Maternal satisfaction and perceived quality of care during childbirth in a tertiary care Italian Obstetrics Unit: a cross-sectional study

Abstract

Background

Maternal satisfaction is a widely used indicator for evaluating the quality of maternity services and is linked to important psychological and relational outcomes. In Italy, limited data have been published on women’s childbirth experiences, generally showing high satisfaction, but highlighting areas needing improvement, such as communication and pain management, especially during emergency cesarean section or operative vaginal delivery. This study primarily aimed to assess women’s overall evaluation of their labor and delivery experiences. Additionally, we examined sociodemographic and obstetric factors that may influence maternal satisfaction and explored satisfaction across specific experiential domains.

Methods

This is an observational, cross-sectional, non-pharmacological, non-profit, monocentric study conducted between June and October 2024 at the Unit of Obstetrics and Maternal Fetal Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan. A total of 696 women were consecutively recruited during their postpartum hospital stay. Participants completed a pseudonymized questionnaire which consisted of three sections: sociodemographic data, obstetric history, and birth experience evaluation using a 5-point Likert scale. Maternal satisfaction was operationalized as a retrospective self-reported appraisal of care. We used logistic regression to estimate prevalence odds ratios (OR) and the corresponding 95% confidence intervals (CI) for the associations between dissatisfaction and selected maternal and obstetric factors.

Results

Overall, 85.3% (95% CI: 82.7%-88.0%) of women reported satisfaction with their labor and delivery experience. Previous childbirth was inversely associated with dissatisfaction (OR=0.53, 95% CI: 0.29-0.97). In contrast, higher maternal age (OR=1.05, 95% CI: 1.00-1.10), labor induction (OR=2.18, 95% CI: 1.31-3.61), and operative delivery (OR=3.37, 95% CI: 2.06-5.51) were positively associated with dissatisfaction. The main concerns reported by dissatisfied women included inadequate pain management, lack of perceived control, and insufficient emotional support.

Conclusions

Despite high overall maternal satisfaction, relevant gaps persist in communication, emotional support, pain management, and perceived control during childbirth. Interventions promoting shared decision-making, structured communication, and systematic use of satisfaction surveys and birth plans may support a more woman-centered approach to maternity care, potentially improving both women’s evaluation of care and the quality of intrapartum services.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12884-026-09582-4.

Introduction

Childbirth represents an extremely sensitive time in a woman’s life, during which active and informed participation of the expectant mother is essential. Maternal satisfaction during labor and delivery is the most frequently reported indicator in assessing the quality of maternity services [1–3]. A positive childbirth experience is associated with enhanced mother-infant bonding, improved maternal skills, and increased self-fulfillment and self-esteem. Conversely, a negative experience may impact maternal mental health, increasing the risk of postpartum depression and post-traumatic stress disorder [4, 5].

In recent years, the term “obstetric violence” has been increasingly used to describe substandard obstetric care. However, this term may be misleading, as it may imply an intentionally harmful action carried out by healthcare providers. Such a perception can be unfair and offensive to many professionals, fostering a defensive mindset and hindering effective collaboration between healthcare providers and birthing women [6].

It is important to recognize that substandard care during labor and delivery may result from multiple factors, including difficulty in adapting behaviors, judgmental or paternalistic attitudes, and inadequate informed consent, particularly in urgent or emergency conditions [7]. Rather than focusing on the term “obstetric violence”, efforts to improve women’s childbirth experiences should aim at understanding the underlying causes and developing strategies based on trust and respect. This approach fosters a more empathic, collaborative, and patient-centered environment. One potential strategy involves the use of satisfaction surveys, which provide valuable feedback from women on their experiences. Such surveys enable healthcare providers to identify areas for improvement and tailor care accordingly [8–10].

Limited data have been published in Italy regarding women’s childbirth experiences, generally showing that about 90% of women have a positive birth experience, as demonstrated by a survey conducted in 1999 by the Italian National Institute of Health [11]. Notably, in 2019, another national survey was conducted by three major scientific societies (AOGOI, SIGO, and AGUI) to provide updated information, based on a larger sample, on the opinion of women delivering in various Italian maternity centers [12]. The findings revealed that most Italian women were generally satisfied with their childbirth experiences. However, areas for improvement were identified, particularly regarding communication of information and pain management, especially in cases of emergency cesarean sections or vacuum-assisted deliveries.

