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Kurdish pregnant women's feelings: A qualitative study
Midwifery 27 (2011) 215–220
Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
Kurdish pregnant women’s feelings: A qualitative study Roonak Shahoei, PhD [Student (Lecturer)]a,, Haliza Mohd Riji, PhD (Associate Professor)b, Zhila Abed Saeedi, PhD (Associate Professor)c a
Faculty of Nursing and Midwifery, Kurdistan University of Medical Science, No. 6 Karbasy Hill, Jam Jam street, Sanandaj, Kurdistan, Iran Faculty of Medicine and Health Sciences, University Putra Malaysia, Malaysia c Faculty of Nursing and Midwifery, Shahid Beheshty University of Medical Science, Iran b
a r t i c l e in fo
abstract
Article history: Received 13 November 2008 Received in revised form 20 April 2009 Accepted 20 May 2009
Objective: to gain a deeper understanding of how Kurdish pregnant women feel about their pregnancy. Design: a qualitative study analysed by a grounded theory approach. Setting: the study was conducted among women in the third trimester of their pregnancy in either their homes or the health-care centres in Sanandaj in the western part of Iran. Participants: 22 pregnant women were recruited and interviewed. Findings: during pregnancy, women experienced a variety of feelings: ‘satisfied and happy’, ‘unpleasant’ and ‘ambivalent’. Conclusions and implications for practice: it is important for midwives to ask pregnant women about their feelings concerning their current pregnancy, childbirth and future motherhood. If they express negative or ambivalent feelings, these should be discussed in greater detail and their causes identified. Special consideration should be given to primiparous women and multiparous women with negative experiences of previous pregnancies. & 2009 Elsevier Ltd. All rights reserved.
Keywords: Qualitative research Grounded theory Feelings Pregnancy
Introduction During pregnancy, women not only experience psychological and emotional changes, but their behaviours may also change according to their feelings and moods, notably during the early stages. Their emotions become more stable and they gain a sense of well-being as the pregnancy progresses (Campbell and Lees, 2000). For most women, pregnancy is a period when they are affected by a multitude of factors residing within themselves or originating from external factors. Unplanned pregnancy, change in body image, emotional security, cultural expectation, financial situation and level of support from partners are some of the factors that can influence their feelings and attitudes. Women’s emotions and behaviours are greatly affected by their level of maturity and readiness for child-bearing (Leifer, 2005). Women’s feelings change over the first trimester through the second trimester. The first trimester is when they focus on the pregnancy and on accepting the new reality (fetus) as being part of their identity. As the pregnancy progresses, they begin to have a sense of the child as their own separate entity. As the nausea and fatigue of the first trimester have passed, they feel much better. They make a point to make the pregnancy apparent to those around them and feel the glow of pregnancy. The second trimester
Corresponding author.
E-mail address: [email protected] (R. Shahoei). 0266-6138/$ - see front matter & 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2009.05.011
is even happier when extra attention is given to them (Klossner, 2006). Although the third trimester is a time of active emotions with visible preparation for childbirth and parenthood, it is also a period when a number of fears surface. First, there are fears for their own and the baby’s lives. Second, they may undergo grief as they anticipate the loss of attention and special prerogatives they received during pregnancy. Psychologically, there is the inevitable separation of the baby from the body, and there is also a feeling of loss as the full uterus collapses and becomes an empty vessel. Slight depression, increased dependency and introversion, and vulnerability are other feelings experienced by pregnant women as they reach the third trimester (Varney et al., 2004). This period is marked by extreme sensitivity and overreaction. Finally, towards the end of pregnancy, most women feel tired of being pregnant (Klossner, 2006). In sum, pregnancy is a time of stress for many women (Pillitteri, 2004). Disappointment, rejection, anxiety, depression and unhappiness prevail. Moreover, there may be interpersonal problems between pregnant women and their mothers that they have to resolve (Varney et al., 2004). Although there are common psychological responses to pregnancy, behaviour in response to these vary according to culture. Beliefs about male and female roles, the significance of the pregnancy and the child, and the view of pregnancy as a normal event in life will naturally influence pregnant woman’s psychological condition.
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Until now, little has been known about Kurdish women’s responses to pregnancy. It was, therefore considered pertinent to obtain a deeper knowledge of this phenomenon. Against the backdrop of social, cultural and economic changes that have taken place in Kurdistan, a qualitative study of women during pregnancy would be useful to gain an understanding of the causes of various emotion women may experience. Such knowledge can be useful in improving information and support during pregnancy and motherhood.
Methods A qualitative design was chosen as it is particularly suited to studying complex phenomena or processes that are less understood (Lincoln and Guba, 1985). The research took place over a nine-month period in the health-care centres of the Medical Sciences of Kurdistan University in Sanandaj, a centre of the Kurdistan province in the western part of Iran. Study participants were recruited from maternity units in three health-care centres. A purposive sample was used. Sample size was not pre-determined but was determined when interviewing reached saturation, i.e. when no new data emerged regarding a category and categories (Strauss, 1987; Rice and Ezzy, 1999). The sample was restricted to 22, as no new data were generated after the 20th interview. The researcher orientated midwives on the maternity unit of study on the particular characteristics for choosing participants. Once identified, the midwives would then ask those women for permission to be approached by the researcher. When a potential participant expressed interest in the study and permission to approach was obtained, the researcher reviewed the criteria required for inclusion in the study (e.g. being a Kurdish woman, being in the third trimester of pregnancy, no physical disability). The purpose of the study was explained to the participants, and informed consent obtained from those who wished to participate. Participating women were asked to provide baseline demographic data and contact information. Each woman was also notified about the time needed for the interview. The date of the interview was arranged to suit the woman. All interviews were conducted in the Kurdish language by the first author who is a midwife. Each interview was tape-recorded with the woman’s permission. The length of the interviews varied, depending on the women’s responses. Each interview took between 50 and 100 minutes (average 70 minutes). Most women (60%) were interviewed once. There were, however, a number of occasions when the researcher needed to obtain more information. Nine participants were, therefore, visited for a second time.
