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  • 1.
    Adlers, Ann-Cathrine
    Högskolan i Halmstad, Sektionen för hälsa och samhälle (HOS).
    Att främja normal förlossning: Barnmorskans främsta uppgift2011Independent thesis Basic level (degree of Bachelor), 10 poäng / 15 hpOppgave
    Abstract [sv]

    En graviditet och förlossning är i de allra flesta fall en normal livshändelse. De senaste decennierna har andelen instrumentella- och kejsarsnittsförlossningar ökat på bekostnad av den normala förlossningen. Trots fler interventioner ses ingen skillnad i den maternella och perinatala morbiditeten och mortaliteten. I barnmorskans arbetsområde ingår att handlägga den normala graviditeten och förlossningen. Syftet med studien var att beskriva hur barnmorskan kan främja en normal förlossning. Studien genomfördes som en litteraturstudie där 13 vetenskapliga artiklar, med både kvantitativ och kvalitativ ansats, analyserades. I resultatet framkom tre kategorier som beskriver hur barnmorskan främjar normal förlossning. Barnmorskan skapar genom närhet en god relation till kvinnan och ger vägledning. Genom att använda sig själv som kunskapskälla bidrar barnmorskans sinnen, erfarenheter av tidigare förlossningar och formell kunskap till att fatta korrekta beslut. Barnmorskan stödjer och bekräftar det normala individuellt efter kvinnans behov, vilket skapar en säker miljö runt kvinnan och förhindrar onödiga interventioner. Då det råder en medicinsk kultur inom förlossningsvården, behöver barnmorskans arbete kring normal förlossning stärkas. Forskning behövs på organisationsnivå, eftersom omgivande system inverkar på barnmorskans arbete med att främja den normala förlossningen.

  • 2.
    Adlers, Ann-Cathrine
    Högskolan i Halmstad, Sektionen för hälsa och samhälle (HOS).
    Att verka som lots - Ett sätt för barnmorskan att främja normal förlossning2012Independent thesis Advanced level (degree of Master (One Year)), 10 poäng / 15 hpOppgave
    Abstract [sv]

    Trots att majoriteten av alla graviditeter bedöms normala, ses en ökad frekvens av interventioner under förlossningsförloppet, där kejsarsnitt utan medicinsk indikation utgör en del. En orsak kan vara att vården av kvinnor med okomplicerad graviditet, bedrivs på samma nivå som en komplicerad graviditet. För både kvinnan och barnet kan ett kejsarsnitt leda till ökad risk för hälsoproblem. I barnmorskans ansvarsområde ingår att självständigt handlägga vården vid normal, okomplicerad graviditet och förlossning. Barnmorskan har i sitt arbete även möjlighet att verka för att främja kvinnors hälsa. Syftet med studien var att öka förståelsen för hur förlossningsbarnmorskor främjar den normala förlossningsprocessen. En icke deltagande observationsstudie, av sammanlagt fyra barnmorskor i verksamhet på förlossningsavdelning, genomfördes vid två sjukhus. Grounded Theory användes som metod för datainsamling och analys. Som resultat framkom kärnkategorin att verka som lots samt fyra underkategorier. Primärt skapar och förankrar barnmorskan en relation med kvinnan. Genom förlossningens olika faser bedömer, underlättar och bekräftar barnmorskan förlossningsförloppet individuellt efter kvinnans behov. Kategorierna formar tillsammans en modell som beskriver vad barnmorskan utför; i verbal och i tyst kommunikation och i att agera eller att avstå från att agera, för att främja en normal förlossning. Behov finns av fortsatt forskning kring vad i barnmorskans handläggning av förlossningsprocessen som gynnar den normala förlossningen. Det är även väsentligt med forskning på organisationsnivå då det inverkar på hur barnmorskan främjar den normala förlossningen.

