Choosing where to give birth is an important decision (Meredith and Hugill, 2017). In some countries, women can choose to give birth at home or in a hospital (Verhoeven et al, 2022), while in others, health policies require women to receive birth services in medical centres and hospitals (Rigg et al, 2017). For example, the American Committee of Obstetrics and Gynecology announced that while they respect women's right to choose their place of birth, medical centres and hospitals were the safest places to give birth and they did not support home birth (Davis-Floyd et al, 2020). The World Health Organization's policy is that ‘women can choose to give birth at home if they have low-risk pregnancies, receive the appropriate level of care, and if problems arise, programmes arrange for emergency transfer to a maternity unit with appropriate personnel/equipment’ (Daviss et al, 2021). Even in low-risk pregnancies, unexpected events may occur and birth planning should include a multidisciplinary team (Hadebe et al, 2021).
In Iran, the Ministry of Health's national health programme considers a birth that takes place outside a hospital or medical centre to be unsafe (Ghazi Tabatabaie et al, 2012). Home birth is not supported by the government and all women in the perinatal period are advised to attend a hospital or health centre to give birth. However, women and their families may choose to give birth at home for a number of reasons, including financial constraints or cultural beliefs.
One factor affecting women's decision of birth place was the COVID-19 pandemic (Siakhulake et al, 2021). In countries such as the Netherlands, America and Europe, where home birth is supported by the government, the number of home births increased during the pandemic (Quattrochhi, 2023). The COVID-19 pandemic led many countries to introduce quarantines and social distancing measures to prevent the spread of infection (Tabari et al, 2020; van Manen et al, 2021). Healthcare services, including maternity services, were also affected by these measures, such as needing to reduce the number of antenatal appointments provided (Rasmussen and Jamieson, 2020). In Iran, guidelines were adopted to reduce the risk of infection with COVID-19. For low-risk pregnant women, the number of antenatal appointments was reduced from 8 to 4 sessions and, in many cases, women received counselling through telephone calls to health centres instead of face to face (Benski et al, 2020). The COVID-19 pandemic created challenges for those who were pregnant or who gave birth during this time (Schmiedhofer et al, 2022). Psychological and emotional challenges, such as the fear of infection, may have affected the decisions of women and their families in terms of pregnancy care and their choice of birth place (Amiel Castro et al, 2023).
The pandemic may have influenced the decision of some Iranian women to give birth at home for several reasons, including the fear of infecting themselves and their babies with COVID-19. The authors believe that choosing place of birth is a couple's right and should be supported by the government. The aim of this study was to explore Iranian women's experiences of giving birth at home during the pandemic, which may help support implementation of home birth guidelines in Iran.
Methods
This qualitative study used the standards for reporting qualitative research (O'Brien et al, 2014) to explore Iranian couples' experiences of giving birth at home during the COVID-19 pandemic. The study was carried out in Yasuj city in the southwest region.
Participants
A convenience sample of women who had given birth at home during the COVID-19 pandemic, and their partners, were invited to participate in the study. Those who were fluent in the local language, had no condition that impaired their communication skills and had not been diagnosed with a mental illness were included. The women were introduced to the researchers by the midwife who handled their home births, who was familiar with the researchers. The Health Department's records were checked, and no other home births were found to have taken place in the city during the same time.
Women were invited to participate after an explanation of the study's purpose. Data collection was intended to continue until data saturation; however, only six women met the inclusion criteria and so their husbands were also interviewed. After interviewing the fourth husband, no new codes were obtained, making the final participants a total of six women and four men.
Data collection
Data were collected through in-depth semi-structured interviews, arranged at a time and place of the participants' choosing. The participants were asked to provide demographic information and were then asked open questions, beginning with ‘please explain your experience of giving birth at home during the COVID-19 pandemic and tell me how you felt at that time’. The next questions were directed based on the participants' answers. No interview guide was used.
All interviews were conducted by LB at the participants' homes and lasted 50–65 minutes. Interviews were conducted in Iranian and transcribed. The researcher also noted participants' body language and facial expressions. Data collection took place between 26 August and 3 October 2023.
Data analysis
Data were analysed using Graneheim et al (2017) qualitative content analysis approach. This involves identifying and condensing meaning units, coding these units and developing subcategories, categories and themes (Akhtarkia et al, 2023). The whole interview was selected as the unit of analysis. Words, sentences or paragraphs with content related to the study aim were considered ‘meaning units’. According to their latent concept, these units were grouped to form condensed meaning units, which were abstracted, labeled and converted into codes. The codes were grouped into subcategories and categories based on similarities and differences. Finally, by comparing the categories, the latent content of the data was extracted and labeled as a theme. All interviews were coded separately by two researchers (MSM) and (LB) who shared obtained codes. Disagreements were resolved with two other researchers. Following analysis and write up, the manuscript was translated to English by a professional translation agency, Edit Native.
