Abstracts

Introduction

Although delivery is a physiological process typically without complications ¹1. World Health Organization. WHO recommendations Intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018., political, socioeconomic, cultural, institutional, technical-scientific changes, as well as changes in health and medical work models (which have become more technical and interventionist), have ended up characterizing delivery as an act of medical-hospital responsibility since the mid-21st century ²2. Nakano AR, Bonan C, Teixeira LA. A normalização da cesárea como modo de nascer: cultura material do parto em maternidades privadas no Sudeste do Brasil. Physis (Rio J.) 2015; 25:885-904.^,33. Kaplan L. Changes in childbirth in the United States: 1750-1950. Hektoen Int 2012; 4(4). https://hekint.org/2017/01/27/changes-in-childbirth-in-the-united-states-1750-1950/.
https://hekint.org/2017/01/27/changes-in... ^,44. Patah LE, Malik AM. Models of childbirth care and cesarean rates in different countries. Rev Saúde Pública; 2011; 45:185-94.^,55. Maia MB. Humanização do parto: política pública, comportamento organizacional e ethos profissional. Rio de Janeiro: Editora Fiocruz; 2010.^,66. McCool WF, Simeone SA. Birth in the United States: an overview of trends past and present. Nurs Clin North Am 2002; 37:735-46..

While this medicalization of delivery has presented a positive impact on decreasing maternal and neonatal mortality rates, it has also resulted in medical interventions without scientific indications and loss of women’s autonomy over the labor process ¹1. World Health Organization. WHO recommendations Intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018.^,55. Maia MB. Humanização do parto: política pública, comportamento organizacional e ethos profissional. Rio de Janeiro: Editora Fiocruz; 2010.. Consequently, cesarean section rates have increased globally in the first two decades of the 21st century ⁴4. Patah LE, Malik AM. Models of childbirth care and cesarean rates in different countries. Rev Saúde Pública; 2011; 45:185-94.^,77. Boerma T, Ronsmans C, Melesse DY, Barros AJD, Barros FC, Juan L, et al. Global epidemiology of use of and disparities in caesarean sections. Lancet 2018; 392:1341-8.^,88. Nino Y. The increasing cesarean rate globally and what we can do about it. Biosci Trends 2011; 5:139-50.^,99. Martin AM, Hamilton BE, Osterman MJK, Driscoll AK. Births: final data for 2018. Natl Vital Stat Rep 2019; 68:1-47.^,1010. Departamento de Informática do SUS. Nascidos vivos - Brasil. Parto cesário de 2000 a 2020. http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sinasc/cnv/nvuf.def (accessed on 05/Jul/2022).
http://tabnet.datasus.gov.br/cgi/tabcgi.... , often exceeding the 10% to 15% recommended by the World Health Organization (WHO) ⁴4. Patah LE, Malik AM. Models of childbirth care and cesarean rates in different countries. Rev Saúde Pública; 2011; 45:185-94.^,1111. Appropriate technology for birth. Lancet 1985; 2:436-37., and even surpassing vaginal childbirth rates in Brazil, Cyprus, Dominican Republic, and Egypt ¹²12. World Health Organization. Global Health Observatory data repository: births by caesarean section - data by country. https://apps.who.int/gho/data/node.main.BIRTHSBYCAESAREAN?lang=en (accessed on 05/Jul/2022).
https://apps.who.int/gho/data/node.main.... .

