Introduction

Pregnancy and childbirth are two natural physiological phenomena that are among the amazing life events for every mother. Bestowing a maternity identity, childbirth is a divine, though stressful, event of life for every woman with effective impacts on their quality of life². Moreover, childbirth is a multidimensional experience³ with unparalleled pain, emotional tension, fatigue, Vulnerability, risk of physical harm or even death, and behavioral role changes⁴. During childbirth, women gain important experiences that accompany them throughout their life^5,6. The concept of satisfaction has nowadays got an utmost prominence in the healthcare system⁷. Indeed, client satisfaction refers to one’s overall attitude and inclination towards their entire healthcare experience. Satisfaction is attained once the patient’s/client’s perceived quality of healthcare services not only remains positive and satisfactory but also meets and surpasses their expectations. Accordingly, the awareness of one’s attitude towards health services has been projected as a new era in ensuring the quality of healthcare in the recent years⁸. Childbirth is known as a multifactorial phenomenon comprising physical, emotional, physiological, social, cultural and psychological dimensions affected by various personal and environmental factors⁹. Women’s satisfaction with the experience of childbirth plays a determinative role in maintaining the mental health of family and society as a decisive indicator for evaluating the quality of childbirth services. Since childbirth is the main reason of referring pregnant women to healthcare units for receiving health services, evaluation of their satisfaction with the provided cares during labour pain and delivery has become a dominant issue in assessing the quality of healthcare services and policies as well as appropriacy propriety? of healthcare decision-making and management³. With regard to the fact that one can simultaneously feel dissatisfied with some aspects of a satisfactory experiences, the overall satisfaction with delivery experience should not be solely sought in childbirth evaluation; that is factors affecting satisfaction with childbirth in different cultures should also be considered. The ultimate proposed objective of Iran healthcare system is to succeed in complying with WHO standards of reducing C-section delivery rates through promoting vaginal delivery. The fact that evaluation of childbirth satisfaction amongst Iranian women, who are living in a distinct cultural context is dissimilar to other parts of the world, has become a research priority in Iran. Thus, further investigations into maternal satisfaction with childbirth seems necessary in order to meet the country’s healthcare needs for improving fertility rate and achieve the proposed objectives through prompting women towards vaginal delivery and promoting fertility. Furthermore, since childbirth is a unique experience involving sophisticated emotions¹¹ and in-depth qualitative data, it requires profound understanding to evaluate women’s expectations for and/or satisfaction with this exceptional process. Preceding research have had an objective and quantitative assessment on maternal satisfaction with childbirth; thus, no qualitative study has been found in this area. Some studies, however, investigated maternal satisfaction as a sub-outcome lacking sufficient depth and breadth¹². Consequently, the present study aimed at determining the women’s experience and perception of factors affecting their satisfaction with childbirth.

Materials and methods

The present qualitative study was conducted based on conceptual content analysis. As a systematic technique, content analysis underlines personal experiences and attitudes in order to derive an in-depth description of the intended phenomenon¹³. This rule-governed research method is used for encoding and categorizing textual data to identify their overt or covert themes and patterns^15,16. Data collection have commenced since June 2017 once the present research was approved under the number IR.UMSHA.REC.1396.2688 by ethics committee and letter of recommendations received from the university. Purposive sampling methods was used for targeting and selecting the subjects who are rich source of information so as to be able to actively participate in the research and provide a better description to the researcher. The number of subjects had not been exactly determined since the commence of the present research; so convenience sampling continued to data saturation in Fatemieh (PBUH) hospital affiliated to Hamedan University of Medical Sciences, Booali private hospital and Atieh hospital affiliated to Social Security Organization in Hamedan province and terminated as it reached a total number of 15 participants. Inclusion criteria consisted of mentally-balanced maternal women without a history of psychiatric diseases who were willing to participate in the research once thoroughly informed of the current objectives. The intended participants were selected with maximum demographical diversity. Moreover, data collection instrument included an in-depth semi-structured personal interview. Each interview took 20 to 60 minutes depending on the responsiveness of the participants. Accordingly, the present study performed 17 interviews with 15 participants (i.e. participants 1 and 2 both were interviewed twice). The purpose of the present study was thoroughly explained to the eligible participants by the researcher after conversing with them. Next, if they felt OKEY after the baby was delivered they were interviewed in the breastfeeding room of the same ward with cooperation of the staff. Otherwise, the participants coordinated with interviewers to decide on the time and place of the remaining interviews. Finally, the interviews were carried out at the appointed time and place once consent reached with emphasis on optional participation and the interviewees were assured of the confidentiality of their information and responses, accessibility of the findings and their right to withdraw from at any stage of participation in the present study.

