A Phenomenological Analysis of Rural Women’s Childbirth Preferences

Women’s agency and reproductive control directly bear their current pregnancy and future childbearing experiences. This study deals with knowledge construction in childbirth planning. The study is based on a phenomenological approach relying on in-depth interviews of sixty married women of childbearing age who have recently been through the birthing process. Cultural discourses provide an understanding of socio-familial context reinforcing traditional home birthing. Findings indicate that the desire for natural childbirth experience, apprehensions regarding obstetric interventions by medical doctors, emotional support, comfort and assistance provided by female relatives, traditional birth attendants, and their husbands’ preference add to their decision for home birthing. In addition, another determinant was the role of authoritative knowledge and shared experiences of older women that may deprive many young women of the chance to access maternal care in hospitals. The study suggests that rural women effectively utilize reproductive health care services in Pakistan.


Introduction
Reproductive rights are a part of human rights protected and formally recognized under international law since 1994. Women's childbirth preferences are linked to their autonomy of practicing their reproductive rights. Marge Berer contends that supporting reproductive rights is like keeping the human need and desire to have some measure of control over nature and biology, and over fertility, and to believe that it is ethical to do this (Berer, 2004). Individuals can decide if and when, reproduce, and compile a list of essential elements of reproductive health care (United Nations Population Fund [UNFPA], 2004). Decisions on child planning, birthing, prenatal and postnatal care are components of reproductive rights that are often compromised. The birth of a child is the most important and life-altering event in a mother's life, but at the same time, it may bring more significant health risks for them. Ninety-nine percent of the deaths during child delivery worldwide occur in developing countries. Pakistan has one of the highest maternal mortality rates. Currently, Baluchistan has the highest maternal mortality rate in Pakistan. The major causes of maternal mortality in Pakistan are lack of trained midwives, access to medical care, excessive physical labor during pregnancy, child marriages, and low-income family planning (SAMAA, 2019). Pakistan's Maternal Mortality Ratio (MMR) as of 2019 is 186 per 100,000 live births, with wide variation between provinces (UNFPA, 2020). Maternal mortality in 2020 is 178 deaths per 100,000 live births (Mustafa et al., 2020. The health of the mother and her newborn at birth is likely to determine her future health outcomes and the entire family's well-being (World Health Organization [WHO], 2005). According to WHO, 830 women die of childbirth and pregnancy every day (WHO, 2019). Although maternal mortality rates have declined over recent decades, they remain remarkably high. UNFPA quotes 127 maternal deaths per 100,000 live births in Asia (UNFPA, 2016).
Unfortunately, the reproductive health status of Pakistani women and their utilization of healthcare facilities is not encouraging. The estimated maternal mortality rate is close to 500 per 100,000 live births (WHO, 2004), making Pakistan one of those six countries that contribute to more than half of all maternal deaths throughout the world (Hogan et al., 2010). Other studies also reported that the primary reason causing maternal deaths is unskilled supervision during childbirth, albeit; worldwide, every year, around sixty million women deliver babies at home without assistance from any skilled person (Khan et al., 2009).
Globally women are vulnerable due to their poor health and limited access to resources and services, making them disadvantaged and marginalized (Okojie, 1994;Vlassoff, 1994). The previous studies indicate that the birthing process in South Asian culture has primarily been considered a woman's private matter (Jeffery et al., 1987;Unnithan-Kumar, 2003). Women can be actively involved in the decision-making process, and their choice between alternative avenues for childbirth mainly depends on their perception of risk and their conceptualization of pregnancy and childbirth (Zadoroznyj, 2001). Out of 114 million pregnancies in the Asian region in 2016, it is estimated that about forty-five million were unintended (UNFPA, 2016). Rural women are more vulnerable as compared to urban. Also, the disparities in access and outcome to health care among the rural and urban populations are multilateral. In the developing world, there is a growing population of childbearing-age women in rural communities, which brings about unique inequitable logistical and cultural issues for rural women in general (Schminkey et al., 2019).
The choice to work on women's reproductive rights, including the right to give birth, was based on the rationale that existing human rights declarations somehow fail to address reproductive rights violations happening to women across the globe. The international perspective of women's birthing rights may not be an accurate reflection of the experiences of rural women. Few studies attempted to analyze the empirical relationship between reproductive rights and social norms. This study focuses on how women conceptualize, approach, and experience pregnancy and childbirth in the context of cultural discourse of healthcare decisions, particularly the choice of place of birth. The Phenomenological analysis is used to better understand women's experiences of pregnancy and childbirth. This will clarify linkages between women's childbirth experiences and their socio-cultural context.

