Adler et al.

BMC Pregnancy and Childbirth (2020) 20:415

https://doi.org/10.1186/s12884-020-03106-4

RESEARCH ARTICLE Open Access

Maternal childbirth experience in induced

and spontaneous labour measured in a
visual analog scale and the factors
influencing it; a two-year cohort study
Katti Adler, Leena Rahkonen and Heidi Kruit*

Abstract
Background: Poor maternal childbirth experience plays a role in family planning and subsequent pregnancies. The
aim of this study was to compare childbirth experiences in induced and spontaneous labor and to investigate the
factors influencing the childbirth experience.
Methods: This two-year cohort study included all women with term singleton pregnancies in cephalic presentation
aiming for vaginal delivery at Helsinki University Hospital between January 2017 and December 2018. Maternal
satisfaction in the childbirth experience was measured after delivery using a Visual Analog Scale (VAS) score. A low
childbirth experience score was defined as VAS < 5. The characteristics and delivery outcomes of the study
population were collected in the hospital database and analyzed by SPSS.
Results: A total of 18,396 deliveries were included in the study, of which 28.9% (n = 5322) were induced and 71.1%
(n = 13 074) were of spontaneous onset. The total caesarean delivery rate was 9.3% (n = 1727). Overall, 4.5% (n = 819) of
the women had a low childbirth experience VAS score. The women who underwent labor induction were less satisfied
with their birth experience compared to women with spontaneous onset of labor [7.5% (n = 399) vs. 3.2% (n = 420);
p < 0.001]. Poor childbirth experience was associated with primiparity [OR 2.0 (95% CI 1.6–2.4)], labor induction [OR 1.6
(95% CI 1.4–1.9)], caesarean delivery [OR 4.5 (95% CI 3.7–5.5)], operative vaginal delivery [OR 3.3 (95% CI 2.7-4.0)], post-
partum hemorrhage [OR 1.3 (95% CI 1.1–1.6)], and maternal infections [OR 1.7 (95% CI 1.3–2.4)].
Conclusions: Poor childbirth experience was associated with labor induction, primiparity, operative delivery, and labor
complications, such as post-partum hemorrhage and maternal infections. These results highlight the aspects of care for
which patient experience may be improved by additional support and counselling.
Keywords: Induction of labor, Childbirth experience, Maternal satisfaction, Visual analogue scale, Operative delivery

Background of IOL is approximately 28%. The increasing rates in

The rates of induction of labor (IOL) are rising world- IOL may be explained by increasing maternal age, obes-
wide with currently almost every third labor being in- ity, and medical conditions as well as by improved fetal
duced [1–3]. In Helsinki University Hospital, a tertiary monitoring and management practices. IOL is shown to
care obstetric unit with 13,500 births annually, the rate improve perinatal outcomes without increasing the rate
of caesarean deliveries [4].
* Correspondence: [email protected] An abundance of studies exist on the influence of
Department of Obstetrics and Gynecology, University of Helsinki and Helsinki pregnancy and labor on postnatal physical and mental
University Hospital, Haartmaninkatu 2, 00029 HUS Helsinki, Finland

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data made available in this article, unless otherwise stated in a credit line to the data.
Adler et al. BMC Pregnancy and Childbirth (2020) 20:415 Page 2 of 7

