influential factors leading to decide to have a vaginal delivery. The objective of the present study is to shed light on the motivational factors related to first-time pregnant women's preferences for vaginal mode of delivery to improve understanding about different contributing factors to women's preferences.


  Materials and Methods Top


An exploratory qualitative design with in-depth interviews was employed from September 2015 to March 2016 to discover women's perceptions, beliefs, and motivations expressed in their own words and to gain access to their personal representations regarding vaginal delivery. Recruitment of participants was based on purposeful sampling. The inclusion criteria rigorously addressed the following factors: the minimum age of the women involved was 18 years old, first-time pregnancy, no serious chronic medical conditions, no history of infertility, no indication for cesarean section, no history of mental illness, being in the third trimester (28–36 weeks of gestation) of a singleton pregnancy, and planning to have a vaginal delivery.

After obtaining permission, a community advertisement was placed in obstetricians' offices, public health departments, as well as beauty salons throughout the city of Bandar Abbas, Iran, to enroll target participants. The eligible participants were requested to call a free telephone number with an automatic divert to voicemail, which allowed them to leave a recorded message. A return call was made to the women to ensure their eligibility for participating in the study.

The time and place of the interview were set based on a mutual agreement with the participants. Duration of the interviews ranged from 40 to 60 min. Data were collected through semi-structured face-to-face interviews taking place in a private room by a midwife who was also a PhD candidate in health promotion. An interview guide was employed to facilitate data gathering. Interview questions relevant to research objectives addressed the participants' beliefs regarding vaginal delivery, perceived outcomes of vaginal delivery, as well as factors that might inhibit or facilitate vaginal delivery. To avoid any confusion, the mentioned questions were as simple and straightforward as possible. The collection of the data proceeded until the data were deemed to be saturated with no developing newly conceptual data.

All in-depth interviews were tape-recorded, transcribed, and subsequently analyzed. Inductive qualitative content analysis method used to establish the themes.[13] The data were analyzed in five phases: (a) the records of the interviews were thoroughly read multiple times to make sure that there is a complete understanding of the information as a whole, as well as highlighted the text that captured the theme that related with the fundamental questions. (b) Phrases including material applicable to the objective of the analysis were recognized and allocated into meaning units. The meaning units were compressed in order to decrease the amount of the attained text. Then, the meaning units were categorized with codes. (c) Next, the codes were arranged into classifications and compared based on their differences as well as similarities. (d) Throughout the process of analysis two researchers went back and forth among the codes, texts as well as themes to combine or to split them into new classifications if essential. (e) The classifications as well as testimonials associated to it were given to two additional members of the research group as well as the participants. They were then requested to explain whether their actual views were represented by subthemes and statements and to also write any additional explanations. Then, additional clarifications were collected and the subthemes were rearranged appropriately. The process of reflection and discussion resulted in obtaining an agreement within the research group, which guaranteed the trustworthiness of the provided results. Lastly, themes developed from the subthemes after many discussions among the research group. [Table 1] presented an example of themes, codes, as well as subthemes.
Table 1: Themes and subthemes obtained from content analysis regarding women's motivations for planning a vaginal delivery in their first pregnancy

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Ethical considerations

The study protocol was approved by Ethics Committee of Hormozgan University of Medical Sciences (Ethical code: HUMS.REC.1394.87). Prior to the interview, the researcher explained the purpose of the study and then reviewed the consent form with each of the participants and asked them to sign two copies. One copy had been given to the participants, while the researcher kept the other. Confidentiality matters had been addressed in the consent form including the interview process, the fact that interviews would be recorded and transcribed, storage of recordings and transcripts, contact information, as well as voluntary participation. It is worth mentioning that confidentiality was maintained by allowing the participants to select a fictitious name to be attached to the transcripts.


  Results Top


Twelve Iranian pregnant women planning to have a vaginal delivery within the age range of 19–33 years old volunteered to participate in the study. The average age (SD) of the participants was 26.19 (3.68) years old. Seven of the participants were employees and five were housewives. The most common educational level was a high school diploma.

From the transcripts, 94 initial codes were obtained. These codes were then summed up into three themes as well as six subthemes. The three themes specified in the analysis of the interviews addressing participant's wishes for a vaginal delivery in their first pregnancy were personal beliefs, deliberation and risk assessment, and personal autonomy.

Personal beliefs

In the current study, most of the women who participated alleged that vaginal delivery is a physiologic, normal, as well as natural event. The words “normal” and “natural” delivery were used by the women when referring to vaginal delivery. A number of statements presenting this point are provided.

A 30-year-old woman with secondary education commented: “Giving birth naturally is part of being a woman.” (P1, housewife) A 24-year-old woman with higher education also said: “Normal delivery can be considered as the most meaningful experience in a woman's life.(P2, housewife). Cultural and social norms involve perceptions of behaviors that are typically performed in a community. The participants normally referred to the perception of others' behavior. A 29-year-old woman with higher education expressed the mentioned point this way: “We have always heard that being able to deliver naturally and successfully often makes a woman feel stronger and less fearful about dealing with other challenges in life.” (P3, employee) In the same vein, another participant stated: “We have heard from generation to generation that pregnancy and giving birth is the most normal and natural event on earth, and millions of women go through it without any complications.” (P4, 27-year-old, higher education, employee).

