Positive childbirth experience: A qualitative study

Abstract Aim This study aimed to explore the meaning of a positive childbirth experience expressed by women who had given birth in Iran. Design Qualitative exploratory study. Methods This is a qualitative study conducted on 10 women aged 20–38 years with positive childbirth experience. Data were collected using semi‐structured interviews from 72 hr–2 months after childbirth. Results Data analysis led to into two themes and five subthemes. The themes include control and empowerment. Control theme consisted of three subthemes of preparation, coping and support; and empowerment theme consisted of two subthemes of self‐efficacy and self‐esteem. Women's sense of empowerment to childbirth can be the result of a positive childbirth experience. Therefore, it seems that providing positive experience factors of childbirth plays an important role in women's self‐efficacy and self‐esteem, which requires cooperation and effort at the level of the individual, family, education system and healthcare system.

role in fertility and pregnancy intervals so that negative experience will reduce fertility and increase the distance to the next pregnancy (Gottvall & Waldenström, 2002).
Studies show that fear of childbirth leads to reduce self-efficacy and increase negative experience of childbirth. It also makes to choose caesarean for the next delivery (Al Ahmar & Tarraf, 2014;Christiaens & Bracke, 2007). Melender reported one of the reasons for fear of childbirth is to heard negative stories told by others (Hanna-Leena Melender, 2002).
Sharing women's quotes from different societies makes childbirth as an important event in women's lives, as well as an opportunity to discuss fears, worries, feelings of hopelessness, inadequacy and recognition of women's resources. The service provider should provide an opportunity to share women's quotes from positive childbirth experiences (Callister, 2004).
Some studies of childbirth experiences have been conducted in different countries. The findings of a qualitative study in Sweden has shown that several factors affecting positive childbirth experiences including trusting their body on how deal with delivery pain, mind-body interaction and health care provider and spouse support (Nilsson, Thorsell, Hertfelt Wahn, & Ekström, 2013).
A study in Uganda found that healthcare provider support and care effects on childbirth experiences. Physical and psychology support lead to positive experience, and inappropriate communication and care lead to negative experience (Namujju et al., 2018).
In another study by Attanasio et al. in the United States, it was found that appropriate communication between women and healthcare provider during birth had a positive effect on the experience of childbirth (Attanasio, McPherson, & Kozhimannil, 2014).
Since there has been no study on the positive experience of Iranian women, the aim of this study was to explore the themes related to perception positive childbirth experience to provide useful information to healthcare providers and policymakers that promote positive childbirth experiences.

| Aim and design
This is a qualitative study with a content analysis method conducted on ten women aged 20-38 years with positive childbirth experience.
The criteria included in the study were women with uncomplicated vaginal delivery, cephalic presentation and had healthy infants. To achieve the maximum variation, women with different parity, age and different education were selected. Data were collected during May to June 2018 in Abbas Abad Health Center of Mazandaran University of Medical Sciences, Iran. The sampling process was purposeful. Face-to-face semi-structured interviews were conducted from 72 hr-2 months after childbirth in privacy room at Abbas Abad Health Center. The interviews lasted approximately 35-60 min. In the present study, after ten interviews, the data were saturated and no new data were obtained. At first, general questions were asked to begin the interview and were guided by the participants' responses to the interview process. Initial questions included: "How did your perception childbirth?" and "What abilities did you get with natural childbirth?" The interviews were conducted by the author in Persian and then were translated into English. The process of data analysis was also conducted based on content analysis described by Graneheim and Lundman (2004). In the first step, the interviews were recorded by a tape recorder and then were typed on paper word-by-word by author, and the transcripts were reviewed for several times to obtain a general sense of understanding. In the second step, words and sentences containing information about the research question were considered as semantic units. In the third step, the meaningful units were abstracted and labelled with codes. In the fourth step, the codes were also compared with each other in terms of similarities and differences and grouped into the categories. In the final step, determining the themes based on the categories in the research team. consistency and reliability of the data. For this purpose, additional comments from colleagues and handwriting review were used by participants. The ability to transplant the findings was determined by reporting into two experts and obtaining the same result. The transferability of the study was provided by rich data descriptions (Chiovitti & Piran, 2003;Polit & Beck, 2008).

| RE SULTS
Data analysis led to into two themes and five subthemes. The themes include control and empowerment. Control theme consisted of three subthemes of preparation, coping and support; and empowerment theme consisted of two subthemes of self-efficacy and self-esteem.
The characteristics of selected participants are mentioned in Table 1.

| Control
In this study, it was found that internal and external control of labour process plays an effective role in pleasant perception of labour.
Women's preparation to deal with childbirth as well as applying different approaches for coping childbirth are internal control factors and childbirth support by spouse, relatives and healthcare providers are external factors of birth control.

