Women ' s satisfaction with the childbirth experience : a descriptive research

Introduction: Satisfaction is a complex concept, which we often come across when evaluating the childbirth experience. The purpose of the research was to find out the childbirth experiences of women in Slovenia with regard to their level of satisfaction with the provided perinatal care. Methods: The Slovenian version of the Birth Satisfaction Scale – Revised was used in a non-experimental quantitative descriptive research (Cronbach α = 0.81). The data were collected through an online questionnaire in February 2017. Convenience sampling was used and 301 women, who gave birth in 2016 in Slovenia, participated. Data were analysed with descriptive statistics, the Mann-Whitney U test and Spearman's correlation coefficient. Results: The results of the study have shown that the number of births (U = 6802, p = 0.150), education (U = 7493, p = 0.317), age (U = 5142, p = 0.061) and presence of birth partner (U = 2841, p = 0.730) are not statistically significantly correlated with the assessment of childbirth satisfaction. A lower level of satisfaction was also found in cases of caesarean sections of primiparous, in comparison with multiparous, women (U = 430, p = 0.001). A statistically significant difference was established in the correlation between satisfaction and respondents' residential environment (U = 7029, p = 0.039), professional communication, and level of anxiousness of birthing mothers (rs = 0.397, p = 0,000). Discussion and conclusion: The results have shown that healthcare professionals who are present in childbirth are the key factor in contributing to a positive birth experience. The obtained results open up an opportunity for further research on the communication and attitude of health professionals towards birthing mothers.


Introduction
Satisfaction with childbirth is a complex issue, as has been demonstrated by several studies (Hodnett, 2002;De Orange, et al., 2011;Spaich, et. al., 2013;Hollins Martin, 2014;Hinic, 2015;Macpherson, et al., 2016), whose results are often diametrically opposed to each other.The complexity of satisfaction with childbirth is often affected by subjectivity in evaluating perinatal care.Satisfaction depends on various criteria including lifestyle, past experiences, expectations, values, personality and the society in which the individual lives (Drglin, 2007).Birth is an intimate life event, of which every woman wishes to have pleasant memories.Every woman has her own expectations about the course of childbirth and if her expectations and wishes are considered, then the satisfaction associated with childbirth increases (Hollins Martin, 2014).Hinic (2015) has found that the following parameters affect childbirth satisfaction: quality of healthcare, including the support and communication style of healthcare professionals, participation in the decision-making process, stress (due to unexpected complications and medical interventions), as well as the gap between expectations and real or realised course of childbirth.A particularly negative impact on childbirth is the result of feeling powerless, not having enough social support, unmet expectations, an emergency caesarean section and other operative vaginal procedures performed at childbirth, as well as past traumatic experiences with childbirth and sexual experiences (Hinic, 2015).Hollins Martin (2014) has demonstrated that the following factors affect women's satisfaction with childbirth: being comfortable, being heard, receiving the requested pain relief therapies, cooperating well with the staff during childbirth, a feeling of independence, being well prepared, receiving minimal childbirth injuries and selecting a birth method of her own choice.Levels of satisfaction also change with the time that has passed from childbirth as birthing mothers evaluate their satisfaction differently immediately after childbirth compared to one year afterwards (Mivšek, 2007).Nilsson and colleagues (2013) emphasise that a few years ago healthcare was more focused on complications and risks related to infants and birthing mothers, but was neglecting to consider the experiences felt by women.Childbirth is one of the most important events in a woman's life and its experience is severely individually conditioned.In order to secure a positive experience, healthcare professionals should focus more on the mental and social aspect without neglecting healthcare safety (Nilsson, et al., 2013).The psychological aspect of the childbirth experience is the focus of increasingly more research in obstetrics and midwifery.Feelings of the birthing mother and their views of the childbirth experience are essential for evaluating the success of the care.Research shows that a negative childbirth experience may have psychological consequences such as feeling stressed and powerless, suffering from postnatal depression and posttraumatic stress syndrome (Prosen, 2016, pp. 216, 263).All these factors may also have a negative effect on the mother-child bonding and the next pregnancy, or on the decision whether to have another pregnancy (Carquillat, et al., 2016).The research conducted by Waldenström (2006) found that every tenth woman sought professional help due to her fear of childbirth.Fear is mostly the result of stories related to childbirth that women have heard or read on the internet, as well as previous traumatic childbirth experiences.Before childbirth, women are most often worried for their and their baby's health, actions of healthcare professionals, future family life and the potential need for a caesarean section or complications that might occur during this procedure (Waldenström, 2006;Nilsson, et al., 2013).

