Between Expectancy and Experience: Testing a Model of Childbirth Satisfaction

Abstract

Childbirth is a pivotal event for many women, and evidence suggests that women possess strong expectations regarding this experience. In a longitudinal study of 330 Israeli first-time mothers, we distinguished between physical, emotional, and cognitive factors and used them to assess the underlying mechanism of satisfaction, based on theoretical frameworks of stress and control. Women completed questionnaires during pregnancy and two months postpartum. The negative association between a more medicalized birth and birth satisfaction was partially mediated by perceived control. In turn, specific emotions mediated the association between perceived control and satisfaction: Greater perceived control over the birth environment predicted more positive emotions, less fear, and better perceived care; while greater perceived control over the birth process predicted more positive emotions, less fear, and less guilt. Greater incongruence between the planned and actual birth experience predicted lower satisfaction, mediated by perceived care and feelings of guilt. This investigation unraveled the association between women’s lived birth experience and their birth satisfaction. The findings underscore the value of helping women achieve satisfying births by discussing their expectations with them, providing them with experiences that meet their needs, and supporting those with a gap between their expectations and experience. Respecting individual preferences while lowering blame may improve women’s health and well-being. Additional online materials for this article are available on PWQ’s website at http://journals.sagepub.com/doi/suppl/10.1177/0361684318779537.

Keywords

birth satisfaction place and mode of birth birth expectations perceptions of control emotional experience

The transition to motherhood is a major milestone in many women’s lives, and childbirth is a pivotal event in this process. Consequently, many women in modern societies prepare for birth. Women may have preferences regarding how, where, and with whom they would like to give birth; birth plans, which consolidate women’s preferences and help articulate them to medical staff, are gaining in popularity (Mei, Afshar, Gregory, Kilpatrick, & Esakoff, 2016; Pennell, Salo-Coombs, Herring, Spielman, & Fecho, 2011). At the same time, the actual place and mode of birth could be different from what was initially planned, due to a medical emergency or a change of mind (Burcher, 2012; Gibson, 2014). The experience of childbirth, and the degree to which it diverges from the imagined and idealized birth, may therefore affect women’s long-term psychosocial well-being (Larkin, Begley, & Devane, 2009). Although a healthy outcome is the primary goal, many women typically also desire a birth experience that is positive (e.g., empowering, happy, serene) and satisfying (e.g., pleasing, gratifying; Bryanton, Gagnon, Johnston, & Hatem, 2008). Negative birth experience (e.g., scary, disappointing, distressing) has been linked to postpartum depression (Michels, Kruske, & Thompson, 2013), post-traumatic stress symptoms (Garthus-Niegel, von Soest, Vollrath, & Eberhard-Gran, 2013; Gürber et al., 2012), and postponing the next pregnancy (Gottvall & Waldenström, 2002). Patient dissatisfaction is also linked to filing lawsuits (Stelfox, Gandhi, Orav, & Gustafson, 2005), which are especially prevalent in obstetrics and gynecology (Jena, Seabury, Lakdawalla, & Chandra, 2011). Because of the substantial effect the birth experience may have on women’s physical and emotional lives and on society, it is important to identify the psychological factors and mechanisms that contribute to birth satisfaction.

Satisfaction with childbirth is an appraisal of the labor and delivery process that is likely to be affected by multiple cognitive and emotional factors. Factors such as personal expectations and control, involvement in decision-making, support during birth, and fear have been shown to be important in the appraisal of birth as satisfying (Goodman, Mackey, & Tavakoli, 2004; Hodnett, 2002; Waldenström, Hildingsson, Rubertsson, & Rådestad, 2004). However, these factors have sometimes been included in the operationalization of birth satisfaction, muddying the distinction between predictors and satisfaction itself (Macpherson, Roqué-Sánchez, Legget, Fuertes, & Segarra, 2016; Sawyer et al., 2013). Studies of women in the perinatal period are usually conducted within the health sciences and do not commonly use established theoretical frameworks (Ayers & Olander, 2013). In the current study, we adapted theories from social and health psychology: the transactional model of stress and coping, which emphasizes the fit between expectations and experience, congruence between the individual and the environment, and the crucial role of personal control (Lazarus & Folkman, 1984; Lazarus & Launier, 1978). We also employed Lazarus’s (1991) recommendation to offer specific propositions regarding how diverse emotions are elicited and how each emotion influences subsequent reactions. Based on these theories, and prior research on birth experience, we differentiated global satisfaction from a distinct set of cognitive and emotional predictors that we posited to influence birth satisfaction. As elaborated below, in addition to characteristics of the actual birth, these predictors included incongruence between planned and actual birth, perceptions of control during birth, emotions during birth, and perceptions of intrapartum (during labor and delivery) care.

Objective characteristics of the birth, including mode of birth (e.g., vaginal delivery, caesarean delivery), degree of medical intervention in birth (e.g., epidural analgesia, induction), and the location of birth (e.g., home, birth center, hospital), have each been associated with birth experience and satisfaction. A variety of studies have found differences in satisfaction among women who had spontaneous vaginal delivery, planned cesarean delivery, emergency cesarean delivery, and instrumental vaginal delivery (vacuum or forceps). Women who have emergency deliveries are more likely to report a negative experience: Instrumental vaginal delivery results in a worse experience compared to spontaneous vaginal delivery, and an emergency cesarean delivery results in the worst birth experience (Carquillat, Boulvain, & Guittier, 2016; Karlström, Nystedt, & Hildingsson, 2011; Rowlands & Redshaw, 2012). Also, women who birth at free-standing birth centers report a more positive birth experience than women who give birth in a regular hospital maternity ward (Overgaard, Fenger-Grøn, & Sandall, 2012). In addition, there is evidence that women who birth at home are the most satisfied compared to other groups (Handelzalts, Zacks, & Levy, 2016; Hitzert et al., 2016). Although some studies suggest that medical analgesia reduces satisfaction (Kannan, Jamison, & Datta, 2001; Lindholm & Hildingsson, 2015), other research indicates that the link between analgesia and satisfaction is more complex (Bhatt, Pandya, Kolar, & Nirmalan, 2014; Hodnett, 2002).

