Abstracts

Introduction

The Brazilian Unified National Health System (SUS) was instituted with the enactment of the 1988 Federal Constitution¹1. Brasil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União 1988; 5 oct.. In addition to universality, integrality, and equity principles, SUS is based on popular participation and social control ²2. Brasil. Lei nº 8.080, de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União 1990; 19 sep.. Actions by the Brazilian Ministry of Health demonstrate the importance of the opinion and participation of users in the construction and search for quality and improvement of the entire health system. The Brazilian National Policy for Strategic and Participative Management (ParticipaSUS) ³3. Ministério da Saúde. Política Nacional de Gestão Estratégica e Participativa no SUS - ParticipaSUS. 2ª Ed. Brasília: Editora do Ministério da Saúde; 2009. (Série B. Textos Básicos de Saúde). values the different mechanisms of popular participation and social control. ParticipaSUS encourages the population’s protagonism in the struggle for health by the expansion of public spaces for debates and knowledge construction. Moreover, the Brazilian National Program for the Evaluation of Health Services (PNASS), reformulated in 2015 ⁴4. Ministério da Saúde. Portaria nº 28, de 8 de janeiro 2015. Reformula o Programa Nacional de Avaliação de Serviços de Saúde (PNASS). Diário Oficial da União 2015; 9 jan., had as one of its specific objectives to measure user satisfaction with the care provided by SUS facilities.

Despite significant improvements in recent years ⁵5. Leal MC. Childbirth and birth in Brazil: an evolving scenario. Cad Saúde Pública 2018; 34:e00063818., Brazil still has a low quality of care for childbirth and birth, and high rates of maternal mortality and obstetric violence ⁶6. Leite TH, Pereira APE, Leal MC, Silva AAM. Disrespect and abuse towards women during childbirth and postpartum depression: findings from Birth in Brazil Study. J Affect Disord 2020; 273:391-401.. To face these issues, in 2011, the Brazilian Ministry of Health launched the Stork Network program, to promote the implementation of a new model of care for women’s and children’s health, ensuring access, reception, and resolution of the network care and reduce maternal and child mortality rates. This strategy aims to guarantee women the right to reproductive planning and humanized care for pregnancy, childbirth, and the puerperium ⁷7. Ministério da Saúde. Portaria nº 1.459, de 24 de junho de 2011. Institui, no âmbito do Sistema Único de Saúde (SUS), a Rede Cegonha. Diário Oficial da União 2011; 25 jun.. More than 600 maternity hospitals, public or SUS-affiliated, participate in this program.

To evaluate the extent of implementation of the new care model proposed by the Stork Network program, a cycle of assessment of good practices in childbirth and maternity care was carried out in 2016 and 2017. This cycle investigated the changes in the management model of services and the perception of users, managers, and health professionals to obtain information that can support decision-making on better practices of obstetric care in Brazil.

Women’s satisfaction with the quality of care during childbirth and birth is a crucial source of information for identifying aspects that need to be reviewed and improved in the health system ⁸8. 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. and for preventing long-term negative health outcomes for the mother and the child ⁹9. Bell AF, Andersson E. The birth experience and women's postnatal depression: a systematic review. Midwifery 2016; 39:112-23.. The World Health Organization (WHO) ¹⁰10. World Health Organization. Making pregnancy safer: the critical role of the skilled attendant. https://apps.who.int/iris/bitstream/handle/10665/42955/9241591692.pdf?sequence=1&isAllowed=y (accessed on 18/Aug/2022).
https://apps.who.int/iris/bitstream/hand... recommends assessing and monitoring of maternal and community satisfaction with the healthcare received to enhance quality and efficiency of the health system during pregnancy, childbirth, and postpartum. Moreover, WHO highlighted the importance of a positive birth experience for women in its guideline on intrapartum care ¹¹11. World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. https://www.who.int/reproductivehealth/publications/intrapartum-care-guidelines/en/ (accessed on 18/Aug/2022).
https://www.who.int/reproductivehealth/p... .

