In a sample of 311 Dutch and 249 Belgian women, we tested a model including four social psychological determinants of satisfaction with childbirth which have been the subject of other childbirth satisfaction research: the experience of labour pain [19
], personal control [15
], self-efficacy [25
] and the fulfilment of expectations [19
]. Characteristics of childbirth (such as intended place of birth, length of labour, method of delivery) and of the mother (such as age, parity, level of education, marital status and employment) were controlled for.
Before further discussing the findings, we want to briefly list some of the shortcomings and merits of the study. Weaknesses of our research relate to the timing of the measurement of satisfaction with childbirth. Questionnaires were answered within 2 weeks after delivery. This close to the birthing experience, women might have answered less critically than they would have later on [64
]. However, the two-week time frame applied to all respondents and therefore does not affect the differences between the groups compared. Second, comparability of the Dutch and Belgian sample can be questioned: Belgian women were on the average more highly educated, younger at first birth and more likely to give birth for the first time in comparison to the Dutch. The higher education of the Belgian sample can be explained by the over sampling of home births, since in Belgium women preferring a home birth are on the average more highly educated [5
]. In the Netherlands women are on the average older at first birth in comparison to Belgium and the rest of Europe [65
]. Age and education are controlled for in the analysis. Third, women who refused to participate were not systematically registered. This makes generalization of the results less likely.
Despite the limitations, the inclusion of multiple determinants – labour pain, personal control, self-efficacy and the fulfilment of expectations – into one model proved to be fruitful in explaining satisfaction with childbirth. In addition, we used the Mackey Childbirth Satisfaction Rating Scale to take the multidimensionality of childbirth satisfaction into account. Finally, by estimating the models in both the Belgian and the Dutch sample, we tried to assess the applicability of the model for Belgian and Dutch women. Because both countries have strongly differing maternity care systems, we are confident that the present findings have a more general meaning.
Four important findings arise from this investigation. First, the fulfilment of expectations was the most consistent determining factor of satisfaction with childbirth. Women whose expectations for childbirth were met were more satisfied than those whose expectations were not. This conclusion corresponds to the conceptualisation of satisfaction and confirms previous research [2
]. Moreover, by comparing Belgian and Dutch women, we learned that the fulfilment of expectations is equally important to the childbirth satisfaction of both groups. However, this does not exclude the possibility that Dutch and Belgian women's expectations may differ. This is rather likely because of the diverging maternity care systems. Expectations are context specific, but the association between their fulfilment and satisfaction is not. In addition, we learned from this study that Belgian women's expectations were more easily fulfilled than Dutch women's expectations. This is not surprising when taking the high referral rate into account. Nearly one third of all planned home deliveries end up in hospital [66
]. The ambivalent Dutch maternity care, with its two sciences of obstetrics [11
], might explain the unfulfilled Dutch expectations. In ambivalent social structures, contrary courses of action are simultaneously valued for a single actor in a given situation [67
]. The conflicting normative expectations imposed on Dutch women may result in a decreased childbirth satisfaction, because it is impossible to conform, without being deviant at the same time.
Second, we found that personal control consistently improved satisfaction and buffered the lowering impact of labour pain. The latter mediating effect is limited to satisfaction with the midwife's support, but nevertheless it supports conclusions of Doering et al.
] and Pellino and Ward [68
] and points to the importance of including personal control and labour pain in one analysis. This interplay between labour pain and control might explain the lack of consensus about the relationship between labour pain and childbirth satisfaction.
Third, women with high self-efficacy showed more satisfaction, especially with the support of the midwife and the physician. This result corresponds with the findings of Crowe and von Baeyer [45
] about self-efficacy leading to positive birth experiences.
Personal control and self-efficacy are mediators in the stress process, as predicted by the social stress model [36
]. A demanding birth does not result in dissatisfaction if women keep control, hence feel empowered. The job strain model [69
] designed to explain the impact of work-related stress on health outcomes can equally be applied to childbirth satisfaction. The model postulates that strain results from the joint effects of the demands of a work situation, and the control workers facing those demands, exert [69
]. The practical implication of the model is that in redesigning maternity care an increase in personal control can be pursued, even without affecting the demanding nature of birth itself. In other words, the empowerment of labouring women, not the management of childbirth by means of painkillers, leads to satisfactory birth experiences.
Finally, the model explains the satisfaction scores of Belgian and Dutch women, implying that the social psychological determinants affect satisfaction independently of the context in which they operate.