Evaluation of Effects of Positive Birth Experience on the Perception of Birth of Primiparous Women


 The authors have withdrawn this preprint due to erroneous posting.


Introduction
Pregnancy is a natural process and an important experience, as well as physiological incident that necessitates adaptation to social and physiological changes in a woman's life [1][2][3]. Thus, the pregnant woman adapts to changes related to herself and prepares herself for birth by having good relations with her environment [4]. A women's perceptions of birth, the meaning that they attribute to birth, and their personality characteristics may change according to the society and the culture they live in [5].
Having a positive birth experience is related to active support systems [6]. Thus, fear of giving birth and not receiving su cient support before birth are factors that negatively affect psychosocial health [3,7].
Thus, we sought for a way to increase the positive birth experiences of women. In this study, we aimed to evaluate the birth perceptions of primiparous women after having interactions with women who had a positive experience of giving birth.

Methods
Necessary permissions were obtained from the XXX University Ethics Committee (No: 15386878-044) and the related association where the study took place. Participants provided written informed consent.

Participants
Two hundred and eighty pregnant women applied to the non-stress test (NST) service at XXX Hospital between the dates of June 18 and July 18, 2018; 86 of them matched the inclusion criteria. To participate in the study, women needed to be: 1) having their rst pregnancy, 2) planning a vaginal delivery, and 3) older than 18 years of age. Sixty pregnant women who matched the criteria and had a vaginal delivery took part in this study. The ow chart in Fig. 1 shows the progression of participant selection in this study.

Implementation
The study consisted of two stages. In the rst stage, puerperant women who had positive birth experiences were asked to share their experiences. Written permission was obtained and their voices were recorded. Three puerperant women shared their birth experiences. The sound recordings were merged into a single le.
In the second stage, 60 pregnant were placed into two groups with a simple random selection method.
The rst group was given a sound recording that included positive birth stories. No intervention was made in the 30 pregnant women in the second group. All the pregnant women in both groups underwent a natural birth. A questionnaire including the Perception of Birth Scale (POBS) was applied to these 60 puerperant women in the rst seven days after birth.

Perception Of Birth Scale
This instrument contains ve sub-dimension Likert scales with 25 items. It was developed in 1996 by Fawcett and translated into Turkish in 2004 by Güngör. The scale evaluates how mothers perceive their experiences in normal or unplanned caesarean deliveries [8,9]. The sub-dimensions of the scale are: labor experience, delivery experience, delivery outcome, partner participation, and awareness.

Data Analysis
The collected data were analyzed with SPSS. Percentage, frequency values, and Mann-Whitney U test values were used to evaluate the data.