Factors of satisfaction with childbirth
Satisfaction with childbirth is therefore the result of several factors.The findings of authors of various research works do not match, thus proving how individual satisfaction with childbirth is.The research conducted by Spaich and colleagues (2013) showed that women's satisfaction was most affected by the possibility to participate in deciding on the course of childbirth, getting support from a person that the birthing mother trusts and appropriate pain-relief therapy.Macpherson and colleagues (2016) have found that the most important indicator of satisfaction with childbirth is a professional approach and attitude of healthcare professionals toward the birthing mother.The other significant factor was their partner's participation in the childbirth process.According to the data by the National Institute of Public Health, the share of partners who are present at childbirth in Slovenia has been on the increase.In 2002, 60.7 % of partners were present at childbirth, but by 2015 this number had increased to 77.9 % (National Institute for Public Health, 2017).Drglin and Šimnovec (2009) have found that the support women receive from their birth partner strongly affects their level of satisfaction.Women can be accompanied by their partner, family member, a birth companion (a doula) and others.It has been demonstrated that continuing support decreases the need for analgesics, anaesthesia and procedures such as forceps or vacuum birth and caesarean section (Drglin & Šimnovec, 2009).
The research conducted by Macpherson and colleagues (2016) has shown that feeling pain or absence of analgesia only exert a negligible influence on childbirth satisfaction.On the other hand, some other authors (Hodnett, 2002;De Orange, et al., 2011) have found the contrary; that the level of satisfaction is significantly related to pain and pain relief methods.Unsatisfactory and a highly negative experience results in women being afraid, angry and in pain, which may affect them for several years after childbirth (Hodnett, 2002;De Orange, et al., 2011), including their decision of whether or not to conceive again (Prosen, 2016).
Other authors (Nilsson, et al., 2013;Prosen, 2016) have also found that one of the major factors of childbirth experience and the created image of it being positive or negative is the support given by healthcare professionals participating in perinatal care.This support most affects how women experience childbirth, and consequently the perceived satisfaction in primiparas (Nilsson, et al., 2013;Prosen, 2016).Macpherson and colleagues (2016) have also found that the most important factors that affect the satisfaction with childbirth are individual care and continuing care.Some authors (Sršen, 2007;Bryanton, et al., 2008;Prosen, 2016) have found that the type of birth is strongly related to the childbirth experience.Bryanton and colleagues (2008) even claim this to be the decisive factor related to childbirth satisfaction.
Dimensions of satisfaction with childbirth or childbirth experience are varied and complex, which demonstrates how unique the perception of satisfaction with the childbirth experience is and how various factors affect it.Rare publications on this issue such as the research conducted by Drglin and colleagues (2007) point to the fact that measurement of women's satisfaction with childbirth in Slovenia has thus far not been sufficiently researched.

Aims and objectives
The aim of the study was to find out what kind of childbirth experiences women in Slovenia have with regard to their satisfaction with the provided perinatal care.The goal of the study was to use a validated questionnaire to study or identify the factors related to women's satisfaction with childbirth.To reach the goals the following hypotheses were set: H1: Primiparas are less satisfied with the childbirth experience than multiparas.H2: Evaluations of satisfaction with the childbirth experience statistically significantly differ between demographic groups in terms of the level of education, age or place of residence (urban vs. rural).H3: Professional communication between healthcare professionals and the birthing mother not only decreases her level of anxiousness, but also increases her level of satisfaction.H4: Among birthing mothers who have had a caesarean section, primiparas are less satisfied than multiparas.H5: Women who had a birth partner present at childbirth are more satisfied with childbirth than those who had no one present.

Methods
A descriptive and exploratory non-experimental method of empirical research was used.

Description of the research instrument
An online questionnaire composed of three sets was used in the study.The first set that included 12 open and closed type questions referred to social and demographic data on childbirth.The second section included the Birth Satisfaction Scale -Revised (BSS-R) questionnaire, in Slovenian 'Lestvica zadovoljstva s porodom 2', that has been verified (Cronbach coefficient alfa was 0.79 in the original version) and used in some similar studies (Hollins Martin, 2014;Hollins Martin & Martin, 2015).The BSS-R questionnaire is composed of 10 questions, whereby 1 is the lowest and 5 is the highest level of agreement.It is directed at the quality of healthcare (4 questions), personal characteristics of women (2 questions) and stress that women experienced during childbirth (4 questions).The last set of the questionnaire was an open question where the respondents could express their opinions or talk about their childbirth experience.
The BSS-R questionnaire was translated from English by the first author and to verify the translation corresponded with the original, it was also translated by the second author (World Health Organization, 2017) and finally both authors adjusted the Slovene text to the Slovene cultural context.The questionnaire was designed using the 1KA survey tool.Before publishing the questionnaire, we conducted a pilot study, in which 10 women participated, which was conducted to evaluate the clarity and legibility of the questionnaire.According to these results, two corrections of the text were made.The Cronbach coefficient alpha was 0.81 for the entire sample of the study for the Slovene version of the BSS-R questionnaire, which points to a high level of reliability (Takavol & Dennick, 2011).The author of the questionnaire, who also supplied instructions for using it and the analysis of results, gave written permission to use the BSS-R questionnaire (Hollins Martin, 2014).

