A comparison of Israeli Jewish and Arab women’s birth perceptions

A comparison of Israeli Jewish and Arab women’s birth perceptions

Ofra Halperin, RN, PhD (Senior Lecturer)a,n, O. Sarid, PhD (Senior Lecturer)b, J. Cwikel, PhD (Professor)b

a Emek Izrael College, Nursing Department, Israel b Department of Social Work, Ben Gurion University of the Negev, Beer Sheva 84105, Israel

a r t i c l e i n f o

Article history: Received 10 April 2013 Received in revised form 6 November 2013 Accepted 10 November 2013

Keywords: Childbirth experience Trauma Transcultural nursing

a b s t r a c t

Background: birth is a normal physiological process, but can also be experienced as a traumatic event. Israeli Jewish and Arab women share Israeli residency, citizenship, and universal access to the Israeli medical system. However, language, religion, values, customs, symbols, and lifestyle differ between the groups. Objectives: to examine Israeli Arab and Jewish women’s perceptions of their birth experience, and to assess the extent to which childbirth details and perceptions predict satisfaction with the birth experience and the extent of assessing the childbirth as traumatic. Methods: this study was conducted in two post partum units of two major public hospitals in the northern part of Israel. The sample included 171 respondents, including 115 Jewish Israeli and 56 Arab Israeli women who gave birth to their first (33%) or second (67%) child. Respondents described their childbirth experiences using a self-report questionnaire 24–48 hours after childbirth. Findings: the Arab women were much less likely to attend childbirth preparation classes than the Jewish women (5% versus 24%). Forty-three per cent of the respondents reported feeling helpless, and 68% reported feeling lack of control during childbirth. Twenty per cent of the women rated their childbirth experience as traumatic, a rate much lower than the rate of medical indicators of traumatic birth (39%). The rate of self-reported traumatic birth was significantly higher among the Arab women than among the Jewish women (32% versus 14%). A higher percentage of the Arab women reported being afraid during labour (χ2¼4.97, po .05), expressed fear for their newborn’s safety (χ2¼12.44, po .001), and reported that the level of medical intervention was excessive in their opinion, as compared to the Jewish women (χ2¼5.09, po .05; χ2¼7.33, po .01). However, both the Arab and Jewish women reported similar numbers of medical interventions and levels of satisfaction with their medical treatment. Conclusions: despite universal access to the Israeli health care system, Arab Israeli women use fewer perinatal medical resources and subjectively report more birth trauma than Jewish Israeli women. Yet, they give birth in the same hospitals with the same practitioners and report similarly high levels of satisfaction with the medical services. Taking into account the fact that perceptions of the birth experience differ between ethno-cultural groups will enable professionals to better tailor intervention and support throughout childbirth in order to increase satisfaction and minimise trauma from the experience.

& 2013 Elsevier Ltd. All rights reserved.

Introduction and literature review

Israeli Jewish and Arab women share Israeli residency, citizenship and access to the Israeli medical system. However, language, religion, values, customs, symbols, and lifestyle differ between the two groups (Klug et al., 2009). Israel is not a melting-pot society, but rather more of a mosaic made up of different population groups coexisting within the framework of a single democratic state. As a multi-ethnic,

multicultural, multireligious, and multilingual society, Israel has a high level of informal segregation patterns. Although groups are not separated by official policy, a number of different sectors within the society have chosen to lead a segregated lifestyle, maintaining their strong cultural, religious, ideological, and/or ethnic identity (Jabareen, 2006).

The vast majority of Arab Israelis have chosen to maintain their distinct identity and not assimilate. The community’s separate existence is facilitated through the use of Arabic, Israel’s second official language; a separate school system; literature, theatre, and mass media; and the maintenance of independent Muslim denomi- national court, which adjudicates matters of personal status. Although the development of inter-group relations between Israel’s

Contents lists available at ScienceDirect

journal homepage: www.elsevier.com/midw

Midwifery

0266-6138/$ – see front matter & 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.midw.2013.11.003

n Correspondence to: Nursing Faculty, The Max Stern Academic College Emek-Yezreel, P.O. Box 105, Givat Ela 36570, Israel.

E-mail address: ofrah@yvc.ac.il (O. Halperin).

Midwifery 30 (2014) 853–861

Arabs and Jews has been hindered by deeply rooted differences in religion, values, and political beliefs, the future of the Israeli Arab sector is closely tied to that of the State of Israel. Although they coexist as two self-segregated communities, over the years Jewish and Arab Israelis have come to accept each other, acknowl- edging the uniqueness and aspirations of each community and participating in a growing number of joint endeavours (Bard and Berman, 2012).

