What women have to say about giving birth in Saudi Arabia

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Ibtesam Jahlan (1) Virginia Plummer (2) Meredith McIntyre (3) Salma Moawed (4) (1) Ibtesam Jahlan PhD candidate MCM RN RM Monash University/ King Saud University (2) Plummer, V., Associate Professor Nursing Research RN PhD FACN FACHSM Monash University (3) McIntyre, M., Director of Education Coordinator Master of Clinical Midwifery PhD MEdSt B.AppSc RN RM Monash University (4) Moawed, S. Prof. Dr. Salma Moawed Professor of Maternity & Gynaecological Nursing, Ph. D., M.Sc.N., B.Sc.N. King Saud University Correspondence: Ibtesam Jahlan Monash University/King Saud University Telephone: +61 0421 448 127 Email: ibtesam.o.j@gmail.com

Abstract Background: Reporting the voices of women giving birth in KSA in order to inform policy developments within the Saudi maternity healthcare system is important to understand what the women want from the service and how to improve it. Aim: to explore current birthing services in KSA from care consumers' perspectives by reporting women's birthing experiences and voices. Methods: Within the first 24 hours after giving birth in one of the three selected public hospitals, 169 women shared their birth experience through their responses to an open-ended question on a questionnaire or by contributing in one-to one conversation with the researcher. Findings: Thematically analysing 169 written responses and notes for conversation have produced two main categories which include themes and a number of sub-themes. The first and major category is "The relationship between women and care providers during birth" which is considered by most women the leading cause for better and satisfied birth experience if this relationship is characterised by support, respect, trust, and empowerment. The second category is "Hospital rules and policies and childbirth experience" especially if these policies restrict women's choices and are brought into action without full explanation to women about why these policies are active. Conclusion: Maternity care policy makers in Saudi Arabia have to consider women's voices in building and reviewing maternity policies and focus on empowering childbearing women and ensuring safe motherhood. Key words: Childbirth, Maternity services in Saudi Arabia

1. Introduction and Literature Review
Maternity services in the Kingdom of Saudi Arabia (KSA) have been classed by the World Health Organization (WHO) as comparable with developing countries (1), concurrently, health services in KSA are experiencing rapid modernization, economic growth and diversity (2). Maternity services are also being influenced by these changes. In order to inform policy developments within the Saudi maternity healthcare system as part of the modernisation process it is important to understand what the women giving birth in KSA say about maternity services.

Australia was one of the first countries to conduct reviews of maternity services inviting submissions from women who have been consumers of those services. The review sought women's opinions, experience and degree of satisfaction experienced with the model of maternity care they received (3-7). Globally, scholars used women's birthing experience and their voices to reflect on maternity services. In Scotland, Sweden, Finland and the USA, reviews for maternity services were undertaken by exploring women's and/or health care providers' and policy makers' views about their experiences within the current maternity care system (8-11). It was suggested that more effort is required to improve the information provided to women and the choices available for women regarding the care they receive during pregnancy and birth (9). Trusting the system was found to be a major issue for those women who sought non medicalised care (10). Women reported feeling dissatisfied with the care they received despite the fact that they were deemed to have been provided quality care, as measured by the low perinatal mortality rates. Lack of choice and loss of personal autonomy in decision making regarding the care they received was reported as a major source of dissatisfaction (12, 13).

Maternity research in the Middle East region has been focused on reporting a number of clinical outcomes such as maternal and perinatal mortality and morbidity and common birthing practices in line with the medicalization of birth to reflect on the quality of the maternity services in these countries. A number of studies were conducted in Jordan and were considered to be among the first of their kind in the Middle East reporting women's childbirth experience. These studies show women's negative childbirth experience using different quantitative and qualitative methodologies (14, 15) (16). The lack of inclusion of women's personal experiences of maternity services evidences a gap in the literature resulting in limitation of maternity services review findings for the Middle East area.