| Preparation
Participants in this study stated that preparation (mentally and physically) plays a significant role in the experience of childbirth.
This preparation is created by knowing about the process of childbirth, planned pregnancy and delivery and familiarity with the environment. Participants in the study also stated that they received information from a variety of sources including the media, childbirth preparation classes, parental and other important items:

| Support
In this study, most participants stated that when they were considered, they felt safe and could better control childbirth. This attention includes care provider, spouse and relative support.

| Empowerment
The study found that women with positive childbirth experiences increased their empowerment and became awareness of their strengths and capacities as well as their ability to cope with other life challenges.

| Self-esteem
In this study, women with positive childbirth experiences find out their ability to cope, their responsibility to their family and their independence that these indicates an increase in their empowerment in the life.

| Self-efficacy
The study found that a positive experience of childbirth leads to increased self-efficacy in women. Since self-efficacy is an important prerequisite for behaviour in the situation, with increasing self-efficacy, women in this study had a better understanding of the material role and were more likely to choose vaginal delivery in subsequent childbirth.

| D ISCUSS I ON
In this study, we found that controlling factors of childbirth plays an essential role in childbirth satisfaction. These include preparation, coping and support. This study showed that after a pleasant childbirth, women's self-efficacy and self-esteem were increased, and thus, their ability to improve their health was increased too. Some studies have found that modelling mothers is important in creating realistic expectations; according to Bandura's social learning, experiences are transferred from mother to child (Bandura, 1978). Health policymakers should design programmes to provide maternal and physical preparation.
Participants stated that they used different cognitive and practical approaches to cope and control to childbirth. This is supported by findings from a qualitative study (Aune et al., 2015;Bayrami et al., 2011;Karlström, Nystedt, & Hildingsson, 2015;Shahoei et al., 2014;Vaziri, Khademian, & Behbahani, 2012). Therefore, the provider must identify women's resources during pregnancy to deal with childbirth and strengthen these resources.
The result showed that the mothers who received adequate support of healthcare provider and spouse had positive childbirth experience. This result confirm by other studies (Askari et al., 2010;Aune et al., 2015;Bayrami et al., 2011;Gibbins & Thomson, 2001;Henriksen, Grimsrud, Schei, & Lukasse, 2017;Karlström et al., 2015;Nilsson et al., 2013). Healthcare provider support includes physical and psychological support such as appropriate care and communication (Ford, Ayers, & Wright, 2009). Due to the importance of communication in understanding pleasant delivery, healthcare provider must acquire enough scientific and practical skills in the field of health care.
Women stated that the presence of their husband and other companion during labour helped them better deal with the birth and several studies have suggested the role of spouse support in understanding the experience of childbirth (Gibbins & Thomson, 2001;Henriksen et al., 2017;Karlström et al., 2015;Lundgren, 2005;Nilsson et al., 2013). Healthcare providers should consult with pregnant women to identify a person who is involved in the delivery process.
Empowerment is a process through which people will have more control over decisions, lifestyles and activities that affect their health.
Self-efficacy and self-esteem are one of the dimensions of empowerment. One of the important implications of this study is to increase self-efficacy. Self-efficacy is one's belief in one's ability to perform a particular behaviour successfully, which can influence one's behaviour, thinking pattern and reaction (Bandura, 1997).
Women with high self-efficacy respond well to critical situations and events and solve problems effectively.
High self-efficacy promotes social health including the ability to cope with social challenges, the ability to manage interpersonal disadvantages and the ability to establish and maintain interpersonal relationships and promote emotional health, including the belief in the ability to control and manage stress.

| CON CLUS ION
Women's sense of empowerment to childbirth can be the result of a positive childbirth experience that is influenced by the preparation, coping and support of the service provider and spouse. Therefore, positive experience factors of childbirth seem to play a role in women's self-efficacy and self-esteem, which requires cooperation and effort at the level of the individual, the family, the education system and the healthcare delivery system.

| LI M ITATI O N S
As this study was qualitative, the obtained results cannot be generalized to the entire women population. Lack of sufficient motivation among some of the participants to interview was one of the limitations of this study, and also, this study was done in a small town without ethnic diversity.

ACK N OWLED G M ENTS
The present study was supported by Shahroud University of Medical Sciences as a PhD Thesis. We hereby acknowledge the research deputy for Grant No. 97161.

CO N FLI C T O F I NTE R E S T
The authors have no conflicts of interest relevant to this article.

AUTH O R S ' CO NTR I B UTI O N S
MHT, AK and ZM: Conceptualization of the study, coordination, acquisition of data and drafting of the manuscript. ZS, SK and MM: Acquisition of data and drafting of the manuscript. All authors read and approved the final manuscript.