Lower satisfaction with some modes of delivery may stem not only from the actual birth experience, but from the extent to which it differs from women’s expectations or birth preferences (Hildingsson, 2015; Mei et al., 2016). Women have been socialized into medicalized, intensive mothering and the stereotypic role of “good mothers.” They may have unrealistically high expectations of motherhood, and they often are blamed if their children are not doing well (Jackson & Mannix, 2004). Mothers who feel pressured to be “perfect” and mothers who are feeling guilty for not meeting their parenting expectations are more likely to suffer from adverse mental health states (Henderson, Harmon, & Newman, 2016). In the case of childbirth, Deluca and Lobel (2014) recently demonstrated that unmet expectations are one of the mechanisms that explain the association between mode of delivery and lower birth satisfaction. In addition, studies have found that women who changed their mind about not wanting to use analgesia reported lower satisfaction with their birth experiences compared to women who initially wanted pain relief and received it (Kannan et al., 2001; Soliday, Sayyam, & Tremblay, 2013). A mismatch between a desire for planned cesarean delivery or vaginal delivery and the actual mode of delivery has been shown to increase the risk of post-traumatic stress (Garthus-Niegel et al., 2014). To the best of our knowledge, the effect of incongruence between a wide range of birth plans, starting from home birth and ending with planned cesarean delivery, has not yet been studied.

Control during birth also emerges as a crucial factor in the birth experience (Green & Baston, 2003; Lobel & DeLuca, 2007; Meyer, 2013). There are well-established cognitive–emotional frameworks that suggest feelings of helplessness and loss of control lead to distress and to negative emotions (e.g., Folkman, 1984; Walker, 2001). Based on these theories, numerous studies have established the importance of a sense of control in the birth experience (Fair & Morrison, 2012; Goodman et al., 2004; Tinti, Schmidt, & Businaro, 2011). Deluca and Lobel (2014) found that low perceived control and the violation of expectation of control mediated the relation between actual delivery and lower birth satisfaction. Perceptions of control during birth are usually measured as a unidimensional construct that combines perceptions of control over the environmental circumstances and perceptions of control over the self. However, it is likely that these two constructs are separable (Benyamini, Gozlan, & Preis, 2018); this view is supported by the widely accepted perspective on stress that differentiates person and environment variables (Lazarus & Launier, 1978). There is evidence that women differentiate control over the self (e.g., pain, duration, behavior) from control over the birth environment (e.g., other people present at birth, place of birth, atmosphere). Some women express desires to control the environment, perceiving the birth process as uncontrollable (Namey & Lyerly, 2010). Others prefer to relinquish personal control over the birth environment to health care professionals, in return for greater control over the birth process (e.g., via medical interventions; Snowden, Martin, Jomeen, & Hollins Martin, 2011).

Women’s emotional experiences during birth have also been investigated as predictors of birth satisfaction and postpartum mood (Ayers, Bond, Bertullies, & Wijma, 2016; Harris & Ayers, 2012). Emotional experience during birth is usually measured in terms of global positive or global negative emotions (e.g., Ayers & Pickering, 2005; Waldenström et al., 2004), and very few studies have distinguished among emotions during birth (Harris & Ayers, 2012; Tinti et al., 2011). This paucity of distinct assessment overlooks the importance of differentiating emotions and how they operate separately, in general (Kashdan, Barrett, & McKnight, 2015; Lazarus, 1991), and in relation to perinatal distress in particular (Olde et al., 2005).

Perceptions of care during labor and delivery also appear to contribute to the overall appraisal of the birth, although some studies fail to differentiate between perceptions of care from appraisals of the birth experience itself (Britton, 2012; Sawyer et al., 2013). Recently, the World Health Organization emphasized the importance of intrapartum care and called for greater public attention to this matter. It published a statement titled The Prevention and Elimination of Disrespect and Abuse During Facility-Based Childbirth, which declares that humane and respectful treatment is a basic reproductive right for women (World Health Organization, 2014). The degree to which women feel respected, empathetically cared for, informed, and involved in decision-making is pivotal in the construction of a positive birth experience (Hodnett, 2002; Waldenström et al., 2004). On the other hand, feeling ignored, not supported, abandoned, put under pressure, or that the caregiver is only interested in the baby and not the mother, have been associated with a negative experience (Harris & Ayers, 2012). Feeling a lack of control during birth and having unmet birth expectations also result in more negative perceptions of intrapartum care (Britton, 2012).

The Present Study

We tested a model predicting birth satisfaction based on the theoretical frameworks articulated by Lazarus and colleagues that emphasize the importance of fit between expectations and experience (Lazarus & Folkman, 1984), differentiate personal and environmental control (Lazarus & Launier, 1978), and distinguish among separable emotions (Lazarus, 1991). We tested our model among a sample of women giving birth for the first time (primiparous women) in Israel. We chose to include only primiparous women to eliminate variability due to previous birth experiences. Israel has a pronatalist culture, although abortions are legal under certain conditions and most often subsidized (Granek & Nakash, 2017). Social policies in Israel ease the financial burden associated with childbirth. Women are entitled to universal health care, paid maternity leave, subsidization of childcare, and a monthly stipend equivalent to approximately US$50 per child. The social norm encourages women to have at least two children; Israel has a higher fertility rate (3.1) than other developed countries (1.6; Organization for Economic Co-operation and Development, 2017). Similar to other developed countries in which “perfect motherhood” is idealized (Henderson, Harmon, & Newman, 2016), Israeli women are also heavily invested in their births. Their desire for “perfect babies” is associated with global and local influences (Remennick, 2006). On the general level, these expectations are associated with pan-consumerism and the emerging middle-class ideology of full control of one’s environment. Within the Israeli context, women’s expectations are also associated with birth being a “national mission” (Morgenstern-Leissner, 2006), which is further exacerbated by the highly medicalized social and health policies and practices surrounding pregnancy and birth.