User satisfaction with health services depends on factors related to the users themselves and on factors inherent to health services ¹²12. Esperidião MA, Trad LAB. Avaliação de satisfação de usuários: considerações teórico-conceituais. Cad Saúde Pública 2006; 22:1267-76.. Satisfaction with childbirth is a complex and multifactorial construct, and the quality of the relationship between women and their care provide is essential for a good maternal experience ⁹9. Bell AF, Andersson E. The birth experience and women's postnatal depression: a systematic review. Midwifery 2016; 39:112-23.. In delivery and birth care, satisfaction with maternal care is associated with maternal characteristics, sociodemographic and cultural aspects ⁸8. 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.^,1313. Jackson JL, Chamberlin J, Kroenke K. Predictors of patient satisfaction. Soc Sci Med 2001; 52:609-20., number of interventions performed during labor ¹⁴14. Fumagalli S, Colciago E, Antolini L, Riva A, Nespoli A, Locatelli A. Variables related to maternal satisfaction with intrapartum care in Northern Italy. Women Birth 2020; 34:154-61., and attitudes and behaviors of health professionals ¹⁵15. Hodnett ED. Pain and women's satisfaction with the experience of childbirth: a systematic review. Am J Obstet Gynecol 2002; 186(5 Suppl Nature):S160-72., among others ¹⁶16. d'Orsi E, Brüggemann OM, Diniz CSG, Aguiar JM, Guzman 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.^,1717. Baldisserotto ML, Theme Filha MM, Gama SGN. Good practices according to WHO's recommendation for normal labor and birth and women's assessment of the care received: the "birth in Brazil" national research study, 2011/2012. Reprod Health 2016; 13 Suppl 3:124..

This study aimed to describe the satisfaction of puerperal women with their experience in childbirth and birth care and its association with sociodemographic, clinical and obstetric, and good practices during childbirth care, in maternity hospitals affiliated with Stork Network, in Brazil.

Methods

In this study, data were acquired by the survey Stork Network Assessment (SNA) conducted by the Oswaldo Cruz Foundation, the Federal University of Maranhão, and the Brazilian Ministry of Health. SNA was carried out in 606 public and mixed health facilities. Interviews were carried out with health professionals, managers, and puerperal women and information was collected from the women’s medical records, documentary analysis, and a script for observing the maternity facilities. Only the data from the questionnaire applied to the puerperal women and their medical record were used, which addressed sociodemographic characteristics, labor, and delivery, and the care provided in the maternity hospital ¹⁸18. Bittencourt SDA, Vilela MEA, Oliveira MC, Santos AM, Silva CKRT, Domingues RMSM, et al. Atenção ao parto e nascimento em maternidades da Rede Cegonha: avaliação do grau de implantação das ações. Ciênc Saúde Colet 2020; 26:801-21.. The sample included public and mixed hospitals that, in 2015, met the following criteria: performed 500 or more deliveries in a health region with Stork Network action plan, despite the funding; performed less than 500 deliveries, in a health region with Stork Network action plan and releasing resources. In total, 10,665 women were interviewed and the sampling process can be seen in Vilela et al. ¹⁹19. Vilela MEA, Leal MC, Thomaz EB, Gomes MASM, Bittencourt SDA, Gama SGN, et al. Avaliação da atenção ao parto e nascimento nas maternidades da Rede Cegonha: os caminhos metodológicos. Ciênc Saúde Colet 2020; 26:789-800..