health [5, 6]. Childbirth experience is influenced by a support to women scoring a VAS of 0–4. The women
variety of health, social, and care factors [11]. Women who gave a low childbirth experience score were offered
undergoing IOL are less likely to be satisfied with their a consultation with a trained midwife or obstetrician ac-
care and childbirth experience compared to women with cording to the hospital management guideline.
spontaneous onset of labor [7, 8]. Women may be con- The data on baseline characteristics and delivery out-
cerned about the impact of IOL on the fetus or them- comes of the study population were collected from the
selves and more often express anxiety or report feelings hospital database. The collected delivery parameters in-
of neglect, insufficient pain relief, plans not being cluded the mode of delivery, post-partum hemorrhage
followed, wasted effort, and disappointment if their labor (PPH) ≥ 1000 ml, grade III-IV perineal tear, placental re-
induction is unsuccessful [9]. The progress of induced tention, birth weight, Apgar score, umbilical artery blood
labor is one of the most important factors affecting over- gas values, and admission to the neonatal intensive unit
all maternal satisfaction [10]. Outpatient cervical ripen- (NICU). The correlation of maternal childbirth experi-
ing, sufficient patient information, and the active role of ence and the labor outcome parameters was included in
the woman improve the maternal experience [11, 12]. A the analyses.
poor childbirth experience plays a role in well-being Post-term pregnancy was defined as gestational age ≥
after delivery, family planning, and subsequent pregnan- 41 weeks. Group B Streptococcus (GBS) was universally
cies and deliveries. Thus, considering the increasing screened in all women by a rapid qualitative in vitro
rates of IOL, optimizing the maternal childbirth experi- GBS test (Xpert® GBS, Cepheid, Sunnyvale, California,
ence in induced labor is important. USA). Administration of prophylactic antibiotics was
The aim of this study was to compare the maternal started for all GBS-positive women at the time of diag-
childbirth experience in induced and spontaneous labor nosing ruptured membranes. Gestational diabetes was
and to investigate the factors influencing the childbirth diagnosed by at least one pathological value with a two-
experience. hour oral glucose tolerance test. Failed induction was di-
agnosed after ruptured membranes and 12 hours of oxy-
Methods tocin administration without cervical change. Shoulder
This retrospective cohort study included all women with dystocia was defined as a delivery that required add-
live singleton pregnancies in cephalic presentation at or itional obstetric maneuvers to deliver the fetus after the
beyond 37 gestational weeks with the aim of vaginal de- head was delivered and gentle traction had failed.
livery at Helsinki University Hospital between January The IOL was carried out through oral 50 mcg of miso-
1st, 2017 and December 31st, 2018. The study protocol prostol administered every four hours or a single 40–
was approved by the institutional review board (IRB) of 80 ml balloon catheter (Rüsch 2 way Foley Couvelaire
the hospital region (Helsinki and Uusimaa Hospital Dis- tip catheter size 22 Ch, Teleflex Medical, Athlone,
trict Committee for Obstetrics and Gynecology) (nr. Ireland) retained for a maximum of 24 hours. When a
HUS/3172/2018 and HUS/54/2019). Due to the retro- Bishop score of ≥ 6 was reached, IOL was continued by
spective nature of the study, written informed consent amniotomy in case of intact amniotic membranes and
was waived by the IRB according to national legislation oxytocin in the absence of spontaneous contractions.
(Medical Research Act 488/1999, Chap. 2 a [23.4.2004/ Oxytocin augmentation and continuous cardiotocogra-
295], Sect. 5 and 10a). phy during labor were routinely used.
The primary outcome was the maternal childbirth ex- Statistical analyses were performed using the IBM
perience, which was measured after delivery using the SPSS Statistics for Windows, Version 26.0 (Armonk,
Visual Analog Scale (VAS) score [13]. The VAS is fre- NY, USA). Categorical variables were compared by
quently used in pain measuring, but it has also been the chi-square test and Fisher’s exact test when ap-
used for evaluating patient satisfaction, such as maternal propriate. Data with continuous variables were ana-
satisfaction related to the birth experience [14–16]. The lyzed by a T-test when the data followed normal
childbirth experience measurement was carried out ac- distribution and by a Mann-Whitney U test if the
cording to the hospital policy by the treating midwife be- data did not follow normal distribution. Univariate
fore discharging the patient from the post-partum ward and multivariate logistic regression analyses were
after delivery. The patients were asked to rate their over- performed to assess a relative risk for low VAS.
all childbirth experiences on a scale from zero to 10, Categorical variables were analyzed for odds ratios
where zero stands for the most negative experience pos- (OR) with a 95% confidence interval (CI). Adjusted odd
sible and 10 for the most positive experience possible. A ratios (OR) with 95% confidence intervals (CI) were calcu-
VAS score of four or less was defined as a low score and lated by modelling the data to control for possible con-
a poor childbirth experience based on the local manage- founding factors, as presented in Table 3. A p-value < 0.05
ment recommendation to offer extra psychosocial was considered statistically significant.
Adler et al. BMC Pregnancy and Childbirth (2020) 20:415 Page 3 of 7