Israel has a medicalized birth culture (Benyamini, Molcho, Dan, Gozlan, & Preis, 2017). Hospital births account for 99% of births, the cesarean rate is ∼20%, and epidural analgesia is used in most births (Aviram, 2015). Home births are legal but discouraged (Israeli Ministry of Health, 2012), and they are the only type of birth not funded by the state (Morgenstern-Leissner, 2006). Midwives are the main birth attendants for most births (at home, birth center, or hospital) and obstetricians, though officially in charge, usually only assist complicated births.

Together with the medicalization process, there is also a strong demedicalization movement with activist groups advocating to increase access to women’s preferred place and mode of birth. In response, the Israeli Ministry of Health (2017) issued guidelines to enable non-medicalized births in hospital delivery rooms and several in-hospital birth centers opened and offered more comfortable surroundings for births without medical intervention. However, these centers are few, are not open 24/7, and are available only for women with low-risk pregnancies and on a stand-by basis. The places and some modes of birth in Israel are conflated: Cesarean delivery, instrumental vaginal delivery, and use of epidural are only performed in a standard hospital setting (not in birth centers or home births), and vaginal deliveries without use of epidural are performed in a standard hospital setting, birth center, or at home.

Based on prior research and theorizing about psychological factors that contribute to women’s subjective experience of birth, we developed and tested a model that examined the associations of birth satisfaction with the actual place and mode of birth and with incongruence between women’s anticipated and realized plans. We wished to better understand the underlying mechanisms linking these factors with birth satisfaction by taking into account perceived controllability, by distinguishing the complexity of emotions experienced while giving birth, and by recognizing the role of perceptions of intrapartum care.

As can be viewed in the schematic model (Figure 1), we hypothesized that (1) a more natural mode and place of birth would lead to greater birth satisfaction and incongruence with one’s birth plan and actual birth would lead to lower birth satisfaction, (2) perceptions of control would mediate the association between the predictors (place and mode of delivery and incongruence with birth plan) and birth satisfaction, and (3) emotions experienced while giving birth and perceptions of intrapartum care would mediate the association between perceptions of control and birth satisfaction.

Figure 1.
Schematic hypothesized model. Numbers represent hypotheses as numbered in the text.

Method

Participants

The current report focuses on 330 primiparous women who completed questionnaires at the first two time-points of a large prospective study. The larger study is still ongoing and follows both primiparous and multiparous women up to 6 months postpartum, assessing their adjustment to motherhood (more information about the larger study is available from the corresponding author). Eligibility criteria included a singleton pregnancy (carrying only one child), at least 24 weeks gestation, with vaginal delivery medically possible. Exclusion criteria were being in pain (visual analogue scale score >3) or having a medical emergency. Participants had to be fluent in Hebrew. If women or their infant suffered severe morbidity or mortality, the women were omitted from the study. At study entry (T1), participants’ mean age was 30.0 (±4.5) years and average gestational age was 31.7 (±5.2) weeks. Most (n = 320, 98.5%) of the participants were Jewish and married or cohabiting (n = 314, 95.2%). Detailed participant characteristics are presented in Table 1.

Table 1.
Sample Characteristics of Study Participants.

Socio-Demographics n (%) Obstetric History n (%)

Income Previous pregnancy loss

Below average 49 (15.1) No 261 (80.1)

Average 169 (51.8) Yes 65 (19.9)

Above average 108 (33.1) Fertility treatments

Education No 287 (88.0)

High school 32 (9.7) Yes 39 (12.0)

Professional school 37 (11.2) Pregnancy risk

Undergraduate 183 (55.5) Low risk 285 (86.6)

Graduate 78 (23.6) High risk 44 (13.4)

Country of origin Place and mode of birth

Israel 284 (86.1) Emergency cesarean delivery 38 (11.5)

Other 46 (13.9) Planned cesarean delivery 25 (7.6)

Degree of religiosity Instrumental delivery 59 (17.9)

Secular 225 (68.6) Vaginal delivery with epidural 139 (42.1)

Traditional 58 (17.7) Vaginal delivery without epidural 37 (11.2)

Religious 45 (13.7) Birth center 13 (3.9)

Home birth 19 (5.8)

Note. Income: self-selection of below average, average, and above average income categories; since health care in Israel is universal, this should not affect provision of care. Degrees of religiosity: secular (non-religious), traditional (minimally observant of religious practice), and religious (strictly observant of religious practice). Pregnancy risk: self-reported by women (“Is your current pregnancy defined as high risk? yes/no”).

Procedure and Recruitment

The study was approved by the Research Ethics Committees at an Israeli university, a large healthcare provider and a large metropolitan hospital, and was carried out according to the ethical standards of research with human beings. Recruitment for the study took place between February 2016 and January 2017 at three settings: (1) while waiting for a prenatal check-up at four different Women’s Health Centers of a large healthcare provider in the center of Israel (n = 208, 63.0% of participants); (2) at a large metropolitan hospital when coming for a prenatal class, hospital tour, or check-up (n = 39, 11.8% of participants); (3) purposeful sampling of women who planned more rare, alternative modes of delivery (e.g., home births or birth centers; n = 83, 25.2% of participants).

Recruitment was conducted by a study team that included seven trained social work graduate students (at Women’s Health Centers) and five midwives (at the hospital). Women who were recruited at the clinical settings received an explanation about the study from a member of the study team and were asked for their written consent and contact information. Thereafter, they completed the baseline questionnaire (T1). Women recruited in the purposeful, alternative fashion were reached through specific, natural/home birth Facebook groups, home midwives, or personal acquaintances. Invitations to participate in the study (along with a link to the study questionnaire) were posted by the study coordinator on designated Facebook groups. Midwives who belong to the Israeli Home Midwife Association were asked to forward the link to their patients. In addition, the link was sent to women planning non-medicalized births who were acquainted with members of the study team. These women were sent a link to the online version of the questionnaire which was identical to the paper version. Before filling out the questionnaire, these women were also asked to indicate their consent and provide their contact information.