The voices of Middle Eastern women until now have been silent and unreported, excluded from policy decisions related to quality of maternity care improvement. This situation is at odds with maternity services reviews and research findings globally, that sought the views of women, the key stakeholders of the service when it comes to the quality and safety of maternity services (11, 12, 16, 17).

This study reports Saudi women's experiences of the maternity care they received, viewed through the lens of safe motherhood to provide these women's voices with the opportunity to be heard and in doing so potentially influence maternity service policy developments in KSA.

2. Methods
2.1 Research design
This study is part of a large mixed method study that explored birthing services in KSA from two perspectives, women and health care professionals. Data was collected using the survey and interviews techniques to describe birthing services in Saudi Arabia and how these are viewed by women and maternity health care providers. This paper addresses the findings of the qualitative section of the study related to the women, as consumers of maternity care.

2.2 Study sites and participants
This study took place in three specialised maternity hospitals located in three main cities in Saudi Arabia; Jeddah, Riyadh, Ad Dammam. The number of births in each hospital is approximately 6000 births/ year (18). One of the three hospitals has achieved JCA international accreditation, and offers additional services to those offered by the other two hospitals and consequently experiences a strong demand by mothers seeking to give birth in this hospital. For example, the hospital that had JCA accreditation provides breast feeding classes and consultation through a breast feeding specialised clinic which is run by breastfeeding specialist. The other two hospitals provide routine maternity care. Ethical approval to conduct the research was obtained from Monash University Human Research Ethics Committee after the approval was gained from the three individual participating maternity hospitals in KSA.

2.3 Data collection
One hundred and thirty seven women shared their experiences related to the maternity care they received, in response to an open-ended question on a questionnaire. The questionnaire results are reported elsewhere.

'Apart from meeting your new baby, and knowing that your baby had no serious health concerns, and apart from the pain you had during labour and birth, what was the best and the worse thing about your recent experience of giving birth?'. The questionnaires were distributed to all eligible women giving birth in one of the selected hospitals. Participating women were aged over 18 years, able to read and write Arabic language, had given birth within the previous 24 hours and cleared for discharge from hospital after giving birth to a single / multiple babies (Table 1). The questionnaires were collected in a designated sealed box at the reception desk in each ward. In addition, 32 of the participating women joined the study through one-to-one conversation about their last childbirth experience with the researcher, which was initiated during the distribution and collection of the questionnaires in the hospital wards. Those women either were unable or did not wish to write down their experiences, but wanted to participate in the study. Those women enjoyed having the opportunity to join the conversations to share their birth experiences especially when these conversations took place in a post-natal shared room. Within Saudi culture, women enjoy speaking to other women of their birthing experiences as part of an informal debriefing process providing opportunity to express feelings and fears. This unplanned outcome of this study (female conversations) enriched the qualitative data findings with the researcher notes that were written immediately after each conversation.

Table 1: Participants' Demographics

2.4 Data Analysis
All women's answers for open-ended question and researcher notes for women's quotes were recorded in Arabic requiring the data to be translated into English. Following translation thematic analysis was used to discover patterns hidden within the texts (19). Thematic analysis began with preparing the data by transcribing, translating and organizing the documents. Then the data was explored through reading and re-reading to a point where the researcher felt totally integrated and familiar with the participants` words. After that, the researcher generated initial codes and searched for themes by grouping the similar descriptions and expressions coded until themes emerged. Next, the data analysis findings were validated by reviewing the themes with other research and repeatedly reflecting to ensure there was no missed classification and that the identified themes were valid representations of the participants` perceptions. The final steps were presenting the data analysis and producing the findings report, wherein the resulting themes were identified and described using the participants` words and comments (19, 20).

Rigor was maintained using the golden criteria of trustworthiness for qualitative research outlined by Guba and Lincoln (21), which has been applied widely for ensuring the rigor in most qualitative studies. The criteria, including credibility, dependability, confirmability and transferability were attained through reporting the findings by supporting each theme with women's own words and commentary reflecting women's voices clearly through each theme. Moreover, sufficient description for the sample, data collection and analysis is provided for any possible transferability (22).

