Twenty-seven Jordanian women were interviewed. This included 12 RM and eight EM living in Jordan, who were now grandmothers or would be grandmothers soon. A further seven Jordanian women living in Australia who had given birth to at least one child in Jordan and one child in Australia were also interviewed. The RM and the EM were not related in this study
Recent mothers were aged between 19 and 37 years, with a mean age of 31 years. Experienced mothers were aged between 50 and 59 years, with a mean age of 55 years. All the EM who lived in Jordan had given birth to at least one baby at home. In contrast, none of the EM who had given birth in Australia had given birth at home in Jordan. None of the RM had experienced a home birth as this is now a rare event for Jordanian women. All of the EMs had also experienced birth in public hospital with subsequent children except one EM and the comparisons they made during their interviews have informed this analysis. In addition, four out of 11 EM had experienced birth in private hospitals. In contrast, 14 out of 16 RM had experienced birth in a public hospital and nine out of 16 RM had given birth in private hospital in Jordan.
All of the EM and most of the RM were multiparous, just two of the RM were primiparous. The EMs had between two and ten children and the RMs had between one and five children. Three out of 27 women had one child, four out of 27 women had two children and four out of the 27 women had more than five children. Seven Jordanian women in this study had given birth in both Australia and Jordan. For some their first birth was in Jordan, followed by a birth in Australia, and for others their first birth occurred in Australia with a subsequent birth in Jordan. (see Table 2 for characteristics of the participants).
The initial analysis revealed four major themes that reflected place of birth: ‘Home birth: a place of comfort’; ‘Public Hospital: it’s what you do’; ‘Private Hospital: buying control’ and ‘Australian maternity care: a mixed experience’. There were also four common concepts across the women’s narratives - pain, privacy, the personal and to a lesser extent, purity. These four concepts were present in women’s narratives over time, through generations and across cultures and in the different birth places – at home, in public hospitals and private hospitals in Jordan and in public hospitals in Australia. These were the narratives that EM passed to younger women in their families and each narrative emphasizes women’s sense of being in control or her desire for control over her labour and birth. Each of the themes is discussed separately, however the experience of Jordanian women birthing in Australia is integrated across the first three themes related to birth in Jordan. This is illustrated in the Figure.
Home birth. A place of comfort and control
Only the EM in this study had birthed at home and they talked about home being a place of comfort, where they had the midwife and family around them, providing support. The women who gave birth at home viewed pain during labour as normal, something all women experience and they saw the way they tolerated it as representative of being a ‘good’ mother. Privacy and Purity or cleanliness were also seen as important and were identified as being consistently offered in the home environment.
Birth and labour pain are every day, normal events
For these EM, the dominant discourse around pain during labour was that it was a normal everyday event. It was seen as a part of life, occurring at home, where a woman recovers quickly and gets on with things. The following statements reflect this view: “I think pregnancy and having a baby is an everyday activity” (EM1); “It was the norm to go through that pain” (EM 8) and “It is something women do, I am not the only woman that gives birth we all do. Everyone is the same” (EM3).
It was clear the women who gave birth at home expected a speedy recovery: “The next day after giving birth I was up and running, cooking and vacuuming” (EM 5). For these mothers, home was an accepted place for birth, something all women did:
“I would prefer (to birth) at home more than hospital because there is no need to go to the hospital, it is something all women do” (EM 4).
“At the time I started having labour pain, my family in law were occupied as they were going to visit a girl and to offer a marriage proposal for my brother in law. I told them I was in pain and to postpone it. So they called the midwife for me and they left me alone in the home with the midwife and went to the girl’s house (for the proposal). It (birth) was something normal all women do” (EM 1).
Most of the EM interviewed did not feel or remember the pain of labour and birth:
“I am the type I do not feel a lot of pain. I was surprised at that time because I had a mild pain not really pain and within half an hour I gave birth” (EM 1).