Significance of the Study
Pakistan is now ranked as the fifth most populous country in the world and studies reveal that the socio-cultural setup of the country is the most dominant factor that promotes a high fertility rate that is, 3.6 births per woman in 2016 to 2017. Fertility decisions of couples are affected by under-five mortality to increase the probability of surviving children. However, in the past three decades, it has only declined marginally that is, from 86 to 62 live births per 1,000 children (Goujon et al., 2020).
Limited studies conducted in Pakistan have attempted to investigate the role of culture in shaping women's reproductive health behavior. Most of the research conducted in this field has narrowly focused on health services provision. Lack of relevant data and gaps in the existing knowledge regarding women's reproductive rights calls for more wide-ranging research studies to highlight women-specific health care needs and bring them to the top of the country's National Health agenda. This study is conducted with the prime objective to contribute comprehensive and in-depth data in the context of Pakistani society by identifying ground realities and underlying cultural barriers that restrict women from accessing basic health care facilities. Moreover, on the applied side, it can facilitate health planners, government and non-government organizations, the applied health sector and other stakeholders to design population policies and women healthcare projects using the culture-centered approach to ensure better health outcomes for childbearing women.

Situation in Pakistan
Pakistan is now ranked as the fifth most populous country globally, and studies reveal that the socio-cultural setup of the country is the most dominant factor that promotes a high fertility rate, that is, 3.6 births per woman from 2016 to 2017. Fertility decisions of couples are affected by under-five mortality to increase the probability of surviving children. However, in the past three decades, it has only declined marginally, from 86 to 62 live births per 1,000 children (Goujon et al., 2020).
Limited studies conducted in Pakistan have attempted to investigate the role of culture in shaping women's reproductive health behavior. Most of the research conducted in this field has narrowly focused on health services provision. Lack of relevant data and gaps in the existing knowledge regarding women's reproductive rights calls for more wide-ranging research studies to highlight women-specific health care needs and bring them to the top of the country's National Health agenda. This study aims to contribute comprehensive and in-depth data to Pakistani society by identifying ground realities and underlying cultural barriers that restrict women from accessing basic health care facilities. Moreover, on the applied side, it can facilitate health planners, Government and non-government organizations, the applied health sector, and other stakeholders to design population policies and women's healthcare projects using the culture-centered approach to ensure better health outcomes for childbearing women.

Objectives
Despite substantial academic literature on reproductive health, there is still a lack of understanding about healthcare decision-making and how socio-cultural norms influence women's desire and ability to use various health care options. The present study highlights the philosophy of reproduction by considering individual women's phenomenological understandings of pregnancy and birth planning. The primary objective of this study is to explore how rural women conceptualize childbirth as a process construct knowledge about pregnancy and childbirth. The key research question is to investigate those social, cultural, emotional factors that affect and determine women's choices of birthing places. This choice is either a result of an agency or coercion determined through context.

