Participant characteristics
Table 1 summarises the women demographic characteristics. All women had their last delivery unassisted at home and two participants were primigravidas. Seven participants had one unassisted home delivery, four participants had two unassisted home deliveries and one participant had three unassisted home deliveries. None were pregnant during the interview period.
Table 1: Demographic characteristics of the participants. (n=12)
IDI code
|
Age (years)
|
Highest degree obtained
|
Currently pregnant
|
Parity
|
Number of home births
|
1
|
39
|
Masters
|
No
|
2
|
1
|
2
|
40
|
Degree
|
No
|
3
|
1
|
3
|
40
|
PhD
|
No
|
3
|
2
|
4
|
35
|
Masters
|
No
|
1
|
1
|
5
|
39
|
Degree
|
No
|
2
|
1
|
6
|
43
|
Secondary school
|
No
|
3
|
2
|
7
|
45
|
Degree
|
No
|
7
|
2
|
8
|
37
|
Degree
|
No
|
3
|
1
|
9
|
43
|
Degree
|
No
|
4
|
2
|
10
|
45
|
PhD
|
No
|
7
|
1
|
11
|
41
|
Degree
|
No
|
1
|
1
|
12
|
36
|
Degree
|
No
|
3
|
3
|
Themes
In exploring the reasons for choosing unassisted home birth, four themes emerged from the interviews; being able to have their preferred birthing environment, the belief that birthing itself is a natural and safe process, expression of autonomy and faith.
Theme 1: Preferred birth environment
Women in this study repeatedly highlighted the value of home delivery, for it provided them with the comfort of home and the much-needed privacy during delivery. For some, perceived instrumental and chemical intervention within the hospital setting steered them towards home birth.
Comfort and privacy
For some women, birthing was described as a very personal and intimate process, almost mirroring the act of love making. They perceived unassisted home birth as a conduit to the privacy and comfort that they aspired for. All women unanimously indicated the importance of a comfortable environment during delivery to attain their intimate need. This became an important influencing factor to choose home birth.
“The birthing place; where the mother feels most safe, most comfortable, most secure would be at home and birth is a very personal, very intimate act” IDI 1
“It’s (birth) usually is not to be observed. It’s just like love making, it is very intimate, it’s not meant to be observed (by others)” IDI 6
Avoiding stressful environment
Their need for intimacy shaped their delivery preference for home based over hospital setting. Hospital environment was described as stressful, cold and uncomfortable place to experience the birth of their child. They felt unsafe, scared and had difficulty to be at ease when they had their deliveries at the hospital.
“I want a place that I can feel safe and comfortable, I can relax and give birth easily. That’s how I gave birth at home easily. I’m affected easily by noise and hospital environment. I am very scared of hospital environment. So I know if I couldn’t give birth at the hospital, I need to get ready to give birth at home. The sterile environment of the hospital...there is a lot of needles, sharp instruments, glaring lights. Those are very intimidating to me. I feel very insecure. When I go to the hospital, I feel like …“God I’m going to die”. So I don’t like it” IDI 4
“...so once I get into the labour room, I feel scared and stressed. It's going to be cold. I fear the cold... it’s too cold. I’ve been telling people that I was in pain, but I have to deal with the coldness of the labour room. And then even the steel bar that I have to hold on to during pushing, it’s too cold.” IDI 10
Some women were traumatised by their previous experience of birthing in the hospital and this experience had very much influenced their decision to seek a comfortable environment for their subsequent delivery.
“There must be a different way. I’m not going to go through that (hospital delivery) again... all I remember was it’s not a very good experience...because I didn’t know what to expect. I didn’t really read up so I just trusted the doctor...you are like most probably dehydrated and so hungry and cold and I am just lying down there on my side…. it was really painful. Now I talk about it and I cringe. I had such a huge cut, and going to toilet is like.. It was horrible, horrible” IDI 8
“I was admitted at 8.00 am. 8.00 am until 7.00 pm, I didn’t get to drink even one glass of water, did not eat. I was so restless and tired and was just lying on my back. It wasn’t really a labour ward because it was full and I was like in an extra room with people walking by and going in and out” IDI 2
Theme 2: Birth as a natural process
Exposure to home birth concept
These women were initially introduced to the concept of unassisted home birth by either a close relative, friends or acquaintance. Further reading from home birth books, magazines and online materials that featured topics such as “painless childbirth’ or ‘hypnobirthing’ further convinced them regarding the positive side of home birthing and the ability to perform this. Following this, they went through an active phase of learning and information gathering to familiarize themselves with the delivery practices and routines. They received support by attending home birth group classes, online networking and information from online materials or from books. The knowledge and support helped to solidify and further strengthened their decision making for home birth.
