Childbirth at home: A qualitative study exploring perceptions of risk and risk management among Baloch women in Iran

Midwifery 29 (2013) 44–52

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Childbirth at home: A qualitative study exploring perceptions of risk and risk management among Baloch women in Iran Zhila Abed Saeedi, RN, MS, PhD (Assistant Professor of Nursing)a, Mahmoud Ghazi Tabatabaie, PhD (Professor of Sociology and Social Demography of Health)b, Zahra Moudi, RM, MS, MScIH (PhD Candidate of Reproductive Health)a,n, Abou Ali Vedadhir, PhD (Assistant Professor of Anthropology)b, Ali Navidian, RN, MS, PhD (Assistant Professor of Consulting Psychology)c a b c

Faculty of Nursing and Midwifery, Shaheed Beheshti University of Medical Sciences, Tehran, Iran Department of Demography and Population Studies, Faculty of Social Sciences, University of Tehran, Tehran, Iran Faculty of Nursing and Midwifery, Zahedan University of Medical Sciences, Zahedan, Iran

a r t i c l e i n f o

a b s t r a c t

Article history: Received 3 May 2011 Received in revised form 25 September 2011 Accepted 6 November 2011

Objective: to explain how women who choose to give birth at home perceive and manage the risks related to childbirth. Design: a qualitative, methodological approach drawing upon the principles of grounded theory. Data were gathered by in-depth interviews with women who had given birth at home. Setting: the study was conducted in Zahedan, the capital of Sistan and Balochestan province in southeast Iran. Participants: 21 Baloch women aged 13–39 years who had a planned home birth were interviewed. Nine had been attended by university-educated midwives, eight by trained midwives, and four by traditional birth attendants. Findings: concerning perceived risks, women perceived giving birth in hospital to be risky because of medical interventions, routines and ethical considerations. The perceived risks for home birth were acute medical conditions. Women made their decision to give birth at home based on existing verbal, visual, and intuitive information. The following two categories related to risk management were identified: (1) psychological preparation and (2) medical and logistican preparation. All of the women relied on their own intuition, their midwife and the sociopsychological support of their families to transfer them to hospital in the case of complications. Key conclusions and implications for practice: the women who chose to give birth at home accepted that there was a risk of complications, but perceived these to be due to fate. Technical risks were considered to be a consequence of the decision to give birth in hospital, and were perceived to be avoidable. In addition, the women considered ethical issues as risks that are sometimes more important than medical complications. Women’s perceptions of risk, and the ways in which they prepare to manage risk, are central issues to help providers and policy makers adjust services to women’s expectations in order to respond to the individuality of each woman. & 2011 Elsevier Ltd. All rights reserved.

Keywords: Women Home birth Risk perception Risk management

Introduction Globally, there were around 358 000 maternal deaths occurred in 2008, a 34 % decline from the levels of 1990 (World Health Organisation, 2010). However, despite this decline, 99% of maternal deaths continued to occur in developing countries (World Health Organization, 2010). Nearly two-thirds of maternal deaths

n Correspondence to: Midwifery Department, Nursing and Midwifery School, Mashahir Square, Zahedan, Sistan and Baluchestan Province, Iran. E-mail address: [email protected] (Z. Moudi).

0266-6138/$ - see front matter & 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2011.11.001

worldwide are due to the following direct causes: haemorrhage, obstructed labour, eclampsia, sepsis, and unsafe abortion. The remaining one-third of maternal deaths due to indirect causes or an existing medical condition that is worsened by pregnancy or childbirth (United Nations Population Fund, 2002). A closer examination of maternal mortality in Iran shows a rate of approximately 30 per 100,000 live births (Malekafzali, 2009; World Health Organization, 2010). Iran’s Ministry of Health and Medical Education has implemented several interventions to reduce maternal mortality. As the vast majority of complications and deaths arise during and immediately after childbirth, and due to sudden and unexpected complications (Donnay, 2000), the