Typical questions were as follows: Please explain your experience and feelings of vaginal delivery, (what do you think of your experience of delivery)? Why did you select or what affected your selection of vaginal delivery? What was effective in choosing this hospital for your childbirth? What makes you feel good about your childbirth? What are your most important concerns while thinking of your childbirth? What makes you feel bad about your childbirth? What makes you concerned about your future fertility since the time you delivered? What do you think you should have already known or been provided with to feel satisfied or dissatisfied with your current delivery? After data analysis, the subsequent participants were interviewed with different questions based on the concepts and questions aroused in the researcher’s mind to enable them achieve other dimensions and characteristics of the structured subthemes. Furthermore, exploratory questions were proposed during the interview to enrich the analysis. Such exploratory questions included: Would you please elaborate more on that? Did you mean … by saying …? Would you please clarify? In case of a second interview with the same interviewee, the subsequent questions were asked for more transparency: As discussed earlier, you told that …, would you explain more? Is there any other points you would like to add to what you have already mentioned in your previous interview?

Data analysis was simultaneously performed with data collection on the basis of conceptual content analysis. All the interviews were recorded on a voice recorder once permitted by the interviewees. The recorded interviews were literally transcribed on an MS Word file. Afterwards, the transcriptions were carefully reviewed by the researcher and were initially encoded based on semantic units. The semantic units were severally severely appraised and classified based on their conceptual homogeneity. The themes and subthemes were compared and analyzed to extract inferences.

The scientific accuracy and reliability of data were assessed in accordance with acceptability, reliability, transferability and verification criteria. Data validation was carried out through having long-term involvement with data and having sufficient time for data collection and data analysis in order to obtain more profound data and select more experienced participants. The researcher audited the research team and participants. Data verification was performed through regular data collection and accurate recording of all research stages while data reliability was attained using participant review technique. Several meetings were held with the research team for discussing the collected information to ensure data reliability. Sampling was done with maximum diversity and the details of study, its background and terms of participation were explicated to promote data transferability^17,18.

Results

(Table 1) displays the demography of participants i.e. 15 women who had already undergone childbirth. Subsequently, seven themes, with 20 sub-themes included, were structured once data was analyzed. The extracted themes included the ‘’desire to record the unique experience of childbirth’’, ‘’underlying cultural beliefs on childbirth’’, ‘’understanding of the nature of labour pain’’, ‘’confrontation with ignorance’’, ‘’interaction environment: from support to aggression’’, ‘’confrontation with fear and anxiety’’ and ‘’desire to hug a healthy baby.’’

Desire to record the unique experience of childbirth

This theme consisted of three sub-themes, namely the ‘’enthusiasm for experiencing labour pain’’, ‘’would-be mother’s consciousness and personal control over all labour procedures during delivery’’ and the ‘’love for vaginal delivery.’’ Amongst the participants, the one with an enthusiasm for experiencing the labour pain as a lovely experience stated that: ‘’It was all fine with pain, of course. Thinking of it, I believe it was so lovely and worth the pain.’’

One mother whose consciousness and personal control during delivery played a critical role in her satisfaction with childbirth experience specified that: ‘’the pain was perhaps annoying but not that much, now that I think, to brag about it and say it was too painful that I could literally talk, it seemed not too much pain to me that I could talk and stay awaked at that moment.’’

Some mothers mentioned that their decisiveness in having a vaginal delivery during pregnancy and their love for vaginal delivery had a crucial role in the satisfaction with their childbirth. Vaginal delivery was the one and only choice for most of them and was preferred to C-section delivery. In this regard, a mother expressed that: ‘’caesarean is good but not as vaginal delivery. In vaginal, you somehow feel the pain for a couple of hours but soon after you can get up and breastfeed your baby. You walk around comfortably but that’s not the case in caesarean. Generally, vaginal is more comfortable. Since the time I noticed I’m pregnant I’ve been thinking of vaginal delivery.’’

