A total number of 21204 women with a singleton pregnancy gave birth between Jan 1 2016 to December 31, 2017. A missing value in the EMR on VAS occurred in 4429 women leaving 16775 as the final study population. In the study population, 69% (11493/16775) of the women were very satisfied with childbirth and chose the three highest VAS scores (8, 9 or 10). However, 953 (5.7%) women reported VAS 1-3. Among the 16775 women included in this study, the mean VAS score was 7.94 (SD 2.1). The mean maternal age was 29.7 years (range 14-49 years, SD 5.0). Forty percent (n = 6632) of the women were primiparas and 54 percent (n = 8722) were classified as normal weight (BMI 18-24.9 kg/m2). Table 1 presents a cross-tabulation of maternal characteristics in the study population according to dissatisfaction with childbirth.
Table 1. Maternal characteristics of the study population. In comparison between women with dissatisfaction with childbirth (VAS 1-3) and women not being dissatisfied (VAS 4-10). Chi-squared tests were used for categorical variables and t-tests for numerical variables.
|
Dissatisfaction with childbirth VAS 1-3
(n = 953)
|
Not being dissatisfied with childbirth
VAS 4-10
(n = 15822)
|
|
P-value
|
Maternal age (years)
Mean [SD]
<25
25-35
>35
Missing n
|
30.2 [5.0]
101 (10.6)
700 (73.5)
142 (14.9)
10
|
29.6 [5.0]
2237 (14.1)
11327 (71.6)
2098 (13.3)
160
|
|
0.001*
0.006*
|
Body Mass Index
<18.5
18.5-24.9
25-29.9
30-34.9
35-39.9
>40
Missing n
|
14 (1.5)
469 (49.2)
274 (28.8)
107 (11.2)
42 (4.4)
15 (1.6)
32
|
365 (2.4)
8253 (54.3)
4212 (27.7)
1669 (11.0)
542 (3.6)
185 (1.2)
596
|
|
0.079
|
Parity
Primiparas
Multiparas
Missing n
|
499 (52.4)
438 (46.0)
16
|
6133 (38.8)
9468 (60.0)
221
|
|
<0.001*
|
VAS: visual analog scale. Categorical data are presented as number and (%).*P-values <0.05 were considered as statistically significant.
No association was found between BMI and satisfaction with childbirth. Likewise, no difference in satisfaction with childbirth was shown when comparing normal weight women with the rest of the women in the study sample (p=0.052). Primiparas and women >35 years were more likely to report dissatisfaction.
The risk of dissatisfaction with childbirth in relation to obstetric interventions before birth are shown in table 2
Table 2. Obstetric interventions and risk of dissatisfaction with childbirth. Logistic regression analyses were used to estimate crude and adjusted odds ratios (ORs and aORs) with 95% confidence intervals (CI).
|
Total number of births N=16775
|
Dissatisfaction with childbirth VAS 1-3
|
|
|
Number n (%)
|
Crude OR (95% CI)
|
Adjusted OR (95% CI) a
|
Onset of labor
Spontaneous
Induction
Elective CS
|
|
13071
2655
1049
|
669 (5.1)
232 (8.7)
52 (5.0)
|
ref.
1.78 (1.52-2.07)
0.97 (0.72-1.29)
|
ref.
1.69 (1.44-1.98)
1.00 (0.74-1.34)
|
Epidural anesthesia
Yes
No
|
|
6074
10701
|
509 (8.4)
444 (4.1)
|
2.11 (1.85-2.41)
ref.
|
1.90 b (1.64-2.20)
ref.
|
Oxytocin augmentation
Yes
No
|
|
6455
10320
|
561 (8.7)
392 (3.8)
|
2.41 (2.11-2.75)
ref.
|
2.11 (1.83-2.44)
ref.
|
OR: odds ratio; CI: confidence interval; CS: cesarean section. aAdjusted for maternal age and parity. b Adjusted for maternal age, parity and mode of birth.
Induction of labor (aOR 1.69, 95% CI 1.44-1.98), epidural anesthesia (aOR 1.90, 95% CI 1.64-2.20) and oxytocin augmentation (aOR 2.11, 95% CI 1.83-2.44) were found to be risk factors for dissatisfaction with childbirth after adjusting for age and parity. When epidural anesthesia was further adjusted for mode of birth, the intervention was still a significant risk factor for dissatisfaction with childbirth (aOR 1.75, 95% CI 1.50-2.04).
The results from the analyses of mode of birth are presented in table 3.
Table 3. Mode of birth and risk of dissatisfaction with childbirth. Logistic regression analyses were used to estimate crude and adjusted odds ratios (ORs and aORs) with 95% confidence intervals (CI).
|
Total number of births
N = 16775
|
Dissatisfaction with childbirth VAS 1-3
|
|
|
Number n (%)
|
Crude OR (95% CI)
|
Adjusted OR (95% CI) a
|
Normal vaginal birth
|
13990
|
625 (4.5)
|
ref.
|
ref.
|
Instrumental vaginal delivery
|
852
|
119 (14.0)
|
3.47 (2.81-4.28)
|
2.89 (2.32-3.60)
|
Elective CS
|
1049
|
52 (5.0)
|
1.11 (0.83-1.49)
|
1.12 (0.83-1.50)
|
Emergency CS
|
884
|
157 (17.8)
|
4.62 (3.82-5.59)
|
3.98 (3.27-4.86)
|
OR: odds ratio; CI: confidence interval; CS: cesarean section. aAdjusted for maternal age and parity.