“... this yoga teacher educated us on the process of giving birth-what happens during your caesarean (section). And then, the mother who just gave birth naturally at home shared with me what happened and things like that. So, I’m like “Oh, pretty interesting eh?” so that’s how I shifted my mind.” IDI 12
“I wanted to know more so I read more about pregnancy and all that. So when I read about that hypno-birthing...it just say “this is what I want”. The article is really good. It’s about removing fear, the joy of being pregnant, the joy of giving birth. So, I looked up to the internet, found out more and I called hypno-birthing practitioners. I called two of them, so I choose one of them and I bought the book, I read the book and finished the book before I went to the course. Then it was just like “okay this is what I want to do”. IDI 5
An easy process
The women perceived birthing as an easy process with minimal or rather lack risk of harm to mother and the unborn child. They were convinced of their ability for a normal delivery. Information from the resources on home birthing further strengthen their confidence. They perceived birthing as a physiological process and one woman explained the process of delivery philosophically as the blooming of a flower.
“This (unassisted home birth) is a piece of cake. I gladly want to birth any day or every day because it is easy due to the techniques” IDI 3
“Where is the danger? They talk about baby suffocating, drowning or having bacterial infection. There is no injury! Birthing is not an injury and your baby is not here to hurt you” IDI 6
“You have to smile while giving birth. You have to breathe and you imagine blooming flower opening. The crowning of the head is actually clear rose is opening like that. And something beautiful and not to be scared...these videos, hospital birth and home birth that uses hypno-birthing techniques in which we saw how calm the women was, the wife, the mother was, and the husband have their roles” IDI 3
Ensuring natural processes
The women refused any kind of medical intervention as they tried to experience as natural birth as possible. Furthermore, they perceived that procedures would increase unnecessary risks to their child.
“If you don’t disturb the birth, it’s safer that way. If you don’t disturb, the baby will come out fine. The body will most of the time keep the baby safe” IDI 6
“The dilation drugs (referring to medications given increase uterine contraction) actually creates stress on the baby. It’s an artificial way of surges (referring to uterine contractions). That’s why the CTG shows the baby is in stress...There were like 14 procedures or something like that, done systematically upon caesarean section, all of which shocks the baby, who for the past 9 months is safe and sound.” IDI 3
“I think it matters how your birth is and the birth itself will affect the child. How the baby comes out, by forceps or by vacuum. It actually affects the spine of the baby” IDI 8
“...when you were in labour and then you had meconium, the doctor said its either vacuum or caesarean section. I don’t think it’s the most necessary at that time. Because I don’t feel there was any danger” IDI 6
Theme 3: Expression of autonomy
Being in control
The women in this study expressed wanting to be the decision maker regarding treatment and care, including the choice of birthing place. They believed medical personnel should not be the one who decides the next step of management during childbirth. Any interference by medical personnel during the birthing process takes away the exclusivity and control of their birthing experience.
“I’m able to give birth wherever I want... people respect and acknowledge the right that I have, and acknowledge the autonomy that I can choose wherever place that I want (to give birth)” IDI 1
“...the freedom for the mothers is to deny or to refuse whatever that she is uncomfortable because all is about the mothers. The mother is battling with life and death battle. “So why are you (medical personnel) telling me what to do?” IDI 3
“So, the rhythm of this labour, why is it important and how can you be involved in this labouring process. Because one of the time doctor will tell you “Okay, you come here, then you listen to me.” Hey, now it becomes the doctor’s birth not my birth” IDI 6
Prior to giving birth, some women in this study would develop a birth plan which are used to convey their desired birth experience. It generally includes information such as where she wishes to give birth, who will attend a birth, and what forms of medical intervention and pain relief will be used. Their experience of healthcare providers rejecting their birth plan, specifically on home delivery was one of the strong pushing factors to divert against hospital delivery, despite them adhering to antenatal follow-up.