Description of the research sample
A convenience sample of women (n = 301) who gave birth in Slovene maternity hospitals, was used.The average age of respondents was 29 years (s = 4.660).The majority (n = 126, 41.9 %) had secondary school qualifications.More than one half of the respondents (n = 161, 53.5 %) lived in rural setting.Table 1 gives demographic information in great detail.

Description of the research procedure and data analysis
After the conducted pilot study the questionnaire was published in social media and some of the more popular Slovene web forums (www.medover.netand www.ringaraja.net) between 5 and 23 February 2017.
The respondents were presented with the purpose and aim of the study.They were also assured that participation was voluntary and anonymous.
Data were analysed using the SPSS version 22.0 (SPSS Inc., Chicago, IL, USA).In addition to the basic descriptive statistics (frequency, minimum, maximum, median value, average and standard deviation) the Mann-Whitney U-test and Spearman correlation coefficient were also used.The considered level of statistical significance was 0.05.

Results
Table 2 shows data on pregnancy and the course of childbirth as given by the respondents.In terms of the reasons for their choice of hospital, the respondents could select several answers.They most often chose a maternity hospital that was close to their home (n = 219, 72.8 %), multiparas also because they had already given birth there (n = 62, 20.6 %).A few women (n = 26, 8.6 %) opted for a certain maternity hospital based on other reasons: the most frequent ones were a better response in the case of complications, more qualified and professional staff, previous hospitalisation due to problems during pregnancy in that hospital, advice from a gynaecologist or previously known hospital staff and the fact that they themselves were born there.One respondent gave birth at home at her own wish.
Methods and techniques of childbirth pain relief varied among the respondents: the majority (n = 166, 55 %) selected pharmacological pain relief; others (n = 69, 22.8 %) that answered the questions chose nonpharmacological pain relief.Most (n = 226, 75.1 %) birthing mothers had a partner present at birth, while 0.7 % (n = 2) of women had a birth companion (doula) present.According to the respondents, childbirth took 4 hours on average (s = 6.472); with 54.8 % (n = 165) of respondents childbirth lasted less than 5 hours,  followed by 19.6 % (n = 59) of respondents with whom childbirth took 6 to10 hours.The most women (n = 132, 43.9 %) had a spontaneous, vaginal birth; 17.9 % (n = 54) of respondents had an emergency caesarean section; 12 % (n = 36) of women had a planned caesarean section; 12 % (n = 36) of women had an episiotomy performed during vaginal birth.
The results related to women's satisfaction with childbirth and various situations related to it are depicted in Table 3. Women agreed with the statement "I came through childbirth virtually unscathed" since most (n = 94, 31.2 %) agreed with it completely (mark 4), followed by 20.9 % (n = 63) of those that awarded mark 1.The statement "I thought my labour was excessively long" was evaluated with the lowest mark (1) by 46.2 % (n = 139).Women agreed with the statement that healthcare professionals encouraged them towards independent decision-making, whereby the most (n = 93, 30.9 %) awarded this statement with the highest mark (5).Women did not agree with the statement that they were not anxious during childbirth: the most (n = 86, 28.6 %) awarded mark 1, followed by 20.9 % (n = 63) of those who awarded mark 2. The biggest share of respondents (n = 135, 44.9 %) completely agreed (mark 5) that healthcare professionals provided strong mental and physical support.Also, women agreed that healthcare professionals communicated well with them during childbirth as most women (n = 148, 49.2 %) awarded this statement with mark 5. Women did not agree with the statement "I found giving birth a distressing experience": most women (n = 84, 27.9 %) awarded this statement mark 1, followed by those (n = 66, 21.9 %), who awarded this statement mark 2. They also did not agree with the statement "I felt out of control during my birth experience": 25.9 % (n = 78) of respondents did not agree with this at all.The statement "I was not distressed at all during labour" was awarded with the lowest mark (1): 45.2 % (n = 136) of respondents did not agree with this at all.Most women completely agreed with the last statement that the birth room was clean and hygienic as most women (n = 190, 63.1 %) awarded this statement mark 5.
In verifying the first hypothesis that primiparas are less satisfied with the childbirth experience than multiparas, we used the Mann-Whitney U-test to establish that there is no statistically significant difference between the two average values (U = 6802, p = 0.150), so the hypothesis cannot be confirmed.
The second hypothesis finding out whether the selected demographic data (level of education, age, place of residence urban/rural) are linked to the level of satisfaction was tested with the Mann-Whitney U-test.The results do not show a statistically significant correlation between the variables of education and the level of satisfaction (U = 7493, p = 0.317), so the hypothesis that women with lower qualifications were more satisfied during childbirth than those with higher qualifications, has been rejected.We also checked whether older women were any less satisfied with childbirth than younger ones.The results of the Whitney U-test do not show any statistically significant differences (U = 5142, p = 0.061), so the hypothesis on the correlation between age and the level of satisfaction has also been rejected.However, statistically significant difference was confirmed in regard to place of residence and childbirth satisfaction.Women that live in the rural areas are more satisfied with childbirth than those living in urban areas (U = 7029, p = 0.039).
The third hypothesis related to the fact that good communication of healthcare professionals with the birthing mother results in the birthing mother being less anxious, and was tested with a Spearman's rank correlation coefficient.We have found that there is a statistically significant correlation between the variables (r s = 0.397, p = 0.000), so the hypothesis has been confirmed.For the analysis of the fourth hypothesis which tested whether primiparas who had a caesarean section were less satisfied than multiparas, the Mann-Whitney U-test was used.The results showed statistically significant differences between the variables (U = 430, p = 0.001), so this hypothesis can be confirmed.The last hypothesis tested whether women who had a birth partner present at childbirth are more satisfied with childbirth than those who had no one present.The Mann-Whitney U-test showed no statistically significant differences (U = 2841, p = 0.730), so this hypothesis can be rejected.

