Effect of delivery mode on Chinese women’s maternal satisfaction: a moderated mediation model of support from medical staff and women’s self-assessment of health

Abstract

Purpose

In recent years, the Chinese government has implemented measures to address the rising rate of cesarean deliveries and promote vaginal births, with the aim of improving women’s childbirth experience. However, non-medically necessary cesarean sections and repeated cesarean sections remain prevalent. This study seeks to explore the correlation between mode of delivery and childbirth experiences. Additionally, it examines the moderating and mediating effects of support from medical staff and women’s self-assessment of health on maternal satisfaction across different delivery methods.

Material and Method

This cross-sectional survey was conducted with 140 Chinese mothers who were 1–10 days post-partum at three tertiary hospitals. The mothers were asked to fill out a socio-demographic data form and questionnaires related to women’s maternal satisfaction, mode of delivery, self-assessed health, and perception of medical staff support while they were in the hospital after delivery. The data from the questionnaires were analyzed and compared using SPSS 24.0 and PROCESS 3.2.

Results

This study discovered that the mode of delivery (vaginal birth or C-section) and the perception of support from medical staff significantly influenced maternal satisfaction (β = 0.82, t = 3.42; β = 0.82, t = 10.23). Specifically, women who had a vaginal birth reported higher levels of satisfaction compared to those who had a C-section. The study also found that the perception of medical staff support played a mediating role in this relationship, indicating its influence on women’s satisfaction (β = 0.78, t = 9.58; indirect effect = 0.43, Boot SE = 0.15; 95% CI= [.12–.73]). Furthermore, women’s self-assessed health acted as a moderator in the relationship between the mode of delivery and medical staff support (β = −0.53, t = −2.39; indirect effect = −0.41, Boot SE = 0.19; 95% CI= [–.80–.05]).

Conclusion

The childbirth experience of Chinese women is greatly influenced by factors such as vaginal birth, their perception of care support from medical staff, and their self-assessment of health. This highlights the importance of healthcare professionals providing women-centered maternity services and childbirth education, which can help reduce unnecessary medical intervention and the need for tertiary obstetric care.

Keywords:

• Maternal satisfaction
• mode of delivery
• medical staff support
• self-assessment physical health

Introduction

The evaluation of maternal satisfaction with the childbirth experience is a complex concept that is influenced by many factors. In the China, one in four women has a negative emotion of their birth experience [1]. Women with a negative evaluation of the childbirth experience will be prone to posttraumatic stress disorder, postpartum depression, child abuse, discord between husband and wife, violent injury to doctors, and even medical lawsuits [1–4]. In contrast, they with a positive evaluation of the childbirth experience will gain a positive self-image, adapt to the role of mother more quickly and be more likely to consider having additional children [5,6]. The World Health Organization defines a positive childbirth experience as one that meets or surpasses a woman’s personal and sociocultural beliefs and expectations, including giving birth to a healthy baby in a safe environment, both clinically and psychologically, with consistent practical and emotional support from a birth companion and competent clinical staff who are kind and technically skilled [7]. On the one hand, Positive childbirth experience comes from obstetric-related variables, including maternal and child safety, mode of delivery, and medical intervention [8,9]. On the other hand, it is subject to many subjective cognitive variables, such as personal expectations, fear of pain, and perceived support from medical staff [10,11].

As regards obstetric variables, the mode of delivery plays a very important role in China. There are two opinions on the influence of the mode of delivery. One opinion is that C-section or a medicalized vaginal birth (a cascade of intervention that disturb the normal physiology of labor and birth) has been found to have a negative impact on women’s birth experience [3,12]. Another opinion is that C-section is conducive to improving maternal satisfaction [13], especially, it is the request of most Chinese women [14]. Although the government actively promulgates and implements measures to reduce the C-section rate, the C-section rate increased to 35.6% in 2018 [15]. The administrative control of the C-section rate in China to improve the vaginal birth rate may deviate from the willingness and choice of Chinese women and may result in maternal dissatisfaction and doctor–patient conflict [16]. The relationship between the mode of delivery and Chinese mothers’ maternal satisfaction is still a debated topic.

