Within the first two weeks after delivery, 605 women, of which 261 are Belgian and 344 are Dutch, filled out a questionnaire. In our analysis we focus on this follow-up data. The number of cases in the analysis was reduced to 563, because 19 women left the planned place of delivery blank. Due to missing information on the control variables method of delivery and level of education, another 23 women dropped out of the analysis.
In our sample the age of women ranges between 19 and 44 years, with a mean of 31 years. Dutch women were on the average slightly older at first birth (29.7 versus 28.05 years). Those having their first baby made up 45.8% of the population, and 98.7% were married or living as married. In the Belgian group there were 10% more primigravids. More Belgian (76.1%) than Dutch (40.8%) women completed higher education, and 85.9% of all women were employed, with 84.7% in Belgium and 86.8% in the Netherlands. Of our respondents, 22.5% had a medically assisted delivery (forceps, vacuum extraction or C-section), with 20.8% in Belgium, compared to 23.9% in the Netherlands. A home birth was planned for 37.0% of our respondents. In the Belgian region planned home births represent 24.0% in our sample, compared to 48.0% in the Netherlands. We remind the reader of the oversampling of home births (Table ).
Socio-demographic variables of Belgian and Dutch respondents
In the Belgian sample 87 (34.3%) women wanted a home birth versus 167 (65.7%) a hospital birth (Table ). In the Dutch sample 176 (63.5%) women intended to give birth at home versus 101 (36.5%) who preferred to be taken care of in hospital. In some cases things didn't work out as planned: 18 (7.1%) Belgian women planned a home delivery, but in fact gave birth in a hospital; 82 (29.6%) Dutch women planning for a home birth had a referral to the hospital (Table ).
Respondents according to planned and actual place of birth, country and parity
The mean of the total Mackey Childbirth Satisfaction Rating Scale is 4.18 (st. dev. = 0.53), which is equal to the mean (4.18) reported in the study of Goodman et al. [16
], although we omitted the physician-related items. The means of the subdimensions compare as follows (Goodman et al. versus our means): general: 4.2 versus 4.3; self: 3.8 versus 3.8; baby: 4.1 versus 4.4; midwife: 4.5 versus 4.5; partner: 4.3 versus 4.7. In both countries women were the least satisfied with self-related aspects of birth, with 48.1% on the Belgian side and 30.4% on the Dutch side. In Belgium support of the midwife accounted for the largest percentage of satisfied women (85.5%), and in the Netherlands support of the partner (69.0%). Note that in both Belgium and the Netherlands more women reported being (very) satisfied with the support and skills of the midwife (85.5% and 66.1% respectively) than with the doctor (71.7% and 47.9%) (Table ).
Childbirth satisfaction levels
Linear regression model
We estimated a regression model for five subdimensions (general, self, baby, midwife, partner) and total satisfaction with childbirth. The model consists of two independent variables: the first is actual versus preferred or planned place of birth, which is a categorical variable with four groups: women intending to give birth at home who did, women planning to give birth at the hospital who did (reference group), women who were referred from home to hospital, and women who gave birth at another, unexpected place (e.g., home instead of hospital). The second independent variable is country, Belgium versus the Netherlands (reference group). Age, parity, education and method of delivery are controlled for. Results are shown in Table . Note that the reference groups are the Dutch and the women who wanted to give birth at hospital and did.
Coefficients for satisfaction with childbirth (adjusted for method of delivery, parity, education and age) (N = 563)
The two countries, Belgium and the Netherlands, are characterised by diverging satisfaction scores. Belgian women are more satisfied with childbirth in total (B = 0.31; s.e. = 0.05; p < 0.001) and for all but one subdimension (self: B = 0.29; s.e. = 0.07; p < 0.001; baby: B = 0.18; s.e. = 0.07; p = 0.008; midwife: B = 0.34; s.e. = 0.06; p < 0.001; partner: B = 0.16; s.e. = 0.05; p = 0.003). Note that the Belgian women have an advantage over the Dutch especially in terms of the midwife's support.