Results maternal infections, post-partum hemorrhage, and ad-

During the study period, 19,414 deliveries met the study mission to neonatal care, among women whose labor
criteria. The childbirth experience VAS score was missing was induced compared with those whose labor was of
in 5.2% (n = 1018) of the deliveries, leaving a total of 18,396 spontaneous onset (Table 1).
women included in the study. Of these, 28.9% (n = 5322)
underwent IOL, and 71.1% (n = 13 074) were of spontan- Figure 1 presents the distribution of the childbirth ex-
eous onset. perience VAS score in the groups of induced and spontan-
The mean maternal age was 31.8 (SD 5.0) years with eous labors. The mean (SD) VAS score was lower in
the mean BMI 24.2 (SD 4.7) and the mean gestational women with induced labor compared to spontaneous on-
age 40.2 (SD 1.2) weeks. The characteristics and labor set of labor (7.7% vs 8.2%; p < 0.001). The VAS scores did
outcomes of the study population are shown in Table 1. not differ between the induction methods of a balloon
The women undergoing IOL were older, more obese, of catheter or misoprostol (VAS < 5 balloon catheter 7.5% vs.
more advanced gestational age, more often primiparous, misoprostol 8.7%; p = 0.24). The proportion of a score of
or more often had IVF-pregnancy, gestational diabetes, 9 − 10 was higher among women whose labor was of
and a history of previous CS (Table 1). The main indica- spontaneous onset (Fig. 1). Overall, 4.5% (n = 819) of the
tions for labor induction were post-term pregnancy women gave a low childbirth experience VAS-score < 5.
(30.2%), prolonged pre-labor rupture of membranes Primiparous women were more often less satisfied with
(28.1%), gestational diabetes (10.6%), and hypertensive their childbirth experiences compared with multiparous
complications (7.2%). The overall CS rate was 9.3% (n = women [6.8% (n = 587) vs. 2.4% (n = 232); p < 0.001]. This
1727). There were more caesarean deliveries (19.5% vs. was observed in the both groups of induced and spontan-
5.3%; p < 0.001) and labor complications, such as eous labors (Table 2). In both groups, women also more

Table 1 The characteristics and delivery outcomes in women with induction of labor and spontaneous onset of labor (n = 18 396)
Induced labor Spontaneous labor (n = 13074) p-value
(n = 5322)
n % n %
Age > 35 years 1613 30.3 3297 25.2 < 0.001
Height < 164 cm 1967 37.0 4651 35.6 0.01
BMI ≥ 30 1023 19.2 1165 8.9 < 0.001
IVF 313 5.9 525 4.0 < 0.001
Smoking 417 7.8 971 7.4 0.40
Primiparous 2799 52.6 5840 44.7 < 0.001
Post-term (≥ 41 weeks) 2259 42.4 3419 26.2 < 0.001
Gestational diabetes 1324 24.9 2505 19.2 < 0.001
Previous CS 462 8.7 834 6.4 < 0.001
Birth experience VAS-score < 5 399 7.5 420 3.2 < 0.001
Operative vaginal delivery 665 12.5 1515 11.6 0.08
Caesarean delivery 1040 19.5 687 5.3 < 0.001
Placental retention 140 2.6 190 1.5 < 0.001
Shoulder dystocia 22 0.4 40 0.3 0.25
Maternal infection 183 3.4 175 1.3 < 0.001
Sphincter injury 110 2.0 262 2.1 0.78
a b
Maternal severe complication 7 0.1 10 0.1 0.27
Post-partum hemorrhage ≥ 1000 ml 775 14.6 1181 9.1 < 0.001
5-min Apgar score < 7 157 3.0 221 1.7 < 0.001
Umbilical artery pH < 7.05 74 1.5 147 1.3 0.58
NICU admission 345 6.5 661 5.1 < 0.001
Abbreviations: BMI body mass index, IVF in vitro fertilization
a
Relaparotomy n = 2, pulmonary embolism n = 1, sepsis n = 1, uterine rupture n = 3
b
Postpartum hysterectomy n = 1, uterine rupture n = 9
Adler et al. BMC Pregnancy and Childbirth (2020) 20:415 Page 4 of 7

Fig. 1 The distribution of birth experience VAS-score in induced and spontaneous onset of labor (n=18 396)

