R Safadi

International Journal of Nursing Practice 2005; 11: 269276

R E S E A R C H PA P E R

Jordanian women: Perceptions and practices of rst-time pregnancy

Reema Safadi RN PhD
Assistant Professor, Al Zaytoonah Private University, Amman, Jordan

Accepted for publication May 2005

Safadi R. International Journal of Nursing Practice 2005; 11: 269276 Jordanian women: Perceptions and practices of rst-time pregnancy

A womans child-bearing encounter is an experience that reects the cultural beliefs and practices of the society. The purpose of this study was to describe the perceptions and practices of urban, low socioeconomic, Jordanian women (aged 18 30 years) in relation to their pregnancy career. An opportunistic sample consisting of 67 Muslim rst-time pregnant women who followed up antenatal care at two maternity-care centres in East Amman was selected. A qualitative approach, including ethnographic semistructured interview, participant observation data from the households and clinics and oblique interviewing in random conversations initiated by the primigravidae, was conducted over 18 months. Women gave elaborative accounts of their pregnancy and childbirth expectations in narrative, phenomenological forms. Qualitative data analysis was performed concurrently with data collection, revealing the essential themes of immediacy of pregnancy; familial support and changing networks, especially for the after-birth period; fear of pain and medical interventions, all emphasizing the traditional and religious perceptions and practices in a familial context. Key words: ethnography of pregnancy and birth, Islam, Jordan, primigravid women.

INTRODUCTION
This research paper is part of a larger study aimed at exploring the cultural factors involved in the behaviours of Jordanian, rst-time pregnant women and their family grouping. The study originated reexively from my observations in maternity wards and the literature about childbearing experience. The research concept was inuenced by three factors: (i) being a woman who was brought up in an Arab Muslim country; (ii) my own child-bearing experience in two different cultures, the United States of America and Jordan; and (iii) my nursing education background and specically reecting on my own observations in the maternity wards and clinics.

Literature review
Child bearing and childbirth is a personal experience that leaves its mark for a long period in a womans life. Researching this experience had its beginnings in the West by exploring birth outcomes and interventions. Research was initially concerned with safer birth and its technological organization, as indicated by the Peel Committee Report in 1970.1 Anthropologists, as part of their transcultural interests, investigated this experience to explore the cultural beliefs and practices of pregnancy, childbirth and the postpartum period.29 Jordans 1978 Birth in Four Cultures was a groundbreaker in the anthropology of birth, where she stated birth is everywhere socially marked and shaped.10 In Jordan, child-bearing care is still located within the medical model and women are well-attended medically in order to lower the statistics of maternal and infant mor 2005 Blackwell Publishing Asia Pty Ltd

Correspondence: Reema Safadi, Al Zaytoonah Private University, PO Box 925 555, Amman 11190, Jordan. Email: rsdoghmi@hotmail.com

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tality and morbidity rates.11,12 Leininger, the founder of cross-cultural nursing, pointed out recently that nursing care literature revealed no research related specically to the Arab Muslim culture.13 Khalaf and Callister conducted the only study discussing childbirth in Jordan.7 Their study sample, comprised of 32 women (14 primiparae and 18 multiparae) was interviewed within the rst few weeks after birth. Similarly, the purpose of this study is to highlight the common beliefs and practices of primigravid women, which will enable nurses and health professionals to understand more about the culture of childbirth and plan nursing care accordingly.

Ethically, each woman was interviewed privately to obtain her consent for participation. Women were assured that their decision to participate or withdraw would not affect their antenatal or postnatal care in the centre. Permission for recording the interviews was also elicited and the women were given the option to destroy the tape after transcription.

Data collection
Collecting data implied seeking participants own accounts of the child-bearing experience. This involved semistructured interviews, which were carried out primarily by the researcher. Besides interviewing, the researcher used the observational approach and the taking of eld notes to enrich the interview data. The cooperation of health-care providers (nurses, midwives and doctors) was an essential part of completing this study until the data was fully saturated. Spradley refers to the importance of ethnographic interviewing and participant observations to learn about the cultural beliefs of the people under study.15 All interviews were tape-recorded, transcribed verbatim, translated into English and underwent consecutive analysis, revealing themes as they emerged.