Literature Review
The year 2020 is declared as the year of the Nurses and Midwives across the globe (WHO, 2020). Reproduction and birth planning have long been a priority concern for many scholars investigating macrolevel birth-related decision-making processes (Lee & Kirkman, 2008). The reasons and consequences of different experiences and outcomes with maternity health among groups in terms of geography are of particular interest to social scientists (Gilbert et al., 2004;Roth & Henley, 2012). Not only this, but women from relatively lower socio-economic strata also use essential reproductive health care services than the ones from higher socio-economic status. Educational status of women, their spouses, their exposure to channels of mass media, employment, birth order, wealth quintiles of the household, and age of pregnancy are significant contributors to the inequalities of the reproductive rights of women (Khan et al., 2020) Many studies support the argument that decisions made by individual women are primarily shaped by their cultural contexts. On the one hand, educational attainment and the resulting family planning usage significantly impact domestic hunger, poverty, and mortality within the family context (Abuya et al., 2019). Li (1993) argued that social pressure, limited resources, and inaccessible health facilities in some developing countries are the most significant factors that hamper effective decisions and increase reproductive complications among women. However, against the widely held family value, "women are homemakers; where men are providers"; things are changing about the empowerment of women and their role in familial decision-making (Hwang, 2018;Tiliouine & Achoui, 2018). Similarly, the pregnancy rate is higher in non-urban areas (Ngubane & Maharaj, 2018). In urban areas, the hike in education has raised employment opportunities and shared, or reduced economic dependence on men, and thus women gain negotiation power in marriage, childbirth, and decision-making power (Al- Khraif et al., 2020;Hwang, 2018;Khraif et al., 2017).
The decision to deliver at home or any health facility primarily depends on the wishes and beliefs of the motherin-law (Piet-Pelon et al., 1999). This is particularly important in many South Asian cultures where the mother-in-law holds decision-making authority related to pregnancy and childbirth. Opposition and the unsupportive attitude of the family members can put women in a vulnerable situation where they may find it hard to make decisions on their own, even in a state of emergency. They may not use family planning methods even if they wish to do so (Kadir et al., 2003). Poor interpersonal relationship with Lady Health Workers or health care providers often leads young rural women to unawareness of modern contraceptives. Also, they believe that the fear of being judged, confidentially, and the right to privacy is not maintained at these health care centers (Ngubane & Maharaj, 2018).
Pregnancy and decisions related to it (such as whether to seek antenatal care, place of childbirth, or the type of attendant to assist in delivery) is normatively the discretion of the older women in the family who are considered siyani (wise and experienced) and their decisions have binding effect. The expecting mother is not supposed to make personal choices, and the opinions as all her healthcare requirements are considered the responsibility of her mother-in-law (Mumtaz & Salway, 2007). Women who consult their mother-in-law in family planning matters are more inclined toward adopting modern contraceptives (Fikree et al., 2001). Education may have a role in decision-making for women (Matsumura & Gubhaju, 2001). However, the findings of different studies suggest that decision-making authority mainly rests with the males and elderly women.