3. Results
Thematically analysing women's written responses provided through returned questionnaires and researcher's notes for woman-to-woman conversations resulted in a variety of women's comments that reflect the approach of maternity care delivered in each hospital. Two main categories of comments evolved from the data collected regarding what women believed was the best and the worse things that happened to them during their experiences of maternity care. A variety of themes and subthemes have been reported within these two categories. The extracted categories and themes represent women's childbirth experience in Saudi Arabia. The first and major category is "the relationship between woman and care providers". The second category is 'hospital rules and policies and the childbirth experience'. (Table 2)

Table 2


3.1 The relationship between women and care providers during childbirth
The relationship between women and care provider is one of medical domination in Saudi Arabian maternity services where women are expected to leave all important decisions to the staff (nurses and doctors) as they are perceived to know best. The first common experience reported by women relates to the maternity care providers' support and attitude towards the women and their respect and interactions with the women. This category has been divided into seven themes.

3.1.1 To be respectful "treating me with respect and not underestimating me as a human":
A number of mothers reported appreciation of the staff who treated them respectfully:

P23: "In the labour and delivery room the staff treated me very well and with respect.
P134: "the best thing was treating me with respect and humanity and not underestimating me as a human".

Conversely, women who were treated with disrespect during their birth experience expressed their unpleasant feelings in their words.

P6: "The worse thing was ignoring me…and not respecting my psychological condition during labour".
P300: "I felt the difference between the treatment of the nurse who treats with more respect than the consultant did."

Similarly, a number of women described feeling embarrassed by some staff actions that they considered as disrespectful and humiliating:

P189: "the worse thing was that during suturing time after birth, the situation was bad as the Dr.(F) and complete medical team were in the room which embarrassed me."
C31: "during pushing and delivering the baby's head, some blood splashed over the doctor. So, she got angry and said "what brings me here?" what does she means by that? Why she is working in this area if it cause her disgust ….."

3.1.2 Explain everything "I did not have any choice in anything" "not enough information was given to me":

A number of women expressed their satisfaction with the information and explanation they received during their last birthing experience. This was dominated by women who gave birth via caesarean section because of its surgical requirements and by those who had previous childbirth experiences.

P51: "as it was a caesarean section I knew everything".
P173: " the best thing was knowing the labour and birth stages".
A group of women from the three hospitals expressed their needs for adequate ante-natal education and during birth explanations to understand what would be done to them during labour and birth and why.
P267: "I did not know what was the injection given with I.V? Also what was the injection given in my thigh?"
P12: "I did not have any choice in everything, the midwife left me without dilatation [episiotomy] till the baby came out without any assistance."

Moreover, women sought for more information during pregnancy to correct any misconceptions about labour and birth and how to take care of themselves and their babies after birth.

P273: "when the labour pain started I had too much of (flower water + saffron) which increased the pain with no cervical dilatation occurring. I do not recommend taking anything without a doctor's prescription"
P193: "Not enough information given to me about my stitches and how to take care of them."
P80: " "I refused to take a deep breath during pushing because that will draw the baby water…"
Some women needed more information about their childbirth experience than others.
P80: "my daughter had the umbilical cord tied around her neck and I think this is happened because they did not let me push when I was ready to, is that true?"

Another group of mothers questioned the presence and the role of some maternity care providers who attended their labour and birth.

P11: "I am a human, and having student trainer during my birth increased my fears. They should ask for my permission on that."
P309: "the worse thing was having a male doctor and nurses in my birthing room while no need for that."

A large number of women have not understood the breastfeeding policies implemented across a number of the hospitals included in this study. More antenatal education is required to adequately prepare women for the change. The main area that women required more education before the birth was the mechanism of the breastfeeding and the reasons why breastfeeding was enforced immediately following the birth.

P100 : "I do not know how to breast feed my baby and know how to latch my baby to my breast"
C 10: This woman's son was in the nursery and she did not know what to do with the milk accumulated in her breast.