The outcome “satisfaction with childbirth care” was obtained with the open-ended question “Would you like to say anything else?”, at the end of the questionnaire. The answers were then categorized by two researchers according to the content. Answers classified as “satisfied” were those that praised the institution and/or professionals; made positive comparisons to previous experiences of childbirth and expressed the idea that the woman’s expectations for the moment of childbirth were met. Answers were classified as “dissatisfied” when contained information about dissatisfaction or complaints against the institution and/or professionals, reports of lack of something that the woman expected at the time of delivery and that her expectations were not met. In total, 2,185 women (20.5%) expressed an interest in exposing their opinions on their experience with the care received in the maternity facilities associated with the Stork Network. The reports were divided into two groups: satisfied and dissatisfied. However, 116 reports (5.3%) reflected aspects that simultaneously covered both categories of satisfaction and dissatisfaction and their responses were disregarded. In the end, 2,069 women composed the population of this study.

Variables were used to characterize the hospital and the woman: geographic macroregion (North, Northeast, Southeast, South, and Central-West), hospital size (≤ 1,499, from 1,500 to 2,999, ≥ 3,000 births/year), age (< 20, from 20 to 34, ≥ 35 years old), education (< elementary, complete elementary, ≥ complete high school), race/skin color (white, black, brown, others), marital status (without a partner, with a partner), parity (primiparous, 1, 2, and 3 or more previous deliveries), planned pregnancy (yes, no), mode of delivery (vaginal, cesarean), newborn admitted to the internsive care unit (ICU) (yes, no), and fetal death (yes, no). Furthermore, questions about the care received at the maternity hospital, waiting time at the reception, and good practices and interventions performed in labor and delivery were used.

First, an exploratory analysis of the data was performed by comparing the women who wanted to speak with those who did not want to speak at the end of the study. Subsequently, the characteristics of the hospital and the mothers who wanted to speak at the end of the questionnaire were analyzed according to satisfaction with care. The analyses were presented with absolute and relative frequencies. Pearson’s chi-square and Fisher’s exact tests were used to compare the groups.

Since many variables were considered, the method of exploratory factor analysis (EFA) was used to summarize them, for later input in the statistical model, which aimed to identify factors associated with the satisfaction of the puerperal woman with motherhood. Thus, it was possible to construct latent variables by analyzing the correlation patterns. To verify whether the data supported the EFA, Bartlett’s test of sphericity was applied and the Kaiser-Meyer-Olkin (KMO) statistic was , in which cut-off points considered were: < 0.5 unacceptable; 0.5-0.6 weak; 0.6-0.7 median, 0.8-0.9 good; and 0.9-1.0 very good ²⁰20. Kaiser HF. An index of factorial simplicity. Psychometrika 1974; 39:31-6..

Two EFAs were performed, one including the whole study population with the variables of respectful care for the puerperal woman and the other considering those of care during labor/delivery and the newborn, applicable only to women who went into labor and had a vaginal delivery. As a criterion for selecting the number of factors, a parallel analysis was considered. Retained factors were those with a self-value greater than the average of the random sample.

Weighted least squares was the method for factor extraction. Considering that the data had a binary character, the tetrachoric correlation matrix was used in the EFA. Moreover, seeking a better interpretation of the factors found for the set of data for labor and delivery and the newborn, a rotation in the load matrix was performed using the varimax method. The cut-off point used for the factorial loads was 0.40.

For the model, the outcome variable was satisfaction with the care received; the explanatory variables were the characterization of the hospital, the sociodemographic characteristics of the puerperal women, and the factors generated by the EFA. Considering the binary outcome, logistic regression was chosen. Thus, it was possible to estimate the adjusted odds ratios and their confidence intervals. Since some factors only apply to those women who underwent vaginal delivery, a model was made for this group (1,156 women) and another for women who underwent cesarean section (913 women). To verify the association between the outcome and the other variables, simple models were first made. Variables whose simple models gave a p-value greater than 0.20 were not considered for the multiple model. In the multiple model, the variables were included according to the manual backward method, that is, all variables were included in the model and removed one by one according to theoretical and statistical relevance. To assess the model adequacy, the Hosmer-Lemeshow test was used.