Discussion
The subject of the study was factors that are related to the satisfaction of women with childbirth.Previous research has shown that women's satisfaction is particularly related to the quality of care including the support and communication of healthcare professionals, followed by participation in the decision-making process, level of stress (due to unexpected complications or medical interventions) and discrepancies between the expected and actual course of childbirth (Hinic, 2015).
The study verified how the selected demographic characteristics (age, education, place of residence) and the number and type of childbirth are linked to women's satisfaction with childbirth.Previous research has shown that the number of births is in some cases related to women's satisfaction with the birthing experience and that multiparas are more satisfied (Ferrer, et al., 2016).In our case satisfaction proved not to be the decisive factor as the results of the analysis did not show any connection between the number of births and the level of satisfaction with the childbirth experience.In the research conducted by Hollins Martin and Martin (2015) with the same measuring instrument (BSS-R) this connection was demonstrated.228 women who had given birth no longer than 10 days ago were included in the study.It was found that multiparas who had an experience with childbirth were more satisfied than primiparas (Hollins Martin & Martin, 2015).Nilsson and colleagues (2013) think that it is very important that the experience of the first childbirth is a positive one as it affects women's self-image, positive feelings towards the child, easier adjustment to the role of the mother and the future childbirth experience.
Satisfaction with childbirth may also be connected to certain personal characteristics of a woman such as age, qualifications and place of residence.In our research the level of satisfaction is only influenced by the place of residence as women coming from the rural areas expressed a higher level of satisfaction that those that come from the urban areas.It has not been demonstrated that the respondents' level of education and age affect their level of satisfaction.Moreover, studies conducted with the same measuring instrument conducted by Hollins Martin (2014), and Hollins Martin and Martin (2015) showed that age had no effect on the level of satisfaction with childbirth.
Our research has found a strong connection between the level of satisfaction with the childbirth experience and the attitude and communication of the healthcare professionals with the birthing woman.Some women were satisfied with the attitude of healthcare professionals, while others had negative experiences related to this.Some were so marked by the attitude of healthcare professionals and a negative childbirth experience to the extent that they were reconsidering whether or not to have another child.On the contrary, those with whom healthcare professionals established good communication, were more satisfied than others.
Communication is highly significant as women wish to know what is happening to them, which interventions will be performed and want to be thoroughly informed.Communication of healthcare professionals with the birthing woman is important also in making decisions related to pain relief therapy.Birthing mothers wish to be involved and it is important for them to receive support and advice from healthcare professionals (Nilsson, et al., 2013).In the research that included 559 Slovene birthing mothers, Mivšek (2007) found that more than one half of the respondents were not satisfied with how they were being informed about pain relief therapies.Professional communication should be established at the first contact with the birthing woman as this is the only way to successfully support her through the childbirth (Nilsson, et al., 2013).Women included in the Slovene study (Mivšek, 2007) thought that the communication of healthcare professionals was inefficient and lacking as only one half of the birthing mothers were informed about the procedures during childbirth.Many also received pain relief therapies unknowingly.
Satisfaction with childbirth in our research was also affected by the type of childbirth.We have demonstrated that primiparas who have had a caesarean section were generally less satisfied, especially those who wanted to give birth naturally.Caesarean section in multiparas is not as closely related to their levels of satisfaction since they had either had a caesarean section, which did not surprise them to a great extent, or they had given birth naturally and had experienced what most primiparas wish to experience.