Contrary to this increase in cesarean section rates ¹²12. World Health Organization. Global Health Observatory data repository: births by caesarean section - data by country. https://apps.who.int/gho/data/node.main.BIRTHSBYCAESAREAN?lang=en (accessed on 05/Jul/2022).
https://apps.who.int/gho/data/node.main.... , studies carried out in countries at different levels of development have shown that, generally, women prefer vaginal childbirth ⁵5. Maia MB. Humanização do parto: política pública, comportamento organizacional e ethos profissional. Rio de Janeiro: Editora Fiocruz; 2010.^,1313. Coates D, Thirukumar P, Henry A. Women's experiences and satisfaction with having a cesarean birth: an integrative review. Birth 2020; 47:169-82.^,1414. Reiter M, Betrán AP, Marques FK, Torloni MR. Systematic review and meta-analysis of studies on delivery preferences in Brazil. Int J Gynaecol Obstet 2018; 143:24-31.^,1515. Mazzoni A, Althabe F, Liu NH, Bonotti AM, Gibbons L, Sánchez AJ, et al. Women's preference for caesarean section: a systematic review and meta-analysis of observational studies. BJOG 2011; 118:391-9.^,1616. Stoll KH, Hauck YL, Downe S, Payne D, Hall WA; International Childbirth Attitudes-Prior to Pregnancy (ICAPP) Study Team. Preference for cesarean section in young nulligravid women in eight OECD countries and implications for reproductive health education. Reprod Health 2017; 14:116.^,1717. Zhang H, Wu J, Norris J, Guo L, Hu Y. Predctors of preference for caesarean delivery among pregnant women in Bejing. J Int Med Res 2017; 45:789-807.^,1818. Mazzoni A, Althabe F, Gutierrez L, Gibbons L, Liu NH, Bonotti AM, et al. Women's preferences and mode of delivery in public and private hospitals: a prospective cohort study. BMC Pregnancy Childbirth 2016; 16:34.^,1919. Domingues RMSM, Dias MAB, Nakamura-Pereira M, Torres JA, d'Orsi E, Pereira ANE, et al. Processo de decisão pelo tipo de parto no Brasil: da preferência inicial das mulheres à via de parto final. Cad Saúde Pública 2014; 30 Suppl:S101-16.^,2020. Ylmaz SD, Bal MD, Beji NK, Uldag S. Women's preferences of method of delivery and influencing factors. Iran Red Crescent Med J 2013; 15:683-9.. Cesarean section, in turn, is preferred by multiparous women undergoing this mode of delivery ¹³13. Coates D, Thirukumar P, Henry A. Women's experiences and satisfaction with having a cesarean birth: an integrative review. Birth 2020; 47:169-82.^,1414. Reiter M, Betrán AP, Marques FK, Torloni MR. Systematic review and meta-analysis of studies on delivery preferences in Brazil. Int J Gynaecol Obstet 2018; 143:24-31.^,1515. Mazzoni A, Althabe F, Liu NH, Bonotti AM, Gibbons L, Sánchez AJ, et al. Women's preference for caesarean section: a systematic review and meta-analysis of observational studies. BJOG 2011; 118:391-9.^,1717. Zhang H, Wu J, Norris J, Guo L, Hu Y. Predctors of preference for caesarean delivery among pregnant women in Bejing. J Int Med Res 2017; 45:789-807.^,1919. Domingues RMSM, Dias MAB, Nakamura-Pereira M, Torres JA, d'Orsi E, Pereira ANE, et al. Processo de decisão pelo tipo de parto no Brasil: da preferência inicial das mulheres à via de parto final. Cad Saúde Pública 2014; 30 Suppl:S101-16.^,2020. Ylmaz SD, Bal MD, Beji NK, Uldag S. Women's preferences of method of delivery and influencing factors. Iran Red Crescent Med J 2013; 15:683-9. and among those with private health insurance ¹⁴14. Reiter M, Betrán AP, Marques FK, Torloni MR. Systematic review and meta-analysis of studies on delivery preferences in Brazil. Int J Gynaecol Obstet 2018; 143:24-31.^,2020. Ylmaz SD, Bal MD, Beji NK, Uldag S. Women's preferences of method of delivery and influencing factors. Iran Red Crescent Med J 2013; 15:683-9.. The preference for cesarean section was associated with fear of pain ⁷7. Boerma T, Ronsmans C, Melesse DY, Barros AJD, Barros FC, Juan L, et al. Global epidemiology of use of and disparities in caesarean sections. Lancet 2018; 392:1341-8.^,1313. Coates D, Thirukumar P, Henry A. Women's experiences and satisfaction with having a cesarean birth: an integrative review. Birth 2020; 47:169-82.^,1616. Stoll KH, Hauck YL, Downe S, Payne D, Hall WA; International Childbirth Attitudes-Prior to Pregnancy (ICAPP) Study Team. Preference for cesarean section in young nulligravid women in eight OECD countries and implications for reproductive health education. Reprod Health 2017; 14:116.^,1818. Mazzoni A, Althabe F, Gutierrez L, Gibbons L, Liu NH, Bonotti AM, et al. Women's preferences and mode of delivery in public and private hospitals: a prospective cohort study. BMC Pregnancy Childbirth 2016; 16:34.^,2020. Ylmaz SD, Bal MD, Beji NK, Uldag S. Women's preferences of method of delivery and influencing factors. Iran Red Crescent Med J 2013; 15:683-9., perception that it is safer than vaginal delivery ¹³13. Coates D, Thirukumar P, Henry A. Women's experiences and satisfaction with having a cesarean birth: an integrative review. Birth 2020; 47:169-82.^,1818. Mazzoni A, Althabe F, Gutierrez L, Gibbons L, Liu NH, Bonotti AM, et al. Women's preferences and mode of delivery in public and private hospitals: a prospective cohort study. BMC Pregnancy Childbirth 2016; 16:34.^,2020. Ylmaz SD, Bal MD, Beji NK, Uldag S. Women's preferences of method of delivery and influencing factors. Iran Red Crescent Med J 2013; 15:683-9., negative previous experiences in delivery ¹³13. Coates D, Thirukumar P, Henry A. Women's experiences and satisfaction with having a cesarean birth: an integrative review. Birth 2020; 47:169-82., influence of health professionals, friends, and family members ¹³13. Coates D, Thirukumar P, Henry A. Women's experiences and satisfaction with having a cesarean birth: an integrative review. Birth 2020; 47:169-82., and limited access to information about the characteristics of these two modes of deliveries ¹³13. Coates D, Thirukumar P, Henry A. Women's experiences and satisfaction with having a cesarean birth: an integrative review. Birth 2020; 47:169-82.^,1717. Zhang H, Wu J, Norris J, Guo L, Hu Y. Predctors of preference for caesarean delivery among pregnant women in Bejing. J Int Med Res 2017; 45:789-807..