In light of these findings, we performed an internal survey to evaluate the satisfaction level of women delivering in our maternity ward, one of the busiest obstetric units in Italy, through the administration of a pseudonymized satisfaction questionnaire regarding their labor and childbirth experience, to be completed during the postpartum hospital stay.

The main objective of this study was to assess women’s overall evaluation of their personal labor and delivery experience. For the purpose of the current study, this self-assessment was interpreted as a measure of maternal satisfaction, reflecting a retrospective evaluative appraisal rather than a comprehensive account of lived experience or subjective perception. The secondary objectives were: (1) identifying potential sociodemographic or obstetric history characteristics that may influence the level of maternal satisfaction, and (2) exploring satisfaction rates in specific areas of interest to identify key aspects requiring greater attention for improving obstetric care.

Methods

Study design, setting and population

This was an observational, cross-sectional, non-pharmacological, non-profit, monocentric study carried out between June and October 2024 at the Unit of Obstetrics and Maternal Fetal Medicine of the Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico in Milan with the authorization from the Hospital Data Protection Officer and the Medical Director.

Women aged 18 years or older who had given birth in the delivery room of this center, and who agreed to complete the satisfaction questionnaire were eligible for this study. The formal exclusion criterion was the inability to understand written Italian. In addition, women admitted to the Intensive Care Unit immediately after delivery were not systematically approached during their ICU stay and were therefore unlikely to be included, as well as women experiencing stillbirth.

Patients were consecutively recruited during their postpartum hospital stay - either during the immediate postpartum observation period or in the postpartum ward prior to discharge. At our institution the average duration of postpartum hospitalization is approximately 3–4 days. No formal screening log of excluded women was maintained.

Women were asked to provide an overall self-assessment of their personal experience of labor and delivery through the administration of a pseudonymized satisfaction questionnaire (see Additional file 3). The questionnaire was distributed by medical or midwifery staff but was self-administered and completed independently by participants. Individual responses were not accessible to the staff involved in clinical care.

The questionnaire was developed internally by a multidisciplinary team of obstetricians and midwives, drawing on existing literature and commonly used domains in childbirth satisfaction surveys [13, 14].

It consisted of three sections:

• a first section including sociodemographic questions on age, household composition, number of children, place of residence, nationality, education level, employment status, and marital status;

• a second section addressing general health status and pregnancy-related aspects, such as date of delivery, number of pregnancies, parity, conception mode, type of prenatal care, participation in childbirth preparation courses, reason for choosing the hospital, type of birth, and induction of labor;

• a third section evaluating specific experiential domains of the labor and delivery experience, such as kindness and availability of healthcare staff, freedom to ask questions, communication by healthcare staff, adequate communication in case of operative delivery/episiotomy, perception of lack of respect, attention to emotional needs, consideration of personal ideas/expectations, pain management, perception of control over the situation, support for skin-to-skin contact, and quality of healthcare. In addition, women’s overall personal experience was also assessed to provide a summary measure of maternal satisfaction.

In the third section, each question offered five possible responses based on a Likert scale, with scores ranging from 1 to 5.

For the purposes of the present analysis, the overall self-reported evaluation of personal childbirth experience was used as an indicator of maternal satisfaction, capturing a retrospective overall appraisal of care rather than a detailed reconstruction of lived experience or subjective perception.

Questionnaire data were subsequently transferred to an electronic database.

The study period was selected for pragmatic and organizational reasons and allowed the collection of a large consecutive and representative sample within routine clinical practice. To assess the representativeness of the study sample, its baseline characteristics were compared with those of the population of women who gave birth at our institute in 2024, based on data from the institutional annual database.

Data analysis

Women were defined as satisfied with their labor and delivery experience at our facility if they reported an overall rating of “Very positive” or “Positive”, while they were defined as dissatisfied if they reported an overall rating of “Neutral”, “Negative”, or “Very negative” (Question 15, Section  3 of the questionnaire). The overall satisfaction rate was obtained by dividing the number of satisfied women by the total number of women included. The 95% confidence interval (CI) of the overall satisfaction rate was provided.

