key: cord-0993769-lrh6ac6w authors: Mollard, Elizabeth; Kupzyk, Kevin title: Birth Satisfaction During the Early Months of the COVID-19 Pandemic in the United States date: 2021-12-03 journal: MCN Am J Matern Child Nurs DOI: 10.1097/nmc.0000000000000777 sha: e0c2bbe449500d9f357ed72bf5f97523bfacf5fb doc_id: 993769 cord_uid: lrh6ac6w PURPOSE: The purpose of this study was to describe birth satisfaction in women who gave birth in U.S. hospitals during the earliest months of the COVID-19 pandemic (March–July 2020). STUDY DESIGN AND METHODS: A cross-sectional survey of 747 postpartum women who gave birth in the United States during the early COVID-19 pandemic was conducted. Participants in the United were recruited via social media. They completed a questionnaire that included demographic, health, and obstetric experience questions, and the Birth Satisfaction Scale-Revised. Descriptive statistics, t-tests, analysis of variance (ANOVA) models, and nonparametric correlations were performed. RESULTS: Higher birth satisfaction scores were associated with higher income, marriage, white race, vaginal birth, having a birth partner present, and sufficient support during birth. Factors negatively associated with birth satisfaction were separation from infant, unplanned cesarean birth, neonatal intensive care unit admission, hypertension, preeclampsia, hemorrhage, depression, and anxiety. CLINICAL IMPLICATIONS: Presence of birth partners, sufficient birth support, and minimizing separation of mother and infant improve birth satisfaction. Obstetric complications, including unplanned cesarean birth, negatively affect birth satisfaction. There are racial disparities in birth satisfaction. It is critical to develop further interventions to end racism in maternal health care. The COVID-19 pandemic has affected women's birth experiences Burgess et al., 2021) . Women giving birth during the pandemic have shown a high likelihood of experiencing a traumatic birth, perinatal mental health disruption, and poor maternal-infant bonding (Hessami et al., 2020; Mayopoulos et al., 2021) . During the earliest months of the pandemic, uncertainty about the COVID-19 virus led to severe and restrictive maternity care changes throughout the United States (Breman et al.; Burgess et al.; Davis-Floyd et al., 2020; Peña et al., 2020) . To prioritize infection control, hospitals reduced or excluded support persons, required universal masking and COVID testing, excluded doulas as members of the health care team, separated infants from mothers with symptoms, modifi ed immediate skin-toskin contact and early initiation of breastfeeding practices, and encouraged early discharge Bornstein et al., 2020; Breman et al.; Del Rio et al., 2021; Peña et al.) . Nurse-to-patient ratios were affected by the rise of COVID-19 patients throughout the hospital, and many nurses were forced to work longer hours and mandatory overtime (Grimm, 2021) . Pain control options were affected by anesthesia provider availability and nitrous oxide discontinuation in some settings (Podovei et al., 2020) . Dramatic changes to the maternity care environment affected women's abilities to make autonomous decisions about their birth and altered their perceptions of safety (Mollard & Wittmaack, 2021) . By midsummer of 2020, clinicians, researchers, and other maternal health advocates demanded that, despite necessary restrictions called for by the pandemic, women's human rights must still be prioritized through respectful maternity care practices (Reingold et al., 2020) . A satisfying birth experience begins a positive trajectory for the mother-i nfant dyad. Women with satisfying birth experiences feel empowered by childbirth, report higher self-esteem, and are more likely to confi dently engage in health-promoting behaviors like breastfeeding (Hinic, 2017) . A negative birth experience is associated with impaired maternal-infant bonding and adverse psychological effects, including depression and posttraumatic stress disorder (Bell & Andersson, 2016; Chabbert et al., 2021) . A woman's experience with birth occurring in the hospital affects her long-term perceptions of and future interactions with the health care system. A woman's satisfaction with her birth is multifaceted and personal (Martin & Fleming, 2011) . Birth satisfaction is affected by previous life experiences, culture, education, and temperament. Birth satisfaction is affected by stress levels and preparation for childbirth (Hinic, 2017; Miron-Shatz & Konheim-Kalkstein, 2020) . Birth dissatisfaction has been associated with obstetric interventions and complications during birth including emergency cesarean birth, postpartum hemorrhage, instrumental birth, and poor infant status (Falk et al., 2019) . Little is known about birth satisfaction in women who gave birth in U.S. hospitals during the early months of the COVID-19 pandemic. Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved. lated using the Qualtrics survey research sample size calculator (Qualtrics, Provo, UT) using number of women who gave birth in the United States in the most recent year with published data (Martin et al., 2019) . Sample size was calculated with a confi dence level of 95% and a 5% margin of error. Institutional Review Board approval was obtained and participants were recruited to complete the questionnaire hosted on the secure REDCap platform. After informed consent was obtained, participants reported demographic and health information (e.g., diabetes, hypertension), questions about obstetric history (e.g., birth method, obstetric complications like shoulder dystocia), if they had a support person present, whether they felt they had enough birth support, if they were separated from their infant, information about their infant such as if the infant was admitted to the neonatal intensive care unit (NICU), and the 10-item Birth Satisfaction Scale-Revised. The Birth Satisfaction Scale-Revised (BSS-R) is the globally recommended standardized measure to quantify maternal satisfaction with labor and birth in postpartum women (Barbosa-Leiker et al., 2015; Martin & Martin, 2014; Nijagal et al., 2018) . The BSS-R is a valid and reliable 10-item self-report instrument that uses a 0-4 Likert scale on each question (Martin & Martin) . The BSS-R was developed based on the original 30-item Birth Satisfaction Scale and has since been validated in the United States (Barbosa-Leiker et al.; Martin & Fleming, 2011) . Overall scores range from 0 to 40, with a higher score indicating more satisfaction. The BSS-R focuses on overall birth satisfaction and has three subscales including stress experienced during labor (hereinafter referred to as labor-related stress), women's personal attributes, and the quality-of-care received (Martin et al., 2018; Martin et al., 2020) . Increased use of medical interventions, insuffi cient medical care, pain, overall distress, and infant health can impact labor-related stress (Martin & Fleming, 2011) . Women's personal attributes include expectations about birth, sense of control, coping, and ability to prepare for childbirth (Martin & Fleming) . The quality-of-care provision includes satisfaction with the birth environment, support, and relationships with health care providers (Martin & Fleming) . Higher scores on the subscales associate with more satisfying experiences in quality-of-care (range 0-16), women's personal attributes (range 0-8), and labor-related stress (range 0-16; Martin et al., 2018) . Before analysis, total scores and subscale scores were calculated, and descriptive statistics were determined. Cronbach's alpha was assessed for total scores and each subscale to examine the internal consistency reliability of the BSS-R. Differences in BSS-R scores across categories of key demographic and birth-related variables were assessed using t-tests and analysis of variance (ANOVA) models. Relationships between BSS-R outcomes and con-Facebook and Instagram. We selected our audience to include; Location: Living in the United States, Age: 18-43, Gender: Female; People Who Match Interests: Parents: New Parents. Posts also were shared by groups and individuals on social media. Before beginning the study, minimum sample size was determined to be 385 participants. This number was calcu- Of the 747 women included in this analysis, 21 (2.8%) did not have a birth partner present at birth, 132 (17.7%) were separated from their baby after birth, and 116 (15.5%) of the babies had NICU stays after birth. Cr onbach's alpha in this sample was .804 for overall BSS-R scores, .731 for the quality-of-care subscale, .668 for women's personal attributes, and .678 for labor-related stress. The average BSS-R score was 27.78 (SD = 6.5). The average BSS-R quality-of-care was 13.48 (SD = 2.49), average women's personal attributes was 4.45 (SD = 2.19), and average labor-related stress was 9.85 (SD = 3.40). Higher income was associated with higher BSS-R (r s = .137, p < .01), quality-of-care (r s = .108, p < .01), labor-related stress (r s = .077, p < .05), and women's personal attributes (r s = .127, p < .01). Table 2 shows how employment, marital status, and race were associated with birth satisfaction in our study. We conducted a cross-sectional study of 747 postpartum women who gave birth in U.S. hospitals during the fi rst 5 months of the COVID-19 pandemic to describe birth satisfaction during this unprecedented time. We found relationships b etween birth satisfaction and demographics, maternal health, and birth