frequently gave a low childbirth experience VAS score fol- Discussion

lowing emergency CS or operative vaginal delivery com- In this two-year tertiary hospital cohort study of 18,396
pared to spontaneous vaginal delivery (Table 2). women, a total of 4.5% of women had a low childbirth
experience VAS score. Poor childbirth experience was
Women who had a low childbirth experience VAS associated with primiparity, labor induction, operative
score were more often obese, smokers, primiparous, delivery, and maternal labor complications, such as PPH
post-term, more often had IVF-pregnancy, and under- and infections. As the maternal childbirth experience
went IOL (OR 3.0 95% CI 2.1–2.8) (Table 3). There may play an important role in family planning and sub-
were higher rates of CS (32.0% vs. 8.3%; p < 0.001, OR sequent pregnancies, assessing the factors influencing
5.2 [95% CI 4.4-6.0]) and operative vaginal delivery childbirth experiences is important. These results high-
(25.8% vs. 11.2%; p < 0.001 OR 2.8 (95% CI 2.3–3.2)] light the specific patient groups and aspects of care for
among women who had a low VAS score compared which patient experiences could be improved by add-
to those with a VAS- score > 5 (Table 3). A low child- itional support and counselling.
birth experience score was also associated with labor In this study, primiparity was a significant risk factor for
complications, such as placental retention, shoulder a low childbirth experience score. This was also observed
dystocia, maternal infection, sphincter injury, PPH, in a previous survey study on more than 5,000 women in
maternal severe complication, and NICU admission which multiparous women were more likely to have a
(Table 3). After the multivariable analysis was ad- positive experience than primiparous women [17].
justed for factors presented in Table 3, only primipar- Consistent with our results, IOL and labor interven-
ity, labor induction, CS, operative vaginal delivery, tions are associated with more negative childbirth expe-
maternal infection, and PPH remained significant riences compared to spontaneous onset of labor [7, 8].
(Table 3). In a mixed-methods study on 5,333 women, delay in

Table 2 Low birth experience score (n = 819) presented as proportions of the parity and the mode of delivery groups
Induced labor (n = 399) Spontaneous labor
(n = 420)
n % p-value n % p-value
Parity < 0.001 < 0.001
Nulliparous 285 10.2 302 5.2
Multiparous 114 4.5 118 1.6
Mode of delivery < 0.001 < 0.001
Caesarean section 180 17.3 82 11.9
Spontaneous vaginal 134 3.7 212 1.9
Operative vaginal 85 12.8 126 8.3
Adler et al. BMC Pregnancy and Childbirth (2020) 20:415 Page 5 of 7

Table 3 Characteristics and delivery outcomes in women with low birth experience score compared to women with average or
good birth experience (n = 18 396)
VAS < 5 (n = 819) Vas ≥ 5 p-value Unadjusted Adjusted
(n = 17 577)
n (%) n (%) OR (95% CI) OR (95% CI)
Age > 35 years 207 25.3 4703 26.8 0.35 0.9 (0.8–1.1) 0.9 (0.8–1.1)
Height < 164 cm 314 38.5 6304 36.1 0.161 1.1 (1.0–1.3) 0.9 (0.8–1.1)
BMI ≥ 30 133 16.2 2055 11.7 < 0.001 1.5 (1.2–1.8) 1.2 (1.0–1.5)
IVF 51 6.2 787 4.5 0.02 1.4 (1.1–1.9) 0.9 (0.7–1.3)
Smoking 79 9.8 1309 7.6 0.02 1.3 (1.0–1.7) 1.3 (1.0–1.6)
Primiparous 587 71.7 8092 45.8 < 0.001 3.0 (2.6–3.5) 2.0 (1.6–2.4)
Post-term (≥ 41 weeks) 338 41.3 5340 30.4 < 0.001 1.6 (1.4–1.9) 1.1 (1.0–1.3)
Induced labor 399 48.7 4923 28.0 < 0.001 2.4 (2.1–2.8) 1.6 (1.4–1.9)
Gestational diabetes 188 23.0 3641 20.7 0.12 1.1 (0.9–1.3) 1.0 (0.9–1.2)
Previous CS 59 7.2 1237 7.0 0.89 1.0 (0.8–1.3) 1.1 (0.8–1.5)
Caesarean delivery 262 32.0 1465 8.3 < 0.001 5.2 (4.4–6.0) 4.5 (3.7–5.5)
Operative vaginal delivery 211 25.8 1969 11.2 < 0.001 2.8 (2.3–3.2) 3.3 (2.7–4.0)
Placental retention 24 2.9 302 1.7 0.01 1.7 (1.1–2.6) 1.2 (0.7–1.9)
Shoulder dystocia 7 0.9 55 0.3 0.01 2.7 (1.2–6.0) 1.6 (0.7–3.9)
Sphincter injury 25 3.1 347 2.0 0.03 1.6 (1.3–2.4) 1.4 (0.9–1.2)
Maternal infection 64 7.8 294 1.7 < 0.001 5.0 (3.8–6.6) 1.7 (1.3–2.4)
PPH ≥ 1000 ml 174 21.5 1782 10.2 < 0.001 2.4 (2.0–2.9) 1.3 (1.1–1.6)
a b
Maternal severe complication 5 0.6 12 0.1 < 0.001 9.0 (3.2–25.6) 3.0 (1.0–9.3)
NICU admission 80 9.8 926 5.3 < 0.001 2.0 (1.5–2.5) 0.9 (0.7–1.1)
a
Uterine rupture n = 2 (of which one underwent hysterectomy), relaparotomy n = 1, pulmonary embolism n = 1, sepsis = 1
b
Uterine rupture n = 10, hysterectomy n = 1, relaparotomy n = 1