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Ministry of Health and Medical Education has emphasised the provision of essential obstetric care services and hospital birth. However, the most recent official data show that 10.8% of women in urban areas of Sistan and Balochestan province do not comply with this policy to give birth in hospital (Integrated Management Evaluation System, 1994). Sistan and Balochestan province, located in southeast Iran, bordering Pakistan, is among the most deprived provinces in the country. Zahedan, the setting for this study, is the capital and the most populous city of this province (population of 689,444 in 2009). The population of Zahedan consists of two ethnolinguistic groups – Baloch and Sistani – plus Afghan refugees. The Baloch and Sistani ethnolinguistic groups are the indigenous people of the province. The Baloch people live mainly in Pakistan and Iran, and represent the majority population in Zahedan. They are typically Sunni Muslim, the largest Islamic religious group, while non-Baloch inhabitants of the province are Shiite or Shia. The population growth rate and total fertility rate in Zahedan were 2.5% and 3.6%, respectively, for women of reproductive age in 2009. Fifty-three maternal deaths were reported between 2005 and 2010, 10 of which occurred following a home birth. Childbirth services in the area include four comprehensive essential obstetric care services and two birth centres. These centres, which are located in the city suburbs, are managed by qualified midwives and are open 24 hrs/day. The midwives at these centres assist with normal vaginal childbirth, but are not allowed to administer antibiotics to treat infections or anticonvulsants to treat seizures. They are also banned from removing the placenta manually, and refer women in this situation to hospital. Despite the availability of these facilities, 12% of women still choose to give birth at home attended by a traditional birth attendant, a trained birth attendant or an educated midwife from a private office (Maternal Health Office, 2011). There is wide recognition that a major factor contributing to maternal mortality is the infrequent use of health facilities for childbirth (Kanti and Rumsey, 2002; Duong et al., 2004; Berry, 2006; Say and Raine, 2007). A brief review of the literature suggests that psychological and sociocultural (Steinberg, 1996; Gabrysch and Campbell, 2009) studies of decision-making have gained increased attention over the last two decades. In light of the importance of the decision-making process, many disciplines have put considerable effort into studying and clarifying decisionmaking (Murphy and Longo, 2009, pp. xi–xii). The literature, at a glance, demonstrates that decision-making takes place in and affects our everyday life in many ways. Firstly, it allows us to rationalise and choose the most appropriate actions or strategies for a particular event or task in order to attain the best outcome. Secondly, it allows us to be flexible in an ever-changing world, reacting quickly to both routine and specific life matters in a timely manner. Thirdly, it allows us to enhance the chance of success and minimise the chance of failure (Chan, 2009, p. 21). The issue of decision-making is not simple, but is closely related to our culture or styles of knowing and living in a highly reflexive world. Many scholars believe that qualitative approaches should be considered when exploring the sociocultural and psychological aspects of decision-making. For example, Chan (2009, pp. 22–23) proposed a 6Rs framework (reference, reflexivity, replication, remarks, reproach, and registration) to ensure good practice in the preparation and implementation of these studies. In this view, women’s health-related decisions about giving birth at home or in hospital cannot be an exception, as they are closely intertwined with the women’s daily lives and living conditions, life chances (structure) and life choices (agency), proposition to act (habitus) and meaning in life (Bourdieu, 1990, pp. 53–55; Cockerham, 2007, pp. 49–74). As Bourdieu reflected, ‘the habitus makes possible the free production of all the thoughts, perceptions, actions

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inherent in the particular conditions of its production – and only those’ (Bourdieu, 1990, p. 55). In this view, a woman’s decision about her childbirth can be deeply embedded and understood in the frame of the habitus. Therefore, some scholars have suggested that a woman’s decision about her childbirth is affected by her habitus in general, and her perception or construction of risks associated with childbirth in particular. In a broad sense, the notion of risk means different things to different people. Actions and understanding of risk go beyond the individual, as risk is a sociocultural construct that reflects cultural values, symbols, history and ideology (Sjoberg, 2004). Moreover, prior life experiences and health-care providers can affect a woman’s perception of risk (Jordan and Murphy, 2009). Understanding the determinants of risk perception may provide insight into well-organised measures to adjust services to women’s expectations, as what suits one person may not suit another (East et al., 2008, p. 167). Therefore, the current study aims to explain how Iranian Baloch women who choose to give birth at home rationalise and perceive it, and how they manage the risks of planned home birth.

Methods Approach This study draws methodologically on a qualitative approach. This methodological approach may be most simply defined as the techniques associated with the gathering, analysis, interpretation and presentation of narrative data and/or information. Qualitative research strategies are narrative in form, and qualitative (thematic) data are analysed using a variety of inductive and iterative methods, including the grounded theory (Teddlie and Tashakkori, 2009). In considering the nature of research questions and the purpose of this study, strategies and principles of grounded theory were used to provide a logical set of procedures to answer the research questions and manage the collected data and evidence. The essence of grounded theory is an inductive– deductive interplay that does not begin with a hypothesis, but with collecting data and allowing relevant ideas to develop (McGhee et al., 2007). It is also an endeavour to declare the anthropocentric nature of sociocultural life and its fundamental interactional processes, as Chenitz and Swanson observe that ‘the reality or meaning of situation is created by people and leads to action and consequences of action’ (Bassett, 2004). ‘This implies that a set of social or psychological relationships and process exist in the world, can be reflected in appropriate qualitative data, and can be captured by grounded theory’ (Pidgeon and Henwood, 2009, p. 627). In this view, grounded theory can promote a better and more comprehensive understanding of the decision-making process and management of the risks of home birth by the participants. Sample and recruitment Twenty-one Baloch women with a history of home birth participated in the study. They were recruited using qualitative purposeful sampling, which involves making choices about cases or setting according to initial prespecified criteria (Pidgeon and Henwood, 2009, p. 635). In order to recruit women with homebirth experience, the researchers contacted four midwives who had a private office and assisted with home births. To identify women who had given birth at home without the assistance of educated or professional midwives, the Maternal Health Office was contacted for the name and telephone number of a trained birth attendant. This birth attendant recruited two additional traditional birth attendants. The midwives were informed about

