Studying the effect of implementing the World Health Organization's labor and delivery management program on improving mothers' experience and satisfaction of childbirth

Abstract

BACKGROUND:

The experiences that women gain from the childbirth process are considered as one of the important childbirth outcomes. On the other hand, one of the important factors for deciding on the next pregnancy is the type of experience gained from the previous childbirth. Having a negative experience and dissatisfaction with the previous childbirth reduces the likelihood of deciding to have another pregnancy. Adding woman-centered care, including safe childbirth checklist, can play an important role in satisfaction with childbirth and the childbirth experience. Therefore, this study was conducted to determine the effect of the labor and delivery management program on the experience and satisfaction of vaginal delivery.

MATERIALS AND METHODS:

This clinical trial study was conducted on 940 women (two groups of 470) with gestational age less than 37 weeks, who were hospitalized for vaginal or cesarean delivery in 2022. Twenty-five 1-h sessions were allocated to train care providers by the principal investigator. Within 48 h after delivery, the McKay Childbirth Satisfaction Questionnaire and after at least one month after delivery, the Childbirth Experience Questionnaire, version 2.0, were completed by mothers who had given birth in the intervention and control groups and by research assistants. Finally, the data were analyzed with SPSS software.

RESULTS:

The results of the independent t-test showed that the level of satisfaction (and its dimensions) was significantly higher in the intervention group (P < 0.001). Also, the results of the independent t-test in the two groups showed that the level of experience (and its subscales) was significantly higher in the intervention group (P < 0.05).

CONCLUSION:

The Labor and Delivery Management Program, using the World Health Organization checklist, was able to increase pregnant mothers' satisfaction with the birth process and create a positive experience for them. Achieving these outcomes increased mothers' desire to have another child.

Introduction

Unfortunately, studies conducted in the field of midwifery have rarely addressed women’s mental health and have rarely evaluated maternal experiences in outcome assessments.[1] While examining mothers’ experiences of childbirth allows caregivers to better understand mothers’ needs and expectations and provide effective interventions based on client needs to increase mothers’ satisfaction.[2,3] Factors such as the level of labor pain,[4] level of awareness, type of delivery,[5] caregiver support during childbirth,[6] level of pregnant mother’s involvement in the decision-making process,[4] and childbirth experiences affect women. Also, unplanned medical interventions during childbirth, such as emergency cesarean section,[7] fear of childbirth, instrumental vaginal delivery,[4] prolonged labor,[8] and the need for neonatal intensive care,[9] have been studied in various countries to investigate women’s childbirth experiences and related factors, and therefore, efforts have been made to identify and improve childbirth experiences. According to a longitudinal study in Sweden, which measured women’s experiences two months and one year after childbirth, more than a third of women had very positive experiences of childbirth, and feeling in control, using various types of pain management knowledge, spontaneous labor, and how women evaluate midwifery care have been identified as factors affecting women’s positive experiences.[10] Also, in a national study in Canada, they reported on 6,421 women. About 9% of women had a negative experience of childbirth, and the most important associated factors were older age, experience of violence in the past two years, poor perceived health, unintended pregnancy, cesarean delivery, and admission of the baby to the intensive care unit.[9]

The experiences that women gain from the birth process are considered to be one of the important outcomes of childbirth because these experiences remain with them throughout their lives.[11] According to a cohort study in Japan, women remember their birth experiences clearly even after five years of giving birth.[12] Unfortunately, reproductive health services have traditionally focused their efforts and resources on reducing perinatal mortality and have paid less attention to the mother’s experiences of childbirth and her beliefs about motherhood and the birth process.[13,14] In European countries, an effort has been made to change this type of care toward woman-centered care while maintaining the quality of care (QoC).[15] Thus, it is suggested that the care system can be improved and promoted by involving the patient in its care process.[16,17,18,19] Thus, patient satisfaction and experiences with their care process are now considered as quality indicators.[17,20,21] On the other hand, adverse experiences of childbirth can affect breastfeeding,[22] posttraumatic stress disorder,[23,24] maternal–infant attachment,[25] acute stress reactions and postpartum depression,[26,27] decision to become pregnant again,[28] and type of delivery in the next pregnancy.[29,30] A study in Iran reported the prevalence of negative childbirth experiences among primiparous women (37%),[31] which is higher than other studies in other countries.[9,32] In recent decades, there has been a continuous decline in births and the transition from natural to controlled fertility in Iran. In recent years, the proportion of young people in the country’s population has decreased and the proportion of old people has increased, which indicates the aging of the Iranian population. Currently, one of the policies of the Iranian country, to deal with the decline and aging of the population, is to encourage couples to have children.[33] One of the important factors for deciding on the next pregnancy is the type of experience gained from the previous birth. Having a negative experience and dissatisfaction with the previous birth reduces the likelihood of deciding to have another pregnancy.[28] To deal with the decline and aging of the population, it is necessary to create pleasant experiences for mothers with support packages.[28]

