Grieving over the past and struggling forward – a qualitative study of women’s experiences of chronic pain one year after childbirth

Objective: To describe women’s experiences of chronic pain related to childbirth approximately one year after labour. Design: A qualitative design with face-to-face interviews analysed using inductive qualitative content analysis. Participants: Twenty women who reported chronic pain, with onset during pregnancy and/or following labour, approximately one year after childbirth. Findings: The analysis revealed an essential theme, “Grieving over the past and struggling forward ”, and three categories “Mourning the losses ”, “Struggling with the present ” and “Managing the future ”. Conclusions: This study provides new knowledge about women’s experiences of chronic pain one year after child-birth. The pain severely reduced women´s previous ability to perform physical and social activities, negatively impacted psychological well-being and altered their self-image. Most of the women adopted a positive attitude and hoped for improved health in the future, although constantly struggling with the pain and its consequences. Implications for practice: This knowledge is particularly important as chronic pain may not diminish with time in predisposed individuals who may need help and support from health professionals in their endeavour to manage their pain. Healthcare providers, i.e. midwives, gynaecologists and general practitioners need to understand women´s experiences of chronic pain from their own perspective to improve identiﬁcation and treatment of pain following childbirth, thus preventing women’s suﬀering and potential long-term health problems. Future studies are warranted to further explore and discuss women’s coping strategies, health seeking behaviour and experiences of health care.


Introduction
Although there is growing evidence of the scope and prevalence of chronic pain related to childbirth, there is still a gap in knowledge among healthcare providers, i.e., midwives and gynaecologists, of this serious health issue and its consequences.Studies have shown that healthcare workers in obstetrics tend to neglect childbirth-related morbidities beyond the immediate postpartum period, and there seems to be a lack of strategies for identifying and assessing women with persisting pain in the later phase of postpartum care.In depth knowledge of women's experience of chronic pain related to childbirth, as 2015 ) or on symptoms related to obstetric injuries, such as anal sphincter muscle injury ( Heron-Marx et al., 2007, Lindqvist et al., 2018 ;O'Reilly et al., 2009 ;Priddis et al., 2014 ).These studies have shown that pelvic girdle pain related to pregnancy has a significant negative effect on women's health and quality of life up to 20 years after the pregnancy ( Engeset et al, 2014 ;Gutke et al., 2018 ).Pain and other consequences, such as urinary and faecal incontinence, prolapses of vaginal walls and sexual dysfunction, after an obstetric injury during childbirth led to physical, psychological, and social limitations as well as shattered expectations of family life ( Lindqvist et al., 2018 ;Priddis et al., 2014 ).
According to IASP (International Association for the Study of Pain) pain is defined as, "An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage."( Raja et al., 2020 ).Pain is thus a multidimensional experience and includes sensory, affective, and cognitive components ( Porro, 2003 ).The experience of pain is always subjective and individual, and each person experiences pain in their own way despite similar external circumstances ( Coghill, 2010 ).The ability to feel acute pain is extremely important and a strong driving force in our survival, but chronic pain often leads to suffering and disability ( Goldberg & McGee, 2011 ).Regardless of the cause, pain is considered chronic if it persists for three months or more ( Treede et al., 2019 ).Chronic pain is a result of maladaptive structural and functional changes in the nervous system which have the capacity to be more complex in their pathophysiology and can become irreversible with time ( Fine, 2011 ).The negative consequences of chronic pain include depression, fear and anxiety, sleep disturbances and increased fatigue.Furthermore, pain can influence family relationships, lead to reduced work capacity and impaired finances as well as increased care needs ( Breivik et al., 2006 ;Fine, 2011 ).In addition, individuals with chronic pain are often at risk of developing further complications, including physical and psychological dysfunctions ( Fine, 2011 ).As chronic pain related to childbirth occurs relatively early in life, the physical, psychological, social, and financial consequences for the women, but also for society, may be extensive.Therefore, pain should always be identified and treated, to prevent women's suffering as well as to minimize the risk of the development of chronic pain and its consequences.
Hence, the aim of this study was to describe women's experiences of chronic pain related to childbirth approximately one year after labour.

