lllilllllllllllllllllillllllll llllllllillll ,

31293 01712 0035

 

 

 

This is to certify that the
thesis entitled

Associations Among Birth Planning,
Childbirth Education, and Satisfaction
with the Birth Experience l

presented by

Sandra J. Metzger

has been accepted towards fulfillment
of the requirements for

 

Master of Science degree in Nursing

 

 

Major professor

[hue January 16, 1998

 

0-7639 MS U is an Affirmative Action/Equal Opportunity Institution

 

 

LIBRARY

Michigan State
University

 

 

 

PLACE IN RETURN BOX
to remove this checkout from your record.
TO AVOID FINES return on or before date due.

 

DATE DUE DATE DUE DATE DUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1M mm.p66-p.14

 

ASSOCIATIONS AMONG BIRTH PLANNING, CHILDBIRTH EDUCATION, AND
SATISFACTION WITH THE BIRTH EXPERIENCE

By

Sandra J. Metzger

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1998

ABSTRACT

ASSOCIATIONS AMONG BIRTH PLANNING, CHILDBIRTH EDUCATION, AND
SATISFACTION WITH THE BIRTH EXPERIENCE

By

Sandra J. Metzger

The purpose of this study was to explore the associations among birth planning,
childbirth education (CBE), and satisfaction with the birth experience. Primiparous
women were interviewed by phone at 6 weeks postpartum. Data were examined for
differences in satisfaction with childbirth based on whether there was any type of birth
plan, and whether the birth plan was written or verbal-only. The possible interaction
effect of CBE classes and birth planning on satisfaction was also explored. There were
18 women with written birth plans, 61 with verbal birth plans, and 16 women with no
birth plan. Women in this study had very high mean satisfaction scores when rating their
childbirth experiences. No significant differences were found to support an effect of
CBE or birth planning on satisfaction in this sample. Although no significant differences
in satisfaction were found among women based on the variables in this study, findings
suggest a relationship between the congruence of a woman’s expectations for her
childbirth experience and the actual event, and her perception of satisfaction. More
detailed assessment of the level or degree of birth planning may also help to clarify the
associations among the study variables. Health care providers should continue to
empower their clients through support of CBE and birth planning to promote realistic

expectations for and positive perceptions of their childbirth experiences.

Copyright by
SANDRA J. METZGER
1998

To my loving husband, Matt,
and my daughters, Leah and Sarah,
without whose love, support, and understanding,

all my efforts would be meaningless.

iv

ACKNOWLEDGEMENTS

I would like to thank my thesis chairperson, Rachel Schiffman, and the members
of this research project, Linda Beth Tiedje, Mildred Omar, and Jacqueline Wright, for the
opportunity to work with them as a member of this research team. I appreciate their
professionalism and their enthusiasm with the research process, and their willingness to
share their knowledge with me. When I became involved in this project, I felt very
fortunate to be able to do research related to childbirth, a topic that I truly love.
Throughout the process of conducting this research, I have come to know how blessed I
have been with such wonderful and supportive mentors. I also want to recognize Carol
Buzzitta and Alyne McCann, who were also an integral part of this great research team.

I would also like to acknowledge the support I received from my supervisor,
Denise Green, and my other friends at work (Linda, Pat, Fran, Cyndi, Bonnie, Sandy, and
Sue), who helped keep me sane and encouraged me through the long years of graduate

school. Thank you all so much for your undying support!

TABLE OF CONTENTS

LIST OF TABLES ................................................ viii
LIST OF FIGURES ................................................ ix
Introduction ....................................................... 1
Background of the Problem ..................................... 1
Statement of the Problem ...................................... 4
Purpose and Research Questions ................................. 6
Conceptual Framework .............................................. 6
Theoretical Definitions of the Study Variables ...................... 6

Birth Flaming ......................................... 7

Childbirth Education .................................... 9

Satisfaction with the Childbirth Experience ................. 10

Conceptual Model ........................................... 11
Literature Review ............................................ 15

Birth Plans ........................................... 15

Satisfaction with the Childbirth Experience ................. 19

Childbirth Education ................................... 23

Relationship of Existing Literature to the Present Study ........ 24

Methods ......................................................... 27
Research Design ............................................ 27
Sample .................................................... 28
Instrumentation ............................................. 28
Operational Definitions ....................................... 30

Birth Plans ........................................... 3O

Childbirth Education ................................... 3O

Satisfaction with the Childbirth Experience ..... ‘ ............ 30

Procedure .................................................. 31
Recruitment of Subjects ................................. 31