Methodology and Locale
Several factors are kept in mind while choosing the locale of the study. These are prior knowledge of the area and the cultural setup, ease to communicate in local language mainly spoken by the majority of the residents in the selected community, availability of the trusted and cooperative key informants for gaining entry, and acceptance in the locale, which is a pre-requisite for rapport-establishment, and in-depth data collection.
Planning and finalization of research tools before commencing fieldwork is essential. This research is a case study conducted in a Punjabi village that comprises sixty-eight households. The residence pattern of the community is patrilocal, and the descent is traced Patri-lineally. Endogamous marriages are common and mostly arranged by the family elders. The Village economy is mainly based on non-agricultural activities, and most of the men work as factory workers, daily wage laborers, and some own small businesses.
The study is carefully planned by selecting relevant research techniques to optimize the credibility of research findings. The data collection for this anthropological inquiry is completed during the year 2013. To articulate the lived experiences of women and the sensitive nature of the topic, qualitative research methods are employed. The socio-economic survey collects baseline demographic information in the initial fieldwork stage and establishes a good rapport with the villagers. In the second phase, a deep insight into the village's cultural setup is acquired through detailed observation generally informally and participated. The use of "participant observation" is beneficial in becoming an accepted member of the community that not only allowed to participate in the local events and ceremonies but also in collecting first hand and direct information by observing interaction patterns and roles of different family members, women's authority and contribution in household decision-making, the kind and extent of power dynamics at home, etc.
The first stage of the study is exploratory. In-depth interviews are conducted with the 60 married women of reproductive age preferentially selected on their reproductive histories. Open-ended questions are preferred to evoke an emic perspective of the respondents by encouraging them to provide a holistic account of all those factors that they thought increased or restricted their ability to access health care.
The interviews are conducted in the local language from those women who belonged to 1) different socio-economic backgrounds representing lower and middle-class households 2) with both joint and nuclear family structures 3) where women are engaged in some sort of income-generating activities both inside and outside of their households and where women do not work, 4) women with recent deliveries, fertility, reproductive illnesses and also women who are more vocal and willing to provide information. The selection of the respondents is justified to choose the most representative sample. This selection is based on careful field observations and the insights gained from the key informants.
In essence, women with a history of some reproductive illness, experience of childbirth, or fertility decision-making process are selected for in-depth interviews. For a holistic understanding of the phenomenon under study, focus group discussions (FGDs) are conducted by community members and service providers such as traditional birth attendants, LHVs, and spiritual healers. Although key respondents are childbearing women, alternate perspectives are also incorporated by adding inputs from their husbands, doctors, nurses, and parallel medical service sectors such as herbalists, quacks, spiritual healers, and other relevant persons from the village.
The phenomenological analysis is used to understand women's experiences of pregnancy and childbirth and, in a broader sense, conceptualize the linkages between women's childbirth experiences and socio-cultural circumstances. The phenomenological analysis provided a relevant framework for understanding various psychological and socio-cultural dimensions regarding women's reproductive processes. More interestingly, the use of narratives in respondents' interviews proved helpful in understanding how women constructed their reproductive rights in the specificity of their socio-cultural norms and enacted their agency. All the statements, proverbs, and local terms used during interviews and informal discussions are translated verbatim into English for data analysis.
Research ethics as developed by the American Anthropological Association (Wynn, 2008) are followed while carrying out this study to gather the information that is held under ethical and moral considerations. The overall objective of the research was communicated to the respondents for obtaining their informed consent. Participants in the study are taken into confidence to ensure their voluntary participation. The audio and visual privacy of the respondents is not compromised during the data collection process. Information received from the participants is kept confidential and anonymous. Verbatims are used with pseudonyms to maintain the confidentiality of the respondents.
In a traditional Pakistani rural setup, it is not considered appropriate for unmarried girls to inquire about issues related to sexuality and reproduction, etc. Being married, I had the edge to discuss sensitive issues with my respondents after establishing a good rapport and winning their trust concerning their married life, reproduction, and sexuality. I assured them that their information would remain confidential. I conducted in-depth interviews with married women of reproductive age because the main focus of the study is to explore their narrative on reproductive rights, yet, to have a representative sample supporting views from their husbands, doctors, health service providers, traditional and spiritual healers, and Moulvis (clergy) from the community are also incorporated. It was challenging for me as a female researcher to interview men on a sensitive topic, but I overcame this by interacting with men either in critical informants or females of the household.

Results & Discussion
The primary demographic data of the respondents are represented in the following table. It has been presented in terms of age-wise distribution of selected respondents, their level of education, family type, and monthly household income of their families (Table 1). All names used in this article are pseudonyms assigned to the respondents to maintain their privacy and confidentiality. This data suggests that most women are from the 30 to 39 age group and belong to the lower socio-economic class as recorded monthly household income information. Most women are barely literate, or their education level is less than matriculation. There is a diversity in the respondents' family types, reflecting that not all women have familial pressure in the birthing decision. The findings from this study are mainly discussed under three broad themes. The first thematic area described how the entire process of childbirth is traditionally perceived. The second section of the study highlights the ways women choose a place for giving birth and how they negotiate these health-related decisions with people around them. These are the/social relations that are likely to influence women's decision-making and their thinking about planning a birth. This includes husband, other family members, particularly mothers and motherin-law, midwives, physicians, LHVs, friends, etc., all of whom may shape a woman's thinking about planning a birth. The third section illustrates those factors that encourage women's preference for home birthing.

