Women's Experiences of Emotional Recovery from Childbirth-Related Perineal Trauma: A Qualitative Content Analysis.

BACKGROUND: The postpartum health care program in Iran is limited to the first six weeks of delivery and only focuses on women's physical problems. It seems that the issue of emotional recovery is underestimated in postnatal women with prenatal injuries. This study was designed to explore women's experiences of emotional recovery from childbirth-related perineal trauma.
METHODS: This qualitative content analysis was performed on 22 postnatal women with perineal trauma during labor at Omol-banin Hospital from the 20th of April to 25th of December in Mashhad, Iran in 2016. The participants were purposively selected between 10 days to one year after childbirth. Data were collected through semi-structured interviews and saturated after 26 interviews. The analysis of data was concurrently carried out using conventional content analysis adopted by Elo and Kyngas (2008). The MAXQDA software (Ver.10) was used for data organization.
RESULTS: Emotional recovery after birth trauma is defined as going on a journey from negative emotions to subjective well-being. Two super-ordinate generic categories emerged from the analysis: 1) feeling trapped in multifaceted issues, and 2) regaining possession of life. The participants encountered numerous concerns initially and with the help of family and community support, they regained the ability to dominate life and develop a pleasant mood. Improving physical functions had an essential role in regaining emotional well-being and enjoying daily life.
CONCLUSION: The results of this study promoted our understanding of the emotional recovery in women with childbirth-related perineal trauma. This helps the caregivers to understand woman's emotional concerns and needs in order to offer appropriate counseling services.

INTRODUCTION

Perineal injuries are serious complications during labor, which occur in 65-85% of cases during childbirth.[1,2] According to a study in Iran, the incidence of perineal injuries (2018) in hospitals of Kashan is estimated to account for 84.3% of births.[3] Perineal tears occur with varying degrees. In the first degree tear, the perineal injury involves the superficial perineal skin and mucus of the vaginal opening, whereas in the second degree tear lacerations extend to the perineal muscles and fascia.[4] In severe perineal tears (third and fourth degree), the anal sphincter and rectal mucosa are torn, respectively.[5]

Severe perineal tears during delivery affects the maternal physical as well as emotional health. This seems to be a challenge for promotion and acceptance of normal vaginal birth in Iran.[6] Emotion is a mental condition associated with feelings, behavioral responses, thoughts, and a degree of displeasure or pleasure.[7] Emotion is an affect that is based on reflex response to pain and associated conditions.[8] Negative emotions disturb the balance of the body.[9] Insomnia, agitation, depression, anxiety, angry, grief and irritability are the results of neglecting emotional disorders.[4,7,10] Stress-related emotion is the core concept of health behavior. Stress is considered as an etiological factor in chronic diseases. Increased production of hormones such as adrenocorticotropin and cortisol which induce stress responses, is associated with immunologic changes, bouts of depression, grief and emotional distress,[7] low quality of life, functional disorders, and chronic diseases whose final outcome would be lack of emotional health.[9] Emotional health is defined as emotional intelligence (understanding) and emotional regulation (ability to self-control).[9] Therefore, emotional recovery can be considered a return to emotional health or a steady emotional state.[11]

Postpartum period (postnatal) begin immediately after birth as the recovery period after birth. Theoretically, it refers to the first 6-8 weeks after delivery, which is associated with psychological, physical and social changes.[12] Postpartum depression, disrupted mother-baby attachment, reduced breastfeeding, and delayed cognitive and social development in infants are the result of emotional disorder of the mother.[13] Depression with a prevalence of 10-37% can lead to a child’s behavioral problems in life by creating a poor relationship between the mother and baby.[4,9] Therefore, the care provided following the birth is critical for the future of the mothers and newborn babies. These changes which occur during the postnatal period determine their well-being and potential for a healthy future.[14] The incidence of anxiety during the first six months of postnatal period was estimated to be from 6.1% to 27.9%. Postpartum anxiety may have negative effects on the child development and parenting.[15]