CBE subjects ................................... 31

Non-CBE subjects ............................... 32

Conduction of the Phone Interviews ....................... 33

vi

Data Analysis ............................................... 34

Protection of Human Subjects .................................. 35
Assumptions and Limitations .................................. 36
Assumptions .......................................... 36

Limitations ........................................... 36

Results .......................................................... 37
Demographics .............................................. 37
Results Related to the Research Questions ........................ 41
Research Question 1 ................................... 41

Research Question 2 ................................... 42

Research Question 3 ................................... 43

Other Findings .............................................. 44
Discussion ....................................................... 45
Interpretation of Findings ..................................... 45
Revision of the Conceptual Model .............................. 54
Implications for Advanced Practice Nursing ....................... 5 8
Implications for Research ..................................... 63
Summary .................................................. 67
APPENDICES .................................................... 68
APPENDIX A: Outcomes Interview Schedule ..................... 68
APPENDIX B: Informed Consent Forms ......................... 80
APPENDIX C: Human Subjects Approvals ....................... 84

LIST OF REFERENCES ............................................ 87

vii

LIST OF TABLES

Table 1: Means and Standard Deviations of Age and Education for Birth Planning
Comparison Groups .......................................... 38

Table 2: Demographic Characteristics for Birth Planning and Non-Birth Planning
Groups .................................................... 39

Table 3: Demographic Characteristics of Written and Verbal-only Birth Planning
Groups ................................................... 401

Table 4: Means and Standard Deviations of Satisfaction with the Birth Experience
Scores ..................................................... 42

Table 5: Mean Satisfaction with the Birth Experience Scores for Birth Flaming by
CBE ...................................................... 43

Table 6: Means, Standard Deviations, and t-test Analyses of Satisfaction with the
Birth Experience Scores by Labor-related Variables ................. 45

viii

LIST OF FIGURES

Figure 1: Birth Planning, Childbirth Education, and Satisfaction within
King’s Theory of Goal Attainment .............................. 13

Figure 2: Revised Birth Planning, Childbirth Education, and Satisfaction
within King’s Theory of Goal Attainment ......................... 56

ix

Introduction

ac ' ro n f Pr l m

Childbirth is an important event in the life of a woman and her significant others.
The birth of a new child is a developmental milestone, both personally for the individual
parent, and collectively for the family. The parents’ perceptions of the childbirth
experience can have a profound effect on the transitions that are necessary when a new
infant enters a family (Green, Coupland, & Kitzinger, 1990). The experience may also
influence the clients’ relationships with their health care providers and the overall health
care system (Seguin, Therrien, Champagne, & Larouche, 1989; Simkin, 1991). Ensuring
a positive and satisfying childbirth experience should, therefore, be a goal of health care
providers to promote favorable physiological and psychological outcomes.

Patient satisfaction is an important aspect of health care, especially as it relates to
maintaining and increasing market share in the competitive health care environment.
The childbirth experience is an especially crucial time for ensuring patient satisfaction
with care, since it is frequently the first experience many new families have with the
health care system. Many hospitals target the childbearing population as the focus of
many of their marketing strategies to entice new families to seek care at their facilities.

Active participation in decision making during the labor and delivery process has

been shown to be a predictor of satisfaction with the birthing experience (Brown &

2

Lumley, 1994; Green et al., 1990; Humenick & Bugen, 1981; Seguin et al., 1989). Birth
planning, whether written or verbal, can be an important method of enhancing the
decision making abilities of the expectant mother. In the process of the preparation of a
birth plan, the pregnant woman and her significant others can be given an opportunity to
express their desires and goals for their birthing experience based on their knowledge,
experience, cultural practices, and values.

Currently, childbearing families are faced with a multitude of options that may be
considered for childbirth. Due to the high degree of global mobility, culturally diverse
expectant parents come to the health care provider with widely varying levels of
knowledge and expectations about pregnancy and the childbirth experience. Depending
on previous experiences and exposures, expectant parents may have little socialization in
or knowledge about the health care system in general, or the childbearing process.
Although the ultimate goal of childbirth for both parents and health care providers is
safe, positive maternal and infant outcomes, the means to that end may be widely varied.
Childbirth education classes can serve as an important source of information and can
promote the development of a birth plan, thereby assisting expectant parents to approach
the childbirth experience with greater preparedness.