descriptions to correspond closely with their meaning in Kurdish, while making them grammatically correct for English readers. Ethical considerations Permission to conduct the study was received from the Medical Sciences of Kurdistan University. Participants were given verbal and written information about the study, and given the opportunity to ask any questions concerning participation. All participants were informed that their participation in the study was voluntary and that their names would remain confidential. They were reassured that their care would not be affected if they chose not to participate in the study. Moreover, they could withdraw from the study at any stage without offering explanations. Written consent was also received. Analysis Following grounded theory practice, data collection and data analysis were conducted simultaneously. A constant comparative method of analysis was used as data were reviewed and grouped into categories and subcategories. In the first stage of the analysis, initial coding, the interviews were read line by line, and codes were identified and labelled. The coding process helped the researcher to remain close to the data. Sometimes ‘in vivo’ quotations were picked up directly from the text and used as open codes (Strauss and Corbin, 1990). The second step was to scrutinise the open codes and make decisions about which codes to keep as the most relevant for the aim of the research. The chosen codes and quotations were then repeatedly compared and sorted into categories according to their content and meaning. Between the open codes and a category, the dimensions were identified, which helped to describe what a category was about. During this process, the emerging categories and their dimensions were continually compared with the original text to exclude the risk that some findings might be based on misunderstanding. The following steps were taken to satisfy the requirements of credibility, fittingness, confirmability and auditability. Colleagues skilled in the paradigm listened to a few tapes, read the verbatim transcripts, and compared their interpretations with the investigator’s category scheme. In addition, five women received a hard copy of their transcripts. Audio trails were created for all interviews to demonstrate how categories were formed. These were confirmed by colleagues.
Findings
Interviews
Participants’ profiles
The women were individually interviewed in their own homes or a private room at the health-care centre in the third trimester. A semi-structured interview schedule guided the investigator during the audio-taped interviews. All interviews started with the same question: ‘Could you please tell me what does pregnancy mean for you?’ The women’s responses were recorded and clarified with probing questions: for example, ‘what do you mean by sayingy?’ or ‘what made you think so?’ All interviews were transcribed verbatim in the Kurdish language by the first researcher. Transcription accuracy was checked by a colleague who read randomly chosen transcripts while listening to the audiotape. The analysis was also undertaken from the Kurdish transcripts, and only verbatim quotations presented in the writing for publication were translated into English. The researcher has attempted to translate the women’s
Twenty-two women aged 20–35 years (average 27 years) participated in this study. All women were born and resided in Sanandaj. Most participants described themselves as housewives (77%) and the remainder were employed (23%). The women differed in educational level, ranging from basic schooling to university, with most being high school graduates (73%). All participants were married, because childbirth outside of marriage in Kurdish culture is practically non-existent. Fifteen women were primigravida and seven were multigravida. Their gestational ages varied between 29 and 39 weeks (average 34 weeks). Feelings described by the women were grouped into three main categories: ‘satisfied and happy’, ‘unpleasant’ and ‘ambivalent’. To maintain confidentiality, the women’s quotations used to illustrate the categories are identified with numbers. Participants
R. Shahoei et al. / Midwifery 27 (2011) 215–220
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were anonymous and are reported using interviewee-assigned numbers (#).
got from others. They became more pleased as others gave them more affection:
Satisfied and happy Feelings of satisfaction and happiness were described by the pregnant women in relation to ‘joy and consent’, ‘maternal feelings’, ‘closer relationship with husband’, ‘sense of supporting, ‘God’s blessing’, ‘more affectionate towards mother’ and ‘a sense of ownership and responsibility’.
I’m happy and sometimes I wish I could always be pregnant because my husband, his family and my family pay more attention to me and I don’t want this to stop. (#3) Now, I feel I have more intimacy in my life and my family pay more attention to me, it is pleasurable for me. (#17) I think the whole family supports a pregnant woman and this is so important for her. (#20)
Joy and contentment. All participants reported that they had a sense of joy and contentment: I want to be pregnant and I’m very happy about my pregnancy. (#1) Since I sense a quickening of the fetus, I feel happy and this sense of happiness has increased during pregnancy. (5#) At first, I didn’t want to be pregnant because my situation didn’t permit me to have a baby. But now I’m completely satisfied and delighted to be pregnant. (#13) Maternal feeling. Most women explained that feeling the existence of another being inside them brought a special and pleasant sense for them. They believed that this maternal feeling is exclusive and unexplainable: Maternal feeling is a good sense. Nobody has this kind of sense except a mother. (#7) I don’t know how I can describe my sense. I have a feeling that I can’t explain. You can’t understand maternal feeling unless you become a mother. (#15)
The women’s parents and parents-in-law often supported them and shared the worries and joy of the pregnancy. Their bonds were becoming stronger during pregnancy. Women explained that their husband’s family’s treatment of them has changed: During this time my husband’s family gave me more support, their conflicts, criticism and scorns are removed. (#3) Appreciation of God’s blessing. Most pregnant women in this study believed that pregnancy was a gift of God to the mother and this new life is awarded to her by God. Moreover, they described that pregnancy increased their belief in God. Furthermore, they are praying God for gift: I feel pregnancy is the best gift of God to mother because being a mother is really delightful. (#2) I think this pregnancy increases my belief in God. (#22) Some women explained that they trusted God more and they had insight into God’s greatness as a result of pregnancy:
Maternal feeling is a very interesting sense and it is extremely pleasant when you have another being inside your abdomen and you feel it within yourself. (#2)
When I found out I was pregnant; I trusted God and thought this is God’s gift for my small family. (#8) Having a baby after 10 years is God’s blessing and my baby is a mercy shown to me by God. (#16)
Sense of closer relationship with husband. Most of the women in this study claimed that pregnancy brought about changes in their relationship with their husband. They expressed the importance of sharing the pregnancy with their husband. It was a way of getting closer to each other and strengthening the family bonds. Furthermore, many women described how the baby had already affected their lives in terms of heightened responsibility and maturity:
