Primiparous women’s experiences of normal vaginal delivery in Iran: a qualitative study

Birth is the most challenging physiological and psychological events in the women’s life [1, 2]. Childbirth is not only a transition to motherhood, but also it is associated with considerable physical and emotional impacts in a mother’s life [3]. It has a powerful effect on women’s lives with long-term positive or negative effects [4, 5]. A positive birth experience can have long-lasting profits such as the improvement of the relationship between a mother and a child, the development of parents’ well-being, self-confidence, and the quality of life [2, 6]. In contrast, a negative birth experience could affect their sense of motherhood and womanhood [7]. It is associated with negative health outcomes, post-traumatic stress disorder, decrease in rates of exclusive breastfeeding, interruption to social relationships, dysfunction in mother-infant relationships, fear of childbirth, increased tendency for an elective caesarean section in future pregnancies [1, 2, 5, 7].

The first child’s birth and the choice of delivery type are considered as the most important events for the primiparous women. The normal vaginal delivery (NVD) as a normal physiological process has many benefits for both the mother and the child [8]. Today, cesarean section is the first option for primiparous women in most countries especially in Iran [9]. Cesarean section, in comparison with NVD, has many dangerous consequences for the mother and the child [8, 10].

Based on the evidence, religious, cultural, and socioeconomic factors influence the perception of delivery and childbirth [11]. Aziato et al. (2016) also considered that religious and traditional beliefs cannot be separated from the childbirth [12]. As majority of Iranians are Muslim (98%), religion and spirituality play an important role in all aspects of life, especially in pregnancy and childbirth [13]. During pregnancy, women intensify their prayers to assure their God’s protection, safe delivery and blessings. It affords them the confidence of going through a safe delivery [12]. Muslim women believe that their sins would be forgiven because of the pain and the hardship of NVD. Also, they state that God gives Heaven to women who have a normal child birth.

In recent years, the rate of cesarean section is 48% in Iran that has increased to 87% in some private hospital [8, 14], most of which are without medical indication [8, 15]. The causes for the high rate of caesarian section have been studied [8, 16‐20]. Sahlin et al. (2013) mentioned that negative child birth experience is one of the contributing factors on women’s tendency for choosing cesarean section [21]. Evidence showed that 10–20% of all women have negative birth experiences [7].

The reason why the rate of cesarean delivery has increased so dramatically in Iran is not entirely clear. It is important to know what has happened over the recent years. What has changed that despite the religious context in Iran, the tendency of primiparous women with no prior birth experience is less likely to NVD? Exploring women’s perception about normal childbirth experiences can enable policy-makers to identify the factors removing undesirable and negative experiences of childbirth and thus facilitate a pleasant childbirth experience for mothers through educational and structural interventions. In addition, through the recognition of women’s perception of NVD, societies can be directed towards a positive understanding of vaginal delivery, which can ultimately lead to maternal health promotion. Pazandeh et al. (2017) stated that improving the quality of care and creating a positive experience of NVD with minimal complications should be the primary goal of health care providers [22]. Therefore, considering the cultural, religious, and socioeconomic differences in the Iranian context, it seems necessary to explore the primiparous women’s perception toward NVD experience.

A descriptive qualitative design using a content analysis approach was conducted to extract the experience of Iranian women’s experience regarding normal vaginal delivery. Data gathering lasted from June to October 2016. The context of data gathering was a state hospital in Kashan, a city in the center of Iran.

Totally, 17 primiparous women took part in the study. The age of the participants ranged from 19 to 34 years old. Furthermore, the majority of participants were living in an urban area with average income, different educational level, and medical insurance. As illustrated in Table 2, three main themes were emerged from data including “Immersion in stress”, “Pain, the essence of NVD”, and “Strategies for situation management” which indicated the nature and dimensions of the women’ perceptions of NVD.

This qualitative study aimed to explore the primiparous women’s experiences of NVD process. “Immersion in stress” was considered as the main theme of the present study. “Immersion in stress” was associated with two factors including loss threat and stressful context. ‘Fear of damage to the infant during childbirth’, ‘fear of abnormal infant’, ‘fear of death’, ‘fear of damage to genital organs’ were the sources of stress in the present study. In line with the previous studies, our findings indicated that the women in labor were excessively concerned about their infants and maternal complications during the normal childbirth [9, 25‐28]. Ravangard et al. (2017) stated that normal birth is inevitably influenced by emotional, social, and psychological stresses that inhibit pleasant feeling during NVD process [29]. McLeish & Redshaw (2019) also concluded that psychosocial stress of normal childbirth can cause poor emotional wellbeing and hinder successful adaptability to the maternal role [30]. Elvander et al. (2013) believed women with high fear of childbirth have reported the lowest pleasant experience [31].