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the study and asked to explain its purpose to the women they had assisted during a home birth within the previous four months. Women with precipitous labour who were forced to give birth at home were excluded. The midwives asked women for their consent, and then their telephone numbers were given to the interviewer. The interviewer contacted the women and asked for their informed consent to participate in the study. If the women agreed to participate, a mutually agreeable appointment was scheduled. In addition, a theoretical sampling technique was used. ‘In conjoint with constant comparison, theoretical sampling is the process whereby the researcher decides what data to collect next and where to find them in order to continue to develop theory as it emerges’ (Holton, 2007, p. 627). Researchers deliberately seek participants who had a particular response to experiences or for whom particular concepts appear significant (Morse, 2007, p. 240). The sampling process ceased once comparative data analysis showed that maximum theoretical variation had been achieved, namely the ‘saturation rule’ (Pidgeon and Henwood, 2009, p. 635). In other words, the researchers were convinced that they understood what they were seeing, it was culturally consistent (Morse, 2007, p. 243), and new ideas would not be formed leading to a dilemma (Bassett, 2004, p. 64). Twenty-one Baloch women who had a planned home birth were interviewed. Of these women, nine were attended by an educated midwife, eight by a trained midwife and four by a traditional birth attendant. Of the 21 participants, two women participated with their husbands; 16 participated with their mother, mother-in-law or sister; and three participated alone. Data collection Data were gathered through in-depth, unstructured interviews in the participants’ homes. The interviews lasted between one and 3 hrs. An unstructured interview was conducted to collect data on the subject of risk related to home birth—what did the women think about probable risks related to childbirth at home? Further open-ended questions built upon the women’s responses to the questions and further clarifications or details of their responses and the complete narrative; for example, ‘how did you handle these thoughts? How did your husband react to your decision?’ All interviews were conducted in Persian with a slight Baloch accent by one of the investigators who has a Baloch background. The interviewees were reminded of their right to withdraw from the study at any time. All interviews were audio taped, transcribed verbatim and analysed. Ethical considerations Permission to conduct this study was obtained from the Shaheed Beheshti University of Medical Sciences Ethical Committee and relevant local authorities in Sistan and Balochestan province. The investigators obtained the participants’ permission to perform and audio tape the interviews. The confidentiality of information was guaranteed, as the name and personal information of the interviewees was not mentioned in the tapes or transcripts. All tapes, transcripts and information sheets were given special codes and kept separately to protect the women’s anonymity. Data analysis In line with grounded theory methodology, data analysis involved the complementary process of coding and categorising data, and developing analytical questions and a conceptual model. Following the transcription of the first tape, the first step was line-by-line reading and open coding of the data, based on the

principles of grounded theory. Data coding was undertaken by the primary researcher (midwife), a counselling psychologist and a qualitative sociologist. Open coding refers to reading the transcript and naming or coding each line of text (Gibbs, 2007, p. 52). Some of participants were given the transcript and codes to confirm them or add comments. In order to gain greater insight, two Baloch birth attendants (a qualified midwife and a trained birth attendant) who helped women with home birth were asked to review the transcripts and help with interpretations. The constant comparison helped to identify the meaning behind the surface text. Subsequently, the investigators shifted from description, especially using the respondents’ terms, to a more categorical level of coding (Gibbs, 2007, p. 42). Fig. 1 shows the categories and subcategories that emerged through the process of data analysis. Finally, all of the findings were presented to five midwives and four mothers who were not participating in the study for critical assessment.

Findings Twenty-one Baloch women aged 13–39 years were interviewed. They had previously experienced 1–8 pregnancies. One of them was illiterate and the education level of the others ranged from elementary to high school national diploma. Previous childbirth locations, parity, previous types of childbirth, and the insurance status of the women are presented in Table 1. Regarding the risks of home birth, two central themes emerged: perceptions of risk and management of that risk. In terms of perceived risks, women perceived giving birth in hospital to be risky because of medical interventions, routines and ethical considerations. The perceived risks of home birth were acute medical conditions. Categories related to risk management were as follows: psychological preparation, and medical and logistic preparation. Perceptions of risk Perceptions of medical risks The Baloch women’s statements revealed that they did not perceive chronic conditions to be a risk factor or a good reason to visit a doctor. One of the women stated: They told me, in the birth centre, that I was suffering from severe anaemia and I should see a doctor; I replied that I have had this problem for a long time and it is normal for me and I do not think that something bad would happen to me. (Interviewee 7, age 25 years). Later in the interview, Interviewee 7 stated: In the health centre, I was told: if you have massive bleeding during labour you will probably die, but I had anaemia during my previous delivery and you see I did not die. (Interviewee 7, age 25 years). In addition, other women did not consider the presence of a chronic disease to be a reason to give birth in hospital: She told me that my blood pressure was high (130 mmHg) and I had to have a hospital birth, but during my last pregnancy, my blood pressure was also 130 mmHg and I had home birth without any problem. So, this time I also had a home birth and refused to go to the hospital. (Interviewee 14, age 29 years). The women considered acute signs (e.g. loss of consciousness) to be an indication that they should attend hospital. The women also considered their previous knowledge about the risk of

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Socio, cultural and economic context

Religious belief

ion uit Int

Presen ce o f re lati ves

Accessibility

Medical & Logistic preparation

Financial forecast

nce ura

Self care

Emotional supports Ins

Pre nat al ca re

Management of complications

rm No

ien ce

wife Mid

Exp er

Av oid an ce

Psychological readiness

Risk management

Perceived risk of homebirth

Decision to birth at home

Perceived risk of hospital birth

Fig. 1. Conceptual model explaining how women manage the risk of home birth.