Study design
The qualitative research method was chosen to explore how women experienced chronic pain and its impact on their lives because it adds a deeper understanding of the phenomenon studied from the person's own perspective ( Kvale et al., 2014 ).Thus, the qualitative method may elicit an understanding of experiences of living with chronic pain, as pain is quintessentially a subjective, dynamic, and multi-dimensional experience ( Osborn and Rodham, 2010 ).Data were collected through semi-structured, face-to-face interviews and analysed using inductive qualitative content analysis.

Recruitment
The present study is a follow-up of a prospective, multicentre, quantitative prevalence study, that investigated incidence and characteristics of chronic pain related to pregnancy or labour, and included 1171 women who had given birth eight months earlier ( Molin et al., 2020 ).The time point (8 months) for the study was chosen according to recommendations regarding duration of chronic pain for research purposes, defined as at least 6 months ( Dworkin et al., 2012 ).The participants were provided with written information about the qualitative study in relation to the initial quantitative part and they were informed that they may be contacted for future research if they agreed.Contact details were obtained via the informed consent form in the main study.The women were eligible for the present study if they: (1) gave written consent to be contacted concerning an interview, and (2) reported pain related to pregnancy or labour at the time of the study.All women, who met the inclusion criteria (n = 195), were divided into three groups depending on pain onset: Group 1, pain with onset during pregnancy (n = 106); Group 2, pain with onset in relation to labour (n = 53); and Group 3, both pain with onset during pregnancy and pain that had begun in relation to labour (n = 36).These criteria represent a strategy to obtain as much variety as possible in the material to deepen the understanding of chronic pain after childbirth.A random sample was selected in each group, and the women were contacted by telephone by the first author (BM).Women were provided with verbal information about the study and asked again if they wanted to participate.Participation in the study was truly voluntary and there was no monetary compensation for their time, still the interest in participation in the study was high.The selection procedure continued until a total of 20 women had given their second consent to be interviewed.This sample size was considered to be sufficient in order to obtain a rich material and make it possible to reach saturation ( Guest et al., 2006 ).By the seventeenth interview, the interviewer recognized patterns in the interviewees' experiences.The last three interviews confirmed the researcher's sense that saturation had been reached.After the 20 interviews had been conducted, three were not considered relevant to the study.Because of this, a further three women were selected according to the above selection procedure and a total of 20 interviews were included in the analysis.An overview of the selection procedure is presented in Fig. 1 .

Participants
Of the included 20 participants, five had pain with onset during the last pregnancy, eight women had pain that started during labour and seven had both pain that started during the pregnancy and in relation to labour.Table 1 displays demographic information and participant characteristics.

Data collection
A semi-structured interview guide was developed to ensure that the same range of topics would be discussed but which also allowed flexibility during the interview ( Patton, 2015 ).The guide was developed by the research team, consisting of pain researchers, midwives, a psychologist and an obstetrician, after a literature review.The interview guide covered women's experiences of chronic pain related to pregnancy and/or labour and how pain affected their daily lives.Prior to the interviews, a pilot interview (not included in the analysis) was conducted by the first author (BM) to validate the questions.However, no changes were required.The main questions in the interview guide were: "Could you tell me about your experience with pain?" and "Does the pain affect your life and, if so, how? ".Support questions were used throughout, as needed, to ensure the depth and detail of the woman's story ( Patton, 2015 ).Data were collected between June and November 2016.The women were interviewed in a single, face-to-face interview at a date and time convenient to them.The informants chose the location for the interview.Seventeen interviews took place at the woman's home, two at the woman's workplace and one at the researcher's workplace.Each woman was interviewed on one occasion and by the first author (BM).The interviews were audio recorded and lasted between 15 and 56 minutes (mean = 32, median = 28).