Delivering according to plan ²¹21. Preis H, Lobel M, Benyamini Y. Between expectancy and experience: testing a model of a childbirth satisfaction. Psychol Women Q 2019; 43:105-17.^,2222. Fleming SE, Donovan-Batson C, Barbosa-Leiker C, Martin CJH, Martin CR. Birth Satisfaction Scale/Birth Satisfaction Scale-Revised (BSS/BSS-R): a large scale United States planned home birth and birth centre survey. Midwifery 2016; 41:9-15.^,2323. Srivastava A, Avan BI, Rajbangshi P, Bhattacharyya S. Determinants of women's satisfaction with maternal health care: a review of literature from developing countries. BMC Pregnancy Childbirth 2015; 15:97.^,2424. Sawyer A, Ayers S, Abbott J, Gyte G, Rabe H, Duley D. Measures of satisfaction with care during labour and birth: a comparative review. BMC Pregnancy Childbirth 2013; 13:108.^,2525. Cook K, Loomis C. The impact of choice and control on women's childbirth experiences. J Perinat Educ 2012; 21:158-68. contributes to maternal satisfaction with hospitalization for delivery. Participating in the choice of mode of delivery; ease of access to the hospital of delivery; facility with appropriate physical structure; availability of medicines and equipment; receiving dignified, respectful, and courteous treatment; privacy and confidentiality in care; availability of technically competent physicians and nurses (especially during emergencies); provision of cognitive and emotional support; and good delivery outcomes were associated with greater satisfaction with the delivery healthcare service in a systematic review ²³23. Srivastava A, Avan BI, Rajbangshi P, Bhattacharyya S. Determinants of women's satisfaction with maternal health care: a review of literature from developing countries. BMC Pregnancy Childbirth 2015; 15:97.. Conversely, the perception of intense pain, especially during labor induction, instrumental vaginal delivery, emergency cesarean section, and prolonged labor, were associated with a negative experience ²⁶26. Waldenström U, Hildingsson I, Rubertsson C, Radestad I. A negative birth experience: prevalence and risk factors in a national sample. Birth 2004; 31:17-27..

Maternal satisfaction with childbirth hospitalization has been more commonly investigated based on theories of satisfaction with care received in health services ²³23. Srivastava A, Avan BI, Rajbangshi P, Bhattacharyya S. Determinants of women's satisfaction with maternal health care: a review of literature from developing countries. BMC Pregnancy Childbirth 2015; 15:97.^,2424. Sawyer A, Ayers S, Abbott J, Gyte G, Rabe H, Duley D. Measures of satisfaction with care during labour and birth: a comparative review. BMC Pregnancy Childbirth 2013; 13:108.. These theories are based on previous expectations or experiences that occurred during delivery or even on attributes of health services ²⁴24. Sawyer A, Ayers S, Abbott J, Gyte G, Rabe H, Duley D. Measures of satisfaction with care during labour and birth: a comparative review. BMC Pregnancy Childbirth 2013; 13:108.^,2727. Bleich SN, Özaltin E, Murray JL C. How does satisfaction with the health-care system relate to patient experience? Bull World Health Organ 2009; 87:271-8.. Its measurement instruments in quantitative surveys often assess one or more determinants of maternal satisfaction with labor/birth and vary in the number of items (6 to 30 questions), response options (dichotomous or Likert scale), and variable construction (single score and uni- or multidimensional constructs) ²²22. Fleming SE, Donovan-Batson C, Barbosa-Leiker C, Martin CJH, Martin CR. Birth Satisfaction Scale/Birth Satisfaction Scale-Revised (BSS/BSS-R): a large scale United States planned home birth and birth centre survey. Midwifery 2016; 41:9-15.^,2323. Srivastava A, Avan BI, Rajbangshi P, Bhattacharyya S. Determinants of women's satisfaction with maternal health care: a review of literature from developing countries. BMC Pregnancy Childbirth 2015; 15:97.^,2424. Sawyer A, Ayers S, Abbott J, Gyte G, Rabe H, Duley D. Measures of satisfaction with care during labour and birth: a comparative review. BMC Pregnancy Childbirth 2013; 13:108.^,2828. Costa DDO, Ribeiro VS, Ribeiro MRC, Esteves-Pereira AP, Sá LGC, Cruz JAS, et al. Psychometric properties of the hospital birth satisfaction scale: Birth in Brazil survey. Cad Saúde Pública 2019; 35:e00154918..

Based on the above, this study presents the following hypothesis: there should be no differences in maternal satisfaction with hospitalization for vaginal delivery and cesarean section if they are performed as idealized and planned by pregnant women.

