In the past decade, efforts to achieve the five millennium development goals reduced maternal mortality and the prevalence of complications during pregnancy and childbirth (United Nations, 2015). However, improving the quality of maternity care is also essential to achieve the new sustainable development goals related to maternal health (World Health Organization (WHO), 2016).To promote positive childbirth experiences, the WHO (2015) recommends implementation of evidence-based and respectful maternity care. This approach refers to providing appropriate medical interventions at the right time, and preserving women's dignity in line with her personal and cultural needs and preferences (WHO, 2015; 2019). However, the medicalised model of care is dominant in many parts of the world and women continue to experience unnecessary interventions during labour and childbirth, which adversely impact their birth experiences (Abuya et al, 2015; Dzomeku et al, 2017; Ishola et al, 2017).
Studies have found that 10—20% of women have a negative experience of giving birth (Larsson et al, 2011). A distressing birth experience may lead to a woman developing post-traumatic stress disorder that increases the risk of postpartum depression, reduces the likelihood of having more children and causes problems in relationships between mothers and their babies and partners (Smarandache et al, 2016; Nystedt and Hildingsson, 2017; Hildingsson et al, 2021).
Iran is a middle-income country with good maternal health indicators (Khatooni et al, 2019). The country has a robust health system, and most births take place in maternity services under the supervision of healthcare professionals. However, the medicalisation of childbirth has increased in recent years (Sedigh Mobarakabadi et al, 2015; Pazandeh et al, 2017; Ghobadi et al, 2018), meaning normal birth is usually compounded with several interventions, such as augmentation and induction using oxytocin, fundal pressure and episiotomy (Pazandeh et al, 2017).
Currently, Iran has a high rate of caesarean section births (Khatooni et al, 2019) and is ranked fourth in the world in terms of unnecessary caesarean sections (Gibbons et al, 2010). It ranks second in the world for total number of caesarean sections and has the highest caesarean section rate in Asia (Gibbons et al, 2010). The caesarean section rate increased from 35% in 2000 to 47.9% in 2014 (Betran et al, 2016).
The Ministry of Health and Medical Education (2006) in Iran supports normal birth without harmful interventions. It advocates for avoiding unnecessary caesarean sections through the provision of free normal childbirth in public hospitals and childbirth preparation classes, and the refurbishment of labour wards to increase women's comfort and privacy in mother-friendly hospitals (Ministry of Health and Medical Education, 2006). However, caesarean section rates are still high (Shahshahan et al, 2016; Shirzad et al, 2021).
A woman's childbirth experience is an important measure of childbirth and has a significant role in evaluating and improving the quality of childbirth care (Hulton et al, 2000; WHO, 2016). Previous studies have identified certain demographic characteristics as factors that influence a woman's birth experience, including their expectations, attendance at childbirth classes (Jafari et al, 2017), birth environment (Askari et al, 2010), unnecessary routine interventions (Pazandeh et al, 2017; Kasegari et al, 2020) and the availability of supportive and respectful care (Ghobadi et al, 2018; Moridi et al, 2020). The present study explored women's experiences of normal birth in a large teaching hospital in Guilan province in Iran. The aim was to identify and thus improve women's experiences and the quality of birth care, as well as reducing caesarean section rates.
Methods
Study design
This cross-sectional study was conducted at a teaching hospital in Guilan province from July to August, 2018. A total of 133 women were approached about participating in the study, recruited using convenience sampling. Overall, 126 women were included in the study, as seven declined to participate.
The inclusion criteria for women were being 18 years old or older and having given birth to a full-term, single and healthy infant without complications. To recruit participants, the first author accessed the list of women in the postpartum ward at the hospital. The potential participants were informed about the aim and objectives of the study and invited to participate when they were stable, around 2—3 hours after birth.
The sample size was determined based on the mean (49.8) and standard deviation (8.6) of a pilot study conducted on a sample of 25 women from the hospital. The pilot sample was not included in the main study.
Data collection
Data were collected using two questionnaires; one developed by the researcher, and the pre-existing childbirth experience questionnaire (Dencker et al, 2010). Those who agreed to participate completed the questionnaires between 6 and 24 hours after birth, when they were stable and were then discharged from the postpartum ward.