Despite the confirmation of these disorders in postnatal women and their effects on the infant,[5,14,15] there is no specific screening, and there is no evaluation of emotional recovery, especially in women with perineal tears during the postnatal period.[5,14] However, they are exposed to emotional changes due to painful perineum or other signs or symptoms of illness such as wound infection, urinary incontinence, sexual disorder, etc.[8,16-18] Also, it is not clear when an emotional recovery occurs, while one of the stressful problems of the postpartum period is the lack of attention to the emotional state of the mother.[19] Therefore, care providers cannot be assured that women have received the necessary care. Considering the women’s fears and feelings is one of the first steps to understand the emotional recovery.[10] Mothers’ experiences of their emotional recovery by discovering the challenges of the care programs can help the policymakers to improve the quality of mental health programs in women with perineal injuries. [20] The qualitative research can help us to interpret and better understand the world of the women from their own perspective.[21] The lack of adequate knowledge about the emotional recovery of women with perineal trauma in childbirth, especially in our culture, led the researchers to conduct the present study. Thus, this qualitative study was designed to explore the women’s experiences of emotional recovery from childbirth-related perineal trauma. It seems that it could raise the awareness of policy- makers towards improving the postpartum care programs.

MATERIALS AND METHODS

This qualitative study was performed using a conventional content analysis, which was performed on 22 postnatal women with perineal trauma during labor at Ommol-banin Hospital from the 20th of April to the 25th of December in 2016 in Mashhad, Iran. Face-to-face semi-structured interviews were conducted with each women during a time period between 10 days to one year after childbirth. Participants in this study were Iranian women with perineal tears during normal delivery, who had a wanted pregnancy and gave birth to their neonates with Apgar score>7 during the last year in Ommol-banin hospitals in Mashhad, Iran. Mothers with neonates with prematurity or any congenital abnormalities or failure to access were excluded. Ommol-Banin hospital is a specialized hospital for women under supervision of Mashhad University of Medical Sciences.

The participants were selected using purposive sampling; in the beginning, to recruit the participants, the researcher got permission from the director of the hospital to have access to health information system (HIS) in order to be able to obtain the participants’ characteristics including telephone number and obstetric data related to pregnancy, labor, mode of birth, perineal status and birth weight, which were retrievable via HIS.

The researcher, after having a phone contact and explaining the aim of the study to the participants, requested them to determine the time and place most convenient to them to be interviewed. A free-of-charge visit was provided by the gynecologist. Also, they were assured that their data would remain anonymous and confidential. The interviews were conducted after obtaining informed consent in a quiet and confidential room near the gynecologic clinic. The interviews, which were conducted by the first author took place and lasted for between 40-70 minutes. The main characteristics of the participants and their mode of delivery are shown in Table 1. An interview guide was developed with a focus on the participants’ experiences of the emotional recovery after birth. The main questions were the following:

Table 1

Characteristics of the participants included in the study

Participant	Age (year)	Educational level	Parity	Birth weight (gram)	Delivery Staff	Mode of delivery	Degree of laceration	Recovery time (week)	Delivery interval (Days)	Repair in the operating room
1	33	Associate degree	2	3200	Midwife	NVD a	2 th degree	6-8	201
2	34	Dipoloma	1	3500	OB-GYN resident	Vacuum extraction	Ep b+3rd degree	-	353	+
3	30	Dipoloma	2	3580	Midwifery student	NVD	Ep+3rd degree	-	344	+
4	25	Dipoloma	2	3100	Midwife	NVD	1st degree	-	15
5	25	Dipoloma	1	4300	OB-GYN resident	NVD	Ep+4thdegree	-	159	+
6	29	Primary school	2	3700	Midwife	NVD	4rddegree	-	192	+
7	33	Middle school	3	3800	OB-GYN resident	NVD	3rd degree	12	311	-
8	24	BSc	1	2910	Midwifery student	Vacuum extraction	Ep+3rddegree	-	24	+
9	26	Dipoloma	1	2370	Midwife	NVD	Ep+4rd degree	-	189	+
10	30	Dipoloma	1	3900	OB-GYN resident	Vacuum extraction	Ep+4th degree	16	345	-
11	19	Middle school	1	3350	Midwife	NVD	EP	10	107	-
12	31	Middle school	2	3780	Midwife	VBAC c	1st degree	2	23	-
13	43	Diploma	2	2480	OB-GYN resident	VBAC	3 rd degree	10	159	-
14	25	Middle school	1	3160	OB-GYN resident	NVD	Ep+3rd degree	18	198	-
15	19	Diploma	1	3160	OB-GYN resident	NVD	Ep+3 rd degree	12	35	-
16	29	Associate degree	1	2990	OB-GYN resident	Vacuum extraction	Ep+3 rd degree	16	137	-
17	26	Diploma	1	2750	Midwife	NVD	Ep+3 rd degree	12	267	-
18	20	Middle school	1	2200	Medical student	NVD	Ep large	8	56	+
19	20	Middle school	1	3100	Midwifery student	NVD	EP	10	73	-
20	31	Primary school	1	3200	OB-GYN resident	NVD	1st degree	8	73	-
21	31	Primary school	2	3020	Midwifery student	NVD	1st degree	6	53	-
22	18	Diploma	1	3030	Medical student	NVD	EP	4	53	-