Deliberation and risk assessment

Deliberation is the process of gathering, comparing, evaluating, and analyzing information as well as assessing the risks about delivery options by considering a woman's preferences, then final decision will be made about the mode of delivery.[14] Four subthemes found in the interviews were all related to this theme, which were namely balancing the advantages and disadvantages of having a vaginal delivery as well as the advantages and disadvantages of an unnecessary cesarean section. Participants mentioned several advantages of vaginal delivery and disadvantages of cesarean delivery. With respect to the advantages of the vaginal delivery, a 27-year-old woman with higher education asserted that: “You can hug your baby right after normal delivery. Furthermore, this behavior helps you promote and build strong bond with your baby.” (P4, employee) Another participant referred to this issue in this way: “Women can better take care of their newborn after a normal delivery while in the cesarean delivery you need someone to take care of you.” (P3, 29-year-old, higher education, employee) Women also highlighted a number of practical concerns regarding breastfeeding immediately following vaginal delivery. This point is highlighted by one of the participants in the following terms: “Women can breastfeed immediately after a normal delivery. I remember my sister suffering from breastfeeding after cesarean.” (P5, 30-year-old, higher education, employee). It is noteworthy that the majority of the advantages related to vaginal delivery focused on the fast recovery. A 28-year-old, secondary education said: “Recovery time after normal delivery is so fast in comparison to that of cesarean, in which you have to deal with pain and scar for weeks.(P6, housewife).

Pain was recognized as the only disadvantage of vaginal delivery as expressed by the participants. While many of the women stated that with a vaginal delivery there was extreme pain, they also stated the pros of tolerating the pain as well. For example, a 30-year-old woman with secondary education declared that: “My mother said that in vaginal delivery you experience pain lasting only for hours. The pain will finish after the baby is born, and you will forget everything immediately. However, in cesarean delivery the pain will last for several weeks.(P1, housewife) In line with the previous statement, one of the women pointed that: “I am ready to tolerate pain because I know that after a few hours the pain would be gone, and I would enjoy holding my baby.(P2, 24-year-old, higher education, and housewife).

A number of participants stated that they would be completely displeased with their birthing experience if they were not completely alert for their first out-of-womb interaction with their newborn. A 30-year-old woman with higher education said: “Delivery and birth is a special thing, a special bond. A lot of people said that by cesarean you're missing that part of pushing and bringing that child into the world on your own. I was ready to tolerate that pain just not to lose the mentioned joy.(P7, employee).

Another participant mentioned: “The amount of pain experienced during vaginal delivery is not a matter as long as you are conscious. The best thing with vaginal delivery is that you are awake and alert during the whole time unlike cesarean delivery that you're missing out almost everything.(P8, 31-year-old, diploma, employee).

Some women voiced high levels of fear and anxiety when faced with possible cesarean delivery. A 29-year-old woman with higher education commented: “What I think is the biggest reason not to ask for a cesarean delivery is just the anxiety and fear of anesthesia. You always hear the worst things occurring during cesarean delivery(P3, employee). Similarly, another woman expressed that: “I was always worried about not waking up after general anesthesia, this is my biggest nightmare.(P2, 24-year-old, higher education, employee) Likewise, it is pointed that: “What I don't like about cesarean is that your options will be limited in future. I always heard that 'once cesarean, always cesarean.' It means that if you choose cesarean for the first time, you won't have any other options except cesarean in the next even if you do not like it.(P9, 26-year-old, diploma, employee) Most women were able to state a few advantages when asked to identify the advantages of a cesarean section. Almost all participants believed that cesarean has no advantage and it should be performed just to save the mother and child from complicated delivery. The most popular advantage that was perceived and cited by the women was how fast the procedure went, as one participant said: “The procedure of cesarean is faster than vaginal delivery. It takes only 30 minutes to get the baby out of the womb.(P10, 28-year-old, higher education, employee).

Personal autonomy

Ownership of the decision was one of the central concepts described by the participants. Informing and decision-making processes were the two subthemes categorized under “ownership of the decision” theme. Majority of the women highlighted the importance of gaining further knowledge regarding childbirth. In this regard, a 30-year-old woman commented: “I have got too much information about the normal delivery process from a very helpful TV program named 'childbirth magazine'(P7, higher education, employee). Another participant also said: “I watched a video of normal delivery on the internet. It was very touching. It seems to me that the mother really had too much joy from her experience. I wished to experience the same pleasant time.(P9, 26-year-old, diploma, employee).

Almost all the participants considered midwives and healthcare providers as the main source of providing information about the mode of delivery. Several mothers participated in childbirth classes to gain knowledge about what to expect regarding the childbirth experience. A 21-year-old woman articulated: “I took part in prenatal classes so I could learn a lot about vaginal delivery. It was beneficial. They played videos of a natural birth and a cesarean delivery. I can claim that at least I better prepared myself for vaginal delivery... in comparison to cesarean delivery.(P11, diploma, housewife).