experience. Demographic variables associated with birth satisfaction in our study were higher income, marriage, and white race. White and married women tended to have higher overall birth satisfaction on all scales except laborrelated stress. Education and employment were not associated with overall birth satisfaction. Our fi ndings differ from Hinic (2017), which found no difference between BSS-R scores and participant demographic factors. Employment was unstable during the time of study, and tinuous and ordinal variables, such as income or highest level of education, were examined using nonparametric correlations. All analyses were carried out using IBM SPSS version 25, and a .05 alpha level was used to determine statistical signifi cance. Between May and July 2020, the paid advertisements reached 73,696 people and 6,497 people engaged with (read) the ads. Of those, 1,622 women clicked on the REDCap survey link and 885 postpartum women aged 18-43 who gave birth between March 1 and July 9, 2020 participated in the study. This number far exceeded the required minimum sample size due to success of the paid ads. There was at least one participant from each U.S. state and there were no oversampled regions. The BSS-R was completed in entirety by 747 participants (84% of eclampsia, and hemorrhage were not related to quality-ofcare scores in our study which may indicate that care intensity increases when serious medical events occur, thus not affecting quality-of-care satisfaction scores. Women's self-identifi ed depression or anxiety was associated with lower overall birth satisfaction and lower subscale scores. Previous research has shown relationships between depression and anxiety and lower birth satisfaction (Bell & Andersson, 2016) . Having a birth partner present, perception of suffi cient support during birth, and vaginal birth were associated with improved birth satisfaction. Birth experience variables negatively associated with birth satisfaction included unplanned cesarean birth, separation from infant, and NICU admission. The average BSS-R total score was lowest among women who gave birth without a birth partner (M = 22.1, SD = 6.1) when compared with all other variables in our study. Women in our study who had no birth partner present or felt they had insuffi cient support had lower overall birth satisfaction and lower subscales relative to those who had a partner or felt supported. Support has been associated with birth satisfaction in previous work; however, policies that limited partners and other support due to the pandemic may have made this issue more widespread (Attanasio et al., 2014) . Women who were separated from their infant or had an infant admitted to the NICU had lower birth satisfaction and lower scores on all subscales. Previous literature though employment and education were not related to overall BSS-R, they were related to lower women's personal attributes scores. This may mean that education and employment improve inherent traits like confi dence and preparedness, which may transfer to a more satisfying birth (Miron-Shatz & Konheim-Kalkstein, 2020) . Women of color had lower birth satisfaction in our study, similarly to Breman et al. (2021) and Janevic et al. (2021) who found that Black and Latina women had reduced birth satisfaction during the COVID-19 pandemic. These fi ndings are consistent with Hamm et al. (2019) that previously reported racial disparities in birth satisfaction. In addition to the ongoing racial health disparities in maternal health, women of color were disproportionately affected by COVID-19 as well as tension occurring throughout the United States related to systemic racism during the study period (Jones, 2021; Wo odworth et al., 2020) . Maternal health complications can affect a woman's birth experience. Unlike in Janevic et al. (2021) , COVID-19 positivity was not related to overall birth satisfaction in our study, although our sample of COVIDpositive individuals was relatively small. This may indicate that though having the COVID-19 infection causes stress and affects other outcomes, the overall birth experience can still be preserved when a woman is ill. Other maternal health factors that were negatively associated with birth satisfaction were hypertension, preeclampsia, hemorrhage, depression, and anxiety. Hypertension, pre- racial diversity limited the analyses. Providing the survey in English limited our sample to English-speaking participants. Due to the large sample size, we were more likely to fi nd statistically signifi cant differences between variables. Many of our results may have been unrelated to the pandemic. Future research should focus on prospective and longitudinal designs and use a sample more representative of the general