The perception of episiotomy among Iranian women: a qualitative study

Episiotomy entails widening the vaginal opening in the second stage of labour by making an incision in the perineal muscles (Rasouli et al, 2016). Although the rate of episiotomy reduced in some countries between 1992 and 2003, its prevalence has been reported as 40% in England, 54% in North America and 99% in Eastern Europe; in Iran, the rate has been reported as 97% in primiparous women (Kajoye Shirazie et al, 2009; Cunningham et al, 2010). In the World Health Organization's (WHO, 2017) Maternal Health and Safe Motherhood Programme, episiotomy is classified as a method that is often misused, because there is evidence that its routine use causes harm. In fact, routine episiotomy is associated with increased grade 3 and 4 rupture and damage to the anal sphincter muscles (WHO, 2017). This injury then needs to be repaired and pain, bleeding, infection and dyspareunia are among the problems experienced by women after repair (Jiang et al, 2017). In the early 1990s, increased pressures caused a reduction in the rate of routine episiotomy in England, but in general, recommendations to reduce episiotomy rates have been mainly based on the views of health service providers, with little consideration for women's views or priorities (Jiang et al, 2017).

Globally, research has shown many women, especially primiparous women, are scared of childbirth because of their fear of routinely-used episiotomy (Liu and Fairweather, 1991; Sule and Shittu, 2003; Inyang-Etoh and Umoiyoho, 2012). Labour and childbirth are physical and mental endeavours from which women can derive profound feelings of power and success, or conversely, experience emotions such as anger, guilt and hurt feelings (Vaziri et al, 2013). Processing the negative aspects of childbirth requires time to gather one's mind and reduce confusion. It is important for women to process and comprehend the outcomes of childbirth, as the quality of these experiences can affect the health of a mother and her child, as well as a mother's emotional connection and desire to have further children. A previous negative experience of childbirth or healthcare, or a fear of the perception of this experience are some of the main reasons that lead mothers to choose to have a caesarean section in future pregnancies (Vaziri et al, 2013; Pazandeh et al, 2017). The WHO (2018) has recently recognised the need for a ‘positive childbirth experience’ that is consistent with the new global strategy for women's, children's and adolescent's health (2016-2020). According to this strategy, the increasing emphasis placed on women's participation in clinical decision-making and the importance of this participation for their experience mean the perceptions and experiences of women about episiotomy have grown ever more significant (WHO, 2018).

It is commonly believed that episiotomy without anaesthesia will cause no pain, especially if performed at the peak of uterine contraction when the perineum is stretched (Senanayake et al, 2011). This is an unfounded belief, since women experience substantial pain during an episiotomy, which can be prevented through local anaesthesia (Abubakar et al, 2015). There is still controversy about the best obstetric method to reduce perineal trauma. The treatment for perineal trauma is different depending on its severity, the techniques conventionally used in the region in question and personal preference of the woman. The perineal wound may have significant short- or long-term physical and mental effects (O'Kelly and Moore, 2017). Given the challenges of episiotomy, it is necessary to know more about women's perception of it. Describing the experiences of vaginal birth and the interventions performed can help midwives and healthcare workers provide the best prenatal and postpartum care (Valizadeh and Bayrami, 2009). Cultural, social and economic differences between different societies require separate study of each society's particular experiences. Thus, given the importance of improving maternal health, which is the fifth of the Millennium Development Goals, and considering that understanding women's perceptions of care can increase midwifery personnel's ability to properly perform their duties (Vaziri et al, 2013; Iles et al, 2017), the present study was carried out to investigate the perceptions of episiotomy recipients at hospitals and healthcare centres affiliated with the Shahid Beheshti University of Medical Sciences in Tehran.

Methods

Qualitative conventional content analysis was used for this study. Interviews were held with 20 service recipients (nulliparous or multiparous women at least 6 weeks after their episiotomy) with maximum diversity in terms of age, time since episiotomy, parity, education, occupation, history of episiotomy and type of hospital. The inclusion criteria were women who had an experience of episiotomy and were willing to take part in the study. Purposive sampling was used to recruit participants until saturation of the data was achieved. Sampling was carried out in hospitals and health centres affiliated to Shahid Beheshti University of Medical Sciences in Tehran. The lead researcher then reviewed the records of the women eligible for the study and contacted them to schedule a face-to-face interview with those who consented to participate.