As regards the impact of cognitive variables on the birth experience, the perception of medical staff support has a significant impact on maternal satisfaction. Feeling care supported and having sufficient information during childbirth by nurses or midwives or doctors can greatly enhance the subjective childbirth experience [11]. On the contrary, feeling unseen or unheard during delivery and receiving disrespectful care [17], as well as dissatisfaction with the care support provided by midwives during pregnancy [18], or the communication with obstetricians [19], were associated with a more negative birth experience. Matsuoka and other surveys in Asian countries show that compared with women in maternity hospitals in Japan, Vietnam, Indonesia, and Laos, the average value of Chinese women’s sense of accomplishment in childbirth is lower, which is related to the low level of care and support perception provided by medical staff. In addition, different modes of delivery will have an impact on the maternal perception of medical staff support. Compared with vaginal birth, women who give C-sections are more likely to be satisfied with the support of professionals [20], because they can seek additional information and support from professionals and receive comprehensive care and support from them throughout the decision-making and implementation of a C-section [21].

Maternal physical health self-assessment refers to the women’s subjective evaluation and expectation of physical health [22]. Limited research is available on the connection between self-rated health prior to pregnancy and childbirth experience, but poor health appears to be a strong predictor of negative childbirth experience [23]. The study found that women delivering via C-Section under general anesthesia had more higher ratios for health assessment as negative, compared with women giving birth spontaneously vaginally [24]. Pregnant women with positive health self-assessment results can usually deliver smoothly and naturally with a low incidence of complications, but with low self-assessed health are prone to many physiological and psychological problems, such as poor evaluations by the support of medical staff, macrosomia, and anemia [25]. During childbirth, health assessment appears to be closely related to women’s connection with their maternity care providers as well as to open and clear communication [26].

Existing studies have proven that there is a high correlation between delivery mode and mothers’ maternal satisfaction, but there is no direct evidence on which factors play a mediating role. Based on the perspective of social psychology, this study proposes three hypotheses with a moderated mediation effect.

H1. Vaginal delivery has a positive effect on Chinese women’s maternal satisfaction.

H2. Chinese women’s perception of support from medical staff mediates the relationship between the delivery mode and maternal satisfaction.

H3. Maternal self-assessed health has a moderated mediation effect on the relationship between the delivery mode and maternal satisfaction through perception of support from medical staff in China.

Methods

Description of sample

This study is a cross-sectional survey that used a quota sampling method for pregnant women attending three tertiary hospitals located in Shanxi Province with COVID-19. The number of births per year of urban hospital A is around 6500, that of hospital B and hospital C are above 4000 in rural. The sampling ratio is 1/100 that samples 65 people from A, 40 people from B or C. The participants were 1 and 10 days post-partum and involved in a questionnaire survey of maternal health and social support research project between May 2022 and August 2022. The research team conducted standardized face-to-face interviews to collect questionnaires at the maternity ward. 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. A total of 220 questionnaires were distributed in this survey: 185 questionnaires were collected and 140 were validly answered, for a valid response rate of 75.7%, Hospital A was 66, Hospital B was 38, and Hospital C was 36. This research was carried out in compliance with the approval of an appropriate ethics committee, registration number: JNU20211217IRB01.

In the Chinese obstetric system, obstetric hospitals are categorized into three levels: primary, secondary, and tertiary. Primary hospitals are responsible for providing comprehensive medical services to the community, including prevention, rehabilitation, and healthcare. All Chinese women are required to give birth in secondary or tertiary hospitals [27]. In these hospitals, obstetric care is divided into primary, secondary, and tertiary levels, which are supervised by obstetricians. If women have a low-risk pregnancy, they have the option of antenatal examination with obstetrician, giving birth with obstetric nurses (they are called midwives at tertiary hospital), and postnatal care with nurses at secondary or tertiary hospitals. However, women with high-risk pregnancies are always under the supervision of an obstetrician and therefore give birth in tertiary hospitals.

Measurement instrument

This questionnaire was based on previous research to collect data, and used the following variables [20]:

Women’s maternal satisfaction (DV)

A single item was used to assess positive childbirth experience based on No. 13; it was evaluated on a 5-point scale (1 = much worse than expected, 5 = much better than expected), with higher scores representing a more positive childbirth experience.

Mode of delivery (IV)

A single item based on No. 5; included the mode of delivery that the women used: i. vaginal birth; ii. painless childbirth; iii. C-section; iv. induced childbirth; v. forceps-assisted childbirth. In the actual process of data analysis, i, ii, iv, and v were incorporated into the category of ‘vaginal birth‘. That is, ‘0‘ represents ‘C-section‘ and ‘1‘ represents ‘vaginal birth‘.

Self-assessed health (moderator V)

A single item based on No. 42; Chinese women were asked to assess their health, and their responses were measure on a 5-point scale: (1 =very poor; 2 = relatively poor; 3 = normal; 4 = relatively good; 5 = very good).

