1. Introduction
Maternal satisfaction is the most direct and important evaluative indicator for the childbirth process and healthcare services. It refers to the positive evaluation of different dimensions of the childbirth experience [
1]. A number of studies have shown that maternal satisfaction could affect the mother’s physical and mental health, the relationship with their baby, and the willingness to give birth again [
2,
3,
4,
5]. Women with high childbirth satisfaction have a good sense of self and can adapt to the role of mother more quickly [
2]. In contrast, women with low childbirth satisfaction are prone to postpartum depression, child abuse, marital discord, violent injuries, and even medical litigation [
6,
7,
8].
Women’s maternal satisfaction has been proven to be influenced by multiple variables. On the one hand, it comes from the relevant objective conditions of the maternal delivery process, including pain in labor, self-rated physical health, delivery method, medical intervention, and mother and child safety [
9,
10,
11]. On the other hand, it is subject to many subjective cognitive and emotional factors during the labor process, such as the mother’s expectations, fear of pain, childbirth self-efficacy, participation in decision making, and maternal perception support from medical staff [
1,
4,
11,
12,
13,
14].
Extant literature has primarily focused on the actual delivery method of the parturient (cesarean section or vaginal delivery) and its impact on childbirth satisfaction [
15,
16]. However, little research has paid attention to the consistency between the expected and actual delivery method and its effect on women’s childbirth satisfaction. Inconsistent delivery methods are a manifestation of the ethical dilemma of medical staff, including the informed knowledge, respect, self-actualization, and consistency of awareness and facts [
15]. In fact, conflicts also arise between mothers and medical staff in terms of the consistency of delivery methods. Researchers have found that the final delivery method was not based on mothers’ own requirements, but on the medical staff’s decisions [
17].
As the research trend shifts from focusing on “biomedicine” (e.g., medical analgesia intervention, midwifery services, and nursing quality) [
4,
18] to bio-psychological-social medicine [
19], the focus on women’s needs during delivery has changed from mother and child safety to subjective and humanized delivery. The influential factors of maternal satisfaction from social-psychological perception could be divided into control factors and support factors. Control factors include physical self-assessment, personal control, self-efficacy, and emotional management [
1,
20], and support factors include the care and support perception provided by medical staff, as well as the quality of communication between medical staff and pregnant women [
12,
21]. However, there has been no systematic study on the impact of social-psychological factors on maternal satisfaction in China. Chinese mothers have a low level of maternal satisfaction in Asia [
22], and we propose that such low satisfaction stems from poor attitudes and support of medical staff and suppressed maternal self-efficacy. This is because a pregnant woman needs adequate knowledge, motivation, and skills to access, understand, appraise, and apply health information to make decisions about the health of herself and her unborn baby [
23].
Previous research has found that maternal satisfaction could reflect the trust relationship between pregnant women and medical staff [
4,
11,
24]. Especially in China, the delivery satisfaction of most mothers is closely related to medical staff. Women have high expectations for medical staff to support them. They prefer medical staff who are friendly, caring, and respectful, who share information, and who treat each mother equally. However, Chinese mothers rarely feel or receive support from medical staff, and they are instead sometimes yelled at, ridiculed, abused, and treated impatiently by doctors. The gap between expectations and reality frustrates maternal expectations, making women uncomfortable and reducing maternal satisfaction [
25]. Moreover, the poor attitude of medical staff and little childbirth experience has made Chinese women not dare to express self-needs and forced them to rely too much on medical staff, inhibiting the positive effect of self-efficacy during the childbirth process.
Therefore, this research tried to analyze and respond to the ethical issues surrounding the childbirth experience, especially the situation and relationship between medical staff and mothers regarding information acquisition, information awareness, plan modification, etc. Based on this research question, this article studies the influencing factors and internal mechanisms of maternal satisfaction from the perspective of social psychology and specifically discusses the relationship between the consistency of delivery mode between expectation and practice, the perceived support from medical staff and maternal self-efficacy, and the effects on maternal satisfaction.
3. Study 1
3.1. Materials and Methods
This study conducted a questionnaire survey for mothers who gave birth between 1 and 10 days earlier in six obstetrics and gynecology hospitals in Shanxi Province (three urban general hospitals and three rural general hospitals). In order to protect the privacy of the obstetric hospitals and mothers, the hospitals in this survey were named “A~G”. The number of births per year of the six hospitals is above 6000, which represents the comprehensive strength of the obstetrics departments of the hospitals and the actual birth situation of obstetrics departments in China.
