Women's experiences of maternity care: satisfaction or passivity?

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Abstract

This study is a first attempt to describe Lebanese women's responses to the medical management of their pregnancy and delivery. A qualitative approach in data collection and analysis was adopted to gain an in-depth view of women's perceptions. Women of any parity undergoing a normal vaginal delivery during the three months preceding the interview were interviewed in different areas in Lebanon: one urban, one semi-rural and two remote rural. Childbirth for all the women interviewed was managed within the medical system. Findings show that women accord total trust to their physicians, and very rarely question the usefulness of many routinely applied procedures, even those which the literature shows are unnecessary. When probed, women report that many aspects of the technical care are intimidating and that they experience discomfort with these procedures. Women are more vocal about patient–provider communication and value good interaction with their provider. The extent of passivity and feelings of discontent women have varies according to their social class and the amount of psychosocial support they receive throughout the process of childbirth.

Introduction

In Europe and North America, there is a considerable body of scientific and popular literature documenting women's discomfort with some routine obstetric procedures (Homans and MacCormack, 1982, Davis-Floyd, 1993, Martin, 1993). Indeed, women's dissatisfaction with routine hospital care was an impetus behind research documenting the discomfort, or even harm, caused by some hospital routines (Chalmers et al., 1989). The increasing use of technology and the impersonal treatment by medical personnel also led to a shift from hospital to home, and from doctor to midwife-attended deliveries (Abel and Kearns, 1991).

In developing countries, professional delivery is increasingly being promoted. However, there is little data documenting women's perceptions of normal delivery in a medical environment. Most of the existing literature focuses on traditional childbirth practices during home births (Steinberg, 1996) or on perceived barriers to hospital care in the case of a medical emergency necessitating hospital delivery (Prevention of Maternal Mortality Network, 1992, Thaddeus and Maine, 1994). Nevertheless, there are many developing country settings where the proportion of deliveries in medical facilities is high.

In Lebanon, 88% of births take place in hospitals, and 89% are under the care of medical providers (Ministry of Public Health, 1998). The Lebanese system of health care today is characterized by a largely unregulated system of private practice oriented toward highly technical secondary and tertiary care (Van Lerberghe et al., 1997a). A review of hospital policies vis-à-vis normal childbirth in Lebanon showed that many procedures and practices such as perineal shaving, enemas, induced labor and episiotomies, are in routine use and are applied to women without indication (Khayat and Campbell, 1999). Systematic reviews of randomized controlled trials evaluating the efficacy of these procedures and practices collated in the Cochrane Library have shown them to be of no benefit to mothers (Cochrane Library, 1998).

The quality of care received by women is an essential aspect of reproductive health. In Lebanon, interventions which eliminate harmful practices and promote beneficial ones are needed. However, it is essential to understand Lebanese women's perception of the care provided to them, in order to inform the debate about practices such as routine perineal shaving (which neither increases nor decreases risk but may decrease women's satisfaction) and to bring ammunition to support arguments concerning elimination of harmful practices and promotion of beneficial ones.

Recent studies in the Middle East region or other developing countries have acknowledged the usefulness of women's reports in assessing the quality of care (Kempe et al., 1994, Mawajdeh and Al-Quotob, 1996). The involvement of women in decision-making processes concerning their pregnancy and birth, and their sense of control over the whole process is viewed as an important determinant for women's satisfaction with childbirth (Salmon and Drew, 1992, Beattie, 1995). Patient satisfaction surveys have also shown that patient–provider communication plays an essential role in determining patient satisfaction (DiMatteo, 1994). If the rhetoric on listening to women's voices is to move on to action, it is important to begin to understand how women feel about existing services and what they want in terms of improved services.

This study is a first attempt in Lebanon to understand women's views and responses to the management of their pregnancy and delivery. It also aims to reveal women's awareness of the range of childbirth options, and their actual needs concerning their experience in reproduction. The objectives of the study are:

  • to understand the actual childbirth experience of women in Lebanon and their views of pregnancy, delivery and postpartum stages.

  • to assess women's satisfaction with care received during different stages of childbirth and what women perceive as “best practices”.

  • to identify women's needs which remained unmet by the care provider.

  • to measure women's awareness of alternative choices.

Section snippets

Data collection

Semi-structured interviews were conducted with women from three areas in Lebanon: (1) remote rural areas (one village in the Bekaa and one village in Akkar), (2) semi-rural areas (one village in the Bekaa) and (3) urban areas (hospitals in Beirut and the suburbs). Women of any parity who had had normal vaginal delivery within the three months preceding the interview were eligible. A total of 117 interviews were completed. Interviews typically took 45 min to 1 h to complete. Women were asked to

Findings

The 70 women from the semi-rural village and the remote rural villages in the Bekaa and Akkar had similar socio-demographic characteristics. They were mainly of middle to low social class1. Most had at least a primary education, very few were illiterate, and two had university education. All of them were housewives. Their husbands' educational levels were similar to their own educational attainment and the husbands' occupations included agricultural work, taxi or trucks drivers, teachers and

Discussion

The qualitative analysis of different experiences of women during childbirth in three areas in Lebanon, Beirut, the Bekaa and Akkar, reveals that women want professional delivery, often in the hospital setting. This is in accordance with population-based statistics from the same regions, where the proportion of hospital deliveries are estimated to be 94.3% in Beirut, 75.3% in the north (where Akkar is located) and 91.7% in the Bekaa (Ministry of Public Health, 1998). Women in Lebanon and other

Acknowledgements

The authors wish to thank the Mellon Foundation grant to the Faculty of Health Sciences, American University of Beirut for the Population and Reproductive Health Program and UNICEF, Lebanon for funding this study. Support for writing was provided by the European Commission DGXII Avicenne Initiative through the MAMAH Network. We also appreciate the support provided by UNICEF, Lebanon, particularly Dr. Ali El-Zein, in facilitating access to the remote rural villages. We want to extend our

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