Underlying cultural beliefs on childbirth

This theme involved three subthemes as ‘’labour pain helps endure life difficulties’’, ‘’belief on the hardship of labor pain’’ and ‘’tendency to follow medical instructions.’’ Some participants had such feelings as getting older, becoming more patient and being more tolerant of life difficulties once they underwent the labor pain, which increased their satisfaction with vaginal delivery. According to a mother who felt becoming more tolerant of life hardships: ‘’It feels like as if you get older and you can tolerate more difficulties because nothing is harder and more painful than this, I believe. So you can endure any hardship in life.’’

The tendency to follow medical instructions, such as attracting the midwife’s attention by heartily listening to her commands, also played a crucial role in satisfaction with vaginal delivery. In this regard, a mother stated that: ‘’I was all ear like kids listening to them. I admitted whatsoever they told me. You know because I felt they are honestly helping me so I should be more careful.’’

Inattentiveness to the advices of others was one of the factors affecting satisfaction with vaginal delivery. A mother declared that: ‘’I never talked about it with anyone even my sister or sister-in-law. I never asked about how the pain fells like or how it goes on or what steps are there to give birth. I searched it on the net but never asked anyone. I was cool with it.’’

Understanding the nature of labour pain

The above-titled theme included three sub-themes i.e. ‘’fearful labour pain’’, ‘’progressive labour pain’’ and ‘’irresistible labour pain.’’ Many participants expressed more fears and anxiety about vaginal delivery due to their awareness of delivery stages and process through watching videos of vaginal birth, which affected their satisfaction with childbirth. However, a mother, who preferred to remain unnoticed of how vaginal delivery proceeds, declared that:

‘’If I learnt about it, I’d be more stressful. So I would like to step into it as a fait accompli.’’

Some women assumed progressiveness and irresistibility as the integral parts of labour pain. For instance, a mother asserted that:

‘’Yeah, vaginal is expected to be painful. Midwives stay up all the day through besides you as much as they can, they nurse you in any way possible but you should tolerate the pain; you know, as you make your bed, you must lie on it.’’

Confrontation with ignorance

This theme involved three sub-themes including ‘’unfamiliarity with persons and relationships’’, ‘’unfamiliarity with childbirth procedures and rules’’ and ‘’unfamiliarity with the hospital environment.’’ That is, participants considered unfamiliarity with persons and relationships, such as unfamiliarity with the nursing midwife, as a reason for dissatisfaction with childbirth.

‘’Nobody has told me who my midwife is. They were not one or two around; students come and go and I felt too bad that I had no idea who is around or who the doctor is.’’

A mother, who was unfamiliar with the childbirth procedures and rules, such as ignorance of the succor of an assistant midwife until the delivery time, stated that: ‘’I was not informed I would have an assistant midwife until yesterday when I was about to deliver.’’

Unfamiliar with the hospital environment, another would-be mother felt unsupported and imprisoned in the labour pain room and affirmed that: ‘’I felt imprisoned and alienated. They left me in a solitary room where I was not allowed to leave.’’

Interaction environment: from support to aggression

The above-titled theme encompassed four subthemes, namely ‘’pleasant environment’’, ‘’supportive interaction’’, ‘’aggressive interactions’’ and ‘’staff negligence.’’ Interaction environment implies that participants’ needs surpass the mere medical and midwifery requirements to undertake the delivery process meaning that a pleasant environment involving being understood and having an experience of environmental satisfaction as well as supportive interaction comprising longer relationship with the delivery agent had significant impacts on their satisfaction with vaginal delivery. A participant expressed her satisfaction as: ‘’I was generally satisfied and comfortable. They told me I could get off the bed, use the restroom, sit on the therapy ball to relieve my labor pains, use oxygen. They were helpful. I was also allowed to walk around the corridor and walk in the room. I had freedom.’’

Regarding aggressive interaction such as misbehavior and unaccountability of staff and nurses demoralizing and discouraging the mothers, one participant stated that: ‘’They were always nagging with mistreatment. They told me ‘stop being corny, it’s not your first-time delivery; you’ve already had two kids, why thinking of the third?’; you know they misbehaved as such but I had to tolerate.’’