Health indicators in Israel present a picture of poorer health along with lower socio-economic levels in the Arab population as compared with the Jewish population (Israel Center for Disease Control, 2005). For example, life expectancy in 2002 was about three years less for Arab Israelis than for their Jewish counterparts (Central Bureau of Statistics, 2004). In 1995, a National Health Insurance Law (NHIL) was enacted, providing health care services for all Israeli residents (Shvarts, 1998). The aim of the law was to provide equal health care services for all, with the expectation that adequate use would decrease the differences in health status between the two population groups in Israel. Arabs have a pattern of health care utilisation that is characteristic of lower socio- economic status (SES) groups, even after adjusting for levels of SES (Van Doorslaer et al., 2006). This pattern includes less use of specialist care, more use of family doctor care, and higher rates of hospitalisation. Other low-SES groups and minorities have been shown to have this pattern of health care utilisation (Schoen et al., 2000; Baron et al., 2004; Roos et al., 2005; Van Doorslaer et al., 2006), suggesting that factors associated with ethnicity beyond SES may be associated with health care utilisation. In the years since the founding of the State of Israel, the Israeli Arab commu- nity sector has made great strides in almost every area of development. For example, the median years of schooling of Arab Israelis rose markedly over a 35-year period (1961–1996) from 1.2 to 10.4 years (Reiter, 2009). For example, infant death rates per thousand live births decreased significantly during that same 35-year period (Reiter, 2008).

Research shows significant cultural differences between women of Arab origin and women of Jewish origin in childbirth rates and practices. The birth rate is 2.98 per 1000 among Jewish women and 3.51 per 1000 among Arab women (Israel Central Bureau of Statistics, 2011). Significant differences between Arab and Jewish women have been reported on participation in an antenatal course and in post-partum follow-up visits, which were higher among Jewish than Arab women (Klug et al., 2009). Arab women are usually accompanied to the delivery room by female relatives, whereas Jewish women are usually accompanied by their partners (Klug et al., 2009). Epidural anaesthesia prevalence is higher among Jewish women (Klug et al., 2009), though Arab women demonstrate more pain behaviours during childbirth (Lewando-Hundt et al., 2001; Klug et al., 2009). Several researchers have explained this behaviour by the lack of language proficiency in Hebrew, leading to the demonstration of pain symptoms as an effective way to attract attention and care without the use of language (Weisenberg and Capsi, 1989; Harrison, 1991; Sheiner et al., 1999). The expressed wish to breast feed is found to be higher among Arab women (Lewando-Hundt et al., 2001; Klug et al., 2009). Studies conducted in Israel show that Arab women reported a higher rate of breast feeding compared with Israeli Jewish women (The Ministry of Health, the State of Israel 2002; Chertok et al., 2004).

Cultural values serve as an important framework for under- standing an individual’s beliefs about major life events and transitions. Birth is considered a significant life event that is particularly affected by the cultural context (Homer et al., 2002; Cassar, 2006). Health beliefs regarding childbirth experiences preserve cultural values, help the pregnant woman define the significance of childbirth, and promote her ability to cope with the childbirth process, as well as the personal and health

consequences (Roberts, 2002; Cassar, 2006). The way a woman in labour responds to the birthing experience is shaped and expressed through spiritual, religious, and cultural traditions (Callister et al., 1999; Cassar, 2006). When significant life events (such as the birth of a child) occur, personal religiosity may increase (Albrecht and Cornwall, 1998), possibly due to a greater sense of wellbeing, personal happiness, and life satisfaction (Callister et al., 1999). How a woman perceives her childbirth experience can influence her overall feeling of satisfaction, com- petency, and psychosocial well-being (Hardy, 2011).

For most women, the birth of a child is a key life transition, and when well supported by family and medical staff it can be described as a moment of satisfaction and reward (Nelson, 2003). There remain, however, a proportion of women who are deeply distressed following birth. Reports of distress are fre- quently linked with descriptions of complicated, negative, or traumatic birth experiences (Waldenström et al., 2004; Dahlen et al., 2010; Sarid et al., 2010). Sarid et al. (2010) found that 23% of women defined their first birth experiences as either negative or traumatic, and 32% of a community sample reported at least one such birth experience. This rate decreased in second to fourth childbirths. A first traumatic birth was a strong predictor of reporting subsequent traumatic childbirths. Traumatic births were associated with fears and anxieties during pregnancy, C-section, or vacuum childbirth, as well as a lack of persons who spoke their native language in their social networks.

Soet et al. (2003) suggested that up to 34% of women from the United Kingdom (UK) report their birth experience as traumatic. An Australian study showed similar results, finding that one in three women continued to experience traumatic related symp- toms four to six weeks after a traumatic birth (Creedy et al., 2000). In research conducted among Israeli Jewish women, Sarid et al. (2010) showed that stressful life events associated with the reproductive cycle, such as fertility problems, abortions, and traumatic birth experiences, significantly contribute to the devel- opment of depressive and pain symptoms several years following the negative birth experiences. Traumatic childbirth was found to be a significant predictor of post-partum depression and a lower rate of breast feeding the infant (Segal-Engelchin et al., 2009).

