In previous research some determinants of childbirth satisfaction have been proposed, but only a few authors [1–3] considered the multiple determinants within a single study. Social psychological determinants most authors agree about – expectations about childbirth, labour pain, personal control and self-efficacy – are assessed in relation to satisfaction with childbirth in one analysis. In addition, most of the research focuses on single countries. The question of course is, to what extent the results can be generalised between countries, despite huge variation in childbirth delivery practices.
Although Belgium and the Netherlands share a common history, geography and language, health care in general and maternity care in particular are differently organised. The birth systems can be placed in an international context wherein Belgium represents the mainstream obstetric practice characterised by a highly medicalised approach. The Dutch childbirth system, however, is well known for the high rate of home births. Approximately 30% of Dutch pregnant women have a home birth  versus less than 2% of Belgian women . In both countries women can attend primary or secondary caregivers. In the primary care system women deliver at home with a midwife, sometimes accompanied by a general practitioner. In secondary care, childbirth takes place in a hospital under supervision of an obstetrician. In the Netherlands, however, primary caregivers function as gatekeepers . They refer women to secondary care in cases of a reduced chance of a normal birth. In Belgium the great majority (more than 98%) of women consult an obstetrician immediately.
The analytical typology of van Teijlingen , enables us to characterise diverging maternity care systems. The medical model is the dominant paradigm in modern health care and emphasises the body-mind dualism  and the risky nature of childbirth. This biomedical focus is doctor-centred and pregnant women are regarded as passive patients, lacking the knowledge or authority to decide on medical treatment. The social model embraces the holistic approach and views birth as a normal physiological process. The medical status of women having children is not the only relevant information, their social roles and status are also taken into account . Manifestations of the social model in the Netherlands are the strong independent midwifery profession , the belief in the normality of childbirth , the positive attitude towards home births , and the low obstetric intervention rates [11, 12] compared to other European countries. However, this does not mean that the medical model is completely absent from Dutch maternity care. De Vries  points to two sciences of obstetrics in the Netherlands, one in favour of and one against home births. In Belgium the medicalisation of childbirth and the absence of a strong independent midwifery profession  translates to the discouragement of home birth practices  and high intervention rates. Belgian maternity care, however, does not result in lowered average satisfaction scores in comparison to the Dutch .
We assessed four social psychological features – expectations about childbirth, the labour pain, personal control and self-efficacy – associated with childbirth satisfaction in one explanatory model, taking the subdimensions of satisfaction with childbirth into account. Through the use of a Belgian and Dutch sample the applicability of the model in divergent maternity care systems is explored.
Despite a considerable amount of research, satisfaction is poorly defined . Theoretical models regarding patient satisfaction, such as the discrepancy and fulfilment theory  and the value-expectancy model , are relied on. Following Linder-Pelz , we define satisfaction as positive evaluations of distinct dimensions of childbirth. It is generally agreed that satisfaction is a multidimensional concept, influenced by a variety of factors . This means that women can be satisfied with some aspects of childbirth and dissatisfied with others . A review of the literature indicates four main determinants of childbirth satisfaction: labour pain [19–23], personal control [15, 20, 21, 23, 24], self-efficacy [25, 26] and expectations for labour and birth [19–21].
Reports about the relationship between the intensity of pain and satisfaction seem to provide mixed results. Some researchers found that painful experiences result in lowered satisfaction [1, 19, 27–29], others pointed out that the experience of high levels of pain does not necessarily bring about a dissatisfied mother [2, 30]. In a longitudinal study assessing the quality of women's birth experience, Doering et al.  reported that pain does reduce the quality of the birth experience, but even so, remaining in control is more important to a pleasurable experience. In a systematic review Hodnett  concluded that pain and pain relief do not play a major role in childbirth satisfaction, unless expectations regarding either are unmet. Apparently, if the question about the influence of the experience of labour pain on satisfaction with childbirth is rigorously reviewed a considerable consensus is reached. Associations between pain intensity and other determinants of satisfaction, e.g., control and the fulfilment of expectations, are suggested.
Expectations about childbirth
Many authors pointed to the evaluative aspect of childbirth satisfaction [15, 16, 18, 31]. Janzen et al.  defined satisfaction, corresponding with the "discrepancy" model [17, 33], as "the experience which results from the subjective evaluation of the distinction between what actually occurred and what the individual thinks should have" (2006, p. 44).
Expectation as a determinant of satisfaction is related to the need for the familiar, which means that socially created expectations influence satisfaction . Expectations refer to a role system. The role of a labouring woman involves a set of expectations concerning her own behaviour and of people in other roles such as the midwife, the partner, or the physician. By demanding the expected of one's self and each person present, a workable order is created. Violation of expectations disturbs this order and threatens both self-evaluations and relationships with others. In other words, the deviation from what is normal or expected creates distress . Satisfaction is a state of mind reflecting the evaluation of the birth experience as a whole compared with several antenatal values and expectations. If expectations are met, the corresponding values and beliefs are affirmed. If not, conflicts arise, which may bring about distress. However, as Pearlin  stated, mediating factors can play a buffering role between the discrepancy and the reaction to it. Personal control is one of those mediators.
Many conceptualisations of satisfaction refer to expectations as a major determining factor of satisfaction [34, 37–39]. Researchers have shown that women whose expectations for childbirth are met are more satisfied than those whose expectations are not [2, 19, 20]. Expectations related to several aspects of labour and delivery, such as emotions [20, 40], the length of labour , the need for interventions [20, 40], the condition of the child , and the support of the partner and the medical staff , have been researched. Although the fulfilment of expectations received some attention in the childbirth satisfaction literature, it has not yet been included in a model with multiple determinants, except by Goodman et al..
Personal control and self-efficacy
Personal control has been shown to be the strongest predictor of satisfaction with childbirth . Many authors point to the perception of control during birth as essential to feeling satisfied and empowered [1, 15, 19, 20, 30, 41, 42], even if expectations are violated. Although pain management is the best short-term solution to help women cope with childbirth, personal control provides a long-term benefit . If women participate actively, they are empowered by the experience of control . Moreover this empowering experience has a cumulative effect, increasing self-efficacy for the next birth . We distinguished between perceived personal control and self-efficacy. The latter reflects a personality characteristic of confidence in the ability to cope with any stressful situation , which predicts a positive childbirth experience . Self-efficacy is also related to lower levels of pain [26, 46] and method of delivery . Personal control refers to the opposite of powerlessness, which is a type of alienation . Alienation is thought to be a consequence of the medicalisation of childbirth . The degree of women-centeredness and medicalisation of care varies according to place of birth  and the maternity care system .
Determinants such as childbirth expectations  and personal control  have been shown to be strongly related to the birth environment. The results of these studies suggest that the influence of childbirth expectations and personal control can be context specific, hence different for Dutch and Belgian women.
The purpose of our study is to assess the influence of expectations about childbirth, labour pain, personal control and self-efficacy on Belgian and Dutch women's satisfaction with childbirth.