METHODS Design
In the current study, a qualitative design was selected to explore the cultural aspects of the child-bearing experience. It is an approach that explores the culture of a group or a subgroup from an emic perspective by using research methods that focus on the everyday life of the people. It explicates how people construct their social reality and offers accounts of that, making their experience accountable to others. Womens experience during pregnancy and childbirth is more than giving a report of the phenomenon under investigation. It involves a thick description, explaining the process producing the experience.14 By thick description, Geertz not only means discussing peoples values, rituals sentiments and justications, but also incorporating the more macro features of societys change processes. The population of the study (n = 67) was primigravid women visiting two maternity health-care centres in East Amman. They came from a low socioeconomic class (in reference to the husbands income) representing the urban, poor, working sector of the population. Selection was done by an opportunistic sampling method.The selection criteria included: rst-time pregnancy, married, age range = 1830 years, literate, not developing complications during pregnancy (i.e. pre-eclampsia or bleeding) and, most importantly, a willingness to participate. The demographic characteristics of the participants showed a mean age of 21.9 years, while the husbands mean age was 27.7 years. Educationally, women had a higher mean of years of school education than their husbands: 11.9 and 10.4 years, respectively.
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Tools
A semistructured questionnaire consisting of 120 openended questions was constructed for the data collection on the rst visit at the maternity health-care centre. This tool consisted of questions related to demographic information, family history, perceptions, expectations and practices. Another tool was the eld notes book for writing my observations during an interview or in maternity hallways. Some interviews were conducted during home visits where other family members were present, mainly the mother-in-law. If a woman raised a topic not in my sequence, I went with it and tried not to use the questionnaire as a rigid interview, which allowed the questions to ow like a long conversation resembling a jigsaw frame.

Sample

Data analysis
As the research was going on, data was emerging through various methods: the interviews, observations and childbirth notes. These ndings emerged over a period of 18 months, culminating in the nal three months of postbirth interviews. The childbirth and postpartum period are not discussed in this paper and it will only focus on

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the antenatal period interviews. Morgan stated that qualitative researchers use the data themselves as a source of their codes.16 Using my inside knowledge, or reexivity, as a cultural tool in the coding exercise, I began with a widely dispersed universe of the range of possible categories. Then, they were synthesized into broader categories, knowing the whole time that these were second order categories. An example of this is a womans statement referring to her expressions of delayed pregnancy and telling her husband, If it were for me, I would give you a twin every minute. In the broader meaning, this sentence gave more than one meaning: (i) the need for immediate pregnancy; and (ii) the pressure to which she is exposed to become pregnant. The overall meaning is the cultural value of giving birth to children, especially when newly married, to gain acceptance in a patrilineal context. The coding was done at different stages. This was done primarily between the researcher and another Jordanian nursing faculty member as the rst few interviews emerged. This led to the development of the initial themes to be probed further in the next interviews. The second stage of coding was performed between my supervisor and myself, a British male outsider and a Jordanian female insider to come to an agreement about a specic theme. This was part of a continuing dialogue. Data discourse with my supervisor prompted data-theorizing through discussions on some cultural meanings of the data. We started with some transcripts, read them together and then discussed the meanings of some of the answers. We agreed on some and disagreed on others. The idea differed based on the cultural meaning of the words. For example, I understood the meaning of a statement by one participant, My mother-in-law told me not to touch anything, as I heard it in its context: the mother-in-law was angry because the young woman was asleep all day and did not offer any help in housework chores, thus refusing her assistance then. The other explanation produced by my supervisor was that some societies practise cultural beliefs and taboos relating to the impurity of pregnancy. On matters like these, I noticed the importance of understanding the culture that the researcher is studying in order to make the appropriate interpretation of the meanings. The initial coding was done by noting key themes in the margin of the transcribed text and was nalized by identifying the most prominent themes. Checking frequencies of the codes was done to get a sense of what was

in the data.16 Codes were calculated, put into broader meanings and given as the nal theme of the child-bearing meaning.