Methods

Type of study

A cohort study was conducted with data from the first two stages of the Birth in Brazil study - a hospital-based population survey, which aimed to study the incidence, associated factors, and consequences of cesarean section in Brazil. The first stage was carried out from February 2011 to October 2012, and the second stage from March 2011 to February 2013 ²⁹29. Leal MC, Silva AAM, Dias MAB, Gama SGN, Rattner D, Moreira ME, et al. Birth in Brazil: national survey into labour and birth. Reprod Health 2012; 9:15.^,3030. d'Orsi E, Brüggeman OM, Diniz CSG, Aguiar JM, Gusman CR, Torres JA, et al. Desigualdades sociais e satisfação das mulheres com o atendimento ao parto no Brasil: estudo nacional de base hospitalar. Cad Saúde Pública 2014; 30 Suppl:S154-68.^,3131. Vasconcelos MTL, Silva PLN, Pereira APE, Schilithz AOC, Souza Junior PRB, Szwarcwald CL. Desenho da amostra Nascer no Brasil: Pesquisa Nacional sobre Parto e Nascimento. Cad Saúde Pública 2014; 30 Suppl:S49-58..

Sampling and data collection

From a list of 1,403 hospitals with more than 500 deliveries per year registered in the Brazilian Information System on Live Births (SINASC), 266 were selected. The sample was stratified by Brazilian macro-regions (North, Northeast, Central-West, Southeast and South), type of municipality (state capital or not) and hospital administration (public, private or mixed). Each stratum presented at least 450 postpartum women selected from five or more hospitals. Inverse sampling was used to select the number of research days (minimum of seven) to reach 90 interviews per hospital. Information on data collection and sample design of the Birth in Brazil study is detailed in three articles ²⁹29. Leal MC, Silva AAM, Dias MAB, Gama SGN, Rattner D, Moreira ME, et al. Birth in Brazil: national survey into labour and birth. Reprod Health 2012; 9:15.^,3030. d'Orsi E, Brüggeman OM, Diniz CSG, Aguiar JM, Gusman CR, Torres JA, et al. Desigualdades sociais e satisfação das mulheres com o atendimento ao parto no Brasil: estudo nacional de base hospitalar. Cad Saúde Pública 2014; 30 Suppl:S154-68.^,3131. Vasconcelos MTL, Silva PLN, Pereira APE, Schilithz AOC, Souza Junior PRB, Szwarcwald CL. Desenho da amostra Nascer no Brasil: Pesquisa Nacional sobre Parto e Nascimento. Cad Saúde Pública 2014; 30 Suppl:S49-58..

In the first stage, 24,200 puerperal women were interviewed during childbirth hospitalization ¹⁹19. Domingues RMSM, Dias MAB, Nakamura-Pereira M, Torres JA, d'Orsi E, Pereira ANE, et al. Processo de decisão pelo tipo de parto no Brasil: da preferência inicial das mulheres à via de parto final. Cad Saúde Pública 2014; 30 Suppl:S101-16.^,2929. Leal MC, Silva AAM, Dias MAB, Gama SGN, Rattner D, Moreira ME, et al. Birth in Brazil: national survey into labour and birth. Reprod Health 2012; 9:15.^,3030. d'Orsi E, Brüggeman OM, Diniz CSG, Aguiar JM, Gusman CR, Torres JA, et al. Desigualdades sociais e satisfação das mulheres com o atendimento ao parto no Brasil: estudo nacional de base hospitalar. Cad Saúde Pública 2014; 30 Suppl:S154-68.^,3131. Vasconcelos MTL, Silva PLN, Pereira APE, Schilithz AOC, Souza Junior PRB, Szwarcwald CL. Desenho da amostra Nascer no Brasil: Pesquisa Nacional sobre Parto e Nascimento. Cad Saúde Pública 2014; 30 Suppl:S49-58.. In the first follow-up, 16,255 mothers were contacted and re-interviewed by telephone, on average 90 days (from 45 days to less than six months) after delivery ²⁹29. Leal MC, Silva AAM, Dias MAB, Gama SGN, Rattner D, Moreira ME, et al. Birth in Brazil: national survey into labour and birth. Reprod Health 2012; 9:15.^,3030. d'Orsi E, Brüggeman OM, Diniz CSG, Aguiar JM, Gusman CR, Torres JA, et al. Desigualdades sociais e satisfação das mulheres com o atendimento ao parto no Brasil: estudo nacional de base hospitalar. Cad Saúde Pública 2014; 30 Suppl:S154-68.^,3131. Vasconcelos MTL, Silva PLN, Pereira APE, Schilithz AOC, Souza Junior PRB, Szwarcwald CL. Desenho da amostra Nascer no Brasil: Pesquisa Nacional sobre Parto e Nascimento. Cad Saúde Pública 2014; 30 Suppl:S49-58..

The basic sample weights were estimated as the inverse of the product of the inclusion probabilities at each stage and calibrated so that the estimates of the total live births of the strata corresponded to the total live births obtained from SINASC. For the telephone follow-up, conducted six months later, the probability of puerperal women’s response was modeled by the variables available at the baseline survey to correct the sample weights for non-response in the second phase. The probability of response was estimated as a function of the three variables that define the stratum (macro-region, capital or not, and hospital administration) and the Brazilian Economic Classification Criteria ³²32. Associação Brasileira de Empresas de Pesquisa. Critério de classificação econômica Brasil. São Paulo: Associação Brasileira de Empresas de Pesquisa; 2005.: age group, paid employment, satisfaction with the pregnancy at the beginning and stillbirth or neonatal death ³¹31. Vasconcelos MTL, Silva PLN, Pereira APE, Schilithz AOC, Souza Junior PRB, Szwarcwald CL. Desenho da amostra Nascer no Brasil: Pesquisa Nacional sobre Parto e Nascimento. Cad Saúde Pública 2014; 30 Suppl:S49-58..