Data collection

Data were collected using in-depth and semi-structured interviews between September 2018 and May 2019. Interviews were conducted in public healthcare centres or hospitals, by a member of the research team. The interviews lasted between 45 and 50 minutes and were conducted in Farsi. The interviews began with an open-ended question such as ‘what were your feelings and perceptions about the [episiotomy] incision?’ and were followed by probing questions, such as ‘can you elaborate on that?’, ‘did episiotomy have any complications for you; if so, what were they?’ and ‘are you happy about receiving an episiotomy incision during childbirth?’.The probing questions used were based on the participants' answers. All interviews were recorded and transcribed verbatim. Data were analysed simultaneously with collection. Data collection continued until saturation had been reached and no new data were available.

Data analysis

Conventional content analysis based on the Graneheim et al (2017) method was used to analyse the data. First, each recorded interview was immediately transcribed verbatim on paper and then typed up in Microsoft Word 2018, and the data were analysed in MAXQDA. Next, ‘meaning units’ were identified following a review of the transcribed texts, which was done several times. Then the interviews transcribed on paper were reviewed several times to develop a general idea of the participants' understanding and experience of episiotomy and prepare to find topics. Meaning units were converted into codes and the interview texts were encoded. This process was continually controlled by the researcher to ensure there was consensus among the research team members. Next, similar initial codes were placed in subcategories and related subcategories were placed in one category. Finally, the categories that conveyed a common concept were formed into a theme.

Data rigour and accuracy

The rigour and accuracy of the data were confirmed using the four criteria proposed by Lincoln and Guba (1994): credibility, dependability, transferability and confirmability.

Credibility and acceptability include a set of measures that enhance the likelihood of finding reliable results. These measures include prolonged engagement and ongoing observation, triangulation, external checking and member checking (Speziale et al, 2011; Holloway and Galvin, 2016). In the present study, the researcher used prolonged engagement and immersion in the data and with the study subjects to improve credibility, as well as using the approval of the encoded texts by the participants and research team members.

From a conceptual perspective, trustworthiness is similar to internal consistency or reliability in quantitative approaches (Stommel and Wills, 2004). The steps taken in the present study to improve dependability included documenting the interviews in both audio files and handwritten texts and then re-encoding the text of the interviews after an interval of a few days. The results of the second encoding were compared with the results of the first to obtain common codes. Additionally, external checks were used, as the process was reviewed by two external judges with sufficient information in the field of methodology and the research topic. The researchers implemented any necessary changes to the research and analysis process as a result of this external check.

Transferability denotes the scope of the findings or their application to other users and answers the question ‘are the results fit for or transferable to other users?’ (Guba and Lincoln, 1994). To ensure transferability in this study, efforts were made to exclude any researcher assumptions or bias in the process of data collection and analysis. Transferability was also achieved by providing a rich description of the data and appropriate quotations, followed by clear interpretations. The transferability of the results to larger populations was enhanced by selecting a sampling method with maximum diversity and selecting the most knowledgeable samples. Confirmability was assessed using external checks. The interviews and the extracted codes and categories were reviewed by a number of professors with expertise in qualitative research to ensure that similar results were obtained.

Ethical considerations

The present study was approved at the Shahid Beheshti University of Medical Sciences (code of ethics: IR.SBMU.PHARMACY.REC.1398.088 and IR.SBMU.PHARMACY.REC.1400.211). The participants gave informed written and verbal consent to participate in this study. In addition, they were briefed on the ethical principles of the research, including the study objectives and methods, the anonymity of the samples and the confidentiality of their data, and their right to withdraw from the study as they wished.

Results

Data saturation was reached after interviewing 20 service recipients. Table 1 presents the demographic details of the episiotomy service recipients.

