ABSTRACT

Objective:

This study aims to investigate the effects of general and spinal anesthesia methods on the birth satisfaction of women in cesarean deliveries with the birth satisfaction scale (BSS) and to determine the factors affecting birth satisfaction.

Method:

This descriptive cross-sectional study included 350 women who delivered by cesarean section under general and spinal anesthesia in a tertiary healthcare institution between June 2022 and November 2022. The patients were divided into groups S (spinal anesthesia) and G (general anesthesia). The data collection form and the “BSS” were filled in by face-to-face interview technique on the day of discharge to women who had a cesarean section.

Results:

A total of 350 women who had a cesarean section, 228 (65.1%) in group S and 122 (34.9%) in group G, participated in the study. While 59.7% (n=209) of the women were primary school graduates, 6.9% (n=24) were university graduates. The mean BSS score was significantly higher in group S compared to group G (108±13 vs. 104±12, p=0.005). The preference for spinal anesthesia in university graduates and general anesthesia in illiterate women was significantly higher (p=0.021). When evaluated according to educational status, BSS scores were significantly higher in university graduates (p=0.002).

Conclusion:

Birth satisfaction scores were high in women with a cesarean section under spinal anesthesia. In addition, preference for spinal anesthesia and BSS scores were high in university graduate sociowomen. Informing women with low educational levels about spinal anesthesia and eliminating any concerns may increase the preference for spinal anesthesia and the satisfaction of delivery.

Introduction

Pregnancy and childbirth are among the most important and unique experiences that affect women’s lives physically, psychologically, and socially. In birth satisfaction, the training received in preparation for birth, the pain experienced during the birth process, the care and needs of women, the mode of delivery, and the sense of individual control of the birth are of great importance. In addition, it is effective for pregnant women not to be included in the decision-making process and to receive support from someone they trust during delivery (1-3). The determination of birth satisfaction is crucial as it indicates maternal care quality and shows the well-being of the newborn and mother.

The satisfaction level of women from obstetric services in health institutions from various regions of is between 54 and 90% (4,5). Positive birth experience increases women’s self-confidence and contributes positively to establishing stronger relationships with their children and planning for future births. Negative birth experience; is associated with inadequacy in breastfeeding and maternal attachment, postpartum depression, neglect of child care, sexual reluctance, and fear of the subsequent birth (6).

Cesarean section rates are increasing in Turkey and the rest of the world. Spinal anesthesia; has advantages such as the faster recovery of gastrointestinal functions after surgery, providing postoperative analgesia, lower risk of drug toxicity for mother and baby, early mobilization in the postoperative period, and early communication between mother and baby (7). In addition, complications have been reported to be higher in general anesthesia (8). For all these reasons, the preference for spinal anesthesia is increasing in cesarean deliveries.

This study aims to investigate the effect of general and spinal anesthesia methods on the birth satisfaction of women in cesarean deliveries with the “birth satisfaction scale (BSS)’’ and to determine the factors affecting the level of birth satisfaction.

Materials and Methods

This prospective descriptive cross-sectional study was approved by the Clinical Research Ethics Committee of the University of Health Sciences Turkey, Kanuni Sultan Süleyman Training and Research Hospital (date: 06.04.2022, number: 90). The work was started following the principles of the Declaration of Helsinki. Verbal and written consent was obtained from all women who gave birth in the study.

The Design, Universe, and Sample of the Study

Women who gave birth by cesarean section between June 2022 and November 2022 at the University of Health Sciences Turkey, Kanuni Sultan Süleyman Training and Research Hospital and agreed to participate in the study were included.

Inclusion criteria for the study;

• Eighteen years of age and older who had a cesarean section under general and spinal anesthesia in the hospital where the research was conducted,

• Not having a high-risk pregnancy, not having health problems in herself or her baby, not being treated in the postnatal intensive care unit for herself or her baby,

• Not a refugee or a citizen of another country, fluent in Turkish and with no communication problems,

• Primiparous and multiparous women who agreed to participate in the study and had elective cesarean delivery during working hours were included (Figure 1).

Figure 1

In the hospital where the study was conducted, the number of cesarean deliveries in 2021 was 3248, and the number of vaginal deliveries was 3033. The study’s sample size: According to the sample size formula used when the universe is known, it was calculated as 343 at a 95% confidence interval by using the Epi info 7.2.5 program. A total of 350 women who had cesarean delivery under spinal and general anesthesia were included in the study. The patients were divided into groups G (general anesthesia group) and S (spinal anesthesia group), and their BSS scores were analyzed. At the same time, socio-demographic characteristics affecting birth satisfaction in the whole population were investigated.

