Women’s Experiences of Labour And Birth: A Meta-Synthesis of Qualitative Research Evidences

Background: Childbirth and its experience have the potential physical and psychological impact in the short and long term on mothers’ lives. This study aimed to identify and synthesize the qualitative researches in this regard to obtain a deep understanding of this phenomenon. Methods: In this study, articles were searched in databases such as Scopus, Pubmed as well as search in google scholar, Science Direct, key journals, and relevant theses using a predened search strategy. Searching and selecting the articles and extracting data were performed by two independent authors. After searching, screening, and evaluating the studies, the nal synthesis was completed on fourteen articles. Results: The meta-synthesis showed that there were two themes, four categories, and nine sub-categories. The themes include “perception” and “perspective”. Perception theme was derived from the two levels of control and security. Perspective theme was derived from of self-ecacy and self-esteem. Conclusion: Childbirth experience is affected by different factors. Health care systems should consider these factors in their patients during pregnancy and childbirth on their policies and guidelines.


Background
Childbirth is a paradoxical event that begins with sadness and disappointment and ends with the birth of a living baby, which is accompanied by joy [1]. Childbirth is one of the most signi cant events in human life. Although childbirth is di cult and stressful, a woman who gives birth to her child experiences the most exciting and happiest moment of her life. Childbirth experiences have potential physical and psychological impacts in the short and long term on mothers' lives [2].
Childbirth experiences are unique and re ect women's feelings and personal interpretations of the birth process. For some women, the experience of birth means hard work accompanied by joy, and for others, it is a stressful, overwhelming, and unpredictable experience [3].
In a study by Karlstrm et al., women described their childbirth experiences as incredible, strange, magical, and di cult and, the women described the positive experience of childbirth as being con dent in their ability to give birth, being mentally and physically prepared, having positive expectations, and having a secure and supportive relationship with a healthcare provider [4].
Women have negative childbirth experiences due to disrespectful care (i.e., not allocating enough time for women during labor and delivery, refusing to listen to women's complaints, not paying attention to women's needs and wants, indifference, lack of empathy, not paying attention to women's requests for help), insu cient information (women are unaware of what they need and how their delivery is progressing, and examinations are performed without explanation from the service providers), and unsupportive husband [5].
Positive childbirth experience increases self-con dence, self-e cacy, mother-infant attachment, acceptance of motherhood, positive feelings towards the child[6, 7], patience, responsibility, selfsu ciency, independence, and women's quality of life, and empowers women in general [8]. Negative childbirth experience leads to loneliness, shame, humiliation, insecurity, fear, lack of self-con dence [5], disempowerment, post-traumatic stress disorder (PTSD), postpartum depression, and fear of the next childbirth [9,10]. Despite the importance of childbirth experience, there is no general agreement on the concept of delivery experience. Labor and childbirth experiences are subjective and complex; they are associated with physiological and psychological processes, while also being in uenced by the social, environmental, organizational, and political contexts [2].
To identify the variables involved in the concept of delivery experience, several studies have been conducted using various qualitative, quantitative and mixed methods regarding the childbirth experiences of women who have had vaginal delivery. Therefore, this study aimed to investigate a series of in-depth studies to use the results in the design of future interventions and planning.