Results
The mean age of the women was 23.51 ± 3.47 years. The minimum age of the women was 18 years and the maximum age was 35 years. Almost all of the women (96.70%) had no chronic illness, and almost all of the women (98.30%) reported that they had no problems during pregnancy. In this cohort, 43.30% of the women had received no training before birth, while 56.70% of them had received training; 29.41% of them had received training in the NST room, but 44.11% of participants did not provide any information about the unit in which they had training, e.g. community clinics or through a midwife. The total scale average score was 55.01 ± 13.34. The sub-group means were: 3.60 ± 5.22 for delivery experience, 16.68 ± 4.87 for labor experience, 11.35 ± 4.10 for partner participation, 5.28 ± 2.21 for awareness, and 18.08 ± 2.65 for delivery outcome.
The mean age of the experimental group subjects was 23.90 ± 3.79 years; this was 23.13 ± 3.13 years for the control group. While the training experiences of both the control group and the experimental group, their experiences of having problems or illness during pregnancy were similar. The characteristics of the groups are shown in Table 1. The total scale score had a minimum of 22 and a maximum of 81 in the control group, whereas the experimental group had a minimum of 28 and a maximum of 80. A signi cant relationship was found between the groups in terms of total scale scores as well as the "delivery experience" and "labor experience" sub-scale scores. A statically signi cant relationship was not found in terms of the "partner participation", "awareness", and "delivery outcome" sub-scales, although the mean scores of the experimental group were higher (Table 2). No comparison was made with the scale score as the experiences of having problems during birth and pregnancy were rare. No signi cant relationship was found between having training experience before birth and the scale total score (p > 0.05). As shown in Table 3, a comparison of sub-scale groups and having training experience before birth suggests that the "awareness" sub-group score was statistically signi cant (p < 0.05). Discussion: The birth perception of women is affected by many factors, such as personal characteristics, expectations of birth, whether it is a planned pregnancy or not, a supportive environment or partner, and birth stories heard in the environment. These factors may lead women to perceive birth in a positive or negative way. These factors can be expanded. In the present study, positive birth stories were used as the intervention. Sharing birth stories is a common and important practice [10]. Among the bene ts of sharing birth stories are the opportunity to integrate a signi cant incident into the framework of a mother's life experience, the opportunity to share a signi cant life experience, the opportunity to talk over feelings of fear, anxiety, inability, disappointment or "missing parts", the opportunity to understand the strong sides of women, and the opportunity to get in touch with other women [11]. Within the framework of birth stories, it was found that after sharing birth stories with the women in the experimental group, women in the experimental group said that they had a positive birth experience and had higher birth perception scale scores compared to control group; this was statistically signi cant. We can infer that the sharing of positive birth stories ensures perceiving birth in a positive way.
In addition to hearing about birth from friends and the community, stories of negative birth experiences are also found in the media. In a study conducted in 2010 by Morris and McInerney on the media in the United States, it was suggested that there is not a correct description for how women typically give birth in the United States, and these ways do not coincide with evidence-based birth practices [12]. Similarly, television programs about giving birth sometimes appear on screen in our country. In contrast to positive birth stories, these programs may affect the birth perceptions of women in a negative way. They may even make birth traumatic. Contrary to the present research, it was reported in a study by Coşar and Demirci (2012) that women are not in uenced by birth stories, as only 41.2% of the women in that study said that their perceptions changed according to positive or negative stories [13]. This situation suggests that this birth story was not in parallel with our study as it was not considered positive or negative.
Negative birth perception may affect the birth process and may even reduce the comfort of the baby and the mother. The professional support given to the mother and the sense of control women feel may prevent a negative birth experience [14]. According to a study by Nystedt and Hildingsson (2017), elective caesarean section and a high pain level are considered to be negative birth experiences by women [15]. It has been reported that men and women think, in a way, that "birth gives pain". It is clear in our research that the sub-sections on labor and delivery experience were signi cantly different in the experimental group in which the women listened to positive birth stories. This may be due to perceiving the delivery experience in a more positive way and coping with the pain better.
In a study conducted by Yılmaz and Nazik (2018), no signi cant relationship could be found between POBS scale scores and receiving training before birth [14]. Similar to the ndings of our study, a signi cant relationship was found in the sub-dimension of "awareness". This indicates that, even if it does not change birth perceptions, receiving training before birth increases awareness in birth perception.
In a study where birth perception was evaluated in preparatory classes before birth, it was found that the total scale score and all the sub-groups were statistically signi cant [13].

Conclusions:
Positive birth stories affect the birth perception of women in a positive way. Midwives should share positive birth experiences in training and preparatory classes for birth and they should provide interactions between women who have had a positive birth experience and other women. They should investigate the reasons for negative birth experiences and take precautions against these. News about giving birth should re ect the truth and positive birth experiences should be given more place in the media. and the related association where the study took place. Participants provided written informed consent.

Abbreviations
-Consent for publication: Not applicable.
-Availability of data and material: The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.
-Competing interests: There are no con icts of interest for any of the authors. -Funding: This research did not receive any speci c grant from funding agencies in the public, commercial, or notfor-pro t sectors.
-Author contributions: DMÖ Conceived of the study, and participated in its design and coordination and helped to draft the manuscript. EÇ and BG talked to 3 people who had a positive birth. EÇ and BG provided data to be collected. SGMA participated in the design of the study and performed the statistical analysis. All authors have contributed to and approved the manuscript at all stages of the study. The ow chart which shows the progress of the participants in this study