The researcher-developed questionnaire comprised 15 items and was developed based on WHO (2018) guidelines for intrapartum care. The childbirth experience questionnaire is a valid and reliable measure for evaluating women's childbirth experience, which was developed in Sweden (Dencker et al, 2010) and has been validated for use in several countries including the UK, Denmark and China (Walker et al, 2015; Zhu et al, 2015; Boie et al, 2020).The questionnaire has 22 items that assess four domains of the birth experience: ‘own capacity’, ‘professional support’, ‘perceived safety’ and ‘participation’. For 19 of the items, the response format is a 4-point Likert scale, and the remaining three items use a visual analogue scale. The possible score ranges from 22—88, and the average scores in each area are based on a scoring range of 1—4.
To determine the quantitative content validity of the childbirth experience questionnaire, 10 midwifery experts were asked to complete a checklist examining the relevance, simplicity and clarity of each item. The calculated content validity ratio and content validity index were over 0.8, indicating validity (Drost, 2011). The same process was conducted for the researcher-developed questionnaire.
To assess reliability, the questionnaire's internal consistency was calculated using Cronbach's alpha, which was 0.73 overall (individual capacity: 0.71, personnel support: 0.78, participation: 0.76, perceived security: 0.70).
Data analysis
Data analysis was conducted using the Statistical Package for Social Sciences software (version 20). Descriptive statistics, frequency, means and standard deviation were calculated. Spearman's rank correlation coefficient was used to calculate the correlation of women's childbirth experience with confounding variables. Linear regression was performed to adjust the estimated effect of factors on birth care experience (significance level: P<0.05).
Ethical considerations
The ethics committee of the University of Guilan (IR. COM.GUMC.REC.1394.143) granted ethical approval for this study. Permission was also obtained from the study hospital.
Participants were informed about the aim and objectives of the study, data confidentiality and their freedom to leave the study at any stage. They were invited to participate in the study 1—2 hours before completing the questionnaires.
Results
A total of 126 women were included in the study. The majority were 20—35 years old (90.4%) and the mean age was 27.17 ± 5.71 years. Most women were housewives (96.0%), had primary education (52.6%) and were urban residents (68.3%). More than half were first-time mothers (56.3%), had a planned pregnancy (77.8%) and had wanted to have a normal childbirth (56%). The majority had received prenatal care (88.6%), but only a few (17.5%) had attended preparation for childbirth classes (Table 1).
Table 1. Demographic characteristics
| Characteristic | Category | Frequency, n=126(%) | R | P value |
|---|---|---|---|---|
| Age (years) | <20 | 1 (0.8) | 0.18* | 0.350 |
| 20-35 | 114 (90.4) | |||
| >35 | 11 (8.8) | |||
| Maternal education | Primary | 66 (52.6) | 0.13* | 0.140 |
| High school graduate | 50 (39.7) | |||
| Academic | 10 (7.9) | |||
| Occupation | Housewife | 121 (96.0) | -0.88† | 0.260 |
| Self-employed | 2 (2.0) | |||
| Employee | 2 (2.0) | |||
| Family income | Weak | 3 (2.4) | -0.09* | 0.290 |
| Average | 122 (96.8) | |||
| Good | 1 (0.8) | |||
| Parity | 1 | 71 (56.3) | 0.26* | 0.003 |
| 2 | 37 (29.4) | |||
| &3 | 17 (13.5) | |||
| Planned pregnancy | Yes | 98 (77.8) | 0.36† | 0.350 |
| No | 28 (22.2) | |||
| Desire to have normal birth | Yes | 55 (43.7) | 0.27† | 0.002 |
| No | 52 (41.3) | |||
| No difference | 19 (15.1) | |||
| Attended preparation for childbirth classes | Yes | 22 (17.5) | 0.26† | 0.230 |
| No | 104 (52.5) | |||
| Prenatal care | Yes | 124 (88.4) | 0.99† | 0.100 |
| No | 2 (1.6) |
*Spearman's correlation coefficient, †Independent t-test
Childbirth experiences
The mean childbirth experience score was 52.70 (range: 22—84, standard deviation: 9.25). The mean scores for own capacity and professional support were 15.57 (range: 7—28, standard deviation: 4.16) and 14.68 (range: 5—20, standard deviation: 3.40) respectively. The mean scores for perceived safety and participation were 16.03 (range: 6—24, standard deviation: 3.78) and 6.96 (range 3—12, standard deviation: 1.87) respectively. Personal support had the highest mean-balanced score (2.93 ± 0.43) and participation had the lowest (2.33 ± 0.79) (Table 2).