Normal vaginal delivery;

Episiotomy;

Vaginal birth after cesarean section

What happened to you in the early postpartum period and thereafter?

What emotional changes did you experience after perineal repair?

When did you feel you recovered after perineal tears?

In-depth, semi-structured interviews were repeated for participants 2, 5, 6, and 22 because at the end of the interviews they requested to consult again with their spouses about giving complete information. Data saturation was achieved after 26 interviews with 22 participants.

In-depth, semi-structured interviews were repeated for participants 2, 5, 6, and 22 because at the end of the interviews they requested to consult again with their spouses about giving complete information. Data saturation was achieved after 26 interviews with 22 participants.

The recorded interviews were transcribed verbatim and analyzed using the qualitative conventional content analysis suggested by Elo and Kingas (2008).[22] The data obtained were analyzed through the three main phases of preparation, organizing and reporting. In the preparation phase, the transcripts were read several times to obtain a general understanding of the subject. Then, the parts related to the study questions were identified and coded. The comparison of the codes in terms of their differences and similarities led to the development of subcategories and then categories inductively. The MAXQDA software (Version 10) was used for data management.

In the present study, all the participants were assured that all information they gave during the interview remained confidential. This research was approved by Ethics Committee of the School of Nursing and Midwifery, Mashhad University of Medical Sciences (code: IR.MUMS.REC.1395.568).

For trustworthiness, prolonged engagement with data comparison and member checking by the first three participants increased the credibility of the study. Also, expert debriefing (the third and fourth author) was used in the analytic phase and they confirmed appropriate decisions and analytic process (dependability). Furthermoreý, some quotations, codes, sub categories and categories were evaluated by the research team (conformability). Transferability of the data was provided via a purposive sampling which made maximum diversity in demographic characteristics and degree of perineal laceration.

RESULTS

Nine women (40.9%) had first and second degrees of perineal injury and 13 women (59.1%) had severe perineal injuries (third and fourth degree) after vaginal delivery. The mean age of the participants was 27.3±8.10 years (range 18 to 43 years) and they were eight primipara and 14 multipara women.

During data analysis, one main category, two generic categories and four sub-categories emerged. Moving from negative emotion to subjective well-being and life (main category) emerged from two categories including “feeling trapped in multifaceted issues” and “regaining possession of life”. Other sub-categories, sub-sub categories and codes are shown in Table 2.

Table 2

Main category, generic categories and sub-categories which emerged from the analysis

Codes	Sub-sub categories	Sub-categories	Generic categories	Main category
Agitation feeling	Demonstrating negative inner feelings	Experiencing negative mood state	Feeling trapped in multifaceted issues	Moving from negative emotion to subjective well-being and life
Boredom with sickness
Nervousness due to pain
Having dispute with husband	Confronting with negative emotions
Being unkind to the infant
Being aggressive towards parents
Concern about digestive problems	Fear of health problems	Facing with various concerns
Fear of gas passing
Fear of re-hospitalization
Worried about the discontinuity of marriage	Thinking to marital life and financial problems
Concerned about dyspareunia
Anxious about the cost of treatment
Feeling of happiness	Rescue of worrying symptoms	A pleasant feeling of improved mood	Regaining possession of life
Reduction of grief due to feeling better
Stopping making excuse
To end the verbal conflict	Overcoming negative Emotion
To control nervousness with good mood
To stop abstinence
Feeling better with more ability	Gaining activity and energy	Recapturing vitality
Starting homework
Restarting daily activities
Regaining hope in life	Returning of hope
Doing the chores with love
Showing love to the infant