“So I told my parents that I had a stomach pain, so they took me to the doctor to see why I was tired, so the doctor examined me and said I would give birth in the next 15-30 minutes” (EM 2).
Pain is something that a ‘good’ mother copes with
Some of the EM believed it was important to handle the pain of childbirth to be a good mother. The phrase, “I need to feel it” was used by several EMs in their interviews (EM 3, EM 7; A-JEM 3) and EM 8 added, “It is labour pain so no one can help you in relieving that pain and I think to be a good mum you have to feel the pain of birth”. An EM who gave birth to her last child in a private hospital where pain medication seemed to be an assumed part of the service appeared to regret having pain relief as she linked labour pain with being a good mother:
“In the private hospital they gave me some painkillers in the end but I did not really need it and I think I can handle the pain and I should feel the pain to be a good mum” (EM 3).
This same woman reflected on her birth at home stating, “There is no need for pain relief because I can handle it” (EM 3). The EMs also talked about alternative, non-medicated approaches to pain relief, “I had a hot shower and had some home hot herbs to increase my contractions and finish it quickly” (EM 3) and “The midwife helped me by doing perineal massage with olive oil, it helped me a lot” (EM 7). Some of these strategies they used were spiritual in nature, “This scared me but I prayed and made a lot of ‘Prayers” (EM 5) and “The midwife put Quran for me that made me relax” (EM 4).
I had privacy at home and it is clean
Birth at home was also preferred by the EMs because women’s privacy was protected and they did not have to share a room, as was often the case in the public, and sometimes the private hospitals. At home the midwife was viewed as guarding women’s privacy, “She did not let anyone see me and asked them (family members) to stay within the same room but in a place where they could not see my body, to sit beside my head” (EM 7). Some midwives preferred family members to stay in another room only allowing them permission for brief visits with the woman.
“The midwife at home gives me more privacy and care, I had been at home with myself and my family members stayed in a room beside my room” (EM 3).
The EMs also preferred giving birth in their own home as it was their domain and they knew it was clean, “It is my house, it is cleaner” (EM 7) and “The home is cleaner (than a public hospital), you are more comfortable in your own house and its environment” (EM 1).
She stayed with me the whole time
While privacy was protected at home, women were not left alone. They either had support from the midwife or family, for example, participants described, “She (midwife) stayed with me the whole time until I gave birth” (EM 8); “Yes I had my mum and my mother in law” (EM 6) and, “At home you were with family, sometimes in the room and sometimes just outside going about their business, so you felt comfortable” (EM 1).
None of the participants included their husbands when talking about others’ role at the home birth, as husbands were not allowed to attend the labour and birth at that time.
“My whole family is around me, my husband and the other kids but they stayed in the other room. I just feel better and more comfortable” (EM 8).
They described the kindness and compassion of the person who was with them, “She (the midwife) was really good and very kind woman” (EM 4). One EM contrasted their experience with birth in a public hospital:
“She used to be patient with me, not like in the (public) hospital; they would leave you alone in the room. Staying with one person the whole time during birth is better” (EM 2).
The women also talked about the practical support they received at home, “Yes, they make ‘prayer’ for me, they supported me” (EM 5) and EM 2 stated, “Yes I think it is important they support her, help her, look after her and help her eating, drinking and going to the toilet”. Another EM stated this support was important because it could prevent postnatal depression, “It is very important because there is no time for you to get depressed, they help you, they make you food and they stay around you most of the time” (EM 1).
Mother to daughter: passing on birth stories?
Given their experience of birthing at home, the EM were asked what would they say about birth to their daughter / daughter in law. All of EMs except one EM tried not to frighten their daughter / daughter in law by telling them that the labour pain is a normal pain that they are going to go through. They have tried to reassure them by these words. As one EM told her daughter in law, “It is like a daily event in life, nothing to worry about and you will not have a lot of pain when you give birth” (EM 1); while another said: “It is an easy process, not that much pain” (EM 7). Only one EM told her daughter the truth about the labour pain, “You are going to go through a difficult and painful process and you will stay with contractions and lots of pain for at least two days” (EM 5). And when we asked her about this, she replied that it is better for her daughter to know what she is going to go through and to expect a degree of pain so she will tolerate it.