In the scientific literature, there is no consistent definition of traumatic birth experiences and no systematic way to assess birth trauma. The terms birth trauma and traumatic birth experience are used synonymously. Beck and Watson (2008) define birth trauma as ‘actual or threatened injury or death to the mother or her baby’ (p. 229). Women may also perceive their birthing experience to be traumatic as a result of the intervention that was implemented during the birth process, the mode of birth (caesarean or vaginal), and the way in which women are treated by health care professionals (Beck and Watson, 2008). Women may have a seemingly normal birth, but feel traumatised by believing that their infant will die, feeling violated by intimate examinations, or perceiving hostile or negative attitudes of people around them (Elmir et al., 2010). Experiencing trauma during childbirth, irrespective of the development of posttraumatic stress disorder, can have a negative impact on the mother’s psychological functioning and post partum adjustment (Soet et al., 2003).

Women recall their birth experiences over time, and the effect of the traumatic experience does not subside for many of them (Sarid et al., 2010). A traumatic birth experience can have a severe impact on women and their families. Women have reported negative effects on their relationship with their partner, including sexual dysfunction, disagreements, and blame for events of the birth, as well as a negative effect on the mother–infant attachment (Reynolds, 1997; Waldenström et al., 2004; Ayers et al., 2006). Women may have either avoidant or anxious attachments with their child (Ayers, 2004; Olde et al., 2006). In one study, nearly all

O. Halperin et al. / Midwifery 30 (2014) 853–861854

women reported initial feelings of rejection towards the infant, but this seemed to change over time (Ayers et al., 2006). Birth trauma can also lead to distressing problems that hinder mothers’ breast feeding attempts (Bailham and Joseph, 2003; Sarid et al., 2010). The impact of birth trauma on mothers’ breast feeding experiences can lead women down two strikingly different paths. One path can propel women into persevering in breast feeding as a means of compensating both mother and child for an earlier negative experience, whereas the other path can lead to psychological distress and the wish to reduce the burden associated with breast feeding (Beck and Watson, 2008).

The serious ramifications of perceiving the birth experience as a negative one are now being recognised in different countries. For example, in Sweden, women who reported a very negative birth experience of their first child had fewer subsequent children and a larger time interval to the second infant, as compared with women who reported positive birth experiences (Gottvall and Waldenström, 2002). Beck (2004) found that the essential com- ponents of a traumatic birth were the lack of communication and caring by labour and delivery personnel and the provision of unsafe care. However, perceiving birth as traumatic may lie in the eye of the beholder (Beck, 2004). Thompson and Downe (2008) noted that women who have an apparently normal vaginal birth with no intervention may also perceive their birth as traumatic.

To date, to the best of our knowledge, no research on birth trauma has been conducted with an intercultural emphasis and in close proximity with the childbirth. This topic is especially important to medical personnel, who might be unaware of the impact that cultural beliefs and behaviours may have on shaping birth experiences. Health care professionals may also respond stereotypically to women in labour, which can add to the women’s perceived stressful childbirth experience. The rationale for this study was to provide a greater understanding of cultural values and behaviours of Arab and Jewish women in labour. We believe that this knowledge will assist in developing sensitivity to women in labour and enhance support for women from different ethno- cultural groups throughout their birth experiences and the transi- tion to parenthood. The objective of this study was to compare Israeli Arab and Jewish women’s perceptions of their birth experi- ence, as well as the medical and psychosocial characteristics of the birth.

Method

Research design

This cross-sectional study was conducted in two post partum units of two major public hospitals in the northern part of Israel, a region characterised by wide variations in ethno-cultural groups (Israel Central Bureau of Statistics, 2011). Between August 2011 and August 2012, we approached Israeli Arab and Jewish women 24–48 hours post-childbirth and invited them to participate in a study of their childbirth experiences. The study was approved by the Helsinki Committee of the two medical centres. We obtained informed consent prior to completion of a self-report question- naire. The interview was conducted in Hebrew. The Arab-speaking population residing in northern Israel is fluent in Hebrew, which is the language of everyday transactions and is taught together with Arabic in schools (Rubanovsky, 2005).

Sample characteristics

All women who gave birth between August 2011 and August 2012 as either a first or second birth were included in the study population. Inclusion criteria were being able to speak and

understand Hebrew and giving birth to a live infant of 34–42 weeks gestation (Brandon et al., 2011; Boyle and Boyle, 2013). Those who delivered in the window of 34–37 weeks were included only if they had a normal vaginal birth with no additional complications. Questionnaires were given to 230 women at their bedside in the maternity ward of each hospital. Of the 230 women, complete questionnaires were obtained from 171 (74.3% response rate). The rest did not complete the questionnaire either because they had no time or did not feel well at the time.