Scale of satisfaction with hospitalization for delivery

The scale of satisfaction with hospital for delivery, with a total of eleven items, was part of Block III (Satisfaction with Hospital Care) of the Birth in Brazil survey. It is an instrument that mainly assesses the work of health professionals during childbirth hospitalization ²⁸28. Costa DDO, Ribeiro VS, Ribeiro MRC, Esteves-Pereira AP, Sá LGC, Cruz JAS, et al. Psychometric properties of the hospital birth satisfaction scale: Birth in Brazil survey. Cad Saúde Pública 2019; 35:e00154918..

The first seven questions of this scale were extracted from the World Health Survey and adapted to childbirth hospitalization (items 1 to 7) ³³33. World Health Organization. World Health Survey: B - individual questionnaire, rotation - C. Geneva: World Health Organization; 2002.. As satisfaction with hospital care during delivery involves aspects not covered in these seven World Health Survey questions, one question on verbal, psychological, and physical violence practiced by care professionals (item 8), and three questions on general satisfaction with delivery, postpartum, and neonatal (items 9 to 11) were added. Psychometric analyses of the scale showed that it was a unidimensional construct of ten items with 0.91 composite reliability ²⁸28. Costa DDO, Ribeiro VS, Ribeiro MRC, Esteves-Pereira AP, Sá LGC, Cruz JAS, et al. Psychometric properties of the hospital birth satisfaction scale: Birth in Brazil survey. Cad Saúde Pública 2019; 35:e00154918..

Theoretical model and variable

The theoretical model (Figure 1) was presented as a directed acyclic graph (DAG). The exposure variable mode of delivery was dichotomized into vaginal delivery and cesarean section. The outcome satisfaction with childbirth hospitalization was tested as a 10-item unidimensional latent variable. Mode of delivery and its predictor variables were collected in the after birth and the outcome satisfaction in the first stage of the follow-up.

The predictive variables of the mode of delivery were the following: Brazilian Economic Classification Criteria ³²32. Associação Brasileira de Empresas de Pesquisa. Critério de classificação econômica Brasil. São Paulo: Associação Brasileira de Empresas de Pesquisa; 2005., categorized as D/E, C and A/B, according to possession of goods and the education level of the head of the family, with categories A and B having greater purchasing power; maternal schooling, measured in years of study (0-4, 5-8, 9-11 or ≥ 12 years); marital status, categorized as: single, consensual union, and married; maternal age at birth, with categories < 20 years old, 20-34 years old, and ≥ 35 years old; type of hospital according to funding, with the Brazilian Unified National Health System (SUS) and private categories; previous cesarean section, with the primiparous categories, with and without cesarean section; preference for the mode of delivery, categorized in “had not decided”, “normal delivery”, and “cesarean section”; and, also, categorized as “no” and “yes”; “pregnancy and/or delivery complications” ¹⁹19. Domingues RMSM, Dias MAB, Nakamura-Pereira M, Torres JA, d'Orsi E, Pereira ANE, et al. Processo de decisão pelo tipo de parto no Brasil: da preferência inicial das mulheres à via de parto final. Cad Saúde Pública 2014; 30 Suppl:S101-16.; “private health insurance coverage of delivery”; “link to the hospital”; and “same professional at prenatal and childbirth”.

To construct the variable “pregnancy or delivery problems”, the occurrence of the following situations that could be associated with the decision for cesarean section was investigated: pre-existing clinical diseases, alterations in the cervix, intrauterine growth restriction, oligohydramnios, polyhydramnios, Rh-negative blood, placenta previa, placental abruption, loss of amniotic fluid, gestational diabetes, gestational hypertension, eclampsia, threatened preterm labor, fetal distress, syphilis, urinary tract infection, HIV infection, toxoplasmosis, streptococcal vulvovaginitis, congenital malformation, hepatitis B and C, complications that influence the negative outcome of the newborn, complications that influence the mode of delivery, and previous uterine surgery and seizure.

Statistical analysis

Counterfactual approach ³⁴34. Morgan SL, Winship C. Counterfactuals and causal inference. 2nd Ed. New York: Cambridge University Press; 2015. was used to estimate the effect of mode of delivery on maternal satisfaction with childbirth hospitalization. Initially, the propensity score was estimated with logistic regression ³⁵35. Guo S, Fraser MW. Propensity score analysis: statistical methods and applications. Thousands Oaks: SAGE; 2010. in the birth database. Via the back door criterion, a method proposed by Pearl ³⁶36. Pearl J. Caudality: models, reasoning, and inference. 2nd Ed. New York: Cambridge University Press; 2019. and Pearl et al. ³⁷37. Pearl J, Glymour M, Jewell NP. Causal inference in statistics: a primer. Chichester: John Wiley & Sons; 2016., the minimum set of adjustment for confounding was selected with the help of the public domain program DAGitty (http://www.dagitty.net/) ³⁸38. Textor J, Hardt J, Knüppel S. DAGitty: a graphical tool for analyzing causal diagrams. Epidemiology 2011; 22:745-51..