Birth in public hospitals – It is what you do
Most of the RM and some of the EM interviewed had given birth in a public hospital in Jordan. The statement, “It is what you do, you go to hospital for birth,” represented the meaning that RM gave to birthing in a public hospital. The RM did not think that a woman had to suffer when giving birth, “I did not want to experience the pain that’s why I went to the hospital to give birth” (RM 9). But this was not their experience and in contrast to birth at home, women birthing in the public sector spoke vividly and with distress about their experience of pain during labour and birth. For RM the “pain was unbearable”, while EM birthing in either Jordan or Australia continued to see birth as normal and labour as something that good mothers embrace or at least must tolerate. In the context of a public hospital in Jordan, women’s needs for privacy, personal care and support and for purity or cleanliness were not met. In the public sector, women had no option to request what they wanted.
Pain as unbearable
Statements from the RM reflect their distress at the pain they experienced during labour and birth, “It was unbearable pain, I cannot handle it” (RM 11); “It was a nightmare and I really do not want to get pregnant anymore” (RM 2). For RM, particularly first time mothers, the negative experiences of labour pain continued if they had an episiotomy during birth. As some RM said:
“It was very hard. Especially with my first baby because I had an episiotomy, it was very painful and hard to move around” (RM 7).
Recent mothers were particularly aggrieved that they had to experience this pain, declaring that “pain was not normal” (RM 11) and “there is no need for it when you can take it away” (RM 6) and RM 9 stated, “You should not have to suffer to be a mother” (RM 9).
In contrast to these RM, the EM who had also had at least one baby in a Jordanian public hospital, continued to view labour pain as normal, something women do and tended to respond negatively to pain relief, “I would not have asked for painkillers as I see no need for it” (EM 5) and,
“It is something women do, I am not the only woman that gives birth, we all do. Everyone is the same. So why not be strong and handle the pain” (EM 8).
This same perspective was offered by the EM who had given birth in Australia. Even though mothers giving birth in Australia had more options for medicated pain management, they maintained their view that pain was a normal part of labour and birth: “I need to feel it” (A-JEM 3) and,
“I want to feel that feeling when the baby’s head comes out of my body. At that time I felt that I was doing something extraordinary” (A-JEM 7).
The RM were distressed that they were denied pain relief in the public hospital. Even if they asked the midwives for pain relief in labour, the women stated they were not listened to, “I asked for painkillers, they refused and told me ‘it is good for you’” (RM 6); and RM 11 stated “At least give the woman painkillers to help with the pain; they do not give it at all even if it is your first baby”.
Recent mother 2 described the response from midwives to her request for pain relief: “go to a private hospital if you need painkillers”.
This experience contrasted with RM who had given birth in Australia, some of whom had the opportunity to discuss with midwives the available options for pain relief in labour: “The midwife at antenatal clinic explained to me the options I have for pain relief in labour and I decided to choose the gas” (A-JRM 5). This participant went on to say, “There were a lot of options for medicated pain relief but I preferred to use Pethidine injection as it helped me a lot to ease my labour pain.”. However, the EMs who had birthed in Australia indicated they put up with the pain because they had no idea about pain relief in childbirth,
“No, I do not know but you know those days we did not know much about painkillers, no idea of this” (A-JEM 6).
However, the offer and use of medication was not necessarily a positive experience for the women accepting medicated pain relief in Australia, “I just do not like things that make me dizzy and that’s what these painkillers do” (A-JRM 1). Other women stated: “They gave me the gas. I do not like it as my mouth dried from it, and I felt it did not take the pain away.” (A-JEM 7).
Some women birthing in Australia were also critical of midwives, noting that at times the midwives refused to give them pain relief in childbirth or sometimes midwives “tricked” the mothers by convincing them to use the gas as a pain relief.