FINDINGS
The following display of the ndings illuminates the pregnancy career by describing a womans demographic data, her background to pregnancy, its planning, expectations and practices. Before introducing the ndings, it is important to give a feeling of the research background and the participants who provided the data for this research. The total population of Jordan is 5 329 000, with an average household size of 5.8 persons. The population growth rate is 2.8% and follows the regions political population inux from the neighbouring countries. The total fertility rate is 3.5 in urban areas and 4.2 in the rural areas.17 As mentioned earlier, 67 primigravid women were selected from two maternity centres. Forty-ve per cent of them were married to a relative, that is, a cousin or a close second-degree relative. Thirty-ve per cent of the group lived in extended family housing with in-laws or in the same building in direct, daily contact. Economically, the only income to the family was the working husband, with a mean monthly income of $JD139. The gross domestic product per capita is $JD98, which puts them in the lower socioeconomic class.17 None of the participants worked during pregnancy. Three women (10%) smoked, which was stopped upon pregnancy, as the women told me of their awareness of the dangers of smoking during pregnancy. Sixty-four per cent of the husbands (n = 43) were smokers of >510 cigarettes per day. In general, these women followed an unlavish lifestyle, abiding with the Islamic rules of modesty, wearing hijab veils and long clothes. Although they shared a common social background, they differed in certain individual personality characteristics in respect to assertiveness, perceptions of their rights as individuals and inuences of external factors. It was apparent that some women were more critical of the family processes and health services. An example was one woman who stated that she was capable of telling her mother-in-law that she wanted to look after her baby in contrast to another who unwillingly yielded this right to her mother-in-law, which left the new mother to be only the bearer of the baby. Criticism of the health services was exemplied in statements, such as they (nurses) dont listen to you, they only wanted to do their job, not caring about how you feel, while other women felt submissive to nurses decisions regarding
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choices of care; for example, episiotomies or not seeing the baby immediately after birth.

Pregnancy background
Asking women about whether their rst pregnancy was planned or not reected the cultural and societal beliefs. The meaning of planning a pregnancy is different here. To this group of women, it did not mean a mathematically planned pregnancy according to the fertility cycle, but a matter of just a decision to have a baby or not and take it as it comes. Taking contraceptives is not taken into consideration by a newly wedded woman. However, some responses to planning the pregnancy were a mixture of uncertainty and lack of choice as it was implied that it was left to fate and Gods will to be decided (see Table 1). A common characteristic of all planned or unplanned pregnancies was to get pregnant immediately after getting married. Seventy per cent of the participants stated that they were subjected to pressure from various sources: inlaws (30%), husbands (20%), friends and community (12%) and parents (3%). Pressure was imposed very soon after marriage and became a monthly issue causing much of the marital conicts. A woman can be asked by her husbands family to seek medical assistance for infertility as early as three months after marriage, visiting one doctor after another looking for answers for the delayed pregnancy. A woman remains a stranger until she gives birth to a rst child. As her rst baby is born, her name changes, ignoring her rst name and, out of higher regard, she will be called Um, meaning the mother of, and followed by the boys name. If her rst born was a female, then a second immediate pregnancy is imminent in order to give birth to a male child.The birth of a male baby will honour her with the name and lead to her being integrated into the family.

However, women who did not plan a pregnancy were not upset or unhappy about its occurrence, nor were their husbands. The reasons given for not wanting a pregnancy were that they were still young and not yet ready to become a mother. One woman stated: My husband wants that we spend some time together to enjoy ourselves before having children. Husbands reasons for delaying pregnancy were mainly nancial constraints. These men were aspirant lower class, concerned about providing for their small family and the independence of their parents. All women were advised by family members against the use of contraceptives prior to the rst pregnancy and only natural methods, that is, abstinence or the calendar method, were allowed.

