Because of increased awareness of communities about the risks and harms of C-section, researchers are searching for ways to encourage mothers toward choosing natural childbirth. As a result, physiologic factors such as the presence of husbands and environmental variables are now more prominent than before.
In early-twentieth century, physiologic childbirth was a typical part of normal life and mothers often gave birth to their children at family places (where they lived their daily life) with the help of their families and friends [1]. In the second decade of the twentieth century, however, advancements achieved in medical sciences and the transfer of the childbirth process to hospitals and medical centers led to emergence of obstetrics and gynecology as a medical specialty. Shortly after, anesthesia, analgesia, episiotomy, etc. became common practices in this field [2].
Although these medical advancements and hospital measures, especially C-section, have facilitated the process of childbirth and have improved the overall health of mothers and infants (especially women with high-risk pregnancies), they have had irreparable negative effects as well. Because of their fear of the delivery environment and labor pain, women prefer to undergo C-section rather than give natural birth. In addition to physical and psychological harms, this strong tendency toward C-section has had many negative social effects. Natural childbirth is a very safe process through which maternal instincts result in a very satisfying sensation. C-section, on the other hand, is an invasive surgery with many physical post-operation complications [3]. In addition to experiencing more physical problems, mothers who undergo C-section show more psychological symptoms than mothers who give natural birth. These symptoms include self-centered rather than infant-centered attention in the first year of birth, lack of maternal confidence in infant-related affairs in the first year of birth and etc. [4].
Due to the alarming results of studies carried out about the harmful effects of C-section for mothers with low-risk pregnancy, anesthetic measures such as epidural injection for controlling labor pain and the side effects of child delivery as well as use of LD, LDR, LDRP rooms have become more commonplace. In addition to make it possible for husbands to accompany their wives throughout the delivery process, these measures and systems allow establishment of a familiar and friendly atmosphere similar to that of home for laboring mothers [5]. Although some physicians believe that laboring women must turn off the thinking part of their brain at the time of giving birth to activate their survival instincts and that the presence of their husbands can disrupt this process, many laboring women become overjoyed to be able to share their childbirth experience with their husbands [6, 7]. Many studies have shown that nothing can replace the role and presence of the husband during the delivery process especially in emergency condition, even nurses who are helping the laboring mother [8, 9]. Table 1 shows the results of some of the studies that have highlighted the role of husbands in managing labor pain during the physiologic delivery process.
Table 1
Some of the reasons mentioned by various studies for women’s tendency toward C-section and the effect of the presence of husbands on the childbirth experience
| Study title | Sample population/ methodology | Finding |
1 | In the Nepalese context, can a husband’s attendance during childbirth help his wife feel more in control of labour? [10] | 309 laboring women in total; 97 accompanied by their husbands; 96 accompanied by one woman; 11 accompanied by their husband and a woman; 105 with no accompany (control group) | Labor pain control was significantly higher among laboring women accompanied by their husbands. |
2 | The effect of presence of trained husbands beside their wives during childbirth on women’s anxiety [11] | 84 laboring women in total; 28 accompanied by their trained husbands; 28 accompanied by a supporting midwife; 28 with no company (control group) | Labor stress was significantly lower in the fourth phase of childbirth among laboring women accompanied by their husbands. |
3 | The effect of the presence of the husband during childbirth [12] | 200 laboring women in total; 100 accompanied by their husbands; 100 with no company (control group) | The duration of labor pain was less, C-section rate was lower and intrauterine injuries were fewer among laboring women accompanied by their husbands. |
4 | Effects of fathers’ attendance to labor and delivery on the experience of childbirth in Turkey [13] | 50 laboring women in total; 25 accompanied by their husbands; 25 with no company (control group) | High rate of satisfaction among laboring women accompanied by their husbands |
5 | The best encouraging persons in labor: A content analysis of Iranian mothers’ experiences of labor support [14] | Observations and semi-structured interviews with 25 individuals | The presence of a companion, e.g. their husband, a family member, or a doula, during labor helped them better deal with the labor process, particularly when they felt lonely |
6 | The child’s father, an important person for the mother’s well-being during the childbirth: A hermeneutic study [7] | Analysis of the data acquired from 67 first-time Swedish mothers | Some women expressed that as their partner knew them so well, they only had to glance at him for him to know what to do. |
7 | Husband gatekeeping in childbirth [15] | Deep interviews with 200 mothers | The eager presence of the husbands was reported effective in reducing labor pain and increasing childbirth satisfaction. |
8 | Effect of the presence of support person and routine intervention for women during childbirth in Isfahan, Iran: A randomized controlled trial [16] | 100 laboring women in spontaneous labor in four groups: group 1 received routine intervention with a support person; group 2 received routine intervention without a support person; group 3 received a support person without routine intervention; group 4 did not receive routine intervention or a support person. | The presence of a support person during labor in Iranian women decreases labor length and improves labor outcomes. |
9 | Women’s experience with social presence during childbirth [17] | Qualitative descriptive study using interviews conducted with 16 women in the immediate postpartum period after vaginal birth | The women felt most comfortable in the presence of someone who “knew them best”, offering a sense of personal connection in the birth environment. |