Data analysis
Data were analysed using inductive qualitative content analysis.Qualitative content analysis is a suitable method to systematically analyze the texts when exploring a variety of experiences as it highlights

Table 2
The steps of the analysis.
Step of the analysis What was done Step 1. Transcription The interviews were transcribed verbatim Step 2. Content review Each interview was read several times to obtain a sense of the whole picture.
Step 3. High level coding The meaning units relevant to experience of the chronic pain after childbirth were identified and marked with different colours Step 4. Detailed coding The meaning units were moved to an analysis template, condensed and coded.At this stage, efforts were made to stay close to the manifest text Step 5. Categorization/grouping The codes were grouped into categories that reflect the central message of the interviews Step 6. Analyses The categories were compared for similarities and differences and either divided into subcategories or merged into a new category.This process was carried out back and forth until a consensus was reached Step 7. Synthesis The theme was constructed based on the content of the identified categories in a more interpretative manner.
similarities and differences.In the inductive approach no prepared theory or model is utilized in the analytical process as it would be too restrictive given the exploratory nature of the study ( Krippendorff, 2019 ).
Based on the purpose of the study, the 20 included interviews were analysed using inductive qualitative content analysis, following the procedure described by Graneheim and Lundman (2004) .The analysis was performed in a stepwise manner, manually, and Microsoft Word and Excel were used to support data management.The first author (BM) transcribed the recorded data verbatim.The transcription was read several times to get an overall understanding of the material.The meaning units relevant to experience of the chronic pain after childbirth were identified and marked with different colours.Thereafter, the meaning units were moved to an analysis template, condensed, and coded.At this stage, efforts were made to stay close to the manifest text.Next, the codes were labelled together in categories that reflected the central messages of the interviews.The categories were compared for similarities and differences and either divided into subcategories or merged into a new category.This process was carried out back and forth by three of the authors (BM, SZ, and SG).Finally, the themes were constructed, based on the content of the identified categories, in a more interpretative manner.Table 2 illustrates the different steps in the analysis process.The first author (BM) was responsible for the analysis and two of the co-authors (SZ and SG) monitored the whole analysis process and categorization.The results were discussed among all the authors until a consensus of understanding of the data was reached.

Ethical approval
This study was carried out in line with the guidelines contained in the Helsinki Declaration ( World Medical Associations, 2013 ).Ethical approval was obtained from the Regional Ethics Review Board in Stockholm (Dnr 2015 / 236-31).The participants obtained both verbal and written information about the study.They were informed that participation was voluntary and were assured that data would be treated confidentially.Furthermore, they were informed that they could withdraw from the study at any time and contact the research team if they needed to talk to someone after the interview.The women gave their written and verbal consent before the interview, both to the interviews and the collection of additional demographic information and obstetric data from the patient record system, Obstetrix, such as delivery route and parity.

Results
The analysis of experiences of living with chronic pain related to childbirth revealed an essential theme, "Grieving over the past and struggling forward ", as the experiences of chronic pain led to a sense of multiple grief in women´s lives and as the women constantly struggled with the pain and its consequences.The women experienced that they were not able to perform the daily activities they could before preg-nancy.It also emerged that the women unconsciously adjusted their lives to make things work optimally.They were also mourning that they were restricted in their social relationships and they experienced that the relationship with their life partner had become more strained.Due to the pain and lack of energy as well as because they had become more dependent on their partners, it was challenging for them to control their emotions and their patience was decreased.In addition, the women experienced a variety of negative feelings and mourned that they had changed as persons to the extent that some of them could not recognize themselves.Further, they were disappointed and felt guilty about having pain but also because they did not live up to the role model of a mother.Older siblings were also sometimes affected, receiving less attention than before.Finally, both hope and despair emerged about the future, including thoughts that life would return to more like it was before childbirth but also a gloomier view of the future.When future children were discussed, the women were hesitant.They felt anxiety regarding whether they would be able to withstand further strain, and some of them gave up their dreams of having a larger family.The essential theme encompasses all the categories that emerged in the interview data: 1. "Mourning the losses ", 2. "Struggling with the present " and 3. "Managing the future ".The main categories and subcategories are presented in Fig. 2 .

Mourning the losses
This category reveals that regardless of whether the intensity of the chronic pain related to childbirth was described as extreme or mild, the pain caused an extensive impact on women´s lives in terms of daily activities, relationships and experiences of themselves.

