Design

The study is an integrative literature review according to the method described by Whittemore and Knafl¹². Integrative literature review incorporates both quantitative and qualitative data and mixed-methods studies. Problem identification, literature search, data evaluation, data analysis and presentation of results are the five stages in this method¹².

Literature search

Eligible studies included qualitative, quantitative and mixed-methods studies reporting women’s experiences of facility-based childbirth and maternity care. The inclusion and exclusion criteria were developed using the PEOS (Population, Exposure¹³, Outcome, Study type) framework (Table 1). Studies were eligible if they were published in English between 2012 and 2023 and reported women’s experiences, perceptions, satisfaction, support, respectful maternity care, communication, or quality of care related to facility-based childbirth. Studies conducted in countries belonging to the WHO-defined South-East Asia Region were eligible for inclusion. Review articles, editorials, commentaries, conference abstracts, study protocols, and studies that did not report women’s childbirth experiences, were excluded. The search strategy was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines¹⁴ and with the assistance of a librarian at Dalarna University. PubMed and CINAHL were searched, in addition to reference list screening. The search strategy combined controlled vocabulary terms and free-text keywords related to intrapartum care (e.g. support and clinical management during labor and childbirth) and/or postpartum care (e.g. support for women and newborns, neonatal examinations, breastfeeding, and postpartum contraception). Search terms were adapted to the indexing systems and search functionalities of each database. Boolean operators (AND/OR) were used to combine search concepts. The full search strategy for each database is presented in the Supplementary file. The first author conducted the title and abstract screening, full-text eligibility assessment, and data extraction. Any uncertainties regarding study eligibility or interpretation were discussed with the co-authors until consensus was reached. A total of 2864 and 22 additional records were identified from CINAHL, PubMed, and reference list screening. The total records identified was then 2886. The additional sources consisted of reference lists from review articles identified through the database searches. First, 39 duplicate records were removed. The remaining records were then screened based on their titles and abstracts. Subsequently, 104 full-text articles were assessed for eligibility, of which 78 were excluded. This process resulted in 26 included articles in the review (Figure 1). The excluded articles and the reasons for exclusion are presented in the Supplementary file.

Figure 1

Prisma flow chart of selection of studies

Data evaluation

Pluye’s Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of the selected articles. The MMAT is a critical appraisal tool comprising 25 criteria across five study categories: qualitative studies, quantitative randomized controlled trials, quantitative non-randomized studies, quantitative descriptive studies, and mixed-methods studies¹⁵. The quality assessment was conducted independently by the first two authors. Methodological quality was assessed using the Mixed Methods Appraisal Tool (MMAT). The appraisal focused on methodological rigor, transparency of reporting, appropriateness of the study design, data collection and analysis procedures, and potential sources of bias. For descriptive purposes, studies were categorized as having high (76–100%), moderate (51–75%), or low (≤50%) methodological quality. The appraisal was used to identify methodological strengths and limitations of the included studies and to support interpretation of the findings rather than to exclude studies based on a predefined cutoff value (Table 3). Following the quality assessment, all 26 articles met the inclusion threshold and were retained for analysis.

Data analysis

An inductive content analysis according to Elo and Kyngäs¹⁶ was performed manually. The included articles were read several times, and text units reflecting the opportunities and challenges associated with a positive childbirth experience for women giving birth in health facilities were extracted and transferred to an Excel spreadsheet. The extracted text was then read repeatedly, and relevant text units were assigned codes. The codes were compared based on their similarities and differences and grouped into subcategories. To capture both positive and challenging childbirth experiences, opportunities and challenges relating to the same phenomenon were organized within the same category. The coded text units were condensed and further analyzed to identify patterns and relationships. Subcategories were subsequently grouped into generic categories, which were then abstracted into a main category. An example of the qualitative content analysis process used in the integrative review of the 26 studies^17-42 is presented in Table 2.

Quality of care

Opportunities and challenges related to the provision of quality care encompassed various aspects of healthcare and are described under the following subcategories: 1) Organization of care, 2) Care practices, and 3) Environment and resource availability.