“We discussed the birth plan. But it was not well accepted. You know the first thing doctor said like “Oh! This is very western.” That was his comment. And then like “Oh, we don’t know about this”. Things like that.” IDI 6
“He (the doctor) just look at my birth plan and said “okay.. alright,.” It’s like very sarcastic and very like “yeah, right whatever.” You know. So, when he said “Yeah okay I’ll sign it.” But there are a few things he put like a question mark. Like can I move about (during labour) -he put question mark. I could sense that he is not going to change his ways. I found out that he never not did episiotomies. Which is scary. It is a standard procedure for him.” IDI 8
Some expressed that by giving the doctors permission to perform intimate physical examinations for example vaginal examination equates to losing control of their own body. This led to fear of giving birth in the hospital as they felt their rights were violated once they were in the labour room.
“...once when I am in the hospital, they are going to do something that even I won’t do to myself. For example vagina examination. Your husband won’t do to you, even I won’t do it to myself. But, you give up your autonomy to this stranger.” IDI 1
“... I didn’t have to be checked all the time (when giving birth at home). Somebody putting their fingers in me and all that.” IDI 3
Empowered
Generally, the women felt that giving birth at home gave them a sense of empowerment. They were able to do normal activities at home during labour, unlike in the hospital where they would be confined to bed for foetal monitoring. They believed that being in control of their body will eliminate fear thus making birth safer as mothers were more in tune to what was happening in and around them.
“It gives me some kind of empowerment. I was able to go about, go upstairs, downstairs, drink water and watch television. I was being relaxed at home. Doing normal things in between the contractions” IDI 3
“Eliminate fear and then the women will have confidence. They feel empowered and are more in tuned with their body. That will make birth safer.” IDI 6
The women described the birthing process to be partly driven by their feeling of security, being in control of the birthing process and knowing exactly what to do to ease themselves. These feelings combined, made them confident in giving birth unassisted at home.
“I knew what was going with my body, I’m not insecure or afraid because I know what was going on and I know what it takes to relief myself. All I had to do was to do deep breathing and my husband had to do that light massage to release the hormone” IDI 5
“I really wanted to give birth at home.. I will do it myself. Maryam (Mary, Mother of Jesus) (peace be upon her) did it herself. I’m going to birth myself...whether I’m at home, in the hospital, in the car, on a tree.. I know what my body does.” IDI 1
Theme 4: Faith
Women proceeded with unassisted home birth as they have confidence in their ability to proceed with the delivery of the new born naturally as they submit totally to any outcome determined by the Almighty.
Self-trust
The women allowed their bodily instincts to lead the birthing process with a trust that an undisturbed birth would most likely to confer into positive outcome. Total belief and submitting their body and mind wholeheartedly to God gave a sense of calmness to the women.
“My level of confidence to God, at that time, I knew you (referring to God) created me to give birth naturally because you (referring to God) are the Fairest, Most Loving. You are not subjecting me to the pain. Because of that, I am relaxed about giving birth at home.” IDI 3
“It’s a very spiritual experience. There are many people who felt during the birth…spiritual presence or whatever. Feel connected” IDI 6
Fatalism
These women believed that their pregnancy itself was a gift from God and the process of birthing was also driven by God. This stance provided the courage to overcome the fear of labour as they surrendered to any outcome that might occur.
“You see, that’s why our five (National Principles of Malaysia)... The first one is Trust in God, right? Basically that helps to remove fear because when you remove fear you can hear your instinct clearer. Because when you are scared your body tensed up. Then you, actually create the complication” IDI 6
“It’s so magical because I surrendered to God. ... Not doctors, not nurses, not my mother or mother-in-law, or my dad. Ultimately it’s you and God... between life and death” IDI 3
These women believed that by total submission to God, they do not need medical advice and they are fully responsible for their decisions. With this strong belief, they are free to choose their birthplace and whatever consequences that may happen is because of fate.
“Fate and destiny isn’t it? There will be risks wherever you give birth, either in hospital or at home.” IDI 2
"I'm a perfect creation of my God and why do I doubt my creation? We (humans) are perfect. We can give birth; we can be pregnant.” IDI 12
One woman reported a critical situation when her baby was born and there was suspicion of a complication from the birth process. She reflected the miracle of total submission to God even though her baby was born lifeless with the umbilical cord encircling around neck.
“You know the transition of the “spirit” coming in…. because when my baby was born she did not cry. There was no sign of her at all. This is scary ... and the next thing you know...she cried right after the adzan (call for prayer) and you’ll be in awe” IDI 12