Measures

A self-report questionnaire was administered to the women 24–48 hours after giving birth. This questionnaire was an adapta- tion and expansion of a questionnaire used in an earlier study which examined Israeli women’s pregnancy and birth experiences (Segal-Engelchin et al., 2009; Sarid et al., 2012). In order to test the adequacy and internal validity of the modified research instru- ment prior to the present research, a pilot test was conducted with a small group of 35 Arab and Jewish women. Both the setting and the way in which the questionnaire was administered were the same as those used in the main study. On the basis of the results, which showed adequate variable distribution, the questionnaire was deemed valid and comprehensible. Although the reported childbirth experiences relied on self-report questionnaires, their reports of medical procedures were validated against their medical files.

The questionnaire included the following questions:

(1) Immediate assessment of childbirth as traumatic, measured using dichotomised answers (yes, no).

(2) Satisfaction with the childbirth experience, rated as a number on a scale of 0–100.

(3) Pregnancy complications, measured by asking respondents whether there were any complications during their pregnancy (preeclampsia, gestational diabetes, etc.) (dichot- omised answers: yes, no).

(4) Childbirth number (0¼first, 1¼second). (5) Duration of birth in hours. (6) Type of birth (vaginal birth, forceps, vacuum extraction,

planned and emergency C-section). These data were also extracted from the women’s medical records.

(7) Additional medical procedures during childbirth: episiotomy, emergency care in the delivery room for the newborn, medical problems to the mother or the newborn after birth (dichotomised answers: yes, no).

(8) Negative experiences during childbirth: helplessness, lack of control, too much medical intervention, fear during labour, fear for the newborn’s safety, physical harm during birth, physical harm to the infant during labour, feeling that her life was in danger, feeling that her infant’s life was in danger (dichotomised answers: yes, no).

(9) Extent of pain during labour (0–100). The more pain the women experienced, the higher their stress during childbirth. Following the approach of Pirdel and Pirdel (2009), we define labour stress as the psychological state which combines fear and pain, as experienced by women during labour and reported retrospectively in the post-partum period.

(10) Previous stressful life events, measured using the Traumatic Events Questionnaire (TEQ). The TEQ assesses experiences with nine specific types of traumatic events (e.g., accidents, crime, adult abusive experiences) reported in the empirical literature as having the potential to elicit PTSD symptoms (Vrana and Lauterbach, 1994). (Dichotomised answers: yes, no). Cronbach’s alpha was .91. This questionnaire has been used in other studies of trauma and childbirth, both in Israel

O. Halperin et al. / Midwifery 30 (2014) 853–861 855

(Lev-Wiesel et al., 2009) and in the US (Schwerdtfeger and Shreffler, 2009).

(11) Demographic variables included ethnicity (Jewish/Arab), age, education, marital status, religiosity, place of birth, number of previous childbirths or pregnancies, and number of children.

Participants

Participants were 171 Israeli women who gave birth to their first (n¼57, 33.3%) or second (n¼114, 66.7%) child. Jewish women comprised 67.3% (n¼115) of the sample and Arab Muslim women 32.7% (n¼56). Participants’ ages ranged between 18 and 41 years old, with a mean age of 28.95 years (SD¼4.81). The Jewish women were older (M¼30.43, SD¼4.14) than the Arab women (M¼25.91, SD¼4.68), and the age difference was statistically significant (t(169)¼6.42, po .001). The great majority of the women were married (n¼161, 94.15%), whereas 4.68% (n¼8) were single and 1.17% (n¼2) were divorced. Most of the Arab women (92.9%) and nearly three-quarters of the Jewish women (73.9%) were Israeli- born (n¼85, χ2¼10.16, po .01). All the Jewish women who were not born in Israel emigrated from the former Soviet Union.

About half of the Jewish women had an academic education (n¼61, 53.0%), as compared with a third of the Arab women (n¼19, 33.9%) (χ2¼ .38, p4 .05). Most of the Jewish women were employed (n¼104, 90.4%), as compared with over half of the Arab women (n¼33, 58.9%) (χ2¼23.47, p4 .05). About two-thirds of the Jewish women were secular in their religious observance (n¼74, 64.3%), as compared with one-fourth of the Arab women (n¼14, 25.0%) (χ2¼24.05, p4 .05). More than half of the Arab women viewed themselves as traditional, as compared with a quarter of the Jewish women (Arab n¼31, 55.4%; Jewish n¼27, 23.5%). A similar number of Arab and Jewish women viewed themselves as religious (Arab n¼11, 19.6%; Jewish n¼14, 12.2%) (χ2¼24.05, p4 .05). In sum, most of the women were married and were born in Israel. The Jewish women were older, more likely to be employed, had a higher degree of education, and were more secular.