10 | A place for the partner? Expectations and experiences of support during childbirth [18] | 8 couples living in Hampshire, UK, who were interviewed six weeks before the birth and approximately 12 weeks following labor and delivery | Support provided by the male partner evoked very positive responses from the women. The fathers perceived that they were very helpful to their partner during childbirth. Though the women mostly found childbirth straightforward some fathers, nevertheless, found the experience stressful. |
11 | Requests for cesarean deliveries: The politics of labor pain and pain relief in Shanghai, China [19] | Drawing upon ethnographic fieldwork and in-depth interviews with 26 postpartum women and 8 providers | To reduce C-sections, policy makers should address the lack of pain relief during childbirth and develop other means of improving the childbirth experience that may relieve maternal anxiety, such as allowing family members to support the laboring woman and integrating a midwifery model for low-risk births within China’s maternal-services system. |
12 | Midwives perceptions of partner presence in childbirth pain alleviation in Nigeria hospitals [20] | A descriptive cross-sectional quantitative study in the maternity units of four hospitals in Abuja, Nigeria with the participation of 100 midwives selected through convenience sampling | The partner’s presence was perceived as contributing to pain relief and has been a non-pharmacological technique reported to be utilized by midwives for pain management during childbirth. |
13 | Husband’s role in assistance of laboring process: Systematic literature review [21] | Systematic literature review of 6 articles taken from the PubMed database.; inclusion criteria: articles 2009–2018, full text, qualitative study design | Husbands have a crucial role in the laboring process; husbands not only help fulfill the wives’ needs during the maternity process, but also make mothers feel more comfortable. |
14 | How women experience the presence of their partners at the births of their babies [22] | A phenomenological study of 40 Finnish women’s experiences of their partners’ presence at the births of their children | For the women, the partners are not only support persons but also, above all, the fathers-to-be, a double and sometimes paradoxical assignment in the health care culture. |
Studies in many countries have shown that involving men in reproductive health interventions can help improve maternal outcomes [23] but there is no mention of the husband’s satisfaction and its direct impact on the management of the mother’s pain and the delivery process. The husband’s satisfaction is important because many physicians believe that adrenaline secretion is “contagious” and that an anxious husband can affect his wife’s oxytocin secretion. When the adrenaline level rises, the secretion of oxytocin decreases and this interferes with the labor progress [24].
Providing the husband with useful information as well as a comfortable atmosphere and physical space can better prepare him for playing the role of support [25]. Although several numbers of studies have been carried out about mothers’ need for social support and companions so far, not a lot more studies focus on the experiences and perceptions of husbands who support their wives during childbirth in Iran. Understanding perceptions of husbands particularly on support they provided may improve not only their involvement [25] but also establish strategies that enhance the quality of childbirth department in order to increase their satisfaction.
Several studies in Iran that explored the reasons behind the increasing CS rates, identified a range of factors including fear of labour pain, perceived safety of CS, concerns about complications following vaginal delivery [26]. A researcher [27] interviewed more than 200 mothers and found out that the role of the husband in preparing his wife for physiologic birth is crucial. The desire and satisfaction of the husband to participate in the labor control procedure plays an important role in reducing the mother’s pain and increasing her satisfaction with natural delivery. A study conducted in 2002 showed that a natural delivery with the presence of close family members in LDRs room can significantly reduce labor time and pain [28].
These measures (using home-like delivery wards and the husband’s presence) in Iran are more complex and limited. One of the first actions taken in line with the government’s decision for reforming the healthcare system in 2014 was establishment of LDR rooms in Iran’s hospitals [29, 30]. A total number of 2022 LDR rooms have been built in 350 hospitals of Iran with the aim of encouraging mothers to give natural birth in private, safe and satisfying environments [29, 30]. Other measures taken by Iran’s Ministry of Health and Medical Education for reducing the rate of C-section include free natural childbirth services in public hospitals, eight free prenatal educational sessions, establishing specialized natural birthing wards where midwives play an important role and optimization of existing wards for having safe natural childbirths with minimal labor pain [29, 30].
The presence of a husband in the labor ward as a supporting company for his laboring wife can be challenging based on the culture and customs of the society in which they live. Due to special cultural values in Iran, this issue is even more difficult as structured and targeted arrangements are still missing. Because of these shortcomings, the presence of husbands in the labor ward is either completely prohibited in most Iranian hospitals or it is regulated by very strict rules. As a result, husbands cannot have an effective presence during their wives’ childbirth process.
Regardless, due attention should be paid to husbands’ perception and expectations of childbirth spaces prior to any decision-making about their presence in LDR rooms during normal physiologic delivery. Such spaces can be classified into two general aspects: environment and physical structure. Considering the stressful conditions in delivery rooms and the special cultural conditions in Iran, husbands’ perception of these spaces, both environmental and physical, are fundamentally important and this study sought to explore this subject.
In the following sections of the paper, first the husbands and laboring mothers’ preferences of delivery spaces will be discussed; then, the environmental and physical characteristics of these spaces will be briefly reviewed. Then the conceptual model of the study developed about how husbands perceive the environmental and physical characteristics of natural childbirth spaces will be introduced. Finally, the proposed model will be evaluated and interpreted using the results of the questionnaire-based survey and the structural equation modeling (SEM) method in SmartPLS software.