Methods
In this meta-synthesis study, a number of qualitative studies on childbirth experiences were collected, and all the data obtained from each qualitative study was interpreted and combined together; eventually, a general picture of the events, concepts, and phenomena was presented with the objective of achieving a new conceptual level or new theories.
This systematic review comprised of ve steps based on the American Dietetic Association (ADA) guidelines as follows [11].
1. Designing questions and search strategy, 2. Design a Search plan, 3. Critical appraisal of the articles, 4.
Extracting the data from selected studies, and synthesizing the nding, 5. Drawing conclusions.
Step One: Designing questions and search strategy Questions were designed based on the SPIDER format. SPIDER is a tool used for searching in qualitative and mixed methods studies. The main question of this review study was: What were the experiences and Women OR Mother* AND Experience* OR Perception* OR Opinion* OR View* AND Labor* OR Childbirth OR Delivery OR Birth* AND Vaginal birth AND Qualitative Step two: Design a Search plan The search for articles was performed both electronically and manually. The electronic search was performed on famous international websites of Scopus, PubMed, google scholar and Science Direct and as well as related journals and theses. The manual search included precise review of the articles' list of references. The searching process is presented in the PRISMA chart and appended. (Fig. 1) First, duplicates and articles not in English were excluded, then the articles were evaluated by reviewing the titles and abstracts; the appropriate papers were selected, and nally, the full texts of the articles were reviewed to determine if they were related to the study objective.
Step three: Critical appraisal of the articles To assess the quality of the studies, the Critical Appraisal Skills Program (CAPS) tool was used for studies with different methods [12]. This tool includes the following: a clear statement of the aims of the research, qualitative methodology appropriate, the research design appropriate to address the aims of the research, the recruitment strategy appropriates to the aims of the research, an appropriate data collection, discussed data analysis, discussed the role of the relationship between researcher and participants, considerate ethical issues, discussed clear statements of ndings discussed the implications for practice. Studies with a score of 7/10 and higher were selected.
Step four: Extracting the data from selected studies, and synthesizing the nding Fourteen high-quality studies were selected, and data was extracted according to the answer to the research question.
Step ve: drawing conclusion The ndings of the 14 studies were combined, and similar concepts were identi ed and integrated, and then the themes and sub-themes were extracted. Data combination was performed in three steps according to Thomas and Harden's guidelines [13].
The rst and second stages included line coding for the results and concepts of studies, then grouping was performed until the concepts were repeated. The third stage included extracting themes according to the classi cations, which resulted in two themes. The themes included perception and perspective on childbirth experiences.

Results
The qualitative part of this meta-synthesis study was carried out in six countries (i.e., Sweden, Norway, English, Iran, Turkey, and Uganda). In total, interviews were conducted among 269 women in these 14 studies; these studies were performed using content analysis, in-depth interviews, phenomenological studies, focus group study, and combined study. (Table 1) The meta-synthesis showed that there were two themes, four categories, and nine sub-categories. The themes include "perception" and "perspective". Perception theme was derived from the two levels of control and security. Perspective theme was derived from of self-e cacy and self-esteem. ( Table 2) Kind of next birth [17,22] Self esteem Self-knowledge [4,8,14,17,22].