  • 3.
    Carlsson, Ing-Marie
    Högskolan i Halmstad, Akademin för hälsa och välfärd, Centrum för forskning om välfärd, hälsa och idrott (CVHI), Hälsofrämjande processer.
    Being in a safe and thus secure place, the core of the early labour: A secondary analysis in a Swedish context2016Inngår i: International Journal of Qualitative Studies on Health and Well-being, ISSN 1748-2623, E-ISSN 1748-2631, Vol. 11, artikkel-id 30230Artikkel, forskningsoversikt (Fagfellevurdert)
    Abstract [en]

    Background: Early labour is the very first phase of the labour process and is considered to be a period of time when no professional attendance is needed. However there is a high frequency of women who seek care at the delivery wards during this phase. When a woman is admitted to the delivery ward, one role for midwives is to determine whether the woman is in established labour or not. If the woman is assessed as being in early labour she will probably then be advised to return home. This recommendation is made due to past research that found that the longer a woman is in hospital the higher the risk for complications for her and her child. Women have described how this situation leaves them in a vulnerable situation where their preferences are not always met and where they are not always included in the decision-making process.

    Aim: The aim of this study was to generate a theory based on where a woman chooses to be during the early labour process and to increase our understanding about how experiences can differ from place to place.

    Methods: The method was a secondary analysis with grounded theory. The data used in the analysis was from two qualitative interview studies and 37 transcripts.

    Conclusion: The findings revealed a substantive theory that women needed to be in a safe and thus secure place during early labour. This theory also describes the interplay between how women ascribed their meaning of childbirth as either a natural live event or a medical one, how this influenced where they wanted to be during early labour, and how that chosen place influenced their experiences of labour and birth.

  • 4.
    Carlsson, Ing-Marie
    et al.
    Högskolan i Halmstad, Akademin för hälsa och välfärd, Centrum för forskning om välfärd, hälsa och idrott (CVHI), Hälsofrämjande processer.
    Hallberg, Lillemor R.-M.
    Högskolan i Halmstad, Akademin för hälsa och välfärd, Centrum för forskning om välfärd, hälsa och idrott (CVHI), Gruppen för forskning om hälsofrämjande och Livsstilsförändrande arbete.
    Odberg Pettersson, Karen
    Högskolan i Halmstad, Akademin för hälsa och välfärd, Centrum för forskning om välfärd, hälsa och idrott (CVHI).
    Swedish women's experiences of seeking care and being admitted during the latent phase of labour: A grounded theory study2007Inngår i: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 25, nr 2, s. 172-180Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Objective: to gain a deeper understanding of how women who seek care at an early stage experience the latent phase of labour.

    Design: a qualitative interview study using the grounded theory approach.

    Setting: the study was conducted at a hospital in the southwestern part of Sweden with a range of 1600-1700 deliveries per year. The interviews took place in the women's homes two to six weeks after birth.

    Participant: eighteen Swedish women, aged 22-36, who were admitted to the tabour ward while they were stilt in the latent phase of tabour.

    Findings: 'Handing over responsibility' to professional caregivers emerged as the core category or the central theme in the data. The core category and five additional categories formed a conceptual model explaining what it meant to women being admitted in the early stage of tabour and their experiences of the Latent phase of tabour. The categories, which all related to the core category, were labelled: (1) 'longing to complete the pregnancy,' (2) 'having difficulty managing the uncertainty,' (3) 'having difficulty enduring the stow progress,' (4) 'suffering from pain to no avail' and (5) 'oscillating between powerfulness and powerlessness.'

    Conclusions and implications for practice: findings indicate that women being admitted to the tabour ward in the latent phase of tabour experienced a need for handing over responsibility for the tabour, the welt-being of the unborn baby, and for themselves. Midwives have an important role in assisting women with coping during the latent phase of tabour, and in giving the women opportunity to hand over responsibility. This care should include validation of experienced pain and confirmation of the normality of the slow process, information and support. © 2007 Elsevier Ltd. All rights reserved.