Data Collection and Data Collection Tools

Questionnaire forms were applied to the women who agreed to participate in the study, on the day of discharge, in their rooms, and when alone by using the face-to-face interview technique. The researchers prepared the data collection form, and the “BSS” was used to collect the data (Table 1). In the data collection form, women’s socio-demographic data (age, number of births, educational status, employment status) and obstetric and neonatal clinical data (gestational week, visual analog scale score at the 6^th-hour postoperative, APGAR score of the newborn at 1 and 5 minutes) were questioned.

Table 1

BSS

Martin and Fleming (9) developed the BSS in 2009 to evaluate the birth satisfaction of women. The scale was prepared in English and consisted of 30 items. BSS is a five-point Likert-type scale scored according to the answers given. ”I strongly agree” is 5 points; “I agree” is 4 points; “I neither agree nor disagree” is 3 points; “I disagree” is 2 points; “I strongly disagree” is 1 point.

The total number of points taken from the scale varies between 30 and 150. Items 4, 8, 12, 15, 16, 17, 19, 20, 21, 23, 25, and 29 of the BSS are scored in reverse order. As the score obtained from the scale increases, the level of birth satisfaction increases, and the scale has no cut-off value. When the scale was created, validity and reliability studies were not carried out, and central themes and sub-themes were determined in line with the literature review results. Three overarching themes were selected in the scale:

1. Quality of care provision

2. Women’s attributes

3. Stress experienced during labor (Table 2).

Table 2

Turkish validity and reliability of BSS Cetin et al. (10). Cronbach’s alpha coefficient was determined as 0.62.

In our study, the total Cronbach’s alpha coefficient for BSS was 0.82, 0.68 for the first theme, 0.62 for the second theme, and 0.72 for the third theme. The general validity of the BSS was tested, and its items were found to be suitable and sufficient for factor analysis (KMO=0.75, p<0.001).

Statistical Analysis

SPSS 26.0 (SPSS Inc., Chicago, USA) program was used to analyze the data. Descriptive data are expressed as the number of patients, percentage, mean, standard deviation, and range. The conformity of the variables to the normal distribution was evaluated analytically (Shapiro-Wilks test) and visually (histogram). Mann-Whitney U and Kruskal-Wallis H tests were used to analyze non-normally distributed quantitative data. Mann-Whitney U test was used in the analysis of the scale data. The chi-square test was used in the analysis of categorical data. The Bonferroni test was used as a post-hoc test to determine the difference between groups in categorical data. The statistical significance limit was accepted as p<0.05.

Results

A total of 350 women, 228 (65.1%) in group S and 122 (34.9%) in group G participated in the study. While the mean age and distribution range of the cases were 29.4±5.5 (18-44) in group S, it was 28.8±4.9 (18-38) in group G. The mean parity was 2.2±1.2 in group S and 2.1±1.3 in group G. When examined according to their educational status, 59.7% (n=209) of the population were primary school graduates. In comparison, 6.9% (n=24) were university graduates. When evaluated according to employment status, 87.7% (n=307) of the entire population was not working. The mean gestational week of both groups was 38±1.3. While newborns’ mean 1^st minute (min) APGAR scores were 6.9±0.6 in group S, it was 6.7±0.7 in group G. The mean post-operative 6^th-hour visual analog scale (VAS) scores were 5.1±1.9 in group S and 5.6±2.1 in group G. The mean BSS scores and range of distribution, were 108±13 (66-137) in group S, while it was 104±12 (71-130) in group G (Table 3).

Table 3

When the BSS themes were evaluated, there was no significant difference between the groups’ quality of care delivery (p=0.152). The personal attitudes of the women and the satisfaction levels of their stress experiences during the birth process were significantly higher in group S (p=0.003 and p=0.031, respectively) (Table 4).

Table 4

When the evaluation was made between groups, BSS scores in group S were significantly higher than in group G (p=0.005). The mean age, number of births, and women’s employment rates were higher in group S, although insignificant (p=0.619, p=0.519, p=0.147, respectively). The rate of university graduates in group S and the rate of illiterate women in group G were significantly higher (p=0.021). In group S, newborns’ APGAR scores (1^st and 5^th min) were significantly higher, while post-operative 6^th-hour VAS scores were significantly lower (p=0.036, p=0.032, p=0.037, respectively).

When the factors affecting birth satisfaction levels were investigated, the mean BSS scores of women aged 30-44 were higher than those aged 18-29, although insignificant (p=0.201). When compared according to education levels, the highest BSS scores were among university graduate women, and the lowest BSS scores were among high school graduate women. There was a significant difference between BSS scores according to education level (p=0.002). The BSS scores of illiterate women were significantly higher than those of high school graduate women. The BSS scores of university graduate women were considerably higher than high school graduate women (adj. p=0.019 and p=0.004, respectively). Although not substantial, BSS scores were high in workers and multiparous women (p=0.153, p=0.425, respectively) (Table 5).