Analysing the data produced one theme with two categories, a total of six subcategories and 20 codes, which are outlined in Table 2. The participants had both positive and negative views of episiotomy, which can be considered a fairly strong stimulus that affects participants' experiences and perceptions. Participants' perception, inference and image of this stimulus can change their perceptions and behaviours.

The overall theme, change of perceptions and behaviours, was made up of two categories: negative experiences and views on episiotomy and positive views and experiences. The negative experiences and views consisted of four subcategories: a bad experience of episiotomy, poor body image, decision to change future mode of childbirth and lack of inclination toward episiotomy. The second category encompassed positive views of episiotomy and consisted of two subcategories: the episiotomy service recipient's satisfaction and not changing mode of childbirth for reasons related to episiotomy.

Negative experiences and views of episiotomy

A bad experience of episiotomy

The behaviour and performance of some service providers during episiotomy and its repair had led to a bad experience for some recipients. This subcategory was composed of four codes:

• The unpleasant sensation caused by needle insertion in the previous episiotomy
• Dissatisfaction with the current episiotomy
• Change of hospital because of the unpleasant experience of episiotomy
• Feeling unable to give birth without episiotomy.

The sense of needle insertion during the process of repair, despite the administration of anaesthesia, was described as unpleasant by some of the participants.

‘I felt the needle piercing my body in my first childbirth, and it wasn't very pleasant.’

(P13, episiotomy in first and second childbirth, 6 and 3 years before the study, respectively)

One of the service recipients talked about her dissatisfaction with her current episiotomy because she had not yet recovered and believed that the incision was made only because the service providers were in a hurry to finish the childbirth process. Those around her who had undergone episiotomy were also somewhat dissatisfied with the incision.

‘The site of my stitches has not yet got well; it is deformed and I'm not at all happy. Most women I have seen in my family and among friends are unhappy with the incision they make at the end to finish childbirth faster.’

(P7, episiotomy in first childbirth, 4 months before)

Some participants attributed their episiotomy complications to the hospital in which they had their previous vaginal birth, and felt that the service providers had inadequate experience and knowledge. These women had therefore decided to change their hospital because of their unpleasant past experience with episiotomy.

‘I no longer wish to give birth at a public hospital. I want to do this at a place operating based on principles, where the repair is properly carried out.’

(P10, episiotomy in first and second childbirth, 4 and 1 years ago, respectively)

Some service recipients had performed special exercises during pregnancy to prevent episiotomy, and failing to give birth without an episiotomy had made them feel helpless.

‘One of my goals was to get no incision during my vaginal birth. I did all the exercises, but the pain of labour had exhausted me when the time came. I was unhappy about not giving birth without incision, because it turned out the opposite of what I had imagined.’

(P3, episiotomy in first childbirth, 3 months before)

Poor body image

For some participants, episiotomy complications had distorted their body image and they reported different reactions toward this poor image. This subcategory included four codes:

• Losing previous beauty
• Being unwilling to look at the site of the episiotomy in the mirror
• Despising one's body because of the complications associated with the episiotomy site
• Despising the episiotomy site because of deformation.

The participants stated that episiotomy destroys the beauty of a woman's body, that even stitching cannot restore this beauty, and this loss will be permanent.

‘When a part of the body is cut off, one feels one is no longer beautiful.’

(P4, episiotomy in first childbirth, 2 months before)

‘Stitches make one's body look ugly and remain ugly forever.’

(P15, episiotomy in first and second childbirth, 4 years and 50 days before, respectively).

‘Do you think that when the beauty of a woman's body is lost through an incision, it can ever get fixed with suturing?’

(P16, episiotomy in first childbirth, 8 years before)

The complications caused by episiotomy made the participants unwilling to see the site of their episiotomy in the mirror:

‘My stomach turned every time I saw this excess flesh on me in the mirror.’

(P6, episiotomy in first childbirth, 3 years before)

‘The first days after childbirth, it didn't affect me much because I didn't know that the stitches were still healing. But after a while, when the stitches had dissolved and I had not healed and saw the gap was still open, I didn't even want to touch myself, let alone look at it in the mirror.’