Table 1 Background characteristics of participating women at the time of interviews. Characteristic

Number

Place of previous delivery Home Hospital Without previous experience

7 7 7

Midwife Educated midwife Trained midwife Traditional birth attendance

9 8 4

Type of delivery Normal delivery Caesarean section Without previous delivery Parity First child Second child Third or more Insurance With insurance Without insurance

11 3 7

Some of my neighbours and relatives said that the hospital has lots of risks. (Interviewee 14, age 29 years). As a result, the care provided in hospitals may be considered risky and unacceptable in the sociocultural context of Zahedan. In line with what the women had heard, learned and experienced during their lives, they decided not to go to hospital, particularly for their first childbirth, as they believed that they would be hurt, get sick and experience bleeding (e.g. abnormal bleeding after childbirth). The women had negative attitudes towards caesarean section, which is performed in hospital. A number of women declared their general feelings about caesarean sections through the following narratives: Caesarean is an awful misery. (Interviewee 5, age 39 years). Caesarean is an adversity. (Interviewee 2, age 32 years).

7 5 9 10 11

hospital birth. One woman recalled her experience of hospital birth: When I was stitched up after my first childbirth, I had pain, it became infected, I had too many problems. So, I refused to go to the hospital for my second childbirth. (Interviewee 17, age 38 years).

This view was derived from personal experience and the experience of others. For example, with reference to the experience of one of her relatives (her niece), one woman declared: When her abdomen was opened (the caesarean incision), my sister said: ‘they were brushing her’ [wound debridement]. (Interviewee 3, age 35 years). In addition, caesarean section was considered a threat to their fertility. One of the women remarked: I did not want to undergo caesarean because I would like to have two to three more children, then will have to undergo a caesarean for all of them. (Interviewee 3, age 35 years). The women believed that caesarean section ruins the routine of life. For example, one woman commented:

Perceptions of sociocultural risks Women learn about the risks of hospital birth from other people. One woman commented:

Caesarean is an adversity and you need to be hospitalised for some days. Moreover, after caesarean, I can’t take care of my child and myself. (Interviewee 5, age 39 years).

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Most of the women had an issue with the rationale behind caesarean section and its wide prevalence in Iran (40% of all deliveries were by caesarean section in 2009) (Vedadhir et al., in press). Baloch women declared that doctors exposed them to caesarean section unnecessarily in order to achieve quick delivery. One woman expressed her distrust in doctors through the following statement: In hospitals, doctors are ready for caesarean, and if the childbirth lasts only for a short time, for some reasons they will soon precede to an operation. (Interviewee 1, age 37 years). As a result, these women avoided this risky environment (hospital) by giving birth at home. They rationalised their attitudes and decisions to give birth at home based on the potential risks hospital. For example:

Risk management The following two categories address the management of the risks of home birth: mental preparation (psychological readiness), and medical and logistical preparation. Psychological readiness Sociocultural, economic, and spiritual contexts increased the women’s mental readiness for decision-making about home birth. In line with their statements, the current study determined that mental or psychological preparation is the main category in rationalising and accepting home birth. The subcategories of psychological readiness, and medical and logistical preparation are shown in Fig. 1.

It is better to stay at home and give birth at home because, considering health and safety, home is much better. (Interviewee 21, age 26 years).

Norms. The data revealed that most women considered home birth to be safe as it is the socio-cultural norm in their community. As one of the women noted:

For Baloch women, risks are not merely medical, but are also shaped and perceived based on sociocultural structures. In perceiving or constructing the risks of childbirth, the women accentuated the notions of gender and gender-based differences, amongst other structural factors, in the intensively gendered society of Iran. A 28-year-old woman addressed the issue in this way:

Our ancestors didn’t go to hospitals, my mother, and my grandmother delivered their babies at home. (Interviewee 7, age 25 years).

Men think that hospitals are safer; they just know that blood pressure might be low or high, they just know these things. They do not enter the delivery room and they do not see what happens there. (Interviewee 15, age 28 years). From the viewpoint of Baloch women, threats to their beliefs, schemas, values and dignity are sometimes considered as greater dangers than medical risks. Several women shared the following opinion: The educated midwives and doctors are quarrelling when you are complaining of pain and there is no one to help you. (Interviewee 8, age 24 years). Many women also addressed the issue of Hijab and their related concerns in the hospital, asserting its meaning for Muslim Baloch women. A number of women declared their general concerns about Hijab as follows: When we go there, they undress us and we are scared without Hijab. (Interviewee 7, age 25 years). They further expressed their feelings toward hospitals through declarations such as: I am afraid of hospitals, I have stress, and the name of hospital itself is horrible. (Interviewee 1, age 37 years). While the data reveal that medical risks are central to women’s health status and should be considered, they also explain other dimensions of the risks of hospital birth, as women’s significant beliefs, schemas, values and dignity were questioned in the hospital. As a final point, the women always perceived and rationalised the risks of hospital birth by comparing them with the risks of home birth: It was my first childbirth, I had fear, I was afraid of hospitals more than the risks of home birth. (Interviewee 4, age 21 years). I wished to have a comfortable and secure childbirth. Therefore, I preferred to stay at home as I found home safer than the hospital. (Interviewee 9, age 19 years).