Perception of medical staff support (mediator V)

The variable included four items based on No. 25; consisted of following items: ‘the nurses have consistently provided excellent healthcare and assistance throughout the entire perinatal period‘; ‘during pregnancy, the doctors imparted a great deal of obstetric knowledge and provided some guidance‘; ‘the doctors and midwives showed a high degree of respect and paid much attention in the process of delivery‘; ‘after delivery, the doctors and nurses provided quality care physically and mentally and shared the baby-care knowledge‘. The items were answered on a 5-point scale (1 = very unsatisfied, 5 = very satisfied). These items were proven to combine as one factor (KMO = 0.83, p < 0.000) and to explain 73.21% of the variance.

Data analysis

All the data were processed and analyzed using SPSS 24.0 and PROCESS 3.2. (1) The study employed descriptive analysis to assess the normality of the main variables and gather demographic and sociological characteristics of the respondents, including age, educational degree, and occupation. (2) Descriptive statistics were used to analyze the mean and distribution of key variables. (3) Reliability analysis was performed to ensure measurement consistency. (4) Correlation analysis was conducted to examine the relationship between key variables. (5) Regression analysis was performed to analyze the impact of the mode of delivery (independent variable) on women’s maternal satisfaction (dependent variable). Additionally, PROCESS was utilized to investigate the moderated mediation effects of support from medical staff and women’s self-assessment of health between the independent variable and dependent variable.

Results

Descriptive statistics

Among the 140 participants, the Mean age was 25.55(SD = 3.20), with the youngest participant being 18 years old and the oldest being 36 years old. Out of the participants, 97 (69.3%) gave birth for the first time, 42 (30.0%) for the second time, and 1 (0.7%) for the third time. Regarding women’s education, 10 (7.1%) have completed primary school, 29 (20.7%) have completed junior middle school, 28 (20.0%) have completed senior middle school, and 73 (52.2%) have attained a college degree or higher (refer to Table 1 for more information on demographics).

Table 1. Statistics for each variable.

	N(%)	M(SD)
Age at first birth		25.55(3.15)
Region
Urban	66(47.1)
Rural	74(52.9)
Education
Primary school	10(7.1)
Junior middle school	29(20.7)
Senior middle school	28(20.0)
College +	73(52.2)
Occupation
Government-related	67(47.9)
Private, foreign, and individual	29(20.7)
Unemployed	44(31.4)
Mode of delivery
Vaginal birth	88(62.8)
C-section	52(37.1)
Medical measures		1.51(1.06)
episiotomy	37(42.0)
oxycontin	37(26.4)
artificial rupture	30(21.4)
pressing the abdomen	30(21.4)
Self-assessed health		1.96(0.85)
Perceptions of medical staff support		3.88(1.09)
The nurses have consistently provided excellent healthcare and assistance throughout the entire perinatal period		3.82(1.20)
During pregnancy, the doctors imparted a great deal of obstetric knowledge and provided some guidance		3.87(1.19)
In the process of delivery, the doctors and midwives showed a high degree of respect and paid much attention.		3.91(1.24)
After childbirth, the doctors and nurses provided quality care physically, mentally and shared the care knowledge		3.89(1.23)
Maternal satisfaction		3.54(1.32)
dissatisfied	17(12.1)
relatively dissatisfied	17(12.1)
neutral	16(11.4)
relatively satisfied	53(37.9)
very satisfied	37(26.4)

N = 140.

Table 2. Moderated Mediation Model.

Variables	PMSS					MS	MS
	(Path a)					(Path b)	(Path c)
	B	T	B	t	B	t	B	T	B	t
MoD	0.540	2.782**	0.567	2.973**			0.826	3.423**	0.399	2.108***
PMSS					0.823	10.238***			0.783	9.589***
SAH	−0.226	−2.069*	−0.234	−2.186*
MoD*SAH			−0.531	−2.395**
R^2	0.097		0.140		0.454		0.085		0.473
F	6.689**		7.542***		104.812***		11.715**		56.060***

*p<.05 **p<.01 ***p<.001; MoD = mode of delivery, MS: maternal satisfaction; PMSS: perception of medical staff support; SAH: self-assessed health.

In terms of the mode of delivery, all of the total participants, 88 (62.8%) had vaginal deliveries, which included 84 who had a regular vaginal delivery, 3 who had a painless delivery, and 1 who had a forceps delivery. On the other hand, 52 (37.2%) had C-sections. It is noteworthy that all 88 Chinese women who underwent vaginal birth received medical interventions, such as the administration of oxytocin (26.4%), artificial rupture of membranes (21.4%), and episiotomy (42.0%).