The timing of making decision was diverse among the women. Some of the women made quick decisions, even before their pregnancy, while for some of them took too much time to make their final decision. How the women justified their decision as well as the systems and the supports that consolidated their decision is defined as enhancing autonomy. The mentioned points are indicated in the following expressions:

I was not sure about my decision till I met my midwife. She gave me all the required information for making the appropriate decision. I can say that she informed me very well, and I was happy that she gave me all the valid information to make the right selection. Vaginal delivery is the best choice for me.(P11, 21-year-old, diploma, housewife).My decision to give birth naturally began following my discussions with several midwives. It was then that I realized I have to do the hardest work I'd ever do. I was told that this is one of the most important decisions that I would experience in my life. Being in charge of making this important decision was accompanied with too much satisfaction(P12, 29-year-old, diploma, employee).


  Discussion Top


The study sheds light on the process that first-time pregnant women experience to make decision about their mode of delivery. The main asset of the present analysis was the implementation of the qualitative research design to examine the motives behind choosing vaginal delivery by first-time pregnant women. As a result, it was possible to draw assumptions regarding the women's perspective toward the essential factors affecting their selection as well as their attitude toward having a vaginal delivery. A number of key motivating factors were identified, which were influential in choosing vaginal delivery.

The main finding revealed that the women in this study expressed positive beliefs toward vaginal delivery surrounded by feelings which were often described as joy, happiness, and overwhelming. Almost all participants in this study reported that the childbirth experience is a unique and special event in women's lives. This is in line with another study of reporting the attitude of women requesting vaginal delivery.[15]

The result of this study revealed the ways women assessed and managed the risks and other implications of their decisions. All decision-related actions included some form of comparative processes regarding the risks and expectations of the two different options or undesired events in an uncertain future. Whenever the mothers' assessment of the medical risks for cesarean delivery was much greater than that of vaginal delivery, they eventually proceeded to give birth vaginally. Women weighed up the advantages and disadvantages of vaginal and cesarean deliveries, and women choosing vaginal delivery considered it to be better than a cesarean delivery. A number of preferences or advantages associated with vaginal delivery were found in the present study such as bonding and successful breastfeeding, quicker recovery, fewer care requirements, and minimum pain experience after delivery. Regarding the negative views of a cesarean delivery, many of the women stated that it was the complications in recovery, risks of anesthesia, the agony of the postpartum period, and higher levels of fear and anxiety. This is consistent with the findings of other studies.[16],[17],[18]

Vaginal birth is perceived as a painful process for all the participants. The participants, depending on their family background, personality, and the amount of support they received from significant individuals in their lives, used diverse ways to cope with the pain. For many of the women, having pain is a necessary factor in the experience and it's what defines the conversion to motherhood.[19] This hypothesis has been supported by some researchers who have shown that the experienced pain is the greatest and unforgettable part of having a child.[20] Nonetheless, when the method of childbirth was discussed, many of the women stated that there was pain when having a natural childbirth throughout the vaginal delivery, though it was tolerable. However, it was apparent to them that when having a cesarean section the pain was nonexistent in the beginning, but then it emerged as an effect of the procedure and definitely became more disabling as well as persistent.[21]

Our results pointed to a significant effect of the feeling of being in control that was dependent on the mode of delivery. Following expressing their reasoning for a vaginal delivery, the women also explained their method of gathering information, which took place before they made their decision on whether they wanted to give birth vaginally or through a cesarean. Gathering information about vaginal versus cesarean delivery was important for mothers to make their decisions. The participants articulated the importance of information seeking before any decision-making. The results of a mixed method study conducted in Iran revealed that there was insufficient information and several misunderstandings concerning the modes of delivery, which were influential when making the decision.[22] There were many different sources that were used by the women in the current study that offered information regarding the knowledge acquisition stage, however, enhancing autonomy to communicate and participate in care and make right decision were the most important. Addressing only first-time pregnant women can be considered as one of the limitations of the present study. It is possible that multiparous women, based on their own personal experiences, could have different views as well as preferences for their mode of delivery. Because most of our participants were educated, considering these specifically targeted participants, the results may not be generalizable to all the other pregnant women. Another limitation is that this study was exploring the motivations of women who chose to have a vaginal delivery. Interviewing another women who want to undergo cesarean may reveal other aspects of women's motivation. However, this claim requires further investigation involving larger samples in different society.


  Conclusion Top


A number of key motivating factors such as fast recovery after vaginal delivery, immediate breastfeeding, powerful bonding were identified, which were influential in choosing vaginal delivery. It is expected that the obtained findings will be beneficial to midwives who care for pregnant women throughout their pregnancy, during childbirth, and afterwards. Awareness of the fact that the provided information shapes women's beliefs and can lead to attitude changes, midwives played a key role in shaping positive and healthy attitudes toward natural birth giving as well as empower them to make autonomous decision.

Acknowledgement

This study was supported by Hormozgan University of Medical Sciences, so we wish to thank Hormozgan University of Medical Sciences for the research grant (grant number: 9441).

Financial support and sponsorship

Hormozgan University of Medical Sciences

Conflicts of interest

Nothing to declare.



 
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