(P10, episiotomy in first and second childbirth, 4 and 1 year before, respectively)

In addition to a reluctance to look at the site of the episiotomy, the complications of the incision also made participants uncomfortable with their own body.

‘I still have this feeling. I don't like my body at all, I dislike my body so much that I don't want any gynaecologists to see my body either. I don't like to see the gynaecologist even for a simple examination, and I don't like to talk to anyone about it to tell them my problems.’

(P10, episiotomy in first and second childbirth, 4 and 1 years before, respectively)

As a result of the poor repair made, the changes had led to a general hatred toward the site of the episiotomy in the participants.

‘You know, it's been broken into two pieces down there. Think of how an ear gets torn in the middle; it's like that for me, and I don't like it.’

(P14, episiotomy in all four childbirths, 16 years before)

‘Well, pardon me for putting it this way. I didn't even like to go to the toilet, where I'm forced to touch the stitches' site.’

(P10, episiotomy in first and second childbirth, 4 and 1 years before, respectively)

Decision to change future mode of childbirth

As a result of the complications and problems associated with episiotomy, some participants had decided to change their mode of childbirth, not knowing how unlikely it was to need an episiotomy in subsequent childbirth, or thinking that they could avoid an episiotomy by attending physiological birth preparation classes and exercising. This subcategory consisted of three codes:

• Changing mode of childbirth because of poor neonatal conditions
• Changing mode of childbirth because of episiotomy
• Changing mode of childbirth out of fear of past events.

Some participants had decided to opt for a different mode of childbirth because of poor neonatal conditions and the likelihood of adverse events during childbirth.

‘Because of what happened to my child this time, I will choose caesarean section next time, since I don't want to put my child at risk.’

(P11, episiotomy in first childbirth, 6 months before)

Some recipients had no desire to have a vaginal birth with an episiotomy because of the difficult nature of postpartum care and the delayed recovery.

‘The postpartum care was very difficult for me. My skin healed slowly. I may not give natural birth at all.’

(P10, episiotomy in first and second childbirth, 4 and 1 years before, respectively)

Some service recipients had requested to change their mode of childbirth to prevent past events from happening again out of fear of such events.

‘I was really afraid that these events could happen again. The same room, the same conditions, the same incision and the same stitches; these were on my mind.’

(P13, episiotomy in first and second childbirth, 6 and 3 years before, respectively)

‘Actually, yes, I did tell them. Since I feared having the same things that had happened during my previous vaginal birth happen again, I mean the incision I had gotten unknowingly, I told my doctor that I wanted a caesarean section next time.’

(P11, episiotomy in first childbirth, 6 months before)

Lack of inclination toward episiotomy

The negative outcomes of episiotomy were responsible for some participants' unwillingness to have an episiotomy in future births. This subcategory consisted of five codes:

• Unwillingness to have episiotomy in future deliveries
• Regretting vaginal birth for reasons related to episiotomy
• Lack of prior readiness for undergoing episiotomy
• Preferring childbirth without episiotomy
• Episiotomy ruining the joy of childbirth.

Participants expressed their unwillingness to have an episiotomy in future births and stated that they would have avoided undergoing an episiotomy had they had adequate knowledge and experience of the incision.

‘I am never going to let them do it again. This happened because I had no experience the first time, but if someone had taught me at the beginning and I knew about it, I would not have allowed the incision to happen, although it may be comfortable and painless for some.’

(P7, episiotomy in first childbirth, 4 months before)

‘No, I no longer want it, because it was too hard for me. The care steps I had to take and its late recovery bothered me a lot.’

(P16, episiotomy in first childbirth, 8 years before)

Some participants regretted having a vaginal birth because of the painfulness of their stitches and the undesirable complications that emerged or their spouse's dissatisfaction.

‘If I had known that these stitches would be so painful, I would have opted for [a caesarean ] section.’

(P9, episiotomy in first childbirth, 15 months before)

My stitches got opened up 3–4 days later. I was in so much pain, the incision was so bad that I said to myself a thousand times that I wished I had had [a caesarean] section.’