Based on the findings regarding women’s maternal satisfaction, it was observed that 17 women expressed dissatisfaction with their childbirth experience, accounting for 12.1% of the participants. Similarly, 17 women reported being relatively dissatisfied with the childbirth experience, also comprising 12.1% of the sample. In addition, 16 women indicated that they had neutral feelings toward the childbirth experience, representing 11.4% of the respondents. On the other hand, 53 women expressed relative satisfaction with the childbirth experience, accounting for 37.9% of the participants, while 37 women reported being very satisfied, making up 26.4% of the sample. Overall, it can be noted that more than half of the Chinese women in the study expressed satisfaction with their childbirth experiences (M = 3.54, SD = 1.33).

Based on the self-assessed health results, it was found that 47 participants (33.6%) perceived their health as very poor before childbirth, while 57 participants (40.7%) considered their health to be poor. Additionally, 29 participants (20.7%) regarded their health as moderately good (20.7%), and only 7 participants (5.0%) believed their health to be relatively good (5.0%). These findings suggest that a majority of Chinese women assessed their health as very poor before childbirth.

Based on the perception of medical staff support, it was found that 92 participants expressed continuous satisfaction with the care and assistance provided by the nurses (65.7%). Additionally, 95 participants reported satisfaction with the extensive childbirth-related knowledge and guidance provided by the doctors before childbirth (67.9%). Furthermore, 97 participants agreed that the doctors and midwives displayed a higher level of respect and attentiveness toward their feelings (69.3%). Moreover, 92 participants expressed satisfaction with the physical and mental care as well as the baby care knowledge provided by the doctors and nurses (65.7%). In summary, the women involved in the study held a positive view regarding the support offered by the medical staff, with an average rating of 3.88 (SD = 1.09).

Among all the variables examined, the mode of delivery demonstrated a positive correlated with maternal satisfaction (r = 0.29, p < 0.01), vaginal birth had higher maternal satisfaction. Additionally, there was a positive correlation between maternal satisfaction and the women’s perception of support from medical staff (r = 0.68, p < 0.001). However, the women’s assessment of their health exhibited a negative correlation with maternal satisfaction (r=-0.19, p < 0.05). Notably, demographic variables didn’t have a significant effect on maternal satisfaction.

The testing of moderated mediation effect

The intermediary test H2 following Model 4 of PROCESS 3.2 [28], examined the mediation analysis using the mode of delivery as the independent variable (IV), maternal satisfaction as the dependent variable (DV), and perception of support from medical staff as the mediating variable (MV). All variables were found to be free from multicollinearity. The analysis results as shown in Table 2, indicate the following: (1) Path a reveals that mode of delivery has a significant positive impact on the perception of support from medical staff (β = 0.54, t = 2.78, p < 0.01). (2) Path b demonstrates that perception of support from medical staff has a significant positive impact on maternal satisfaction. (3) Path c, which includes both modes of delivery and perception of support from medical staff in the analytical model, reveals a significant direct effect of the IV on DV in the presence of the mediator (β = 0.39, t = 2.11; β = 0.78, t = 9.59). The 95% Boot CI for the direct effect of IV on DV ranged from 0.02 to 0.77 (direct effect = 0.39, Boot SE = 0.18). Additionally, the indirect effect through MV ranged from 0.12 to 0.73 (indirect effect = 0.43, Boot SE = 0.15). The indirect effect accounted for 51 and 81% of the total effect. Therefore, H2 was supported.

Table 3. Testing moderating effect by Bootstrap method.

Variables	Effect	95%CI
MoD→PMSS→MS	0.427**	0.128–0.723
MoD→MS	0.399**	0.024–0.774
MoD*SAH→PMSS→MS	−0.411**	−0.803–0.050
MoD→MS	0.409**	0.030–0.787

**p<.05, MoD: mode of delivery; MS: maternal satisfaction; PMSS: perception of medical staff support; SAH: self-assessed health.

To examine the relationship between mode of delivery and perceived support from medical staff, a moderated mediation model was constructed using Model 7 of PROCESS3.2. All nonstandard zed coefficients were included in the analysis (Bootstrap5000, 95% CI) [28]. The mediating effect of self-assessed health on the relationship between IV and MV was assessed (Table 3). The results indicated a significant indirect effect of self-assessed health on the relationship between IV and MV (indirect effect =-0.41, SE = 0.19, 95%CI= [−.80, −.05]). Specifically, the interaction between mode of delivery and self-assessed health had a significant impact on support from medical staff (β = −0.53, t = −2.40, p < 0.01). To further analyze this, we plotted IV against MV, for low and high levels of health. Simple slope tests revealed that for Chinese women with high self- assessed health, vaginal birth significantly predicted greater support from medical staff compared to C-section (Figure 1). This suggests that when women with a high self-assessment of their health status undergo vaginal delivery, their evaluation of medical staff’s care and support tends to be lower, resulting in lower satisfaction with the delivery. Therefore, H3 was verified.