  • 5.
    Carlsson, Ing-Marie
    et al.
    Högskolan i Halmstad, Akademin för hälsa och välfärd, Centrum för forskning om välfärd, hälsa och idrott (CVHI), Hälsofrämjande processer.
    Ziegert, Kristina
    Högskolan i Halmstad, Akademin för hälsa och välfärd, Centrum för forskning om välfärd, hälsa och idrott (CVHI), Hälsofrämjande processer.
    Sahlberg-Blom, Eva
    Hälsoakademin, Örebro University, Örebro, Sweden.
    Nissen, Eva
    Karolinska Institutet, Stockholm, Sweden.
    Maintaining power: Women's experiences from labour onset before admittance to maternity ward2011Inngår i: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 28, nr 1, s. 86-92Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: in Sweden pregnant women are encouraged to remain at home until the active phase of labour. Recommendation is based on evidence, that women who seek care and are admitted in the latent phase of labour are subjected to more obstetric interventions and suffer more complications than women who remain at home until the active phase of labour. The aim of this study was to obtain a deeper understanding of how women, who remain at home until the active phase of labour, experience the period from labour onset until admission to labour ward. Method: interviews were conducted with 19 women after they had given birth to their first child. A Constructivist Grounded theory method was used. Findings: 'Maintaining power' was identified as the core category, explaining the women's experience of having enough power, when the labour started. Four related categories: to share the experience with another', to listen to the rhythm of the body', to distract oneself and to be encased in a glass vessel', explained how the women coped and thereby maintained power. Conclusions: the first time mothers in this study, who managed to stay at home during the latent phase of labour, had a sense of power that was expressed as a driving force towards the birth, a bodily and mental strength and the right to decide over their own bodies. This implies that women who maintain power have the ability to make choices during the birth process. The professionals need to be sensitive, supportive and respectful to women's own preferences in the health-care encounter, to promote the existing power throughout the birthing process. © 2010 Elsevier Ltd.

  • 6.
    Ehrnberger, Karin
    et al.
    Royal Institute of Technology, School of Machine Design, Stockholm, Sweden.
    Räsänen, Minna
    Södertörn University, Huddinge, Sweden.
    Börjesson, Emma
    Högskolan i Halmstad, Akademin för informationsteknologi, Halmstad Embedded and Intelligent Systems Research (EIS).
    Hertz, Anne-Christine
    Högskolan i Halmstad, Akademin för informationsteknologi, Halmstad Embedded and Intelligent Systems Research (EIS).
    Sundbom, Cristine
    Royal College of Arts, Crafts and Design, Stockholm, Sweden.
    The Androchair: Performing Gynaecology through the Practice of Gender Critical Design2017Inngår i: Design journal, ISSN 1460-6925, E-ISSN 1756-3062, Vol. 20, nr 2, s. 181-198Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    This paper highlights the important role that design plays when it comes to women's overall experiences of ther gynaecological examination. It exemplifies how the examination can become renegotiable through the practice of a critical design. We will reflect this in the design of the contemporary gynaecological examination chair (GEC). We used women's experiences as a starting point for the design of an Androchair (a conceptual male equivalent of the GEC), in order to make the experiences critically visible. Inspired by the view of the gynaecological examination as a performance where the Androchair is represented as a prop and was placed on a stage as a discussion object during a public seminar. The Androchair allowed for both critical and multiple readings of the GEC and through that, the gynaecology examination at large. Moreover, it stimulated a discussion about alternative ideas towards achieving a more positive experience. © 2017 Informa UK Limited, trading as Taylor & Francis Group.

  • 7.
    Grönvall, Kerstin
    et al.
    Högskolan i Halmstad.
    Larsson Lantz, Åsa
    Högskolan i Halmstad.
    Förlossningsplanen: till nytta eller hinder?2012Independent thesis Basic level (degree of Bachelor), 10 poäng / 15 hpOppgave
    Abstract [sv]

    Förlossningsplaner är sedan några årtionden tillbaka vanligt förekommande inom vården av födande kvinnor. I barnmorskans profession ingår att i dialog med de blivande föräldrarna ge stöd och förberedelse inför förlossning, och att ge stöd, trygghet och kontinuitet under förlossningen. Vården ska bedrivas i samråd med de blivande föräldrarna. Förlossningsplanen kan ha olika utformning och kan vara skriven av föräldrarna själva eller tillsammans med barnmorskan. Dess syfte är att underlätta kommunikationen mellan kvinnan och vårdgivaren, och att öka kvinnans deltagande i beslutsfattande. Önskemålen i förlossningsplanerna varierar och speglar de blivande föräldrarnas olikheter. Det finns ett behov av kunskap om förlossningsplanens betydelse i vården, och om den har någon positiv effekt för den födande kvinnan. Syftet med litteraturstudien var att belysa effekten av förlossningsplanen ur den födande kvinnans perspektiv. I litteraturstudien bearbetades elva vetenskapliga artiklar som grund för resultatredovisningen. Resultatet visar att förlossningsplanen kan påverka kvinnans förlossningsupplevelse, relation med vårdgivare och egenmakt att hantera förlossningen positivt, men den kan också  ha en negativ effekt på relationen med vårdgivaren och öka kvinnans oro. Förlossningsplanen bör utarbetas i god tid med hjälp av barnmorska, och det är viktigt att förlossningsplanen uppmärksammas och används under förlossningen. Fortsatt forskning om blivande föräldrars inflytande, och om maktbalansen mellan dem och vårdgivaren behövs.