Studies have shown that adding woman-centered care to maternal support packages, including safe childbirth checklist (SCC), can play an important role in improving mothers’ experiences of childbirth by promoting supportive and effective communication during labor.[34,35] A study of mothers’ experiences of QoC and the potential benefits of implementing the WHO SCC has shown that the implementation and enforcement of SCC can potentially improve safety and QoC.[36] The WHO SCC is designed as a tool to improve the QoC provided to women giving birth. The checklist is a 29-item, organized, evidence-based list of essential obstetric practices that target the leading causes of maternal mortality, stillbirth, and neonatal mortality that occur in health care settings worldwide. Each checklist item represents a critical action that, if missed, could result in serious harm to the mother, the baby, or both. The checklist targets the four critical phases of labor: admission, just before vaginal or cesarean delivery, 1 h after delivery, and before discharge, and for each phase, reminds providers of the evidence-based practices for that phase.[37]

Considering the importance of improving health care and the positive impact of using this checklist in studies conducted in other countries, and considering that integrating other elements of the QoC framework, such as woman-centered care in SCC, can play an important role in improving mothers’ birth experiences and promoting supportive and effective communication during labor.[34,35,38]

Therefore, the researchers of the present study decided to conduct a study aimed at determining the effect of the labor and delivery management program on the experience and satisfaction with vaginal birth.

Materials and Methods

Study design and setting

This study is a randomized clinical trial that was conducted in 1401 in the maternity wards of Imam Khomeini, Ayatollah Taleghani, Sina, and Allameh Karami state hospitals.

Study participants and sampling

All women with singleton pregnancies with a gestational age of 37 weeks and above, of any age and ethnicity, with any obstetric history, and with any number of deliveries, who were admitted for vaginal delivery were included in the study. The exclusion criteria were as follows: women who were admitted for elective cesarean section, women who were admitted for any reason except vaginal delivery, women who were transferred directly and urgently to the delivery room or operating room upon arrival, and women with a gestational age of less than 37 weeks who were admitted for vaginal delivery or cesarean section. The two-proportion comparison formula was used to determine the sample size. In the formula, α = 0.01 and β = 0.1, and based on the results of previous similar studies[39] and based on the percentages of natural births, two groups were considered, p1 = 0.730 and p2 = 0.844. The initial sample size was estimated to be 798 people in total. In addition, by considering 15% attrition, the final sample size increased to 940 people (two groups of 470 people). Sampling was performed using the available nonprobability method.

Data collection tools and techniques

After obtaining written permission from the World Health Organization to translate the WHO SCC and receiving the ethics code number IRAJUMS.REC1401.049 from the Ethics Committee of Ahvaz Jundishapur University of Medical Sciences and registering the trial in the Iranian Registry of Clinical Trials (IRCT) system with number T20220501054711N1, this randomized clinical trial was conducted in four eligible government hospitals in Ahvaz (Imam Khomeini, Ayatollah Taleghani, Allameh Karami, and Sina hospitals). The website www.random.org was used for randomization; therefore, in the end, two hospitals were placed in the intervention and control groups, one of which was educational and the other noneducational. Given that randomization was performed on a hospital basis, not individually, the women in the study were assigned to only one intervention group in each of these hospitals. In the intervention groups, labor and delivery management was in accordance with the WHO Safe Delivery Checklist, and in the control groups, it was in accordance with routine practice.

After providing an introduction letter to the management of the study hospitals, the executive leaders of the selected hospitals (a director, a senior gynecologist, and the head of the labor unit) were informed about the type of intervention and the study objectives by the principal investigator during a meeting. Initially, in the intervention hospitals, the principal investigator provided training on the content of the safe delivery checklist and its relationship to patient safety and how and when these items should be implemented to all providers of care to pregnant women (midwives and residents), working in labor and delivery, operating room, and postpartum ward, during a 1-h session (for each group or individual). A total of 25 1-h sessions were allocated to train the providers of care by the principal investigator. Within 48 h after delivery, the McKay Childbirth Satisfaction Questionnaire and, after at least one month after delivery, the Childbirth Experience Questionnaire, version 2 (CEQ) 2.0, were completed by mothers who had given birth, in the intervention and control groups, and by research assistants.

The McKay Childbirth Satisfaction Questionnaire is measured on a 5-point Likert scale (very dissatisfied to very satisfied) with a score range of 1–5 and a score range of 32–160. Scores of 32–64 are classified as dissatisfied, 65–96 as satisfactory, and greater than or equal to 128 as completely satisfied.[40] The validity of the instrument was confirmed by exploratory factor analysis, and its reliability was confirmed by Cronbach’s alpha of α = 0.78.[41]

The WHO SCC is a 29-item, evidence-based, and essential checklist for the four phases of childbirth, from the time a pregnant woman is admitted to the hospital to discharge, and includes seven practices during admission and labor, five practices immediately before delivery or cesarean section, nine practices in the first hour after delivery, and eight practices before discharge. To determine the validity of the SCC, Backward and Forward Translation, Content and Face Validity were used.