Trustworthiness
Four criteria were used for data trust and reliability: validity, reliability, confirmability and changeability (Nguyen et al, 2021). To support trustworthiness, peer review and long-term, continuous interaction with the data were used. Findings were shared with the participants during data collection and analysis to ensure that they were consistent with the participants' experiences. To ensure reliability, results were recorded in detail at all stages. Transferability was achieved by providing a rich description of the research report. The research team held several meetings to review findings; two researchers read the files multiple times and independently performed data analysis. Then codes, theme clusters and conflicting themes were discussed to reach a consensus. The involvement of more than one researcher in the analysis process increased the data's reliability.
Ethical considerations
This study was approved by the ethics committee of Yasuj University of Medical Sciences (reference: IR.YUMS. REC.1400.203) in July 2022. Participants provided verbal informed consent to participate, and for the content of the interviews to be recorded. They were assured of the confidentiality of their responses.
Results
Participants' demographic characteristics are shown in Table 1. The women were aged 28–39 years old and two-thirds (66.7%) of them had earned a diploma. Half of the women were employed and none had been vaccinated for COVID-19. The men were aged 27–40 years old, most had attended high school (75.0%) and one had a diploma (25.0%). All four men were employed.
| Variable | Category | Frequency, n |
|---|---|---|
| Age (years) | Women: 28–39 |
|
| Education | Up to high school | Women: 2 |
| Diploma | Women: 4 |
|
| Bachelor's degree or higher | Women: 0 |
|
| Employment status | Employed | Women: 3 |
| Unemployed | Women: 3 |
|
| Vaccinated for COVID-19 | Yes | Women: 0 |
| No | Women: 6 |
Analysis revealed one overall theme, linking dread and joy, with two themes: subjective factors (seven subthemes) and objective factors (five subthemes) (Table 2). The couples experienced dual feelings: a fear of COVID-19 and of giving birth at home, and joy after a successful home birth.
| Theme | Subtheme | Codes |
|---|---|---|
| Subjective factors | Faith in God and hope | I was sure that God had not forgotten me |
| Self confidence | I always had high self-confidence | |
| Motivation | The fear of corona made the hospital soft | |
| Curiosity | I always wanted to see how childbirth is done | |
| Fear and anxiety | I was full of passion. I didn't know what was going to happen | |
| Excitement | I felt alive again | |
| Risk | I feel that we did a dangerous thing by not going to the hospital | |
| Objective factors | Home | It was my own house and I could do whatever I wanted |
| Spouse | The best part was that my husband was with me | |
| Experienced midwife | An experienced midwife was by my side and made me less afraid | |
| Personal items | When I was in a lot of pain, I looked at the picture of my first child | |
| Midwifery equipment | The midwife sometimes listened to the baby's heartbeat with a small device |
Subjective factors
Subjective factors that influenced participants' experiences encompassed seven subthemes, including participants' faith in God and hope, self-confidence, motivation, fear and anxiety, excitement and risk.
Faith in God and hope
The participants reported that their faith in God made them feel able to give birth at home, despite the pain, and felt calm and happy after the experience.
‘I was indeed in a lot of pain and cried a lot, but I was sure that God had not forgotten me. I trusted in God’.
Their faith in God gave them hope, which helped them to have a positive experience.
‘When the midwife examined me and said I was making good progress, I felt very hopeful and thanked God’.
Self-confidence
Most of the women noted that self-confidence and self-belief helped them to navigate the challenges of giving birth at home during the pandemic.
‘I always felt that we had high self-confidence and I didn't like to lose this confidence because of my decision, and despite the pain during childbirth, I tried to maintain my confidence. It was a strange feeling’.
Motivation
The pandemic was the main motivator behind most participants wanting to give birth at home.
‘Honestly, what made me not want to go to the hospital was the fear of corona. The death rate had increased so much, I was afraid for myself and my child and stayed at home’.
Fear and anxiety
The circumstances surrounding the COVID-19 pandemic caused participants to experience fear of two events simultaneously: contracting COVID-19 and unwanted complications related to giving birth at home.
