Jordanian women´s Feelings, Opinions and Knowledge of Vaginal Examination during Child Birth

ABSTRACT

Objectives: To explore the feelings, opinions and knowledge of vaginal examination during normal labour in Jordanian women and to establish current practice of midwifery and obstetric staff regarding intimate examination to assess progress in labour. 

Methods: This study used a cross-sectional correlational design. A semi-structured questionnaire was used, and interviews with 150 postpartum women   were conducted. The study was carried out during the postnatal period by three qualified midwives. The completed questionnaire and all data were analyzed using (SPSS) version 19. Descriptive statistics and non-parametric statistics Fisher Exact test were used. Also `validated´ the questionnaire data against the medical records.

Results: Vaginal examinations were conducted with short intervals and were done frequently.Seventy-six women (50.7%) were examined between 5-12 times and one hundred ten (73.3%) were examined by 2-3 persons. There was a significant association between the proportion of women receiving vaginal examination during childbirth and parity, type of delivery, birth attendant, the number of examiners, and VE attendant (P = 0.0, 0.002, 0.001, 0.000, 0.000, respectively). 59% reported severe pain during the examination, 56.7% reported that VEs were beneficial and 66% had correct information. Sixty –one percent of women reported that health care provider asked permission without giving instructions.

Conclusion: Jordanian women are exposed to frequent and short interval vaginal exams during childbirth. The examinations are conducted by too many providers. Women reported suffering from pain, and poor respect for dignity and humanity, with insufficient means of privacy . Although the majority of women were asked permission to perform the examination there was poor communication regarding indication,preparation and findings. 

Keywords: Feeling, Jordanian Women, Opinion, knowledge, Vaginal Exam, 

JRMS Aug 2017; 24(2): 58-69 / DOI: 10.12816/0039644 

 Introduction

 The vaginal examination (VE) is an internal examination of the vagina and cervix (1).It is considered as a significant  clinical assessment tool to help understanding  the most exact measures of childbirth  progress (2). During childbirth, vaginal examination gives the health care provider the important information regarding cervical dilatation, effacement, fetal head position and status of a membrane (3). Worldwide researchers are interested in examining the number of VE´s performed in relation to the length of childbirth. Several studies have detected that women appear to have more VE than predictable during childbirth, in spite of theavailability of guidelines on implementing VE at certain institutions. But, these different guidelines simply  lack information on the ideal time to perform  VE during childbirth  or what the average rate of VE during childbirth (4, 5).  The World Health Organization (WHO 1996) proposed  that the number of vaginal examinations should be restricted during the first stage of labor usually, one every 4 hours is enough if childbirth is proceeding on smoothly. Experienced birth attendees can sometimes limit the number of examination to one (6). Shepherd 2013conducted a cross-sectional survey among 144 female patients at a National Health Service hospital (NHS) in the UK. They found that the number of VE carried out were from 1-7 with the mean of 2.9. This increased  with labor time and 70% of women had more than expected VE when the procedure of four hourly vaginal examinations was implemented(7). Repeated vaginal examinations expose women to the hazards ofChorioamnionitis (8, 9)  puerperal sepsis(10), and may influence future fertility(8) . Also, repeated vaginal examinationshave an impact on the newborn health.Seven or more repeated vaginal examinations during childbirth make the newborn 4.5 times likelyto develop neonatal sepsis and needs longer hospital stay on antibiotic treatment. Newborns seem to acquire group B streptococcus with repeated vaginal exams which may lead to complications of antibiotic use such as : allergy , asthma and anti-microbial resistance (11). Frequent vaginal exam may limit activity  in childbirth resulting in poor quality contractions and increase the probability for  labor  augmentation(12). During child birth, Women may report feelings of guilt, shame, exposure, loneliness, powerlessness that impact on their self confidence in their capacity to deliver. VE also adds more pain, discomfort and anxiety to the laboring women (13-18). There is a little evidence in Arab countries of women knowledge, opinion, feeling and experience of the vaginal exam during normal childbirth. Three studies have been performed that are relevant to the Jordanian population (3,19,20).