Statistical analyses

Data regarding demographics, pregnancy and pre-pregnancy stress, childbirth details and stress in childbirth, the childbirth experience and satisfaction with it, as well as childbirth recall, were described with frequencies, means, and standard deviations. Comparative differences between the Arab and Jewish women were examined with the χ2 test suitable for comparison of nominal and ordinal variables and t-tests.

Findings

Pregnancy and pre-pregnancy stress

The distributions of demographic and psychological variables before labour for the Arab and Jewish women are presented separately in Table 1. The great majority of both the Jewish and Arab women reported that their pregnancies had been planned (n¼143, 83.6%; χ2¼ .13, p4 .05) and that they had suffered no complications during this period (n¼122, 71.3%; χ2¼1.21, p4 .05). No significant differences were found between the Arab and Jewish women regarding partner support during pregnancy, with most women reporting partner support (n¼162, 94.7%; χ2¼ .00, p4 .05). Psychological problems before or during pregnancy were not reported by the majority of women (n¼145, 84.8%; χ2¼ .05, p4 .05).

Pregnancy stress was reported according to several measures. Most women noted that they did not experience anxiety (n¼164, 95.9%; χ2¼1.13, p4 .05), sleeping difficulties (n¼166, 97.1%; χ2¼ 2.51, p4 .05), nervousness (n¼166, 97.1%; χ2¼2.51, p4 .05), mood changes (n¼160, 93.6%; χ2¼ .07, p4 .05), or restlessness (n¼167, 97.7%; χ2¼ .11, p4 .05) prior to or during pregnancy. That is, most women did not experience pregnancy-related stress or major psychological problems.

In response to a general question regarding stressful life events, almost half of the women (n¼78, 45.6%) responded that they did have stressful life events during the pregnancy, with no differences found between the ethnic groups (χ2¼ .65, p4 .05). Women reported experiencing an accident, assault, war, terror, life- threatening disease, and the like.

Childbirth details and stress in childbirth

Table 2 presents the childbirth details of the participants by ethnicity. Very few statistically significant differences were found between the Jewish and Arab women on details regarding their births. Eighteen per cent of the women attended a childbirth preparation course, with significantly more Jewish women (24%) than Arab women (5%) (χ2¼9.15, po .01). Labour was induced for about one-fifth of the women, somewhat more among the Arab women (χ2¼16.66, po .001). Forceps and vacuum extraction were rarely used, but were more common among the Arab women (χ2¼5.09, po .05). Episiotomy was used in over one-third of the cases, more so among the Arab than among the Jewish women (χ2¼7.33, po .01).

In comparing the Arab and Jewish women (see Table 2), we can see more similarities than differences between the two groups. For about two-thirds of them, it was their second labour (one-third reported the first labour), and most were accompanied to labour by their husbands or by several people. Almost all women gave birth during the 37th–42nd weeks of pregnancy. Childbirth lasted up to 72 hours, with a mean of about 10 hours and no statistically significant difference between the ethnic groups.

In about 60% of the cases, birth was vaginal, and in others it was a planned caesarean section (about 20%) or emergency caesarean section (about 20%). Epidural was used in about 80% of the cases. Pain killers, such as Nitrous and Pethidine injection, were used in almost one-fifth of the sample, more so among the Arab than the Jewish women (χ2¼7.00, po .01). Non-pharmacological methods, such as relaxation, breathing techniques, positioning/movement, massage, hydrotherapy, music, guided imagery, acupressure, and aromatherapy, are comfort strategies offered by midwives and were used by less than 10% of the women.

Maternal or neonatal medical problems were experienced in 15% of the cases, and emergency procedures were initiated for 17% of the newborns in the delivery room, such as oxygen to stabilise independent breathing. There were no statistically significant differences between the Jewish and Arab women on these outcomes.

Childbirth experience and satisfaction

The great majority of women expressed a high level of satisfaction with the childbirth experience, such as receiving supportive treatment (n¼166, 97.1%), information and guidance (n¼165, 96.5%), and good post-labour treatment (n¼166, 97.1%). Most women felt that they were listened to (n¼167, 97.7%) and that the staff treated them properly (n¼169, 98.8%). In response to a general question regarding satisfaction with the childbirth experience using a VAS scale (0–100), both the Arab and Jewish women reported a mean of 80.17 (SD¼21.52), with no significant difference found between the ethnic groups (t(169)¼ .37). The

O. Halperin et al. / Midwifery 30 (2014) 853–861856

comparison between the Arab and Jewish women on their experience of childbirth is shown in Table 3.