labor induction, delay in transfer to delivery ward, and findings because failed induction and labor dystocia were
delay in receiving pain relief were mentioned as the key common indications for CS in our study.
themes for poor childbirth experiences [8, 18]. This may Neonatal care admission was not found to be a signifi-
explain why some women with successful IOL and vagi- cant factor in childbirth experiences in some studies [10,
nal delivery in our study were not satisfied with their 20, 21], while in others, it was found to be salient [10].
childbirth experiences. In addition, a lack of information In our study, admission to NICU was not associated
and choice as well as feelings of disappointment, anxiety, with a low childbirth experience score; however, mater-
and neglect have been discussed in previous studies [5]. nal post-partum complications were associated with
These negative feelings are more likely to occur in cases poor childbirth experiences in our study, which may
of failed induction, prolonged labor, and other labor partly be explained by maternal health issues, perhaps
complications [15], which was also observed in our study preventing an active role in the postnatal care of the in-
in which labor complications, operative delivery, mater- fant and breastfeeding. Furthermore, the length of post-
nal infections, and PPH were associated with poor child- natal hospital stay and delay in recovery may have
birth experiences. Furthermore, post-partum problems influenced interactions between the mother and the in-
and length of post-partum hospital stay have been previ- fant [11].
ously associated with negative childbirth experiences The major weaknesses of our study are the retrospect-
[11], which was also reflected in the current study. ive design and the childbirth experience VAS score be-
In our study, women who had CS or operative vaginal ing a subjective rating that may have been influenced by
delivery were less likely to have a positive childbirth ex- a variety of factors, such as individual variation of mid-
perience compared to women with spontaneous vaginal wives discussing the birth and obstetric interventions
delivery, which is in line with previous studies [8, 19]. and presenting the VAS scale. Furthermore, non-native
Failed induction and prolonged labor have previously speakers were involved in the study, so there may have
been reported as significant factors of a negative child- been a lack of clarity involved in some cases. The VAS
birth experience [9, 10]. This may explain some of our score is a narrow measurement for overall birth
Adler et al. BMC Pregnancy and Childbirth (2020) 20:415 Page 6 of 7

experience, and it may be influenced by several factors, Funding

such as delivery expectations, social status, support, This study received no funding.

labor analgesia, communication with medical staff, in-

Availability of data and materials
volvement in decision making, and the opportunity to The data that support the findings of this study are available from the
discuss the labor after delivery. However, Larsson and Helsinki Uusimaa Hospital District but restrictions apply to the availability of
colleagues have shown VAS to be suitable for evaluating these data, which were used under license for the current study, and so are
not publicly available. Data are however available from the authors upon
the negative childbirth experience, and VAS has been reasonable request and with permission of the Helsinki Uusimaa Hospital
validated for assessing birth experiences by comparing District.
VAS with the Wijma Delivery Expectancy/Experience
Questionnaire with a significant correlation between the Ethics approval and consent to participate
The study protocol was approved by the institutional review board (IRB) of
two measurements [14, 16] According to the hospital the hospital region (Helsinki and Uusimaa Hospital District Committee for
protocol, the VAS assessment was performed 1–3 days Obstetrics and Gynecology) (nr. HUS/3172/2018 and HUS/54/2019). Due to
after delivery, just before discharging the patient from the retrospective nature of the study, written informed consent was waived
by the IRB according to national legislation (Medical Research Act 488/1999,
the postpartum ward. The optimal time for evaluating a Chap. 2 a (23.4.2004/295), Sect. 5 and 10a).
birth experience may be questioned, and the VAS score
in our study may have been influenced by the short time Consent for publication
interval from delivery and the initial positive feelings to- Not applicable

wards having a baby [22]. However, this is a large two-

Competing interests
year cohort with more than nine of 10 women who de- The authors declare that they have no competing interests.
livered in a large tertiary care hospital having given the
childbirth experience score, which adds to the value of Received: 26 May 2020 Accepted: 9 July 2020

the study. The authors acknowledge that investigating

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