A caesarean section may have a negative effect on the childbirth experience with primiparas and multiparas (Hinic, 2015).In the research conducted by Carquillat and colleagues (2016), which included 291 respondents, it was found that women who had an emergency caesarean section had many problems later.They felt as if they had failed and regretted that they had to give birth in that way.They also regretted that they had not experienced such first contact with their child that they wanted (Carquillat, et al., 2016).A similar study (Hollins Martin, 2014) where the same measuring instrument was used (BSS-R) compared the level of satisfaction between those that gave birth vaginally and those that gave birth with a caesarean section.It was found that there were statistically significant differences between these two groups in terms of satisfaction with childbirth only in evaluating the level of anxiousness (those who gave birth vaginally were less anxious).The study conducted on birthing mothers in Scotland (also with the BSS-R questionnaire) showed that women who had a spontaneous vaginal birth were a lot more satisfied with childbirth as those who gave birth with a caesarean section (Hollins Martin & Martin, 2015).
The literature (Drglin & Šimnovec, 2009;Holloway & Kurniawan, 2010;Yuenyong, et al., 2011) mentions many positive effects of perinatal support on the birthing woman, which however, was not confirmed by our study.Also, women without the support listed in the literature as being suitable perinatal support, were satisfied with the childbirth.In addition, some birthing mothers that had such support were actually a little less satisfied with the experience of childbirth, as in some cases, the person who was present at birth proved not be supportive.We did not predict such results since many studies show a great influence of perinatal support.Holloway and Kurniawan (2010) found in their research that nearly all respondents had the continuous support of the birth partner during childbirth.Mostly, it was their partners who were present, but some also had their parents, siblings or a grandmother present, while others were without a birth partner.Women with a birth partner used pharmacological pain relief less often and had a higher level of satisfaction with the childbirth experience (Holloway & Kurniawan, 2010).Also, Yuenyong and colleagues (2011) showed that women with additional support provided by an accompanying female person (mother, sister or female friend) reported on a shorter active labour stage, less anxiety and childbirth pain, and related higher levels of satisfaction with childbirth in general.Due to such deviations from most other studies, a more detailed study and analysis on accompanying person at childbirth would be needed.
The limitations of the present study are especially the size and random structure of the sample.Partially a limitation is also some questions, which are not precise enough, however, the questionnaire is still highly standardised and reliable.Despite these limitations, the study gives an important insight into women's satisfaction with childbirth and the childbirth experience in Slovenia.There are possibilities for further qualitative and quantitative research of this topic, such as testing and validation of various measuring instruments for measuring satisfaction.Moreover, additional research studies in certain areas of our study (e.g.communication, perinatal support, independent decision-making, detailed analysis of differences between the birthing mothers from the rural and urban settings) based on which relevant strategies related to the education of employees, including employee training, and the implementation of new practices that have proven inappropriate, would be needed.

Conclusion
Women's satisfaction with childbirth is difficult to measure due to its complex nature.Most scales for measuring satisfaction differ significantly.Some focus on the attitude of healthcare professionals towards the birthing woman, while others emphasise the perinatal support, the presence of pain, the environment or the first contact with the infant.To be able to measure the holistic satisfaction with childbirth, several of the mentioned parameters should be joined together.The BSS-R questionnaire used in our study emphasises the attitude of healthcare professionals towards the birthing woman, women's personalities and stress that women experienced during childbirth.The results have shown that women in Slovenia are relatively satisfied with the overall experience of childbirth in all the mentioned areas.They were most satisfied with their relationship with healthcare professionals, the possibility of making decisions and receiving information, which should also be addressed in clinical practice as satisfaction with childbirth significantly influences motherhood and consequently also the image of childbirth for other women.

Table 1 :
Respondents demographic data

Table 2 :
Data related to pregnancy and labour

Table 3 :
Women's satisfaction with childbirth