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Table 3 Measure of mismatch and results of included studies

From: When birth is not as expected: a systematic review of the impact of a mismatch between expectations and experiences

# Description of birth expectations Time point Description of birth experiences Time point Calculation of mismatch Name & description of outcome measure Time point Findings
1 Women were asked: ‘right now, what type of birth would you like for this pregnancy?’ Answers were coded as follows: vaginal birth, caesarean birth, don’t know/unsure Pregnancy Actual mode of birth, from medical records 3 months after birth Match VBAC-VBAC* (preference for VBAC, had VBAC)
Match ERCS-ERCS (preference ERCS, had an ERCS),
Match ERCS-EMCS (preference for elective caesarean section, had an Emergency caesarean),
Mismatch VBAC-ERCS (wanted VBAC, had ERCS)
Mismatch VBAC-EMCS (wanted VBAC, had EMCS)
No preference
Health Related Quality of Life (HRQoL)- The Short Form-36 Health Survey version 2 (SF-36v2) [13]. This includes six dimensions: physical functioning, role limitation, social functioning, pain (bodily), mental health (psychological distress and psychological well-being) and vitality (energy/fatigue). 3 months after birth Women with a match between their preference of birth and actual birth mode had higher HRQoL scores compared to women with a mismatch.
Women with a “match VBAC-VBAC” had the highest HRQoL utility scores, and women in the “mismatch VBAC-ERCS” and “mismatch VBAC-EMCS” groups had the poorest.
2 Preference for a caesarean section (CS) based on the following question: “If I could choose, I would rather deliver by CS.” The answers were coded as: yes (“highly agree”, “agree”) or no (“disagree”, “highly disagree”). 32 weeks pregnant Information on birth by elective CS was obtained from the hospital’s birth record. After birth Match 1 (no preference for CS, no elective CS),
Match 2 (preference for CS, elective CS),
Mismatch 1 (no preference for CS, elective CS), and
Mismatch 2 (preference for CS, no elective CS).
Impact of events scale [14] which measures PTSD symptoms of intrusion and avoidance. Higher scores reflect a higher degree of post-traumatic stress, and a score above 34 on the Impact of Event Scale has been suggested to indicate that a PTSD condition is likely to be present. 8 weeks after birth A significant interaction effect between preference and actual mode of birth (F = 7.15, p = .008) and PTSD symptoms. Bonferroni post-hoc tests found significant differences in PTSD symptoms between Match 1 (no preference for CS, no elective CS) and Mismatch 2 (preference for CS, no elective CS)
Key findings from regression analysis were: (a) women who preferred CS, but whose actual mode of birth was vaginal, had a higher level of post-traumatic stress symptoms, and that (b) psychological factors such as fear of childbirth symptoms of depression, and anxiety were particularly potent risk factors that could explain parts of this effect.
3 Preferred birth – measured using a computerised standard gamble exercise where women were presented with a hypothetical choice of birth types and had to pick their preference for it (0 = least desired outcome; 1 = most preferred outcome). 24–36 weeks pregnant Actual mode of birth After birth A score was calculated for women’s preference for vaginal birth (between 0 and 1). Preference for vaginal birth and actual mode of birth were used as predictors for postnatal depression symptoms. Patient Health Questionnaire (PHQ-9) [15] which is used to assess depressive symptoms. Scores range from 0 to 27; higher scores indicate more depressive symptoms. 8–10 weeks and 6–8 months There was a significant interaction between birth mode and vaginal birth preference on the PHQ-9 score at 8–10 weeks after birth (p = .047).
Women with higher vaginal birth preference who had a CS birth had higher mean PHQ-9 scores at 8–10 weeks after birth (p = .027).
4 Labour and Delivery Scale [16] - Questions are answered on a 7-point scale (1 = negative – 7 = positive) regarding factors important to labour and birth. 5–9 months pregnant Labour and Delivery Scale [16]
Reworded to ask about how women experienced labour and birth.
2 days after birth Scores were totalled and a discrepancy score was calculated by subtracting postnatal scores from prenatal score. Positive scores show that labour was more positive than expected, negative scores show labour was worse than expected 1. Multiple Affect Adjective Checklist (MAACL) [17] which measures positive and negative affect. Women were asked to mark “x” by the adjectives describing how they felt at the present moment. If more negative affect words were chosen women were assigned a negative score.
