Most women describe the birth of a child and childbirth as a meaningful event in their lives, but the occurrence of childbirth injuries unpleasantly changes their physical and emotional state for a long time (1). More importantly, perineal injuries or traumas, especially severe ones, unpleasantly affect a woman's emotional and physical stability after delivery for a long time (2,3). According to the definition of the World Health Organization, childbirth morbidity is any condition that occurs in the mother during pregnancy or childbirth and has a negative impact on maternal health (4). Childbirth trauma is one of the cases of maternal morbidity that threatens the health of mothers after childbirth due to worrying complications in physical, emotional and social areas. Perineal trauma during childbirth is divided into three groups; class one: no perineal trauma, class two: mild perineal trauma (first and second degree tear) and class three: severe perineal trauma (third and fourth degree tear) (5). The World Health Organization (2018) has reported the incidence of severe perineal tears as 24 per 1000 deliveries (between 9 and 33 cases) worldwide (6). Cola reported a rate of severe perineal tear during 2011 and 2015 as 0.6-8% in Italy (7, 8). There is no statistic in Iran, but Mesdaghinia (2010) has reported the prevalence of grade 3 and 4 perineal tear as 0.16% in Kashan's maternity ward during 2007 and 2009 (9).
Severe perineal trauma has severe effects on maternal health and can lead to long-term pelvic pain, late wound healing, readmission, inability to perform tasks, and concerns about no return to healthy status and loss of marital stability results in decreased health (10). These problems cause mothers to suffer physically and mentally for months and, of course, affect the quality of life of women (11).
Meaney et al. (2016) in a qualitative study on 14 women with obstetric and midwifery complications such as preeclampsia, gestational diabetes, placenta previa, and perineal tear stated that the main reason for their dissatisfaction was the inability to manage and treat postpartum complications. They recommend the childbirth caregivers that mothers be given complete information about the delivery status and possible complications before discharge (12), while many of these women with birth -related perineal injuries attribute their problems to inadequate care (13). Lack of continuity of care and inadequacy in postnatal care (PNC) can hinder the achievement of PNC-related goals, which is maternal and infant health (1).
However, mothers' experience of the postpartum period in mothers with perineal childbirth trauma is unknown and undefined. Due to the fact that patients' views have a special place in estimating the need for care and quality of health care (14,15), and patients' views are a function of culture, ethical principles and values that govern each society, the need for a qualitative study on the experience of women in postpartum care in women with perineal childbirth trauma was felt to meet their needs and increase their level of satisfaction. Since a qualitative study provides a suitable solution to explain the concept and produce clear and operational definitions of the phenomenon under study (16) in the field (Iran), so this study was performed to explain the understanding and experience of women with perineal childbirth injuries regarding postpartum care.
Materials and Methods
This study was conducted adopting a qualitative content analysis approach.
The qualitative content analysis is the recommended method in cases when there is little knowledge about the subject and there is no certain framework for the concept or phenomenon (17). Therefore, qualitative content analysis was used as the characteristics of quality postpartum care in women with perineal trauma was unclear.
In this study, 22 women with various degrees of perineal trauma were purposively selected between 10 days to one year after childbirth from hospitals and healthcare centers in Mashhad, Iran in 2016. Inclusion criteria were the absence of any medical disease and giving birth to a healthy singleton baby. Study settings included educational hospitals and public health centers in Mashhad, Iran, due to the admission of higher rate of women with normal pregnancy and childbirth. Purposeful sampling was performed with maximum variation based on degree of injuries and type of normal delivery. Data collection was done through in-depth and semi-structured face-to-face interviews. The interview began with a general question and then continued with more specific questions: What experience do you have with postpartum care? Or what are the characteristics of a good postpartum care? And what did you expect from health professionals who give you postpartum care?
In this research, the analysis started at the same time as data collection. Data analysis was performed using a conventional qualitative content analysis approach based on the method of Elo and Kingas including three steps of preparation, organization and reporting (2008) (17). In the first stage or preparation phase, the whole interview was considered as the unit of analysis and then read several times to get a general understanding of the concept. Then, the related parts of the text to the quality postnatal care were identified. In the second stage or organization, open coding, providing coding sheets, grouping similar codes, categorization and abstraction were done, during which all the text was coded and grouped based on similarities, and finally similar groups were placed in one class. In the third stage, which is reporting, the results were reported in categories.