Moving from Negative Emotions to Subjective Well-Being

Transition from unpleasant affects like being angry, gloomy, and anxious to pleasant affects such as having a lot of energy, happiness, and returning to interests happened as the participants’ healing progressed. All participants had a better sense of life when their physical problems were fewer and the ability to do their activities could exacerbate the feeling of being better. Based on the participants’ experiences moving from negative emotions to subjective well-being emerged from two general categories of “feeling trapped in multifaceted issues” and “regaining possession of life”.

1. Feeling Trapped in Multifaceted Issues

The participants were sad with an understanding of their abnormal state. They were also concerned about their body, the relationship with their spouse as well as medical expenses. Feeling trapped in multifaceted issues emerged from two sub-categories of “experiencing negative mood state” and “facing various concerns”.

1.a. Experiencing Negative Mood State

Negative feelings such as boredom, agony, anger, hate and guilt were the most common problems in the early postpartum period, but postpartum women said that their inner feelings arose from prolonged negative inner feelings. One participant four months after her childbirth with an extended episiotomy said: “I’ve got a problem, because the healing of my perineal wounds has been delayed; you know, it took two months. My doctor also told me it was too long for healing. My neighbor gave birth to her child at the same time; the perineal stitches repaired soon, you know, just within less than two weeks” (P11). The majority of the participants, who experienced severe degrees of perineal trauma, said that because of having negative emotions they showed aggressive behaviors towards their relatives or friends. Negative emotions are the reactions that appear to be manifested in the person’s appearance, such as frown, nervousness, and laugh. One of the participants 6 months after the childbirth stated: “My problems include pain, constipation, and nervousness. This illness has made me nervous” (P9).

1.b. Facing Various Concerns

The experience of confrontation with various concerns was described by some participants, especially by women who experienced more serious injuries. These worrying thoughts included concerns about their bodily disorders, their ability to continue their marital life with spouse and the high expenses of their medical treatment. Long-term complications imposed additional therapeutic expenses for them directly and indirectly. The direct costs included direct payments and provision of medications. The women were involved indirectly in caring costs as well; that is the long-term presence of caregivers (families) added the indirect family costs.

A participant (who was extremely worried about her marital stability said: “Only when I recovered, just like the status that I had before pregnancy, I thought then that I was healthy.…I have trouble going to sleep because I always think what would be my future? Do I get my health back? My concern is that I don’t know, eventually, my problems would be resolved or not? For instance, could I be in love with my husband as before?” (P5).

Another participant who experienced the third degree of perineal trauma during labor was also worried about her health consequences and said: “It is difficult for me to tolerate) the symptom of disease), because it took a long time….I just can’t believe that I’ll get my health back again.” (P8). Financial problems were another problem for the participants.

Participant 6 who delivered six months later talked about her concern, “I think I referred 7 or 8 times to the doctor. I haven’t got enough money. How can I get healthy without money?... It made me feel very anxious and very angry; they hurt me (sick), and so they should pay the costs” (P6).

2. Regaining Possession of Life

After the participants understood change in their body and perceived the normalization of their physical function, the second stage of emotional recovery happened and participants gained control of their life. This process shows that normalization may be a new life for women due to the changes occurring in the general functioning of the body, as with other injuries. However, normalization was acceptable for women when their physical functioning did not limit their daily activities. With the help and support of the family and the husbands, the participants were able to overcome their unwanted and annoying emotions during the recovery process, which was completed when the participants felt they were able to do their activities again and enjoyed their work and had inner satisfaction. This category emerged from two sub-categories including “a pleasant feeling of improved mood” and “recapturing vitality”.