Previous personal or family experience. The women considered home to be an appropriate place for natural childbirth, and relied heavily on their mothers’ positive experiences: Our mothers have given birth at home and they have good ideas about homes. (Interviewee 6, age 19 years). Of all our relatives, no one goes to hospitals, all give birth at home and they have not had a problem. (Interviewee 8, age 24 years). I said like the others, I will probably not face a problem, God willing (Enshaallah). (Interviewee 13, age 23 years). Women’s personal positive experiences of home birth justified and rationalised the safety of home birth and the appropriateness of their decision. As a result of their constructive lived experience, Baloch women continually attempted to give birth at home. As one of the women stated: Someone says to me ‘if you give birth to your child at home, you may have bleeding’, but I did not have bleeding with my first child. (Interviewee 7, age 25 years). Intuition and avoidance. However, the women did not deny the risks of home birth. One woman explained the issue in the following words: I don’t deny all risks as maybe something happens during the childbirth at home. (Interviewee 18, age 30 years). In an endeavour to manage the potential risks, or even death, Baloch women used various mental or psychological coping mechanisms, including avoidance. The evidence demonstrated that this avoidance was constructed based on positive experiences, confidence in their own and their infants’ health through prenatal care, and trust in their intuition. Two women expressed their sense of confidence as follows: I didn’t think about the end and what will happen. I just thought about the beginning. (Interviewee 21, age 26 years). When I was completely aware that my child is healthy and I knew that childbirth at home is comfortable, I didn’t think that something might suddenly happen to my child. (Interviewee 3, age 35 years).

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Religious belief. Moreover, facing the potential risks, they resorted to God. They experienced relaxation and peace by accepting the divine providence, and believing that the risks are independent of the place of childbirth. A number of women declared their faith in God: I entrust myself to God, while in danger. (Interviewee 8, age 24 years) Death and life of a human is in the hands of God, if God wants you to die, you will die, no matter where you are, here or in hospital. (Interviewee 15, age 28 years). Based on the above-mentioned beliefs, for Baloch women, childbirth at home is advantageous and offers comfort. Hence, they avoided an escapable risk and accepted their destiny in some way (unavoidable risk). As one women noted: All risks and difficulties of childbirth are not predictable from the beginning. We said it’s in God’s hand and we got rid of hospitals. (Interviewee 4, age 21 years). Medical preparation Prenatal care to ensure a healthy pregnancy and childbirth. One of the most important issues addressed by the women in this study was that home is the place for childbirth for women without problems: That is completely correct that hospitals have all the facilities and equipment but while I don’t have any problems and the child is safe and sound, home is a much better place for childbirth. (Interviewee 3, age 35 years). Therefore, they attempted to maintain their own health and that of their foetus during pregnancy. One woman expressed her view as follows: After being sure about health status of the mother and the baby, the rest is in the hands of God. (Interviewee 4, age 21 years). Women had health cheques including sonography, routine laboratory tests and physical examinations during pregnancy. In this way, they ensured their own health prior to giving birth at home. As one woman commented: I was sure that no problems would occur as the doctor had told me that the child was ok and the childbirth is normal. (Interviewee 3, age 35 years). However, if any medical or clinical problems were diagnosed, the women acted to protect and improve their health in order to give birth at home: If they say that the blood pressure is high, we’ll be more careful. (Interviewee 8, age 24 years). The lady said that your blood pressure is high; I visited a doctor two or three times, the doctor prescribed me half a high blood pressure tablet per day and I took them so I was told I didn’t have the problem anymore. (Interviewee 14, age 29 years). These women were determined to give birth to their children at home, partly because they had not been referred to hospital by a doctor. As one woman declared: The personnel and the doctor of the health-care centre told me ‘your anaemia isn’t serious’. (Interviewee 13, age 23 years).

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A key point that can endanger the health of mothers and infants is the belief among women that a healthy pregnancy guarantees safe childbirth and the health of the infant: If you are being checked and supervised during these nine months and you have no problems, it is unlikely to face a problem such as fetal hazards during delivery. (Interviewee 3, age 35 years).

Trust in midwife. Some evidence suggested that the role of the midwife was important in decision-making about giving birth at home: I thought about childbirth risks, I did believe that the equipment of hospital is more, even so I asked the idea of my midwife. She said that childbirth at home doesn’t have any risks and you can easily give birth to your child at home. (Interviewee 9, age 19 years). I was completely sure about my grandmother’s job (uneducated local midwife) and that nothing would happen. (Interviewee 10, age 23 years). The close relationship between the woman and her midwife prepared women to trust and follow their midwife. As a result, midwives’ screening and referrals of complicated cases to the hospital were highly significant. Moreover, women abdicated the active role of checking their health during pregnancy to the midwife, an important issue for maternal mortality. They trusted and relied on their midwife to diagnose and manage the potential risks. As one woman stated: My mother told me that you will bleed, I said: if I bleed, my midwife will diagnose. My midwife is educated; if a problem occurs she will take me to the hospital. (Interviewee 1, age 37 years). Delayed diagnosis of a problem can lead to a mother’s death. One woman stated: If the midwife says there’s a problem and the child is not going to be born here, then we will take her to hospital; whatever the midwife says I will accept. (Interviewee 7, age 25 years). Although the women believed that hospitals are risky places that should be avoided for the health of their infant and themselves, they acknowledged its protective role. As one woman noted: Hospitals have oxygen and instruments for taking blood pressure, these are good. (Interviewee 16, age 23 years). However, hospital visits only occurred when all endeavours to give birth at home failed and the woman was forced to go to hospital. One woman said: If the midwife comes and diagnoses a difficult childbirth and it is really impossible to give birth to the child at home, then we will have to go to the hospital. (Interviewee 8, age 24 years). Sometimes, these compulsions were also related to the diagnosis of fetal compromise during pregnancy and childbirth. One women said: If the doctor tells you the suffocation of the fetus is probable, we will go to the hospital. For instance, for my first childbirth, they told me that the child has passed stool (meconium) and would suffocate. Well, in such cases we are ready even for caesarean. (Interviewee 8, age 24 years).