Out of 1,059 primiparous and multiparous women who were approached at the clinical settings and were eligible to participate in the larger study, 764 agreed to participate and completed the baseline questionnaire (72.6% recruitment rate). The main reasons for not participating were disinterest, dislike of surveys, concerns about anonymity, and lack of time. Two women were later excluded because of perinatal infant mortality. Another 214 women were recruited by the alternative sampling methods (the third setting). Since the invitation to the questionnaire in the alternative sample was online, we were unable to determine their recruitment rate. Overall, across all sites, 976 women who completed the baseline questionnaire were included in the larger study. Of these women, 413 (42.3%) were primiparous and thus eligible for the current analyses.

The study team followed up when the women were approximately two months postpartum (M = 9.4 weeks, SD = 2.2; T2). We sent women who gave us an email address a unique link to the questionnaire, which was on Qualtrics software (Provo, UT, 2017), 2 months after their due date. A few women who did not use email were mailed a paper questionnaire with a return envelope (n = 8, 2.4% of participants). Return rates for the second questionnaire were high (n = 342, 82.8%). Women who did not have a score on the birth satisfaction measure were not included in analysis for the current study (n = 12), resulting in a final sample of 330 primiparous women.

Although attrition between baseline and T2 was relatively low (17.2%, n = 71), there were slight differences between women who completed and did not complete the second questionnaire. Women who did not answer T2 were less educated (2.63 ± 0.95) compared to women who did answer (2.90 ± 0.87), t(88.60) = 2.19, p = .03. There were no differences in their obstetric background. Women who did not complete the T2 questionnaire planned a less natural place and mode of birth (2.32 ± 0.64) compared to women who did complete this questionnaire (2.75 ± 1.06), t(145.00) = 4.44, p < .001.

Measures

Study measures were completed in Hebrew at both time points. The measures were administered in the following order: baseline (T1), socio-demographics and obstetric history, planned place, and mode of delivery; postpartum (T2), actual place and mode of delivery, global birth satisfaction, perceptions of intrapartum care, perceived self-control, and emotions during childbirth.

Socio-demographics and obstetric history

At baseline, we assessed commonly used socio-demographic (educational level, income level, marital status, religion, religiosity, and country of origin) and obstetric history variables (past pregnancy loss, fertility treatments to conceive current pregnancy, and pregnancy risk).

Planned and actual place and mode of delivery

At baseline, we asked women to identify how they planned to give birth (hereafter, planned birth). The birth options that were presented to them cover all birth possibilities in Israel and each has distinct features: planned cesarean delivery, vaginal delivery with epidural analgesia, vaginal delivery without epidural analgesia in a regular delivery room, delivery in a birth center, and home birth (mode of delivery in the last two options is also vaginal delivery without epidural analgesia). At T2, the women were asked about their actual place and mode of delivery (hereafter, actual birth) in a similar way to baseline, with the addition of unplanned birth possibilities: emergency cesarean delivery and instrumental vaginal delivery (vacuum extraction or forceps). A panel of three obstetricians and four midwives rated these options on a medical to natural continuum and had almost perfect agreement (perfect agreement on almost all ratings except for two experts who ranked two adjacent preferences in the opposite order than other experts). Therefore, the actual birth variable categories were ordinal, ranging from 1 (most medical) to 7 (most natural), based on the following coding: (1) emergency cesarean delivery, (2) planned cesarean delivery, (3) instrumental vaginal delivery, (4) vaginal delivery with epidural analgesia, (5) vaginal delivery without epidural analgesia in a regular delivery room, (6) vaginal delivery without epidural analgesia in a birth center, and (7) home birth.

Incongruence with birth plan

We assessed incongruence with the birth plan (hereafter, incongruence) by comparing self-reports of the planned birth and actual birth. The planned birth responses were coded using the same scale as actual birth (without the emergency options 1 and 3). We calculated an incongruence score by computing the absolute value of the difference between planned birth and actual birth (see Table 2 for clarification). The possible range was 0 (no incongruence) to 6 (greatest incongruence).

Table 2.
Incongruence Between Planned and Actual Birth-Score and Frequencies (N = 326).

Actual Birth: Emergency Cesarean Delivery Planned Cesarean Delivery Instrumental Birth Vaginal Delivery With Epidural Vaginal Delivery w/o Epidural Natural Birth Center Home Birth

Planned Birth

Planned cesarean delivery 1 (1) 0 (12) 1 (0) 2 (2) 3 (0) 4 (0) 5 (0)

Vaginal delivery with epidural 3 (20) 2 (8) 1 (37) 0 (83) 1 (10) 2 (2) 3 (0)

Vaginal delivery without epidural 4 (5) 3 (3) 2 (13) 1 (32) 0 (11) 1 (2) 2 (0)

Natural birth center 5 (10) 4 (2) 3 (7) 2 (16) 1 (13) 0 (9) 1 (0)

Home birth 6 (1) 5 (0) 4 (2) 3 (5) 2 (1) 1 (0) 0 (19)

Note. Bold numbers represent the incongruence score; numbers in parenthesis are n of women by planned and actual birth. Underlined numbers represent women who had a more medical birth than they had planned. No shading denotes no incongruence, light shading denotes one incongruence step, and darker shading represents incongruence of two or more steps.

Perceived self-control

We assessed perceptions of self-control at T2 using a postpartum adaptation of the self-control index of the Control During Childbirth Questionnaire (Benyamini et al., 2018). The Control During Childbirth Questionnaire was developed in a previous large Israeli study to assess women’s desires and expectation for control during childbirth. It was found to be valid and reliable (αs = 0.73–0.82). The current version measures women’s perceptions of self-control over different dimensions of childbirth. The measure has two subscales: (1) the perceived self-control over the birth environment subscale (hereafter, perceived control-environment) comprised 6 items such as control over “the medical staff’s actions” or “interventions during birth,” α = .85; and (2) the perceived self-control over the birth process subscale (hereafter, perceived control-process) comprised 4 items, such as control over “the childbirth pain” or “your behavior during birth,” α = .76. Participants were asked to rate how much control they felt they had on a scale ranging from 1 (none) to 5 (a lot). Scores for each subscale were calculated by averaging the item responses with higher scores indicating more control (possible range = 1–5).