Table 2. Mean scores of childbirth experiences and its dimensions
| Childbirth experience (score range) | Mean ± standard deviation | Balanced scores (range: 1-4) |
|---|---|---|
| Own capacity (7-28) | 15.57 ± 4.16 | 2.40 ± 0.60 |
| Personnel support (5-20) | 14.68 ± 3.40 | 2.93 ± 0.43 |
| Perceived safety (6-24) | 16.03 ± 3.78 | 2.67 ± 0.40 |
| Participation (3-12) | 6.96 ± 1.87 | 2.33 ± 0.79 |
| Total (22-84) | 52.70 ± 9.25 | 2.56 ± 0.42 |
There was no statistical relationship between most demographic characteristics and childbirth experience. Only parity (P<0.003) and the desire for a normal birth (P<0.002) had a significant correlation (Table 1).
Routine care and interventions
Figure 1 shows the prevalence of routine care practices and interventions during participants’ labour and birth experiences. More than half of the participants were permitted to drink water during labour (61.7%) and had the freedom to change position or move (51.6%). The majority had more than three vaginal examinations (66.7%) were augmented by oxytocin (85.2%) and received an episiotomy (99.8%). All participants shared a room with other parturient women during labour and were not granted privacy during vaginal examinations. They were all transferred to another room when close to giving birth and around a third (26.0%) were dissatisfied with this sudden and fast transfer.
The majority of participants (51.0%) received some information about their care but most (70.6%) were not involved in decision making about childbirth care. Most were not asked for permission to conduct a vaginal examination (90.0%). More than half did not feel they received sufficient emotional support and respectful care that they felt they deserved (56.9%). Some reported mistreatment (42.9%), such as shouting and criticism, during labour and birth (2.1%).
According to Spearman's rank correlation coefficient calculations, there was a statistically significant positive correlation between a woman's childbirth experience and having freedom to drink and change position (P<0.001) and being granted privacy during vaginal examinations (P<0.01). There was also a statistically negative correlation between women's experiences and not receiving emotional support (P<0.01) and respectful care (P<0.01).
A linear regression model was developed to determine the influence of women's obstetric and individual characteristics and the care they received on their childbirth experiences (Table 3). The model identified the independent predictors for women's birth experiences as having the desire for a normal birth, having the freedom to drink and change position, receiving emotional support and respectful care. Women who did not desire a normal childbirth were 2.5 times more likely to have lower childbirth experience scores (P<0.001). Women who had the freedom to drink and change position or walk during labour were twice as likely to have a higher childbirth experience score than those who did not have such choices (P=0.01). Women who did not receive emotional support from their caregivers or who experienced disrespect were 2.03 (P=0.009) and 5.39 times more likely to have lower birth experience scores (P<0.01).
Table 3. Linear regression model for factors related to childbirth experiences
| Model | Unstandardised coefficients | Standardised coefficients | t | P value | |
|---|---|---|---|---|---|
| B | Standard error | ||||
| Constant | 77.03 | 4.420 | 17.39 | 0.000 | |
| No desire to have normal childbirth | -2.50 | 0.923 | -0.157 | -2.20 | 0.000 |
| Having the freedom to drink and change position | 2.02 | 0.810 | -0.17 | 2.47 | 0.015 |
| Having privacy during vaginal examinations | 6.43 | 3.400 | 0.12 | 1.88 | 0.060 |
| Not receiving emotional support | -2.03 | 0.846 | -0.132 | -1.89 | 0.009 |
| Not receiving respectful care | -5.39 | 0.955 | -0.384 | -5.10 | 0.000 |
Discussion
This study examined women's birth experiences in Iran and assessed their relationship with demographic and birth characteristics. The results demonstrated that women's overall childbirth experiences and their related domains were low, with no domain receiving a mean-balanced score greater than 3 out of 4. Previous studies in Iran have also highlighted that women's experiences during childbirth are not optimal, and women have negative experiences during childbirth (Sedigh Mobarakabadi et al, 2015; Pazandeh et al, 2017; Ghobadi et al, 2018).
According to the WHO (2016) maternity care framework, a woman's birth experience is an indicator for evaluating and improving the quality of care. Quality of maternity care can be split into three domains: respectful care and preserving dignity, emotional support and effective communication with women and their families (WHO, 2016).
In the context of this study, Iran, the medical model of childbirth care is dominant and low-risk women often experience unnecessary and harmful interventions, such as unnecessary vaginal examinations, augmentation or induction of labour and episiotomy (Sedigh Mobarakabadi et al, 2015; Pazandeh et al, 2017).