  • 8.
    Johannesson, Ulrika
    et al.
    Division of Obstetrics and Gynecology, Department of Clinical Sciences, Danderyd Hospital, Stockholm.
    Sahlin, Lena
    Division of Reproductive Endocrinology, Department of Woman and Child Health, Karolinska Institutet, Stockholm.
    Masironi, Britt
    Division of Reproductive Endocrinology, Department of Woman and Child Health, Karolinska Institutet, Stockholm.
    Hilliges, Marita
    Högskolan i Halmstad, Sektionen för ekonomi och teknik (SET), Bio- och miljösystemforskning (BLESS), Biomekanik och biomedicin.
    Blomgren, Bo
    AstraZeneca Safety Assessment, Södertälje.
    Rylander, Eva
    Division of Obstetrics and Gynecology, Department of Clinical Sciences, Danderyd Hospital, Stockholm.
    Bohm-Starke, Nina
    Division of Obstetrics and Gynecology, Department of Clinical Sciences, Danderyd Hospital, Stockholm.
    Steroid receptor expression and morphology in provoked vestibulodynia2008Inngår i: American Journal of Obstetrics and Gynecology, ISSN 0002-9378, E-ISSN 1097-6868, Vol. 198, nr 3, s. 311.e1-311.e6Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Objective: This study was undertaken to survey the steroid receptor expression and morphology in the vulvar vestibular mucosa in women with provoked vestibulodynia.

    Study Design: Fourteen patients and 25 controls without oral contraceptives were included. Vestibular biopsy specimens were obtained and analyzed by using immunohistochemistry, followed by computerized image analysis of estrogen receptors greek small letter alpha and β, progesterone receptors A and B, glucocorticoid receptor, androgen receptor, and the proliferation marker Ki67. The morphology was estimated by measuring 4 parameters in the epithelium.

    Results: There was a significantly higher expression of estrogen receptor greek small letter alpha in both the epithelium (P = .04) and the stroma (P = .02) in the patient specimens compared with the controls. There were no significant differences in the other analyses performed.

    Conclusion: There is an increased expression of estrogen receptor greek small letter alpha in the vestibular mucosa but the epithelial morphology seems unaffected in women with provoked vestibulodynia. Further studies regarding plausible associations to neurogenic inflammation are needed.

  • 9.
    Mirskaya, Maria
    et al.
    Högskolan i Halmstad, Akademin för hälsa och välfärd.
    Lindgren, Eva-Carin
    Högskolan i Halmstad, Akademin för hälsa och välfärd, Centrum för forskning om välfärd, hälsa och idrott (CVHI).
    Carlsson, Ing-Marie
    Högskolan i Halmstad, Akademin för hälsa och välfärd, Centrum för forskning om välfärd, hälsa och idrott (CVHI).
    Online reported women’s experiences of symptomatic pelvic organ prolapse after vaginal birth2019Inngår i: BMC Women's Health, ISSN 1472-6874, E-ISSN 1472-6874, Vol. 19, artikkel-id 129Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Pelvic organ prolapse (POP) is a major public health problem with a relative high lifetime risk of surgery. The main risk factor for developing POP is vaginal birth. Many women become symptomatic later in life and most of the existing research on symptomatic pelvic organ prolapse (sPOP) predominantly concentrates on the effects of the condition on postmenopausal women. However bothersome symptoms of POP can be reported as early as in women’s 20s and may occur shortly after vaginal birth. Limited studies provide an insight into daily life of fertile women with sPOP. Thus, we aimed to explore fertile women’s experiences of symptomatic pelvic organ (sPOP) after vaginal birth.

    Methods: An inductive, text-driven approach was taken by selecting thread posts from an internet forum written by 33 Swedish fertile women who had experienced sPOP after vaginal birth.