Emotions during childbirth

To assess emotions during childbirth at T2, we measured the presence of 27 different emotions during childbirth. The scale we used was designed for the current study by combining two measures; each had previously demonstrated strong psychometric properties. We included 16 negative emotions women can have regarding their birth, based on the Hotspots Emotions and Cognitions Scale (Harris & Ayers, 2012), and 11 positive emotions women can have during childbirth, based on the positive aspects of the Delivery Expectancy/Experience Questionnaire (Wijma, Wijma, & Zar, 1998). The items were translated using forward-and-back translation by two experts fluent in both English and Hebrew. Participants were asked to rate to what extent they experienced each emotion during their recent birth on a scale ranging from 0 (not at all) to 3 (all the time). Exploratory factor analysis with an oblique rotation extracted five factors (see Supplement 1 at http://journals.sagepub.com/doi/suppl/10.1177/0361684318779537). The first four factors almost perfectly replicated the negative emotion subscales identified by Harris and Ayers (2012), and the last factor included all the positive emotions adapted from Wijma, Wijma, and Zar (1998). The five scales, fear, anger, dissociation, guilt, and positive emotions, all had good internal reliability (αs = 0.75–0.94). Average item scores were calculated for each subscale with higher scores indicating stronger emotions (possible range = 0–3).

Perceptions of intrapartum care (hereafter, perceptions of care)

At T2, we used a tool developed for the current study, based on the 3-item Patient Perception Score (Siassakos et al., 2009) and 10 additional items assessing interpersonal interactions with medical staff. The scale encompassed different dimensions of intrapartum care (Sawyer et al., 2013) and included perceptions of communication, respect, safety, involvement in decision-making, and emotional support. Prior to administering the scale, its face validity was assessed by midwives and Israeli women who had recently given birth. The scale included 13 statements regarding the birth attendants such as “Members of the team calmed me down” and “I felt abandoned by members of the team” (reverse scored). Participants were asked to rate their level of agreement with each statement ranging from 1 (completely disagree) to 5 (completely agree). The measure was unidimensional and internally reliable (α = .94). Scores were derived by calculating the average item response. Higher scores indicated a more positive perception (possible range = 1–5).

Global birth satisfaction (hereafter, birth satisfaction)

This was measured using the Childbirth Satisfaction Scale (Graham, Lobel, & DeLuca, 2002). The scale includes 8 items assessing subjective general satisfaction with the birth experience such as “I am satisfied with the way I delivered” and “I wish my labor and delivery had gone differently than they did” (reverse scored). The scale was translated for the current study using forward-and-back translation by two experts fluent in both English and Hebrew. Women were asked to rate their agreement with the statements ranging from 1 (completely disagree) to 5 (completely agree). The scale was unidimensional and internally reliable (α = .93). Scores were derived by calculating the average item response with higher scores indicating greater satisfaction (possible range = 1–5).

Statistical Analyses

To test the study hypotheses, we initially conducted univariate analyses among all the variables in the model using Pearson’s correlations. Next, we used Structural Equation Modeling (SEM) to assess the goodness of fit of the hypothesized model. Criteria were established a priori for modifying the model. Nonsignificant paths (p > .05) were removed one at a time until all paths in the model were significant and a well-fitting, parsimonious model was reached. Values indicating good fit were set as: comparative fit index (CFI) > 0.95, Tucker–Lewis index (TLI) > 0.95, standardized root mean square residual (SRMR) < 0.08, root mean square error of approximation (RMSEA) < 0.06 (Hu & Bentler, 1999). An analysis of missing data showed that less than 3.4% of the variables from the hypothesized model for all 330 cases were missing. We used Little’s Missing Completely at Random (MCAR) test to examine whether data were missing completely at random. Little’s test resulted in χ²(61) = 78.83, p = .06, indicating that there were no identifiable patterns in the missing data. Consequently, pairwise deletion was used for the univariate analyses, and Full Information Maximum Likelihood data imputation was conducted for the SEM. Analyses were performed using SPSS 24 (IBM Corp., 2016) and Mplus 7.4 (Muthén & Muthén, 2015).¹

Results

Most of the variables in the study had great inter-individual variability, indicating an array of birth experiences (Table 3). The most common actual birth was vaginal delivery with epidural (n = 139, 42.1%), followed by instrumental birth (n = 59, 17.9%), emergency cesarean delivery (n = 38, 11.5%), and vaginal delivery without epidural in a regular delivery room (n = 37, 11.2). Fewer women had a planned cesarean delivery (n = 25, 7.6%), home birth (n = 19, 5.8%), or birth in a natural delivery room (n = 13, 3.9%). As can be seen in Table 2, less than half of the women (n = 134, 41.1%) actualized their planned birth (i.e., scored 0 on incongruence). The rest of the women experienced incongruence (n = 192, 58.9%), which was mostly due to an actual birth that was more medical than planned (n = 176, 91.6%). For half of the women who experienced an incongruence (n = 95, 49.5%), it was an incongruence of one step (i.e., scored 1 on incongruence), such as planned birth by vaginal delivery with epidural and actual birth by instrumental vaginal delivery. For the other half of the women who experienced an incongruence (n = 97, 50.5%), the difference was two or more steps from what they had planned (i.e., scored 2–6 on incongruence), such as planned a vaginal delivery without epidural and experienced an emergency cesarean delivery.

Table 3.
Descriptive Information and Intercorrelations Between the Study Variables (N = 330).