More affectionate towards mother. Most participants mentioned that their pregnancy brought changes in relationships. The woman’s own mother was especially important to her at this time and she needed her approval. While she respected both of her parents, she felt more affectionate towards her mother during pregnancy. In addition, she could understand her mother a little more. Furthermore, women discussed more with their mothers and were more relaxed with them:
I feel now both of us have more passion and I think pregnancy increases our attachment to each other. (#9)
I feel I’m changed in all aspects, my understanding is increased. Now, I think I can understand my parents more. I have more respect for my mother and I sense more comfort with her, I hadn’t this sense before. I can now tell my problems to my mother and ask her for help. (#7) I love to talk about my feelings with my mother. Since I have been pregnant, I can understand my mother and her worries. I love to tell her I can understand your troubles now for my birth and looking after me. (#18) I’m satisfied that I’m going to be a mother. I love the sense of motherhood because I can realise the value of my parents. (#16)
I think during pregnancy, the dependency of a woman and her husband increase, and it improves their relationship. Since I have been pregnant, we have had fewer problems and arguments. Now I sense my husband loves me more and his support has increased. (#13) yintimacy has increased in my life, relationship with my husband is improving and it makes me feel comfortable. (#17) However, some women experienced a feeling of losing their husbands’ interest during pregnancy: Sometimes, I think pregnancy and having a baby creates a gap among couples. (#10)
One woman said that her mother’s reaction caused her to regret her pregnancy:
Sense of supporting. Most of the participants in this study liked pregnancy because of the increased attention and support they
My mother criticised me because of my pregnancy. Her reaction made me ashamed. I don’t know why she doesn’t want me to be pregnant. (#8)
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A sense of ownership and responsibility. Some women described that pregnancy brought them a sense of needing to provide the safekeeping of the baby. In addition, they explained how the baby had affected their lives in term of heightened responsibility: I feel, God gives me an entity and I have to keep her. (#3) yI have a sense of responsibility, I’ve never experienced this sense beforey.I try to keep her safe. (#13) Unpleasant feelings The category of unpleasant feelings were described by the participant in relation to ‘fear’, ‘anxiety and despair’ and ‘being unpleasant’. Fear. Fears described by the women were divided into four subcategories: fear because of the baby’s health, fear of childbirth, fear of disability, and fear of other reasons. Most women in this study reported fear of childbirth. The most commonly reported fear was cause of pain: I’m very afraid of childbirth pain. (#2) I’m afraid of dyingyI’m sure I would be died during delivery. (#3) Some participants were afraid of procedures related to the birth of their baby, including having an episiotomy and a vaginal examination:
Further fears that women mentioned include: losing their husband, criticism and being scorned by their husband’s family: I feel I will lose my husband. Since we’ve been married, we have been with each other but now I feel I will lose my husband. He will go out by himself and I’ll be alone with the baby. (#3) Sometimes I wish I wasn’t pregnant. I’m afraid I won’t be able to carry out my responsibility and will be scorned by my husband’s family. (#5) The feeling of anxiety and despair. In this study, women were worried about their fetus or themselves. The anxiety related to the fetus was about lack of fetal movement, fetal health, abnormality and the birth: Whenever I can’t feel my baby moving, it makes me worried. (#3) I worry that there is already something wrong with the baby. (#2) The worry related to themselves was about losing their husband’s affection, irreversibility of the physical judged by others, losing their job, financial difficulties, being incompetent to satisfy the needs of older children, the couple being distant from each other and being judged by others:
I’m afraid of snipping. (#3) Other women feared that they would not be able to go through natural childbirth: I’m afraid I won’t be able to do it, I won’t be able to deliver the baby. (#2) Some multigravida stated that, because of their experience in a previous pregnancy, they were afraid of being ill treated by delivery staff. They mentioned that midwives and doctors were rude to women during labour and childbirth. Some nulliparous women stated that their fears were due to the environment of the labour room, because they had heard comments about unkindness of staff from other women: I’m really afraid because some of the midwives and doctors don’t pay attention to you and yell at you. (#21) However, some women were afraid of the absence of a doctor when giving birth: I’m afraid of delivery, because it will be during the New Year holiday and there won’t be a doctor and midwives. (#1) In addition, participants described their fear for their baby as follows: This is my biggest fear. I have fear all the time. What will I do if I have a preterm labour? (#8) I’m very afraid for the health of my baby. I always want God to help me. (#19) During the interviews, some participants stated that their fears had developed because of the feeling of disability: I’m afraid I won’t be able to have a natural delivery. (#5) There were some fears about not being a good enough mother: Sometimes, I regret my pregnancy. I feel I can’t take care of my child and educating him. (#4)
When I knew that I was pregnant, it made me worry. We have a lot of financial difficulties; we have to plan for the future. (#12) Sometimes I think this baby causes us to be distant from each other. (#10) Being unpleasant. Some women in this study claimed that they felt uncomfortable. This was because of physical or psychological changes. Some of them had experienced nausea and vomiting in early pregnancy. Many of them complained about fatigue, physical (body) changes, gaining weight, sense of being heavy, and a sense of untidiness and feeling messy: I hate my appearance. I feel annoyed and embarrassed when my husband looks at my belly. I think it makes me look fat and ugly. (#5) In addition, many of the participants described rapid changes in their mood. Periods of strength and easy living might suddenly change to feeling weak, sensitive, anxious, isolated, and not wanting to communicate with others, regret, depression, discomfort, short temper, disliking the baby, being unattractive, and not enjoying pregnancy: yduring the second trimester, I noticed that my clothes were tight. I felt a sense of shame and it made me regret my pregnancy. I feel I’m uglyysometimes I love to be alone (#4) Ambivalence Some participants in this study reported that they are experiencing joy and unpleasantness: I think, pregnancy has pleasant and unpleasant senses for a mother. (#14) I actually have a sense of ambivalence. Sometimes I love it (pregnancy) but other times I’m afraid of it. (#12) I know pregnancy brought happiness and troubles for me (#8) You know, when you are pregnant, you have a sense of sweetness and bitterness about it. (#5)
R. Shahoei et al. / Midwifery 27 (2011) 215–220