This study focused on the exploration of the associations between the preparation
of a birth plan, participation in childbirth education classes, and the primiparous
woman’s overall perception of satisfaction with her birth experience. To strengthen
decision making during labor and delivery, and to enhance positive perceptions of the

birth experience, pregnant women and their significant others must be provided with

3

information to empower them to exercise their rights to decide what is best for them
during their childbirth. Expectant parents should be provided with complete, current
information about all options available to them, including the risks, benefits, advantages,
and disadvantages of each of their possible choices (Lothian, 1993). Birth plans,
however, have not been highly recognized or used as a tool to enhance decision making
and satisfaction during childbirth (Way, 1996).

Birth planning has undergone an evolution during the 20th century. After the
early years of the 1900s, when birthing moved out of the home and into the hospital,
physicians controlled the management of women’s birth experiences, and women were
socialized to believe that the medical plan of management was what was “best” for them
(Lindell, 1987; Lothian, 1993). Until the natural childbirth movement of the 19605, a
birth plan was an unheard of entity. Birth plans were devised as a means for women to
voice their demands for decreased medication and instrumentation to the medical
establishment. Birth plans were generally viewed, as described by Way (1996), as “a
subversive act ....symbolic of a couple’s determination to have some say in the
‘management’ (or lack thereof) of their labor and birth” (p. 10). Early birth plans were
usually lists of “don’ts” and were symbolic of the mistrust which existed between
expectant parents and physicians. More recently, birth plans have become an instrument
that can be used to assist expectant parents to clarify their values and goals, to facilitate
communication with health care providers, and to provide continuity of care through the
various stages of the childbirth experience (Moore, Hopper, & Dip, 1995).

The Advanced Practice Nurse (APN) or other health care provider can have an

4

open discussion with the client and her significant others during the prenatal period in
which information can be imparted, options can be considered, and a mutually
acceptable plan of labor management can be negotiated. If the plan is developed during
the prenatal period, the patient and the health care provider can enter into the actual labor
and delivery experience with a clear understanding and realistic expectations of the
process. Realistic expectations and open communication can help to ensure that the
expectant parents will emerge from their childbirth with positive perceptions of the
experience.
m n f Pr 1 m

There is growing empirical evidence about the effectiveness and outcomes of
perinatal education, however there is insufficient research that addresses the variables in
this study. Lindell (1988) reported that research about psychological outcomes has
shown that positive attitudes toward labor and delivery and early maternal infant
attachment may be promoted through participation in childbirth education programs.
Findings concerning the physiological outcomes such as duration of labor, use of
analgesia and anesthesia, and infant outcomes are inconclusive. Few researchers have
specifically explored the factors that influence the perception of satisfaction with the
childbirth experience. Lindell and others (Bramadat & Driedger, 1993; Lumley, 1985)
have cited methodological problems associated with the measurement of satisfaction as a
childbirth outcome. Lumley referred to satisfaction with childbirth as a “soft outcome”,
and addressed some of the problems with its measurement related to obstetric care.

Dimensions of the assessment process that may have had an effect on the measurement

5

of childbirth satisfaction were presented: where and when the assessment of satisfaction
was done, who did the assessment, what measurement tools were used, and if samples
were representative of the population.

Another problem that has been identified with childbirth satisfaction literature is
that many of the studies used a pain management model in which decreased pain
perception was examined as the primary factor predictive of a satisfying childbirth
experience. Humenick (1981) first proposed and later tested (Humenick & Bugen, 1981)
a different model of measuring childbirth satisfaction, that of mastery, or control, as
being the key factor affecting a woman’s perception of satisfaction with her birth
experience. This model has been supported by other studies in which the researchers
concluded that perceived painfulness in labor was not necessarily related to satisfaction,
and that one of the most predictive factors of a positive birth experience was a woman’s
perception of control and ability to actively participate in decision making (Bramadat &
Driedger, 1993; Green et al., 1990; Lowe, 1996; Seguin et al., 1989; Simkin, 1991).

Although the literature on childbirth education and birth satisfaction is limited,
there exists even less literature addressing the use of birth plans. Ekeocha and Jackson
(1985) and Moore et al. (1995) evaluated the use and effectiveness of birth plans in their
respective practice environments, and found that most women perceived birth plans as
having positive benefits. Springer (1996) explored the relationship between the
preparation of a birth plan and women’s levels of anxiety at the end of their series of
childbirth classes, but found no significant differences between women with and without

birth plans. None of these studies attempted to relate the use of a birth plan or

6

participation in childbirth education to any measures of satisfaction with the childbirth
experience.
Purpose and Research Questions
The purpose of this study was to examine the associations between the
preparation of a birth plan, participation in childbirth education, and a primiparous
woman’s perception of satisfaction with her birth experience. The following research
questions were addressed:

1. Is prenatal birth planning (written or verbal) associated with a primiparous
woman’s overall satisfaction with her childbirth experience irrespective of
childbirth education?