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The role of relatives. From the start of decision-making to the end of childbirth, the role of the husband in supporting and actualising the decision to give birth at home, or preventing the woman from giving birth at home was quite important. In fact, the men’s high perception of medical risks led the women towards hospitals. One woman explained: My husband was saying that he wouldn’t let me have childbirth at home. He told me that I am afraid you have already undergone caesarean. (Interviewee 2, age 32 years). In addition, the women’s perception or construction of the risks was important. When women perceived their home to be safer than hospital and decided to give birth at home, they used various methods to remove resistance to their decision. Having the support of their husband was an essential aspect of giving birth at home. The following quotations reflect how husbands in the Baloch community play a key role in rationalising and decision-making about the mode of childbirth: My husband wanted me to go to hospital. I explained the problems of hospitals to him and convinced him that home is better for me and I’m more comfortable at home. (Interviewee 3, age 35 years). At last, the husband’s family and even more important than them, the husband, should agree with childbirth at home. (Interviewee 9, age 19 years). Furthermore, home birth was associated with tranquillity and confidence: I feel relaxed when everyone is beside me, my mother, my father, my husband, my uncles, my mother-in-law; they are all there. (Interviewee 10, age 23 years). If something happens, my family and relatives are present to take me to hospital. (Interviewee 3, age 35 years). Financial forecast. The women’s narratives indicated that financial forecast was occasionally provided by insurance: I forecast to have childbirth at home; I said I would get my insurance so that if a problem occurred, I would not face any problem to pay the money. (Interviewee 17, age 38 years). I get insurance for a rainy day, I said maybe I should go to the hospital. (Interviewee 14, age 29 years). As a final point, Baloch women described their home births with satisfaction: I am absolutely pleased with my childbirth at home. (Interviewee 6, age 19 years).

Discussion This study investigated how childbirth decisions are made by Baloch women, and how they rationalise and justify their decisions to give birth at home. More specifically, this qualitative study explored Baloch women’s constructions and lived experiences of childbirth in order to develop an understanding of how they perceive, typify and manage the risks of home birth in comparison with the risks of hospital birth. This article primarily calls attention to the point that childbirth does not occur in a sociocultural vacuum, but is a sociocultural construction (Ishikawa et al., 2002). According to Selin and Stone (2009, p. xvi), decisions about childbirth ‘regarding place of birth, position, who receives the baby and even how the mother may or may not behave during the actual delivery, are usually made by other people’. This study revealed that Baloch women living in

Zahedan continue to choose to give birth at home, despite the availability of specialised childbirth services. The homebirth decision-making process involves assessment of the risks and benefits of giving birth at home and in hospital. As Gutnik et al. (2006) discussed, one of prevailing systems that people use to realise and assess risk is ‘experimental system’. This system uses past or lived experiences, emotion-related association and intuition when making decisions. People often assess a risk associated with a behaviour or lifestyle in terms of how easily they can recollect past examples, or how easily they can picture such episodes. In contrast, diseases or harmful conditions that are difficult to imagine (because of unfamiliarity) may reduce the perceived likelihood that they will occur (Timmermans, 2005). By telling birth stories or narratives, women teach other women about risk. Hence, knowledge and mythology of childbirth and its risk is constructed and legitimised through social interaction among women (Nolan, 2011, p. 25). For the women in the current study, personal experience and knowing people, including close relatives, who had experienced negative technical and ethical aspects of hospital care affected their view of the risks associated with hospital birth. The medical and risk-averse approach, which indicates the need for hospitalisation and medical care of all women (Jomeen, 2010, p. 15), has neglected many important forms of care that make women feel safe, such as psychological and social impacts (El-Nemer et al., 2006; Catling-Paull et al., 2010). Some women doubt the quality of clinical care in hospital and, at times, even perceive it to be risky (Tinoco-Ojanguren et al., 2008). Some of the practices employed in hospital are not acceptable to women, and are considered a threat to their safety and fertility. In addition, the multiparous women in the current study stressed unethical or immoral aspects of hospital care. Consequently, these negative experiences of hospital care led to a sense of fear and dread. Sjoberg (2004) asserted the risk-as-feeling hypothesis that responses to risky situations result, in part, from the influence of direct emotions, including feelings such as worry, fear, dread, or anxiety. Negative emotions related to these experiences influence individuals’ habitus, schemas, attitudes, images, judgements (Gutnik et al., 2006), and perceived risk (Sjoberg, 2000). This can lead to exit (switching to other products/services or suppliers) and negative word of mouth about services (East et al., 2008, p. 168). Evidence showed that services are likely to be more responsive to word of mouth than most goods. Furthermore, those who complained about health services were over four times more likely to defect than those who did not (East et al., 2008, p. 184). Dahlen (2010) discussed the 0.1% doctrine in maternity care, and explained that we think about the one adverse event rather than the entire positive outcome. However, women in this study moved from the 0.1% to 99.9% doctrine, meaning that they concentrated on all the positive outcomes more than the one adverse event. The results of this study are consistent with similar findings that people engage with risk deliberately because they are looking for particular benefits linked to that particular risk, rather than taking risks without the awareness that they are doing so (Soane and Chmiel, 2005). There is ample evidence that when women decide to give birth at home, they consider the risks of this mode of childbirth (Catling-Paull et al., 2010; Lindgren et al., 2010; Nolan, 2011, p. 29). Accordingly, these women must be prepared psychologically. Risk is closely tied to cultural adherence and social learning, as argued by proponents of the cultural theory. Depending on whether one is socially participating and which groups one belongs to, one will focus on different types of risk. People choose what to fear and how much to fear it (Oltedal et al., 2004). As the findings revealed, home birth is common among Iranian Baloch families, and the women’s stories and lived experiences support