Pregnancy and expectations

In this area, a number of questions were raised to discuss a pregnant womans expectations of her supportive network, the number and gender of children she would like to have, the future of her baby, and pregnancy and birth experience expectations. Exploring the issue of the people expected to give support during pregnancy, husbands were given the highest expectations (45%), followed by mothers (42%) and sisters (15%). This high percentage of expected husbands support during pregnancy fell signicantly for the afterbirth period (6%). After birth, emphasis for support was placed on the mother (67%) and the mother-in-law (39%). Very few women indicated an independent role after birth (22.3%). Some common examples of statements given were: I want my husband because he is the most concerned. I want my mother with me because she will pray for me.

Table 1 Opinions about planning a pregnancy (n = 67) Description Planned this pregnancy Not planned this pregnancy Wanted immediate pregnancy Pregnancy determined by God Indeterminate N 29 33 47 17 5 % 43.3 49.0 70.0 25.4 7.5

Some participants gave more than one response.

Interestingly, health-care providers were expected to give the least support (6%). Enquiring about the place that women choose to stay at after giving birth and the discharge from the hospital indicated a preference for their own home (57%), followed by staying with their in-laws (28%) and their parents (15%). However, even though a woman wanted to stay at her own home, help was always anticipated by a mother or motherin-law moving in with her until the new mother undertakes the motherhood role.

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Expectations for children: number, gender and future

Questions about a womans preference regarding the number of children she wished to have presented a reection of the cultural value of children and family size. None of the participants indicated one child only, with a tendency for a larger family: two children (16%), three children or more (78%). The remainder of the group left it to Gods will as to the number He wanted to bestow on them. Regarding gender preference, 21% wanted male children and 25% wanted female children. Reecting on my own observations and interviews, I noticed that women were careful in telling me about their preference for a boy. They (54%) often used ambiguous answers by indicating to me that they did not favour any and would not dictate to God what they wanted. Reexively and from my own notes (March 1998) in one antenatal session, we discussed gender preference, and it was noted that there was a bias towards boys. This was justied by saying that it would please their husbands and families if they gave birth to a boy. Discussing the womens ideas for their babies future highlighted two values: higher education (79%), as in becoming doctors and engineers, and good manners (53%). Table 2 displays participants wishes for their babies future.

as backache, vomiting, and general fatigue, mood change, loss of appetite and sleeplessness (60%). During pregnancy, major concerns were related to the birth experience (40%), fear of having an abnormal baby (22%) and fear of medical intervention (18%). However, more than half (55%) indicated that they would not worry, leaving this fate to Gods care in an attempt to reassure themselves. Examples of the expressed fears of giving birth to abnormal children are given in the following excerpts: I want to have a normal baby because I am married to my cousin. I pray to Allah that I give birth to a normal baby. This fear is related to the womens awareness of recessive gene abnormalities that are frequently discussed in the media and the growing concern about consanguineous marriages. Other expected fears included the fear of pain during birth (67%), the fear of death during childbirth (28%) and the fear of exposure to strangers, especially male doctors (10%). Interestingly, it was observed that fears were associated with higher levels of complaints. For the postpartum period, worries about nancing the babys expenses were the greatest concern (42%). Fortyeight per cent of the group was pessimistic about the postpartum period. However, 34% of the group thought having a new member would bring harmony and happiness to the family. Some went on to add that the baby might improve their marital status and mitigate family friction. Forty per cent of the participants expressed worries about their lack of skills and signied low selfcondence in caring for their newborn baby.

Expectations of the child-bearing experience

During pregnancy, the majority of the participants expected multiple problems. Almost no one suggested a symptom-less or problem-free pregnancy. There were worries about physical and psychological symptoms, such
Table 2 Wishes for the babys future (n = 67) Wishes Follows father/mother Anything Allah wishes Pursuing higher education Good manners Good health Better than father/mother No response N 2 18 53 36 7 7 1 % 3.0 27.0 79.0 53.0 10.4 10.4 1.5

General practices and life activities during pregnancy

Questions in this area explored the lifestyle changes and plans of management during pregnancy. Here, I initiated the enquiry by investigating the lifestyle modication that occurred. A common feature about changes was related to physical problems, that is, backache, abdominal pain, headache, heartburn and leg and knee cramps. When the women mentioned these complaints, they described themselves as becoming lazier and sleepier for most of the day. Other changes included psychological complaints, such as mood changes that made the women less tolerant,
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Some participants gave more than one response.