Maternal age was described as mean ± standard deviation. Difference between satisfied and dissatisfied women was tested by t test. Categorical variables were reported as absolute frequencies and percentages. Differences in proportions between satisfied and dissatisfied women were tested using Mantel-Haenszel chi-square test, accounting for the potential confounding role of age.

We used univariable and multivariable logistic regression models to estimate prevalence odds ratios (OR) and the corresponding 95% confidence intervals (CI) for the association between selected maternal and obstetric factor - such as maternal age (treated as continuous), parity, mode of conception, induction of labor, mode of delivery, and participation in childbirth preparation courses - and dissatisfaction with the labor and delivery experience. Covariates were selected based on prior literature, clinical relevance, and patterns observed in descriptive analyses. Multicollinearity among independent variables was assessed using the Variance Inflation Factor (VIF), with all values below 2, indicating no significant multicollinearity. Subjects with missing data (< 5%) were excluded from the analyses.

In addition, we descriptively reported the specific experiential domains by showing the distribution of women’s satisfaction with various aspects of their labor and delivery experience, as measured by Likert-scale questions. We indicated the percentage of respondents selecting each response option, highlighting the domains with the highest proportion of negative responses among dissatisfied women.

Statistical significance was defined as p-value < 0.05.

Results

Among the 696 women included in the study, 594 (85.3%; 95% CI: 82.7%–88.0%) reported being satisfied with their labor and delivery experience. The distribution of responses across the original five-point Likert scale was as follows: 8 (1.2%) reported “Very Negative”, 12 (1.7%) “Negative”, 82 (11.8%) “Neutral”, 174 (25.0%) “Positive”, and 420 (60.3%) “Very Positive”. The study sample showed no significant differences in baseline characteristics (age, education, parity, conception method) compared to the population of women who delivered in our Institute in 2024 (Supplementary Table S1). Maternal characteristics in the two groups of satisfied and dissatisfied women are reported in Supplementary Table S2. Dissatisfied women were older than satisfied ones (mean age: 35.9 ± 5.3 years vs. 34.3 ± 5.0 years, p = 0.01), more frequently nulliparous (75.0% vs. 56.4%, p < 0.01), and more likely to have conceived through assisted reproductive technologies (17.8% vs. 8.3%, p = 0.02). They were also more frequently employed full-time (89.1% vs. 77.6%, p = 0.01). No differences emerged regarding nationality, place of residence, marital status, and educational level.

Participation in childbirth antenatal courses differed between the two groups (70.6% in dissatisfied vs. 56.3% in satisfied, p < 0.01). Women who attended antenatal classes at the study hospital more frequently reported having received adequate information regarding the ward and the labor and birth process compared with those attending classes elsewhere.

Regarding obstetric characteristics, induction of labor was more frequent among dissatisfied women (60.0% vs. 49.2%, p = 0.04). Mode of delivery was associated with satisfaction (p < 0.01): dissatisfied women were less likely to have a spontaneous vaginal delivery (42.6% vs. 68.3%) and more likely to undergo operative vaginal delivery (13.9% vs. 4.9%) or urgent cesarean section (26.7% vs. 7.5%).

Consistently, satisfaction rates differed across modes of delivery, being higher after spontaneous vaginal delivery (90.3%, 95% CI: 87.6–93.1) and elective cesarean section (87.0%, 95% CI: 81.3–92.8), and lower after operative vaginal delivery (67.4%, 95% CI: 53.4–81.5) and urgent cesarean section (62.0%, 95% CI: 50.7–73.3).

Table 1 shows OR and 95% CI for dissatisfaction according to selected maternal and obstetric factors. Previous childbirth was inversely associated with dissatisfaction (OR = 0.53, 95% CI: 0.29–0.97), whereas increasing maternal age (OR = 1.05, 95% CI: 1.00–1.10), induction of labor (OR = 2.18, 95% CI: 1.31–3.61), and operative delivery (OR = 3.37, 95% CI: 2.06–5.51) - including operative vaginal delivery and cesarean sections - were positively associated with dissatisfaction.

Table 1.