Women's Conceptualization of Delivery & Childbirth
Most of the women in this study explained birthing as a natural event. For most women, their conceptualization of birth commonly included phrases like "it's natural" "natural process" that a woman's body must complete naturally. Women generally described the birthing experience in their narratives as "a duty assigned by nature by their sex and gender role of being a mother as an essential attribute that makes them a real and complete woman." It is commonly believed that giving birth does not require a trained medical professional's expertise or assistance. For the most part, hospitals are only kept as a backup for medical emergencies.
Women in the villages are socialized to keep quiet about their pain and remain patient (saabir) in times of suffering. One respondent said.
Making noise during childbirth only prolongs labor. Allah protects mothers giving birth, so one should stay quiet and remember Allah. Mothers are promised to get the reward for each contraction (dardain) they bear during childbirth. This is the reason mothers have heaven under their feet.
One other woman commented.
Women have a natural capacity to endure pain. Labor contractions do have a cure (Shifa for many internal problems. Women waste dirty blood during delivery, which is refreshed by their bodies with fresh blood.
The "authoritative knowledge in this environment is not based on the biomedical understanding of reproductive health; Rather, it is based on women's practices over generations". Women have seen their mothers and grandmothers doing it in the same way. This becomes more prominent when it comes to choosing a place of delivery. Most of the women mentioned that they agreed to deliver at home on the recommendations of their mother-in-law and mother and other married ladies who were mothers. Shaistanarrated it in this way:

I was terrified on my first delivery as I had heard of it as a painful process. It confused me to choose between a hospital or home birth, But everyone suggested that home delivery is better because of the presence of family members. My mother-in-law said that she gave birth to seven children, all with the midwife's assistance, and nothing wrong happened. Going to the hospital at midnight is shameful, and an elevated risk as doctors prefer their ease and haste for cesareans births to charge more money. I followed her (mother-in-law) advice and delivered it at home. My mother-in-law gave me a concoction made of hot milk and desi ghee to ease the labor pain. She tried various home remedies and massaged my body from time to time. In hospitals, nurses do not bother. She (her mother-in-law) was right as I had less trouble at home.
Shaista's views illustrate that she preferred home birth as families encourage women to stay home. Sarwat discusses this as: Going to the hospital costs more, and besides that, my mother and grandmother all gave birth at home. Women go to the hospital only when they have some medical issue. Most of the women in the village known to me gave birth at home. It is easy because the midwife is from our town and knows how to deal with a case. I was in labor for a whole day, but the midwife helped me, and I did not need to go to the hospital. Women in this study viewed "other women" and "traditional birth attendants" as a source of professional knowledge that not only shaped their birthing ideology but also helped them in making informed decisions.

