In this observational cohort, we demonstrated that Black race, cesarean birth, and increasing labor length were independent risk factors for low birth satisfaction among women who underwent labor induction. Furthermore, we identified racial disparities in birth satisfaction for women undergoing IOL. Specifically, Black women had lower satisfaction with the overall birth process, as well as the domain that reflects preparedness for labor.
Maternal birth satisfaction is important to women and impacts maternal and neonatal morbidity. There is a paucity of data around birth satisfaction for women undergoing labor induction. Prior studies compared women who underwent labor induction with those in spontaneous labor, demonstrating decreased birth satisfaction among women undergoing labor induction and evaluating for underlying causes of that difference [3, 4]. Henderson (2015) performed a mixed methods study, surveying 5333 women who gave birth in the United Kingdom in 2009, 20% of which were induced. In the qualitative analysis, the main thematic concerns that emerged regarding IOL were delay, staff shortages, neglect, as well as pain and anxiety in relation to getting the labor induction started. Shetty (2005) compared 450 women undergoing IOL with 450 women in spontaneous labor, again demonstrating lower maternal birth satisfaction in the IOL group (70.4% vs 79.5%, p = 0.006). Of note, each of these studies used differing scales from ours to determine level of maternal birth satisfaction.
While labor inductions may be associated with low maternal satisfaction, many obstetric scenarios necessitate labor induction. In addition, in context of the ARRIVE trial, a large multicenter study performed through the Maternal Fetal Medicine Units (MFMU) Network demonstrating decreased cesarean birth rates as well as lower rates of hypertensive disorders of pregnancy when comparing elective labor induction at 39 weeks vs. expectant management for low risk pregnancies, women may elect for IOL at increasing rates [12]. Interestingly, in that study, women in the labor induction arm reported higher labor agentry scores, indicating an increased sense of control over the labor process, when compared with the spontaneous labor group. Of note, all women in that group elected to participate in the trial knowing there was at least a 50% chance of undergoing a labor induction in the 39th week. Thus, it becomes critical to determine risk factors for low birth satisfaction among women undergoing IOL in order to target these women during the labor induction process.
Prior work examining risk factors for decreased birth satisfaction during labor induction has focused on mode of delivery. Ezeanochie et al. found that among women undergoing IOL in a Nigerian population (n = 252), those who delivered via cesarean were significantly more likely to be dissatisfied than those who birthed vaginally (13.3% vs 61.1%, p = 0.001) ( [13]). Simpson et al. (n = 551) found that more women who had a cesarean reported that they would not want to have an IOL again in comparison to those who had a vaginal delivery (57.4% vs 34%) ( [14]).
Our findings confirm cesarean birth as a risk factor for low maternal birth satisfaction, underscoring that birth mode clearly plays a role in a woman’s overall perception of the birth process. Our data also found increasing labor length as a risk for low maternal birth satisfaction. This highlights women’s appreciation of a faster labor induction time. Our final independent risk factor for low maternal birth satisfaction, Black race, has not previously been demonstrated and required additional probing. When determining which aspects of the survey were most influenced by race, the domain reflecting preparedness for labor most explained this difference. Thus, a gap in prenatal care education or counseling at admission for IOL regarding what to expect in the labor and birth process may explain this disparity. Of note, a difference in mode of birth was also seen by race, a finding that has been observed in other studies [15]. In exploratory analyses, this finding held true when adjusting for confounders including insurance type, parity, and bishop score at start of labor induction. This observation deserves further investigation, as reducing this disparity could improve both maternal satisfaction and maternal morbidity. In addition, in this study, no difference was seen regarding maternal birth satisfaction by Bishop score and cervical dilation at labor induction start. This is likely secondary to our source population, which required an unfavorable cervix for inclusion. Larger differences might have been seen with more heterogeneous starting cervical exams.
This study has significant strengths. With a large percentage of Black women, our population was well poised for assessment of racial disparities in IOL. Further, a high percentage of all eligible women completed the survey, limiting selection bias. One limitation of this study was its completion at one large, urban, academic institution, possibly limiting its generalizability. Thus study was performed using a convenience sample, and thus we may not have been powered to see differences in individual survey measures. Furthermore, we are confined by the intrinsic limitations of the BSS-R, our means of determining maternal birth satisfaction in this study. No cutoff scores have been established to determine “satisfaction” using the BSS-R; thus, for the purposes of this analysis, our population’s mean score was utilized as a cut point. In addition, while both total and sub-scale BSS-R scores have been previously validated as robust tools in large, diverse populations of delivering US women, the survey is not specific to labor induction.