2.a. A Pleasant Feeling of Improved Mood

The majority of our participants with severe birth trauma described the positive feeling or emotion after they experienced getting rid of their health problems and concerns. This stage was promising for them because it seemed that they had rescued from inability and worrying symptoms. One of the participants in her second interview in the third month after delivery who suffered from urinary incontinence revealed her happiness after interrupting her incontinence. “Once urinary incontinence started, I was frightened to be in bed with my husband, but now, after one month, I’m not worried about it; I got better…. now, I feel very much better and satisfied with myself, I think I got rid of sickness as well as sadness” (P8). Overcoming feelings and emotions occurred rapidly for women with mild injuries; a young participant who experienced a normal delivery with a mild tear described his happiness as follows: “Entirely, 10 days after childbirth, I was able to do my activities. I could take care of my baby. This made me happy” (P4). Of course, there was a delay in emotional changes of women who experienced higher degrees of perineal tears. One participant who gave birth to her baby by vacuum extraction described emotional changes at the end of the fourth month after delivery although she was not fully recovered, even after eleven months, as she was still suffering from anal incontinence and gas passing. Therefore, she did not believe that she had returned to her previous health. “After New year ceremony, I got better. My depression got better and I didn’t make any excuse; I didn’t want to cry anymore” (P10).

2.b. Recapturing Vitality

Recapturing vitality was associated with regaining hope and suffering less from postnatal complications. In this stage, all of the participants with birth trauma focused on the positive sides of life and everything they could be grateful for them. The beginning of daily activities was a promising issue for them. Therefore, two subcategories emerged from this category including “Returning of hope” and “Gaining activity and energy”. The findings of the study showed that various reasons had been found for return of hope in the participants’ experiences. Most of the participants said they hoped to reduce their weakness and disease and to overcome it earlier (returning of hope), like a participant who described the loss of pain with hope. “When there is no pain, the mood becomes better, he person feels better, and thinks you are good. You are hopeful regarding life” (P3).

Another participant, who had a strong motivation for motherhood due to the history of infertility, reported that all the postpartum problems are tolerable because the child is worthy. “Since I couldn’t have a baby and I wished to have one, I would endure it ... Well, then, I would tolerate …wherever I wanted to be. I had many stitches. I felt very painful when I was sewing. I am very hopeful now to live” (P14). All participants with mild to severe trauma considered ability as the most valuable thing in their lives because it affected their independence. Most of them said that their anger, hatred, or even aggression were caused by their disability. With the prolongation of the disability period, most of women tried to get benefit from the existing social support. Participant no. 16 had gone to her mother-in-law’s house to be supported. “My family took care of me for 45 days after childbirth; then, I felt better, and had better mood because I could do my work; I’m so well. I’m not too nervous. I can protect my baby myself” (P16). Some participants described her husband’s support as the most important factor in their recovery process. Because in addition to physical support (helped to do the chores), they greatly benefited from their spiritual support. “You do not feel good and your mood will not change at all, except for the support of the husband in the first month” (P10).

DISCUSSION

This is the first study on emotional recovery in Iranian postpartum women with experience of perineal trauma following childbirth .The findings of this study has shown that emotional recovery is like a journey, which begins immediately after the childbirth and gradually terminates during the postpartum period, although the length of this journey is different among women and has a wide spectrum. This spectrum has two extremes. In one extreme, there is a couple of unpleasant experiences, including worries and bad mood with a feeling of being ill and weak, which continues towards the second extreme, in which the participants have feeling of an improved mood while regaining the possession of life. However, the duration of recovery and each phase in women with severe trauma was far more than that of women with mild traumatic perineum, which is why the recovery process was clearer in them. In other words, when the participants realized that the symptoms of their illness were being gradually improved, they were satisfied with the experience of returning to the positive mood. These results showed that postnatal women with perineal trauma experienced movement from negative emotions to subjective well-being after childbirth by improvement of the physical symptoms of the disease. Subjective well-being was reported as the highest level of positive affect with a high level of life satisfaction as a synonym of happiness. Subjective well-being is sometimes equivalent and possibly interchangeable with happiness, and the maximum level of subjective well-being means maximum happiness in a person.[23,24] However, some researchers found that life satisfaction was a separate issue of subjective well-being. This satisfaction depends on the environmental conditions, the individual’s genetics and, in particular, the power of coping with the events. Supportive circumstances facilitate the use of coping strategies and adaptation to the conditions of this psychological process.[23,25] The dynamics of the recovery process towards changing mood is consistent with the results of the present study.