Limited daily activities
The women experienced that pain could be caused or aggravated by various activities, such as certain movements, sitting, walking, exercising, lifting, carrying, doing housework or caring for the baby.The physical impact of pain severely limited the women´s ability to perform daily activities that were simple before the pregnancy: I can't vacuum, I can't empty the dishwasher because it hurts.I can't sit and watch a movie on the couch without getting up and moving.(Primipara, 25-year, no. 6) Furthermore, the women described that the pain caused sleep problems, fatigue, lack of energy and increased need for rest.The pain and the exhaustion limited women's activities to the degree that they could not live a normal life:

Affected relationships
The experience of chronic pain severely limited maintaining social relationships.The women refrained from socializing with others because the pain was unpredictable, and they felt they could not control it.The physical disability restricted mobility and rendered the women unable to participate in leisure activities, such as physical exercise or having dinner with family or friends.It was stressful to be among other people, as the women quickly became exhausted due to many sensory impressions.
I have not hung out much with friends because I cannot stand more than two or three hours, then I am exhausted.(Multipara, 39-year, no.8) Another reason why women refrained from participating in social events was that they did not want to ruin the joy and pleasure of others.Some women also experienced being met with distrust and scepticism.These experiences led to the women isolating themselves at home and restricting their social circle.
And I also look so fresh then, alert and everything like that.No one can believe that I am in so much pain.So, I think it's hard even for my family, they do not understand.(Primipara,no. 7) The chronic postpartum pain also affected women's relation with their life partner.The women often felt more dependent on their partners than before the pregnancy.In addition, due to difficulties in controlling their emotions because of the pain, the women often ended up in conflict with their life partners.They could also experience that their partner did not understand them or their suffering, and some women felt that they could not talk to their partner about the pain because they thought it was embarrassing.
The pain really destroys a lot between me and my partner, it hurts us very much.He has received a lot of shit to put it bluntly -sorry, but actuallybecause I am in pain and feeling so bad.And that he, he is a guy, he has not gone through everything, so he cannot understand in the way that I want him to.He can understand what he sees and hears, but he cannot understand how I feel, so that -it destroys.(Primipara, 28-year, no. 1)

Altered self-image
In addition, pain and its consequences could cause cognitive impairment, such as decreased memory function and concentration, which had a negative impact on women's daily life and lowered their self-esteem.Furthermore, the experience of chronic pain often led to mental distress as the women experienced a variety of negative feelings, such as lack of joy, lot of sadness or negative thinking.Other feelings also reported were anger, irritation and impatience.
So the family has noticed it the most, someone has commented -"where is happy Linda, why are you so angry"?Well, try having pain all the time, and you will see how it is.(Multipara, 39-year, no.8) One woman described herself as a strong, healthy and positive individual before pregnancy, and negative and bitter after childbirth: I've always been positive, always happy, never really seen anything as negative.It's always possible to find something positive in negative things.Life has not been a bed of roses and therefore I have chosen to focus on the positive instead of the negative.But now I have become a very bitter person.(Primipara, 28-year, no 1) These experiences could lead to an altered self-image.The women could not recognise themselves as the persons they used to be and found it difficult to reconcile themselves: I don't like who I have become.(Multipara, 39-year, no.8)

Struggling with the present
This category describes how living with pain and its consequences made the women's' daily life a constant struggle.They struggled with feelings of failure and disappointment, and had to make many adjustments as well as reprioritise.At the same time, they experienced pain's negative impact on their role as mother.