The perception theme was derived from the two levels of control and security. One of the most important factors causing childbirth experience to be pleasant is preparation through information obtained from various sources, including participation in childbirth classes and acquisition of related knowledge in these classes, reading various books, journals and websites, or using advice from family members and other reliable individuals like midwives or the gynecologist. Based on the obtained knowledge, the mother recognizes that the labor pain and childbirth problems are part of the childbirth process and this preparation leads to realistic expectations. Realistic expectations have a positive effect on the satisfaction of positive experiences [4,[14][15][16][17]. In the conducted review, having con dence in the ability to give birth had resulted in a positive attitude and the feeling that labor pain and its problems are under control [4,14,18].
"For me, the mental training was important…it was very good. We talked a lot about expectations, which is useful not only when giving birth, and about our relation that we do this together" [4].
"I read that I should think of a mountain top. That I had to get up and up. I was at the top of the mountain when I started to push. And then I had to get down again. And that was it!" [19] Several qualitative studies have indicated that feeling safe and calm during labor and delivery is a key factor in having a pleasurable childbirth experience. Paying attention to the pregnant mother in decisionmaking and husband and care provider's support are essential factors in making mothers feel secure and peaceful.
Seeing and listening to childbearing woman is another key factor in women's sense of security. This includes participating the mother in the delivery process and decision-making during labor and childbirth [3,4,14,15,[21][22][23]. The presence and support of the husband and other reliable people leads to mental relaxation and a sense of safety and con dence [4,8,18].
"When I came back to the labour ward they told me "the baby has reached you push", I was not feeling any energy. ….my husband helped me, held me and he never feared. When the baby was coming out, he told me that "bambi" (meaning my friend) push more, the head is coming, add in more effort. … I felt good, I liked it so much because he gave me support, and he was there" [3] Women stated that they needed professional support in addition to medical and midwifery services. Professional support includes the presence and support of midwives through the constant presence of a midwife during delivery to guide the pregnant woman, inform her of the progression of labor, and provide other necessary information [4, 15- "I had a very kind midwife and she had always enough time for me. I experienced that she was genuinely interested in me and my pregnancy. She remembered me…" [22] "She was a very warm and caring person, I felt safe. She always explained what happened and what she did. Yes … I was relaxed in a way, I thought this would be just as natural as driving to the shop and buying dinner." [22] Theme: Perspective After delivery, women will experience different feelings, positive and negative attitudes, as well as changes in their lives. Having positive experiences in vaginal childbirth leads to forming a positive attitude in women toward the choice of vaginal childbirth for the next pregnancy and the desire to have more children [4,8,22]. Reversely, negative experiences in childbirth may lead to negative attitudes and the choice of cesarean delivery for the next pregnancy and the lack of subsequent fertility.
"Giving birth is very sweet, there is no pain as sweet as labor pain and childbirth and I choose vaginal delivery again, if I want to give birth." [17] "I am very proud of myself because I'm a mother. I am proud that I have a baby and I am very happy. I can't imagine myself without my baby." [8]