A total of 220 questionnaires were distributed in this survey: 145 were recovered, 117 were validly answered, and the valid response rate was 69.0%. Among the 117 participants (Mean
age = 25.55, SD
age = 3.20, Max
age = 36, Min
age = 18), 81 (69.2%) gave birth for the first time, 35 (29.9%) for the second time, and 1 (0.9%) for the third time. Regarding geographical distribution, there were 48 urban women (41%) and 69 rural women (59%) (refer to
Table 1 for more information on demographics).
At the beginning of the survey, all participants signed an informed consent form. They were guaranteed anonymity and allowed to discontinue the survey at any time. The participants were informed that the survey consisted of multiple sections to understand their satisfaction with delivery. After the survey, each participant could receive a bag of laundry as a reward.
The questionnaire included four parts: (1) Delivery mode. The participants were asked to answer the following questions about the delivery mode: the actual delivery mode (1 = vaginal delivery without anesthesia, 2 = painless delivery, 3 = caesarean section, 4 = suction delivery, 5 = forceps delivery). During data analysis, we categorized the delivery mode into 0 = caesarean section, 1 = vaginal delivery (including the options of 1, 2, 4, and 5, all childbirth through the women’s birth canal and vagina, with and without medical intervention). They also answered the consistency of delivery method (1 = yes; 0 = no). (2) Perception of support from medical staff was adapted from Matsuoka et al. (2009), with four items to evaluate the attitude and behavior of medical staff (a = 0.908). The items consisted of “The medical staff provide me with continuous care and assistance”, “The obstetricians provide me with abundant delivery knowledge and guidance during pregnancy”, “During childbirth, the medical staff especially respected and valued me,” and “After giving birth, the medical staff provided me with physical and mental care and shared parenting knowledge”, using a 5-point Likert scale (1 = very dissatisfied, 5 = very satisfied). These items were proved to combine as one factor (KMO = 0.849, p < 0.000) and explain 78.702% of variance. (3) Maternal satisfaction with the delivery experience was measured using a 5-point Likert scale (1 = very dissatisfied, 5 = very satisfied). (4) Demographics were collected, including age at first birth, age at second childbirth, occupation, education level, and living area (1 = urban, 0 = rural).
3.2. Results
Common method bias check. Given the nature of a single-shot cross-sectional survey, we first checked whether there was a common method bias before the formal data analysis. Harman’s one-factor analysis was conducted [
42] by including all of the items of key variables for an exploratory factor analysis using a maximum likelihood solution. In Study 1, we identified three factors and found the first factor accounted for 33.558%, which is below the criterion of 50% [
43]. Therefore, there is no common method bias in Study 1.
Description of delivery mode and consistency. Among the 117 participants, 78 (66.7%) had vaginal deliveries (including 74 with vaginal delivery, 3 with painless delivery, and 1 with forceps delivery), and 39 (33.3%) had cesarean sections. As for the delivery mode consistency, 81 women claimed that they experienced their desired delivery method (69.2%), and 36 (30.8%) women had a delivery method inconsistent with their expected method. Among the 36 mothers, 20 (17.1%) conducted the inconsistent delivery method because of abnormal conditions during childbirth; the others were forced to choose a cesarean section because of the doctors’ advice (11, 9.4%), the woman’s changed willingness (4, 3.4%), or their family’s suggestion (1, 0.9%).
Main effect. The mean, standard deviation, and correlation analysis of key variables in Study 1 are shown in
Table 2. Regression analysis was conducted with the consistency of delivery mode as the independent variable and maternal satisfaction as the dependent variable. The results showed that the consistency of delivery mode could positively increase maternal satisfaction (β = 0.413, t = 4.863,
p < 0.000), and it still had a significantly positive effect (β = 0.419, t = 4.642,
p < 0.000) on maternal satisfaction after controlling for some demographics, numbers of delivery, and numbers of medical intervention (results referred to
Table 3). In addition, compared with women who expected and practiced a consistent delivery mode (M = 4.05, SD = 0.92), women who expected and practiced an inconsistent delivery mode had a lower satisfaction with delivery (M = 3.06, SD = 1.22). Thus, H1 was supported.