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unable to sleep, with less desire for sexual activity and feeling bored and lonely. In general, lifestyle changes involved protective behaviours to prevent harming a pregnancy. This also applied to the husbands reaction and incorporation of pregnancy, as in becoming more distanced/protective of their wives (42%), distancing/ avoiding (12%), working harder to earn more money (22%) and no change of behaviour (36%). Researching husbands complaints, as told by the woman herself, during a pregnancy did not show any notable meaning here: there were stomach aches and heartburn complaints (16%). Almost 18% mentioned having minor complaints, such as headaches, toothaches, backache and nausea and vomiting. However, the majority (57%) indicated that nothing had changed and no new distinctive complaint was mentioned. Regarding cultural practices, there were two questions discussing womens view of placenta management and circumcision after birth. There was no specic belief related to the management of the placenta and the question raised curiosity regarding what possibly could be done with a placenta after birth. However, some women mentioned old stories they had heard from their mother, neighbours or friends about burying the placenta in the backyard, preventing animals from eating it and, thus, avoiding harm to the mother and the newborn baby. Others indicated that it was hung at the door post and dried in the sun as a measurement of baby protection. In reference to circumcision, this is a practice that is culturally valued and is thought to be an obligatory rite in Islam. Most women indicated their wish to have their baby boy circumcised early and even before being discharged from the hospital, as this would be pain-free and less harm is incurred. In general, it is to be celebrated with other practices, such as reading the Quran Athaan in the newborns ears and giving the baby a bath using salty water during the rst week of birth.

DISCUSSION
One striking aspect of this research work is the special relationship I built with the participants of this study, which allowed me to collect more data than what was expected. The interviews and antenatal classes (not discussed in this paper) were an opportunity for us to discuss participants concerns about pregnancy and other marital problems. At the beginning of class sessions, I noticed the womens reservation as they treated me like other authority gures, but as the classes went on, this hesitation was
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eliminated and they freely discussed health and personal matters that were considered embarrassing to talk about. This rapport informed me of the social encounter and family dynamics of the Jordanian family and enhanced my awareness of this groups needs and cultural views and obligations. An in-depth disclosure of husbandwife, wifein-laws, and woman and external, surrounding dyads informed me extensively and enabled me to perceive a feministic approach to this work. In the Arab world, the family is the basic unit of social organization. It evolved as a patriarchal, pyramidal system with respect to age, gender and extended relations.18 Inside a Jordanian family, based on the division of labour laws, the roles are segregated and traditionally considered as complementary. The father has the authority and is responsible for breadwinning and the mother is the housewife and is responsible for the rearing of children.The wife joins the husbands lineage, lives virilocally and the children take the fathers surname. A woman moves to the household of her husband and is caught within the axis of the sociodynamics of the mother-in-law and the husband. Initially, the woman is marginal and immediate pregnancy becomes an important aspect of this marriage in order to have her integrated into the new family dynamics. The immediacy of pregnancy was an essential theme that was repeated often by women who had difculties in getting pregnant early in their marriage. Statements such as It is expected to happen or everyone asks you if you are pregnant were very common. Social pressure allows the woman no choice but to follow what is expected from her. This pressure follows the religious rules, which encourage marriage and multiplication: Marriage is my custom: he who dislikes it does not belong to me (Hadith by Prophet Mohammed, Peace be upon Him). In another Hadith it was said Marry and multiply, so that I may be gloried in my community over other communities.19 Becoming a mother gives a woman a higher status in the family and a titular recognition, as in calling her Um, which means the mother of and followed by the boys name. This is not the case for a baby girl. After giving birth to a girl, a mother is not allowed a rest period and her status is insecure until she gives birth to a boy. Anthropologists studying birth in the region also mentioned this meaning of favouring boys. Morsy described the signicance of having children to men in an Egyptian village (FatiHa) by stating that fathers valued many children and males, in particular, and considered that as an indication of their virility.9 This was also emphasized by Granqvist about women in