2. Distress rating scale (DRS [18]) was used to evaluate the discomfort caused by the physiological sensations experienced by women during birth.
2 days after birth Positive discrepancy scores (i.e. women who experienced labour more positively than expected) were correlated with positive mood measured by MAACL (adjectives) and with low distress measured by DRS.
5 Wijma Delivery Expectance Questionnaire (WDEQ-A [19]) is a 33-item scale that measures women’s antenatal feelings and fears about childbirth. Late pregnancy Wijma Delivery Experience Questionnaire (WDEQ-B [19]) but is worded so that it can be completed after birth to assess fear of birth, feelings, and thoughts. 4 weeks after expected due date To compute differences between a woman’s expectations and her actual experience, a difference score was calculated so that negative scores represented an experience that was more negative than expectations and positive scores revealed a more positive experience. Traumatic Event Scale [20] was used to assess PTSD resulting from childbirth. 4 weeks after expected due date Severity of pain in the first stage of labour, increased feelings of powerlessness, history of sexual trauma, negative expectation difference, less social support, increased medical intervention, lack of adequate information, higher expectations of pain, and length of labour were significant predictors of perceptions of the childbirth as traumatic. This model accounted for 55% of the variance in traumatic experience. T-test analyses also showed expectation differences were associated with perception of labour as traumatic.
6 Preferred mode of birth
“If you could choose your mode of delivery, would you prefer a vaginal or Caesarean section”
30 weeks pregnant Actual mode of birth
Self-report and medical file data
8 weeks after birth A new variable was constructed; the “Preference-Actual mode of delivery-Congruence” (PAC) variable resulting in four outcomes:
(1) Preferred VD (vaginal delivery) - actual mode VD
(2) Preferred VD- actual mode CS
(3) Preferred CS - actual mode VD
(4) Preferred CS - actual mode CS’
Fear of childbirth (FOC)
WDEQ-A & WDEQ-B [19] was measured during pregnancy and after birth. The higher the sum score, the more severe is FOC. A sum score 85 indicates severe FOC, whereas a sum score 0–84 indicates none to moderate FOC.
30 weeks pregnant
8 weeks after birth
The results showed a significant interaction effect of time and PAC groups. The VD- > CS group showed less decrease of FOC scores from pre- to postnatal compared to other groups. Bonferroni post-hoc tests showed that the VD- > VD group, had the lowest mean FOC scores at both T1 and T2.
The VD- > CS and CS- > VD groups had higher FOC scores at T2 scores than the VD- > VD group.
When controlling for psychological variables (anxiety and depression scores during pregnancy) only the VD- > CS remained a significant predictor of higher FOC scores.
7 Wijma Delivery Expectancy Questionnaire (WDEQ-A) [19] 25–40 weeks pregnant Wijma Delivery Experience Questionnaire (WDEQ-B) [19] After birth (exact time point not clear) A difference score was calculated between the two versions. Negative scores represented an experience that was more negative than expected and positive scores revealed a more positive experience than expected. (a) The PTSD Module of Structured Clinical Interview [21] measured PTSD based on DSM-IV criteria. (b) The Modified PTSD Symptom Scale [22] which measured self-report PTSD symptoms based on DSM-III criteria. 3 & 6 months after birth The women classified in the PTSD group reported a more negative childbirth experience than expected (p < .001). Other factors also associated with PTSD was less social support, higher trait anxiety, greater antenatal depression scores and a less positive perception of care received during labour
8 The degree of control women expected to have during labour and birth was measured by the 21-item Expectations About Childbirth Scale (EC1) designed by the authors of the paper. Participants rated their expectations of control during childbirth on a five-point Likert scale, with higher scores indicating greater expected control. 7–9 months pregnant Experience of Childbirth Scale Questionnaire was the same measure but phrased in the past tense (e.g., “I had very little say over the way my labor and delivery went”) to assess perceived control during childbirth. 4–8 weeks after birth The Unmet Expectations of Control variable was calculated by subtracting the scores from the postnatal questionnaire from the antenatal questionnaire. (a) Childbirth Satisfaction Scale consisted of eight items such as “I am happy with my childbirth experience,” and “I wish my labor and delivery had gone differently than they did,” with a 5-point response scale (1 = Strongly Disagree, 5 = Strongly Agree)
(b) Beck Depression Inventory [23] was used to measure depressive symptoms.