Prevalence odds ratios (OR) and 95% confidence intervals (CI) of dissatisfaction with labor and delivery experience according to selected maternal and obstetric factors

	Prevalence OR (95%CI)a	Prevalence OR (95%CI)b
Maternal Age	1.07 (1.02-1.11)	1.05 (1.00-1.10)
Parity
Nulliparae	Ref.	Ref.
Parae	0.43 (0.27-0.70)	0.53 (0.29-0.97)
Mode of conception
Spontaneous	Ref.	Ref.
Medically assisted	2.40 (1.34-4.33)	1.53 (0.79-2.97)
Induction of labor
No	Ref.	Ref.
Yes	1.55 (1.01-2.38)	2.18 (1.31-3.61)
Mode of delivery
Vaginal	Ref.	Ref.
Operative vaginal/Cesarean section	2.90 (1.89-4.46)	3.37 (2.06-5.51)
Childbirth preparation course
No	Ref.	Ref.
Yes	1.87 (1.18-2.95)	1.17 (0.66-2.07)

^aDerived from univariable logistic regression models

^bDerived from a multivariable logistic regression model simultaneously including terms for maternal age, parity, mode of conception, induction of labor, mode of delivery, and participation in childbirth preparation courses

Additionally, Figs. 1 and 2 show the adequacy of information reported by women regarding operative vaginal delivery and episiotomy. For operative vaginal delivery, most women completely or somewhat agreed that they had received adequate information (90.0%), while smaller proportions reported having received no information (2.5%) or expressed disagreement regarding information adequacy (2.5%) (Fig. 1). For episiotomy, 85.7% of women completely or somewhat agreed that information had been sufficient, whereas 7.4% reported receiving no information, and smaller proportions expressed disagreement (3.5%) or a neutral position (2.5%) (Fig. 2).

Fig. 1.

Information about operative vaginal delivery in women undergoing vacuum assisted delivery

Fig. 2.

Information about episiotomy in women who had a vaginal delivery

Figures 3 and 4 display satisfaction levels across specific domains among women classified as overall satisfied (N = 594) and dissatisfied (N = 102), respectively. Among satisfied women, high levels of agreement were observed across most domains, particularly regarding overall quality of care, clarity of communication, and the ability to ask questions. Pain management and perceived control showed comparatively lower agreement. In the dissatisfied group, lower agreement was observed across most domains, with higher proportions of neutral or negative responses, particularly in relation to pain management, perceived control, emotional support, and communication-related aspects.

Fig. 3.

Satisfied women (N = 594)

Fig. 4.

Dissatisfied women (N = 102)

Discussion

Main findings

This study confirms a high level of overall maternal satisfaction in an Italian delivery unit, consistent with national data from a 2019 survey conducted by the three major Italian scientific societies (AOGOI, SIGO, and AGUI), which reported generally high satisfaction with childbirth care among Italian women. However, several domains emerged as requiring improvement. In particular, pain management, communication, perceived control, and emotional support were the domains most frequently reported with negative experiences among dissatisfied women [15].

These findings emphasize the importance of comprehensive and patient-centered care in shaping maternal satisfaction [16]. Discrepancies emerged in the adequacy of information provided, particularly among women who attended childbirth preparation courses outside our Institute. As demonstrated by Mohaghegh et al. and Mueller CG et al., the significant differences in perceived information quality highlight potential inconsistencies in the comprehensiveness of childbirth education across different healthcare settings, underscoring the need for structured and standardized antenatal education to ensure equitable access to essential childbirth-related information [17, 18].

Additionally, the lightly lower satisfaction rates observed among women receiving prenatal care at our center could reflect unmet expectations regarding the transition from antenatal to intrapartum care. If the level of communication, emotional support, or perceived autonomy experienced during pregnancy did not align with their expectations for labor and delivery, dissatisfaction may arise. In line with the Cochrane Review by Hodnett E.D. et al., these results emphasize the importance of ensuring continuity of care and a patient-centered approach throughout the entire perinatal period to enhance maternal satisfaction [19].

Maternal characteristics also played a role. Women in the dissatisfied group were older and more frequently conceived via assisted reproductive technologies. As previously described by Poikkeus et al., these women may have heightened expectations or specific concerns related to increased medical risk, prolonged fertility treatment, and the psychological burden associated with assisted conception and more medicalized pregnancies [20].

Previous childbirth was inversely associated with dissatisfaction, suggesting that multiparous women may experience greater confidence, familiarity with the birth process, and more realistic expectations, contributing to a more positive appraisal of care [21].