All tests considered a 5% significance level and the R programming language was used, version 3.6.1 (http://www.r-project.org), “psych” package, and SPSS, version 23 (https://www.ibm.com/).

Results

Most women who spoke lived in Southeast (26%), Central-West (22%), and the capitals and respective metropolitan areas (82.9%). Regarding sociodemographic profile, 70.2% were aged from 20 to 34 years old and had a high education level (50.8%). When giving their opinion, 52.4% of them did so to express their satisfaction with care, and almost half to make complaints. Women in the Southeast (26.3%), Central-West (24.6%), and South (18.7%) regions declared to be more satisfied, in the same way as women who had a vaginal delivery (59.2%) and were attended in smaller hospitals (19.3%) (Table 1).

Their satisfaction was related to the care received at the hospital (Table 2): little waiting time for registration at the reception (84.1%); experiencing good practices of labor and delivery, such as being allowed to walk (74.4%), eat (50.5%), having access to non-pharmacological methods for pain relief (65.9%); being able to breastfeed the newborn in the delivery room (34.5%); making skin-to-skin contact (54.6%); receiving information (72.2%), and having a companion during hospitalization (96.3%). Another component associated with women’s satisfaction was the constant presence of a health professional (64.7%); being called by their name (84.6%); allowed to answer questions (77.3%); felt welcomed (94.7%), not mistreated (93.5%), and had their doubts answered (88.6%).

In the EFA (Table 3), three factors were generated: the first was positively related to questions about respectful care to the puerperal woman and negatively to the mistreatment - identified as “respect to the puerperal woman”; in the second, the latent variable extracted was “presence of the companion” and the questions about the presence of the companion were positively correlated; the third, entitled “delay in care”, was positively related to the waiting time at the reception. The three factors explained 53.3% of the total data variance. The results of the KMO (0.63) and Bartlett’s sphericity test (p-value < 0.001) showed that the data supported the EFA.

Regarding the set of variables of good practices in labor, delivery, and to the newborn, three factors were extracted: the first, entitled “good practices”, was positively correlated with pain relief practices during labor; the second was positively related to interventions performed during labor and delivery; the third presented a positive relationship with breastfeeding and skin-to-skin contact practices, entitled “contact with the baby”. Together, the three latent variables explain 43% of the total data variance. The variable whose variance was mostly explained by common factors was “use of non-pharmacological methods” since the variance that was least explained was skin-to-skin contact (Table 4). The results of KMO and Bartlett’s sphericity test were 0.75 and p-value < 0.001, respectively.

Table 5 shows the results of the multifactorial analysis for mothers’ satisfaction according to the mode of delivery. For vaginal delivery, satisfaction was inversely associated with admission to larger hospitals (0.62) and suffering interventions during labor and delivery (0.83). Satisfaction was positively associated with multiparity (three or more children) (1.98), receiving good care practices for labor and delivery (1.24), respecting the puerperal woman (1.40), and having contact with the newborn immediately after birth (1.20). For cesarean section, satisfaction was positively associated with living in the Central-West (1.91) and South (2.00), respect for the puerperal woman (1.47), and the presence of a companion (1.25).

Discussion

Among the women who decided to speak at the end of the interview, most reported satisfaction with the healthcare received, lived in capitals and metropolitan areas, had a high education level, and were older. Regarding cesarean sections, maternal satisfaction was positively associated with living in the Central-West and South regions and the presence of a companion during hospitalization. For vaginal delivery, satisfaction was inversely associated with large hospitals and suffering interventions during labor and delivery; however, it was positively associated with multiparity, good practices for labor and birth care, and having contact with the newborn immediately after birth. Respect for the puerperal woman was associated with satisfaction both in cesarean sections and in vaginal delivery.

Most women who shared their opinion had a high education level, since it can lead to greater knowledge about their rights in birth care and to recognize the importance of expressing issues considered relevant by them for the study results and the improvement of the care provided by the health system ²¹21. Al Ahmar E, Tarraf S. Assessment of the socio-demographic factors associated with the satisfaction related to the childbirth experience. Open J Obstet Gynecol 2014; 4:585-611..