Methods

This study utilized a cross sectional correlation design was carried out at King Hussein Medical Center (KHMC) which is a general referral military hospital with about 800 births per month and around (9,000-10,000) births per year. Qualified midwives and physicians are the main health care providers in the labor room. KHMC is a teaching hospital for nurses, midwives and physicians, both for undergraduates and postgraduates. The obstetric department has 70 beds in the postnatal wards, 10 beds for the first stage and five delivery beds on the labor ward. We recruited married Jordanian women aged between 16-45 years who had delivered at the KHMC. Women who had precipitate delivery, preterm delivery,   presented in labour at full dilatation or showed signs of fetal distress were  excluded. The total sample size was 180 women. Of these 12 women discharged against medical advice , 10 women were not able to be interviewed by researchers and the last 8 women changed their mind regarding participation .This left a final cohort of 150 women. Approval for conducting the study was obtained from Ethical Committee at KHMC. Approvals from the director of Obstetrics and Gynecology department and head of nursing were obtained . A semi-structured questionnaire, which was used in the Palestanian study,REf was used in our study. It was in Arabic language which made it easier to adopt the questionnaire for Jordanian women who have the same culture and language. The questionnaire was developed by Dr. Hassan and colleagues at Birzeit University at the department of community medicine in 2012. Hassan and colleagues conducted their study in a general referral governmental hospital in Palestine, the nearest to Jordan. They approved using their questionnaire for our study.The questionnaire consisted of two parts; The first part; looks at socio-demographic and obstetrics information including, age, parity, education level, type of delivery, birth attendant, number of examiners, number of VE’s and  place of previous delivery. The second part asks open-ended qualitative questions to explore the women’s experience, feelings, opinions and knowledge regarding VE during normal childbirth. The questionnaire was piloted on ten post-partum women who were not included in the study and have the same inclusion criteria of main participants to ensure their understanding of the adapted questionnaires. Researcher made some small changes to the instrument after piloting the study on 10 postpartum women in the same setting, e.g.classified the frequency of vaginal exams into three categories: (0-4 times, 4-12 times, more than 12 times). Participants had plenty of time to answer open questions about knowledge, experience, feeling and their opinions of vaginal examination during childbirth. Nature and purpose of the study were explained. Upon agreement of participation, each participant asked to sign a consent form. The questionnaire was given to them to complete on the postpartum ward. Data was collected during the period between March and June 2015.  

Data were collected by three qualified midwives who trained on data collection procedures. They collected data during their daily shifts. The first phase of data collection started from admission to labor room until delivery and transfer to the postpartum ward. This is to ensure that the collected data that met the study criteria and to validate documentation of vaginal examination procedure. The  second phase of data collection was on the  postpartum ward where researcher  administered  open questions and allowed for  women to express their feelings, opinions, and experience in their owns words  and in Arabic language. In addition, validation of women reports were done by reviewing the medical records of documented VE’s by the same midwives who conduct the interview for women.

Definitions of variable

We categorized frequency of vaginal examination into three categories based on the literature as shown earlier.Researchers consider the frequency of VEs 0-4 times as low frequency and 5-12 times as high frequency. Also, define a low number of providers as 1 provider and high number as two or more.

Methods of Data analysis 

A total of 150 women completed the questionnaire and all data were analyzed using the statistical package for social science (SPSS) version 19. Descriptive statistics were used to describe the characteristics of the study sample (socio- demographics and obstetrics characteristics:  women age, parity, educational level, type of delivery, birth attendant, the number of examiners, VE attendant, place of previous delivery and frequency of VE. Non-parametric statistics such as Fisher Exact test were used to examine the relationship between demographic and obstetrics variables and the frequency of vaginal exams during normal childbirth p - a value of ˂ 0.05 was considered to be significant. The open-ended qualitative questions were typed in Arabic and then translated into English .The English text was read line by line for the content and coded. The assigned codes for all response were entered into SPSS statistical software version 19. 

Results

Women's Demographic and Obstetric Characteristics We interviewed 150 women of age varied from 16- 45, about (64%) of women age varied from (24-30) years, two thirds of women (n=99, 66%) were multiparous. 45% of women had completed their tertiary education. Most women (n=104, 69%) were delivering for the first time at KHMC. The majority (n=134, 89%) were delivered normally. 65% of childbirth were attended by midwives Table I.

Table I: Demographics and obstetric characteristics of participant (n=150)   

Women´s experience 

The frequency of VE was categorized into three categories: 0-4 times, 5-12 times, and above 12 times. Half of the women (n=76) reported undergoing VE between 5-12 times during their childbirth, and around (42%, n=42) reported undergoing vaginal exams four times and below. (73%) of women reported being examined by 2-3 persons, only 10% of women were examined by one person. Most of the women 76.7% were examined by both physician and midwife (combination). Most women 88% preferred to be examined by midwives. Table II

Table II: The women's reported characteristics of the vaginal examination practice during normal childbirth (n= 150).