Organization of care

Seventeen studies contributed to this subcategory^{17,18,21-28,31,32,34,35,39,41,42}. An opportunity for a positive childbirth experience based on the organization of care was related to the availability, accessibility, and affordability of services provided by healthcare providers in health facilities^{17,18,21-28,31,32,34,35,39,41,42}. In four studies conducted in Bangladesh, India, Sri Lanka, and Nepal^26,31,32,39, between 68.7% and 86.9% of women (sample sizes ranging from 305 to 3949 participants) reported satisfaction with the overall childbirth services. One study from India²⁵ reported that 34.4% of 180 women were satisfied with the services, while the remaining women reported neutral perceptions; none expressed dissatisfaction. Some studies indicated that women were satisfied with the competency of healthcare providers^18,23,26, their availability throughout childbirth²², and the time spent with them²⁷.

Other studies reported that women experienced adverse events during childbirth^24,42. A challenge to achieving a positive childbirth experience was the inattentiveness of healthcare providers during labour^21,24,41. Women believed that free maternity services²³, the continuous availability of healthcare providers throughout labour^21,28,42, and following healthcare providers’ instructions¹⁷ would contribute to a positive childbirth experience. Women who did not have to pay for services reported higher levels of satisfaction³⁴. Despite negative experiences with the services or healthcare providers, women expressed gratitude toward the health system and the providers for helping them achieve a safe birth and survive the childbirth process^23,24:

Care practices

Seventeen studies contributed to this subcategory^{18-23,27,29-31, 33,34,36-39,41}. Women valued practices that contributed to a safe birth outcome and often accepted interventions they believed were necessary to protect their own lives or the lives of their newborns^{18-23,27,29-31,33,34,36-39,41}. Opportunities and challenges in care practices included health education, medical procedures, and interventions related to maternal and newborn care. Opportunities for a positive childbirth experience were identified when care was provided in accordance with evidence-based practices^18,39, national guidelines^20,30, and good clinical practices, such as avoiding unnecessary caesarean sections²². In Nepal, where a perinatal care quality improvement package was implemented, the percentage of women reporting satisfaction with care increased from 58% to 62% (n=54919)³³. Health education varied and covered topics such as breastfeeding, newborn care, self-care, family planning, and follow-up care for women and children^{19,21,22,33,34,36-38}. Challenges to a positive childbirth experience were related to newborn care, pain management, and harmful practices. Challenges in newborn care included inadequate attention to newborn needs, such as a lack of skin-to-skin contact or kangaroo mother care^30,38, the absence of neonatal examinations conducted in the mother’s presence³⁶, inadequate breastfeeding support^19,21, and insufficient counselling on newborn care^19,21,36. Women also reported harmful practices, such as the use of external fundal pressure to facilitate birth^18,29 and the performance of episiotomy, as well as the suturing of episiotomies and vaginal tears, without anaesthesia^18,41. Although episiotomy was unpopular among women, many accepted the procedure because they believed it was necessary to save their lives²³. Women experienced pain during labor and the postpartum period regardless of the mode of birth, reflecting challenges related to inadequate pain management^{19,20,23,27,31}:

Environment and resource availability

Seven studies contributed to this subcategory^{18,21-23,28,30,34}. Opportunities and challenges for a positive childbirth experience were also related to the environment and resource availability within health facilities. Several studies showed that the cleanliness of the health facility was important to women^{18,22,23,28,30}. One study from Sri Lanka involving 1265 women reported that 88.8%, 88.0%, and 81.1% of women were highly satisfied with the availability of resources, the space available in the facility, and the cleanliness of the toilets, respectively³⁰. Women also associated adequate infrastructure and the availability of basic resources with a positive childbirth experience, including access to beds, clean facilities, and essential amenities within the health facility^{18,21-23,28,30,34}. Challenges included limited space in rooms³⁴, overcrowding¹⁸, and unclean environments^22,28. Studies also showed that women were dissatisfied with facilities lacking access to water²⁸, insufficient bed availability^18,23, the absence of heating facilities during winter¹⁸, and the lack of a call button to request assistance²¹:

Emotional and physical support

Opportunities and challenges related to the provision of emotional and physical support are described under the subcategories: 1) Strengthening women’s capabilities, 2) Birth companions, and 3) Communication.