“My sister told the midwife to give me the gas, she said she does not need it; my sister told her just give it to her. She gave me the gas mask and we later noticed that she did not turn the gas on” (A-JRM 1).
They thought midwives sometimes withheld medicated pain relief, “I am telling her I am in pain with no screaming but she refused. So I pretty much gave birth on my own with no painkillers at all” (A-JRM 4). In contrast A-JRM 2 believed that midwives used medication because they were busy, “I felt the midwives gave the gas to me just so I keep busy with it and they can help others”.
Privacy is non-existent
In the public hospital in Jordan there was no privacy. Experienced and recent mothers described the settings where they birthed in Jordan public hospitals, “There are like six women in the same room, so no privacy” (RM 6); and “It was very easy for others to see me during labour and birth and that was very distressing for me” (RM 10). Some women did not voice concerns about privacy as it was what they expected. For example, one EM who had birthed in a public hospital considered sharing the same room with other women during birth as normal, but she insisted that the curtains should be drawn between the beds but that there is no need for each woman to have her own room, “No it does not have to be that everyone has their own room, at least to have curtains closed all the time” (EM 4). The description ‘covered with a simple sheet’ represented a level of privacy that was acceptable to some women “However, they were very respectful and always covered me with the sheets” (RM 7), while not for others: “There was a sheet only covering the lower part of my body, but this is quite embarrassing, no privacy” (RM 3). This lack of privacy was intensified by the invasive approach of some health professionals during labour and birth. For example, women talked of being examined vaginally many times and by many different people: “It is embarrassing and makes you very uncomfortable” (RM 4) and another stated:
“Yes, every time there was someone different examining me. That’s the problem. It was annoying and frustrating and it hurts a lot” (RM 9).
The EMs who birthed in public hospitals 20 years ago in Jordan talked about being able to demand more privacy where there were no medical students attending the birth.
“Only the midwife and the doctor were present in the labour room in that time and this was a kind of privacy for me” (EM 1).
In contrast, the women who had birthed in a public hospital in Australia talked about the privacy they were afforded: “I had a really big room, very clean and a bathroom for myself” (A-JRM 5). All of them appreciated having their own room during labour and birth in Australia. As A-JRM 2 stated, “Yes I was on my own room, on my own complete privacy”. They also appreciated the care that health staff took care of their privacy during birth.
“Not one of my family is allowed to be in the labour room when the doctor is present for an internal checkup” (A-JRM 5).
The Australian Jordanian women also noted that they only had one midwife or health professional in their room at one time offering them more privacy in contrast to Jordanian public hospitals:
“You have your own room and you have one midwife and she introduced herself to me, but when the time of my birth was near, the midwife changed and I was attended by another because the previous midwife finished her shift.” (A-JRM 4).
She left me alone
The experienced and recent mothers who birthed in public Jordanian hospitals reported that they were not allowed to have a support person with them during labour, “They do not allow anyone to come in with me in the labour room” (RM 7). Women also felt abandoned by health professionals: “In the public hospitals they leave you until you give birth” (EM 6). Their request for support in public Jordanian hospitals was often met with the same response as when they asked for pain relief,“When I told them to let my mum to come in with me in labour they said ‘go to private hospital if you want to let anyone to come in with you in labour’” (RM 9).
Most women wanted to have either their husband and or their mother with them.
“Probably my mum and my husband. That would be nice because they will help me and are there for me and support me” (RM 6).
Again the women who birthed in a public hospital in Jordan and also in Australia, contrasted the two experiences in terms of support:
“The hardest thing was when I went to the hospital (in Jordan) and I was going to go in by myself with no one with me. I was very scared” (A-JEM 7).
“At least stay with me (the midwife) or let my husband be with me. They did not allow anyone to come in with me at all, they had no sympathy” (A-JRM 4).