Table 5

Discussion

The experiences of women in the intrapartum and postpartum period and their satisfaction with the health services they receive have become increasingly important. Many scales, such as the birth satisfaction and postpartum comfort scales, have been developed and used for this purpose (9,11). The delivery type is a critical factor affecting women’s satisfaction with birth. Çelik and Çelik (11) reported that those who gave vaginal birth had higher postpartum comfort than those who had a cesarean section. The same study said that postpartum comfort was higher in those who had a cesarean section with regional anesthesia than in those with a cesarean section with general anesthesia. Fleming et al. (12) evaluated labor satisfaction with BSS in their study and reported that the mean BSS score was 128.9±9. The same survey emphasized that those who had a vaginal delivery had higher birth satisfaction than those who had a cesarean section. In our research, spinal anesthesia was applied in most of the cesarean deliveries (65.1%) that participated in the study, consistent with the literature. The birth satisfaction score of the whole population was 106±13. At the same time, the birth satisfaction scores of those who had a cesarean section in group S were significantly higher than those of group G (BSS score 108±13 vs. 104±12, p=0.005).

Pain is one of the negative experiences in childbirth. Problems experienced in the postpartum period, and the birth process, can affect birth satisfaction. Huang et al. (13) determined that the pain experienced in the postpartum period negatively affects birth satisfaction by preventing the mother’s comfort, performing the baby, and self-related care activities. A study conducted with primiparous and multiparous women reported that one-third of women had problems in the postpartum period. The most common problem is a pain in the operation area and standing up during cesarean deliveries (14). In our study, the BSS scale was used to evaluate birth satisfaction. When the themes of the BSS were compared between the groups, no significant difference was observed in the quality of care. On the other hand, in the sub-headings of stress level during delivery and attitudes of pregnant women, birth satisfaction scores were found to be significantly higher in the spinal anesthesia group. Following the literature, we think pain palliation in postpartum is essential for birth satisfaction in cesarean deliveries.

It has been reported that maternal age may affect birth satisfaction (1,2,6). However, studies also report that age does not significantly affect birth satisfaction (15-17). In our study, although the mean age of the spinal anesthesia group was higher than the general anesthesia group, no significant difference was found. Although the BSS scores of women aged 30-44 in the entire population were high, no significant difference was observed.

Parity can also affect birth satisfaction. Bilgin et al. (15) reported that the level of birth satisfaction in multiparous women is higher than in primiparous women. In our study, BSS scores were significantly higher in group S. The mean parity in this group was higher than in general anesthesia, although it was insignificant. In our study, although BSS scores in multiparous puerperal women were higher than those in primiparous, no significant difference was observed. The fact that multiparous and older women are more experienced in both spinal anesthesia and childbirth than primiparous women and are more effective in decision-making is effective in spinal anesthesia preference and birth satisfaction.

One of the factors that affect women’s birth satisfaction is education. It has been reported in some studies that education status does not affect birth satisfaction (15,17). However, studies also note that increased education level increases birth satisfaction (16,18). In our research, illiterate women had a significantly higher preference for general anesthesia; similarly, a priority for spinal anesthesia was considerably higher in university graduates. Our study also found that education level greatly affected birth satisfaction (p=0.002). While the mean BSS scores in higher education graduates were 114.1±11.6, the mean BSS scores in the whole population were 106±13.

One of the factors that may affect birth satisfaction is the working status of women. Studies report that working status does not affect women’s birth satisfaction (2,18). However, Goodman et al. (18) said working women had higher labor satisfaction. In our study, the rate of working women in the spinal anesthesia group was high, although it was insignificant. When the whole population was evaluated, the BSS scores of working women were higher than those who did not, although insignificant (BSS score =110.6±12.4 vs. 105.8±12.9, p=0.153).

Study Limitations

The main limitation of our study is that it is single-centered, and the sample size is relatively small. Additionally, it is not a randomized controlled trial. The anesthesiologist informed the patients about general and spinal anesthesia, and the decisions were left to the patients, and groups were formed. Since general anesthesia is mainly preferred in our clinic for risky pregnancies such as placenta previa, HELLP syndrome, and pregnant with fetal anomalies, these pregnant were not included in the study. Birth satisfaction scores may have been lower in these pregnant women.

Conclusion

In conclusion, this study found that the birth satisfaction scores of women who had a cesarean section under spinal anesthesia were significantly higher than those who had general anesthesia. In addition, the educational status of women affects their anesthesia preferences and birth satisfaction scores. Informing women with low education levels about spinal anesthesia and eliminating their fears and concerns may enable them to prefer it. Thus, it can increase satisfaction with the birth process, essential in women’s lives.

Ethics

Ethics Committee Approval: This prospective descriptive cross-sectional study was approved by the Clinical Research Ethics Committee of the University of Health Sciences Turkey, Kanuni Sultan Süleyman Training and Research Hospital (date: 06.04.2022, number: 90). The work was started following the principles of the Declaration of Helsinki.