The Decision Regarding the Place of Delivery
Field findings reveal that families hold decision-making authority, and women locate this within their cultural norms. Traditional practices are episteme of knowledge and play a vital role in shaping women's perception of their reproductive health. Their discernment is mainly drawn from their plan to go through various phases of reproductive years, primarily informed by their family traditions and community values. Women's choice of place for giving birth reveals their economic and socio-cultural context: for example, the presence of the mother or mother-in-law, traditional birth attendant or other female relatives, etc. Traditionally, in the village, the mother-in-law and other female family members provide comfort and facilitate the TBA having prior experience going through these stages themselves, which educates them to support others. That is how women benefit from each other's experiences. For women, the home environment ensures emotional support of other women, security, comfort, and honor. Women explained that mostly husbands decide the place of delivery, and generally, they make decisions by determining when the situation becomes life-threatening. Only then do they decide on moving their women to the hospital. The hospitals or medical facilities referred by these women are Government run Mother-Child health care centers or hospitals with obstetrics and gynae departments. These are average public health facilities run by the State and bear no charges for treatment except for the medicines if un-available at the hospital. How one respondent shared her story of the complications that occurred after she went into labor and the actions taken provides insight into the different decisionmaking roles family members play in such situations. Fahmida said.
During pregnancy, I was examined by a well experienced 'dai' (Traditional Birth Attendant) in the village who suggested that the baby is quite healthy and seems difficult to deliver at home in the third trimester. I was young, just 21 years old, and on top of that, I was fragile. My husband and his mother did not agree with the recommendations of 'dai' to take me to the hospital, assuming that surgical births are more costly and harmful. My mother-in-law kept telling me that I had to give birth at home just like she and other family women did. I was pretty afraid, but I had to stay quiet due to the pressure of my husband and his family.
In this scenario, she had to minimize her agency to prove herself a good wife and daughter-in-law. She did not want to show stubbornness (zid) and appeared demanding. After she gave birth at home, she suffered from massive blood loss and severe pain due to the dai's several inducements. Several other birth experiences indicate limited decision-making autonomy of women in the context of choosing the place of delivery and cannot demand to be taken to the hospital against the will of their families. Razia, another respondent, delivered her child at home. Her husband and his brothers thought it shameful for a pregnant woman visiting the hospital to reveal it through her protruding belly by exposing herself in front of other men (ghair aadmi). She is often not allowed to visit any hospital, mother-child health center, or gynae clinic for anti-natal checkups. Razia had a complicated experience of childbirth. She said, Although I delivered the baby quickly, the placenta did not come out. My situation became critical due to excessive bleeding. The dai and older females tried different strategies. They put hair in my mouth so that I would vomit, but nothing worked, and despite the dai's massage and other remedies placenta did not come out for a few hours. My baby became so 'serious,' and so did I. I was taken to the nearest hospital in the State of unconsciousness, where I was given treatment. But till then, I lost so much blood that I was nearly dead. I still feel horrible whenever I think of that time.
These two examples and other similar ones highlight women's helplessness even in situations of obstetric complications and emergencies. They cannot voice their health concerns and assert that their condition necessitates hospitalization. Preference for home birthing is further intensified with the experiences of older ladies who persuade young women with their stories of home birthing without any assistance or even in agricultural fields.