2. Is there a difference in. overall satisfaction with the childbirth experience between
primiparous women who have a written birth plan and primiparous women who
have only a ygrbal birth plan irrespective of childbirth education?

3. Is there an interaction between attendance at childbirth education classes and
birth planning on a primiparous woman’s overall satisfaction with the childbirth
experience?

Conceptual Framework
r ' fin' i f t V ' l
The concepts of birth planning, childbirth education, and satisfaction with the
childbirth experience were first explored through examination of existing literature, and
then defined for the purposes of this study. The concepts were then examined in the

context of King’s conceptual model and theory of goal attainment for nursing.

Bi 1 n'n

Moore et al. (1995) defined a birth plan as “a written statement of a woman’s
wishes about the birth of her baby that aims to open up channels of communication
between caregivers and women” (p. 29). Similarly, Springer (1996) stated that a birth
plan “is a tool that can be shared with health care professionals to express preferences in
regard to the events of labor and birth. It allows for greater involvement by the woman
and her partner in decisions related to obstetrical management” (p. 21). Another
description of a birth plan was a list of Options and procedures on which expectant
mothers were asked to record their preferences about the various aspects of care, which
was offered with explanations for each of the options and procedures (Ekeocha &
Jackson, 1985). The development of a birth plan according to Carty and Tier (1989)
“results in a realistic plan for birth and in the development of a relationship between the
family and care provider based on mutual trust and respect” (p. 11 1). Birth planning
provides an opportunity to explore the expectant parents’ fears, hopes, family values, and
patterns of interaction, allowing the formulation of a realistic plan “not based on the
fantasy of the ideal birth, nor developed out of fear; rather it is rooted in the family’s
needs” (Carty & Tier, 1989, p. 112).

Birth planning has several components based on the definitions and descriptions
in the literature. A birth plan can be used as an educational and informational strategy to
increase knowledge and understanding of the options, procedures, and rationales for their
use that are available in different practice settings (Carty & Tier, 1989; Ekeocha &

Jackson, 1985; Moore et al., 1995). Another component of the birth planning process is

8

assisting the expectant parents to evaluate their values, cultural practices, strengths, and
desires, in order to develop realistic goals and specific strategies to achieve them (Carty
& Tier, 1989; Ekeocha & Jackson, 1985; Way, 1996). Open and effective
communication and the development of mutual respect is a third aspect of prenatal birth
planning. The development and use of a birth plan demonstrates to the expectant parents
that the health care provider is interested in their wishes, and that the parents are
respected as mutual participants in their care (Carty & Tier, 1989; Ekeocha & Jackson,
1985; Moore et al., 1995; Way, 1996). A final element of a birth plan is the facilitation
of decision making during the labor and delivery process. Because the physiological
processes of childbirth are not under voluntary control, and parents’ expressed plans may
not be able to be followed, prior discussion of possible complications and contingencies
of care can facilitate decision making during labor when the woman is most vulnerable
(Ekeocha & Jackson, 1985; Moore et al., 1995; Springer, 1996).

For the purposes of this study, a birth plan was defined as a written or verbal plan
developed during the prenatal period by the expectant mother and the health care
provider who would be performing the delivery. Although not assessed in this study, a
significant other may also have been involved in the birth planning process. Birth
planning may have included, to varying degrees, discussion, sharing of information,
clarification of roles, and identification of preferences and choices concerning the
management of the labor and delivery. Conceptually, the birth planning process included
setting realistic goals and establishing strategies to achieve them. Appropriate birth

planning was conceptualized to foster improved communication within an atmosphere of

9

mutual respect and participation, and facilitate decision making during the childbirth
experience.
'1 i i