As seen in the table, several statistically significant differences are apparent between the ethnic groups with respect to their childbirth experience. Almost three-quarters of the women reported being afraid during labour, more so in the Arab sector than in the Jewish sector (χ2¼4.97, po .05). Furthermore, almost half of the women expressed fears for the newborn’s safety, again more so by the Arab women than by the Jewish women (χ2¼12.44, po .001). Almost one-fifth of the women felt that their lives were

in danger, more so among the Arab women than the Jewish women (χ2¼4.92, po .05). About 15% of the women felt that their infant’s life was in danger (χ2¼5.09, po .05). About one-fifth of the women rated their childbirth experience as traumatic, more so among the Arab women than among the Jewish women (χ2¼7.86, po .01).

A meaningful portion of the women reported negative experi- ences related to childbirth. About 40% of the whole sample reported feeling helpless, and a little over half reported feeling a lack of control. About a third of the women reported that there

Table 1 Distribution of pregnancy and pre-pregnancy stress by ethnicity (n¼171).

Jewish (n¼115) Arab (n¼56) Total (n¼171)

n (%) n (%) n (%)

Planned pregnancy Yes 97 (84.3) 46 (82.1) 143 (83.6) χ2(1)¼ .13 Pregnancy complications No 79 (68.7) 43 (76.8) 122 (71.3) χ2(1)¼1.21 Partner support during pregnancy Yes 109 (94.8) 53 (94.6) 162 (94.7) χ2(1)¼ .00

Prior to and during pregnancy Psychological problems No 98 (85.2) 47 (83.9) 145 (84.8) χ2(1)¼ .05 Anxiety No 109 (94.8) 55 (98.2) 164 (95.9) χ2(1)¼1.13 Sleeping difficulties No 110 (95.7) 56 (100.0) 166 (97.1) χ2(1)¼2.51 Nervousness No 110 (95.7) 56 (100.0) 166 (97.1) χ2(1)¼2.51 Mood changes No 108 (93.9) 52 (92.9) 160 (93.6) χ2(1)¼ .07 Restlessness No 112 (97.4) 55 (98.2) 167 (97.7) χ2(1)¼ .11 Stressful life events Yes 50 (43.5) 28 (50.0) 78 (45.6) χ2(1)¼ .65

Table 2 Distribution of childbirth details by ethnicity (n¼171).

Jewish Arab Total

n (%) n (%) n (%)

Birth First 38 (33.0) 19 (33.9) 57 (33.3) χ2(1)¼ .01 Second 77 (67.0) 37 (66.1) 114 (66.7)

Accompanied at childbirth Yes 97 (84.3) 51 (91.1) 148 (86.5) χ2(1)¼1.46 Preparation course Attended 28 (24.3) 3 (5.4) 31 (18.1) χ2(1)¼9.15nn Pregnancy week 34–36 6 (5.2) 3 (5.4) 9 (5.3) χ2(2)¼ .35

37–39 69 (60.0) 31 (55.4) 100 (58.4) 40–42 40 (34.8) 22 (39.3) 62 (36.3)

Labour induction Yes 14 (12.2) 22 (39.3) 36 (21.1) χ2(1)¼ 16.66nnn

Birth duration .50–72 hours

M¼8.84 (SD¼10.78)

M¼12.15 (SD¼13.21)

M¼9.93 (SD¼11.70)

t(169)¼1.75

Mode of childbirth

Vaginal birth Yes 64 (55.7) 39 (69.6) 103 (60.2) χ2(1)¼3.08 Used forceps Yes 1 (.9) 0 (.0) 1 (.6) – Used vacuum extraction Yes 4 (3.5) 7 (12.5) 11 (6.4) χ2(1)¼5.09n Used episiotomy Yes 35 (30.4) 29 (51.8) 64 (37.4) χ2(1)¼7.33nn Caesarean section Planned 23 (20.0) 7 (12.5) 30 (17.5) χ2(1)¼ .01

Emergency 28 (24.3) 9 (16.1) 37 (21.6)

Interventions during labour

Epidural Yes 93 (80.9) 43 (76.8) 136 (79.5) χ2(1)¼ .39 Other pain killers (nitrous, Pethidine injection)

Yes 14 (12.2) 16 (28.6) 30 (17.5) χ2(1)¼7.00nn

Natural pain killers (essential oils, reflexology)

Yes 12 (10.4) 4 (7.1) 16 (9.4) χ2(1)¼ .48

After childbirth Special infant care (incubator heating, respiratory assistance)

Yes 19 (16.5) 10 (17.9) 29 (17.0) χ2(1)¼ .05

Medical problems (as indicated in the medical records)

Yes 19 (16.5) 7 (12.5) 26 (15.2) χ2(1)¼ .47

n po .05. nn po .01. nnn po .001.