3.1.3 To be good listener and trust women's body "the best was listening to my fears and calm me down":
Being cared by someone who listened to women's needs was a significant factor in a good birthing experience for some participants:

P279: "the best was the doctor (F) and the nurse because they were the only two who listened to my fears and calmed me down during the birth".

Women reported feelings of humiliation because no one listened to them when they were in labour. For example several women were very upset and described their experiences:

C31: "I was in pain and I almost kissed their hands to check me up "sit down just sit" they said. So I kept bothering them until they examined me and they found that I was 8 cm dilated."

Then, P80 supports that:
P80: "I felt ready to push, but the nurse stopped me from pushing and called me a liar. Then someone came and examined me and saw my baby's head clear just sitting there."

Another woman described her experience of medical errors as a consequence of staff not listening to her.

P105: "The decision was to do caesarean section and they start assessing my sensations by pinching me and I told them that I felt that but the Dr.(M) said to me 'you are joking' and I replied 'it is not the time for jokes, I am in the O.R and I am between life and death'. So they started cutting the incision and I felt the scalpel and the stretching; and off course I screamed very loudly. Then they said fine, fine and they gave me complete anaesthesia".

3.1.4 To provide safe care "I felt safe because I was in caring hands"
Despite the fact that mothers believed that feeling safe during labour and birth required a good relationship with the staff and being informed of the progress, many women did not have that experience. These women felt unsafe which lead them to not have a pleasant childbirth experience.

P171: "the best thing was I gave birth in this hospital which has better care and safety for patients and informing patients about their rights".
C31: "They documented my blood type as positive while I am negative, so when I asked for the injection they told me I do not need it. So, I told them I had an abortion before in this hospital and I had the injection. Finally, they did blood test for me. To be honest, I am very scared about my baby because of the wrong information they have so they may give my baby the wrong treatment"

Feeling safe for many women was associated with receiving kindness from their caregiver:
P204: "the best thing occurred to me during my last birth was the treatment of the health team with humanity. I felt safe in their hands".
P219: "I felt safe because I was in caring hands. This was my best birth".

3.1.5 Caring and helpful staff "they treated me as a princess"
Participating women reported their pleasant childbirth experience when in the care of helpful, caring staff, and described how this improved their psychological status and assisted in their ability to cope with the difficulties of their births:

P120: "the best thing was the help of the staff during labour and birth."
P134: "The midwife who took care of me was better than the doctor (F) who I met. Those midwives knew everything about my condition better than the doctor herself and they treated it very well, my regards to them."

Alternatively, one woman who reported receiving good care also expressed her feelings when encountering uncaring staff.

3.1.6 I needed support and cooperation "support during labour to relieve psychological stress"
Being cared by supportive cooperative staff was a primary factor in the mothers' assessment of a better birthing experience:

P298: "the best thing was the medical team continuous support till the birth complete"
P281: "the medical staff team in the birthing room were very cooperative and understanding".
Many women reported looking for support and cooperation from staff and not finding it:
P196: "I waited for 2-3 hours in the waiting area until I could not tolerate the pain anymore and I was deteriorating physically and psychologically."
P279: "After all this I have been left in the birthing room till 4 pm without food or pain killer and with complete ignorance to all my calls and no kindness".

Experiencing pain is the first characteristic for any birth experience; a number of women reported their needs for staff support and cooperation in order to gain control over pain.
P49: "one of the worse things was the labour pain it was very intense, but it was treated very well and I was satisfied"
P45: "the worse thing was the pain and contraction without analgesics."
P12: "….I did not have any pain relief or oxygen [nitrous oxide]".

Having an induction was not a pleasant experience for some women and they took the time to express their feelings about it.

P121: "the worse thing was being induced in my first birthing experience but then everything went good with staff help."

Having vaginal examination and episiotomy or stitches are considered by most Saudi women as a sensitive uncomfortable procedure and one that increases women's fears and anxiety.

P305: "they agonize us with vaginal examination."
P146: "My birth was soft, easy because I did not have any operation or episiotomy".