Feeling like a failure
Many women felt frustrated and disappointed that they were still in pain, that the pain affected their lives to such a great extent and that they could not carry out their usual roles and daily routines.Another source of these feelings was the experience of being dependent on others.Furthermore, the women also struggled with feelings of injustice and jealousy about women who were able to give birth without suffering any negative consequences.
You feel that it is a bit of a failure that the body does not hold up as you think it should be able to do, it is clear that I should be able to give birth to two children without my body being completely destroyed afterwards.(Primipara,no. 20) The women accused themselves of not being able to give birth to a child without negative consequences or blamed themselves for not being able to prevent the chronic pain.
It feels like I obviously did something wrong because -even though everything went so well -I have so much pain.(Primipara,no. 12) Disappointment, inadequacy and guilt were also recurring features of women's stories regarding motherhood.The pain and its consequences, such as limited mobility or fatigue could result in the women not being able to meet their child's needs, like participating in activities including baby swimming or playing with the child.In addition, many women had difficulty carrying or lifting the child due to pain and physical disability.The safety of the baby was another concern, as the women worried about dropping their children because of the pain.A bad conscience and feelings of guilt also concerned older siblings.
I very often feel that I neglect my child because I cannot be with him.This is really awful, and it makes me really sad.I have a very bad conscience.(Primipara,no 6) Adjusting life To avoid the pain or its aggravation, the women had made many adjustments and compromises in their lives.They had learned what activities they should avoid or how to perform them in a different way.This could mean that they refrained from exercising, from driving a car, lifting the child, having dinner sitting on the sofa instead of at the dining table or that they cycled standing.These adjustments were often made unconsciously: I do not notice how I restrict myself in what I do and not do, because I have learned, that, no, this activity will cause pain, so I avoid it.(Primipara,no. 19) When the women experienced pain in or around the vagina they could choose to avoid undergo a gynaecological examination or insert an intrauterine contraceptive.The fear of anal pain during defecation led to one woman avoiding eating: I have pain in my anus, and it hurts when I defecate.If I defecate once it works, but if I defecate more than once then it hurts really, really bad.So, I do not eat, because it hurts so much.(Primipara, 28-year, no 1) The pain or fear of pain during intercourse was a major area of concern for many women.The women dealt with their anxieties either by not resuming intercourse after childbirth or, after a painful attempt to perform it, by avoiding or minimizing sexual intimacy.In some cases, even though they knew that intercourse would cause pain, the women still sought sexual intimacy, struggling between it and the price they had to pay.I want to, but I know it will hurt so I ask myself how much I want it?Is it worth to have pain a few days afterwards or will it be no sex, which should I choose?It is very frustrating.(Multipara,no. 8)

Enduring the pain
When some pain provoking activities, such as caring for the baby, walking or sitting could not be avoided, the women performed these activities anyway because they felt that they had no choice but to endure the pain: Well, I just think that there is not much solution to this, and I just have to endure the pain.(Multipara,no. 2) In addition, the women experienced that they often had to prioritize and could not focus on themselves.They felt that they did not have the time, money, or energy to manage the pain in the way they would like to, for instance by exercising or through physiotherapy treatment.There was no doubt that the women endured the pain because they were always prioritizing their child over themselves: You end up with a lot when you have a child, you do it, you stand it because you put them in first place, and they always come first.(Primipara, 35-year, no.5)

Managing the future
This category identified women's hopes and worries about the future, which included thoughts about having another baby.

Hovering between hope and despair
Despite the extensive impact of pain on their lives, most women adopted a positive attitude and hoped for improved health in the future.They were convinced that the pain would disappear over time or that the symptoms would at least subside.And if they still experienced the pain, the women hoped that it would decrease to the degree that it would be easier to control and not interfere with their lives.
I still look quite positively at the future.I think I will recover to the extent that I will be able to do what I want.(Primipara,no.3)Women whose symptoms had improved over time expressed more hope than those whose pain had worsened or who had equally severe symptoms.
The pain has gotten so much better over the past three, four months so I think I will be so much better with time, that I will not be disturbed by it.(Primipara,no.3)Almost all of the interviewed women did not work at the time of the interview as they were on maternity leave.However, some women expressed a strong concern that the pain would be enduring and that it would continue to limit their lives.They were also worried that they would not be able to work or that work would aggravate the pain.
Yes, I'm worried if it's ever going to be okay or if I'll be able to go back to work.(Multipara,no.11)

Ambivalence about having another baby
When talking about the future, the women often expressed a fear of becoming pregnant and giving birth to a child again because they were worried that the pain would be aggravated during pregnancy or after labour.Some of the women had decided to give up their dreams of having a larger family and some were hesitant.If they were considering having another child, they wanted to postpone the pregnancy.
My husband and I have talked about having another child, and our relationship cannot go through such a phase again, at least not for a while.So, it feels like it limits us in our thinking about whether we should have another child.(Primipara,no.3)