Association between frequency of vaginal examination and selected demographic and obstetric characteristics

Non-parametric Fisher exact test was used to assess if there was a significant association at p level = 0.05 between frequency of VE and selected  demographic and obstetric characteristics:( age , parity , educational level , history of previous birth at KHMC ,type of delivery , birth attendant , number of examiners , VEs attendant and place of previous delivery ).The results showed no statistically significant difference between the proportion of women receiving VE below four times or between 5-12 times during childbirth and their age, educational level, and place of previous delivery (P = 0.531, 0.252, and 0.394, respectively. There were significant associations between the proportion of women receiving vaginal examination during childbirth and parity , history of previous birth at KHMC , type of delivery , birth attendant, number of  examiners, and VE attendant (P = 0.000, 0.002, 0.002,  0.001, 0.000, 0.000, respectively ).The proportions of women who had vaginal exams 5-12 times during childbirth were significantly larger when women had first time delivery ( primiparous ) than multiparous  women,  first time delivered at KHMC, women who had NVD, and when birth attended by midwife , and when VEs attended by combination midwife and physician, finally when the number of providers were 2-3 persons . Table III

Table III: The prevalence of frequencies of VE during normal childbirth by selected demographic and obstetric characteristics (N=150).

N=150,*Fisher's exact test, **P≤0.05. MOH: Ministry of Health, VE: Vaginal examination.

Women’s opinions of VE 

Women expressed their opinion regarding vaginal examination during childbirth. All responses were coded into four categories: beneficial, VEs done when indicated, an insufficient mean of privacy, no respect for dignity and humanity as shown in Table 4. Around 56.7% of women reported that VEs were beneficial, 25.3% of women reported insufficient means of privacy, 16% of women reported VEs should be done when indicated, and only 2% of women reported no respect of human dignity or humanity during VE.

Women feelings of VE

Women were asked open qualitative questions to express their feelings toward vaginal examination during childbirth on their own words. The content of women words or responses was categorized into four categories: embarrassing, assuring, discomfort and painful as shown in Table 4.Around (59%, n=89) reported VEs were painful , 23% of women reported embarrassment, 15% of women reported discomfort and only 2% of women reported that VEs  were reassuring.

Women’s knowledge of VE

Two thirds of the women had correct information regarding VE’s such as: measure cervical dilatation, check labor progress, and check fetal descent. On the other hand, around 32% of women have incorrect information regarding vaginal examination; some women think that VEs accelerate dilatation;others think that VEs check birth defects. Only 1.3% of women did not have any information about VEs. Some women have correctbut mixed with other incorrect information, especially primiparous women. 

Permission statement during VE

Women were asked: How many times health care providers asked to do VE’s? What they were told about the examination? Then all women responses were collected and coded into three categories such as: Giving instruction and ask permission for VEs, ask permission without instruction and complaint response. About 61.3% of women reported that health care providers asked permission for the examination without providing instruction, and 32.7% of women complained from examination such as: health care provider perform the exam too frequently without explanations of results. Only 6% of women reported that they received instructions and information’s regarding the exam and also health care providers asked permission to have the examination. The most reported response (please prepare yourself for the examination, after five minutes I will return to perform the examination), during the exam (relax, take a deep breath and prepare yourself for an internal examination). Table IV

Table IV: women's feelings, knowledge, opinions and permission statement for performing VE’s during childbirth

Discussion 

Most deliveries were attended by midwives which are a common practice at our hospital. Doctors were attending high risk and instrumental deliveries. Almost 1/3 of our patients were primigravidas. All our patients were educated with 18% who had primary education and that is a reflection of Jordanian women.  Our findings showed that more than half of women reported having vaginal exam more than five times, 11 women had vaginal exams more than 12 times. Almost seventy-five percent of patients were examined by two to three different persons. These findings provide evidence that VE’s were used routinely for most Jordanian women during labor, which contradicts the WHO recommendations that the number of vaginal examinations should be limited and restricted to indications during the first stage of labor. This is usually one every 4 hours if labor proceeds smoothly. Also during normal childbirth there should be adequate reasons to interfere with the normal process of labor. (6) Our results showed that the majority of women prefer to be examined by midwives and female doctors which is consistent with our culture in Jordan.  