The balance of pre-exposure variables was verified via standardized absolute differences in means and variance ratios between vaginal childbirth or cesarean section groups using the tebalance command after the teffects ipw routine command in Stata, version 14 (https://www.stata.com) ³⁹39. StataCorp LLC. Stata treatment-effects reference manual: potential outcomes/counterfactual outcomes release 15. College Station: Stata Press; 2017.. Balance was reached as the standardized absolute differences in the means ranged from -0.10 to 0.10 and the variance ratios from 0.8 to 1.2 ⁴⁰40. Austin PC. Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples. Stat Med 2009; 28:3083-107.^,4141. Leite W. Practical propensity score methods using R. Thousands Oaks: SAGE; 2017.. Observations were weighted as follows: for the group born by cesarean section, weight was the inverse of the probability of cesarean section and it was the inverse of the probability of vaginal delivery for the group born by vaginal delivery, i.e., the inverse of one minus the probability of being born by cesarean section.

The effect of the mode of delivery on satisfaction was estimated in a structural equation model with mode of delivery as exposure and the satisfaction construct as response variable, weighted by the inverse of the selection probability, considering the complex sampling design. The weight was estimated considering the different probabilities of sample selection, the losses to follow-up, and the weight obtained from the propensity score ⁴²42. Nguyen TL, Collins GS, Spence J, Daurès JP, Devereaux PJ, Landais P, et al. Double-adjustment in propensity score matching analysis: choosing a threshold for considering residual imbalance. BMC Med Res Methodol 2017; 17:78.. Standardization was performed only for the response variable. Comparisons were made between weighted percentages considering only the complex sampling design to those also considering losses to follow-up to assess to what extent inverse probability weighting was able to reduce selection bias.

Mplus version 8.5 software program (https://www.statmodel.com/) was used and, as the variables were ordinal categorical, the weighted least square mean and variance adjusted (WLSMV) ⁴³43. Byrne BM. Structural equation modeling with Mplus: basic concepts, applications, and programming. New York: Routledge; 2012. was used.

The model fit was tested using the following indicators: (a) p-value < 0.05 and upper limit of the confidence interval < 0.08 for the root mean square error of approximation (RMSEA) ⁴⁴44. Brown TA. Confirmatory factor analysis for applied research. 2nd Ed. New York: Guilford Press; 2015. index; (b) values > 0.95 for the comparative fit index (CFI) and Tucker Lewis index (TLI); and (c) standardized root mean square residual (SRMR) < 0.05 ⁴²42. Nguyen TL, Collins GS, Spence J, Daurès JP, Devereaux PJ, Landais P, et al. Double-adjustment in propensity score matching analysis: choosing a threshold for considering residual imbalance. BMC Med Res Methodol 2017; 17:78.^,4545. Kline RB. Principles and practice of structural equation modeling. 4th Ed. New York: Guilford Press; 2016..

Ethical aspects

The project complied with the principles of Resolution n. 196/1996, which deals with research involving human beings, and the Brazilian National Health Council and its complementary rules. It was approved by the Ethics Research Committee of the Sergio Arouca National School of Public Health, Oswaldo Cruz Foundation (ENSP/Fiocruz, CAAE 0096.0.031.000-10). Those responsible in each institution and all postpartum women signed an informed consent form at the face-to-face interview.

Results

For the purposes of this study, from the total of 24,200 deliveries in the hospital sample, 488 multiple births, 64 neonatal deaths, as well as missing data for mode of delivery (n = 304), maternal education (n = 104), marital status (n = 8), economic class (n = 154), maternal age at delivery (n = 4), and the same professional attending prenatal care and childbirth (n = 28) were excluded, totaling 23,046 cases in the first stage. In the first follow-up, after losses and exclusions, 15,582 complete cases remained.

In the follow-up, there was a lower proportion of mothers from classes D/E, < 9 years of maternal schooling, single, younger than 20 years, users of SUS, without previous cesarean section, with preference for normal delivery, without pregnancy and labor complications, without health insurance, without link to the hospital, and not attended by the same professional at prenatal and childbirth. Inverse probability weighting considering losses to follow-up reduced selection bias - weighted percentages that considered losses to follow-up were closer to those at birth than to those at follow-up uncorrected (Table 1).

More than half of the interviewees in the final sample of this study (52.2%) underwent cesarean section (result not shown). Almost all predictor variables tested were independently associated with cesarean section, except for the Brazilian economic classification, having health insurance at delivery, and link to the hospital. The predictors strongly associated with cesarean section were same professional at prenatal and childbirth (OR = 5.53; 95%CI: 4.34-7.05), pregnancy and/or labor complications (OR = 4.58; 95%CI: 4.04-5.19), childbirth hospitalization in a private hospital (OR = 4.40; 95%CI: 2.48-7.79), and previous cesarean section (OR = 3.65; 95%CI: 3.06-4.34) (Table 2).