Discussion The overall purpose of the present study was to investigate and describe Kurdish pregnant women’s feelings during pregnancy. Pregnancy should be viewed in the context in which it occurs (Campos et al., 2008). Since pregnancy is a socially constructed experience, it seems that pregnancy has different meanings to different women. In other words, the way in which pregnant women feel about pregnancy and childbirth may be affected by their cultural background. Social expectations and cultural values affect Kurdish pregnant women’s responses to their pregnancy and the idea of motherhood. In Kurdish society, pregnant women’s reaction to pregnancy and their expression of feelings are affected by the way in which the women are raised, their beliefs about male and female roles, the significance of the pregnancy, pregnant woman’s role in society, view of pregnancy as a normal event, the values of children, family influences, relationships with husband and family, financial status, life experiences, education, philosophy of life, and expectations. The findings of this study support previous research on various aspects of pregnancy, for example variations in mood and worries (Rubin, 1984; Mercer, 2004) and changing relationships (Rubin, 1984; Hoffman et al., 1994). All seven multiparous women in the study had previously given birth vaginally. They experienced pain and had negative experiences because of ill treatment by the midwives. The same findings have been reported in other studies (Jolly et al., 1999; Sasito et al., 2001; Melender, 2002; Sercekus and Okumus 2009). Mathews and Callister (2004) claim that essential factors in preserving the quality of the birth experience are behaviour from caregivers that demonstrate valuing and respecting that these qualities are important for the woman’s ability to maintain dignity during childbirth. According to Anderson (2000), midwives are extraordinarily powerful, especially when a woman is in labour, and it is essential that the midwife uses that power in a sensitive and wise way to the best advantage of the woman in their care. All participants in this study expressed at least some fear associated with pregnancy or childbirth; the most commonly reported fear about childbirth was fear of labour pain and childbirth. This finding was in agreement with previous studies (Melender and Lauri, 1999; Sasito et al., 2001; Melender, 2002; Eriksson et al., 2006; Nilsson and Lundgren, 2009; Sercekus and Okumus, 2009). Furthermore, they had fears related to the health of their baby, their own health, and their relationships with their husband and family. This finding was also reported by Melender and Lauri (1999), Melender (2002), and Sercekus and Okumus (2009). Some women stated that their fears were due to not being a good enough mother (Melender and Lauri, 1999). Moreover, this study showed that criticism from the husband’s family or being scorned by them can make pregnant women fearful and distressed. Previous studies have not shown this cause. A potential limitation of this study is that all participants were Kurdish pregnant women in Sanandaj; the findings might have been somewhat different if women from other cultures were included. Also, pregnant women might have difficulties in talking because of social norms about what feelings are considered appropriate for women during pregnancy. Moreover, it must be taken into consideration that a qualitative study implies interaction between researchers and participants, and that the researcher’s pre-conceptions might influence interpretation of the material (Charmaz, 1995). Nevertheless, pre-conceptions can be a limitation or a strength. The first author is a Kurdish woman and a midwife with clinical experience, which might sensitise the processing of the data. The second and third authors are
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recognised qualitative researchers who have published several studies.
Conclusion The findings of this study indicate that Kurdish women experience a range of feelings during pregnancy: ‘satisfied and happy’, ‘unpleasant’ and ‘ambivalent’. Thus, it is important for midwives to ask pregnant women about their feelings concerning the current pregnancy, childbirth and future motherhood. If she expresses negative or ambivalent feelings, these should be discussed in greater detail and their causes identified. Special consideration should be given to primiparous women and multiparous women with negative experiences of previous pregnancies. Midwives might therefore need further training on how to meet and support pregnant women with negative or ambivalent feelings. These findings are important markers for further research concerning women’s experiences of anxiety, fear and ambivalent feelings, as well as midwives’ perceptions about and their interaction with pregnant women.
Acknowledgments We would like to thank all the women who participated in this study. We thank the faculty of medicine and health sciences of the University Putra Malaysia and Medical Science Kurdistan University for their approval of the study. The first author is grateful to Mr. Abad Dokht for his assistance during the translation of data and his comments. References Anderson, T., 2000. Feeling Safe Enough to Let Go: the Relationship Between a Woman and her Midwife During the Second Stage of Labor. Palgrave Macmillan, London. Callister, L.C., 2004. The pain of child birth: perceptions of culturally diverse women. Pain Management Nursing 4, 145–154. Campbell, S., Lees, C., 2000. Obstetrics by Ten Teachers, 7th edn. Gutenberg Press ltd, Gutenburg Press, Tarxien, Malta. Campos, B., Dunkel schetter, V., Abdou, C.M., Hobel, C.J., Glynn, L.M., Sandman, C.A., 2008. Familialism, social support, and stress: Positive implications for pregnant latinas. Minority Psychology 14, 155–162. Charmaz, K., 1995. Grounded Theory: Rethinking Methods in Psychology. Sage, London. Eriksson, C., Jansson, Hamberg, K., 2006. Women’s experiences of intense fear related to childbirth investigated in a Swedish qualitative study. Midwifery 22, 240–248. Hoffman, L., Paris, S., Hall, E., 1994. Developmental Psychology Today. McGraw Hill, New York. Jolly, J., Walker, J., Bhabra, K., 1999. Subsequent obstetric performance related to primary mode of delivery. British Journal of Obstetrics and Gynaecology 106, 227–232. Klossner, N., 2006. Introductory Maternity Nursing. Lippincott Williams and Wilkins, Pearson Education Inc, New York, United States of America. Leifer, G., 2005. Maternity Nursing: an Introductory Text. Elsevier Saunders, Lippincott Williams and Wilkin, Philadelphia, United States of America. Lincoln, Y.S., Guba, E.G., 1985. Naturalistic Inquiry. Sage, Markham, ON, Canada. Melender, H.L., Lauri, S., 1999. Fears associated with pregnancy and childbirth: experiences of women who have recently given birth. Midwifery 15, 177–182. Melender, H.L., 2002. Experiences of fears associated with pregnancy and childbirth: a study of 329 pregnant women. Birth 29, 101–111. Mercer, R.T., 2004. Becoming a mother versus maternal role attainment. Journal of Nursing Scholarship 36, 226–232. Nilsson, C., Lundgren, I., 2009. Women’s lived experience of fear of childbirth. Midwifery 25, e1–e9. Pillitteri, A., 2004. Maternal and Child Health Nursing. Lippincott Williams and Wilkins, Philadelphia, United States of America. Rice, P.L., Ezzy, D., 1999. Qualitative Research Methods: a Health Focus. Oxford University Press, Melbourne. Rubin, R., 1984. Maternal Identity and the Maternal Experience. Springer, New York.
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Sasito, T., Salmela-Aro, K., Nurmi, J.E., Halmesmaki, E., 2001. Psychosocial characteristics of women and their partners fearing vaginal childbirth. British Journal of Obstetrics and Gynacology 108, 492–498. Sercekus, P., Okumus, H., 2009. Fears associated with childbirth among nulliparous women in Turkey. Midwifery 25, 155–162.