The reason behind performing VEs too frequently and by many providers related to many reasons: primarily, to the presence of lack of communications between both midwives and obstetricians and lack of adherence with international standards of practices especially that 76% of VE performed by combinations of midwives and obstetricians. Secondly, related to the presence of too many student midwives and doctors in training. Thirdly, midwives taking care of more than three laboring women per shift (8 hrs.shift), which contradicted the worldwide midwives to laboring women ratio 1:1. The last reason is the overload of work and the active management of labor. Jordanian midwives like their colleagues in Palestine, performed VE’s too frequently when they were busy. (21) Midwives could take more time to sit with the woman, observing other signs of labor and listening to the women. In many cases, the midwives may be able to conclude that the women are in active labor and avoid an internal examination. Given the high number of examinations done because of signs of second stage of labor, it is also possible that the midwives perform a vaginal examination rather than trusting that a woman’s urge to push is truly a sign of second stage labor.  Primiparous Jordanian women's were examined more frequently than multiparous during their childbirth. These findings   support those of Hassan et al (2012) that primiparous women are examined more frequently and needlessly than multiparous because of their longer labor (3).The available international evidence showed that women worldwide reported that vaginal examinations cause negative response such as embarrassment with genital exposure, physical pain, and discomfort which may, in turn, lead to feelings of helplessness and vulnerability, dehumanization and a violation of privacy (3, 15, 16, 22).In our study, around 59% of women reported pain which is less than that reported by Hassan et.al (3) with about 82% of women in the study complained of pain during VE.  Discomfort was reported in 15% of women in our study, and 23% reported embarrassment. Feeling pain indicates that examiner may have inadequate hand skills. Doctors and midwives should be guided through education and monitoring to acquire the proper competencies to perform VE’s with minimum pain and discomfort for the laboring women (23-25).The embarrassing sensitive nature of VEs for both women and health care provider is significant and clear in the conservative Arab and Muslim cultures where VE’s are very sensitive subjects. (24) Most of our patients reported pains during vaginal exams and 23% of patients reported embarrassment compared to 50% reported same complaint in a previous Jordanian study in 2008(19) . This is not acceptable and we should work on training our doctors and midwives in these areas. One central finding in our study indicates that two-thirds of women had correct information regarding performing vaginal exams by stating that they were ‘to check dilatation` and ‘to check labor progress´. Women acquired information's from previous deliveries experiences and by asking health care team during their childbirth. Reviewed literatures suggested that women mainly acquired information from midwives caring forthem during their childbirth (26). Midwives should recognize and understand women’s feeling ofbeing shy and uncooperative during the vaginal exams. Midwives will gain the women’s respect and cooperation if they carefully explain the procedure and the reasons for doing the exam. Also, the midwives should always keep the women informed and reassured regarding the normal progress of labor and inform the women when to have the exam with all the necessary instructions. These preparations will make the women psychologically and physiologically ready for the exam (27). In our study, around 60% of women were asked permission to have the examination but without giving instruction or information.  The procedure of VE should be explained to the women so that she can relax and breathe deeply, this helps to prevent some of the discomfort and pain which was reported by many of our patients. Quarter of our women complained of insufficient mean of privacy during VE’s and that the exams were conducted with no respect for humanity or dignity of the women. Arab and Muslim women might feel more comfortable if the healthcare providers announced their arrival before they enter the rooms, thus permitting time for the women to cover themselves and be prepared (28).Midwifery profession is guided by the code of ethics which regulate professional responsibilities and duties. Example of these ethics that midwives develop a partnership with women with whom they share care that leads to informed decision-making, consent to an evolving plan of care. Midwives provide care for women with respect for cultural diversity. Midwives respond to the psychological, physical, emotional and spiritualneeds of women seeking health care and midwives should understand the adverse consequences that ethical and human rights violations have on the health of women (29).

Recommendation 

Enhancing the positive relationship between laboring women and health care provider through proper communication, care planning and providing comfortable vaginal examination .Considering the importance of VE’s to obstetrics care and the need to implement evidence-practice for vaginal examinations.

Limitations 

Our sample of patients is small. The study was conducted at KHMC where practices in this area are changing from the traditional teaching to an evidence-based practice. We hope that repeating the study in few years we would get improvement in our practices in looking after laboring Jordanian women.