The balance was obtained for all variables, with the exception of preference for the mode of delivery and pregnancy and/or labor complications; as for these variables, the standardized absolute difference between the means of both groups was either slightly below or slightly above -0.10, more stringent cutoff, but still ranging from -0.20 to 0.20, i.e., a less stringent but still acceptable cutoff (Table 3).

Both crude and inverse selection probability weighted models showed good fit. In the crude model, cesarean section was associated with greater satisfaction with delivery (standardized coefficient - SC = 0.258; p-value < 0.001, RMSEA = 0.040) (90%CI: 0.038-0.042; CFI = 0.973; TLI = 0.966; SRMR = 0.034). However, after weighting, the association between mode of delivery and satisfaction was no longer statistically significant (SC = 0.046; p-value = 0.056) (Figure 2).

Discussion

The results of this study showed that users of Brazilian hospital services were equally satisfied with hospital admission for both vaginal and cesarean delivery.

The limitations of this study are related to selection and memory biases, losses to follow-up, and characteristics of the instrument that measured satisfaction. Regarding memory bias, the authors consider that the data collection time from 45 days to less than six months after delivery was adequate to measure maternal satisfaction with hospital admission for delivery. This is because a systematic review on instruments to measure satisfaction with care during labor and childbirth suggested that interviews should be conducted after hospital discharge so that problems that occurred during hospitalization were not overshadowed by the birth of a healthy baby ²⁴24. Sawyer A, Ayers S, Abbott J, Gyte G, Rabe H, Duley D. Measures of satisfaction with care during labour and birth: a comparative review. BMC Pregnancy Childbirth 2013; 13:108.. Concerning the selection bias, the weighting technique by the inverse of the selection probability was performed. The final weight was estimated considering the different probabilities of sample selection, the losses to follow-up, and the weight obtained from the propensity score. The joint use of these techniques tends to reduce the likelihood of selection bias and confounding that arise due to the variables used to derive the weights. However, selection bias and confounding due to other variables not included in the weight calculation may still be present.

The scale used in this study to measure maternal satisfaction with hospital admission for delivery showed good evidence of validity and excellent psychometric properties ²⁸28. Costa DDO, Ribeiro VS, Ribeiro MRC, Esteves-Pereira AP, Sá LGC, Cruz JAS, et al. Psychometric properties of the hospital birth satisfaction scale: Birth in Brazil survey. Cad Saúde Pública 2019; 35:e00154918.. As for the instrument to assess the work of health professionals in delivery care, a systematic review drew attention to the fact that the interpersonal relationship between the user and the health team was the main determinant of satisfaction with childbirth hospitalization ²³23. Srivastava A, Avan BI, Rajbangshi P, Bhattacharyya S. Determinants of women's satisfaction with maternal health care: a review of literature from developing countries. BMC Pregnancy Childbirth 2015; 15:97..

This study advances compared to other studies due to the set of methodological strategies used: (a) a prospective cohort study with random and stratified sampling at three levels was conducted: macro-region, type of municipality (capital or not capital), type of hospital administration, which brought together women from different socioeconomic and cultural conditions in a large country such as Brazil; and (b) a set of methodological techniques was used to better study causality relationship: directed acyclic graphs, counterfactual approach, maternal satisfaction with childbirth hospitalization outcome estimated as a latent variable, and estimation of the causal effect in a structural equation model with inverse weighting of selection probability, with weights derived from the propensity score, follow-up losses, and considering the complex sampling design.

No difference in satisfaction with hospital admission according to mode of delivery can be explained by the women’s final decision between the vaginal childbirth and cesarean section since, at the end of pregnancy, they gave birth as planned. This finding is in line with analyses of qualitative, quantitative, and systematic review studies that found similar satisfaction when the mode of delivery planned was performed ²¹21. Preis H, Lobel M, Benyamini Y. Between expectancy and experience: testing a model of a childbirth satisfaction. Psychol Women Q 2019; 43:105-17.^,2222. Fleming SE, Donovan-Batson C, Barbosa-Leiker C, Martin CJH, Martin CR. Birth Satisfaction Scale/Birth Satisfaction Scale-Revised (BSS/BSS-R): a large scale United States planned home birth and birth centre survey. Midwifery 2016; 41:9-15.^,2323. Srivastava A, Avan BI, Rajbangshi P, Bhattacharyya S. Determinants of women's satisfaction with maternal health care: a review of literature from developing countries. BMC Pregnancy Childbirth 2015; 15:97.^,2424. Sawyer A, Ayers S, Abbott J, Gyte G, Rabe H, Duley D. Measures of satisfaction with care during labour and birth: a comparative review. BMC Pregnancy Childbirth 2013; 13:108.^,2525. Cook K, Loomis C. The impact of choice and control on women's childbirth experiences. J Perinat Educ 2012; 21:158-68.^,4646. Silva ACL, Félix HCR, Ferreira MBG, Wysocki AD, Contim D, Ruiz MT. Preferência pelo tipo de parto, fatores associados à expectativa e satisfação com o parto. Rev Eletrônica Enferm 2017; 19:a34.. Our results are in agreement with those reported in a cross-sectional study with 355 Swedish postpartum women who were interviewed before hospital discharge, in which no differences were observed in maternal satisfaction according to vaginal and cesarean mode of delivery ⁴⁷47. Spaich S, Welzel G, Berlit S, Temerinac D, Tuschy B, Sütterlin M, et al. Mode of delivery and its influence on women's satisfaction with childbirth. Eur J Obstet Gynecol Reprod Biol 2013; 170:401-6.. In another study, which recruited 335 German women who had full-term newborns without congenital malformations, no differences were found in the satisfaction of women who had vaginal childbirth or cesarean section, including emergency cesarean section and surgical vaginal delivery. The authors concluded that the mode of delivery did not directly influence women’s satisfaction with delivery. The factors that improved woman’s experience with birth the most were decision-making power, support received, and effective analgesia ²⁷27. Bleich SN, Özaltin E, Murray JL C. How does satisfaction with the health-care system relate to patient experience? Bull World Health Organ 2009; 87:271-8..