O. Halperin et al. / Midwifery 30 (2014) 853–861 857

was too much medical intervention, more so by the Arab women than by the Jewish women. About one-fifth of the women revealed that they were physically hurt during labour, and some noted that their infant was physically hurt. The average degree of pain was assessed as 68 (out of 100). Medical indicators of traumatic birth (i.e., use of forceps, vacuum extraction, episiotomy, emergency caesarean section, special care for the newborn, or medical problems of the mother or newborn after birth) were found in 39.2% of the women, with no significant differences between the ethnic groups (χ2(2)¼1.01, p4 .5).

Discussion

The current study comparatively analysed birth experiences and perceptions of Israeli Arab and Jewish women 24–48 hours after childbirth. The health-related behaviours of the participants differed with respect to their ethnic background. For example, the Arab women were less likely than the Jewish women to attend childbirth preparation classes, which encourage women to keep antenatal care appointments as part of their preparation for the birth process. This finding supports those of other studies that Israeli Arab women are less likely to receive antenatal care on a regular basis when compared to Jewish women residing in the north or centre of the country (Klug et al., 2009). It is suggested that in general Arab women do not participate in childbirth preparatory classes because in the Arab culture pregnancy and birth are considered natural processes that reveal the skills and strength of a healthy mother, rendering frequent medical mon- itoring superfluous (Greene, 2007; Klug et al., 2009). Furthermore, for many Arab primiparae, the primary source of information preparing her for childbirth is her mother or mother-in-law (Cassar, 2006; Greene, 2007; Reitmanova and Gustafson, 2008). In the Israeli Western culture, similar to other developed coun- tries, the medicalisation of pregnancy and childbirth has reduced the importance of informal and family-transmitted information. Thus, the traditional role of the older women in the family as supporting the pregnant and birthing mother has been relegated to an informal and not authoritative source of knowledge (Mendlinger and Cwikel, 2005/2006).

The ‘halo effect’ – the immediate relief felt by women when labour is over – and their enchantment with their infant lasts for a few weeks and often temporarily overrides negative aspects. Memories of the unpleasant aspects, such as complications, frightening events, or unexpected interventions, often emerge

later as the ‘halo’ wears off (Bennett, 1985). On the other hand, women’s impressions of the psychosocial care they received (e.g., sharing of information, respectful treatment, attentiveness and emotional support, a welcoming environment) seem to remain quite constant over time and, when positive, may be associated with increasingly positive later overall impressions of their births (Simkin, 2004; Waldenström et al., 2004).

In an examination of Arab-American culture in connection with childbirth and pregnancy, Greene (2007) found that preventive health practices are uncommon in the Arab culture in the US. Arab women do not receive adequate antenatal care because they do not see a need unless a complication arises. Findings from previous research showed that participation in antenatal courses is also hindered by a lack of feasibility, lack of doctor’s recom- mendations, and financial problems (Cliff and Deery, 1997). A study conducted in Israel showed that primigravida women who did not know Hebrew well did not participate in the course because of the language barrier (Betty et al., 1998). Childbirth preparation was also found to be related to childbirth satisfaction (Goodman et al., 2004).

Betancourt et al. (2003) suggested that disparities in health status are due to variations in patients’ health beliefs, values, references, and behaviours. Childbirth, as a significant life event, takes place within the cultural context. Culture influences the birth experience of women, and the decisions they make through- out labour and birth are formed by their perceptions and cultural customs (Maputle and Jali, 2006). A sociocultural perspective to birth integrates all aspects of the birth into a coherent narrative. Birth can be conceptualised as a medical procedure, stressful but part of family life, a natural process, or a highly personal and fulfilling achievement (Jordan, 1993).

Currently, researchers and clinicians recognise the effect of pregnancy-specific anxiety, with fear of childbirth being an aspect of this anxiety (Hall et al., 2009). A clinically significant fear of childbirth is estimated to affect 20–25% of pregnant women (Zar et al., 2001; Geissbuehler and Eberhard, 2002; Alehagen et al., 2006; Rouhe et al., 2009; Haines et al., 2011), but 6–16% of pregnant women suffer from a severe fear of childbirth (Saisto and Halmesmaki, 2003; Laursen et al., 2008; Nieminen et al., 2009; Schroll et al., 2011). Fear is commonly articulated as fear of unbearable pain, fear for the woman’s and infant’s safety, and fear of obstetric injuries (Schytt and Hildingsson, 2011). Findings from previous studies conducted in Australia (Johnson et al., 2002; Haines et al., 2011), the UK (Geissbuehler and Eberhard, 2002), Switzerland (Hall et al., 2009), the United States and Canada (Zar

Table 3 Distribution of the childbirth experience by ethnicity (n¼171).