Conclusion

Jordanian women were exposed to frequent and short interval VE during childbirth. The exams were conducted by too many providers. Women reported suffering from pain, no respect for dignity and humanity, insufficient means of privacy and the majority of women were asked permission to perform the examination but without giving instructions.It is important for health care providers to understand women feeling experiences during VE’s in order to improve the women expectation of care provided to them during their childbirth. Evidence based midwifery practices include a minimal number of examination with a minimum number of providers. According to the study findings, doctors and midwives at our hospital should improve their practices during looking after laboring women and implement evidence based practices during vaginal examinations. This will improve the quality of care for our patients.

References

1.    Department of Health. Queen land clinical guideline .2015.The vaginal examination in labor. Evidence Based Midwifery-Royal College of Midwives Library. Effective: 03/2015 Review: 04/2017.Available from: www.health.qld.gov.au/qcg.

2.    Dixon L, Foureur BA. The vaginal examination during labour: is it of benefit or harm? New Zealand College of Midwives Journal. (42).

3.    Hassan SJ, Sundby J, Husseini A, Bjertness E. The paradox of vaginal examination practice during normal childbirth: Palestinian women´s feelings, opinions, knowledge, and experiences. Reproductive Health. 2012 9(1):1.

4.    Enkin M, Keirse MJNC, Chalmers I, Enkin E. A guide to effective care in pregnancy and childbirth: Oxford University Press Oxford; 2000.

5.    Stewart M. Midwives' discourses on vaginal examination in labour: University of the West of England; 2008.

6.    World Health O. WHO recommendations for augmentation of labour: World Health Organization.

7.    Shepherd A, Cheyne H. The frequency and reasons for vaginal examinations in labour. Women and birth. 2013; 26(1):49-54.

8.    Maharaj D. Puerperal pyrexia: a review. Part I. Obstetrical & Gynecological survey. 2007; 62(6):393-9.

9.    Zanella P, Bogana G, Ciullo R, Zambon A, Serena A, Albertin MA. [Chorioamnionitis in the delivery room]. Minerva pediatrica.62 (3 Suppl 1):151-3.

10.    Sebitloane H, Moodley J, Esterhuizen T. Prophylactic antibiotics for the prevention of postpartum infectious morbidity in women infected with human immunodeficiency virus: a randomized controlled trial. American Journal of Obstetrics and Gynecology. 2008; 198(2):189. e1-. e6.

11.    Sebitloane HM, Moodley J, Esterhuizen TM. Prophylactic antibiotics for the prevention of postpartum infectious morbidity in women infected with human immunodeficiency virus: a randomized controlled trial. American Journal of Obstetrics and Gynecology. 2008; 198(2):189. e1-. e6.

12.    Jansen L, Gibson M, Bowles BC, Leach J. First do no harm: interventions during childbirth. The Journal of perinatal education. 2013; 22(2):83-92.

13.    Nilsson C, Lundgren I. Women's lived experience of fear of childbirth. Midwifery. 2009; 25(2):e1-e9.

14.    Lewin D, Fearon B, Hemmings V, Johnson G. Women's experiences of vaginal examinations in labour. Midwifery. 2005; 21(3):267-77.

15.    Hilden M, Sidenius K, Langhoff‐Roos J, Wijma B, Schei B. Women's experiences of the gynecologic examination: factors associated with discomfort. Acta obstetricianet Gynecologica Scandinavica. 2003; 82(11):1030-6.

16.    Lai CY, Levy V. Hong Kong Chinese women's experiences of vaginal examinations in labour. Midwifery. 2002; 18(4):296-303.

17.    Larsen M, Oldeide C, Malterud K. Not so bad after all..., Women's experiences of pelvic examinations. Family Practice. 1997; 14(2):148-52.

18.    Bergstrom L, Roberts J, Skillman L, Seidel J. “You'll feel me touching you, sweetie”: Vaginal examinations during the second stage of labor. Birth. 1992; 19(1):10-8.

19.   Hatamleh R, Sinclair M, Kernohan WG, and Bunty B. "Technological childbirth in northern Jordan: descriptive findings from a prospective cohort study." Evidence-Based Midwifery, vol. 6, no. 4, 2008, p. 130 -136.

20.    Hatamleh R, Gharaibeh H, All Banyan A. Jordanian women's perceptions of intrapartum vaginal examination. Evidence Based Midwifery-Royal College of Midwives Library. 2012; 10(4):131.

21.    Hassan-Bitar S, Narrainen S. ‘Shedding light’ on the challenges faced by Palestinian maternal health-care providers. Midwifery. 2011; 27(2):154-9.