Strengthening women’s capabilities

Fourteen studies contributed to this subcategory^{17-23,26,28,29, 31,35,38,40}. Encouragement and supportive care from families, healthcare providers, and fellow women were important opportunities contributing to a positive childbirth experience, as they strengthened women’s ability to cope with labor and birth and to care for their newborns^17-22,40. Studies revealed that women were satisfied with the supportive care they received^26,29,31,35. Women also benefited from spiritual support when their religious and cultural needs were met^17,20,38. During labor, healthcare providers comforted, motivated, and reassured women and helped them maintain their dignity^20,22,23. Women received emotional and practical support from healthcare providers, fellow women, husbands, relatives, and family members^18-22,40.

Women reported confidence in healthcare providers²⁰, appreciated the psychological support they received¹⁹, and felt empowered to care for their babies¹⁹. However, studies also identified challenges related to inattentive healthcare providers who failed to show empathy for women’s labor pain or provide comfort and reassurance^21,23. A lack of supportive care^9,21,23,40 reduced women’s trust in healthcare providers²⁸. Even when supportive care did not fully meet women’s expectations, women prioritized survival over their childbirth experiences, as the importance of survival overshadowed the challenges they encountered:

Birth companions

Eight studies contributed to this subcategory^{18,20-22,28,31,33,41}. Birth companions, such as husbands, female relatives, and friends, represented an important opportunity for a positive childbirth experience by providing emotional and physical support. Women were allowed to have a birth companion during all stages of labour^{18,20,21,31,33}, only during the first stage of labour²², or not at all⁴¹. A study from Nepal reported that fewer than 20% of 54919 women had a companion of their choice during labor³³. The presence of a birth companion was perceived by women as contributing to a positive childbirth experience³¹. However, women also faced challenges related to the presence of birth companions during labor, as being seen in an exposed and vulnerable state was perceived as potentially affecting future relationships¹⁸. Some women asked their companions to leave, even when they were uncomfortable expressing their wishes in their presence²¹. Despite these challenges, women expressed that the presence of a family member in the labor room²⁸, preferably their husbands²², would enhance their childbirth experience:

Communication

Eighteen studies contributed to this subcategory^{18-22,24,26,27,29-31,33,34,36,38,40-42}. Women were satisfied with communication with healthcare providers and the information they received^{20,26,27,29,33,34,38}. Opportunities for a positive childbirth experience included positive interactions with healthcare providers, receiving information, and discussing concerns related to the physiological process of childbirth²⁰ and medical procedures^29,31,33,36, as well as communicating about the care of their newborn^22,30,40. Women’s experiences of communication ranged from effective and supportive communication to a complete absence of communication^{18,19,21,24,27,29-31,33,36,38,40,41}, with poor communication representing a significant challenge. Only 14.6% of 405 women in a study from Nepal received information at discharge²⁷, and 80.4% of 62926 women in Nepal received inadequate information regarding their care³⁶. Furthermore, 85.8% of 400 women in Sri Lanka did not receive information about medications administered during childbirth³¹. Although women received physical care, they were often not given explanations as to why procedures such as cesarean sections were necessary, which led some women to become suspicious of the care provided²¹. Women also encountered language barriers that hindered communication^24,41. Some studies reported that women were able to discuss their concerns and preferences and that healthcare providers responded to them^29,34,38, whereas other studies found that women were unable to do so^36,41. Women attributed poor or inadequate communication to the personalities of individual healthcare providers²¹, as well as to staff workload and overcrowding within the ward^18,19. Women expressed a desire for positive interactions with healthcare providers and clear explanations regarding medical interventions^20,42, as these were considered important components of a positive childbirth experience.

Adherence to principles of women’s rights

Opportunities and challenges related to respect, consent, autonomy, dignity, privacy, and equality of care during childbirth were associated with the principles of women’s rights. These findings are further described under the subcategories: 1) Respectful maternity care, and 2) Equality of care.

