The Effect of Mindfulness-Based Sexual Counseling on Body Appreciation, Sexual Distress, and Sexual Self-Confidence in Postpartum Women With Episiotomy

An episiotomy is a surgical incision made in the perineal muscles during labor to widen the vaginal opening, facilitate the safe and rapid delivery of the fetal head, shorten the second stage, reduce the risk of lacerations, and prevent anal sphincter damage (Carroli \& Mignini, 2009; Shmueli et al., 2017; Goh, Goh, \& Ellepola, 2018; Deyaso et al., 2022). This intervention, normally recommended only for medical indications, has become routine in many countries over time. This has led international health authorities such as the World Health Organization (WHO), the American College of Obstetricians and Gynecologists (ACOG), and NICE to issue clear warnings against unnecessary episiotomy (WHO, 2018; ACOG, 2006; NICE, 2023; Ghulmiyyah et al., 2022). According to the WHO's 2018 guidelines, episiotomy rates vary widely between countries. In Southeast Asia, this rate reaches 63%, while in Europe the average is 20-25%. In Turkey, the overall rate is reported as 52%, 93.3% in primiparous women, and 30.2% in multiparous women. Similarly high rates are reported in developing countries such as India (63.4%), Oman (66%), Cambodia (94.5%), and Taiwan (100%) (Djusad et al., 2024). Episiotomy can affect women's health not only during labor but also in the postpartum period. Research shows that this intervention is associated with complications such as postpartum perineal pain, dyspareunia, decreased sexual desire, and orgasmic disorders (Dedavid da Rocha \& Zamberlan, 2018; Khajehei et al., 2015; Buhling et al., 2018). Furthermore, episiotomy can cause sexual dysfunction, distorted body image, decreased sexual self-confidence, and lowered self-esteem (Khajehei et al., 2015; Buhling et al., 2018; Ghulmiyyah et al., 2022). Female sexual dysfunction is a condition characterized by lack of sexual desire, difficulty with arousal, orgasmic problems, and pain, which negatively affects an individual's quality of sexual life and psychological well-being. Its prevalence in the first 2-3 months after birth varies between 41-83% (De Souza et al., 2015). These disorders threaten psychological health by causing negative changes in body image and self-esteem (Ören \& Yaşar, 2023; Naisri, 2015).

Mindfulness is a mind-body practice that allows individuals to focus on the present moment and observe thoughts, emotions, and bodily sensations without judgment (Durna et al., 2019). Regular practice increases levels of happiness, psychological flexibility, compassion, and self-compassion, and reduces levels of depression, anxiety, and stress (İnci \& Ergen, 2019; Cengizhan \& Uçar, 2023). The literature reports that mindfulness-based interventions have positive effects on sexual dysfunction, body image, and self-esteem. However, studies examining the effects of mindfulness-based sexual counseling on sexual distress, body image, and sexual self-confidence in postpartum women who have undergone an episiotomy are extremely limited. In societies where sexuality is considered taboo, such as those in southeastern Turkey, such an intervention is anticipated to provide benefits at both the individual and societal levels. This study aims to evaluate the effects of mindfulness-based sexual counseling on body image, sexual distress, and sexual self-confidence in postpartum women experiencing episiotomy. The study is expected to fill a gap in the literature and offer a holistic, evidence-based, and culturally sensitive intervention model for postpartum sexual health.