Maternal mental health matters : childbirth related care in Yemen through women's eyes

Background: Yemen has a high maternal mortality and a persistent high home birth rate. Though maternal mortality still lies at the heart of maternal health indicators, there is a growing concern about the impact of mental and behavioural health on maternal health outcomes. World Health Organization (WHO) is proposing a stronger focus on mental health for an integrated delivery of services for Maternal- and Child Health (MCH).

Aim: The overall aim is to gain insight into the experience of Yemeni women of modern and traditional care during childbirth, their perceived mental status and health care seeking patterns. The focus of the thesis is on women’s reproductive mental health in the context of culture and health care systems.

Methods: A multi-stage (stratified-purposive-random) sampling process was used. Two hundred and twenty women with childbirth experience in five governorates – Aden, Lahej, Hadramout, Taiz and Hodeidah – were interviewed by means of a semi-structured questionnaire. Half of the women lived in urban, half in rural areas. Questions concerned the most recent pregnancy and childbirth (location, attendance and perceived quality); postpartum period; women’s empowerment and social and demographic information. A pre-test of the questionnaire was carried out in Taiz. Interviews were made by two Yemeni nurse-midwives and two medical doctors, one of whom was an obstetrician-gynaecologist, and one a Sudanese nurse-midwife. All women approached for an interview were initially explained about the purpose of the study and asked whether they would agree to participate. Interviews lasted for 1-3 hours. All performed interviews were discussed daily among team members.

Results: A large majority of women perceived childbirth as a situation of danger. Fear of death and childbirth complications stemming from previous traumatic childbirth and traumatic experience in the community was rampant. Husbands’ and in-laws’ disappointment in a girl infant constituted a strong sociocultural component of fear. Women without fear gave reasons of faith, social belonging and trust in either traditional or modern childbirth practice, past positive experience of childbirth and the desire for social status associated with children (I). Women in areas with a matrilineal past who were often unassisted during childbirth experienced little fear (I, II). A graded negative association was found between the perceived authority of the woman in childbirth and the level of biomedical training of staff. Women who had their questions answered and requests met during childbirth had 83% higher probability to perceive their own authority and women who reported skin-to-skin contact/ newborn in arms 28% higher probability of not fearing birth (III). Three main themes explained their sense of authority: (i) ‘Being at the centre’; (ii) ‘A sense of belonging’ and (iii) ‘Husband’s role in childbirth’. Authority was experienced primarily among women within the traditional childbirth sector and among women with a matrilineal past (II, III). Women who had previously been able to follow their own individual choice in matters of childbirth were six times more likely to plan a future childbirth in the same location (IV).

Conclusions: Women's perceived own authority during childbirth is decreasing in the context of Safe Motherhood and the expansion of modern delivery care. This is an important reason why women underutilize professional care. Antenatal care has an important role in reducing fear of childbirth including that of institutional childbirth and in strengthening a couple in welcoming a female infant. Yemeni women’s low utilization of modern delivery care should be seen in the context of their low autonomy and status. We call for cooperation between modern and traditional childbirth care. In areas of Yemen with a matrilineal past women’s choice of place of delivery does not seem to be influenced by a need for authority during childbirth.

List of scientific papers

I. Annica Kempe, Töres Theorell, Fatoom Noor-Aldin Alwazer, Samera Abdullah Taher and Kyllike Christensson. Exploring women’s fear of childbirth in a high maternal mortality setting on the Arabian Peninsula. Global Mental Health. Vol. 2 January 2015 e10.
https://doi.org/10.1017/gmh.2015.6

II. Annica Kempe, Töres Theorell, Fatoom Noor-Aldin Alwazer, Kyllike Christensson and Annika Johansson. Yemeni women’s perceptions of own authority during childbirth: What does it have to do with achieving the Millennium Development Goals? Midwifery. Vol. 29, Issue 10, October 2013: 1182-1189.
https://doi.org/10.1016/j.midw.2013.05.013

III. Annica Kempe, Fatoom Noor-Aldin Alwazer and Töres Theorell. Women’s authority during childbirth and Safe Motherhood in Yemen. Sexual & Reproductive Healthcare. Vol. 1, Issue 4, November 2010: 129-134.
https://doi.org/10.1016/j.srhc.2010.07.001

IV. Annica Kempe, Fatoom Noor-Aldin Alwazer and Töres Theorell. The role of demand factors in utilization of professional care during childbirth: Perspectives from Yemen. ISRN Obstetrics and Gynecology. Vol. 2011, September 2011: 382487.
https://doi.org/10.5402/2011/382487