Respectful maternity care

Eighteen studies contributed to this subcategory^{17,18,21-24,27-33,36,38,39,41,42}. An opportunity for a positive childbirth experience arose when women experienced privacy^21,23, dignity⁴², and respectful care^31-33,38. Women were particularly satisfied when privacy was maintained during physical examinations^30,33,38,29 and when their consent was sought before procedures were performed^29,31,42. Lack of privacy and confidentiality^{18,21,27,32,39,41} were reported as challenges to a positive childbirth experience. Lack of privacy was attributed to the absence of curtains separating women in the labor room¹⁸ and the high number of healthcare providers present during physical examinations⁴¹. Non-dignified care included not being addressed by name¹⁸ and exposure of women’s bodies in the labor room^18,39 to male healthcare providers, medical students, and family members^18,21, resulting in feelings of shame and, in some cases, trauma²¹. Women also experienced non-consented care^31,32,41. Consent was not obtained for postpartum contraceptive use^18,21 or episiotomy⁴². A study from Sri Lanka reported that 55% of 400 women felt that they had not been involved in decisions regarding their care³¹. Women were not involved in decision-making related to the mode of birth²¹ or the choice of contraceptive methods^18,21. In some cases, women required their husbands to provide consent for a cesarean section²¹. However, studies from India and Nepal reported that only a few women placed a high value on the opportunity to make informed decisions^18,22. A qualitative study from India²³ reported that a woman who was dissatisfied due to an episiotomy and experiences of verbal abuse nevertheless described her overall childbirth experience as positive because she had been ‘saved’ by the healthcare provider. Some studies reported that women received respectful and non-abusive care^{17,28,29,31-33,36,38}, whereas others documented experiences of physical^{17,18,24,31,41,42}, verbal^17,18,24,42, sexual²⁴, and emotional abuse^17,24 during childbirth:

Equality of care

Eleven studies contributed to this subcategory^{17,18,23,24,29,32, 36,38,39,41,42}. Opportunities for a positive childbirth experience included non-discriminatory care^23,24 and the absence of refusal of care^{17,29,32,36,38,39,41,42}. Women expressed that receiving non-discriminatory care was important for a positive childbirth experience⁴². One study from Nepal reported that none of the 4296 women in the study population was refused care because of an inability to pay³⁸. Another study from Nepal found that only 1.5% of 62926 women were refused care due to an inability to pay³⁶. Challenges to a positive childbirth experience included discrimination and the refusal of care through neglect³², withholding of information¹⁸, and either refusing to perform procedures or performing them in a painful manner¹⁸. In India, 10.2% of 305 women experienced abandonment during childbirth³², while 9.7% of 2639 women in another Indian study²⁹ and 3.9% of 305 women in Nepal³² reported experiencing discrimination by healthcare providers. Women who had personal connections or relatives working within the health facility were sometimes treated preferentially²⁴. Challenges included discrimination, neglect, refusal of care, withholding of information, and unequal treatment based on economic status, language, or sociocultural background^{17,18,24,29,32,39,41,42}. Nevertheless, many remained grateful to healthcare providers for assisting them through a safe birth²⁴, demonstrating how survival was often prioritized over the challenges encountered during childbirth. The importance of survival frequently overshadowed experiences of discrimination and mistreatment:

Limitations

As this study was conducted as an integrative review. The review was not prospectively registered in PROSPERO or another review registry. The main limitation is that title/abstract screening and full-text eligibility assessment were conducted by one reviewer rather than by two independent reviewers. Due to resource constraints, dual-independent screening was not undertaken. Although uncertainties were discussed among the authors, this may have increased the risk of study selection bias. Only studies published in English were included, which may have introduced language bias. The included studies were heterogeneous with regard to study design, setting, populations, and outcome measures, which may have limited comparability across studies. Searches were conducted in two databases and supplemented by reference list screening; therefore, relevant studies indexed in other databases may have been missed. Grey literature was not systematically searched, and publication bias cannot be excluded. Furthermore, four countries within the WHO-defined South-East Asia Region were not represented in the included studies because no eligible published research was identified. Additional research is therefore needed to explore the childbirth experiences of women in these countries and to provide a more comprehensive understanding of the region.