For the validity of the study, the texts were coded through questions from colleagues (supervisors and consultants and two PhD students in reproductive health who were skilled in qualitative research and the subject of the study) and checked by members (three of participants) and also long-term participation of the researcher. In addition, the researcher tries that for the research to be reliable, all stages of the research was recorded in detail from the beginning to the end and were provided to experts for verification. Moreover, to maintain the transferability of the study, the maximum variety of participants was selected and the voice of the participants was reflected.
Mean age of participants was 27.3±8.1 years with age range of 18-43 years, and among women, 10 (45.45%) were undergraduates, 9 (40.9%) graduates, 2 postgraduates and 1 bachelor, 14 primiparous women (63.63%) and 8 multiparous women (36.36%) participated in this study. Six participants (27.27%) were in first trimester, 4 (18.18%) in second trimester, 5 (22.72%) in third trimester and 7 (31.81%) in forth trimester of pregnancy.
In this study, nine participants (40.9%) experienced normal delivery and low degrees of perineal injury (first and second degree) and 13 (59.1%) experienced labor with severe degrees of perineal injury (three and four degree). Four participants (18.2%) experienced vacuum delivery and two cases (9.1%) had normal delivery after cesarean section. (Table 1).
Two categories were emerged and five sub-categories were extracted through conducting 22 interviews (Table 2).
The main category of unethical practices in care
This category was created from the two emerged categories of "lack of occupational irresponsibility" and "unethical communications", which reflect the participants' views about their care during the postpartum recovery period. In other words, women participating in the study described postpartum care as a form of care with neglecting the principles of ethical care. Their experiences during the postpartum period were incomplete and unattended follow-up and failure to provide comprehensive postpartum care on the one hand and unethical communication with them, due to non-compliance with the principles of active listening, honesty, compassion and kindness by health workers. This reflects the non-observance of patients' rights in the event of serious complications for the mother after childbirth.
1.Emerged category of lack of professional responsibility: This category reflects the views of most postpartum women about postpartum care provided in maternity centers, which emerged from two subcategories of: "short term of follow-up" and "neglect of comprehensive care".
1-1-Subcategory of short term follow-up: This subcategory reflects the expectations of participating women about how care is needed during this period. Although most women with mild trauma did not expect much from the centers where they had childbirth and considered health centers to be sufficient to meet their medical needs in the postpartum period; but women with severe perineal trauma considered maternity centers to be passive and unresponsive to their medical needs and assigned postpartum care to health centers, which were also not responsive. A participant said in this regard:
"When they discharged me, they did not say come to be taken care. After delivery, I went to the health center once, for my own examination, but I did not go to the health center anymore, because they don’t examine the sutures. They say go to the doctor" (Participant No. 14, 25 years old, primiparous, normal delivery, episiotomy with third degree tear).
Another participant said:
"They should follow up; they should say that I should go at least 2-3 times to see what happened" (Participant No. 3, 30 years old, second delivery, normal delivery, third degree tear).
Other primiparous woman said in this regard: "when they discharged me, they said me that go to gynecologist if you had any problem, don't come here anymore. You have nothing to do here " (Participant No. 2, 34 years, first delivery, vacuum delivery, episiotomy with third-degree tear).
However, women with mild perineal trauma reported that provided postpartum care is sufficient.
1-2-Sub-category of neglect of comprehensive care
Most participants with severe trauma expressed ignoring their needs after delivery and reported that their unwillingness for next referring is ignoring physical and mental needs.
A participant who had delivery by a student said in this regard:
"I did not want to come to the hospital where I was torn like this. When you come, they didn’t answer about the problems which they created themselves. I cannot sleep with my husband until now, I cannot control my toilet, I cry psychologically all the time. It's not clear How long do I have to endure? I get better or not. Now I'm not at all better, I'm depressed. What should I do? "(Participant No. 3, 30 years old, second delivery, normal delivery, third degree tear).
A multiparous woman who had problem with controlling her abdominal gas after delivery said:
"It's like I don't want anyone to come to my house, because I cannot control myself in public, I'm ashamed to tell anyone. Health care providers know that these issues may occur to me after childbirth, when I am so torn, and they should guide me and take care of my pain, but this is not the case. They did the same as my previous delivery, in which I had no problem. I have lots of other problems now" (Participant No. 7, 33 years old, third delivery, normal delivery, with third degree tear).
