Overall childbirth experience: what does it mean? A comparison between an overall childbirth experience rating and the Childbirth Experience Questionnaire 2.

BACKGROUND: In clinical settings and research studies, childbirth experience is often measured using a single-item question about overall experience. Little is known about what women include in this rating, which complicates the design of adequate follow-up, as well as the interpretation of research findings based on ratings of overall childbirth experience. The aim of this study was to examine which known dimensions of childbirth experience women include in the rating on a single-item measure. METHODS: Ratings of overall childbirth experience on a 10-point numeric rating scale (NRS) from 2953 women with spontaneous or induced onset of labour at two Swedish hospitals were evaluated against the validated Childbirth Experience Questionnaire 2 (CEQ2), completed on one of the first days postpartum. The CEQ2 measures four childbirth experience domains: own capacity, perceived safety, professional support and participation. Internal consistency for CEQ2 was evaluated by calculating Cronbach's alpha. NRS ratings were explored in relation to CEQ2 using empirical cumulative distribution function graphs, where childbirth experience was defined as negative (NRS ratings 1-4), mixed (NRS ratings 5-6) or positive (NRS ratings 7-10). A multiple linear regression analysis, presented as beta coefficients (B) and 95% confidence intervals (CI), was also performed to explore the relationship between the four domains of the CEQ2 and overall childbirth experience. RESULTS: The prevalence of negative childbirth experience was 6.3%. All CEQ2-subscales reached high or acceptable reliability (Cronbach's alpha = 0.78; 0.81; 0.69 and 0.66, respectively). Regardless of overall childbirth experience, the majority of respondents scored high on the CEQ2 subscale representing professional support. Overall childbirth experience was mainly explained by perceived safety (B = 1.60, CI 1.48-1.73), followed by own capacity (B = 0.65, CI 0.53-0.77) and participation (B = 0.43, CI 0.29-0.56). CONCLUSIONS: In conclusion, overall childbirth experience rated by a single-item measurement appears to mainly capture experiences of perceived safety, and to a lesser extent own capacity and participation, but appears not to reflect professional support. CEQ2 shows good psychometric properties for use shortly after childbirth, and among women with induced onset of labour, which increases the usability of the instrument.

Effect of internet-based cognitive behaviour therapy among women with negative birth experiences on mental health and quality of life - a randomized controlled trial.

BACKGROUND: Giving birth is often a positive experience, but 7-44% have negative experiences and about 4% develop posttraumatic stress disorder following childbirth (PTSD FC). This randomized controlled trial (RCT) investigated the effect of internet-based cognitive behaviour therapy (iCBT) for women with negative birth experiences and/or at risk for PTSD FC. METHODS: This was a superiority nonblinded multicentre RCT comparing iCBT combined with treatment as usual (TAU) with TAU only. Data were collected through questionnaires at baseline, at 6 weeks, 14 weeks and 1 year after randomization. The RCT was conducted at four delivery clinics in Sweden and participants were recruited from September 2013 until March 2018. Women who rated their childbirth experience as negative on a Likert scale, and/or had an immediate caesarean section or a haemorrhage of > 2000 ml were eligible. Primary outcomes were symptoms of posttraumatic stress (Traumatic Event Scale, TES) and symptoms of depression (Edinburgh Postnatal Depression Scale, EPDS). Secondary outcomes were satisfaction with life (Satisfaction With Life Scale, SWLS) and coping (Ways of Coping Questionnaire, WCQ). RESULTS: Out of 1810 eligible women, 266 women were randomised to iCBT+TAU (n = 132) or to TAU (n = 134). In the iCBT+TAU group 59 (45%) completed the treatment. ICBT+TAU did not reduce PTSD FC at 6 weeks, at 14 weeks, or at 1 year follow-up compared with TAU, according to the TES. Both the ITT and completer analyses showed significant time and quadratic time effects due to reduction of symptoms in both groups on the TES (re-experience subscale) and on the EPDS, and significant time effect on the self-controlling subscale of the WCQ (which increased over time). There was also a significant main effect of group on the SWLS where the TAU group showed higher initial satisfaction with life. Exploratory subgroup analyses (negative birth experience, immediate caesarean section, or severe haemorrhage) showed significant time effects among participants with negative birth experience on re-experience, arousal symptoms and depressive symptoms. CONCLUSIONS: The ICBT intervention did not show superiority as both groups showed similar beneficial trajectories on several outcomes up to 1 year follow-up. This intervention for women with negative birth experiences and/or at risk for PTSD FC was feasible; however, the study suffered from significant drop out rate. Future studies with more narrow inclusion criteria and possibly a modified intervention are warranted. TRIAL REGISTRATION: ISRCTN39318241. Date for registration 12/01/2017.

Self-rated health before pregnancy and adverse birth outcomes in Sweden: A population-based register study.

BACKGROUND: Poor self-rated health (SRH) at time of childbirth has been associated with adverse birth outcomes. However, it is not known whether prepregnancy SRH contributes to these outcomes or whether SRH is a proxy for some other factors. Therefore, the purpose of this study was to explore the associations between poor SRH before pregnancy and adverse birth outcomes. In addition, maternal characteristics associated with SRH before pregnancy were explored. METHODS: A population-based register study encompassing 261 731 deliveries in Sweden between January 2013 and July 2017 was conducted. The associations between poor SRH before pregnancy, rated at first antenatal visit, and the adverse birth outcomes of stillbirth, small for gestational age (SGA), and preterm birth were investigated with logistic regression analyses and presented as crude (OR) and adjusted odds ratios (aOR) with 95% confidence intervals (CI). RESULTS: Poor SRH before pregnancy was largely characterized by a history of psychiatric care and was associated with stillbirth (OR 1.37, 95% CI 1.04-1.79), SGA birth (OR 1.29, 95% CI 1.19-1.39), and preterm birth (OR 1.41, 95% CI 1.32-1.50). Adjusting for established risk factors for adverse birth outcomes, poor SRH remained associated with SGA birth (aOR 1.16, 95% CI 1.07-1.26) and preterm birth (aOR 1.25, 95% CI 1.17-1.33), but not with stillbirth (aOR 1.08, 95% CI 0.81-1.43). CONCLUSIONS: SRH assessments could be used in early pregnancy to identify women in need of more extensive follow-up, as SRH appears to capture something beyond currently known risk factors for adverse birth outcomes.