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Palestine, repeating their saying, He who has sons born to him does not die.20 Nowadays, many of these values are still important in the rural and lower socioeconomic classes but of much less signicance among the educated and upper socioeconomic class. Recent statistics in Jordan show an average of 4.4 children in a family lifetime.21 A second theme of importance is the support given to mothers during pregnancy and birth. Living within an extended family, a newly pregnant woman is attached to both her family of origin and to her husbands family. From both she expects to receive affection, afrmation and aid.22 Support follows the traditional family laws and gender division of labour rules. It is the responsibility of the female side of the family. The father is external and he is not expected to provide either psychological support or child care after the birth. His only responsibility is nancial and it is appreciated as his lone task. It was frowned upon if I asked whether the father is expected to change the babys nappies or to give him/her a bath. Richman discussed couvade and pregnant fathers describing complaints, such as sickness, headaches and eye complaints. He also elaborated on the pregnancy careers of fathers along four axes in a dynamic process: (i) the father denies pregnancy; (ii) the father claims that it is the wifes responsibility, denying his role; (iii) the father develops a special bond with the foetus and provides emotional and instrumental help; and (iv) the father claims total identication with the foetus.23 The health-care providers were not regarded as supporters during pregnancy or birth. In the current study, support from a health professional during pregnancy and birth has little signicance to a womans feelings. Their role was perceived within the medical perspective and was rarely involved in antenatal education. A great emphasis was placed on the ultrasound examination, which was especially liked for sex identication purposes. This nding was congruent with what was described by Machin and Scamell.24 Pain expectations, medical intervention, exposure to strangers and abnormality of the newborn were themes associated with birth. These fears were intensied by stories told by other females who experienced a painful, fullof-agony birth. The modern trend of hospital birth is the only accepted trend to these women and a home birth is something of the past. Hospital is a safe place and is associated with the social class advantage. In hospitals, they feel that pain is controlled by medication and that they will not die during birth. It is important to mention here,

that in Jordan, health-care policies are in favour of hospital births for multiple reasons: (i) to improve maternal statistics, that is, neonatal and maternal mortality and morbidity rates; (ii) emergency management difculties related to transportation to hospitals, especially in rural areas; and (iii) the shortage of trained and qualied midwives. Thus, a woman becomes the subject of health-care providers and loses control over her body. Decisions are made for her, including medical interventions, such as enemas, intravenous lines, abdominal monitoring, episiotomies and whatever the care providers think convenient. The husband and female relatives are not allowed to go into labour rooms and, thus, her expected support person is absent during this critical stage of her life. This rule can only be broken if it were a health-care professionals relative or, in special cases, a relative to someone from a higher, prestigious socioeconomic class. To conclude this discussion, it is thought that the expectations and practices of pregnancy uctuate between the old and the new trends. Pregnancy and childbirth are perceived by many Jordanians to be within the traditional and religious expectations, with the extended family providing the psychological and physical support; nevertheless, with the expectation of being away from home in a hospital and under medical supervision using the latest medical facilities. Women still borrow traditional pregnancy practices and birth rituals from the past, but have lost the control over their body by following the recent trends in todays medical technological birth.

LIMITATIONS OF THIS STUDY

It must be remembered here that this study, part of a PhD thesis, was performed single-handedly and, thus, it was not convenient for temporal and nancial reasons to get a more representative sample of the Jordanian population. It only represented a small stratum of the population, making it limited in the generalizability to the whole society. Second, being a researcher from the same culture, although it has some advantages in understanding the meaning of the culture, also might have inuenced the informants accounts of their reality. By this, I mean that they might have taken into consideration the social biases and tried to give me the ideal response that is believed to be accepted in this culture.