Among satisfied women, we found a higher percentage of multiparous women, who, due to shorter periods between labors, are subjected to fewer interventions and can also compare the current experience with previous ones, when these changes in the offer of proper technologies to childbirth were probably not implemented in the health services. Most dissatisfied women lived in the Northern Brazil, demonstrating that significant inequalities between assistance to labor and childbirth persist ¹⁶16. d'Orsi E, Brüggemann OM, Diniz CSG, Aguiar JM, Guzman 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.^,1818. Bittencourt SDA, Vilela MEA, Oliveira MC, Santos AM, Silva CKRT, Domingues RMSM, et al. Atenção ao parto e nascimento em maternidades da Rede Cegonha: avaliação do grau de implantação das ações. Ciênc Saúde Colet 2020; 26:801-21..

Our findings corroborate with previous studies that receiving good labor and delivery practices is associated with puerperal women satisfaction ²²22. Martin CJH, Martinez LJ, Martin CR. Measuring women's experiences of childbirth using the Birth Satisfaction Scale-Revised (BSS-R). Br J Midwifery 2020; 28:306-12.^,2323. Martins ACM, Giugliani ERJ, Nunes LN, Bizon AMBL, de Senna AFK, Paiz JC, et al. Factors associated with a positive childbirth experience in Brazilian women: a cross-sectional study. Women Birth 2021; 34:e337-45.. Ambulation and the use of non-pharmacological methods are practices that can help pain relief and the establishment of bonds with professionals who monitor labor ²⁴24. Thomson G, Feeley C, Moran VH, Downe S, Oladapo OT. Women's experiences of pharmacological and non-pharmacological pain relief methods for labor and childbirth: a qualitative systematic review. Reprod Health 2019; 16:71.. Offering food during labor is an important part of birth care for pregnant women ¹¹11. World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. https://www.who.int/reproductivehealth/publications/intrapartum-care-guidelines/en/ (accessed on 18/Aug/2022).
https://www.who.int/reproductivehealth/p... .

Interventions during labor and delivery are inversely associated with satisfaction ¹⁴14. Fumagalli S, Colciago E, Antolini L, Riva A, Nespoli A, Locatelli A. Variables related to maternal satisfaction with intrapartum care in Northern Italy. Women Birth 2020; 34:154-61.. Women who had fewer interventions during labor and delivery were more likely to be satisfied. Obstetric interventions in Brazil, although decreasing ⁶6. Leite TH, Pereira APE, Leal MC, Silva AAM. Disrespect and abuse towards women during childbirth and postpartum depression: findings from Birth in Brazil Study. J Affect Disord 2020; 273:391-401., are still frequent and occur in higher figures than recommended by the WHO and the Brazilian Ministry of Health ¹¹11. World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. https://www.who.int/reproductivehealth/publications/intrapartum-care-guidelines/en/ (accessed on 18/Aug/2022).
https://www.who.int/reproductivehealth/p... ^,2525. Departamento de Gestão e Incorporação de Tecnologias em Saúde, Ministério da Saúde. Diretrizes Nacionais de Assistência ao Parto Normal: versão resumida. Brasília: Ministério da Saúde; 2017.. The rush imposed on women during labor and childbirth, accelerating this complex process, leads to frustration and an unsatisfactory experience ²⁶26. Leal MC, Pereira APE, Domingues RMSM, Theme Filha MM, Dias MAB, Nakamura-Pereira M, et al. Intervenções obstétricas durante o trabalho de parto e parto em mulheres brasileiras de risco habitual. Cad Saúde Pública 2014; 30 Suppl:S17-32..