Confrontation with fear and anxiety

This theme had two sub-themes of ‘’fear’’ and ‘’anxiety from the risks of childbirth and newborn baby’’. Maternal concern over the healthy birth of the newborn baby could have an inhibitory effect on their satisfaction with vaginal delivery. A participant who was constantly worried about her baby being injured during delivery stated that: ‘’I was only thinking what if my baby wouldn’t survive while I’m tolerating such a great pain and hardship. God forbid, perhaps I’d be depressed if something bad happened.’’

Being stressed out due to mother’s history of an unpleasant vaginal delivery or fear from C-section has disturbed the mind of some mothers. Despite already passing two deliveries, a mother was still stressful and expressed that: ‘’my 3^rd-time birth-giving was more worrying because I’ve had the experience and knew what a painful moment I’m going to go through. I was already stressful but became more scared as I got to the hospital.’’

Desire to hug a healthy baby

This theme included two subthemes of the ‘’desire to give birth to a healthy baby’’ and the ‘’desire to hug a healthy baby’’ affecting maternal satisfaction with vaginal delivery. Hoping that God would bestow her a healthy baby as per the huge pain she was incurring, a mother was confident of delivering a healthy baby and declared that: ‘’It feels good when the baby is healthy and pretty. You incur the pain and hardship and God will give you a good one.’’

Another mother proposed that hugging her baby is the key secret to a happy life. She stated that: ‘’When the baby is born, all pains go away. You feel calm. When it’s born it’s sweet and enjoyable. I’ve never felt such a lovely pleasure.’’

Discussion

The present study was conducted on nulliparous and multiparous women who gave birth in both state and private hospitals. The participants had various academic and economic levels, which was one of the strengths of the present study. Women’s experiences of factors affecting their satisfaction with vaginal delivery were structured based on seven themes, namely ‘’desire to record the unique experience of childbirth’’, ‘’underlying cultural beliefs on childbirth’’, ‘’understanding of the nature of labour pain’’, ‘’confrontation with ignorance’’, ‘’interaction environment: from support to aggression’’, ‘’confrontation with fear and anxiety’’ and ‘’desire to hug a healthy baby.’’ Provided that the patients felt okay, they were interviewed within 6 to 48 hours after childbirth in the breastfeeding room of the same ward with cooperation of the staff. According to the results of the present study, the enthusiasm and love for experiencing vaginal delivery was a significant factor affecting the satisfaction with vaginal delivery especially in nulliparous women. Most of the subjects were satisfied with their opportunity to consciously apprehend all procedures of delivery and vigilantly saw their baby while being delivered. In their quantitative study, Goodman et al. determined factors affecting maternal satisfaction with childbirth in the US. They found that women’s personal control over labor was a substantial predictor of their satisfaction, subscales included, with vaginal delivery.. Guittier et al. conducted a qualitative study on the effect of delivery mode on the childbirth experience of nulliparous women. They indicated that emotional apprehension and control over the first contact with the newborn baby was one of the most important factors affecting a desirable vaginal delivery experience compared with C-section delivery¹⁹. The participants of the present study whose feelings of getting older, becoming more patient and more tolerant of life difficulties, triggered by their vaginal labour pain, marked the insignificance of the pain were more satisfied with vaginal delivery. The tendency to follow medical instructions, such as attracting the midwife’s attention by heartily listening to her commands, also played a crucial role in satisfaction with vaginal delivery. The aforesaid results were consistent with the findings of Mekonnen et al. who displayed that women following the advices of medical staff and nurses to receive necessary information, were more satisfied with their childbirth²⁰. In the present study, most mothers who expressed more fears and anxiety about vaginal delivery due to their awareness of delivery stages and process through watching videos of vaginal birth declared that being less informed about the nature of vaginal delivery had made them less stressful while more satisfied with their vaginal childbirth. Therefore, regarding maternal stress and fear of vaginal delivery, Fenwick stated that specialized training courses held by such professionals as nurses can have a significant impact on pregnant women. Such courses should depict vaginal delivery portray in such a way asto promote confidence in pregnant women and teach them how to control their fear²¹. Corresponding to the findings of Hodnett²² and Lally²³, the results of the present study demonstrated that while their delivery conditions proceeded better than expected, those women whose expectation for a painful experience made them more realistic and less romantic about vaginal delivery became more satisfied than those with a delivery experience worse than expected.