Study Variables 1 2 3 4 5 6 7 8 9 10 M SD

1. Actual birth — 3.69 1.49

2. Incongruence with birth plan −.65 — 1.15 1.33

3. Perceived control—Environment .52 −.31 — 3.26 1.00

4. Perceived control—Process .26 −.19 .62 — 2.78 1.03

5. Positive emotions during birth .31 −.25 .51 .55 — 1.60 0.76

6. Fear during birth −.34 .28 −.42 −.45 −.58 — 0.79 0.66

7. Guilt during birth −.28 .36 −.26 −.23 −.40 .53 — 0.27 0.49

8. Anger during birth −.21 .29 −.30 −.20 −.41 .44 .51 — 0.38 0.58

9. Dissociation during birth .06 .08 −.08 −.23 −.26 .37 .42 .27 — 0.72 0.64

10. Perceptions of care .29 −.33 .49 .29 .45 −.40 −.44 −.58 −.15 — 3.97 0.87

11. Global birth satisfaction .55 −.51 .55 .44 .61 −.63 −.58 −.48 −.24 .55 3.80 1.08

Note. All coefficients between |0.15 and 0.18| were significant at p < .01; coefficients greater than |0.18| were significant at p < .001.

We conducted a series of analyses (t-tests, Pearson’s correlations, and one-way analyses of variance) to test for associations of women’s socio-demographic and obstetric background with birth satisfaction. The associations were all nonsignificant, and therefore, we did not include background variables in further analyses. As seen in Table 3, all variables were significantly correlated with birth satisfaction in the expected directions. It is also noteworthy that most of the emotion subscales were not highly correlated with one another, r = |.26–.58|, indicating their distinctiveness.

Next, we tested the complete hypothesized model in SEM. The full model did not have good fit, χ²(14) = 71.96, χ²/df = 5.14, p < .001, CFI = 0.96, TLI = 0.85, RMSEA = 0.11, SRMR = 0.06. Therefore, we eliminated paths that were not statistically significant in order to reach a parsimonious and theoretically meaningful, well-fitting model. The main difference between the hypothesized and the final model was that in the final model, we did not include anger and dissociation and there was a direct association of incongruence with emotions and perceptions of care (instead of mediation by perceptions of control).

As can be seen in Figure 2, the resulting modified model had good fit, χ²(12) = 31.33, χ²/df = 2.61, p = .002, CFI = 0.98, TLI = 0.95, RMSEA = 0.07, SRMR = 0.05, when considering the combination of fit indices together (Hu & Bentler, 1999). The model explained 64% of the variance in birth satisfaction. The perceived control subscales fully mediated the association of actual birth with the different emotional experiences and with perceptions of care. Emotional experiences and perceptions of care fully mediated the associations between the perceived control subscales and birth satisfaction. The perceived control subscales were also associated with different emotions: Greater perceived control-environment was associated with more positive emotions, less fear, and greater perceptions of care, while greater perceived control-process was associated with more positive emotions, less fear, and less guilt. Greater incongruence was associated with more guilt and lower perceptions of care which partially mediated the negative association between incongruence and birth satisfaction. The direct positive association of actual birth and negative association of incongruence with birth satisfaction remained significant even after including all the mediators. All the direct and indirect paths in the model were significant (p < .01). Because of the possible overlap of actual birth and incongruence (which is partly based on actual birth), we tested an alternate parsimonious model with planned birth instead of incongruence (Supplement 2 at http://journals.sagepub.com/doi/suppl/10.1177/0361684318779537). This model had good model fit, although not as good as the model depicted in Figure 2. Moreover, none of the direct or indirect paths leading from planned birth to birth satisfaction were significant. Because of the theoretical importance of incongruence between expectancy and experience, and the empirical support seen in the significant paths identified in the incongruence model, we chose to focus on this model and not on the model with the planned birth variable.

Figure 2.
Parsimonious structural equation model predicting global birth satisfaction. p < .01, *p < .001. All correlation coefficients (drawn in gray) were greater than r = 0.24 and significant at p < .001. Values are not displayed for visual clarity.

Discussion

The refined model confirmed our hypotheses regarding the associations of lower birth satisfaction with a more medicalized birth and greater incongruence with plan (Hypothesis 1), the mediating role of perceived control (Hypothesis 2), and the mediating role of distinct emotional experiences and perceptions of intrapartum care (Hypothesis 3). To the best of our knowledge, this study is the first to disentangle the conceptual complexity of the childbirth experience and to offer a fine-grained portrait of the associations among discrete cognitive and emotional constructs. The model we examined uncovers mechanisms that contribute to women’s satisfaction with childbirth. It specifies how the actual birth and the extent to which it differs from the woman’s plans independently predict birth satisfaction through intervening variables that include distinct perceptions of control, emotional experiences, and perceptions of the care received during birth.

The type of birth (i.e., mode and place of delivery) has often been the sole predictor examined in research on birth satisfaction. Our results highlight that greater satisfaction results not only from the type of birth that takes place but also from its congruence with women’s expectations and plans. In our study, close to half of the women did not give birth as they had planned and, in most cases, it was due to experiencing a birth more medical than anticipated. It is possible that in a medicalized birth system, women who wish to fulfill their plan to birth non-medically have to be very assertive and even “lucky”––lucky because (1) medical emergencies may arise without warning and necessitate intervention even in women who are thought to be at low-risk, and (2) not all birth attendants are supportive of non-medicalized births, and the few natural-birth centers that exist are only available on a stand-by-basis. Even after controlling for all proposed mediators, both place and mode of delivery and incongruence with plan still had direct associations with birth satisfaction. This suggests that place and mode of delivery and incongruence with plan each have unique predictive validity that goes beyond what is explained by their associations with perceived control, emotions, and perceptions of care. As hypothesized, the positive association between birth satisfaction and a less medicalized place and mode of delivery was mediated by perceived self-control. Contrary to our hypothesis, we did not find that the association of birth satisfaction with incongruence was mediated by perceived self-control. It is possible that this was due to the strong association between the actual birth and the perceived-control variables which explained most of the variance in perceived-control.