The significant association between mode of labor and delivery and maternal satisfaction highlights the impact of birth experience on women’s overall perception of care. Induction of labor and operative procedures may be perceived as a more medicalized and less physiological experience, often associated with longer labor, increased interventions, and reduced maternal sense of control, all of which may negatively affect satisfaction. Consistent with previous studies, dissatisfied women were less likely to have spontaneous vaginal births and more likely to undergo operative vaginal delivery or urgent cesarean section [22–25].

While such interventions are frequently clinically necessary, these findings reinforce the importance of clear communication, shared decision-making, and emotional support to mitigate feelings of uncertainty and loss of control [26], as emphasized by the ACOG Committee Opinion on Informed Consent and Shared Decision Making in Obstetrics and Gynecology. While such interventions are frequently clinically necessary, these findings reinforce the central role of clear communication, shared decision-making, and emotional support in mitigating feelings of uncertainty and loss of control²⁴. This is particularly relevant in the context of a tertiary referral center, where high clinical complexity and urgent situations are common. In highly medicalized settings, the intensity and unpredictability of care may independently shape women’s expectations and satisfaction, making relational and communicative aspects of care especially critical, even when interventions cannot be avoided [27].

Clinical implications

Although the questionnaire asked women to provide an evaluation of their childbirth experience, the primary outcome was interpreted as maternal satisfaction, reflecting an overall retrospective appraisal of care. This type of rating captures women’s general judgment of childbirth care within a specific institutional context, rather than a detailed account of the lived experience or its personal meaning. Maternal satisfaction, as assessed in this study, is therefore influenced by multiple factors, including expectations, interpersonal interactions, perceived support, and organizational aspects of care. While widely used in maternity care research and useful for evaluating services, such measures do not fully capture the multidimensional nature of childbirth experience described in qualitative or experience-based frameworks [28].

More broadly, many existing instruments in maternity care research predominantly reflect domains considered relevant by healthcare professionals, rather than outcomes that women themselves identify as meaningful, expected, or impactful. This limitation extends beyond the present study and highlights the need for future research to adopt qualitative approaches, mixed-method designs, and the direct involvement of women in questionnaire development, in order to better reflect women’s values, priorities, and perceptions of care [29].

Within these conceptual and methodological constraints, our findings nevertheless provide actionable insights for clinical practice. Domains most strongly associated with dissatisfaction, such as communication, emotional support, pain management, and perceived control, represent key targets for quality improvement. Structured communication strategies, enhanced emotional support during labor, staff training focused on respectful maternity care, and broader integration of shared decision-making and birth planning into routine practice may meaningfully improve women’s overall appraisal of intrapartum care and promote a more patient-centered model of maternity services.

Systematic collection of patient feedback through satisfaction surveys may support continuous quality improvement by enabling healthcare providers to monitor trends, identify critical areas, and evaluate the impact of targeted interventions. However, satisfaction surveys should be interpreted cautiously and complemented by more woman-centered outcome measures, particularly in highly medicalised settings such as tertiary referral centers, where clinical complexity and intervention intensity may independently influence women’s evaluations of care [30].

While maternal satisfaction was the primary focus of this study, childbirth is a shared experience that also involves birth partners, whose emotional needs and perceptions remain underexplored. Emerging evidence suggests that acknowledging and supporting partners’ experiences may contribute to a more positive overall birth experience and should be considered in future research and care models [8, 9].

Finally, promoting informed decision-making through birth plans represents a further opportunity to enhance maternal satisfaction. Birth plans may support maternal autonomy, increase perceived control, and reduce fear and anxiety by facilitating dialogue between women and healthcare providers and aligning expectations with clinical realities. In our study, lower satisfaction among women undergoing operative vaginal delivery or urgent cesarean section underscores the importance of preparing women for a range of possible birth scenarios. Integrating birth planning discussions into routine prenatal care may therefore help mitigate dissatisfaction, and support a more positive and respectful childbirth experience [31, 32].

Strengths and limitations

The main strengths of this study include the large sample size, consecutive recruitment within routine clinical practice over five days per week, and the representativeness of the study population. When compared with the institutional annual database, baseline characteristics such as age, educational level, parity, and mode of conception did not differ from those of women who gave birth at our institute in 2024, supporting the external validity of the findings within this setting. However, nationality was not evenly represented, as adequate knowledge of Italian was required to complete the questionnaire.