What is inferred from the participants’ statements is that they described the delivery environment as an unfamiliar and noisy place, an environment full of pain, fear, anxiety, and without intimacy and friendship. Screaming and shouting of other women who are giving birth in this environment worsen the fear and the anxiety. Khatony et al. (2019) argued that one of the reasons of fear during delivery is related to the hospital environment and low quality of care [9]. Mahmood (2016) stated that unfamiliar, crowded and noisy environment of hospitals make childbirth an unpleasant experience [32]. Akadri and Odelola, (2018) stated that environmental factors and the degree of strangeness of the environment (equipment, sound, light and restrictiveness) have a great effect on labor pain [33]. Based on evidence, interactions among physiologic, psychosocial and environmental factors affect women’s perceptions of labor pain [32]. Women in labor are highly vulnerable. They are in a strange environment, their private body parts are exposed; they have an awful pain and they hear the sighing and screaming of other women in delivery room. They are alone and no family members are present. Based on “fear–tension–pain” theory which was theorized by Grantley Dick-Read, the pain and anxiety during labor leads to the release of catecholamine, which reduce uterine contractions, increase risk of prolonged labor and fetal distress [32, 34]. Thus, in order to create a pleasant perception of NVD, we need to implement procedures to reduce stress, establish a friendly environment and allow the presence of a family member, a friend or a relative.

The result showed that hearing bitter experiences of other women regarding NVD process was the main source of concern in the primiparous women in this study. Latifnejad Roudsari et al. (2015) argued that these birth stories are mostly associated with unpleasant aspects of childbirth, such as psychological anxiety, fear, severe pain, and inappropriate interventions [35]. These negative aspects are also highlighted by social media. Azami-aghdash et al. (2014) showed that social factors are the main determinant of women’s unwillingness to give a normal birth [16]. Review of liturature in Iranian context demonstrated that sociocultural factors have important roles in the selection of delivery type [13, 28, 35]. Based on the available evidence, social factors and incorrect methods of information broadcasting are the most important factors affecting the choice of delivery mode among Iranian primiparous women [9].

Another important experience associated with NVD process was severe labor pain which converted the pleasant feeling of delivery into unpleasant experiences. Women described labor pain as the most horrible pain that they had ever experienced. Majority of studies also describe labor pain as the most severe pain experienced by women [8, 9, 36]. Labor pain is an important concern for every pregnant woman and the inability to relieve it might have a a significant impact on birth outcomes [37]. Based on women’s experiences, labor pain is an inseparable and inevitable component of NVD process. It has been reported that 40% of multiparous women and 60% of primiparous women had experienced severe pain in labor phase [37]. Evidence showed that fear of labor pain is one of the main reasons for selecting cesarean delivery by women [16, 36, 37].

In addition, paradoxical emotions along with pain were experienced by the participants during NVD process. They described labor pain so severe that disturbed the physiological harmony of their body. Boryri et al. (2016) stated that labor pain decreases women’s energy, power and control of the situation [4]. What separates this pain from other pains is that labor pain is followed by a sweet feeling of being a mother. As the pain deteriorates, the mother becomes closer to the baby. In other words, this unpleasant feeling of pain is associated with a sweet ending to having a baby. Callister et al. (2003) maintained that the labor pain differs from the acute or chronic pain of a disease, trauma, and surgical procedures. This pain is worthwhile for women because it bestowed the gift of motherhood to them [38].

The current study showed that even though the pain is the essence of NVD, the women attempted to use various strategies to manage the situation. Thomson et al. argued that owing to multi-dimensional nature of labor pain, women with different socio-cultural backgrounds have to use various coping strategies to adapt with this condition [30]. Self-management, emotional support and spiritual support were important approaches that assisted the participants to cope with this particular situation. Larkin et al. (2012) considered that self-management is a key component of the NVD process and a major predictor of the sense of satisfaction and success among women [39]. Wilson and Simpson (2016) also indicated that women with the ability to cope with psychological anxieties felt a less labor pain [40]. The women in Downe et al’s study considered that NVD can be a fearful and unpredictable event, but women have to maintain personal control to manage the situation [41].

Emotional support is another effective approach for situation management. Kozhimannil et al. (2013) concluded that the emotional support provided by “Doula” can relieve the labor pain, increase the satisfaction, and create a pleasant experience and positive outcome [42, 43]. Doula is an experienced woman who provides continuous emotional support to women during childbirth [30, 43‐45]. Moreover, Boryri et al. (2016) stated that ongoing support from Doula or one of the family members reduced the medical interventions, increased the mother’s satisfaction, enhanced the neonatal outcomes, and improved the psychological wellbeing of mothers [4]. In Iran, it is not possible to attend a baby’s fathers in labor. If these conditions are met, it will be very effective in creating a pleasant experience and reducing fear and anxiety of primiparous women.

Spiritual support was considered as the main approach for situation management among Iranian women. It seems that this concept is originated from religious context in Iran because as mentioned before the majority of Iranian women are Muslim. Based on the evidence, Faith in God is a connection to the superior power that enhances the feeling of control and intrinsically gives power to women [12]. Mutmainnah and Afiyanti (2019) in their study about Muslim women’s experience of spirituality during pregnancy concluded that faith in God enhances self-confidence, self-control, and persistence during delivery and women can overcome the challenge of childbirth [46]. Tork Zahrani et al. (2019) considered spiritual health as a valuable coping strategy for adapting to pregnancy and childbirth [13]. Akadri and Odelola (2018) suggested that religious beliefs may empower women to tolerate the labor pain [33]. Mohamadirizi et al. (2018) argued that religious-spiritual support can increase self-efficacy among women in child birth [47]. Therefore, the planning and establishing an effective training course about religious-spiritual support are recommended.

This study showed that stress and pain were two highlighted issues in NVD process. Increasing women’s awareness of NVD process and what they experience during this process, familiarizing the primiparous women with the simulated delivery room, accompanying these women for emotional support, and providing spiritual support can be effective in situation management to make the child delivery a pleasant and satisfying experience.