However, in a study of 204 U.S. primiparous women who planned and managed to have a cesarean section (n = 44) or vaginal childbirth (n = 160), maternal satisfaction was higher for those who planned to have a cesarean ⁴⁸48. Blomquist JL, Lieschen HQ, MacMillan D, Mccullough A, Hand VL. Mothers' satisfaction with planned vaginal and planned cesarean birth. Am J Perinatol 2011; 28:383-8.. Conversely, another study evaluating 894 women shortly after delivery in Ethiopia, greater satisfaction was observed after vaginal delivery ⁴⁹49. Karoni HF, Bantie GM, Azage M, Kasa AS, Aynie AA, Tsegaye GW. Maternal satisfaction among vaginal and cesarean section delivery care services in Bahir Dar city health facilities, Northwest Ethiopia: a facility-based comparative crosssectional study. BMC Pregnancy Childbirth 2020; 20:473.. Higher satisfaction scores were also reported after vaginal and cesarean section performed before labor in another U.S. study, whereas a greater dissatisfaction was observed in cesarean births performed after the onset of labor ⁵⁰50. Bossano CM, Townsend KM, Walton AC, Blomquist JL, Handa VL. The maternal childbirth experience more than a decade after delivery. Am J Obstet Gynecol 2017; 217:342.e1-e8.. In another study carried out in Sweden, a greater dissatisfaction was detected when the delivery was prolonged or performed by cesarean section ⁵¹51. Kempe P, Vikström-Bolin M. Women's satisfaction with the birthing experience in relation to duration of labour, obstetric interventions and mode of birth. Eur J Obstet Gynecol Reprod Biol 2020; 246:156-9..

Another study from the Birth in Brazil survey also found no differences in overall maternal satisfaction according to mode of delivery in the adjusted analysis. However, in that survey, the outcome general satisfaction with delivery was investigated using the question: “In your opinion, was your delivery care...”, with an instrument measuring maternal satisfaction with hospital admission for delivery, via a dichotomous variable (no and yes) ³⁰30. d'Orsi E, Brüggeman OM, Diniz CSG, Aguiar JM, Gusman CR, Torres JA, et al. Desigualdades sociais e satisfação das mulheres com o atendimento ao parto no Brasil: estudo nacional de base hospitalar. Cad Saúde Pública 2014; 30 Suppl:S154-68.. In contrast, in our study, a more comprehensive measure of satisfaction with childbirth hospitalization was measured via a latent variable, with no measurement error.

In conclusion, no difference was observed in maternal satisfaction with delivery when comparing women who had vaginal childbirth or cesarean section after adjusting for confounding. However, this equal satisfaction among women who gave birth by vaginal delivery in the Birth in Brazil study cohort does not indicate that Brazilian obstetric services always occur with quality and in a humanized way. We must recognize that advances and improvements have been observed in recent years both in the public and private sectors ⁵²52. Leal MC, Esteves-Pereira AP, Vilela MEA, Alves MTS, Neri MA, Queiroz RCS, et al. Redução das iniquidades sociais no acesso às tecnologias apropriadas ao parto na Rede Cegonha. Ciênc Saúde Colet 2021; 26:823-35.; however, inequalities persist, the adoption of good practices is not as frequent as ideal, and humanized care during childbirth is still an objective to be achieved ⁵³53. Leal MC, Bittencourt SA, Esteves-Pereira AP, Ayres BVS, Silva LBRAA, Thomaz EBAF, et al. Avanços na assistência ao parto no Brasil: resultados preliminares de dois estudos avaliativos. Cad Saúde Pública 2019; 35:e00223018..

Acknowledgments

The researchers thank the interviewees, the managers, and the health workers of the maternity hospitals and the Birth in Brazil research team, as well as the Brazilian National Research Council (CNPq); the Brazilian Ministry of Health; Oswaldo Cruz Foundation (Fiocruz) - INOVA Project; and Rio de Janeiro State Research Foundation (FAPERJ) for their financial support.

References

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