Some of the EM and the RM living in Australia and who had birthed in a public hospital in Jordan explained why they thought that the midwives and services in Jordan did not allow anyone to come in with them during labour and birth.
“They do not know how to treat the patient and the family. Maybe do not want families to interfere in their business; that’s why they do not let people come in with their families” (A-JEM 3).
Not so clean
Some of the mothers, both recent and experienced, described hospitals as being unclean, “The cleanliness in the hospitals, there was cockroach on the floor moved between beds in the hospital” (RM 11) and EM 8 stated, “The bathroom was very dirty, it was so unclean, blood and dirt everywhere in the bathroom” and EM 3 described, “She put me on a sheet full of blood and dirt and I told her to change it but she said ‘we have no time you are going to deliver very soon, it is urgent,”. However, some of them considered cleanliness as sanitizing things in the hospital.
“One thing hospitals do not do is sanitise the cupboards, the beds that previous patients had been on. They should sanitize the beds, cupboards and things around you” (RM 6).
Only one experienced mother chose to give birth in the hospital rather than at home because she thought it was cleaner, “It was always clean but really it is the visitors and the women that dirtied the hospital, not that the hospital itself is dirty or unclean” (EM 1).
All of the women who gave birth in Australia appreciated the cleanliness of the hospitals in Australia. As some of them stated that, “Everything around is clean and tidy, so you do not need to worry” (A-JRM 4), and, “I can smell the cleaning products all around the hospital, so I can tell that this place is very clean and sanitized” (A-JRM 1).
Private hospitals - Buying control
In the past 30 years there has been a dramatic increase in the number of births that occur in private hospitals in Jordan. Many participants of this study had given birth to at least one baby in a private hospital. This included nine RM and four EM.
Women choosing a private hospital were seeking control over their birth experience. The prime reason that women gave for choosing to birth in a private hospital was for pain relief. Private hospitals were also described as cleaner, offering some privacy through the ability to purchase privacy through a private room, and have family with you.
“You do not have to suffer as a mum”
The meaning of birth in the private hospital is captured in this statement “You do not need to suffer as a mum”. Recent mothers able to pay for a private hospital chose this option for a range of reasons:
“I want to go to private hospital because I want better care and treatment from the health staff. People that treat you properly. To have your family with you for support” (RM 7).
“In the private hospitals they give me a needle that helps you rest and relax” (RM 8).
But primarily they “like(d) the idea of pain free birth” and they preferred to pay to buy their comfort, privacy and care in the private hospital.
“I preferred to pay money as long as I was in a comfortable place. So if I needed something they would give me” (RM 8).
“It depends what insurance you had. The more you paid the more you guaranteed a bed on your own and other thing” (RM 12).
In the Jordanian private hospitals, there are two options of pain relief in labour - epidural or ‘Dormicum and Valium’ which sedates women during labour and birth, much like twilight sleep used in the past. Some RM liked the idea that they could be virtually asleep during the birth. Recent mother 8 stated, “The injection. It calmed you and put you to sleep. That was right when the baby’s head was crowning” and RM 12 also stated “I like the painkillers they used in private hospitals more than having an epidural and else you can wake up and then had the baby”. In interviews the women were asked if they felt they had missed out on an opportunity to see their baby immediately at birth however, this did not worry some of the women. RM 1 stated, “No, It did not bother me at all, I just want to finish” and another RM 4 said: “I wanted that needle, my doctor gave it to me and I asked for that needle once I was admitted to the hospital”.
However, again in contrast, the few EM who birthed in a private hospital did not favour being asleep during birth. As EM 3 stated “It disturbs the skin to skin bonding. I could not see my baby until three hours of giving birth” and one EM 4 added:
“No I do not like the idea of being asleep when I gave birth. I did not see my daughter straight away and when I woke up I was confused and very tired to even hold my baby” (EM 4).