‘It was very difficult. There was coronavirus everywhere and we didn't dare to go out. On the one hand, giving birth at home without advanced equipment and facilities. There was only a midwife who had a baby's cardiogram machine. The only thing that calmed me down was when we were listening to his heartbeat. He was the first child and I was really scared. When he was born and cried, I didn't know whether to laugh or cry’.
‘Those were difficult days. I struggled with myself whether to go to the hospital or not. We had heard that one of our acquaintances gave birth at home and I asked her about the birth. She told me it was easy, but it was not easy at all. I was in a lot of pain and I was worried about the baby. However, thank God, no problem happened’.
Curiosity
The men highlighted their lack of knowledge about natural childbirth, and their desire to learn about it. Their curiosity helped them to support their partners in the decision to give birth at home.
‘I always had a question about how to give birth naturally. When my wife said that I would not refer her to the hospital because of the fear of corona, I was very afraid that something would happen. However, my wife insisted and I agreed. I wanted to know how the baby would be born. It was amazing’.
Excitement
Many of the participants were excited to give birth at home, especially the men. The birth of their child at home was an emotional process; they experienced fear, pain and happiness at the same time.
‘I didn't think that childbirth would hurt so much. My wife was very upset, but when the baby was born and she started crying, the pain disappeared completely, and it was very exciting. I felt like I was coming back to life’.
Risk
The participants felt that childbirth itself had inherent risks. However, the risk of infection with coronavirus added to the feeling of danger.
‘Daily, cyberspace reported the excess deaths due to the COVID-19 pandemic, and I was more afraid of catching COVID-19. Of course, there was indeed no problem during the birth, but later when I thought about it, I told myself, “wow, I did a dangerous thing, I gave birth at home”. Thank God the baby and I did not have any problems’.
‘Believe me, I'm still very scared when I remember. It was a very dangerous job. No medicine, no facilities. When the midwife realised that I was scared, she insisted that I take my wife to the hospital, but my wife refused and said that her first delivery, which was in the hospital, was very painful’.
Objective factors
The objective factors that influenced participants' experiences included five sub-themes: home, spouse, experienced midwife, personal items and midwifery equipment.
Home
Most participants felt their home was a calm and safe environment, which could increase women's autonomy, help them endure the process and create positive birth experiences.
‘My first birth was in a hospital. Since I left, I couldn't move from my bed, but I was comfortable at home and I could do whatever I wanted’.
Spouse
The presence of family, especially their spouse, was an important factor in improving participants' experiences of childbirth.
‘A man needs to see how much pain a woman is in during childbirth. The best advantage of giving birth at home was that my husband was with me and understood me’.
‘My first birth was done at home during the height of the COVID-19 crisis. I always wished that my husband would be with me during the birth. I was very happy that he understood me and my situation. For my second birth, I also decided to give birth at home. I talked to the midwife of my first birth and she told to me that the coronavirus had subsided and I could be referred to the hospital. I insisted to do my second birth at home, but she refused and I had to go to the hospital. I was very bothered there, but my home was really good’.
Experienced midwife
The presence of an experienced midwife helped participants to have a positive experience. Many felt their presence was necessary for birth.
‘I wanted to give birth at home myself, but honestly, if the midwife didn't accept and come, I would have to refer to the hospital and I am always grateful to her for staying by my side and helping me’.
‘When my wife's pain started, I called the midwife. My wife had arranged with her before, but she never promised 100%. At my insistence, she came and checked my wife, gave us explanations, and said that the hospital has facilities and it is better there. However, my wife cried and insisted that she stay here. If she didn't stay, we wouldn't have had this experience’.
Personal items
Recalling positive memories helped the women to endure the pains of childbirth.
‘I experienced the pain of childbirth twice. I felt better during my second childbirth. I was at home and when I was in pain, I went to the boards and even the photo album and looked at the photos of my first child, and I felt better’.
Midwifery equipment
The participants highlighted that they felt that midwifery/medical equipment was necessary for a home birth. The presence of basic equipment increased their confidence and positive thinking.
‘I was really scared that we didn't go to the hospital, but because of my wife's insistence, I tried not to worry. The midwife regularly checked the baby's heartbeat with a small device, and when we heard a heartbeat, we were less afraid’.
Discussion
The main theme found in this study, linking dread and joy, encompassed a range of subjective and objective factors that influenced the birth experiences of Iranian couples who had a home birth during the COVID-19 pandemic. Childbirth is a physiological and unique phenomenon that can be understood differently by all women depending on the time and place of birth and their condition and context (Akhtarkia et al, 2023). In the present study, despite fears and worries, many of the participants had a positive experience.