RECOMMENDATIONS
The ndings of this study highlight the impact of cultural beliefs on the child-bearing experience. In this regard, it is
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important to realize and respect these inuences, such as the familial network of support, by giving a more active role for the support person, be it the husband or the mother or the mother-in-law. A second point is the ways in which decisions of reproduction are made. Thus, it is important to make the effort to guide families to promote a healthier reproductive life. Third, it is essential to examine the health-care professionals role in providing care and to encourage the inclusion of formal antenatal education as part of the services provided during the childbearing period. A nal recommendation is to address the idea of whether it would be possible for hospitals to incorporate the fathers at births. For further research, a longitudinal study is recommended to disclose more of the cultural aspects of the child-bearing experience. Additionally, a more representative sample of the Jordanian population is recommended.

IMPLICATIONS FOR NURSING PRACTICE

The results of this study have implications for maternity practice, especially in the transcultural perspective. Matters such as antenatal education, understanding family dynamics and support systems are points of reference in giving care to women during this important phase of a womans life. In other words, it is of relevance here for nurses and midwives to integrate the cultural aspects of the experience with the new trends of technology and science without wiping away or ignoring the good of either of these factors.

ACKNOWLEDGEMENTS
This study was conducted at Manchester Metropolitan University, United Kingdom, under the supervision of Professor Joel Richman and Professor Jim Lord. Many thanks are forwarded to them for their support and enrichment of this work.

REFERENCES
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5 Jordan B. Birth in Four Cultures. A Crosscultural Investigation of Childbirth in Yucatan, Holland, Sweden, and the United States. Montreal: Eden Press Womens Publications, 1978. 6 Kay M. Anthropology of Human Birth. Philadelphia: FA Davis Company, 1982. 7 Khalaf I, Callister L. Cultural meanings of childbirth: Muslim women living in Jordan. Journal of Holistic Nursing 1997; 15: 373388. 8 Kitzinger S. The Experience of Childbirth, 4th edn. Harmondsworth: Penguin Books, 1978. 9 Morsy S. Childbirth in an Egyptian village. In: Kay M (ed.). Anthropology of Human Birth. Philadelphia: FA Davis Company, 1982; 147174. 10 Davis-Floyd R, Sargent C (eds). Childbirth and Authoritative Knowledge: Cross-cultural Perspectives. Berkeley: University of California Press, 1997. 11 Ziadeh S, Sunna E. Decreased cesarean birth rates and improved perinatal outcome: A seven-year study. Birth 1995; 22: 144147. 12 Ziadeh S, El-Jallad M, Sunna E. Obstetric uterine rupture: A four-year clinical analysis. Gynecologic and Obstetric Investigation 1999; 48: 176178. 13 Leininger M (ed.). Transcultural Nursing: Concepts, Theories, Research and Practices, 2nd edn. New York: McGraw-Hill, 1995. 14 Geertz C. The Interpretation of Cultures: Selected Essays. London: Hutchinson, 1973. 15 Spradley J. The Ethnographic Interview. New York: Holt, Rinehart & Winston, 1979. 16 Morgan D. Qualitative content analysis: A guide to paths not taken. Qualitative Health Research 1993; 3: 112121. 17 Department of Statistics. Jordan in Figures. 2003. Available from URL: http://www.dos.gov.jo/dos_home/jorg/ 2003/JOR_F_e.htm. Accessed 28 July 2003. 18 Barakat H. The Arab World: Society, Culture, and State. Berkeley: University of California Press, 1993. 19 Jeffery A (ed.). Islam: Mohammad and His Religion. Indianapolis: Bobb Merrill, 1958. 20 Granqvist H. Birth and Childhood among the Arabs: Studies in a Muhammadan Village in Palestine. Helsingfors, Finland: Sderstrm, 1947. 21 Department of Statistics. [Statistical Annual Yearbook 1997.] Amman, Jordan: Department of Statistics, Hashemite Kingdom of Jordan, 1998 (in Arabic). 22 Tarkka M, Paunonen M. Social support and its impact on mothers experiences of childbirth. Journal of Advanced Nursing 1996; 23: 7075. 23 Richman J. Mens experiences of pregnancy and childbirth. In: McKee L, OBrien M (eds). The Father Figure. London: Tavistock, 1982; 89103. 24 Machin D, Scamell M. The experience of labour: Using ethnography to explore the irresistible nature of the biomedical metaphor during labour. Midwifery 1997; 13: 78 84.