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its safety. As a result, they characterised and constructed this mode of childbirth with low risks. Culture is based on the uniquely human capacity to classify experiences, encode such classification symbolically, and teach such abstractions to others. It is acquired through enculturation, the process through which an older generation induces and compels a younger generation to reproduce the establish lifestyle (Oltedal et al., 2004). Therefore, the interviewed women relied on their relatives’ experiences and followed their ways of life. From this view, home birth could be interpreted as a manifestation of faithlessness or distrust in science and the authority of the medical profession (Mitchell, 2010). People consider natural burden and risks as prescribed, almost inevitable, destiny while technical risks are considered to be consequences of decisions and actions. If none other than God can be held accountable, no amount of human activity will improve the situation. The only alternatives are either to flee from risky situations or to deny their existence. People are more likely to deny or suppress rare events. For common events, people are more likely to flee from the danger zone (Renn, 2004). In this situation, women can find peace in reading the Holy Quran, praying and requesting God’s protection from potential risks. Another type of decision-coping style addressed in the present study is defensive avoidance. This style involves techniques such as procrastination to avoid or postpone conflict. Under defensive avoidance, the decision-maker seeks to avoid any cues that could potentially increase his/her anxiety. This is a maladaptive coping style, as it is characterised by a biased and incomplete evaluation of information and often does not result in an optimal outcome (Creyer and Kozup, 2003). As Creyer and Kozup (2003) explained, if women do not assure their physical well-being and have logistic necessities, such as giving birth in the presence of an educated midwife, they are at increased risk for maternal mortality and morbidity. As a result, people who have a tendency to rely solely on defensive avoidance and fate need assistance from individuals who tend not to be defensive avoidant. Confidence is described as an ability to cope with risks and insecurity. Confidence consists of confidence in oneself, confidence in other people, and confidence in organisations or systems (Lindgren et al., 2006). The data demonstrated women’s faith in their ability to give birth at home and their intuitive knowledge/ feeling that no harm would occur (Viisainen, 2001; Sjoblom et al., 2006; Lindgren et al., 2010). Women’s faith in their own intuition is hence a crucial motivating factor in their decision to give birth at home. Women with psychological preparation or readiness need support to perform their decision. The data show that all Baloch women regularly attended antenatal care appointments with the public and private health-care systems. They considered this to be an integral part of preparation for home birth. If an infant dies at home, it is immediately presumed that negligence and/or irresponsibility on the part of the mother must be a significant factor (Nolan, 2011, p. 25). As Viisainen (2001) discussed, medical check-ups and management of medical complications, such as treatment of high blood pressure, could provide reassurance that the pregnancy was medically safe, and this made the women feel physically powerful and confident to have a normal birth at home. In this way, they can defend their choice and receive positive affirmation from relatives and health workers. At the same time, women receive professional support through the presence of midwives. As Jordan and Murphy (2009) noted, women rely on midwives to determine their risk status and provide measures to reduce the risk. As Morison et al.’s study (1999) revealed, based on a sense of trust within the relationship, women accept midwives as individuals who decide when medical assistance and hospital transfer is required. As a result of the

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support they received from midwives and relatives, women were able to escape the vicious cycle in which risk labelling traps women, according to Nolan (2011, p. 32). The midwives helped women to develop confidence in their own decision, ability to give birth and preparation for unpredictable complications. Although the women embraced home birth in an endeavour to reduce the likelihood of having a caesarean section, and to achieve normal childbirth in a safe and secure environment, they relied on hospital resources and expertise when they perceived risk. The results of this study are consistent with MacKenzie Bryers and Van Teijlingen (2010), who stated that a more holistic approach to maternity services is required. This indicates that although science and technology have a place, they should be used to support social and cultural structures and the preferences of the women. In the field, this is interpreted as home birth or low-technique childbirth facilities within local communities with back-up from comprehensive emergency obstetric care units for probable complications.