Strauss, A.L., 1987. Qualitative Analysis for Social Scientists. Cambridge University Press, Cambridge. Strauss, A., Corbin, J., 1990. Basics of Qualitative Research. Newbury Park, Canada. Varney, H., Kriebs, J.M., Gegor, C.L., 2004. Varney’s Midwifery, 4th edn. Jones and Bartlett Publishers, Sudbury.
Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
Kurdish pregnant women’s feelings: A qualitative study Roonak Shahoei, PhD [Student (Lecturer)]a,, Haliza Mohd Riji, PhD (Associate Professor)b, Zhila Abed Saeedi, PhD (Associate Professor)c a
Faculty of Nursing and Midwifery, Kurdistan University of Medical Science, No. 6 Karbasy Hill, Jam Jam street, Sanandaj, Kurdistan, Iran Faculty of Medicine and Health Sciences, University Putra Malaysia, Malaysia c Faculty of Nursing and Midwifery, Shahid Beheshty University of Medical Science, Iran b
a r t i c l e in fo
abstract
Article history: Received 13 November 2008 Received in revised form 20 April 2009 Accepted 20 May 2009
Objective: to gain a deeper understanding of how Kurdish pregnant women feel about their pregnancy. Design: a qualitative study analysed by a grounded theory approach. Setting: the study was conducted among women in the third trimester of their pregnancy in either their homes or the health-care centres in Sanandaj in the western part of Iran. Participants: 22 pregnant women were recruited and interviewed. Findings: during pregnancy, women experienced a variety of feelings: ‘satisfied and happy’, ‘unpleasant’ and ‘ambivalent’. Conclusions and implications for practice: it is important for midwives to ask pregnant women about their feelings concerning their current pregnancy, childbirth and future motherhood. If they express negative or ambivalent feelings, these should be discussed in greater detail and their causes identified. Special consideration should be given to primiparous women and multiparous women with negative experiences of previous pregnancies. & 2009 Elsevier Ltd. All rights reserved.
Keywords: Qualitative research Grounded theory Feelings Pregnancy
Introduction During pregnancy, women not only experience psychological and emotional changes, but their behaviours may also change according to their feelings and moods, notably during the early stages. Their emotions become more stable and they gain a sense of well-being as the pregnancy progresses (Campbell and Lees, 2000). For most women, pregnancy is a period when they are affected by a multitude of factors residing within themselves or originating from external factors. Unplanned pregnancy, change in body image, emotional security, cultural expectation, financial situation and level of support from partners are some of the factors that can influence their feelings and attitudes. Women’s emotions and behaviours are greatly affected by their level of maturity and readiness for child-bearing (Leifer, 2005). Women’s feelings change over the first trimester through the second trimester. The first trimester is when they focus on the pregnancy and on accepting the new reality (fetus) as being part of their identity. As the pregnancy progresses, they begin to have a sense of the child as their own separate entity. As the nausea and fatigue of the first trimester have passed, they feel much better. They make a point to make the pregnancy apparent to those around them and feel the glow of pregnancy. The second trimester
Corresponding author.
E-mail address: [email protected] (R. Shahoei). 0266-6138/$ - see front matter & 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2009.05.011
is even happier when extra attention is given to them (Klossner, 2006). Although the third trimester is a time of active emotions with visible preparation for childbirth and parenthood, it is also a period when a number of fears surface. First, there are fears for their own and the baby’s lives. Second, they may undergo grief as they anticipate the loss of attention and special prerogatives they received during pregnancy. Psychologically, there is the inevitable separation of the baby from the body, and there is also a feeling of loss as the full uterus collapses and becomes an empty vessel. Slight depression, increased dependency and introversion, and vulnerability are other feelings experienced by pregnant women as they reach the third trimester (Varney et al., 2004). This period is marked by extreme sensitivity and overreaction. Finally, towards the end of pregnancy, most women feel tired of being pregnant (Klossner, 2006). In sum, pregnancy is a time of stress for many women (Pillitteri, 2004). Disappointment, rejection, anxiety, depression and unhappiness prevail. Moreover, there may be interpersonal problems between pregnant women and their mothers that they have to resolve (Varney et al., 2004). Although there are common psychological responses to pregnancy, behaviour in response to these vary according to culture. Beliefs about male and female roles, the significance of the pregnancy and the child, and the view of pregnancy as a normal event in life will naturally influence pregnant woman’s psychological condition.
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Until now, little has been known about Kurdish women’s responses to pregnancy. It was, therefore considered pertinent to obtain a deeper knowledge of this phenomenon. Against the backdrop of social, cultural and economic changes that have taken place in Kurdistan, a qualitative study of women during pregnancy would be useful to gain an understanding of the causes of various emotion women may experience. Such knowledge can be useful in improving information and support during pregnancy and motherhood.
Methods A qualitative design was chosen as it is particularly suited to studying complex phenomena or processes that are less understood (Lincoln and Guba, 1985). The research took place over a nine-month period in the health-care centres of the Medical Sciences of Kurdistan University in Sanandaj, a centre of the Kurdistan province in the western part of Iran. Study participants were recruited from maternity units in three health-care centres. A purposive sample was used. Sample size was not pre-determined but was determined when interviewing reached saturation, i.e. when no new data emerged regarding a category and categories (Strauss, 1987; Rice and Ezzy, 1999). The sample was restricted to 22, as no new data were generated after the 20th interview. The researcher orientated midwives on the maternity unit of study on the particular characteristics for choosing participants. Once identified, the midwives would then ask those women for permission to be approached by the researcher. When a potential participant expressed interest in the study and permission to approach was obtained, the researcher reviewed the criteria required for inclusion in the study (e.g. being a Kurdish woman, being in the third trimester of pregnancy, no physical disability). The purpose of the study was explained to the participants, and informed consent obtained from those who wished to participate. Participating women were asked to provide baseline demographic data and contact information. Each woman was also notified about the time needed for the interview. The date of the interview was arranged to suit the woman. All interviews were conducted in the Kurdish language by the first author who is a midwife. Each interview was tape-recorded with the woman’s permission. The length of the interviews varied, depending on the women’s responses. Each interview took between 50 and 100 minutes (average 70 minutes). Most women (60%) were interviewed once. There were, however, a number of occasions when the researcher needed to obtain more information. Nine participants were, therefore, visited for a second time.