Regarding place of birth, we compared women who intended to give birth at home and did, women who planned a home birth but were referred to the hospital, and women with other discrepancies between plan and reality, with women who intended to give birth in hospital and did. When comparing women who gave birth at the place they intended to, it is clear that home births are consistently (total: B = 0.43; s.e. = 0.05; p < 0.001; general: B = 0.30; s.e. = 0.07; p < 0.001; self: B = 0.55; s.e. = 0.07; p < 0.001; baby: B = 0.22; s.e. = 0.08; p = 0.003; midwife: B = 0.44; s.e. = 0.07; p < 0.001; partner: B = 0.15; s.e. = 0.06; p = 0.009) more satisfying than hospital births, especially regarding the self- and midwife-related aspects. Women who have been referred from home to the hospital report lower general satisfaction scores (B = -0.33; s.e. = 0.10; p = 0.001) compared to women who planned and had a hospital birth. However a referral from home to hospital is inconsequential in terms of the other subdimensions of satisfaction (self: B = -0.17; s.e. = 0.09; p = 0.072; baby: B = -0.09; s.e. = 0.09; p = 0.298; midwife: B = -0.06; s.e. = 0.08; p = 0.473; partner: B = 0.06; s.e. = 0.07; p = 0.422). The satisfaction of women who gave birth at other, unplanned for places, (e.g., home instead of hospital or hospital instead of short stay) did not diverge from that of women who intended to give birth at hospital and did (total: B = 0.03; s.e. = 0.07; p = 0.63; general: B = -0.07; s.e. = 0.10; p = 0.504; self: B = -0.001; s.e. = 0.10; p = 0.990; baby: B = -0.06; s.e. = 0.10; p = 0.569; midwife: B = -0.15; s.e. = 0.10; p = 0.116; partner: B = 0.08; s.e. = 0.08; p = 0.334).
To test whether place of birth is associated differently with satisfaction in the two countries, we included three interaction terms, one for each dummy, in our analysis but retained only the significant term, which is "hospital after referral*country". The benefits of a home birth are equal in Belgium and the Netherlands (in total and for every subdimension), but the disadvantage of being referred to the hospital when a home birth was expected is smaller in Belgium. Regarding general satisfaction (Bcountry*place = 0.46; s.e. = 0.19; p = 0.015) and satisfaction with self-related aspects (Bcountry*place = 0.37; s.e. = 0.18; p = 0.041) of birth, Belgian referred women are more satisfied than Dutch women. The coefficients show that when comparing women who had a hospital birth they had planned for with women who had a hospital birth after referral, Dutch referred women are the least satisfied with their birth experience, while Belgian referred women are the most satisfied. Women who had a hospital birth they had planned for, fell somewhere in between and their scores did not differ in Belgium and the Netherlands. In other words, Belgian women who have been referred to the hospital during pregnancy or labour have higher satisfaction scores than Belgian women who planned to give birth in hospital and did. The reverse is true in the Netherlands.
Regarding the control variables (no table), it is clear that multiparous women are generally more satisfied about the birth experience (general: B = 0.20; s.e. = 0.06; p = 0.002) and about the baby-related aspects (baby: B = 0.18; s.e. = 0.06; p = 0.005), but less satisfied about the partners' support (B = -0.12; s.e. = 0.05; p = 0.017). Method of delivery is important for most of the dimensions of satisfaction with childbirth (total: B = -0.18; s.e. = 0.05; p = 0.001; general: B = -0.19; s.e. = 0.07; p = 0.011; baby: B = -0.66; s.e. = 0.08; p < 0.001; midwife: B = -0.14; s.e. = 0.07; p = 0.047), even after introducing place of birth, except for satisfaction with self- (B = -0.07; s.e. = 0.07; p = 0.342) and partner (B = -0.07; s.e. = 0.06; p < 0.289) related aspects. Medical interventions during birth are especially relevant for satisfaction concerning the baby, which is not surprising.
Our results show that place of birth, more specifically being able to give birth at an expected place, determines how mothers evaluate the birth experience. Moreover this feature operates in a different way in Belgium and the Netherlands. The finding that Belgian referred women are more satisfied than Belgian women who planned to give birth at hospital and did, the opposite of which is true for the Dutch, is most remarkable. Place of birth, one of the central differences between the Belgian and Dutch maternity care system, explains part of the diverging satisfaction scores of Dutch and Belgian women.