Discussion

This study examines the relationship between obstetric variables, cognitive variables, and maternal satisfaction with birth from the perspective of Chinese women. Overall, Chinese women expressed high satisfaction with their childbirth experience, with a greater number and higher satisfaction reported for vaginal births compared to C-sections, despite the presence of various medical interventions. These findings suggest that the efforts of the national and local health commissions, as well as medical professionals, to reduce C-section rates have been effective [15].

The main cognitive factors related to the above results were the evaluation of care and support provided by medical staff and self-assessed health. Most Chinese women tend to rate their health as low during pregnancy, which may trigger their fear of delivery, and recognizing the safety and effectiveness of traditional Chinese medical interventions during vaginal delivery can help improve their evaluation of information support and nursing support provided by medical staff. However, women who think they are very healthy have difficulty felled the quality care by medical staff during vaginal delivery. The fact that a woman has a more favorable or less favorable attitude toward medicalization will influence the choices she will make in relation to labor, the degree of planning for it, and the childbirth experience [29], but we should consider health professionals also function as agents. This finding aligns with previous research, suggesting that a women-centered approach in maternity services has been neglected [3]. To enhance Chinese women’s childbirth experience, it may be beneficial to reduce unnecessary tertiary obstetric care.

Maternity services have seen constant improvement, including measures to reduce unnecessary C-sections, the availability of epidural anesthesia, and the introduction of LDR childbirth rooms, which are equipped with soothing music and offer anesthetic-assisted childbirth [30,31]. However, it is important to note that the enhancement of medical services primarily focuses on facilities and technology, rather than ensuring quality care for women [32]. In the current Chinese healthcare system, the rating system for medical service quality does not have a strong correlation with maternal satisfaction [33]. Medical staff are primarily focused on reducing mortality rates and the percentage of C-section cases, while there is limited attention given to the importance of providing respectful maternal care during the process of vaginal birth [34]. Non-clinical intrapartum care practices, such as offering emotional support through labor companionship (Bohren et al. 2019), ensuring continuity of midwife care [35], promoting effective communication, and implementing positive care practices [36], are often overlooked in many healthcare settings. These non-clinical practices play a crucial role in enhancing women’s delivery experience, particularly in the case of vaginal delivery. To improve the quality of medical services for pregnancy and childbirth, it is essential to systematically adjust the practices of care providers. This can be achieved by creating a set of quantitative indicators, such as RMC or the international childbirth initiative [34,37], to assess the interaction between medical staff and women. These indicators should be incorporated into the rating system for medical service quality, and to provide training to all obstetrical medical staff during clinical practice.

Considering that Chinese women have poor evaluations of their own physical health assessment, interventions concentrating on improving childbirth self-assessed health in China should focus on prenatal education for expectant mothers [38]. However, traditional childbirth education is in question as it may encourage compliance with the medicalized childbirth that is produced by a maternity service underpinned by pathogenesis [39]. As previously mentioned, medicalized vaginal delivery is not friendly for highly health assessed pregnant women, which is also a significant finding in our study. Possibly because of the philosophy or teaching methods of childbirth education classes not keeping up with the changing needs of childbearing women [40]. The further research should focus on investigating the childbirth education models that are associated with improving the self-health of Chinese women, as well as it should aim to enhance the healthcare providers’ comprehensive consequences and application abilities in relation to these childbirth education models.

Conclusion

This study explored the relationship between mode of delivery and childbirth experiences and also investigated the moderating and mediating effects of support from medical staff and women’s self-assessment health on these variables. The findings highlight the importance of conducting future studies with larger sample sizes. Understanding how cognitive variables influence maternal satisfaction during different delivery methods can assist healthcare professionals in offering women-centered maternity services and childbirth education, thereby reducing the occurrence of unnecessary medical intervention and tertiary obstetric care.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to restrictions, e.g. their containing information that could compromise the privacy of research participants.

Figure 1. Interaction between mode of delivery and self-assessed health on medical staff’s support.

Additional information

Funding

This work was supported by the National Social Science Fund of China.