Mediation. We predicted that the perception of support from medical staff would mediate the effect of the consistency of delivery mode on maternal satisfaction. A 5000 resampling bootstrapping mediation analysis using consistency of delivery mode as the predictor, perception of support from medical staff as the mediator, and maternal satisfaction as the dependent variable (Hayes 2018, Model 4) confirmed this prediction. The analysis revealed a significant omnibus index of mediation (Effect = 0.2638 SE = 0.1257, 95% CI: (0.0303, 0.5310)). Thus, H2 was supported.
3.3. Discussion
Based on the participants’ self-reported survey results in six hospitals, Study 1 proved that the consistency of delivery mode between expectation and practice behavior had a positive main effect on maternal satisfaction, and a consistency of delivery mode showed a higher satisfaction than that with an inconsistent delivery mode. The mechanism of the above effect was mediated by women’s perception of support from medical staff. Therefore, both H1 and H2 were supported. However, there are two shortcomings in Study 1. On the one hand, the support of medical staff could be further classified, such as the material, emotional, informational, and behavioral support provided by medical staff. On the other hand, women might have the power to control the efficacy of their bodies and influence the whole process of delivery and maternal satisfaction, which may work as a moderator. Study 2 would further address the above issues.
4. Study 2
In Study 2, two more issues were investigated. One was the updated measurement of the perception of support from medical staff, namely, the Breastfeeding Self-Efficacy Scale Short Form (BSES-SF). The other was the inclusion of women’s self-efficacy to test whether it played a moderating role in the relationship between the consistency of delivery mode, perception of support from medical staff, and maternal satisfaction.
4.1. Participants
A total of 237 female participants who had children were recruited from the sample database on the Credamo platform (
https://www.credamo.com/#/ accessed on July and August 2022); these women had not joined Study 1. Among the 237 responses, 32 qualified responses were rejected through automatic screening and attention detection, and finally, 205 valid responses were recovered. All the participants had their first delivery at the average age of 26.09 (SD = 2.53, N = 205), and 57 of them had their second delivery experience at the average age of 30.02 (SD = 2.32, N = 57).
Table 4 shows the basic demographics of participants, including geographical distribution, education, occupation, and monthly household income.
4.2. Procedures and Measures
Study 2 was a survey to test the relationship between the consistency of delivery mode, perception of support from medical staff, mothers’ self-efficacy during childbirth, and maternal satisfaction. Mature scales verified with high reliability and validity were chosen and subsequently translated from English to Chinese, following the back-translation process [
44].
Participants were invited to read the informed consent online at the beginning of the survey. Then, they were asked to answer five parts of a questionnaire. After their answers were checked and qualified, they would receive 5 yuan in RMB as a reward.
The five parts of the questionnaire included: (1) Delivery mode. The participants were asked to answer two questions, namely, the “delivery method in the last delivery experience” and “expected delivery method in the latest delivery experience”, with four options: 1 = vaginal delivery without medical intervention, 2 = vaginal delivery with medical intervention (such as oxytocin, artificial water breaking, lateral incision, etc.), 3 = painless delivery (epidural anesthesia), 4 = cesarean section. Just like Study 1, we combined the choice of 1 and 3 as a new variable, vaginal delivery, compared with the other kind of delivery mode, the caesarean section. (2) Perception of support from medical staff, adapted from the Brinell Childbirth Support Perception Scale (The Breastfeeding Self-Efficacy Scale Short Form) [
45]. The scale has 25 items, such as “the medical staff helped me to familiarize myself with the environment, such as giving me a detailed introduction to the delivery environment”, “the medical staff cared about me, being very kind and friendly, and let me feel honored”, “The medical staff communicated my needs and wishes to the doctor and other hospital staff”, “The medical staff encouraged my husband/main attendant to participate in the production process and gave him a positive response”. A 5-point Likert scale was used (1 = very dissatisfied, 5 = very satisfied) with good reliability (α = 0.962). (3) Maternal perceptions of self-efficacy were assessed using the Childbirth Self-Efficacy Inventory (CBSEI) [
40], with good reliability (α = 0.936). Participants were asked to answer 16 questions, such as “I can relax my body in some ways”, “I can maintain self-control during childbirth”, and “I can give myself positive guidance”, with a 5-point Likert scale (1 = not at all, 2 = rarely, 3 = sometimes, 4 = often, 5 = absolutely). (4) Maternal satisfaction, using a 5-point Likert scale (1 = very dissatisfied, 5 = very satisfied). (5) Demographic variables, including gender, age, occupation, highest educational background, living area (urban/rural), and monthly household income.