In a qualitative study on 12 women living with severe perineal trauma, two sub-themes were extracted, entitled “a broken body” and “lived happily ever after”. “Lived happily ever after” was a sub-theme that completely referred to emotional problems; “a broken body” also includes unanticipated pain and other physical problems these women often have experienced.[26] Although this study did not investigate emotional recovery, women described anxiety of the changes that had occurred and how this might affect their partners and sexual experience. Another study which evaluated emotional effect on women after induced abortion reported that the majority of women experienced anger, guilt, shame, anxiety, depression, feelings of loneliness, and sleeping disorders,[27] but this study evaluated emotional change only without reporting the time of occurrence or recovery process. In our study, emotional change in participants appeared in the first stage of recovery. Of course, there are two differences between this study and our study. Firstly, recovery was not investigated in the recent study, so the results are not comparable. Secondly, our participants did not miss our pregnancy or infancy, and they suffered from chronic signs and symptoms and thought they were unable to even do their task. Therefore, the two groups were not homogeneous about the type of the emotional changes. The fear of future pregnancies was a major concern in women with induced abortions because more than 60% of them had experienced abortion due to fetal anomalies, while in our study many of the participants described their health were a major concern for them. In another qualitative study on 11 women aged 20-42 years old who had vaginal birth in England with different degrees of perineal laceration in the first ten days of postpartum care, it was reported that the process of early postnatal period had a core category including “Striving for normality”.[28] Similarly, the findings of our study showed that postpartum emotional recovery was a process of normalizing emotions, but there is a difference between the two studies; the recent study focused more on the physical aspects of recovery and pain management at the beginning of the postpartum period and emotional changes were not investigated. In our study, hope (recapturing vitality) acted as a trigger to overcome negative emotions, concerns and regaining activity. Hope solves or relieves the physical problems of illness or revaluation in life. The desire for having a child and accepting maternity constraints is an important source for hope. Therefore, an individual’s attempt to change her attitude and adapt herself to the new conditions makes her move toward healing. Therefore, changing feelings is an evidence of changing attitudes as well as adaptation with their conditions. On the other hand, financial support is a problem that needs social support and it is a kind of compensation that should be considered at the health system for women with severe perineal trauma. This finding is in the same line with the results of the majority of studies.[29-31] The important questions that mental health services usually are looking for are how long it takes to recover. The time of recovery was estimated at least 18 months after birth in 15 New Zealandi women who suffered from postpartum depression.[29] other study, it has been reported that recovery occurs during two years after birth,[32] but another study reported that complete recovery takes from ten to twelve weeks in the postnatal period.[33] Although all women in different studies were diagnosed with postpartum depression, these studies were conducted in different countries (Canada, New Zealand, and Taiwan).[29,32,33] Cultural context plays an important role in defining recovery, so women’s perception from recovery depends on their culture.[12] According to our study results, the time of emotional recovery is important in postnatal women with perineal trauma. These women should be cared, especially those who suffer from severe tears. Recovery time should be determined based on the women’s understanding of their current status. According to our findings, emotional recovery occurs when the women realize getting rid of worries and negative moods and regaining activity and energy. The findings of this study can be helpful in deciding whether to continue the postpartum care or not, so the client herself and her perception is the best source to ensure that the natural recovery process has happened or not.

One of the strengths of this study was that participants were recruited during a long time following the childbirth (the first year after childbirth). Also, for the first time the results of this study revealed the emotional recovery of women with perineal trauma. One of the limitations of this study was not addressing social and financial supports and their possible effects on emotional recovery.

CONCLUSION

The results of this study indicated that emotional recovery in women with perineal trauma was a two-phase process. In the first phase, mothers experienced negative emotions and then, with an understanding of a pleasant feeling of improved mood due to physical health, they reached the second phase, i.e. regaining possession of life. The emergence of positive affect was the evidence of women’s emotional recovery. The findings of this study can help clinicians to decide on the need for continued postpartum care, especially emotional care.