Negative childbirth experience in relation to mode of birth and events during labour: A mixed methods study.

OBJECTIVE: To explore descriptions of negative childbirth experience in relation to mode of birth and events during labour. DESIGN: A descriptive study using a convergent mixed methods design. Written responses to open-ended online questions regarding negative childbirth experience were explored using qualitative content analysis. Generated sub-themes were quantified, and stratified on mode of birth and events during labour. PARTICIPANTS AND SETTING: 112 women with low ratings of overall childbirth experience, participating in a randomised controlled trial evaluating internet-based cognitive behavioural therapy in Sweden. Qualitative data were collected before randomisation, three months postpartum. RESULTS: Four sub-themes emerged from the qualitative analysis: Experiencing fear-based emotions, Experiencing physical distress, Being affected by caregivers' and partner's behaviour and Being affected by bad facilities and poor organisation. Only small differences were found when stratifying sub-themes on mode of birth and events during labour. Regardless of mode of birth and events during labour, the childbirth experience was dominated by fear-based emotions. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Mixed-methods analyses demonstrate the challenges in understanding negative childbirth experience in relation to mode of birth and specific events during labour, with results clearly showing the multifaceted nature of this concept. The central role of fear in relation to negative childbirth experience should be considered when designing support during and after labour, to prevent adverse effects of the childbirth experience.

Antepartum and labour-related single predictors of non-participation, dropout and lost to follow up in a randomised controlled trial comparing internet-based cognitive-behaviour therapy with treatment as usual for women with negative birth experiences and/or post-traumatic stress following childbirth.

OBJECTIVES: Internet-based interventions are often hampered by high dropout rates. The number of individuals who decline to participate or dropout are reported, but reasons for dropout are not. Identification of barriers to participation and predictors of dropout may help improve the efficacy of internet-based clinical trials. The aim was to investigate a large number of possible predictors for non-participation and dropout in a randomised controlled trial for women with a negative birth experience and/or post-traumatic stress following childbirth. SETTING: A childbirth clinic at a university hospital in Sweden. PARTICIPANTS: The sample included 1523 women who gave birth between September 2013 and February 2018. All women who rated an overall negative birth experience on a Likert scale, and/or had an immediate caesarean section (CS), and/or severe postpartum haemorrhage (≥ 2000 mL) were eligible. METHODS: Demographic, antepartum, and labour-related/postpartum predictors were investigated for non-participation (eligible but denied participation), pre-treatment dropout (prior to intervention start), treatment dropout, and loss to follow-up. Descriptive statistics and logistic regression were used in the data analysis. RESULTS: A majority (80.3 %) were non-participants. Non-participation was predicted by lower level of education, being foreign-born, no experience of counselling for fear of childbirth, multiparity, vaginal delivery (vs CS and vacuum-assisted delivery) and absence of: preeclampsia, anal sphincter injury and intrapartum fetal distress. Pretreatment dropout was predicted by the absence of severe haemorrhage. Treatment dropout was predicted by vaginal delivery (vs immediate CS), vertex presentation and good overall birth experience. Loss to follow-up was predicted by vaginal delivery (vs immediate CS or vacuum-assisted delivery) and absence of intrapartum fetal distress. CONCLUSIONS: Mothers with no obstetric complications were more likely to not participate and dropout at different time points. Both demographic, antepartum and obstetrical variables are important to attend to while designing procedures to maximise participation in internet-delivered cognitive-behavioral therapy. TRIAL REGISTRATION NUMBER: ISRCTN39318241.

Negative childbirth experience - what matters most? a register-based study of risk factors in three time periods during pregnancy.

OBJECTIVE: To explore the impact of risk factors representing three different time periods during pregnancy on negative childbirth experience. METHODS: This was a register-based cohort study of 80482 primiparas giving birth to singleton, term infants in Sweden 2013-2018, elective caesarean sections (CS) excluded. Hierarchical logistic regression was performed to calculate adjusted odds ratios (aOR) with 95% confidence intervals (CIs) in three blocks, each representing risk factors from one of three time periods: I) before pregnancy, II) pregnancy, III) childbirth. RESULTS: Of the pre-gestational factors, only poor self-rated health (SRH) remained associated with negative childbirth experience after adjustment for pregnancy- and childbirth-related factors (aOR 1.20, 95% CI 1.08-1.34). Psychiatric care during pregnancy and fear of childbirth were both associated with negative birth experience (aOR 1.51, 95% CI 1.35-1.69; aOR 1.50, 95% CI 1.32-1.70), as were all childbirth-related factors included in the model. Women giving birth operatively vaginally or by unplanned CS under regional anaesthesia had three-fold higher ORs for rating their overall childbirth experience as negative (aOR 3.29, 95% CI 3.04-3.57; aOR 3.07, 95% CI 2.80-3.38). The highest OR, 5.44, was seen among women undergoing unplanned CS under general anaesthesia (95% CI 4.55-6.50). CONCLUSION: The main contributing factors to negative childbirth experience are related to labour and birth, but poor SRH prior to pregnancy, together with psychiatric care during pregnancy and fear of childbirth, place the woman in a vulnerable position, and require extra attention.