descriptions to correspond closely with their meaning in Kurdish, while making them grammatically correct for English readers. Ethical considerations Permission to conduct the study was received from the Medical Sciences of Kurdistan University. Participants were given verbal and written information about the study, and given the opportunity to ask any questions concerning participation. All participants were informed that their participation in the study was voluntary and that their names would remain confidential. They were reassured that their care would not be affected if they chose not to participate in the study. Moreover, they could withdraw from the study at any stage without offering explanations. Written consent was also received. Analysis Following grounded theory practice, data collection and data analysis were conducted simultaneously. A constant comparative method of analysis was used as data were reviewed and grouped into categories and subcategories. In the first stage of the analysis, initial coding, the interviews were read line by line, and codes were identified and labelled. The coding process helped the researcher to remain close to the data. Sometimes ‘in vivo’ quotations were picked up directly from the text and used as open codes (Strauss and Corbin, 1990). The second step was to scrutinise the open codes and make decisions about which codes to keep as the most relevant for the aim of the research. The chosen codes and quotations were then repeatedly compared and sorted into categories according to their content and meaning. Between the open codes and a category, the dimensions were identified, which helped to describe what a category was about. During this process, the emerging categories and their dimensions were continually compared with the original text to exclude the risk that some findings might be based on misunderstanding. The following steps were taken to satisfy the requirements of credibility, fittingness, confirmability and auditability. Colleagues skilled in the paradigm listened to a few tapes, read the verbatim transcripts, and compared their interpretations with the investigator’s category scheme. In addition, five women received a hard copy of their transcripts. Audio trails were created for all interviews to demonstrate how categories were formed. These were confirmed by colleagues.
Findings
Interviews
Participants’ profiles
The women were individually interviewed in their own homes or a private room at the health-care centre in the third trimester. A semi-structured interview schedule guided the investigator during the audio-taped interviews. All interviews started with the same question: ‘Could you please tell me what does pregnancy mean for you?’ The women’s responses were recorded and clarified with probing questions: for example, ‘what do you mean by sayingy?’ or ‘what made you think so?’ All interviews were transcribed verbatim in the Kurdish language by the first researcher. Transcription accuracy was checked by a colleague who read randomly chosen transcripts while listening to the audiotape. The analysis was also undertaken from the Kurdish transcripts, and only verbatim quotations presented in the writing for publication were translated into English. The researcher has attempted to translate the women’s
Twenty-two women aged 20–35 years (average 27 years) participated in this study. All women were born and resided in Sanandaj. Most participants described themselves as housewives (77%) and the remainder were employed (23%). The women differed in educational level, ranging from basic schooling to university, with most being high school graduates (73%). All participants were married, because childbirth outside of marriage in Kurdish culture is practically non-existent. Fifteen women were primigravida and seven were multigravida. Their gestational ages varied between 29 and 39 weeks (average 34 weeks). Feelings described by the women were grouped into three main categories: ‘satisfied and happy’, ‘unpleasant’ and ‘ambivalent’. To maintain confidentiality, the women’s quotations used to illustrate the categories are identified with numbers. Participants
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were anonymous and are reported using interviewee-assigned numbers (#).
got from others. They became more pleased as others gave them more affection:
Satisfied and happy Feelings of satisfaction and happiness were described by the pregnant women in relation to ‘joy and consent’, ‘maternal feelings’, ‘closer relationship with husband’, ‘sense of supporting, ‘God’s blessing’, ‘more affectionate towards mother’ and ‘a sense of ownership and responsibility’.
I’m happy and sometimes I wish I could always be pregnant because my husband, his family and my family pay more attention to me and I don’t want this to stop. (#3) Now, I feel I have more intimacy in my life and my family pay more attention to me, it is pleasurable for me. (#17) I think the whole family supports a pregnant woman and this is so important for her. (#20)
Joy and contentment. All participants reported that they had a sense of joy and contentment: I want to be pregnant and I’m very happy about my pregnancy. (#1) Since I sense a quickening of the fetus, I feel happy and this sense of happiness has increased during pregnancy. (5#) At first, I didn’t want to be pregnant because my situation didn’t permit me to have a baby. But now I’m completely satisfied and delighted to be pregnant. (#13) Maternal feeling. Most women explained that feeling the existence of another being inside them brought a special and pleasant sense for them. They believed that this maternal feeling is exclusive and unexplainable: Maternal feeling is a good sense. Nobody has this kind of sense except a mother. (#7) I don’t know how I can describe my sense. I have a feeling that I can’t explain. You can’t understand maternal feeling unless you become a mother. (#15)
The women’s parents and parents-in-law often supported them and shared the worries and joy of the pregnancy. Their bonds were becoming stronger during pregnancy. Women explained that their husband’s family’s treatment of them has changed: During this time my husband’s family gave me more support, their conflicts, criticism and scorns are removed. (#3) Appreciation of God’s blessing. Most pregnant women in this study believed that pregnancy was a gift of God to the mother and this new life is awarded to her by God. Moreover, they described that pregnancy increased their belief in God. Furthermore, they are praying God for gift: I feel pregnancy is the best gift of God to mother because being a mother is really delightful. (#2) I think this pregnancy increases my belief in God. (#22) Some women explained that they trusted God more and they had insight into God’s greatness as a result of pregnancy:
Maternal feeling is a very interesting sense and it is extremely pleasant when you have another being inside your abdomen and you feel it within yourself. (#2)
When I found out I was pregnant; I trusted God and thought this is God’s gift for my small family. (#8) Having a baby after 10 years is God’s blessing and my baby is a mercy shown to me by God. (#16)
Sense of closer relationship with husband. Most of the women in this study claimed that pregnancy brought about changes in their relationship with their husband. They expressed the importance of sharing the pregnancy with their husband. It was a way of getting closer to each other and strengthening the family bonds. Furthermore, many women described how the baby had already affected their lives in terms of heightened responsibility and maturity:
More affectionate towards mother. Most participants mentioned that their pregnancy brought changes in relationships. The woman’s own mother was especially important to her at this time and she needed her approval. While she respected both of her parents, she felt more affectionate towards her mother during pregnancy. In addition, she could understand her mother a little more. Furthermore, women discussed more with their mothers and were more relaxed with them:
I feel now both of us have more passion and I think pregnancy increases our attachment to each other. (#9)
I feel I’m changed in all aspects, my understanding is increased. Now, I think I can understand my parents more. I have more respect for my mother and I sense more comfort with her, I hadn’t this sense before. I can now tell my problems to my mother and ask her for help. (#7) I love to talk about my feelings with my mother. Since I have been pregnant, I can understand my mother and her worries. I love to tell her I can understand your troubles now for my birth and looking after me. (#18) I’m satisfied that I’m going to be a mother. I love the sense of motherhood because I can realise the value of my parents. (#16)
I think during pregnancy, the dependency of a woman and her husband increase, and it improves their relationship. Since I have been pregnant, we have had fewer problems and arguments. Now I sense my husband loves me more and his support has increased. (#13) yintimacy has increased in my life, relationship with my husband is improving and it makes me feel comfortable. (#17) However, some women experienced a feeling of losing their husbands’ interest during pregnancy: Sometimes, I think pregnancy and having a baby creates a gap among couples. (#10)
One woman said that her mother’s reaction caused her to regret her pregnancy:
Sense of supporting. Most of the participants in this study liked pregnancy because of the increased attention and support they
My mother criticised me because of my pregnancy. Her reaction made me ashamed. I don’t know why she doesn’t want me to be pregnant. (#8)
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A sense of ownership and responsibility. Some women described that pregnancy brought them a sense of needing to provide the safekeeping of the baby. In addition, they explained how the baby had affected their lives in term of heightened responsibility: I feel, God gives me an entity and I have to keep her. (#3) yI have a sense of responsibility, I’ve never experienced this sense beforey.I try to keep her safe. (#13) Unpleasant feelings The category of unpleasant feelings were described by the participant in relation to ‘fear’, ‘anxiety and despair’ and ‘being unpleasant’. Fear. Fears described by the women were divided into four subcategories: fear because of the baby’s health, fear of childbirth, fear of disability, and fear of other reasons. Most women in this study reported fear of childbirth. The most commonly reported fear was cause of pain: I’m very afraid of childbirth pain. (#2) I’m afraid of dyingyI’m sure I would be died during delivery. (#3) Some participants were afraid of procedures related to the birth of their baby, including having an episiotomy and a vaginal examination:
Further fears that women mentioned include: losing their husband, criticism and being scorned by their husband’s family: I feel I will lose my husband. Since we’ve been married, we have been with each other but now I feel I will lose my husband. He will go out by himself and I’ll be alone with the baby. (#3) Sometimes I wish I wasn’t pregnant. I’m afraid I won’t be able to carry out my responsibility and will be scorned by my husband’s family. (#5) The feeling of anxiety and despair. In this study, women were worried about their fetus or themselves. The anxiety related to the fetus was about lack of fetal movement, fetal health, abnormality and the birth: Whenever I can’t feel my baby moving, it makes me worried. (#3) I worry that there is already something wrong with the baby. (#2) The worry related to themselves was about losing their husband’s affection, irreversibility of the physical judged by others, losing their job, financial difficulties, being incompetent to satisfy the needs of older children, the couple being distant from each other and being judged by others:
I’m afraid of snipping. (#3) Other women feared that they would not be able to go through natural childbirth: I’m afraid I won’t be able to do it, I won’t be able to deliver the baby. (#2) Some multigravida stated that, because of their experience in a previous pregnancy, they were afraid of being ill treated by delivery staff. They mentioned that midwives and doctors were rude to women during labour and childbirth. Some nulliparous women stated that their fears were due to the environment of the labour room, because they had heard comments about unkindness of staff from other women: I’m really afraid because some of the midwives and doctors don’t pay attention to you and yell at you. (#21) However, some women were afraid of the absence of a doctor when giving birth: I’m afraid of delivery, because it will be during the New Year holiday and there won’t be a doctor and midwives. (#1) In addition, participants described their fear for their baby as follows: This is my biggest fear. I have fear all the time. What will I do if I have a preterm labour? (#8) I’m very afraid for the health of my baby. I always want God to help me. (#19) During the interviews, some participants stated that their fears had developed because of the feeling of disability: I’m afraid I won’t be able to have a natural delivery. (#5) There were some fears about not being a good enough mother: Sometimes, I regret my pregnancy. I feel I can’t take care of my child and educating him. (#4)
When I knew that I was pregnant, it made me worry. We have a lot of financial difficulties; we have to plan for the future. (#12) Sometimes I think this baby causes us to be distant from each other. (#10) Being unpleasant. Some women in this study claimed that they felt uncomfortable. This was because of physical or psychological changes. Some of them had experienced nausea and vomiting in early pregnancy. Many of them complained about fatigue, physical (body) changes, gaining weight, sense of being heavy, and a sense of untidiness and feeling messy: I hate my appearance. I feel annoyed and embarrassed when my husband looks at my belly. I think it makes me look fat and ugly. (#5) In addition, many of the participants described rapid changes in their mood. Periods of strength and easy living might suddenly change to feeling weak, sensitive, anxious, isolated, and not wanting to communicate with others, regret, depression, discomfort, short temper, disliking the baby, being unattractive, and not enjoying pregnancy: yduring the second trimester, I noticed that my clothes were tight. I felt a sense of shame and it made me regret my pregnancy. I feel I’m uglyysometimes I love to be alone (#4) Ambivalence Some participants in this study reported that they are experiencing joy and unpleasantness: I think, pregnancy has pleasant and unpleasant senses for a mother. (#14) I actually have a sense of ambivalence. Sometimes I love it (pregnancy) but other times I’m afraid of it. (#12) I know pregnancy brought happiness and troubles for me (#8) You know, when you are pregnant, you have a sense of sweetness and bitterness about it. (#5)
