Perspectives on Maternity Services in Saudi Arabia

308 Pages·2017·5.12 MB·English

by  Ibtesam Jahlan

Perspectives on Birthing Services in Saudi Arabia

Submitted by

Ibtesam Jahlan
RN, Masters of Clinical Midwifery

A thesis submitted in total fulfilment of requirement for the degree of
Doctor of Philosophy
Monash University

Monash University
Faculty of Medicine, Nursing and Health Sciences
School of Nursing and Midwifery
September 2016
i
Copyright Notices
© Ibtesam Jahlan (2016)

Notice 1
Under the Copyright Act 1968, this thesis must be used only under the normal conditions of scholarly
fair dealing. In particular no results or conclusions should be extracted from it, nor should it be copied or
closely paraphrased in whole or in part without the written consent of the author. Proper written
acknowledgement should be made for any assistance obtained from this thesis.

Notice 2
I certify that I have made all reasonable efforts to secure copyright permissions for third-party content included
in this thesis and have not knowingly added copyright content to my work without the owner's permission.

ii
Declaration
This thesis contains no material which has been accepted for the award of any other degree or
diploma at any university or equivalent institution and that, to the best of my knowledge and belief,
this thesis contains no material previously published or written by another person, except where
due reference is made in the text of the thesis.

Signature:
Ibtesam Jahlan
Date: 09/09/2016.
Ethical approval for this study was granted by the Standing Committee on Ethics in
Research involving Human (SCERH), which is known now as the Monash University Human
Research Ethics Committee (MUHREC). (Appendix IV)
On 4 February 2013; Project number: CF12/1331 – 2012000685.

iii
Acknowledgments
In the Name of Allah, the Most Merciful, the Most Compassionate, I would like first to praise
Allah, who is my primary source of empowerment and who has given me the strength necessary to
keep me going through to the end, especially with four children. Also, I thank Allah for my good
health and for facilitating every stage of this study.
It is my pleasure to thank my supervisor, Associate Professor Virginia Plummer for her patience
and amazing endless academic and personal support and guidance. This support began from the
earliest stages; from choosing the research topic, through the study itself, and until the final
submission. I would also like to extend my thanks to Associate Professor Meredith McIntyre for
her continuous supervision and greatly valued advice and suggestions following the confirmation
of this study. I am also thankful to Prof. Dr. Salma Moawed (Nursing College, King Saud
University, Saudi Arabia) for her external supervision and support during all stages of this study. I
would also like to thank Dr. Carole Gilmour for her supervision in the early stages of the study
leading up to the confirmation of my candidature.
Special thanks also to Dr.Baki Billah for provision of statistical consultation during and after the
data analysis stage of this study. Thank you also to Ms Sara Cielsielski for her editorial assistance.
I extend my deepest gratitude to my husband Adel and my children, Fawz, Salem, Fai and my little
Sarah, who were my journey companions. First, I would like to acknowledge Adel’s support and
sacrifices, as he resigned from his job to support my decision to continue my studies in Australia.
Also, my children who were always there to provide me with direct and indirect support and
encouragement, which helped me greatly in easing any problems I faced and giving me the
iv
confidence to overcome them. I especially thank my eldest daughter Fawz for the help she
provided in taking care of her siblings and for the way that she empowered me by showing her
pride in me and her belief that I can do anything I set out to do. Adel and my children have been
my main source (after Allah) of support and encouragement while conducting this study.
My special gratitude to my family overseas: my mother Nawal, my Father Omar, my sisters
Reham, Rana, Wejdan, Rahaf and Ohoud, and my brothers Saeed and Mohammed for their
continuous prayers, support, and encouragement at every stage of this study.
I would like to thank my best friend, Najat, for her continuous support and advice. From the bottom
of my heart, I thank my friends in Australia Sara, Hawa, Nofa, Ebaa, Fahimah, Nawal and Abeer.
We all listened to and supported each other in overcoming any struggles or problems we faced.
I would like to express my heartfelt thanks to all of the participants, who gave of their time to add
value to this study. Without their kindness in sharing their thoughts, experiences, and views, the
study would not have been possible.
Finally, I acknowledge the financial support of King Saud University Nursing College.