The two perceived self-control constructs were associated differently with specific emotions, underscoring the value of distinguishing types of control, and distinguishing among the emotions with which they are associated (Lazarus, 1991). The separation between perceptions of self-control over the birth environment and over the birth process corroborates foundational theories that differentiate the person and the environment (e.g., Lazarus & Launier, 1978). Perceived self-control over the birth environment corresponds to how one can adapt to the external situation (environment), whereas self-control over the birth process corresponds to the way one handles the physical and psychological self (person). Both types of self-control were associated inversely with fear and directly with positive emotions. Beyond this, however, their association with the remaining two mediators in the model diverged; greater perceived self-control over the birth environment was related to more positive perceptions of care while lack of perceived self-control over the birth process related to feeling more guilt.

Women in the developed world often have an “intensive motherhood” style in which motherhood is medicalized (Henderson, Harmon, & Newman, 2016). This is also true for Israeli women who strive to have “perfect” babies via extensive prenatal testing (Remennick, 2006). Women have strong expectations and place great value on the effects their actions have on their children. When expectations regarding motherhood are not met, this can result in blame, either from society or from the self (Jackson & Mannix, 2004). During pregnancy and postpartum, control—especially over the body—may be diminished. This can elicit feelings of guilt, which are likely to be a manifestation of self-blame, that is, self-blame and guilt for losing control over one’s body and self and for not being able to achieve one’s idealized expectations (Neiterman & Fox, 2017).

When we compared the model containing the women’s planned birth variable to the one containing the incongruence variable, the latter had more power, emphasizing the meaningful emotional ramifications of not having the birth one hoped for. Giving birth is a unique life experience, a pivotal event for many women, especially first-time mothers, who may have been thinking about, dreaming, planning the very birth experience they want to have (Miller & Shriver, 2012). At the same time, birth is highly medicalized and controlled by the medical establishment to which women must adhere as part of their role as “good mothers.” Consequently, women’s birth preferences, especially non-medical ones, are often not realized (Preis, Eisner, Chen, & Benyamini, in press). This problem is further exacerbated by the social expectation that women should give birth in certain ways (Granek & Nakash, 2017), and thus women may feel like they need to “perform.” This may explain why incongruence was the strongest contributor to guilt. Perhaps women who did not realize their plans felt that they let themselves and others down or that they could not achieve the “normal” act of birth (Malacrida & Boulton, 2014). Furthermore, they may also blame others for why the birth did not go as planned––hence the association with more negative perceptions of care (Burcher, Cheyney, Li, Hushmendy, & Kiley, 2016).

Both anger and dissociation were unrelated to perceived control and birth satisfaction in the multivariate model. These findings are in line with those of Tinti, Schmidt, and Businaro (2011), who found controllability during childbirth to be associated with some emotions reported after birth (i.e., fear or positive emotions) but not with others (i.e., anger). In addition, this lack of association could be due to their shared variance with other variables in the model (e.g., anger was strongly correlated with perceptions of care). As for dissociation, it may have a different connotation for different women: It may be an intrinsic part of a natural and positive birth experience (Dixon, Skinner, & Foureur, 2014) or part of a negative experience in a traumatic medical birth (Harris & Ayers, 2012).

Strengths and Limitations

One of the strengths of our study was that it was prospective and measured women’s expectations regarding the kind of birth they planned while they were pregnant. We could more objectively measure incongruence between planned and actual birth. At the same time, causality could not be conclusively determined by this study. However, the a priori model that we constructed and tested was theory driven and modified in a systematic, conceptually meaningful way. We measured birth experiences retrospectively, 2 months postpartum, which could have affected the validity of their assessment due to the participants’ current emotional state (whether positive or negative). Nonetheless, some experts recommend waiting a few weeks before measuring birth satisfaction because measuring right after birth can be skewed by halo effects (Hodnett, 2002).

Our model was complex and accounted for a multitude of psychological factors that contribute to birth satisfaction. However, we could not include all possible predictors of birth satisfaction (such as duration of labor, perceived pain, partner support, or contact with infant after birth), but these are also likely contributors. Our SEM also has limitations that should be recognized. We did not include a measurement model with latent variables (because of the great number of variables in the model) but rather used average responses of items as observed indicators, allowing error in the measurement of these variables. In addition, we methodically removed non-significant paths which runs the risk of overfitting the model to our particular sample. As a consequence, the model that was fit here may not fit another sample equally well. It will be important to test this model with other populations and cultures. Some of the measures we used were devised for the current study and need further demonstration of their psychometric properties. There is also a need to study how these physical, cognitive, and emotional processes may affect maternal adjustment over time and how they influence other outcomes, such as infant caretaking, family planning, and future birth expectations and plans.

Our sample also had several strengths: It was large, made up of first-time mothers, and was heterogeneous in terms of birth expectations. We had a relatively high response rate to the follow-up questionnaire. At the same time, there were some differences in attrition by education and women’s plan regarding mode and place of delivery. There is no way of knowing if these differences biased the results, but there were few differences overall and attrition was negligible, so it is unlikely that there was any substantial bias. Nevertheless, the sample was not representative of the general Israeli population and did not include women living in the periphery of Israel or women who are not fluent in Hebrew.

Practice Implications

Our study results indicate that a main predictor of birth satisfaction is the combination of women’s expectations and experience and, therefore, that birth satisfaction could be improved in several ways. Healthcare providers could offer educational programs, especially for first-time mothers, to help women formulate more realistic expectations regarding their upcoming birth and also introduce the importance of flexibility in case of a medically necessary or personally motivated change from the original birth plan. Birth attendants could improve women’s childbirth experience by trying to meet their birth expectations, giving them as much control as they desire, and addressing their emotional needs (e.g., making them feel cared for, providing them with information, involving them in decision-making, normalizing and reducing fear, and lowering self-blame). Moreover, de-medicalizing births when interventions are not needed will enable more congruence with the plans of women who desire non-medical births, improve their birth experiences, and enhance the health of many women and their infants (World Health Organization, 2018). Finally, women who have had negative emotional experiences may need to be counseled by a trained professional in order to prevent future psychological disturbance. Adjustment disorders (e.g., postpartum depression, postpartum distress) have been shown to be long-term consequences of negative birth experiences (Lobel & DeLuca, 2007). Successful interventions are reviewed elsewhere (Vesel & Nickasch, 2015).