The CEQ was designed in 2010 by Dencker et al.[42] The questionnaire includes the following domains: personal capacity (questions 1, 2, 45, 6, 21, and 22), professional support (questions 11, 13, 14, 15, and 16), perceived security (questions 3, 4, 18, 19, 20, and 21) and participation (questions 8, 9, 10, and 12). The 20 items of the questionnaire are completed in a four-choice format, and three of them are completed in a visual analog scale. The responses are as follows: I strongly agree (score 1), I often agree (score 2), I often disagree (score 3), and I strongly disagree (score 4). The questions, which are answered as a visual scale, are converted to values from 1 to 4: scores 1–40 (score 1), scores 41–60 (score 2), 61–80 (score 3), and 81–100 (score 4). The validity of the Persian version of the CEQ was confirmed by Ghanbari et al.[43] in 2019 and its reliability was confirmed with Cronbach’s alpha = 0.93.

SPSS software was used to analyze the data. Quantitative variables were reported as mean, standard deviation, and qualitative variables as number (percentage). The normality of quantitative variables was examined using the Kolmogorov–Smirnov test. The significance level of the above tests was considered less than 0.05.

Ethical considerations

This study is part of a multiphase mixed-methods doctoral dissertation in midwifery at Ahvaz Jundishapur University of Medical Sciences. It has received ethical approval (Ref. ID: IRAJUMS.REC1401.049) and is registered with the Iranian Registry of Clinical Trials (IRCT20220501054711N1). Participation was voluntary, and all students provided written informed consent.

Results

The results of the independent t-test showed that the level of satisfaction (and its dimensions) in the intervention group was significantly higher (P < 0.001) [Table 1].

Table 1.

Comparison of the overall level of satisfaction (and its dimensions) in the two intervention and control groups

Variables		Group		Number		Mean		Standard deviation		Test statistic (P-value)
Satisfaction with own performance		Intervention		337		31/67		3/712		10/358 (<0.001)*
		Control		309		28/42		4/206
Satisfaction with doctor’s performance		Intervention		337		26/96		2/337		16/121 (<0.001)*
		Control		309		23/8		2/611
Satisfaction with midwife’s performance		Intervention		337		32		2/824		14/468 (<0.001)*
		Control		309		28/59		3/129
Satisfaction with spouse’s performance		Intervention		337		5/05		0/575		40/925 (<0.001)*
		Control		309		2/48		0/976
Satisfaction with child		Intervention		337		12/35		1/735		8/376 (<0.001)*
		Control		309		11/03		2/237
Overall experience of childbirth		Intervention		337		10/04		1/635		6/146 (<0.001)*
		Control		309		9/18		1/894
Overall satisfaction score		Intervention		337		112/08		13/298		7/464 (<0.001)*
		Control		309		105/02		10/443

*Independent t-test

Also, the results of the independent t-test in the two groups show that the level of experience (and its subscales) is significantly higher in the intervention group (P < 0.05) [Table 2].

Table 2.

Comparison of the two intervention and control groups in terms of the level of childbirth experience (and its dimensions)

Variables		Group		Number		Mean		Standard deviation		Test statistic (P-value)
Capacity		Intervention		337		21/08		2/574		2/964 (0.001)*
		Control		309		20/17		2/723
Safety		Intervention		337		15/02		1/801		3/095 (0.002)*
		Control		309		15/51		2/168
Professional support		Intervention		337		12/55		1/858		6/428 (<0.001)*
		Control		309		11/29		2/226
Participation		Intervention		337		9/12		1/786		4/087 (<0.001)*
		Control		309		8/48		2/145
Birth experience score		Intervention		337		57/85		6/339		2/488 (0.013)*
		Control		309		55/28		7/437

*Independent t-test

Discussion

The findings of the present study indicate that the overall score of satisfaction with childbirth and all its dimensions were significantly different in the intervention and control groups. In this way, the average overall score of satisfaction with childbirth in the intervention group was higher than the control group. In the intervention group, the score of each, six subscales of self-satisfaction, satisfaction with physician, satisfaction with midwife, satisfaction with spouse, satisfaction with child, and overall birth experience, were higher than controls. The highest score on the subscale was assigned to satisfaction with the midwife. No study was found that measured the effect of SCC on maternal satisfaction with which the present study could be compared. However, given that one of the most important evidence-based functions in the SCC checklist is encouraging the birthing partner to have a companion, while the control group was not allowed to have a companion, the presence of a companion could be an important reason for satisfaction with childbirth in the intervention group.