(P7, episiotomy in first childbirth, 4 months before)

‘The first time my husband saw it, he was so surprised. I realised that he was surprised that the shape of the incision had remained unchanged. This affected me deeper and made me wish that I had not had this incision, and I wished I hadn't had a vaginal birth.’

(P10, episiotomy in first and second childbirth, 4 and 1 year before, respectively)

During pregnancy, some participants believed they would not need an episiotomy. Others had performed certain preventive exercises and therefore spoke of their lack of preparation for an episiotomy.

‘I didn't think I would be sutured, and I was told about it just after they sewed me back up.’

(P2, episiotomy in first childbirth, 40 days before)

‘It was unexpected, because I used to go to the pool too and my doctor had told me that the baby's head was good for vaginal birth, so I didn't think an incision would be necessary.’

(P11, episiotomy in first childbirth, 6 months before)

‘I thought I would not need an incision, and that they would only cut me if the baby was at risk. But my child wasn't at any risk.’

(P7, episiotomy in first childbirth, 4 months before)

Some service recipients preferred childbirth without an episiotomy because they were aware of the possible complications of the procedure.

‘It would have been excellent if that was not done, since the incision and suturing were so bothering.’

(P8, episiotomy in first childbirth, 7 months before)

‘Well, I prefer not to have an incision in the first place.’

(P10, episiotomy in first and second childbirth, 4 and 1 years before, respectively)

Some participants considered the pain of an episiotomy an impediment to enjoying the process of childbirth.

‘The pain of this incision prevented me from enjoying being with my daughter.’

(P3, episiotomy in first childbirth, 3 months before)

‘The incision, the subsequent care steps and its pain and burning sensation made me derive no joy out of my child's infancy.’

(P13, episiotomy in first and second childbirth, 6 and 3 years before, respectively)

‘The pain I endured ruined the joy of having my baby be healthy and holding him in my arms.’

(P9, episiotomy in first childbirth, 15 months before)

Positive attitudes toward episiotomy

Good experiences and the absence of complications meant some participants had a positive attitude toward episiotomy. Despite preferring childbirth without episiotomy, these participants viewed getting through this stage as a test of their abilities. This category included two subcategories: the participant's satisfaction with episiotomy, and not changing mode of childbirth for reasons related to episiotomy.

Participant's satisfaction with episiotomy

The absence of negative episiotomy consequences in some participants was the reason for their satisfaction with episiotomy and a demonstration of their strength and ability. This subcategory consisted of two codes: satisfaction with childbirth despite episiotomy, and feeling powerful after episiotomy.

Although they preferred childbirth without episiotomy, some participants expressed satisfaction with their childbirth despite having had episiotomy, since they had not developed any complications.

‘Everything was good for me. Like, they told me to do this, do that; they told me all the care steps, everything.’

(P12, episiotomy in first childbirth, 4 months before)

‘I have no problems at all right now, and I'm truly happy.’

(P8, episiotomy in first childbirth, 7 months before)

For some participants, the experience of episiotomy was described as a journey from pain to strength, despite the difficulties and problems, and they felt strong.

‘Well, psychologically, yes. I can say that sometimes I even feel proud of myself when I remember. Not that it can have a negative effect, but when they talk about it to people who want to give birth and ask them and all, I feel proud of myself because it was one of those things that was a big deal to me and for others and still I managed to do it.’

(P1, episiotomy in first childbirth, 3 years before)

‘I feel proud that I was able to give birth naturally, because no one in our family had given natural birth before me and they were all surprised that I had done this, thinking it was an excellent thing. Well, the old generations had done it, but not the new generations.’

(P13, episiotomy in first and second childbirth, 6 and 3 years before)

Not changing mode of childbirth for reasons related to episiotomy

Participants' knowledge about the complications of caesarean section had guided some toward preferring a vaginal birth despite the risk of episiotomy, and their positive experience of episiotomy had made them accept this incision in subsequent births without changing their mode of childbirth. This subcategory consisted of two codes: preferring vaginal birth over caesarean section despite episiotomy, and episiotomy having no effect on the decision about the mode of childbirth.