v
Prologue
My personal journey with nursing and midwifery started many years ago and it was not planned. In
2000 I did not know anything about nursing I did not even know that there was a specialisation
called nursing at the university. With the help of a friend, I chose to apply for nursing, despite the
disapproval of my mother and many close relatives and friends (because I was the first women in
my family to join the medical field), unaware of the community’s disrespectful view towards
nurses. From the beginning, my vision was clear to finish the Bachelor degree, and then to apply
for work at the university so that I could obtain a scholarship for Masters and Doctoral degrees.
Before I was awarded the scholarship, I was already married and had two of my children. This
meant that the decision to travel for study was not only about me. I was introduced to Australia for
the first time by a representative of the Australian Ministry of Health (from the Nursing and
Midwifery School at Monash University), who visited the nursing college at King Saud University
while she was in Riyadh. During her visit, she talked about a new course called a Masters of
Clinical Midwifery. At that moment, I felt that she spoke to me directly, as this was an ideal course
for me.
I moved to Melbourne in 2008 with my family and started a midwifery journey that was full of
happy and unhappy moments and struggles: with new culture, new systems, new relationships and
increased responsibilities. I greatly enjoyed the practical, theoretical and research components of
this Masters course.
In my earlier study on the phenomenology of Saudi women’s views and experiences of first-time
episiotomy, I noted their willingness to talk. Women were happy to talk about their whole
vi
childbirth experiences, from the time they knew they were pregnant until the moment they were
discharged from the hospital. I realized the value of this information, the need to gather it, and how
it could affect services provision in Saudi Arabia. The value of listening to women has been
recognised in maternity care services the world over. As a Saudi woman who has experienced
giving birth in Saudi and Australian hospitals, I recognized that women’s voices are not heard in
Saudi Arabia, and they are not given the chance to exercise their childbirth rights.
Every woman should have the chance to speak up and the opportunity to express her feelings and
reflect on her birth experience. The feedback from the women is extremely valuable, and
policymakers must take it into consideration when reviewing birthing services. This need has
directed my PhD research to explore birthing services in Saudi Arabia through women’s
perceptions. I add clinicians’ and administrators’ perceptions to complete the picture of the current
birthing services available in Saudi Arabia.
Undertaking a PhD in midwifery has assisted me to grow and develop over the last five years,
giving me the confidence to define, advocate for, and complete my research project; to present at
national and international conferences; and to learn how to publish papers. By the last year of my
PhD, I felt a great deal of responsibility for empowering women in my country by educating them
about midwifery and birth. I did not wait until my PhD was finished to do that. I had already started
using social media to educate women: I use my Snapchat account to broadcast educational
materials about different topics related to pregnancy and natural birth. I received hundreds of
messages from women after each topic I delivered, thanking me for the useful information and
telling me that they wanted more. I look forward to returning home and working to support the
midwifery identity and to empower women.
vii
viii
Abstract
The government of the Kingdom of Saudi Arabia (KSA) has recently announced its vision for
2030. This vision is organised into a number of themes: a vibrant society, a thriving economy and
an ambitious nation. The vision highlights the goals to be achieved by that year. One of the key
goals is improving the quality of health services delivered to the community from the capacity of a
developing country to the level of a modern economy.
The research presented in this thesis can be considered a first step in improving the quality of
maternity care, through its examination of the birthing services currently prevailing in KSA. The
aim is to uncover the perspectives of birthing services by women, clinicians and administrators in
Saudi Arabia, to explore the current services, identifying care delivered now in KSA and what is
needed in the future. This was accomplished by exploring the perspectives of women who receive
care and clinicians and administrators who provide care and where the literature is virtually silent.
This thesis presents the findings of 300 questionnaires completed by women prior to their
discharge from hospital, describing their perceptions of birthing and their satisfaction with the birth
care they received. Further, the findings of questionnaires completed by 59 obstetricians and 79
nurses and midwives are reported. The questionnaires were designed to collect both quantitative
and qualitative data, and were collected in specialised maternity hospitals in three cities in Saudi
Arabia: Riyadh, Jeddah, and Dammam. Qualitative data gathered in this study also included three
interviews conducted by the researcher with a nursing director from each hospital.
There were a number of important findings: first, that women’s satisfaction and perception of
control during birth is associated with the presence of supportive, cooperative clinicians who are
ix
good listeners, as well as with the women’s active participation in decision making related to the
birth. Women’s birthing experiences were also improved when their pain was managed well and
when they received individualised, up-to-date, evidence-based birthing care. The study revealed
that there is a gap between clinicians’ and women’s perceptions of their care, suggesting that
clinicians need more support from administrators to deliver safe, evidence based practice care and
meet women’s expectations.
The findings are likely to contribute to an improvement in birthing services and midwifery practice
in Saudi Arabia. In particular, the study draws attention to closing the gap between women’s and
clinicians’ perceptions of safe and satisfying midwifery care and makes it of value to educators,
researchers, clinicians, policymakers and administrators in the maternity health care system in
Saudi Arabia.

x