The puerperal women who are admitted to large hospitals for delivery are less likely to be satisfied with the care provided. This fact may be related to the volume of care provided by the hospital and its ability to manage space and health professionals. Women admitted to large hospitals can often be neglected due to a lack of staff ²⁷27. Hartz Z. Contextualizando a implantação das intervenções e da avaliação em saúde: um ensaio pragmático. In: Samico I, Felisberto E, Frias PG, Santo ACGE, Hartz Z, organizadores. Desafios na Implantação de Programas. Rio de Janeiro: Medbook; 2015: p. 3-20..

Corroborating our findings, Martins et al. ²³23. Martins ACM, Giugliani ERJ, Nunes LN, Bizon AMBL, de Senna AFK, Paiz JC, et al. Factors associated with a positive childbirth experience in Brazilian women: a cross-sectional study. Women Birth 2021; 34:e337-45. reported that contact with the baby shortly after birth and breastfeeding the baby in the first hour after birth is associated with the satisfaction of the puerperal woman. Furthermore, the presence of a companion during hospitalization, which in Brazil has been guaranteed by law since 2005 ²⁸28. Brasil. Lei nº 11.108, de 7 de abril de 2005. Altera a Lei nº 8.080, de 19 de setembro de 1990, para garantir às parturientes o direito à presença de acompanhante durante o trabalho de parto, parto e pós-parto imediato, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2005; 8 apr., has a positive effect on women’s satisfaction ²⁹29. Bruggemann OM, Parpinelli MA, Osis MJ, Cecatti JG, Neto ASC. Support to woman by a companion of her choice during childbirth: a randomized controlled trial. Reprod Health 2007; 4:5.. Another piece of evidence found is the association between women’s satisfaction and the relationship with health professionals. The attitudes and behaviors of health professionals about the ability to provide adequate information and emotional support are the main predictors of satisfaction with childbirth care ¹⁵15. Hodnett ED. Pain and women's satisfaction with the experience of childbirth: a systematic review. Am J Obstet Gynecol 2002; 186(5 Suppl Nature):S160-72.^,1616. d'Orsi E, Brüggemann OM, Diniz CSG, Aguiar JM, Guzman 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.^,1717. Baldisserotto ML, Theme Filha MM, Gama SGN. Good practices according to WHO's recommendation for normal labor and birth and women's assessment of the care received: the "birth in Brazil" national research study, 2011/2012. Reprod Health 2016; 13 Suppl 3:124..

Some differences between factors associated with the satisfaction of the puerperal woman were observed for vaginal delivery and cesarean sections. Regarding cesarean section, women in the South and Central-West regions had a greater chance of being satisfied compared to those in the North. The percentages of cesarean sections in Brazil vary among geographic regions: they are higher in the South, Southeast, and Central-West regions, often indicating an excess of interventions in childbirth. In the North and Northeast regions, the cesarean section rates are slightly lower than other regions. Moreover, the lack of adequate structure in these regions, with worse performance regarding equipment, medicines, and qualified professionals, may explain the greater dissatisfaction of women ³⁰30. Bittencourt SDA, Reis LGC, Ramos MM, Rattner D, Rodrigues PL, Neves DCO, et al. Estrutura das maternidades: aspectos relevantes para a qualidade da atenção ao parto e nascimento. Cad Saúde Pública 2014; 30 Suppl:S208-19.^,3131. Zaiden L, Nakamura-Pereira M, Gomes MAM, Esteves-Pereira AP, Leal MC. Influência das características hospitalares na realização de cesárea eletiva na Região Sudeste do Brasil. Cad Saúde Pública 2020; 36:e00218218..