Participants did not consider the provision of postpartum care to be the solution to all physical, mental and family problems, and stated that the basic condition for providing decent postpartum care was the comprehensiveness of medical services.
2-Emerged category of unethical communications: The emerged category of trying to communicate effectively with the patient reflects patients' expectation from maternity centers to communicate effectively until women fully recover after childbirth, which emerged from three subcategories: "dishonesty", "inactive listening”, and "lack of compassion ".
2-1-Subcategory of dishonesty
Some patients who experienced severe perineal tear expressed discomfort about their uninformed of the complication caused during labor and subsequent complications.
A participant said in this regard:
"I did not understand anything about tearmy perineal injuries at the time of delivery. I did not understand until the next day. What I understood was that they sutured the tearinjuries as mistaken, they opened the sutures again, and the doctor came and sutured again. In the ward, they did not tell me what happened, even they did not tell me what problems I had in the first months. This is not a correct approach with patient" (Participant No. 10, 30-year-old, primiparous, vacuum delivery, episiotomy with fourth degree tear).
Knowing about the problem was also considered important for many because of their readiness for the next pregnancy or planning.
"I did not expect much. I just wanted to know why my delivery was like this. It was different from my cousin or the others. I wanted to know how much it's my fault; and to know would it be the same if I got pregnant again? No one answered me. They didn’t tell how long I would have pain. I've got pain, I've got constipation, I feel different with others, my tearperineal injuries is more" (Participant No. 2, 34-year-old, primiparous, vacuum delivery, episiotomy with fourth degree tear
2-2-Subcategory of inactive listening
This subcategory of participants reflected the fact that patients' speech was not given enough attention during postpartum care, and some caregivers focused only on their examinations or forms of care. A participant said in this regard:
"They didn't behave well. They didn't even look at what I was saying" (Participant No. 5, 25 years old, primiparous, normal delivery, episiotomy with third degree tear).
Another participant said:
"I had a catheter for three or four days, I couldn't urinate, it was so swollen. They cared me for two months, but their behavior was not good, it was all disrespectful. It is not as if they do not listen or look at you when you are sick, and they never asked my opinion at all, they said you should take these pills, I say I feel very bad, they do not listen at all"(Participant No. 16, 29 years old, primiparous, vacuum delivery, third degree episiotomy).
From the point of view of some participants, not listening to patients' opinions and comments and not looking at them during care, which is a sign of negligence, is a disrespectful behavior that they experienced in their postpartum care.
2-3-Subcategory of lack of compassion: In this subcategory, some participants emphasized that they expect caregivers to understand the patient's feelings when providing postpartum care and to comfort her, at least to provide care which they do for their loved ones, not blame them.
A primiparous woman, who was in the sixth month after giving birth, said in this regard: "The woman who was in the health center said: you should cooperate during delivery, you created a problem yourself, you have to endure it) " (Participant No. 13, 43 years old, second delivery, normal delivery after cesarean section, third degree tear).
Participant No. 2 also said: "When I came home, I felt worse, my cousin was giving birth in a government hospital, she's better than me (Participant No. 2, 34 years old, primiparous, vacuum delivery, episiotomy with third-degree tear)."
Providing postpartum care in women with severe birth-related perineal traumas from the participants' point of view was described as a type of care providing with neglect of ethical principles in a professional care. Incomplete follow-up and failure to provide holistic and responsive care for all patient's needs calls into question the professional responsibility of such care. Unethical communication through dishonesty in expressing postpartum complications and reporting what happened to mothers during childbirth, not listening to the opinions and not behaving compassionately as any health care provider likes for their loved ones, are some of the reasons which participants described the challenges in their postpartum care. In their experience, this reflects the conditions of an ethical care in postpartum care. According to Swenson (2018), ethical care is a responsive care that is responsible and solves problems (14).
Most participants with severe perineal trauma expressed poor postpartum care which was due to caregivers not responding to treatment needs and not following up after delivery, so described the rate of achieving optimal and comprehensive care not enough. In the present study, although women with mild perineal trauma were also included in the study, they did not face significant care challenges in the postpartum period, which resulted in the loss of their rights and discomfort, and they considered the provision of routine postpartum care as desirable care which is provided to them in an accessible and responsive manner when referring to health centers. Mirhaghi et al. (2014) in a qualitative study have reported responsibility as one of the ethical themes in patient's care, which has been defined as vigilance, confidentiality and speed of action of caregivers in providing care to patients and as one of the principles emphasizes professional ethics and patient's rights in care and treatment (16).