4.3. Results
Common method bias check. Just like in Study 1, a common method bias was conducted in Study 2. The results showed that 12 factors emerged with eigenvalues larger than 1.00, indicating that more than one factor underlay the data. In addition, the first factor accounted for only 31.298% of the total variance, suggesting that the common method variance may not be a severe concern in the present study.
Description of delivery mode and consistency. In terms of the expectant delivery method, 77 (37.6%) women expected a vaginal delivery without medical intervention, 39 (19.0%) expected a vaginal delivery with medical intervention, 67 (32.7%) expected a painless delivery, and 22 (10.7%) expected a cesarean section. However, as for the actual delivery method, 33 (16.1%) had a vaginal delivery without medical intervention, 96 (46.8%) had a vaginal delivery with medical intervention, 52 (25.4%) delivered by caesarean section, and 24 (11.7%) had a painless delivery. In terms of the consistency of delivery methods, 92 (44.9%) had consistent delivery methods between expectations and practical experience; however, 113 (55.1%) had an inconsistent experience. Among the 92 cases with consistency of delivery mode, 22 (23.9%) experienced vaginal delivery without medical intervention, 30 (32.6%) had medical intervention, 20 (21.7%) had a painless delivery, and 20 (21.7%) delivered by cesarean section. It can be seen that most mothers expected natural labor without medical intervention and painless delivery, but they failed to choose and practice the corresponding delivery method as scheduled.
Correlation. Factor analysis was conducted for self-efficacy and the perception of support from medical staff. Self-efficacy was proved to combine as one factor (KMO = 0.946,
p < 0.000), and the perception of support from medical staff had three sub-factors (KMO = 0.955,
p < 0.000), which were named as the perception of emotional support, behavioral support, and support given to partners. The mean, SD, and correlation of key variables are shown in
Table 5. Demographic variables (education, monthly household income, age at first birth) were not significantly associated with delivery satisfaction and were therefore not analyzed as control variables.
Main effect. Using SPSS 26.0, regression analysis was performed, with consistency of delivery mode (0 = no, 1 = yes) as the predictor and maternal satisfaction as the outcome variable. Meanwhile, the influence of occupation, education, area (1 = city, 2= rural), monthly household income, number of deliveries, and the age at delivery were controlled in Model 2. The results indicated that the consistency of delivery mode could increase women’s maternal satisfaction (β = 0.323, t = 2.623,
p = 0.011) in Model 1 and was still robust in Model 2 (β = 0.342, t = 2.631,
p = 0.011). Results are shown in
Table 6.
Mediation effect. A 5000-resampling bootstrapping mediation analysis using consistency of delivery mode as X, perception of support from medical staff as M, and maternal satisfaction as Y (Model 4) [
46] was conducted to test H2. The analysis revealed a significant omnibus index of mediation (effect = 0.2773, SE = 0.0716, 95% CI = (0.1465, 0.4303)).
Moderated Mediation effect. Following Model 14 of the PROCESS Macro [
46], we performed a 5000-resampling bootstrapping-moderated mediation analysis, with consistency of delivery mode as the independent variable, perception support from the medical staff as the mediator, women’s self-efficacy as the moderator, and maternal satisfaction as the dependent variable. The results revealed a significant index of moderated mediation (effect = 0.1123, SE = 0.0482, 95% CI = (0.0331, 0.2252)). A simple slope test showed that for women with low levels of self-efficacy (M − 1 SD = 2.9141), the mediating effect was significant for the path “consistency of delivery mode → perception of support from medical staff → maternal satisfaction” (effect = 0.2030, SE = 0.0655, 95% CI = [0.0968, 0.3591)), and for women with high levels of self-efficacy (M + 1 SD = 4.1536), the positive effect was strengthened significantly (effect = 0.3422, SE = 0.0906, 95% CI = (0.1822, 0.5430)).
4.4. Discussion
Higher delivery satisfaction depends not only on the consistency of expected delivery mode and practice, but also on the strength of the perception of medical staff’s support and the mother’s self-efficacy. Although the substantive care and guidance of attendants by medical staff are important during childbirth, mothers perceiving to be respected, informed, and to actively participate decision making is essential to build a positive childbearing experience. As Harris and Ayers have pointed out, being neglected, unsupported, under mental stress, or not having attention paid to the mental demands of mothers will lead to negative experience evaluations [
33]. Therefore, women with a high level of self-efficacy would perceive more support from medical staff, and this increases maternal satisfaction. Thus, H1, H2, and H3 were approved.