Subjective factors
A number of subjective factors influenced participants' experience of giving birth at home during the COVID-19 pandemic. Two factors helped participants cope with the pain and manage challenges: belief in God and self-confidence. Mutmainnah and Afiyanti (2019) reported that Indonesian women strongly believed in the presence of God in enduring labour pains, and faith during childbirth reduced feelings of fear and anxiety, helping them to have a positive experience. Khamehchian et al's (2020) study also highlighted that spirituality affects women's satisfaction with childbirth. Uldal et al (2023) reported that in Norway, women's confidence in their ability to manage childbirth could improve their satisfaction with the experience. Jouhki (2012) similarly highlighted that women's self-confidence helped them not to doubt their ability to give birth at home.
Motivation can encourage a person to act and plays an important role in decision making. The participants reported that the ongoing pandemic was a strong motivating factor behind the decision to give birth at home. They did not want to go to the hospital because they feared either they or their baby would become infected. Quattrocchi (2022) reported that interest in home birth increased during the COVID-19 pandemic in many high-income countries because of the fear of contracting COVID-19. Similarly, the present study's participants' perceptions of risk influenced their decision making. They had accepted the risk of giving birth at home because of the risk of contracting COVID-19 at a hospital, and reported that they may not have made this decision in a different situation. Olsen et al (2022) demonstrated that pregnant women's experiences of birth during the COVID-19 pandemic intensified some of their fears.
Most participants experienced a range of strong emotions, including fear and anxiety, but also excitement, during home birth. Emotion is a complex reaction pattern of experiential, behavioural and physiological factors by which a person tries to face an important personal issue or event (Mandler, 2019). Fear of COVID-19 was a strong motivator to give birth at home, but participants were also anxious about issues with a home birth, such as the lack of midwifery equipment. Although childbirth is a physiological phenomenon, unforeseen problems can require medical interventions. Therefore, it is important that women who decide to give birth at home are prepared for emergencies and have a plan for if complications occur. Rice and Williams (2022) reported that in Canada, the COVID-19 pandemic was seen as an opportunity to promote out-of-hospital birth care for low-risk pregnancies.
Understanding fathers' psychological experiences of birth is necessary for compassionate care (Williams et al, 2023). In the present study, the men who participated reported that they were excited about the opportunity for a home birth, but that they also felt fear, pain and joy. For cultural reasons, Iran's childbirth programmes do not typically allow a woman's husband to accompany her in the birth room (Bozorgian et al, 2024). The men who participated in the study felt that they lacked knowledge about natural childbirth and were interested in seeing the birth process. They used the experience of a home birth as an opportunity to satisfy their curiosity and improve their knowledge, which would not have been possible with a hospital birth. RezaeiAbhari and Hesamzadeh (2023) highlighted that in Iran, a lack of knowledge and sociocultural factors prevent husbands from actively participating in planning their wives' physiological childbirth.
Objective factors
The participants reported that physical and objective factors helped to create a positive experience of the challenging process of childbirth. Galera-Barbero and Aguilera-Manrique (2022) highlighted that in Spain, women's positive experiences of giving birth at home were influenced by the security and intimate atmosphere, the presence of their husband, cost reduction and the presence of a midwife. In Ireland, Gregory et al (2023) found that women felt more positively about giving birth at home than in a hospital because of the presence of their husbands and the home environment. With support from the healthcare system, the home can be a safe and intimate environment suitable for birth.
Implications for practice
Despite giving birth at home in a stressful situation, the study's results show that the participants had a positive and pleasant experience, highlighting the importance of women's right to choose the place of birth and the importance of midwives' role in the health of women and families. More research is needed on home birth in Iran, which could be used to inform the creation of national guidelines supporting home birth.
Strengths and limitations
The researchers were familiar with the participants' accents and language, a strength of this study as this helped the interviewer guide the interview and understand the participants' body language. However, the participants were all drawn from one specific city in Iran, meaning that the data cannot be generalised.
Conclusions
The results of this study demonstrate that despite the lack of support for home birth from Iran's Health Ministry, the COVID-19 pandemic encouraged some women to give birth in the perceived safety and comfort of their homes in the presence of their husbands. An experienced midwife and preliminary birthing equipment helped participants have a pleasant experience. The experiences of the pandemic may have provided an opportunity to adopt new policies for management of home births. Planning a home birth, taking into account physical and psychological health and the needs and preferences of low-risk pregnant women could be included in safe birth guidelines for Iran. Further quantitative and qualitative studies should be conducted to investigate home birth throughoutIran.