Conclusions

Satisfaction with birth is important for mothers, families, and society as a whole. The implications of birth satisfaction in the short and long term are far-reaching and have been shown to affect a mother’s mental health, her relationship and interaction with her baby, future family plans, and the likelihood of litigation against medical staff involved in the birth (DeLuca & Lobel, 2014; Gottvall & Waldenström, 2002; Michels et al., 2013). The mechanisms that were hypothesized and assessed empirically confirm and underline the importance of studying the birth experience in an elaborate, detailed, and multivariate manner. This will help us better understand the important role of perceptions of control and discrete emotions in contributing to women’s satisfaction with birth, both when they experience the birth that they anticipate and hope for and when they do not. We hope that this study will enable birth professionals, psychosocial clinicians, and women and their partners to comprehend the importance of not relinquishing their desires for a healthy non-medicalized birth but remaining flexible and reducing blame if it is not achieved.

Supplemental Material

Supplemental Material, Supplement_1_1011770361684318779537 - Between Expectancy and Experience: Testing a Model of Childbirth Satisfaction

Supplemental Material, Supplement_1_1011770361684318779537 for Between Expectancy and Experience: Testing a Model of Childbirth Satisfaction by Heidi Preis, Marci Lobel, and Yael Benyamini in Psychology of Women Quarterly

Supplemental Material

Supplemental Material, Supplement_2_1011770361684318779537 - Between Expectancy and Experience: Testing a Model of Childbirth Satisfaction

Supplemental Material, Supplement_2_1011770361684318779537 for Between Expectancy and Experience: Testing a Model of Childbirth Satisfaction by Heidi Preis, Marci Lobel, and Yael Benyamini in Psychology of Women Quarterly

Supplemental Material

Supplemental Material, PWQ779537_Preis_TeachingSupplement - Between Expectancy and Experience: Testing a Model of Childbirth Satisfaction

Supplemental Material, PWQ779537_Preis_TeachingSupplement for Between Expectancy and Experience: Testing a Model of Childbirth Satisfaction by Heidi Preis, Marci Lobel, and Yael Benyamini in Psychology of Women Quarterly

Socio-Demographics	n (%)	Obstetric History	n (%)
Income		Previous pregnancy loss
Below average	49 (15.1)	No	261 (80.1)
Average	169 (51.8)	Yes	65 (19.9)
Above average	108 (33.1)	Fertility treatments
Education		No	287 (88.0)
High school	32 (9.7)	Yes	39 (12.0)
Professional school	37 (11.2)	Pregnancy risk
Undergraduate	183 (55.5)	Low risk	285 (86.6)
Graduate	78 (23.6)	High risk	44 (13.4)
Country of origin		Place and mode of birth
Israel	284 (86.1)	Emergency cesarean delivery	38 (11.5)
Other	46 (13.9)	Planned cesarean delivery	25 (7.6)
Degree of religiosity		Instrumental delivery	59 (17.9)
Secular	225 (68.6)	Vaginal delivery with epidural	139 (42.1)
Traditional	58 (17.7)	Vaginal delivery without epidural	37 (11.2)
Religious	45 (13.7)	Birth center	13 (3.9)
		Home birth	19 (5.8)

Actual Birth:	Emergency Cesarean Delivery	Planned Cesarean Delivery	Instrumental Birth	Vaginal Delivery With Epidural	Vaginal Delivery w/o Epidural	Natural Birth Center	Home Birth
Planned Birth
Planned cesarean delivery	1 (1)	0 (12)	1 (0)	2 (2)	3 (0)	4 (0)	5 (0)
Vaginal delivery with epidural	3 (20)	2 (8)	1 (37)	0 (83)	1 (10)	2 (2)	3 (0)
Vaginal delivery without epidural	4 (5)	3 (3)	2 (13)	1 (32)	0 (11)	1 (2)	2 (0)
Natural birth center	5 (10)	4 (2)	3 (7)	2 (16)	1 (13)	0 (9)	1 (0)
Home birth	6 (1)	5 (0)	4 (2)	3 (5)	2 (1)	1 (0)	0 (19)

Study Variables	1	2	3	4	5	6	7	8	9	10	M	SD
1. Actual birth	—										3.69	1.49
2. Incongruence with birth plan	−.65	—									1.15	1.33
3. Perceived control—Environment	.52	−.31	—								3.26	1.00
4. Perceived control—Process	.26	−.19	.62	—							2.78	1.03
5. Positive emotions during birth	.31	−.25	.51	.55	—						1.60	0.76
6. Fear during birth	−.34	.28	−.42	−.45	−.58	—					0.79	0.66
7. Guilt during birth	−.28	.36	−.26	−.23	−.40	.53	—				0.27	0.49
8. Anger during birth	−.21	.29	−.30	−.20	−.41	.44	.51	—			0.38	0.58
9. Dissociation during birth	.06	.08	−.08	−.23	−.26	.37	.42	.27	—		0.72	0.64
10. Perceptions of care	.29	−.33	.49	.29	.45	−.40	−.44	−.58	−.15	—	3.97	0.87
11. Global birth satisfaction	.55	−.51	.55	.44	.61	−.63	−.58	−.48	−.24	.55	3.80	1.08

Footnotes

Acknowledgments

We wish to thank all the students, midwives, and obstetricians who helped with this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for the study was provided by the Israel Science Foundation (grant No. 351/16). Work on this article was made possible by a Prof. Rahamimoff Travel grant for young scientists of the U.S.-Israel Binational Science Foundation. In addition, the first author received a fellowship from the Israel Pollak doctoral fellowship program for excellence, Tel Aviv University.

ORCID iD

Heidi Preis

Note

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