According to the present study, confrontation with ignorance including unfamiliarity with the hospital environment and unfamiliarity with childbirth procedures and rules contributed to maternal dissatisfaction while the succor of an assistant midwife until the delivery time led to maternal satisfaction. Likewise, Raven et al. found that quality childbirth cares and rules, increased sense of responsibility and intimate communication between service providers and service receivers, and their families, were considered as vital and effective factors in maternal decision making during childbirth in China²⁴.

Furthermore, Sawyer et al. indicated that staff competency in conveying information and explanation had a significant impact on maternal satisfaction²⁵. In their study entitled ‘’the satisfaction rate of vaginal delivery and related factors in Mahdieh Hospital in Tehran and Shahid Chamran hospital in Boroujerd’’, Dolatian et al. (2006) found that satisfactory childbirth environment was one of the best predictor of maternal satisfaction^26,37. Based on the results of the present study, the interaction environment from support to aggression was a crucial factor affecting childbirth satisfaction which was also highlighted in other studies. The current participants demanded extensive supports during their labour process accentuating the insufficiency of merely scientific and midwifery approach to maternal satisfaction. That is, they required emotional support and empathic behavior on the part of medical staff and associates to help them adapt to the labour pain they are incurring. In Gamble’s et al. quantitative study, the participants prioritized the relationship with care providers²⁷. Waldenstrom et al. displayed that staff support and attentiveness to the would-be mother during labour was highly vital in Sweden²⁸. Similarly, Sawyer stated that staff competency, calmness in crisis, portraying confidence and control in addition to solely listening to the would-be mother, empathy, emotional support and encouragement as well as the succor of father during childbirth significantly affected maternal satisfaction^25,36. Moreover, staff support and communication especially on midwife’s part, was a significant and solid predictor of maternal satisfaction with childbirth experience^26,29. The present study showed that aggressive interaction such as staff misbehavior and unaccountability demoralized and dissatisfied the mother-to-be. Likewise, Beck found that negative communication and lack of support can be accounted as one of the causes of postpartum traumatic disorders and tensions^30,35. According to Karlstrom, firs-time childbirth experience had a vital significance in maternal attitude towards subsequent pregnancies to which the attentiveness of medical staff in delivery room is highly appreciated³¹. Maternal concern over the healthy birth of the newborn baby could also have an inhibitory effect on their satisfaction with vaginal delivery. Most of them were often worried about the potential risks during childbirth triggering a negative attitude towards vaginal delivery and the demand for C-section delivery. The aforesaid findings were consistent with the results of Karlstrom indicating that being stressed out during labour as well as having a prolonged delivery led mothers to fear and agony and increased their inclination to C-section delivery^31,34. Similarly, Vaziri et al. demonstrated that highly stressful mothers adopted a new negative outlook towards vaginal delivery during childbirth and disapproved it for prospective mothers³². In line with the study of Kassai et al. in Brazil²³, the participants of the present study presented a satisfactory expression for vaginal delivery contributed to rapid recovery and return to normal life so as to immediately participate in caring the newborn baby as well as their inexperience of caesarean-related pain and suffering.

Conclusion

The results of the present study indicated that satisfaction with vaginal delivery is multifactorial and reflective of several peripheral aspects associated with the positive key factors imposing various effects with negative outcomes included as well. Therefore, identifying the structure and process of maternal satisfaction with vaginal delivery in Iran would assist the necessity of appropriate cultural strategies for implementing effective interventions to enhance maternal satisfaction with vaginal delivery. It would also promote them through holding childbirth preparation training courses on non-pharmacological prevention and relief of labor pain to make vaginal delivery an enjoyable and indelible experience for women. Besides, midwives and medical staff are highly recommended to pay considerable attention to the psychological and supportive needs of the would-be mothers with their physical health prioritized.

Agradecimientos

Hereby, the researcher of the present study would like to express their sincere gratitude to all the participants, without whom this study would be in vain, and earnestly appreciate the management and staff of Fatemieh (PBUH) hospital affiliated to Hamedan University of Medical Sciences, Booali private hospital and Atieh hospital affiliated to Social Security Organization in Hamedan province.

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Author notes

khakbaza@sina.tums.ac.ir