Despite complications such as pain or burning and sutures, some participants talked about their preference for vaginal birth over caesarean section despite needing an episiotomy, and when comparing these two modes, they believed that episiotomy had fewer and more bearable complications than a caesarean section.

‘I was ready to have another 10 incisions but not undergo [caesarean] section, because it's a very minor thing and I will accept it more readily this time, and I know that nothing particular is going to happen afterwards, and I will accept it a lot easier, and I don't care if the incision is larger or needs more sutures either.’

(P1, episiotomy in first childbirth, 3 years before)

‘Despite all the pain and sutures, vaginal birth is still a lot better than [caesarean] section.’

(P4, episiotomy in first childbirth, 2 months before)

‘I will still bear it the next time around if they want to give me another incision, because [caesarean] section has many more complications, that's why I prefer to have incisions rather than undergo [caesarean] section.’

(P20, episiotomy in first childbirth, 40 days before)

Some participants reported that their decision about mode of childbirth was not affected by having had an episiotomy, and given their previous episiotomy experience, they were ready to accept it in their subsequent childbirths too.

‘I will accept it easier this time, since I know nothing particular will happen afterwards, and I will accept it a lot easier. And I don't care if it's even larger or needs more sutures, I'm not going to change my mode of childbirth next time.’

(P1, episiotomy in first childbirth, 3 years before)

‘No, I only had vaginal birth on my mind from the start. I never considered [caesarean] section even when I wasn't yet pregnant, and now, in spite of the incision, I don't want to have [caesarean] section for my next childbirth at all.’

(P3, episiotomy in first childbirth, 3 months before)

‘Well, now that there are two, I prefer not to get incisions all over [my different body parts]. That's why I prefer vaginal birth again.’

(P13, episiotomy in first and second childbirth, 6 and 3 years before, respectively)

Discussion

This study investigated the perception of episiotomy from the perspective of women who had undergone one for the first time in Iran. The results showed that the participants' viewed episiotomy as leading to a profound transformation, which led to the formation of the overall theme of change of perception and behaviour.

Negative attitudes toward episiotomy

The participants reported having had bad experiences with an episiotomy. Evidence-based studies show that routine interventions in low-risk births do not always ensure maternal and neonatal safety and some medical measures disrupt the natural process of childbirth, causing unwanted complications (Chen and Wang, 2006). For example, in many hospitals worldwide, obstetric and gynaecological interventions, including restrictions on eating and drinking, induction and episiotomy are routinely performed on all women without particular medical justifications (Gungor and Beji, 2012; Priddis et al, 2014; Jahlan et al, 2019). Such interventions can make women dissatisfied with the experience of childbirth, leading them to seek alternative methods for subsequent pregnancies (Jansen et al, 2013).

In the present study, women reported that the pain of an episiotomy or complications from it prevented them from enjoying the birth of their child. Based on the little available evidence, many women have reported negative views on episiotomy because of the postpartum pain and discomfort associated with the incisions and stitches (Gungor and Beji, 2012; Binfa et al, 2016a; 2016b; Jahlan et al, 2019).

In the present study, women reported that the episiotomy had impacted their mental state, as demonstrated by their reluctance to see the evidence of their episiotomy in the mirror and negative views about their own body because of the procedure. Qualitative studies conducted on primiparous mothers with an experience of episiotomy show that episiotomy causes severe anxiety and stress in mothers and affects their postpartum mental health (Coates et al, 2014; Priddis et al, 2014). Other studies show that the damage to the perineum caused by an unnecessary episiotomy can have long-term adverse effects on a woman's mental status, sexual life and the mother–child bond (Borruto and Comparetto, 2016; Stankovic, 2017).