Gaining some control
Private hospitals offered privacy with your own room, RM 5 stated “I had my own room at least, and I was in the same room the whole time, I was not moved to another room like public hospital” and RM 1 noted “In the public hospitals everything was opened, people coming in and out, no privacy at all. But in the private hospital there was privacy”. RM 7 also stated “They examined me vaginally every half an hour in the public hospitals but in the private hospitals every now and then”.
Although this was not always the case. Two women living in Australia and who had their first children in Australia were surprised at the practices in Jordan even in a private hospital:
“I gave birth, there was no bed for me in the maternity ward, they put me in the corridor for two hours waiting for a bed in a private hospital, with people coming and going and men also” (A-JEM 6).
“There was like five women giving birth with me, with no curtains, no nothing, everyone can see each other” (A-JRM 2).
Women also believed that the private hospital was cleaner, RM 5 stated “I preferred to pay money as long as I was in a clean and comfortable place” and EM 4 noted “Big difference between the two (private and public hospital), with cleanliness”.
Some of the RM and EM preferred giving birth in a private hospital not just for the privacy they believed they would receive but so they had the choice of choosing a female doctor.
“If I was to get pregnant again I would go to private hospital because I want a female doctor who would be with me the whole time” (RM 12).
“They just gave me a female doctor as I was wearing the burga, they assigned me a female doctor out of respect” (EM 3).
Most of the Jordanian women who were birthing in Australia also reported that they had the choice of a female or male doctor while giving birth in Australia, “They do not let any male doctors inside the room without your permission” (A-JRM 4) and A-JEM 3 stated:
“They ask you if you want a male doctor from your monthly visits during pregnancy. They see you wearing a scarf and they know you would prefer a female. So they respect you and your religion”.
Sometimes you have someone with you
When birthing in a private hospital in Jordan, women had hoped they would have someone with them. Most indicated that they were allowed one support person to come in with them, “Yes, they allowed my mum to come in with me the whole time during labour” (RM 5) and “They help and support me. It is good to have someone with you; it eases the pain on you” (EM 4). While others stated that some private hospitals refused their request to have someone with them, “No, they did not allow anyone to come in with me in labour” (RM 8).
In contrast, as noted above, the Australian - Jordanian experienced and recent mothers appreciated that the hospitals in Australia allowed some people to stay with them during labour and birth, “It was lovely to have your family around you when you are in that much pain” (A-JRM 4), and, “I appreciated allowing my husband to stay with me the whole time in the labour room” (A-JRM 2). Some of the Jordanian RM who had birthed in both Jordan and in Australia preferred to have their mothers or female relatives instead of involving the husband in the birth process; for example, “So if it was a female relative would be better” (A-J RM 2); “I do not mind my mum but my husband was not much help” (A-J RM 4) and “I do not recommend the husband to come in as he had a hard time dealing with what he saw.” (A-J RM 5).
Only one of the RMs who had birthed in both Jordan and in Australia stated that she did not really want a support person at all in labour.
“I did not really feel I needed anyone as the midwives were good to me” (A-JRM 1).
In the Jordanian private hospitals, women were unlikely to have the same health professional during labour and birth, especially if the birth is complicated and difficult.
“But in private hospital, there was one or two midwives at most. I had not the same midwife the whole time during the birth” (RM 1).
The Jordanian EM and RM who had birthed in Australia had the same problem of dealing with different health staff during birth.
“I have taken a lot of time in my birth so I have dealt with more than one midwife” (A-JEM 7).
“My childbirth experience was a distressing time dealing with many health staff” (A-JRM 4).
Given their experience of birthing in a private hospital, the EM were asked what would they say about birth in a private hospital to the RM. Some of the EM told the RM that “There is no need to go to a private hospital and pay a lot of money to only give birth there, it is just a few hours of labour pain and you can tolerate that pain as any labouring woman can do” (EM 3), while others said: “It (the private hospital) is just good in offering some privacy during birth but the pain is still the same and it is not good for you to take any pain relief, it is good for you to feel that pain” (EM 1).