Preference for Home Birthing
Although most women understand and are aware of the possible associated risks, they emphasized the significance of staying at home. Preference for birthing at home is a reproductive right that they let go of, driven by cultural pressures pronounced by artistic rights. Women are encultured with more fears associated with hospitals and prefer the ease and privacy of their own homes. They also mentioned resisting medical interventions until it becomes inevitable. The meanings of birthing are culturally constructed through the lived experiences of those women who have been through birthing experiences. Moreover, choosing a health facility also depends on the type of medical facilities available to women. Rani's choice of hospital for giving birth sheds light on providing poor-quality health facilities available to women. I went to the hospital when my contractions started around midnight. I remained in labor for one whole day and night. They placed me in an overcrowded ward where a lady doctor only examined me once. After a few hours, when the nurse shifted me into the labor room, I had to share a bed with another lady. They gave me a gown to wear which was full of bloodstains like somebody had just used it. When I asked for a clean dress, the concerned female attendant scolded me that I should have brought a brand new (gown) with me. Her behavior was rude to all the females who were sighing with pain. She used offensive language and said that we enjoy having sex but create a nuisance at the birthing facilities at the time of delivery. It was so disgusting to experience all this.
The story, as mentioned above, highlights the reality of behavior of the paramedics at gynecology and obstetrics, which is sometimes inappropriate. Women who decide to go to the hospital are treated merely as numbers rather than mothers. This phenomenon is further endorsed by the experience shared by another respondent. She said: The hospital staff is insensitive, rude, and pays the slightest attention to patients' pain and suffering. For them, it is a routine matter. I started shivering due to weakness, but they did not even provide me with a blanket to cover my naked legs despite several requests. They neglected me, maybe due to the presence of too many cases. They dislike panicking, and I noticed that they are even harsher with women who have already given birth to children and know the procedure.
The stories mentioned above, in a way, validate the suspicions of women about the careless attitude of health providers. This lack of caring is juxtaposed to the supportive environment of one's home. Also, these women used the hospitals and birthing facilities provided by the Government, which are often not up to the mark. These women were from the lower and lower-middle classes. The socio-economic type of the women determines the kind of medical facilities available to them. This is further echoed by Shabnam's story as she discusses her experience: I went to a hospital to give birth to my first child since I did not want to risk it. I went to the hospital once the labor pain started. I remained in labor for a few hours, and then she (doctor) said it was impossible to deliver naturally and took me for an assisted surgical birth without explaining any reason for that. It was stressful as I never thought it would end up so. They asked my family to arrange a minimum of three bags of blood for blood transfusion immediately. It was a panic situation as my husband had to run after people for blood matches and donations. I was expecting a natural/normal birth, but suddenly the case turned different. They charged us a massive amount of money for cesarean delivery and kept me only for three days, for which they gave me nothing to eat or drink. Everything was brought by my family. Visiting a distant hospital was another hassle for the family members. I received no blood transfusion, and they did not return it. Maybe they collect it from miserable people like us, then sell it. I suffered double as I had to undergo more prolonged labor pains than normal birthing, as well as long-lasting suffering of a C-section.
Shabnam's story illustrates her lack of trust in the hospitals as she suspected that the blood bags were possibly collected not for a genuine cause but rather for sale. She also mentioned "non-provision of food" during her stay, indicating less care provided to women who choose that health facility. Furthermore, she was not explained what went wrong and why a cesarean section was chosen? It left her feeling ignorant as she did not justify what was being done. Her saying, "I suffered double," shows her displeasure for the bio-medical facility. Such stories reinforce other women's suspicions and become hesitant to consult hospitals.
Many women are reluctant to have a cesarean birth and mentioned various concerns such as heavy blood loss and the possibility of any mistake during surgery, fear of not having more than three or four births, infertility, and complications such as infection through the incisions and backache due to anesthesia associated with a cesarean section. They also reported that doctors recommend post-operative precautions that are often difficult to follow. For example, getting pregnant soon after C-section is detrimental to a mother's health, but practically speaking, pregnancies are unplanned, especially where husbands are unwilling to use birth control. They also reported that women who undergo surgery are advised to refrain from heavy physical exertion, but they need to fetch water and many such tasks which require lifting weight. Seher's story explains it as, The narratives mentioned above of women revealed their dissatisfaction and mistrust for health professionals as the way they were treated made them feel ignorant and dejected. Moreover, they have not explained the clinical justification for adopting a particular procedure. This lack of information sharing and the cultural perception regarding the adopted approach determines women's choice of a health facility. As the views mentioned above of Seher highlight, a caesarian section is culturally perceived as a curse and punishment. Women also perceive it as the incompetence of the doctor who could not manage to successfully conduct a vaginal birth. The risk of undergoing a cesarean section helps explain why all those women who received antenatal care in the health facility do not turn up for the delivery and may finally choose to deliver at home as it makes them feel more relaxed and comfortable. Moreover, women also mentioned the cesarean birth at hospitals as against their cultural norms. One of the respondents explained it as, "A surgical birth is common in the hospitals, and that too is performed by male doctors, and the big needle (injection used for anesthesia) is inserted in the spine by a male doctor, which is quite shameful. To be nude in front of a stranger (man) is not our tradition." Hospitals are chosen in case of emergency or life risk or the absence of family members and the inability of home birthing. Moreover, the women stated that family and community beliefs and norms influence their health care decisions to a more significant extent. The circumstances in which they are placed can influence their choices. There are no fixed rules, and many women choose the home and hospital delivery depending on their personal and social circumstances.
Many women preferred delivery at home with the assistance of TBA. One of the respondents said, "Doctors leave you unattended at the last hour, and you are left at the mercy of nurses. But the TBA stays with you most of the time. She lives in the village so she can be called anytime. She does not ask for more money, and they are quite considerate." One of the respondents said, "There is no need to go to the hospital. The pain is the same whether in a hospital or at home." The preceding information explained that women believed to develop fewer complications if they give birth in their own homes. They firmly believed in the experiences of other women who stayed home for childbirth. They also relied on previous occasions (their own or close family women) of home birthing (if any) to support their decision to be safe and satisfied in the presence of other female relatives. It has further become clear that the socio-cultural context and immediate reference group shape the choice of women birthing at home. Studies in developing countries reflect that the second contributor to inequality is the educational level of women and their counterparts, whereas the third reason is the lack of utilization of health care services (Khan et al., 2020). The National Family Health Survey of India had similar findings a few years ago, and the results are consistent with the findings of another study (Goli et al., 2013).