Informed Consent: Verbal and written consent was obtained from all women who gave birth in the study.

Peer-review: Internally and externally peer-reviewed.

Authorship Contributions

Surgical and Medical Practices: H.Ç.A., K.A., Ş.Ç.Y., Concept: H.Ç.A., K.A., Ş.Ç.Y., Design: H.Ç.A., K.A., Ş.Ç.Y., Data Collection or Processing: H.Ç.A., Ş.Ç.Y., Analysis or Interpretation: H.Ç.A., K.A., Literature Search: K.A., Writing: H.Ç.A., K.A.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.

References

Akca A, Corbacioglu Esmer A, Ozyurek ES, Aydin A, Korkmaz N, Gorgen H, et al. The influence of the systematic birth preparation program on childbirth satisfaction. Arch Gynecol Obstet 2017;295(5):1127-1133.

Jafari E, Mohebbi P, Mazloomzadeh S. Factors Related to Women’s Childbirth Satisfaction in Physiologic and Routine Childbirth Groups. Iran J Nurs Midwifery Res 2017;22(3):219-224.

Spaich S, Welzel G, Berlit S, Temerinac D, Tuschy B, Sütterlin M, Kehl S. Mode of delivery and its influence on women’s satisfaction with childbirth. Eur J Obstet Gynecol Reprod Biol 2013;170(2):401-406.

Uzun E, Güney M, Oral B, Özsoy M, Mungan T. Kadın Hastalıkları Ve Doğum Servisi: Verilen Hizmetlerle İlgili Hasta Memnuniyeti ve Etki Eden Faktörler. Uzmanlık Sonrası Eğitim ve Güncel Gelişmeler Dergisi 2006;3:167-171.

Taşçı KD. Doğum Yapan Hastaların Aldıkları Bakımı Hasta Hakları Açısından Değerlendirmeleri. Atatürk Üniversitesi Hemşirelik Yüksekokulu Dergisi 2007;10:26-33.

Smarandache A, Kim TH, Bohr Y, Tamim H. Predictors of a negative labour and birth experience based on a national survey of Canadian women. BMC Pregnancy Childbirth 2016;16(1):114.

Purtuloğlu T, Özkan S, Teksöz E, Dere K, Şen H, Yen T, ve ark. Elektif sezaryen uygulanan olgularda genel ve spinal anestezinin maternal ve fetal etkilerinin karşılaştırılması. Gülhane Med J 2008;50:91-97.

Lynch J, Scholz S. Anaesthetic-related complications of caesarean section. Zentralbl Gynakol 2005;127(2):91-95.

Martin CH, Fleming V. The birth satisfaction scale. Int J Health Care Qual Assur 2011;24(2):124-135.

Cetin FC, Sezer A, Merih YD. The birth satisfaction scale: Turkish adaptation, validation and reliability study. North Clin Istanb 2015;2(2):142-150.

Çelik AS, Çelik EC. Do Delivery Method and Anesthesia Type at Delivery Affect Postnatal Comfort Levels? JAREN 2020;6(1):97-108.

Fleming SE, Donovan-Batson C, Burduli E, Barbosa-Leiker C, Hollins Martin CJ, Martin CR. Birth Satisfaction Scale/Birth Satisfaction Scale-Revised (BSS/BSS-R): A large scale United States planned home birth and birth centre survey. Midwifery 2016;41:9-15.

Huang SY, Sheu SJ, Tai CJ, Chiang CP, Chien LY. Decision-making process for choosing an elective cesarean delivery among primiparas in Taiwan. Matern Child Health J 2013;17(5):842-851.

Pınar G, Doğan N, Algıer L, Kaya N, Çakmak F. Factors that affecting mothers’ postnatal comfort. Dicle Med J 2015;36(3):184-190.

Bilgin NÇ, Ak B, Potur DÇ, Ayhan F. Satisfaction with Birth and Affecting Factors in Women Who Gave Birth. HSP 2018;5(3):342-352.

Henriksen L, Grimsrud E, Schei B, Lukasse M; Bidens Study Group. Factors related to a negative birth experience - A mixed methods study. Midwifery 2017;51:33-39.

Conesa Ferrer MB, Canteras Jordana M, Ballesteros Meseguer C, Carrillo García C, Martínez Roche ME. Comparative study analysing women’s childbirth satisfaction and obstetric outcomes across two different models of maternity care. BMJ Open 2016;6(8):e011362.

Goodman P, Mackey MC, Tavakoli AS. Factors related to childbirth satisfaction. J Adv Nurs 2004;46(2):212-219.

Evaluation of Birth Satisfaction in Caesarean Section with General Anesthesia and Spinal Anesthesia