Antenatal survey of women’s birthing choices in Qatar

Introduction

Although birth is a natural process it can be subject to medical interventions at various stages. Many factors may influence women’s views towards how they would prefer to labour and give birth and how they engage with interventions offered during the process [1]. Satisfaction with birth experience may have implications for the woman’s emotional and mental health and may also influence on their decisions in future pregnancies [2]. Therefore, a knowledge of women’s expectations and beliefs is critical to developing effective patient-centred maternity services.

While women’s birth preferences, especially around maternal request Caesarean sections, have been explored in different parts of the world [3], this aspect remains relatively unexplored in Middle Eastern populations. Therefore, this study was designed with the aim of exploring these attitudes and beliefs in a Middle Eastern population.

Materials and methods

Ethics approval was sought and received from the local Ethics Committee.

A modified validated survey questionnaire [4] exploring pregnant women’s background and birthing choices was selected and piloted (Survey questionnaire Appendix 1). The survey was carried out for a five-month period from August 2018 to January 2019 at Sidra Medicine, Qatar.

The antenatal clinic at Sidra Medicine, is a consultant-led service supported by midwifery/nursing staff and with imaging and full laboratory services. Voluntary participation in the survey was offered to pregnant women attending the clinic on their first visit.

The initial questions in the questionnaire were aimed at collecting demographic data. Events around previous births were then explored followed by plans for future pregnancies. This was followed by questions on the woman’s preferences in the current pregnancy.

Data collected from survey was then analysed using Chi square and Fisher’s exact tests.

Results

A total of 346 pregnant women completed the survey.

Discussion

This is the first study exploring the attitudes and birth choices women who live in Qatar.

The data has been divided into two groups; Arabic and non-Arabic women for analysis. This is because there is a large expatriate population in the Gulf and the opinions of the Arabic women themselves may be difficult to interpret if analysed as a single data set. Arabic women have not been well represented in the literature previously and it is important that their views receive attention.

The main finding of the study was that women in this Middle Eastern population chose vaginal birth as their preferred mode of delivery. When the data was separated, Arabic women showed a preference for vaginal birth with a lesser strength than the non-Arabs (63.2 vs. 79.3%), however after previous birth experiences were taken into account this was not significantly different from the non-Arabic women. In general, the Arabic group appeared to have an expectation of a more medicalised approach to care in labour and birth when compared to non-Arabic women living in the region. A smaller proportion of nulliparous women overall committed to planned caesareans as their choice in our study.

Studies from other parts of the world have found that women preferred vaginal birth as a mode of delivery in many different regions of the world including 93.5% of Australian women [3], 89.6% of North American women [5], 95.1% of Singaporean women [6], 77.8% of Chilean women [7], a majority of Brazilian women [8]. Our results were in line with those from these studies overall but looking at the Qatari/Arabic subset, 63.2% preferred vaginal birth which appears to be a smaller majority.

A larger proportion of the Arabic group preferred caesareans purely by choice (when women with previous caesareans were included) showing a contributory effect of maternal preference for repeat caesarean sections because, on exploring the preferred mode of delivery among Arabic nullipara, only 5% chose planned caesarean sections. To compare this with findings from around the world, 13% of nulliparous women have been found to choose planned caesareans as a preferred delivery mode in the UK [9] and in Asian countries: 3.7% nulliparous women in Singapore [6] and 5% in South Korea [10] made the same choice. It is important to understand the background in relation to these findings. Sidra Medicine, where this study was conducted, is a tertiary care facility running a private care maternity service. A majority of the patients pay for services or access care via medical insurance so the patient group is generally of a higher socioeconomic segment of an already affluent population. A large proportion of our study group (both Arabic and non-Arabic subsets) were highly educated women and half of the group were employed full time. It appears logical that education may have an effect on how women seek and interpret information and may influence their choices. A study on Italian women showed that a high level of education correlated with a higher preference for a planned caesarean section [11]. Despite high levels of education, our findings do not appear in line with this. Obvious cultural differences exist between Italy and the Middle East which may be contributory. Additionally, within this part of the world there is a traditional preference for relatively larger family sizes [12]. A majority of participants, significantly more Arabs in the study, planned further pregnancies and this may have been a factor favouring the choice of a normal birth over a caesarean section for the current pregnancy. Effects of maternal education on health awareness and choices such as breastfeeding are known [13] and demonstrated by these results.

Sources of information in pregnancy can significantly affect birth choices [1]. Studies have shown that among the important factors that can influence a woman’s choice of mode of delivery are information that healthcare professionals provide [3] and information gained through advice from and recounting of experiences by friends or family [14]. In our study, Arabic respondents appeared to rely more on information from relatives and their own previous experiences while their non-Arabic counterparts relied more on information received on healthcare professionals. The differences between the subsets may indicate a cultural difference but also has to be interpreted in the context of non-Arabic expatriate respondents living away from extended families.

Cultural aspects unique to this population may have influenced some of the other findings of this study. In Western populations, 86% of fathers will attend the birth of their infants [15]. Our results showed that a minority of Arabic women had had their husbands as birth partners previously and though over half planned to have husbands as birth partners for the impending birth, this was significantly less than the non-Arabs. It is important to mention here that while Sidra Medicine offers the choice of spouses as birth partners since 2018, this has not been the cultural norm in this part of the world where traditionally this role was played by female relatives. Indeed, the state-run maternity services did not allow spouses to accompany women as birth partners. While fewer Arabic women had husbands as previous birth partners due to this, more women wanted to have husbands present for birth in the current pregnancy. The findings demonstrate that a significant proportion of women in this region wanted to move away from this tradition towards having birth support from their partners and this should perhaps prompt a shift in approach by healthcare facilities in the region.

A significant proportion of women wished to be cared for by a female doctor but non-Arabic women were significantly less likely to have a preference about the gender of their medical attendants. This did not appear to be a surprising finding for this region given the cultural influences.

In general, the Arabic group demonstrated a medicalised approach to care during labour and delivery. This was demonstrated by the findings of a vast majority planning hospital deliveries and a preponderance towards early admission and late discharge from hospital. Women also preferred births to be conducted by doctors or at least supervised by them. There was low acceptability among the participants towards having student observers and care delivered by supervised trainee doctors. These findings have to be interpreted in context. Traditional home birth practices have fallen out of favour with rapid economic development in the area [16] and contemporary healthcare systems in the region are not geared towards providing support for home births and maternity care in the community. Delivery of maternity care is currently largely hospital based and there is easy access to specialised private healthcare on demand for an affluent population [16]. The concept of midwives as independent maternity practitioners is also currently not supported by law in the country [17]. Good quality healthcare here is perceived to be hospital based and physician delivered. These factors would obviously have influenced the above results.

Conclusions

The findings of this study demonstrate that women in the Gulf region are no different in selecting vaginal birth as their preferred mode of delivery when compared to their counterparts worldwide. There are differences in women’s expectations of the delivery of care during labour and birth which may be partly influenced by cultural factors but need to be explored further to enable a better understanding of women’s expectations and deliver high quality care.