Discussion
Our study aimed to describe women's experiences of living with chronic pain related to childbirth approximately one year after labour.The findings of this study and its essential theme, "Grieving over the past and struggling forward ", embrace a sense of multiple losses in women´s lives and their constant struggle with the pain and its consequences.The chronic pain had a negative impact on all aspects of women's lives including their roles as partners and mothers.The women constantly struggled with the pain but, despite that, could also have hopes for improved health in the future.
The chronic pain and its extensive consequences, including physical ability, fatigue, sleep deprivation and cognitive impairment, severely reduced women´s ability to perform their physical and social activities, and prevented them from living as previously.The women expressed grief over the changes and found them challenging.The results confirm the findings of our previous study demonstrating that chronic pain eight months after childbirth interfered considerably with women's daily activities, indicating that pain had a negative impact on the women's daily lives ( Molin et al., 2020 ).The results are also consistent with research exploring persistent, pregnancy-related, pelvic girdle pain, with women reporting that living with the pain disturbed most aspects of their lives and led to a reduced quality of life ( Engeset et al., 2014 ;Gutke et al., 2011 ;Gutke et al., 2018 ;Wuytack et al., 2015 ).
Through the women's descriptions of their experiences in the present study, there was a recurring depiction of the pain's impact on their psychological well-being as it led to a variety of negative emotions.The women described feelings such as, shame, frustration, and disappointment caused by their condition and inability to fulfil the expectations and roles as a wife/partner or mother.Several women also expressed worry and anxiety about returning to work, or further childbirths, to the extent that some had decided to give up their dreams of having more children.Furthermore, the women expressed that they did not recognise themselves anymore and they did not like the person they had become.Studies have shown that individuals with chronic pain may experience multiple negative emotions, such as fear, shame, and guilt and that they often blame themselves for their pain ( Barnes et al., 2018 ).They are often at risk of developing mood disorders including depression and anxiety disorders, as well as suicidal ideation ( Fine, 2011 ;Breivik et al., 2006 ;Bjelland et al., 2013 ;Gutke et al., 2011 ).It has also been shown that insufficient satisfaction and stress not only can have negative impact on women's psychological well-being, it also can have a negative effect on infant attachment ( Atkinson, 2000 ;Åhlund et al., 2019 ).As we discussed in our previous study, because chronic pain related to childbirth occurs early in the women's´lives, the physical, psychological, social, and financial consequences may be extensive.Therefore, we suggest a more active approach to the identification and treatment of pain following childbirth to prevent women's suffering, potential long-term health problems and increased need of health care.
Natural recovery can often occur during the first year after labour ( Lavand'homme, 2016 ;Östgaard et al., 1996 ;Miller et al., 2015 ), but a relatively high prevalence of women report chronic pain many years after childbirth ( Molin et al., 2020 ;Norén et al., 2002 ;Weibel et al., 2016 ;Hannah, 2004 ).In the present study, although several of the women were worried about the future, most of them expressed hopes of improved health.This can be explained by the life adjustment model for the understanding of suffering from chronic pain presented by Gullacksen & Lidbeck (2004) .This model describes the experience of chronic pain as a process consisting of three stages.The first stage is characterized by increasing pain, and disability as well as physical and mental exhaustion.Self-image is perceived as threatened, the pain and its consequences are defended or denied, and despite some worries for the future, there is still hope of improvement.In the second phase the pain has been acknowledged as no longer being temporary and emotional processing becomes apparent.The beginning of the second stage is characterized by sorrow and loss, but later in this stage, self-confidence is restored, and strategies are developed to manage the pain.In order for individuals to be able to move forward, an explanation of pain (a 'pain diagnosis') should be given.The third phase, with the constructive use of past experiences, and competence as well as increased control includes integration and routine adaptation to pain.This adaptation is needed to enable maintaining social contacts or managing work ( Gullacksen & Lindbeck, 2004 ).According to this theory, the women in our study were found to be in the first or at the beginning of the second stage.They considered the pain as a threat as well as experienced feelings of loss and sorrow, while still being optimistic about the future.It is interesting that in the study of Gutke et al., (2018) , who investigated chronic pelvic girdle pain 2-13 years after pregnancy, the participants seemed to span all stages of the life adjustment model.The authors described the women as Typology I and II.The women belonging to Typology I still struggled against the pain and its consequences, they could not accept their diminished quality of life and were still seeking an explanation.In Typology II, the respondents progressed from struggling against pain towards adaptation and acceptance.According to studies, acceptance plays an important role in coping with chronic pain as a process of giving up the struggle with it, remaining active and learning to live a meaningful life despite pain.Greater acceptance of chronic pain has been associated with lower pain intensity, less anxiety and avoidance, depression as well as phys-ical and psychosocial disability ( McCracken et al., 2004 ;Vowles et al., 2007 ).The results of Gutke et al., (2018) , as well as the results of the present study, suggest that the women may need help and individually adapted support from healthcare professionals in their endeavour to manage the pain and to move forward in the process of adjusting life to it."