The results of the present study are consistent with the results of a semiexperimental study by Muhammad Eid et al. (2020)[44] in Damietta, which aimed to investigate the effect of support provided by a companion during labor and delivery up to 2 h after delivery on maternal satisfaction with childbirth. In this study, in the intervention group, companions were present with the women in labor from the moment of admission until 2 h after delivery, and in the control group, women received conventional care and were not allowed to have a companion. The results of this study showed that 84% of the companions in the intervention group provided adequate support to the women in labor, and there was a statistically significant difference in the duration of labor in the first and second stages, such that the duration of labor in the first and second stages was reported to be shorter in the intervention group than in the control group, and satisfaction with childbirth was also higher in the intervention group by 86.7% (65) compared to 20% (15) than in the control group. Similar to this study, in the present study, in the control group, the companion was not allowed to be with the woman in labor, but unlike this study, the companion in the intervention group was required to leave the ward during labor and was present again with the woman in labor after delivery, but was with the woman in labor for the majority of the labor and postpartum process.

The findings of this study also showed that the total score of childbirth experience in the intervention and control groups was significantly different, such that the mean total score of childbirth experience in the intervention group was higher than the control group. In the intervention group, the score of all four subscales was higher than the control group. The highest score of the dimensions was assigned to the personal capacity, followed by the perceived security, professional support, and participation subscales, respectively. No study was found that measured the effect of SCC on mothers’ satisfaction; therefore, the present study is compared with other similar studies. A cross-sectional study was conducted by Zamani et al.[45] in Rasht with the aim of investigating the childbirth experience and its related personal and social factors. The total mean score of mothers’ childbirth experience was reported to be 2.62. According to the balanced scores, among the childbirth experience scales, the highest mean was reported for the professional support scale. Then, respectively, the domains of perceived safety and mother’s personal capacity were located, and the lowest mean was related to the domain of mother’s participation during labor and delivery. Gestational age was one of the important factors, which showed a significant correlation with mothers’ childbirth experience. The birth experience score increased by 2.8 times with an increase of one week in gestational age, respectively. Unlike this study, the highest score was assigned to the professional support dimension and the last to personal capacity. In the present study, the highest birth experience score was assigned to the personal capacity dimension and the third to professional support. Considering that the four dimensions of increasing personal capacity include: spiritual dimension, intellectual dimension, physical dimension, and emotional dimension.[46,50] It seems that companionship was effective in increasing spiritual, intellectual, and emotional capacity by increasing the highest score to the personal capacity dimension.

The findings of the study by Ghanbari et al. (2019),[43] which aimed to develop and implement supportive guidelines to improve childbirth experiences in primiparous women, are consistent with the results of the present study. In this study, women in the intervention group received supportive interventions during labor, delivery, and postpartum, and the control group received routine care at the birth center. The results of this study showed that the mean total childbirth experience score in the intervention group was higher than in the control group. The dimensions of professional support, perceived security, participation, and personal capacity were higher in the intervention group than in the control group, respectively. In the present study, unlike this study, the personal capacity dimension obtained the highest score. The difference in the childbirth subscales in the two studies may be due to the fact that in the present study, the CEQ was completed for both primiparous and multiparous women. In addition, the intervention was based on the Labor and Delivery Department’s SCC, which included companion and spouse support aspects. Therefore, previous childbirth experience and companion support aspects can be effective in increasing personal capacity. Studies have shown that support from healthcare professionals and a suitable physical environment are factors that influence maternal satisfaction. Respectful care, maternal participation in decision-making, and optimization of the birthing environment can improve the mother's experience of childbirth.[47] Therefore, it seems that caring for pregnant mothers based on evidence-based clinical practice and the World Health Organization's safe childbirth checklist, with an emphasis on implementing the above-mentioned factors, in addition to increasing the quality of care, plays a role in increasing maternal satisfaction and creating a positive experience of childbirth.[48,49] It should be noted that a positive experience of childbirth is associated with an increase in the mother's desire to have children.[50]

Limitations and recommendations

The findings of the present study indicate the involvement of several factors in the experience and satisfaction of vaginal delivery among pregnant mothers in public hospitals; therefore, it is recommended that further research be conducted to investigate the effectiveness of the safe delivery checklist in improving the experience and satisfaction of vaginal delivery in public and private hospitals.

Conclusion

The results showed that using SCC causes the average score of satisfaction with childbirth and the average score of childbirth experience to be higher in the intervention group than in the control group. Considering the effectiveness of the program on improving satisfaction with childbirth and childbirth experience, since the country’s policy is to increase the population, one of the ways to increase the rate of pregnancy and childbirth is to increase mothers’ satisfaction with childbirth and childbirth experience, so this program can be used.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.