    Results: The overarching theme “being irreparably damaged” was identified as representing an experience of being disabled by sPOP after vaginal birth. The fertile women experienced that their lives were ruined because of physical and psychological limitations caused by this unexpected, unfamiliar and unexplained condition. Living with sPOP impinged on sexual health, restricted daily and sports activities and affected the women’s ability to fulfill everyday parental duties. This in turn compromised women’s psychological health. In addition, the negligence of healthcare professionals who tended to trivialize and normalize the symptoms led to the belief that there were no sustainable treatments and that women would have to live with bothersome symptoms of POP for rest of their lives.

    Conclusions: This study found that sPOP had a significant negative impact on fertile women’s lives. The women indicated that they had not had the opportunity to voice their concerns and had not been taken seriously by healthcare professionals. It is of the utmost importance to acknowledge this problem and develop guidelines for prevention and management of sPOP to improve the quality of life for women. © Mirskaya, Lindgren & Carlsson. 2019

  • 10.
    Mirskaya, Maria
    et al.
    Högskolan i Halmstad, Akademin för hälsa och välfärd.
    Lindgren, Eva-Carin
    Högskolan i Halmstad, Akademin för hälsa och välfärd, Centrum för forskning om välfärd, hälsa och idrott (CVHI).
    Carlsson, Ing-Marie
    Högskolan i Halmstad, Akademin för hälsa och välfärd, Centrum för forskning om välfärd, hälsa och idrott (CVHI).
    Ruined active life: Experiences of fertile women with symptomatic pelvic organ prolapse in daily physical active life2019Konferansepaper (Fagfellevurdert)
    Abstract [en]

    Background: Pelvic organ prolapse (POP) is a major public health problem. Symptomatic POP (sPOP) affects quality of life and implies an increased risk for surgery. Many women become symptomatic later in life. Existing research on sPOP predominantly concentrates on the effects of the condition on postmenopausal women. However, bothersome symptoms of POP may occur shortly after delivery. This paper provides insight into fertile women's daily physical active lives in order to better understand their situation and improve care for this group.

    Aim: To explore how fertile women with symptomatic POP after vaginal delivery experience their daily physical active life.

    Methods: An inductive, text-driven approach was taken, selecting thread posts from an internet forum written by 33 women. The data presented in this article stem from a larger empirical data that explored fertile women's experiences of symptomatic POP after vaginal delivery (VD). Data were processed using qualitative content analysis. The data consisted of chains of questions and answers or comments on the topic of sPOP, posted on an online forum by fertile women who had experienced sPOP after VD.          

    Results: The theme “Ruined active life” showed that many of the fertile women experienced that their lives were ruined because of unexpected physical limitations caused by sPOP. They found themselves balancing being a parent and being disabled because of sPOP. Bothersome symptoms like vaginal heaviness, fullness, soreness and pain were aggravated by many basic daily activities, generating fear that any action involving physical activity might worsen the situation. The women were extremely scared that doing daily household chores and parenting, e.g. lifting and carrying the baby or using a carrycot, might aggravate the symptoms. Moreover, this fear restricted women from playing active games with their older children, such as helping them onto a swing, teaching them to ride a bike, and jumping on a trampoline. All these restrictions led to feelings of being inadequate mothers, resulting in frustration, sadness, anger, uncertainty and a growing sense of hopelessness.Another substantial result of this study addresses sport activities. For many fertile women, sports activities had played an important role before delivery, and now sPOP restricted them from it. The realisation that they could not continue engaging in sports at the same level of athletic performance as before delivery led to intense grief, anxiety and frustration. For instance, women had to give up running and high-intensity training. Some of them did not dare to participate in any activities at the gym. One of them had to quit her job as a training instructor. Giving up favourite activities that were a part of the women’s identity caused an identity crisis, leading to depression. They often expressed that they “just wanted their life back”, demonstrating an inability to accept the new situation. Discussions concerning exercise and safe workouts were very common in the thread. Women were desperate to find information and sought advice from healthcare providers regarding lifestyle changes and how to adjust physical activity in relation to sPOP. However, it was found to be difficult to access satisfactory, unambiguous information. Instead, information was inconsistent, unclear and difficult to understand. Although some healthcare providers were considered helpful and kind, unfortunately they lacked knowledge, which led to useless advice being given which often was not in line with the information that the women had found out by themselves from independent sources. For instance, one woman was encouraged to continue with life as usual and with exercises such as doing sit-ups in spite of her complaints about aggravating her symptoms by physical activity. The woman was told that “nothing would fall out” and in any case if it did happen she was in no danger. Moreover, the fertile women who sought professional help expressed that normalisation of sPOP as a condition was common among healthcare providers. On the contrary, women did not perceive the symptoms of POP as normal or natural, and the attitude of healthcare professionals was experienced as humiliating and discouraging and caused feelings of not being taken seriously. This led to mistrust, disappointment, frustration and criticism of healthcare professionals and the system.