Conclusion The findings of this qualitative study are significant in that the home is not simply a place to live with family, but also serves as a shelter. It is a safe and amenable place for childbirth that protects woman from the risks of hospital birth, including the risks of caesarean section and other interventions, in the context of a fairly medicalised society. In addition, being at home protects women from the immorality perspective of hospital care, which is sometimes a more important risk than the technical aspects of hospital care. The findings also showed that women who expressed an ‘anti-hospital view’ and chose to give birth at home accepted the potential complications. However, they attributed these complications to fate, unlike hospital complications related to interventions. When women give birth at home after full preparation, dimensional support and in the presence of a qualified or educated midwife, documents have shown that maternal mortality is lower than that for hospital birth (Ministry of Health and Medical Education, 1996). Maternal mortality data and research observations have also shown that most maternal mortality in Iran is associated with women who use defensive avoidance, rely on past experiences, and are attended by traditional birth attendants and relatives (Ministry of Health and Medical Education, 1996). The limitations of the current study include the fairly small group of women recruited from Zahedan in southeast Iran, and the voluntary nature of participation. All interviewed women were Baloch in terms of ethnicity and Sunni Muslim in terms of religion. Therefore, the cultural, ethnic and religious contexts of the participants were not deeply explored. The study may reflect a unique situation within the main city of the province; therefore, no claims are made regarding the wider generalisability of findings, considering that the cities in Sistan and Balochestan province are highly heterogeneous in terms of socio-economic, demographic and ethnoreligious criteria. Further studies are needed to explore the issues raised. It is expected that the audit trail assists to establish trustworthiness, creditability and transferability of the findings and the key implications developed. Notwithstanding these limitations, the study findings offer valuable insight into the lived experiences and socioculturally constructed reality of childbirth and modes of childbirth among Iranian Baloch women. Given the limited body of evidence and information concerning childbirth in Iran, the findings of this study may be valuable to other researchers in light of the recent endeavours to explore the process of childbirth through globally and culturally diverse perspectives, namely childbirth across

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cultures (Selin and Stone, 2009). Finally, the multi- and transdisciplinary approach used in this study seems to offer a valuable contribution to understanding the process of decision-making and potential ambivalences that surround the rationalisation and choice of mode of childbirth in communities with a traditional and religious perspective. Furthermore, this study provides some evidence to suggest that future scholars should be encouraged to consider qualitative enquiry in understanding decision-making and the ways of knowing about and managing the risks of home birth. References Bassett, C., 2004. Qualitative Research in Health Care. Whurr Publisher Ltd.London. Berry, N.S., 2006. Kaqchikel midwives, homebirth, and emergency obstetric referral in Guatemala: contextualizing the choice to stay at home. Social Science and Medicine 62, 1958–1969. Bourdieu, P., 1990. The Logic of Practice. Stanford University Press, Stanford, CA. Catling-Paull, C., Dahlen, H., Homer, C.C.S.E., 2010. Multiparous women’s confidence to have a publicly-funded homebirth: a qualitative study. Women and Birth 24, 122–128. Chan, Z.C.Y., 2009. Psychology of decision-making: 6Rs for qualitative research methodological development. In: Murphy, D., Longo, D. (Eds.), Encyclopedia of Psychology of Decision Making. , Nova Science Publishers, New York. Cockerham, W.C., 2007. Social Causes of Health and Disease. Polity Press, Cambridge. Creyer, E.H., Kozup, J.C., 2003. An examination of the relationships between coping styles, task-related affect, and the desire for decision assistance. Organizational Behavior and Human Decision Processes 90, 37–49. Dahlen, H., 2010. Undone by fears? Deluded by trust? Midwifery 26, 156–162 Donnay, F., 2000. Maternal survival in developing countries: what has been done, what can be achieved in the next decade? International Journal of Gynecology and Obstetrics 70, 89–97. Duong, D.V., Binns, C.W., Lee, A.H., 2004. Utilization of delivery services at the primary health care level in rural Vietnam. Social Science and Medicine 59, 2585–2595. East, R., Wright, M., Vanhuele, V., 2008. Consumer Behaviour. Sage, London. El-Nemer, A., Downe, S., Small, N., 2006. She would help me from the heart: an ethnography of Egyptian women in labour. Social Science and Medicine 62, 81–92. Gabrysch, S., Campbell, O.M., 2009. Still too far to walk: literature review of the determinants of delivery service use. BMC Pregnancy Childbirth 9:34 /http:// www.biomedcentral.com/1471–2393/9/34/S (last accessed July 2011). Gibbs, G., 2007. Analyzing Qualitative Data. Sage, Los Angeles, CA. Gutnik, L.A., Hakimzada, A.F., Yoskowitz, N.A., Patel, V.L., 2006. The role of emotion in decision-making: a cognitive neuroeconomic approach toward understanding sexual risk behavior. Journal of Biomedical Information 39, 720–736. Holton, J.A., 2007. The coding process and its challenges. In: Bryant, A., Chatmaz, K. (Eds.), The Sage Handbook of Grounded Theory.Sage, Los Angeles, CA, pp. 265–289. Integrated Management Evaluation System, 1994. Maternal Program Index. Ministry of Health & Medical Education of Iran. Unpublished data. Ishikawa, N., Simon, K., Porter, J.D.H., 2002. Factor affecting the choice of delivery site and incorporation of traditional birth customs in a refugee camp, Thailand. International Journal of Gynaecology and Obstetrics 78, 55–57. Jomeen, J., 2010. Choice, Control and Contemporary Childbirth. Understanding Through Women’s Stories. Radcliffe Publishing, Oxford. Jordan, R.G., Murphy, P.A., 2009. Risk assessment and risk distortion: finding the balance. Journal of Midwifery and Women’s Health 54, 191–200. Kanti, P.B., Rumsey, D.J., 2002. Utilization of health facilities and trained birth attendants for childbirth in rural Bangladesh: an empirical study. Social Science and Medicine 54, 1755–1765. Lindgren, H.E., Rsdestad, I.J., Kyllike, C., et al., 2010. Perception of risk and risk management among 735 women who opted for a home birth. Midwifery 26, 163–172.

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