Conclusion
The study highlights that the women's perception of childbirth influences their decision on place of delivery and the unawareness of their reproductive rights. The study findings illustrate mainly women are encultured with the cultural ideals shaped up by the rhetoric of good women. Often to fit into the model of those cultural ideals, they forego their will and reproductive rights, whether it is on the decision to conceive, birth spacing, use of contraceptives, seeking medical assistance during pregnancy, delivery, and pre-and postnatal phase. Whenever women seek health information, particularly about their decision of birthing place, one of the most trusted avenues for obtaining this kind of knowledge is, "the fellow and experienced women along with traditional birth attendants. Women rely more on each other, and their shared experiences become a guide for opting for home birthing". Husbands are not excluded from this reproductive arena as they directly influence reproductive decision-making and have the final say in deciding where childbirth should occur. There is a constant negotiation between ethno-familial expectations and the choice of expecting females. The cultural construction of birth as a natural process that elevates one's social position by natural birthing and that too at home also elevates her position in the family and community and drives her to prefer home birthing in the rural areas of Pakistan.
The study highlights the reproductive realities of rural women that are particularly important for redefining current reproductive health policies and practices in Pakistan. Women in this study are reluctant to give birth at hospitals as they believe obstetric interventions are harmful to them. Mistrust on physicians and paramedical staff is a significant factor that encourages women to deliver at home. For them, it appears to be a well-thought decision to have natural and intervention-free birth. Most women also reported great emotional support from their female relatives and midwives and a comfortable home environment where they feel more secure and empowered. The findings of this study show how women choose the place for childbirth by evaluating the risks and benefits associated with the selected venue.
Several studies conducted in other Asian countries, particularly India and Bangladesh, also suggest similar factors, including illiteracy, traditional views, the influence of family elders, strong faith in the expertise of TBA in handling childbirth at home, and fear of undergoing cesarean at the hospital that influences women's preference for delivery at home. The findings and experience from the developing countries suggest a vital need to create a more personalized environment by providing women-friendly services at the hospitals. At the same time, they highlight the need to provide trained midwives for assisting births at home with minimum risk for mothers giving birth.
This study suggests a culture-centered approach to efficiently address the health needs of rural and marginalized women. The study's findings can help policymakers, and health professionals adopt culturally appropriate interventions to address cultural misconceptions and ensure the availability of skilled attendants during childbirth. The study also reinforces the social reality that women's ignorance about reliable health options and alternatives is a significant barrier in making informed choices. Pregnant women should have scientifically correct knowledge of the potential merits and demerits. This suggests that women must choose the place of childbirth with complete information of what these choices could offer.

Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest concerning the research, authorship, and/or publication of this article: It is stated that this was primary research in Applied Anthropology based on fieldwork. It bears no financial liability on the part of any agency or donor, nor does it have any conflict of interest with any organization. It was purely an academic activity.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was carried out as a part of the PhD dissertation of Dr. Aneela Sultana and bears no financial support from any funding agency.

Ethics Statement
The ASRB, Advanced Study Research Board of Quaid-e-Azam University, Islamabad, awarded the research title and degree. The data was gathered through in-depth interviews after taking formal consent of the respondents. To maintain the anonymity and confidentiality of the respondents, their names have been altered. The data is gathered by the primary author. However, the write-up of the article has been completed with the help of the co-authors.