The quality of childbirth experiences affects maternal and neonatal health, the relationship between a mother and infant, a mother's sexual activity and the desire to have another child (Waziri et al, 2012). Factors such as expectations, pain and form of care affect women's experiences (Waziri et al, 2012). In a study of primiparous women, Henriksen et al (2017) showed that women were usually unhappy about unnecessary episiotomies and reported inadequate preparation. A study by Jahlan et al (2019) on the views of primiparous women in Saudi Arabia on episiotomy showed that one participant was unhappy because she had only realised that she had been given an episiotomy during the suturing process. Participants in Jahlan et al (2019) also discussed the pain of the technique and were unhappy about the appearance of the stitches made. Participants stated that this process disrupted their daily life activities and the pain experienced during the recovery process made quickly responding to an infant's emotional needs, such as breastfeeding, difficult, which affected mother–child bonding (Jahlan et al, 2019). This is similar to the findings of the present study, where participants reported difficulties as a result of the pain felt during episiotomy repair and recovery.

Poor body image was another key experience of the participants in the present study. Iles et al (2017) reported that women with an anal sphincter injury experienced changes in their body image and these changes were associated with self esteem and personality. Body image has a complex structure and a range of factors can contribute to dissatisfaction. The strong association between perceived changes in anatomy and changes in body image suggests that the anatomical consequences of a repaired rupture are significant. Women's perception of the changes in vaginal appearance that result from episiotomy may be reinforced by social media and websites that portray adverse birth-related changes and recommend cosmetic surgeries of the genitalia as a solution, such as vaginoplasty and labiaplasty (Braun, 2010; Thibault-Gagnon et al, 2014). The results of a preliminary study conducted by Zielinski et al (2017) on body image, genitalia and sexual confidence following vaginal birth showed that the changes perceived by the participants in the rectum or vagina adversely affected their sexual and physical confidence. In addition, episiotomy has a greater negative effect than anal sphincter tears after vaginal birth or partial tear of the levator ani (Zielinski et al, 2017). The relationship between episiotomy and increased postpartum vaginal dryness and intercourse pain may also contribute to dissatisfaction with body image (Ejegård et al, 2008).

In the present study, participants' experiences had made them unwilling to have an episiotomy and decide to change their mode of childbirth in future pregnancies. He et al (2020) explored women's experiences of episiotomy in China, and reported that some women were scared of having an episiotomy because of a previous experience of incision-induced pain and wanted to avoid becoming pregnant again or opted for a caesarean section in their subsequent pregnancies. In addition, women with a prior experience of episiotomy experienced anxiety during their pregnancy and were less confident about future vaginal deliveries (He et al, 2020). Several women used the term ‘mental overshadowing’ to discuss the negative and long-term effects of episiotomy (He et al, 2020). He et al (2020) describe this term as relating to a negative experience that causes fear or anxiety about the future and resembles the experience of war or personal trauma. Mental overshadowing can refer to the long-term fundamental effects of episiotomy on women. The fear caused by the experience may lead to a woman avoiding having an episiotomy again, either by preventing pregnancy or changing their mode of childbirth in future pregnancies. This experience harms a woman's self-confidence in sexual relationships, and mental overshadowing can persist in some women through the effect it exerts on subsequent deliveries and postpartum sex life (He et al, 2020). This finding agrees with other qualitative studies on vaginal birth (Salmon, 1999; Ilhan et al, 2015).

Studies have shown that as a result of their negative experiences of childbirth affected by various factors, including episiotomy or perineal trauma during childbirth, some women feel helpless and defeated instead of feeling strong. This view was also expressed by participants in the present study. A negative experience of childbirth may have short or long-term effects on women's physical and mental health (Thomson and Downe, 2010; Henriksen et al, 2017). Studies have indicated the effect of negative experiences on a re-emerging or developing fear of childbirth (Garthus-Niegel et al, 2013). Fear of childbirth is associated with an increase in the prevalence of caesarean section and postpartum depression (Størksen et al, 2013; Ryding et al, 2015).

Preventing negative childbirth experiences in mothers is crucial, since it is the most important predictor of post-traumatic stress disorder symptoms and fear of childbirth (Garthus-Niegel et al, 2013; Størksen et al, 2013; Ryding et al, 2015). In addition, women have reported caution and care in subsequent pregnancies as an important factor in preventing the influence of negative experiences associated with previous deliveries (Henriksen et al, 2017).