Emergency CS was the strongest predictor of reporting dissatisfaction with childbirth (aOR 3.98, 95% CI 3.27-4.86). Similarly, an instrumental vaginal delivery was a risk factor for dissatisfaction with childbirth (aOR 2.89, 95% CI 2.32-3.60), compared to a normal vaginal birth. No significant association was found between elective CS and dissatisfaction with childbirth (aOR 1.12, 95% CI 0.83-1.50), using normal vaginal birth as a reference. Obstetric complications after birth in relation to dissatisfaction with childbirth are presented in table 4.
Table 4. Obstetric complications and risk of dissatisfaction with childbirth. Logistic regression analyses were used to estimate crude and adjusted odds ratios (ORs and aORs) with 95% confidence intervals (CI).
|
Total number of births
N = 16775
|
Dissatisfaction with childbirth VAS 1-3
|
|
|
Number n (%)
|
Crude OR (95% CI)
|
Adjusted OR (95% CI) a
|
Obstetric anal sphincter injury
Yes
No
Missing n
|
390
16384
1
|
53 (13.6)
900 (5.5)
|
2.71 (2.01-3.64)
ref.
|
2.07 (1.51-2.83)
ref.
|
Postpartum hemorrhage
<500 ml
500–999 ml
1000–1999 ml
³2000 ml
Missing n
|
11876
3725
815
161
198
|
543 (4.6)
288 (7.7)
82 (10.1)
27 (16.8)
|
ref.
1.75 (1.51-2.03)
2.34 (1.83-2.98)
4.21 (2.76-6.42)
|
ref.
1.65 (1.42-1.92)
2.11 (1.65-2.72)
4.11 (2.68-6.30)
|
Apgar score at 5 min
<4
<7
³7
Missing n
|
19
179
16559
37
|
3 (15.8)
28 (15.6)
918 (5.5)
|
3.00 (0.88-10.28)
3.16 (2.10-4.76)
ref.
|
2.57 (0.74-8.89)
2.95 (1.95-4.47)
ref.
|
OR: odds ratio; CI: confidence interval. aAdjusted for maternal age and parity.
If an OASI was diagnosed the risk for dissatisfaction with childbirth was doubled. PPH of all degrees was also significantly associated with a negative experience, compared with bleeding <500 ml. The adjusted analyses indicated a dose–response relation between amount of bleeding and dissatisfaction with childbirth, the more severe the bleeding, the greater the risk of dissatisfaction. Likewise, the immediate well-being of the infant seemed to highly influence the woman’s reported VAS score. Apgar score <7 at five minutes after birth was found to be statistically significantly associated with dissatisfaction with childbirth (aOR 2.95, 95% CI 1.95-4.47), compared with the reference category Apgar ³7. Apgar score <4 was not related to dissatisfaction with childbirth but low numbers were included in that analysis.
Due to 21% (4429/21204) missing values on VAS in women giving birth during the study period a comparison of available characteristics between women with and without a recorded VAS score was performed. The results of the analyses are presented in table 5.
Table 5. Comparison between women with and without a documented VAS score. Chi-squared tests were used for categorical variables and t-tests for numerical variables.
|
Study population
(N = 16775)
|
Women excluded
(n = 4429)
|
P-value
|
Maternal age (years)
Mean [SD]
<25
25-35
>35
Missing
|
29.7 [5.0]
2338 (14)
12027 (72)
2240 (13)
170 (1)
|
29.6 [5.4]
740 (17)
2900 (66)
638 (14)
151 (3)
|
0.377
<0.001*
|
Body Mass Index (kg/m2)
Mean [SD]
<18.5
18.5-24.9
25-29.9
30-34.9
35-39.9
>40
Missing
|
25.3 [4.9]
379 (2)
8722 (52)
4486 (27)
1776 (11)
584 (3)
200 (1)
628 (4)
|
25.8 [5.1]
126 (3)
2041 (46)
1220 (28)
521 (12)
184 (4)
69 (2)
268 (6)
|
<0.001*
<0.001*
<0.001*
|
Parity
Primiparas
Multiparas
Missing
|
6632 (40)
9906 (59)
237 (1)
|
1491 (34)
2825 (64)
113 (3)
|
Categorical data are presented as number and (%).*P-values <0.05 were considered as statistically significant
The mean age of the study population (29.7 years) was similar to the mean age of the women without VAS (29.6 years) (p=0.377). The mean BMIs were also comparable between the groups (25.3 versus 25.8 kg/m2), although the difference was statistically significant (p<0.001). Moreover, 64% of the women excluded were multiparas, compared to 59% in the study population (p<0.001).