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Discussion The overall purpose of the present study was to investigate and describe Kurdish pregnant women’s feelings during pregnancy. Pregnancy should be viewed in the context in which it occurs (Campos et al., 2008). Since pregnancy is a socially constructed experience, it seems that pregnancy has different meanings to different women. In other words, the way in which pregnant women feel about pregnancy and childbirth may be affected by their cultural background. Social expectations and cultural values affect Kurdish pregnant women’s responses to their pregnancy and the idea of motherhood. In Kurdish society, pregnant women’s reaction to pregnancy and their expression of feelings are affected by the way in which the women are raised, their beliefs about male and female roles, the significance of the pregnancy, pregnant woman’s role in society, view of pregnancy as a normal event, the values of children, family influences, relationships with husband and family, financial status, life experiences, education, philosophy of life, and expectations. The findings of this study support previous research on various aspects of pregnancy, for example variations in mood and worries (Rubin, 1984; Mercer, 2004) and changing relationships (Rubin, 1984; Hoffman et al., 1994). All seven multiparous women in the study had previously given birth vaginally. They experienced pain and had negative experiences because of ill treatment by the midwives. The same findings have been reported in other studies (Jolly et al., 1999; Sasito et al., 2001; Melender, 2002; Sercekus and Okumus 2009). Mathews and Callister (2004) claim that essential factors in preserving the quality of the birth experience are behaviour from caregivers that demonstrate valuing and respecting that these qualities are important for the woman’s ability to maintain dignity during childbirth. According to Anderson (2000), midwives are extraordinarily powerful, especially when a woman is in labour, and it is essential that the midwife uses that power in a sensitive and wise way to the best advantage of the woman in their care. All participants in this study expressed at least some fear associated with pregnancy or childbirth; the most commonly reported fear about childbirth was fear of labour pain and childbirth. This finding was in agreement with previous studies (Melender and Lauri, 1999; Sasito et al., 2001; Melender, 2002; Eriksson et al., 2006; Nilsson and Lundgren, 2009; Sercekus and Okumus, 2009). Furthermore, they had fears related to the health of their baby, their own health, and their relationships with their husband and family. This finding was also reported by Melender and Lauri (1999), Melender (2002), and Sercekus and Okumus (2009). Some women stated that their fears were due to not being a good enough mother (Melender and Lauri, 1999). Moreover, this study showed that criticism from the husband’s family or being scorned by them can make pregnant women fearful and distressed. Previous studies have not shown this cause. A potential limitation of this study is that all participants were Kurdish pregnant women in Sanandaj; the findings might have been somewhat different if women from other cultures were included. Also, pregnant women might have difficulties in talking because of social norms about what feelings are considered appropriate for women during pregnancy. Moreover, it must be taken into consideration that a qualitative study implies interaction between researchers and participants, and that the researcher’s pre-conceptions might influence interpretation of the material (Charmaz, 1995). Nevertheless, pre-conceptions can be a limitation or a strength. The first author is a Kurdish woman and a midwife with clinical experience, which might sensitise the processing of the data. The second and third authors are
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recognised qualitative researchers who have published several studies.
Conclusion The findings of this study indicate that Kurdish women experience a range of feelings during pregnancy: ‘satisfied and happy’, ‘unpleasant’ and ‘ambivalent’. Thus, it is important for midwives to ask pregnant women about their feelings concerning the current pregnancy, childbirth and future motherhood. If she expresses negative or ambivalent feelings, these should be discussed in greater detail and their causes identified. Special consideration should be given to primiparous women and multiparous women with negative experiences of previous pregnancies. Midwives might therefore need further training on how to meet and support pregnant women with negative or ambivalent feelings. These findings are important markers for further research concerning women’s experiences of anxiety, fear and ambivalent feelings, as well as midwives’ perceptions about and their interaction with pregnant women.
Acknowledgments We would like to thank all the women who participated in this study. We thank the faculty of medicine and health sciences of the University Putra Malaysia and Medical Science Kurdistan University for their approval of the study. The first author is grateful to Mr. Abad Dokht for his assistance during the translation of data and his comments. References Anderson, T., 2000. Feeling Safe Enough to Let Go: the Relationship Between a Woman and her Midwife During the Second Stage of Labor. Palgrave Macmillan, London. Callister, L.C., 2004. The pain of child birth: perceptions of culturally diverse women. Pain Management Nursing 4, 145–154. Campbell, S., Lees, C., 2000. Obstetrics by Ten Teachers, 7th edn. Gutenberg Press ltd, Gutenburg Press, Tarxien, Malta. Campos, B., Dunkel schetter, V., Abdou, C.M., Hobel, C.J., Glynn, L.M., Sandman, C.A., 2008. Familialism, social support, and stress: Positive implications for pregnant latinas. Minority Psychology 14, 155–162. Charmaz, K., 1995. Grounded Theory: Rethinking Methods in Psychology. Sage, London. Eriksson, C., Jansson, Hamberg, K., 2006. Women’s experiences of intense fear related to childbirth investigated in a Swedish qualitative study. Midwifery 22, 240–248. Hoffman, L., Paris, S., Hall, E., 1994. Developmental Psychology Today. McGraw Hill, New York. Jolly, J., Walker, J., Bhabra, K., 1999. Subsequent obstetric performance related to primary mode of delivery. British Journal of Obstetrics and Gynaecology 106, 227–232. Klossner, N., 2006. Introductory Maternity Nursing. Lippincott Williams and Wilkins, Pearson Education Inc, New York, United States of America. Leifer, G., 2005. Maternity Nursing: an Introductory Text. Elsevier Saunders, Lippincott Williams and Wilkin, Philadelphia, United States of America. Lincoln, Y.S., Guba, E.G., 1985. Naturalistic Inquiry. Sage, Markham, ON, Canada. Melender, H.L., Lauri, S., 1999. Fears associated with pregnancy and childbirth: experiences of women who have recently given birth. Midwifery 15, 177–182. Melender, H.L., 2002. Experiences of fears associated with pregnancy and childbirth: a study of 329 pregnant women. Birth 29, 101–111. Mercer, R.T., 2004. Becoming a mother versus maternal role attainment. Journal of Nursing Scholarship 36, 226–232. Nilsson, C., Lundgren, I., 2009. Women’s lived experience of fear of childbirth. Midwifery 25, e1–e9. Pillitteri, A., 2004. Maternal and Child Health Nursing. Lippincott Williams and Wilkins, Philadelphia, United States of America. Rice, P.L., Ezzy, D., 1999. Qualitative Research Methods: a Health Focus. Oxford University Press, Melbourne. Rubin, R., 1984. Maternal Identity and the Maternal Experience. Springer, New York.
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