Methodological considerations
According to existing knowledge, a qualitative inquiry provides access to areas that may not be otherwise accessible using quantitative methods ( Kvale et al., 2014 ) and may elicit an understanding of chronic pain ( Osborn and Rodham, 2010 ).In addition, face-to-face interviews enable the interviewer to gain a fuller understanding of the participants' experience.In qualitative research methods, reliability and validity are discussed in terms of trustworthiness which includes transferability, confirmability and credibility.Transferability refers to the extent to which the results can be transferred to other settings ( Elo, 2014 ).For the reader to decide whether transferability to other settings is possible, the method has been described in detail regarding recruitment, participants and analysis.Our study included a diverse sample as the women were recruited from a large cohort and with variation regarding the onset of pain, age, parity, and delivery method.However, recruitment did result in under-representation of single women, women with a lower educational level and foreign-born women.Transferability might also be affected by the fact that those who participate in research tend to be more motivated, well-educated and have more stable social support than those declining participation ( Markovic et al., 2017 ).In addition, the women who decided to volunteer in this study may have been those who experienced the most extensive impact of pain on their lives.This could be a threat to the transferability of the results to other settings or populations ( Graneheim et al., 2017 ;Krippendorff, 2019 ).To strive for confirmability, the process of analysis has been described in detail and citations provided.Credibility was ensured by continuous discussions in various constellations of research group members before data collection and during the analysis on different levels.In addition, the authors' diversity regarding professional and research perspectives contributed to the study's credibility.The first author´s background as a midwife but also a pain educator inspired her to do this study.To have preconceived knowledge of the subject and to be familiar with the context may be a disadvantage and it is important to use reflexivity to ensure objectivity and authenticity throughout the whole research process ( Dwyer & Buckle, 2009 ).The first author was aware of the risks and tried to act as professionally as possible to avoid influencing the informants with her own opinions.At the same time, the preconceived knowledge helped the first author to have a meaningful dialogue with the informants, for instance, asking follow-up questions during the interviews.In addition, to further ensure objectivity, the constant involvement of co-authors without this pre-understanding made it possible to explore and discuss the data in a balanced manner.

Conclusion
This study provides new knowledge about women's experiences of chronic pain approximately one year after childbirth.The pain severely reduced women´s previous ability to perform physical and social activities, negatively impacted psychological well-being and altered their self-image.Despite most of the women assuming a positive attitude and hoping for improved health in the future, they were constantly struggling with the pain and its consequences.This knowledge is particularly important as chronic pain may not diminish with time in predisposed individuals who may need help and support from health professionals in their endeavour to manage it.Healthcare providers need to understand women´s experiences of chronic pain from their own perspective to improve identification and treatment of pain following childbirth, thus preventing women's suffering and potential long-term health problems.

Fig. 1 .
Fig. 1.An overview of the selection procedure.
It's almost easier to say what I feel I can do than can't do.I have no lifeas I see it because I do nothing I used to do.(Primipara, no. 1)

Fig. 2 .
Fig. 2. Category system describing women's experiences of chronic pain after childbirth.
Notes.P: pain onset during pregnancy, L: pain onset in relation to labour, V: vaginal delivery, CS: caesarean section, Primi: primpara, Multi: multipara, ES: Elementary school, USC: Upper secondary school, CL: College, M/R: married or in relationship, S: single.