Several limitations should be acknowledged. Data collection relied on a self-administered questionnaire completed in the early postpartum period. While this approach minimizes interviewer bias and facilitates participation within routine care, it may be associated with non-response or self-selection bias and may be influenced by women’s emotional state at the time of completion.

Another important limitation concerns the use of an internally developed questionnaire that was not formally validated or subjected to psychometric testing prior to use. This may limit construct validity and comparability with studies employing validated instruments. Furthermore, the monocentric design and the highly medicalized tertiary care setting restrict the generalizability of the findings, particularly to low-risk populations or midwife-led models of care.

The subjective nature of maternal satisfaction, which is shaped by socio-cultural background, expectations, and contextual factors, may have further influenced responses. In particular, early postpartum assessment may have led to under-reporting of negative aspects (e.g., gratitude or desirability bias) or, conversely, their overestimation in the presence of unmet expectations.

The dichotomization of the five-point Likert satisfaction scale into a binary outcome was necessary due to the highly unbalanced distribution of responses. This simplification reduces the granularity of inference and may obscure subtle gradients in satisfaction.

Additionally, a history of depression or anxiety was neither an exclusion criterion nor systematically assessed. While this choice was consistent with the aim of reflecting real-world maternal satisfaction in an unselected obstetric population, it may have affected satisfaction ratings.

Further, no formal registry of women who declined participation was available.

Lastly, this study focused exclusively on maternal satisfaction and did not explore partners’ needs or perceptions. Although the questionnaire addressed several relational and emotional dimensions, it remained largely framed from a professional perspective and did not directly capture women’s individual priorities, expectations, or personal definitions of a positive birth experience.

Conclusions

Overall, this study highlights high maternal satisfaction levels while identifying key areas for improvement in maternity care. Strengthening communication and providing comprehensive emotional and informational support are essential for enhancing the childbirth experience. Additionally, integrating satisfaction surveys and birth plans into routine care can promote a more patient-centered approach by ensuring that women’s preferences and concerns are acknowledged and addressed. By systematically incorporating patient feedback into quality improvement initiatives, healthcare providers can refine maternity services, enhance patient-provider interactions, and ultimately improve both maternal satisfaction and clinical outcomes. These findings suggest that women’s overall appraisal of childbirth care is shaped not only by clinical pathways and mode of delivery, but also by relational and organizational aspects of intrapartum care.

Within the limits of a satisfaction-based outcome measure, our results support the integration of structured communication strategies, enhanced emotional support, and shared decision-making into routine maternity care. The systematic use of satisfaction surveys may represent a useful tool for continuous quality improvement, provided that such measures are interpreted critically and complemented by interventions aimed at addressing the experiential dimensions most strongly associated with dissatisfaction.

Future research on maternal satisfaction is crucial to inform evidence-based policies and to ensure that maternity care remains adaptive, equitable, and responsive to the evolving needs and expectations of women and their families. Such research should increasingly adopt woman-centered and co-designed outcome measures, helping to move the evaluation of maternity care toward a more genuinely patient-centered framework, beyond satisfaction alone.

Abbreviations

AOGOI

Italian Association of Obstetricians and Gynecologists

SIGO

Italian Society of Gynecology and Obstetrics

AGUI

Association of Italian University Gynecologists

ACOG

American College of Obstetricians and Gynecologists

Authors’ contributions

IC conceptualization, methodology, supervision; FMPG and VR data curation, writing (original draft, review and editing), visualization; GR, ER, MT, MS investigation; GE statistical analysis.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

The datasets used and/or analyzed during the current study are available with the corresponding author to be presented on reasonable request.

Declarations

Ethics approval and consent to participate

This observational, non-interventional, and non-pharmacological study using pseudo-anonymized data did not require formal approval from an Ethics Committee, according to current national regulations. The study was authorized by the Data Protection Officer and the Medical Director of the Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan. Consent was implied through the voluntary completion of the questionnaire. All data were collected and processed in compliance with applicable privacy regulations and the principles of the Declaration of Helsinki.

Consent for publication

Consent for publication was not required, as the data are pseudo-anonymized and presented in aggregate form. All participants were informed that their responses could be used for research and scientific dissemination and consented by voluntarily completing the questionnaire.

Competing interests

The authors declare no competing interests.