In the present study, irresponsibility, which is in semantic contradiction with the term of responsibility, is described as a lack of comprehensive attention to medical needs and non-abandonment of the patient after childbirth, while in the study of Mirhaghi et al. (2014), this theme is resulted from literature review and no interpretation has been provided. Meaney et al. (2016) in a qualitative study and through semi-structured interviews in the postpartum period with 14 women with severe childbirth complications including severe bleeding achieved the theme of complication management, complication treatment. In the theme of complication management, the participants expressed dissatisfaction from transfer of medical services to other wards (12), this finding is consistent with the present study and participants with birth-related perineal trauma demanded continued care in the postpartum period by maternity centers.
Concerns expressed by women during the postpartum period related to their need for physical recovery and full care and follow-up at home were two extracted themes from the qualitative study by Xiao et al. (2020). Participants were 22 delivered mothers at 30 to 42 days postpartum at Shenzhen Hospital in China. They reported the need for comprehensive care and continued care at home despite the absence of any complications during or after delivery. Home care is a reflection of mothers' need for postpartum follow-up, which is in line with the findings of our study. Other themes in Xiao's study, including paying attention to preparing for parenthood and gaining baby care skills were the other needs and expectations of mothers who gave birth (18) that didn't emerge in the results of our study, which is probably a sign of high priority to follow and cover other needs of mothers in the family in the postpartum period. Culturally, infant's care is a need that is highly regarded by the family in Iran, especially in the first delivery. In the present study, most participants were primiparous, so planning for comprehensive care based on ethical principles is a need that participants in the present study referred to it.
Unethical communication was the second theme of unethical practices in care in postpartum care, which emerged from the themes of dishonesty, inactive listening, and lack of compassion communication. Jolaee et al. (2010) in a review entitled "Nursing Ethics Codes in Iran with respect and commitment" has highlighted that honesty with the patient is one of the ethical codes that caregivers are required to observe (19). Ghaffari Sardasht and et al (2014), in reviewing the quality of preconception care, reported that part of the quality of care is related to the ethical and communication issues between service providers and clients (20). In a qualitative study of 98 midwives describing compassionate behavior during childbirth, Krausé et al. (2020) found three themes: Making meaningful connections with women, Initiating individualized understanding of every woman, and Action through care and support. The theme of meaningful connections with women referred to the two sub-themes of observance of dignity and respect, honesty. Therefore, some part of the desired relationship is related to observance of dignity and respect and honesty. The emergence of empathy in the second theme and comprehensive emotional and informational support in the third theme in the study of Krausé is somehow in line with the results of the present study (21). However, in the qualitative study of Meaney et al. (2016), the participants found that physicians' treatment of postpartum complications without communication or little communication was not effective (12).
In the present study, lack of attention and listening to their opinions and decisions about care and treatment was expressed. Mirzakhani et al. (2020) in a qualitative review study of pregnant women with high-risk pregnancies reported that respect and effective communication with them by listening to their problems are important points in their health and well-being (22). One of the strengths of the present study is the reflect of the voice of postpartum women with birth-related perineal trauma, which by sharing their experiences of postpartum care helps to plan and decide to eliminate the existing short term of the care plan and improve postpartum care. No expressing the views of caregivers in the current study can be one of the limitations of the study.
The current postpartum care of women with birth-related perineal trauma does not meet their expectations and needs. So, it seems that Postpartum care in women with severe perineal trauma needs to be reviewed so that follow-up care and comprehensive provision of required services should be taken into account with focus on effective communication skills including honesty, active listening and compassion. It is the responsibility of medical team to provide and meet postpartum women's medical and health needs until complete recovery in the postpartum period.
This study is part of the PhD thesis (code number: 951362) of the first author (NJ) and financially supported by Vice Chancellor for Research, Mashhad University of Medical Sciences, Mashhad, Iran. Hereby, we express our gratitude to the participants who truthfully shared their experiences with the research team.
Conflicts of interest
Authors declared no conflicts of interest.