3.1.7 To provide the care with a positive attitude "The staff treated us very badly, they have bad attitude":
Many mothers described what they considered to be bad birth experiences:

P195: "the worse things were the nervousness of the nurses and doctor (F)".
P116: "the worse thing was the treatment by the midwife or nurse. It was bad to the extent that she told me if you have any problem go out of the hospital".
C18: "the staff are treating us very badly, they have a bad attitude"

The experience of being treated badly during labour and birth affected women's ability to cope. Some women were unable to overcome this experience:

C28: a woman said after a quiet period "the doctor treated me badly and kept saying "come on come on open your legs stop (Dalaa) [this word means acting like a kid or speaking softly]".
P273: "Everyone I met treated me with respect except the vaccination nurse, she had a very bad manner and had religious racism and no kindness".

Several women who experienced staff with bad attitude reported that this situation prevented them from speaking out for themselves and their babies.

P89: "after she took the baby from me she threw him on cot, he was hurt and cried and I could not say anything because I was tired".
C12: this woman was very upset because the nurse forced her to breastfeed her twin. "I was scared and cried as the nurse pinched and hit my thigh in a funny way to make me breastfeed but I did not like the way the nurse treated me".

3.2 Hospital rules and policies and childbirth experience:
Childbirth experiences in Saudi Arabia are influenced by what is offered and allowed in the hospital in which the woman chooses to give birth. For example, having the husband or family member attending the birth is not a choice offered to women in some hospitals in Saudi Arabia. On the other hand, establishing a new policy such as BFI (Breastfeeding initiation) required better explanation to women in order to prevent any misunderstanding or misinterpretation.

3.2.1 Family Company "I thank everyone who assists in spreading this culture":
For some women having their husband or a family member during labour and birth was an essential element to improving their birthing experience.

P11: "the worse thing was not allowing someone to stay with the patient [woman] although this is the time when they are desperate to have someone with them".
P84: "allow husbands of women to attend the labour, and this should be optional".
P161: ":the best thing happened during my birth experience and I thank everyone who assists in spreading this concept which is allowing my husband to be with me in birthing room, because him being beside me helped me a lot and made my birth easier."
C24: "They did not allow my mother until the doctor came and allowed her"

3.2.2 Breast feeding initiative BFI policy "the worse thing was leaving the baby with the mother all the time"
Participating women were not happy with the 'rooming in' policy introduced by the hospital to support and encourage breastfeeding (BFI). Women expressed their needs for family company during their hospital stay to help them to take care of the baby.

P49: "I was not expecting to care of my daughter because I was in a very bad condition, I was not able to control myself how can I provide care to my daughter".
P214: "the worse thing was leaving the baby with the mother all the time, and not helping the mother changing the baby, because the mother needs someone to help".
C26: a primi (caesarean section) woman was so confused and very overwhelmed….She said "I am very depressed from the pregnancy and birth, I need someone with me I am primi and gave birth caesarean section".

On the other side, women were unaware that this policy has been done for a purpose and interpreted this as neglect on the nurses' behalf. This issue caused an inconvenience for the women and affected their birthing experiences.

C30: "the important thing is their limited care to the baby".
P309: "…Also they did not care of the baby after birth but leaving that to the mother while she is tired"
P12: "…Nurses refuse to provide mums with milk for babies although they knew there is no milk still in their breasts."
P38: "Looking for the nursery for healthy baby to take them from mothers after birth, so she can rest for at least three hours".

4. Discussion
Women were willing to share their birth experiences and were not hesitant to make the most of this opportunity to reflect on what could be changed to improve experiences for other women. The relationship between women and maternity care providers was reported as the dominant factor that influences Saudi mothers' satisfaction with the maternity care they received. The most empowering experience for these women was to be cared for by staff with a positive attitude, someone who provided continuous support, who showed respect for the person and who could be trusted to ensure their safety. This finding has been supported by a number of studies which reported that positive, trusting and cooperative relationships between women and maternity care providers were the greatest influence in women feeling empowered when giving birth (23). The pain associated with labour and birth can be very difficult experiences for women who are feeling vulnerable and unsafe. Women's ability to manage pain during labour is negatively influenced when feeling unsupported and unsafe (24, 25).

