Palestinian women's feelings and opinions about vaginal examinations during normal childbirth: an exploratory study

Abstract

<h3>Background</h3> Vaginal examination is an accepted practice for the assessment of progress during normal childbirth, but its frequent repetition at short intervals has no proven value. It causes pain, discomfort, and anxiety; triggers feelings of fear, shame, guilt, exposure, and powerlessness; and can negatively affect women's satisfaction with childbirth. We report Palestinian women's feelings and opinions about having vaginal examination during normal childbirth. <h3>Methods</h3> In this descriptive, qualitative exploratory study, we used a piloted semistructured questionnaire to interview women after they had given birth, but a few hours before they were discharged from a government hospital in the West Bank. We interviewed every other woman during different 2 days every week over 4 months in 2008. The open-ended qualitative questions were typed in Arabic, translated into English, cross checked against the original questions and coded, and the codes were entered and analysed with IBM SPSS Statistics (version 18.0). Permission to undertake the study was obtained from the Palestinian Ministry of Health, Institute of Community and Public Health, Birzeit University, West Bank, and hospital managers. Verbal informed consent was obtained from all women. <h3>Findings</h3> Five of 200 eligible women declined and we missed the opportunity to invite 19 women; we interviewed 176 women. The mean age of women was 26·3 years (SD 5·9). 119 (68%) women had more than 9 years of education, 132 (75%) lived in rural areas, 46 (26%) had given birth to only one child, and 11 (6%) had more than seven children. Midwives assisted 138 (78%) women during childbirth. Women described their feelings in 359 responses and their opinions in 279 responses. 142 (81%) women reported pain, 119 (68%) discomfort, and nine (5%) embarrassment; and nine (5%) said that having a vaginal examination was reassuring. "I felt as if I am going to die!", said a 34-year-old para 7, examined three times by three different individuals. Another 24-year-old, primipara, examined eight times by five different individuals, said "Vaginal examination is painful and discomforting. But it was much easier when done by a midwife. Sometimes, I felt that physicians are punishing us for being pregnant and they seem like fighting while doing the vaginal examination. While conducting the vaginal examination, physicians are more aggressive, expose women's bodies too much and in an insensitive way." 166 (94%) women reported that vaginal examination during childbirth was beneficial, 13 (7%) thought that it was not necessary, and 11 (6%) reported that it should be done only when indicated. 18 (10%) women reported that during their vaginal examination, the approaches used by the individuals examining them were insensitive, they were not given sufficient privacy, and their dignity was not respected or they were not treated with humanity. According to one woman, "…there should be more privacy—sie, closing the door, curtains on the window." Another 24-year-old primipara, examined seven times by three different people said, "I knew nothing about vaginal examination. Yesterday was the first time I heard about it. It feels so embarrassing, very discomforting and I do not like to be examined at all." <h3>Interpretation</h3> Palestinian women who are pregnant might be subjected to unnecessary pain and discomfort during vaginal examination. Important gaps exist in the practices of health-care providers, including lack of adherence to the ethical and basic standards. Importantly, midwives and physicians need to understand women's feelings and experiences during vaginal examination so as to improve their own practices. They should only do such procedures when necessary and do them with care and respect, without causing unnecessary pain and with minimum discomfort and maximum dignity to the pregnant women. <h3>Funding</h3> Theodor-Springmann Foundation and Quota Scheme from Lånekassen.