Table 5 Example of using qualitative evidence to populate the evidence-to-decision framework criterion on the acceptability of the intervention

Intrapartum care guideline – episiotomy [13]

Commissioned synthesis (women’s findings) [45]

Synthesis finding 1 - Subordination and compliance (high confidence). In a number of contexts, women handed over responsibility for their care to providers – sometimes this was done voluntarily but, more often, choices or decisions were taken out of their hands. Women were not asked for consent for certain procedures (e.g. episiotomy) or were coerced or bullied into having interventions against their will.

Synthesis finding 2 - Perception of pain (moderate confidence). Some women found this procedure extremely painful. In certain situations, the procedure was performed without anaesthetic and was described as being worse than the pain associated with childbirth. For others, particularly those with previous experience of episiotomy, the pain was tolerable

Synthesis finding 3 - Lack of respect (low confidence). In a number of instances, women were not given any choice about having an episiotomy. Their views and concerns were disregarded by health professionals, they were not asked for consent and, in some cases, were not given any anaesthesia to ease the pain

Synthesis finding 4 - [Episiotomy facilitates] an easier birth (low confidence). Amongst some women there was a belief that the use of episiotomy helped to make birth easier by reducing the length of labour and the level of pain

Synthesis finding 5 - Pre-procedure anxiety (low confidence). Some women were worried about the implications of having an episiotomy and felt anxious about potential effects on their body image or their bodily functions

Synthesis finding 6 - Post-procedure discomfort (moderate confidence). Some women experienced both short- and long-term discomfort following an episiotomy. In the short term, this involved difficulty sitting down, using the toilet or having sex and, in the longer term, women experienced general perineal pain up to 18 months after surgery

In a qualitative systematic review exploring women’s and providers’ views and experiences of intrapartum care, women felt they were poorly informed about the reasons for performing an episiotomy and were rarely asked for their permission (high confidence in the evidence). Review findings suggest that women preferred to minimise the level of pain experienced from cutting and stitching, as well as the levels of discomfort experienced following episiotomy (high confidence in the evidence). In addition, they may be ill-prepared for the pain associated with the procedure or the potential short- and long-term consequences (perineal discomfort, difficulty performing normal day-to-day activities, aesthetic deformities, effect on sex life) (low confidence in the evidence). In some instances, women felt that their concerns were ignored or dismissed by staff, whom they perceived to be rude and insensitive (low confidence in the evidence). The review findings also suggest that, in certain countries (e.g. Brazil), women might hold the belief that an episiotomy facilitates a smoother birth (shorter labour, less pain) (low confidence in the evidence). This may be based on an established cultural acceptance of the procedure, largely generated by healthcare providers (low confidence in the evidence)