Positive attitude toward episiotomy

The results showed that although some participants had negative experiences and views, others were satisfied with the episiotomy and had positive experiences. This satisfaction came from feelings of strength and power they derived from giving birth vaginally with an episiotomy. A study conducted by Jahlan et al (2019) found that despite the pain and stitches of an episiotomy, participants were happy with the procedure and willing to undergo it again in the future. Their justification was that a second episiotomy would provide an opportunity to improve the appearance of the sutured perineum and strengthen self-esteem. They also believed that this would reduce the duration of the second stage of childbirth and potential complications (Jahlan et al, 2019). As a result of previous experiences with an episiotomy and post-discharge care, some participants in the present study were willing to accept episiotomy in subsequent childbirths. The use of an episiotomy did not affect their choice of birth mode and their preference for vaginal birth over caesarean section.

To overcome the negative effects of episiotomy, it is important to first establish proper maternal care during childbirth (Jahlan et al, 2019). The WHO recommends that all pregnant women and their infants should be provided with quality care services during pregnancy, childbirth and the postpartum period (Tunçalp et al, 2015). To reduce maternal and neonatal complications and mortality, every pregnant woman needs to receive quality care that uses evidence-based methods during childbirth in a supportive setting. Quality care includes efficient clinical and non-clinical interventions provided by competent health personnel and strong medical infrastructures to achieve better health outcomes and ensure that women have a positive experience. In addition, quality of care is regarded as one of the main components of the right to health and a path for women's and children's self-esteem and equality. To achieve this goal, healthcare measures should be safe, effective, timely, efficient, fair and person-centred (Tunçalp et al, 2015; Çalik et al, 2018). By using evidence-based approaches to childbirth, unnecessary medical techniques and procedures will be discarded and the value of women's expectations will grow, thus leading to increased patient satisfaction and reduced costs (Çalik et al, 2018).

Strengths and limitations

The strengths of the study was that it was qualitative, which derives a nuanced perception of the experiences of episiotomy service recipients. This is an advantage, as interviews with service providers conducted as part of the first author's PhD thesis found that service providers had optimistic views of service recipients' perception of episiotomy and found it to be of little importance. However, for some participants, the duration of suffering and the time point at which their perception had changed were not clear because of the length of time that had passed since their episiotomy, which was a limitation.

Conclusions

The episiotomy recipients had both positive and negative views of episiotomy. The negative views were affected by bad experiences of episiotomy, poor body image after the procedure and a resulting decision not to undergo an episiotomy in future births or a general lack of inclination towards episiotomy. The positive views were affected by satisfaction with the procedure and a resulting decision not to change mode of birth in future pregnancies.

Healthcare systems are responsible for supporting mothers with their physical and mental health; therefore, the authors recommend that health policymakers devise plans to strengthen positive perceptions of episiotomy and eliminate those negatively affecting women's experiences. Childbirth satisfaction has an effect on episiotomy satisfaction, so an effective factor in creating positive views will be to improve the quality of midwifery care. Another effective measure will be to give women more control of childbirth decisions and interventions, such as episiotomy, as this will improve their sense of empowerment.

Key points

• Investigating the perception of women who have had an episiotomy is crucial for providing appropriate care
• This study explored the experiences of 20 women with experiences of episiotomy in hospitals and health centers affiliated to Shahid Beheshti University of Medical Sciences in Tehran
• A lack of negative outcomes and a patient's satisfaction with the episiotomy, despite having difficulties, led to some participants' positive view of episiotomy
• Negative feelings and complications resulting from the recovery period caused negative perceptions of the procedure, and some women decided not to undergo another episiotomy in their next birth or elected for a caesarean section instead of risking having an episiotomy again

CPD reflective questions

• How might a woman's perception and experience during a birth that requires an episiotomy affect fertility behaviour?
• Aside from physical complications, what effects might an episiotomy have on a woman?
• How might an episiotomy affect a woman's choice of delivery in future pregnancies?