8 weeks after birth Time waited to hold baby, perceived threat to self, perceived threat to baby, birth type, perceived control and unmet expectations of control all significantly predicted birth satisfaction.
Prenatal depressed mood, childcare distress, support received from partner, concerns about the self and foetus during pregnancy and perceived control all predicted postnatal depressed mood. Unmet expectations of control did not predict postnatal depressed mood.
9 Thai Childbirth Expectations and Experiences Questionnaire (prenatal)
Own scale, 36-items. Asked about the possible events that women think will happen during their labor and birth. The women were asked “do you think this situation will happen during your upcoming childbirth?” and answered “yes” or “no” to each question
3rd trimester of pregnancy Thai Childbirth Expectations and Experiences Questionnaire (postnatal)
women were asked to complete the second part of the questionnaire, which used the same set of items. Here the women were asked “did this situation happen during labor and birth?” and responded “yes” or “no”
2–3 days after birth Each item was
classified as:
fulfilled expectations – women expected it to happen and it did happen
unmet expectations – women expected it to happen, but it did not happen,
unexpected experiences – women did not expect it to happen, but it did, and
null experiences – women did not expect it to happen, and it did not happen.
(a) Satisfaction with childbirth experience (SCE) - women were asked for each of the 36 items: “how did you feel about what happened?” A 4-point response scale is used: 1 = not satisfied, 2 = low satisfied, 3 = moderately satisfied, 4 = very satisfied
(b) Thai
Childbirth Attitudes Questionnaire (TCAQ) was a 15-item scale adapted from a previous scale [24], that measured FOC.
2–3 days after birth Fulfilled expectations, self-efficacy, and taking a childbirth class were significantly positively associated with SCE.
Fulfilled expectations were a significant predictor of SCE (p < .001) in a regression analysis. Self-efficacy expectancy, childbirth attitudes and education were also significant predictors.
FOC (measured after birth) was associated with a mismatch (i.e. when women did not expect the event to happen but it did) but this relationship was no longer significant after controlling for parity and complications during labour
10 Birth plan requests - Requests could be either a positive request (e.g. I would like delayed cord clamping) or a negative request (e.g. I do not want my baby to get eye ointment). Total number of specific requests was also recorded. > 34 weeks pregnant Medical record chart review After birth Matched plans to medical record. Satisfaction with birth
Women were asked to evaluate their hospital birth experience in three domains: 1) overall satisfaction with their birth experience, 2) if the birth experience was what they expected, and 3) if they felt in control of their birth experience. Questions were phrased as affirmative statements for each measure, and women agreed or disagreed with each statement on a Likert scale of 1–5.
After birth Having a higher percentage of requests fulfilled significantly correlated with greater overall satisfaction (p = 0.03) and feeling that expectations were met (p < 0.01),
Having a high number of requests (> 15) was associated with an 80% reduction in overall satisfaction with the birth experience compared with having 15 or fewer requests (p < 0.01)
11 Planned place and mode of birth- Women were asked how they planned to give birth (e.g. mode of birth, pain relief). Pregnancy Actual place and mode of birth- Women asked about what happened during their birth. 2 months after birth Self-reports of the planned birth and actual birth were compared by calculating an incongruence score. (a) Emotions during childbirth was measured using a scale designed by authors based on hotspots identified in Harris & Ayers (2012) [25] and WDEQ-B [19]. The presence of 27 different emotions during childbirth were used.
(b) Global birth satisfaction was measured using the Childbirth Satisfaction Scale [26].
(c) Perceptions of care was measured using a tool developed for the study, based on the 3-item Patient Perception Score [27] and 10 additional items assessing interpersonal interactions with medical staff.
2 months after birth Incongruence with birth plan was negatively associated with global birth satisfaction (r = −.13, p < .01). This relationship was also mediated by feelings of guilt (r = − 20, p < .001) during birth and perceptions of care (r = .17, p < .001).