The participation of the pregnant woman in the decision-making process of childbirth and the reception and respect given to her was pointed out in several studies as determining factors for the satisfaction of the puerperal woman, overlapping sociodemographic characteristics such as age, education level, and race/skin color. In this study, these factors did not remain in the final model, corroborating these findings ¹⁵15. Hodnett ED. Pain and women's satisfaction with the experience of childbirth: a systematic review. Am J Obstet Gynecol 2002; 186(5 Suppl Nature):S160-72.^,1616. d'Orsi E, Brüggemann OM, Diniz CSG, Aguiar JM, Guzman 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.^,1717. Baldisserotto ML, Theme Filha MM, Gama SGN. Good practices according to WHO's recommendation for normal labor and birth and women's assessment of the care received: the "birth in Brazil" national research study, 2011/2012. Reprod Health 2016; 13 Suppl 3:124..

This study constructed six latent variables that represent summary measures of good practices and interventions during labor and delivery, contact between mother and newborn after birth, respect for the puerperal woman, presence of a companion during hospitalization, and the delayed care to pregnant women. By these indicators, we evaluated different aspects of childbirth care that can lead to differences in women’s satisfaction.

Despite including only the opinions of women who, at the end of the interview, wanted to speak and demonstrated their satisfaction or not with the care received, the sample includes the report of about 2,000 women who attended maternity hospitals distributed in all regions of Brazil. The construction of the satisfaction variable was based on the free reports of women at the end of the questionnaire, being able to acquire a subjective character. During assessment, people who have more extreme reports, that is, those who felt very dissatisfied or satisfied are more likely to express themselves voluntarily. In our study, women from the Southeast and Central-West regions, living in capital cities, of older age, and those with high education levels were more represented in this study, and the proportion of satisfied and dissatisfied women was very similar in the sample. However, it is difficult to assess the impact of this on external validity because we do not have other variables in the study that can assess the satisfaction of women who did not express an opinion about the received care. In total, 116 women who reported mixed feelings (satisfaction and dissatisfaction) were excluded. If these were included in the analyses of the 2,069 women, they would not change the results and conclusions of the study.

In total, 25.5% of women went into labor but had cesarean sections. These women are more exposed to interventions during labor, which could generate differences in satisfaction in this subgroup. Furthermore, these women were included in the analysis group of women who underwent cesarean sections. Satisfaction with childbirth in this subgroup was 46.7% dissatisfied and 53.3% satisfied, very similar to the percentages found in the whole sample (47.7% and 52.3%). The inclusion of this subgroup in the cesarean section category did not bias the study results. Another limitation is related to the construction of the latent variables of good practices, interventions, and contact with the baby, which included only women with vaginal delivery, making it impossible to compare the two modes of delivery.

Notably, SNA showed significant improvements from 2011 to 2017. However, investments in Stork Network decreased in recent years, and in 2022 the Stork Network was extinguished and replaced by the Maternal and Child Care Network (RAMI) ³²32. Ministério da Saúde. Portaria nº 715, de 4 de abril de 2022. Institui a Rede de Atenção Materna e Infantil. Diário Oficial da União 2022; 6 apr.. It is still not possible to know whether there has been a worsening in childbirth care due to the SUS dismantling in recent years. However, during the COVID-19 pandemic, maternal mortality in Brazil increased by 94.4% ³³33. Fundo de População das Nações Unidas. A razão da mortalidade materna no Brasil aumentou 94% durante a pandemia. Fundo de População da ONU alerta para grave retrocesso. https://brazil.unfpa.org/pt-br/news/razao-da-mortalidade-materna-no-brasil-aumentou-94-durante-pandemia-fundo-de-populacao-da-onu (accessed on 27/Jan/2023).
https://brazil.unfpa.org/pt-br/news/raza... .

Women’s satisfaction with labor and birth care is a complex task and can be influenced by subjective factors such as the expectations that women have for such an important moment as the birth of a child. A better understanding of the factors associated with the satisfaction of puerperal women with birth care can contribute to the elaboration of protocols and policies focused on relevant aspects for women and that impact on the quality of the service provided in public maternity hospitals in Brazil.

Acknowledgments

Brazilian Ministry of Health, Oswaldo Cruz Foundation, and Federal University of Maranhão.

References

Publication Dates

History