Studies from Sweden and the UK show that most women in these locations have a positive birth experience (Dencker et al, 2010; Walker et al, 2015). This is because the care system in these countries is designed to promote normal birth and provide evidence-based, respectful and woman-centered maternity care. Maternity services in the UK aim to provide safe, kind, professional, personalised and family-friendly care, where staff are supported to provide woman-centered care (NHS England, 2016). Most low-risk labouring women receive maternity care from midwives and do not experience intrusive and painful interventions during labour and birth.
The present study demonstrated that most of the participants did not receive emotional support from their caregivers and experienced a lack of privacy, not having companions of their choice during labour or being able to participate in decision making about their childbirth. Having the freedom to drink and change position during labour and not receiving respectful care and emotional support were the most important predictors of the birth experience. According to previous studies, emotional support during labour and birth is an essential aspect of care (Sandall et al, 2016; Lunda et al, 2018; Stjernholm et al, 2021). These studies also recognised that labouring women should be supported by companions of their choice, such as their spouse, family members, or a doula, whose supportive relationship favourably impacts the experience of labour pain and are essential for a positive birth experience (Sandall et al, 2016; Lunda et al, 2018; Stjernholm et al, 2021).
In Iran, labouring women are generally not permitted to have a companion of their choice during labour and childbirth (Torkzahrani, 2008). Additionally, the study setting was a teaching hospital, and women received care from obstetric residents, rather than midwives. In teaching hospitals in Iran, midwives are less involved in providing care during labour, childbirth and the postpartum period. Midwives in public hospitals act as obstetric nurses, follow obstetricians’ orders and do paperwork. Midwives are marginalised in the Iranian health system and are not allowed to provide professional care during birth to the extent they are trained to (Pazandeh et al, 2017).
The Iranian approach reflects a medical care model and prevents implementation of the midwifery care model in maternity services (Hildingsson et al, 2021). A qualitative study from Iran that explored midwives’ perspectives reported that disrespectful maternity care resulted from the medical context of birth where low-risk births were managed by obstetricians (Moridi et al, 2020). This approach might impact birth outcomes. Sandall et al (2016) conducted a systematic review which found that women who received birth care from midwives were more likely to have better outcomes and experiences of labour and birth. Women report a positive birth experience when caregivers provide support based on a woman's needs and preferences, even when birth is prolonged or associated with medical complications (Nilsson et al, 2013; Bohren et al, 2017). Additionally, a report from China indicated that when a midwives’ role is marginalised, midwives may lose the required knowledge and skills to provide proper care (Zhu et al, 2015). Midwives in countries such as Sweden have a leading role in providing care for pregnant women during the continuum of pregnancy, childbirth and postpartum. They provide prenatal care for low-risk women, work independently during birth and only involve obstetricians if a labouring woman is in distress (Hildingsson et al, 2021). Implementing midwife-led care for low-risk women may improve women's birth experiences and enhance quality of care during labour and childbirth.
Limitations
This study was conducted in one teaching hospital in the Guilan province. Although Iranian teaching hospitals have a similar organisational structure, women's childbirth experiences may differ between hospitals, and thus this study's results are not necessarily generalisable. Additionally, the study used a small sample size and the results should be interpreted carefully.
The authors could only interview postpartum women in the hospital, which may have affected the participants’ responses, as they may have been concerned about not receiving proper care if they expressed negative experiences. Additionally, although women were approached only when they were stable, fatigue after labour and birth may have affected their responses.
Conclusions
This study evaluated women's experiences of normal birth in a teaching hospital in Guilan province, Iran. The care provided during childbirth resulted in generally low scores across the domains of childbirth experiences, and receiving respectful care and a desire to have a normal birth were contributing factors to these experiences. Quality improvement strategies need to be implemented to promote evidence-based care and ensure healthcare professionals are promoting women's psychological wellbeing and providing respectful care during childbirth. Addressing these issues may improve the quality of childbirth care, women's experiences and the caesarean section rate.
Key points
- This study demonstrated that women's overall childbirth experiences were not well-perceived by women giving birth in Iran.
- The personal support and participation domains had the highest and lowest mean experience scores respectively.
- Respectful care, emotional support during birth and a desire to have natural childbirth contributed to a woman's positive childbirth experience.
- Quality improvement strategies should be used to implement evidence-based care, and interventions are needed to ensure providers are promoting respectful care and woman-centered birth.
CPD reflective questions
- How can health professionals improve pregnant women's birth experiences?
- In your own practice, what barriers exist to implementing evidence-based and respectful care?
- In your own practice, what facilitators exist for implementing evidence-based and respectful care?