22.    Muliira RS, Seshan V, Ramasubramaniam S. Improving vaginal examinations performed by midwives. Sultan Qaboos University Medical Journal. 2013; 13(3):442.

23.    Ker J. Developing professional clinical skills for practice–the results of a feasibility study using a reflective approach to intimate examination. Medical Education. 2003; 37(s1):34-41.

24.    Stewart M. ‘I'm just going to wash you down’: sanitizing the vaginal examination. Journal of advanced nursing. 2005; 51(6):587-94.

25.    Wall LL, Brown D. Ethical issues arising from the performance of pelvic examinations by medical students on anesthetized patients. American Journal of Obstetrics and Gynecology. 2004; 190(2):319-23.

26.    Lewin D, Fearon B, Hemmings V, Johnson G. Informing women during vaginal examinations. British Journal of Midwifery. 2005; 13(1).

27.    Sellers PM. Midwifery: A textbook and reference book for midwives in Southern Africa. Second editition,  Juta Academi .2012

28.    Seeger DM. Muslim Women and United States Healthcare: Challenges to Access and Navigation. 2015.

29.    International Confederation forthe Midwife. International Code of Ethics for Midwives. 2014.

استبيان حول معرفة واراء وشعور السيدات اثناء الفحص الداخلي في غرفة الولادة 

1- ألأسم :          2-العمر :    

3- تاريخ اليوم :                              4- تاريخ الولادة :                   5- وقت الولادة :      

6- عدد الولادات الحية : 

1- اول ولادة                               2- من 2- 5 ولادات           3- اكتر من خمس ولادات 

 7- المؤهل التعليمي : 

1- اقل من الثانوية العامة                     2- ثانوية عاملة                   3- مؤهل جامعي 

8- هل هذه اول مرة تولدي في هذا المستشفى ؟         1- نعم                                    2- لا 

9- اين كانت ولاداتك السابقة ؟ 

10- كيف ولدت هذه المرة ؟

1- طبيعي          2- شفط         3- استخدام الملقط       

11- مين ولدك ؟

1- قابلة         2- طبيب نسائية      3- طبيبة نسائية       4- طالبة متدربة 

12- كم مرة قاموا باجراء الفحص الداخلي ؟

1-  0- 4 مرات       2 – 5- 12 مرة                        3  - اكتر من 12 مرة 

13- عدد الاشخاص الذين قاموا باجراء فحص داخلي ؟

1- شخص واحد     2-  من 2-3 اشخاص                      3- من 4-7 اشخاص 

من قام بفحصك ....................................................................................................

14-كم مرة طلبوا منك إذن فبل الفحص الداخلي ؟ ماذا قالوا لك ؟.............................................

15 – ماذا تعرفين عن الفحص الداخلي ؟ ما هو ؟ ولماذا يعمل ؟ ...........................................

16- ماذا شعرت اثناء الفحص الداخلي ؟.........................................................................

17- ما هو رأيك بالفحص الداخلي ؟ ............................................................................

18 – من تفضلي ان يقوم باجراء فحص داخلي لك ؟

1- قابلة               2- طبيبة                    3- طبيب ذكر 

19- ما هو شعورك اتجاة تجربتك في هذة الولادة ؟ ............................................................

Jordanian women Feeling, Opinions, Knowledge and Experiences of Vaginal Examination during Normal Child Birth

1.   Age…                                                               2. Date………………..  

3. Delivery date…                                                4. Time of delivery…

5. Number of children:

1. First delivery     2. From 2-5 living children         3. More than five children 

6. Education level:

1.  Primary                      2. Secondary                             3. Tertiary

7. is this the first time you delivered in this hospital?                       Yes / No 

8. Where you give birth before?

9. How did you deliver this birth?

1. Normal vaginal         2.vaccum         3. Forceps

10. Who attended your birth?

1. Midwife     2. Male physician      3. Female physician       4. Student 

11. How many times health care providers examined you vaginally during labor?

1. Less than 4 times     2. Between 2-5 times        3. More than twelve times 

12. Number of health care providers who perform vaginal examination:

1. One person    2. 2-3 Persons     3.4-7 persons 

13. Who examined you?

14. How many times the asked for your   permission? What did they say to you?

15. What you know about vaginal exams? What is it? Why it is done? 

16. How you felt during vaginal examinations? 

17. What is your opinion about benefit, importance …of vaginal examinations? 

18. Women preference for vaginal examination? 

1. Midwife    2. Female physician    3. Male physician 

19. What are feelings towards this birth experiences?