population. Like nearly every other element of human life, birthing environments were affected by the COVID-19 pandemic. The COVID-19 pandemic changed the experience of birthing for women and made it challenging for nurses working in maternity care units. Even in pandemic conditions, labor support remains critical to birth satisfaction. Our fi ndings support the negative impact of obstetric and neonatal complications on birth satisfaction, which may have been compounded by the diffi culties of giving birth in a hospital during the pandemic. Although our sample was not representatively diverse, our results showed racial disparities in birth satisfaction. This adds to the large body of research indicating that women of color are experiencing racial disparities in every facet of maternal health care. Women of color were disproportionately affected by COVID-19, exacerbating preexisting racial maternal health disparities. Further work needs to be done to end racism and promote an equal, high-quality birth experience for women of color, which will in turn promote birth satisfaction. Pandemic-related maternity care should include the safe presence of birth partners and other support structures including doulas. Staffi ng ratios for nurses, midwives, and physicians should remain adequate even during a pandemic to ensure patients have access to the support and health care they desire or need. Although it was more common to separate infants from mothers early in the pandemic for potential symptoms of COVID-19, this was largely discontinued, and maternity care units should continue to advocate for mother infant togetherness when possible (Reingold et al., 2020) . Evidence-based initiatives to reduce cesarean birth, such as the Supporting Vaginal Birth Collaborative, should be implemented in hospitals and continue to be promoted throughout a pandemic (Rosenstein et al., 2021 (Hinic, 2017; Kahalon et al., 2021; Martin & Fleming, 2011) . Of note is that our study had a high number of infants admitted to the NICU (15.5%) relative to the most recent data on average NICU admission in 2019 (9.3%; Martin et al., 2021) . Although maternal infant separation and NICU admission have been shown to affect birth satisfaction prior to our study, these may have been more common occurrences during the pandemic (Reingold et al., 2020) . Similar to previous research including In versetti et al. (2021) who studied birthing women during the pandemic, our fi ndings showed that women who had a vaginal birth had higher birth satisfaction on all subscales and overall, in contrast to women with an unplanned cesarean birth (Falk et al., 2019; Hamm et al., 2019; Kahalon et al., 2021; Karlström, 2017) . Hamm et al. (2019) found that cesarean birth resulted in women being three times more likely to be unsatisfi ed than those who had a vaginal birth. Not all birth satisfaction studies have shown differences in birth satisfaction by birth modality, so it is possible that having a cesarean birth during the pandemic was more dissatisfying for women (Barbosa-Leiker et al., 2015; Hinic, 2017) . Cesarean birth increases medical complexity and length of hospital stay which was a concern during the early months of the pandemic and may have affected women's experiences (Bornstein et al., 2020) . Although women with a planned cesarean had lower BSS-R scores than women with a vaginal birth, they had slightly better labor-related stress scores. This is perhaps related to the controlled circumstances of a planned cesarean, which may not have been altered relative to prepandemic practices (e.g., all personnel mask in the operating room). This study was limited by the cross-sectional retrospective design, participant self-selection, social media recruitment, and lack of diversity in participants. Lack of • Having a birth partner present and the perception of having adequate birth support are critical for birth satisfaction. Birth satisfaction may be affected by COVID-19 pandemic-related policies that reduce support structures. • Separating the mother and infant was more common during the early months of the pandemic and was associated with decreased birth satisfaction. • Nurses should recognize that obstetric and neonatal complications during labor and birth may decrease birth satisfaction and use strategies to offer extra support to women facing these circumstances. • There were racial disparities in birth satisfaction in our study, indicating that not all women receive the same birth experience in U.S. hospitals. Nurses should be mindful of providing the same high-quality experience for each individual woman. Further work to eliminate racism in maternity care and all aspects of health care is needed. 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