Jewish Arab Total

n (%) n (%) n (%)

Helplessness 50 (43.5) 23 (41.1) 73 (42.7) χ2(1)¼ .09 Lack of control 73 (62.4) 44 (37.6) 117 (68.4) χ2(1)¼10.32 Too much medical intervention 31 (27.0) 24 (42.9) 55 (32.2) χ2(1)¼4.71 Fear during labour 78 (67.8) 47 (83.9) 125 (73.1) χ2(1)¼4.97n Fear for newborn’s safety 43 (37.4) 37 (66.1) 80 (46.8) χ2(1)¼12.44nnn Physically hurt during labour 24 (20.9) 14 (25.0) 38 (22.2) χ2(1)¼ .37 Her infant was physically hurt during labour 4 (3.5) 7 (12.5) 11 (6.4) χ2(1)¼5.09n Felt her life was in danger 15 (13.0) 15 (26.8) 30 (17.5) χ2(1)¼4.92n Felt her infant’s life was in danger 14 (12.2) 12 (21.4) 26 (15.2) χ2(1)¼2.50 Pain degree (0–100) M¼65.16

(SD¼32.21) M¼72.57

(SD¼29.74) M¼67.58

(SD¼31.53) t(169)¼1.45

Traumatic birth (self-assessed) 16 (13.9) 18 (32.1) 34 (19.9) χ2(1)¼7.86nn Traumatic birth (medical indicators) 51 (29.8) 16 (9.4) 67 (39.2) χ2(2)¼1.01

n po .05. nn po .01. nnn po .001.

O. Halperin et al. / Midwifery 30 (2014) 853–861858

et al., 2001) showed that fear of childbirth crosses cultural boundaries.

The influence of culture on this particular fear has rarely been examined in the present context, and we aimed to fill this gap. Results of the current study showed that the participants feared for themselves and for their infant’s safety during childbirth. This fear was significantly more common among the Arab women than among the Jewish women. Moreover, one-quarter of the Arab participants reported that they were physically hurt during labour, as compared to one-fifth of the Jewish participants. It is possible that the Arab women, who are less likely to attend formal pre- labour classes, had less information or coping skills as a tool to reduce their fears.

A possible explanation for the higher number of Arab women who rated their childbirth experience as traumatic is that fear during labour and feeling unsafe during childbirth can lead to negative memories and shape distressing recollections after child- birth (Ryding et al., 1998; Ayers et al., 2008; Dencker et al., 2010). Although the role of specific counselling for the fear of childbirth has not been shown to ‘cure’ this fear (Ryding et al., 2003; Sydsjo et al., 2012), clinicians must remain alert to women with serious distress and treat these women as soon as possible in order to prevent the consolidation of traumatic memories (Sarid and Huss, 2010). Positive recall of the birth experience is important with regard to future pregnancies and childbirths.

Our results reveal that a statistically significantly higher num- ber of Arab women had medical interventions during their labour and birth, such as induction of labour, episiotomy, use of analge- sics, and vacuum extraction. It is possible that the higher number of Arab womenwho perceive their birth experience as traumatic is related to the medical interventions and the mode of birth, such as vacuum extraction (Allen et al., 1998). These results corroborate previous studies, showing that dissatisfaction with the birth experience is frequently linked to descriptions of complicated, negative, or traumatic births (Waldenström et al., 2004; Dahlen et al., 2010). In particular, unplanned medical interventions during childbirth, such as oxytocin augmentation, emergency caesarean and operative vaginal childbirths, intrapartum complications, and the need for neonatal intensive care, are related to maternal dissatisfaction (Waldenström et al., 2004; Nystedt et al., 2005; Wiklund et al., 2007; Dencker et al., 2010).

Despite the frequent reporting of medical risk factors, such as a high average degree of pain (68), 20% emergency caesarean sections, childbirth lasting up to 72 hours (with a mean of about 10 hours), and various interventions (induction of labour, episiot- omy, maternal or neonatal medical problems), it is interesting to note that there were relatively few study participants who reported having a traumatic birth (29.8%). Nevertheless, it was more commonly reported among the Arab women (39.2%).

In Islamic canonical texts, mothers are described as objects of veneration. Mothers’ pain in labour and weariness in childcare are not viewed as punishment for sin, as described in the Genesis (Chapter 3), but rather as occasions for immense gratitude. Having a healthy infant is a triumph, accompanied by satisfaction and reward (Nelson, 2003). The Qur’an indicates that a Muslim ought to revere one’s mother because a mother ‘beareth him in weakness upon weakness, and his weaning is in two years’ (Qur’an 31:14). The Qur’an also acknowledges the ambivalence that mothers may feel, given the hardships associated with pregnancy and nursing: one’s ‘mother beareth himwith reluctance, and bringeth him forth with reluctance, and the bearing of him and the weaning of him’ (Schleifer, 1996, 52).