Discussion
The results of the present study showed that internal control is effective in forming a positive attitude toward the delivery process. Internal control is the control of thoughts and performance during labor and delivery. One of the factors that plays a role in internal control is preparation and adaptation. Women's mental and physical readiness enables them to control and adapt to the labor and delivery process using cognitive and functional approaches.
Various studies have indicated that the interaction and control of the mind and body play a key role in promoting positive delivery experiences, and a pregnant woman can use different strategies to deal with labor pain, including cognitive and behavioral strategies to control her mind and body. Cognitive strategies include religious and spiritual beliefs, conversation with themselves, focus on pain, and visualization, and behavioral strategies comprise of walking, moving, shifting position, rubbing, and deep breathing.
In addition to the cognitive and behavioral strategies, the patience of pregnant woman during labor or during service provision and stitching and the satisfaction of pregnant woman with the medical care play a signi cant role in controlling the mind and body.
Preparation and adaptation increase self-con dence, self-e cacy, and empowerment in women. Improved empowerment increases participation in self-care and child care. In a study of female selfe cacy, Schwartz et al. showed that reducing fear boosts women's self-e cacy and empowerment during labor and delivery [24]. Empowerment has an essential effect on women's thoughts and behaviors during labor and delivery. Wanted pregnancy, gaining knowledge from different sources, hearing the memories of women with vaginal delivery, attending delivery preparation classes, and previous familiarity with the delivery environment cause psychological preparation and create realistic expectations.
Green, Coupland and Kitzinger reported that women who had positive expectations about their labor felt more in control of their birth experience and more satis ed, and negative expectations about childbirth had an adverse impact on women's well-being [25].
Fenwick et al identi ed factors in uencing realistic expectations as books, magazines, the Internet, TV, and information received from service providers, friends, and trusted colleagues and relatives[26] Some studies highlighted the role of mothers of pregnant women in creating realistic expectations. According to Bandura's social learning, experiences may be transferred from mother to child [27]. It means that if mothers recount good memories about their childbirth, it will have positive effects on pregnant women's attitudes [19].
Bandura emphasizes that strategies to tackle barriers will turn into a tool for personal abilities and skills in future. If one can manage a challenge well, it leads to increased self-e cacy in other tasks, and subsequently, creates a good feeling; in other words, low self-e cacy causes stress and anxiety [27].
The study of Waldenstrom et al showed that one of the effective factors in negative delivery experiences is unwanted and unplanned pregnancy [28]. Findings of AL Ahmar et al. revealed that childbirth preparation, personal control, high self-e cacy, and ful llment of expectations are effective in a positive perception of childbirth [29].
The results of the present study also displayed that seeing and hearing about labor gives a sense of security and yields a pleasant understanding of labor. Social support (family, friends and community), support from service providers (providing appropriate physical and mental care, proper communication, allocating su cient time to childbirth, and informing women of the stages and progress of childbirth) and involvement of women in decisions are external factors in effective control and positive understanding of delivery. Numerous studies have highlighted the impact of spouse support [9,30], service provider support [31][32][33][34], and mothers' participation in decision-making [27,[31][32][33] on positive delivery experiences.
Health care provider support includes the presence of a caring healthcare provider who delivers the necessary support measures, including counseling and information, to help women adjust to the labor and delivery process. Participation means paying attention to the needs and desires of the pregnant woman during delivery. Hodnett et al. in their systematic review identi ed participation in decision making as one of the four effective factors in positive childbirth experience [31].
Several studies exhibited that the presence of husband and good relationship with the husband create a sense of con dence and safety and a positive childbirth experience in women. In the study of Waldestom et al., one of the factors contributing to negative experiences was the lack of husband's support [28].
The support, presence, individual characteristics, practical skills, providing information and guidance and communication skills of service providers also play an important role in a pleasant childbirth experience. The support and presence of the health care provider during labor and childbirth plays a signi cant role in applying cognitive and behavioral adaptation techniques, and it makes the pregnant woman to better adapt to the delivery process and improves empowerment and experience of childbirth.
The ndings of this study are consistent with the results of Henrikesen et al., who found that one of the factors leading to negative experiences was the lack of women's participation in decision making and lack of presence and support of the husband and service provider [21].
Childbirth is a unique experience that affects the individual, the family, and the community. The effects of a positive childbirth experience on the individual include increased con dence in the strength of the body to face challenges and belief in the ability to give birth, which is in line with the results of Karlström, who described childbirth as a transformative experience and noted that mental, physical, and social support of women during labor and delivery increase women's ability, belief and con dence in their power to face challenges.
At the family level, a positive labor experience causes increased patience, accountability, intellectual independence, acceptance of the maternal role, and mother-child attachment. In a study by Power et al., it was also exhibited that the experience of childbirth affects the infant's behaviors, such that deliveries with physical and mental stress increase the baby's crying and restlessness [35].
In another study by Parratt et al., women's delivery experiences were shown to affect their self-esteem, sense of control over the environment, relationship with service providers, self-con dence, self-awareness, and relationship with child[36].
At the community level, a positive childbirth experience increases fertility and tendency to choose vaginal childbirth for the next childbirth and decreases the rate of cesarean section. In this regard, Gottva et al.
showed that a negative childbirth experience decreases fertility and increases birth spacing also demonstrated that positive delivery experiences have a positive effect on the choice of natural childbirth for the next pregnancy and reduce birth spacing [37].

Limitations
This study was conducted on 14 articles with 269 participants from 6 countries with different cultures, experiences and health care systems, so limiting transferability of ndings to other countries. Another limitation of the study is that the method of the studies varied in this meta synthesis, Therefore, this study could complement the individual's studies and could not replace them.
Many factors including cultural, environmental, social and organizational factors have a positive effect on the pleasant of experiences. Health care systems should consider these issues during pregnancy and childbirth for their policies and guidelines, on the other hand, childbirth requires team working and requires coordination and cooperation between the service provider, spouse, and others. Therefore, service providers should invite the husband as a member of the group, identify the needs of women during pregnancy, and provide the necessary preparation for women to adapt to childbirth by using an appropriate strategy.

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.