Women reported feeling dissatisfied with their birth experiences as a result of lacking trust in the maternity care providers who did not give them the respect they deserved. Respect was not shown when staff did not provide them with necessary information on their care and the reasons this care was required, and or not listening to their needs or ignoring their distress. This is evidenced when some participating women took the opportunity to ask the researcher questions about their birth or the condition of their baby. Educating women regarding what to expect during pregnancy, labour, birth and breast feeding, and explaining the role of each member of the maternity care team is a crucial element in the development of a respectful trusting relationship which in turn leads to safe maternity care. The need to be able to trust maternity care providers is closely linked with the degree of respect that was shown to women by the staff (25-28).

Having family members to provide support during labour and birth and post-natally is one of the choices available for women in most maternity settings within developed countries. The attendance of family during labour and birth choice was incorporated into hospitals' policies because of its strong relationship with the women feeling empowered, in control of their birth and being more satisfied with their birth experience. This positive relationship was evidenced by a number of studies conducted worldwide (25, 27, 29). For Saudi women, it was a different story as they reported their dissatisfaction and loss of control as a result of not having the choice to have a family member attending their labour and birth. Only 22% of public hospitals in Jeddah one of the biggest cities in KSA allow a companion to attend labour and birth (2). Nevertheless, participating women highlighted their needs for family support through labour and birth as this would help them feel safe, satisfied and in control. Consequently, women must have the choice to have a family member throughout their labour and birth. To do so maternity policies in KSA required some modification and updating according to women's preferences and latest evidence regarding having family company during labour and birth.

Moreover, women misunderstood the application of the BFI ten steps policy as recommended by WHO within public Saudi hospitals (30). They interpreted the implementation of the policy as maternity caregiver neglect and carelessness, which was accentuated in women's words describing their experiences. Having their babies with them 24 hours and the fact that there is no bottle feeding provided to babies are the reasons causing women's misinterpretation and dissatisfaction with birthing experiences. Changing this policy is not the answer. However, women need to be informed about this policy early during pregnancy, and they must be educated why and how the application of this policy is important (30). This information can be delivered to pregnant women during antenatal education sessions, which will prepare them to accept the care delivered to them later and protect the staff from being misinterpreted.
This study is the first to explore women's birthing experiences in public hospitals in Saudi Arabia. Women have highlighted their needs for better, more satisfying birthing experiences. The overarching need for all women is to be cared for by supportive cooperative positive maternity care providers who deliver safe birth care. In addition to the staff support, women were looking for family support throughout labour and birth as this is not currently an option for them in most public hospitals in Saudi Arabia while it was one of the major women's claims. Furthermore, women showed their demand for more information about labour and birth, that could be fulfilled with frequent accessible affordable antenatal educational classes. This demand also requires continuous explanation and consultation from the staff during labour and birth. This research sets off the base for further research reporting Saudi women's perspectives, voices and experiences regarding maternity care they receive.

The limitation of this study is that the sample excludes women who do not read or write Arabic. Also, while this study was conducted within three large public maternity hospitals that have high birth rate, this is limiting the representativeness of the sample of the study.

Conclusion
Maternity care policy makers and maternity care providers in Saudi Arabia have to consider empowering childbearing women and ensuring safe motherhood. This can be accomplished by reviewing and updating maternity policies with women's preferences and latest up to date research evidence. This study provides findings that focus on empowering women throughout labour and birth with the staff and family support, adequate education and explanation, and availability of choices. The main updates that this study could add are introducing ante-natal educational classes during pregnancy, explaining and consulting women about everything.

Acknowledgements and Disclosures
The authors wish to acknowledge and thank every woman who spent her time writing or conversing with researcher and sharing her birthing experience.

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