    Discussion: The fertile women in this study experienced failure to carry out their parental responsibilities, both physically and emotionally. Fear that activities such as lifting children or playing active games with them might worsen the symptoms led to emotional imbalance. This worry has reasonable grounds, owing to an assumption that increased load to the pelvic floor in the form of elevated intra-abdominal pressure (IAP) contributes to development of POP. It has also been shown that IAP increases during brisk walking and as a result of carrying things in a front carry position, which is used by postpartum women to carry their babies in car seats (1).

    One of the main findings of this study was psychological suffering due to an inability to participate in high-intensity exercise, since for some women, exercise was a part of self-esteem and a natural part of life. It is well established that physical activity has positive effects on health. Moreover, moderate or vigorous physical activity such as brisk walking, cycling, tennis, swimming and running has been shown to reduce depressive symptoms postpartum (2). Some of the fertile women in this study suffered from anxiety and depression and would probably have benefited from participating in physical activity. However, they felt unsure about what kind of physical activities they could resume without worsening their symptoms and became disappointed when they faced a lack of understanding and competence among healthcare professionals in terms of advising suitable exercises. Likely recommendations regarding leisure-time physical activity for postpartum women with depression without sPOP must differ from those with sPOP. One such physical activity that has been found to be suitable for women with sPOP is basic Pilates exercises, which does not raise IAP and, for instance, is safe to recommend for women after POP surgery (3).

    Conclusion and clinical implications: This study demonstrates that sPOP has a significant impact on fertile women’s active life. sPOP restricts daily and sports activities and affects the ability to fulfil everyday parental duties. In addition, the lack of information from healthcare providers regarding suitable physical activities adds more emotional stress and worsens the situation. It is of the utmost importance to acknowledge this problem. There is a need to develop guidelines for management of sPOP after VD, including information regarding safe lifting techniques and suitable exercises. Copyright © ICS 2019.

  • 11.
    Odberg Pettersson, Karen
    et al.
    Högskolan i Halmstad, Akademin för hälsa och välfärd, Centrum för forskning om välfärd, hälsa och idrott (CVHI).
    Christensson, Kyllike
    Department of Woman and Child Health, Division of Reproductive and Perinatal Health, Karolinska Institutet, Stockholm, Sweden.
    de Freitas, Engracia da Gloria Gomes
    Midwifery School, Luanda, Angola.
    Johansson, Eva
    Department of Public Health Services, Division of International Health, Karolinska Institutet, Stockholm, Sweden.
    Adaptation of health care seeking behavior during childbirth: Focus group discussions with women living in the suburban areas of Luanda, Angola2004Inngår i: Health Care for Women International, ISSN 0739-9332, E-ISSN 1096-4665, Vol. 25, nr 3, s. 255-280Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    The aim of this study was to explore how various factors influenced women's decisions regarding place of confinement in Luanda, Angola. Ten focus group discussions were conducted with pregnant and nonpregnant women residing in suburban areas of Luanda and the data were analyzed using the grounded theory technique. Four patterns of action of the main theme, "the molding of women'scare-seeking behavior during childbirth," were identified: (I) the "labor process 'on-course' avoiding pattern"; (II) the "labor process 'off-course' avoiding pattern"; (III) the "labor process 'on-course' approaching pattern"; and (IV) the "labor process 'off-course' approaching pattern." Our findings indicate that personal "courage" and social support empowered women and impacted on their preference for home birth, whereas demand for informal user fees and perceived low quality of care influenced women to avoid institutional care during childbirth, sometimes even in spite ofcomplications. Ability to meet demands for informal user fees and knowledge of childbirth influenced women to seek institutional care. The study highlights the need to improve the quality of available maternal health care addressing the implicit educational, attitudinal, and ethical issues.

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