In most instances in existing literature, childbirth education (CBE) referred to
formal classes that were provided during the prenatal period to pregnant women and their
significant others. Although CBE can occur through a variety of other avenues, such as
self-study through books, videos, or routine discussions with health care providers, most
research has included only formal classes as CBE. Several researchers described the
content of CBE classes and included the following t0pics: anatomy and physiology of
pregnancy, labor and delivery; nutrition and exercise; pharmacological and non-
pharmacological pain management strategies including labor skills such as breathing and
relaxation; common labor and delivery interventions; options for care along with the
advantages and disadvantages of each; postpartum maternal care; infant care and
feeding; and parenting skills (Crowe & von Baeyer, 1989; Lothian, 1993; Lumley &
Brown, 1993; Zwelling, 1996). Lindell (1988) also stated that CBE should include
information to assist expectant parents to prepare a realistic birth plan, understand the
decision making process, and promote active participation in the birth experience.
Various components of CBE were suggested by Lothian (1993), and included presenting
information, enhancing coping skills, fostering support systems, promoting decision
making, and providing client advocacy, with the most essential dimension of CBE being
the promotion of informed decision making.

The definition of CBE in this study was a series of formal antenatal classes taught

10

by nurses which included factual information about pregnancy, labor and delivery, and
postpartum maternal and infant care. Available methods of pharmacological and non-
pharrnacological pain management, common procedures, and the advantages and
disadvantages of various options for care were also discussed in the class content. CBE
classes were presented to provide factual information about pregnancy and the childbirth
experience to promote informed decision making by the expectant parents, encourage
effective communication with health care providers, and empower clients to develop a
realistic birth plan. Expectant parents were encouraged to talk to their delivering
practitioner about their preferences for delivery and the development of a birth plan. In
this study, CBE classes were provided through one provider, thereby ensuring
presentation of content by nurse instructors who were trained to use a consistent
curriculum. Informal programs of self-study were not included or evaluated in this study.
' f i wi h 'l irth x i

The concept of satisfaction has been referred to by some researchers as a positive
feeling about the birth (Humenick & Bugen, 1981; Simkin, 1991). Seguin et al. (1989)
defined satisfaction with childbirth as a general impression of the delivery in which a
woman makes an evaluation of her personal experience based on her expectations.
Bramadat and Driedger (1993) stated that satisfaction is a positive attitude or affective
response to an event that results after a positive evaluation is made of an experience and
of the emotions that are evoked by that experience. They further suggested that the
experience is evaluated and measured against one’s expectations.

Although satisfaction with childbirth is the subject of numerous studies, most

ll

researchers did not specifically define the concept of satisfaction, rather they reported
aspects of the childbirth experience that were associated with satisfaction or
dissatisfaction with the event. Having an active role in decision making, being in control
of oneself, being in control of what was being done, being treated with respect, and
having adequate information are all aspects of childbirth that have been shown to be
associated with satisfaction (Brown & Lumley, 1994; Bryanton, F raser—Davey, &
Sullivan, 1993; Callister, 1993; Green et al., 1990; Mackey, 1995; Seguin et al., 1989;
Simkin, 1991). Evaluation of individual components of satisfaction were examined by
some researchers (Brown & Lumley, 1994; Callister, 1993; Seguin et al., 1989), but the
outcome measure of each component of the childbirth experience was identified as
“satisfaction”.

Satisfaction with the childbirth experience, in this study, was conceptually
defined as a positive global perception of the childbirth experience based on the
woman’s emotional responses to the event and her evaluation of her own performance in
handling the stresses of labor and delivery. Although there are various aspects of
childbirth that have been suggested as components of satisfaction, in this study the
researcher was interested in satisfaction as an outcome measure of the overall positive or
negative impression of the childbirth experience, rather than the evaluation of specific
components of the process.

ConceptuaiMitdsl
The theory of goal attainment by Imogene King (1981) was used as a framework

to conceptualize the relationships between the study variables: birth planning, CBE, and

12

satisfaction with the childbirth experience. King used a systems framework to explain
the interrelationships among individuals, groups, and social systems, and to describe the
role of nursing within the health care system. In the theory of goal attainment for
nursing, King ( 1981) states that nurses “purposefully interact with clients mutually to
establish goals and to explore and agree on means to achieve goals” (p. 142). Several
propositions of the theory are that if transactions are made, goals will be attained, and if
goals are attained, satisfactions will occur.

In King’s model (1981), individuals are identified as separate personal systems.
Interpersonal systems are those in which two or more individuals interact. The most
important concept associated with effective function of the interpersonal system is that of
transaction. King defines a transaction as “a process of interaction in which human
beings communicate with environment to achieve goals that are valued” (p. 82).

Each individual experiences an interaction based on his or her own perceptions.
King defines perception as the individual’s “representation of reality” (King, 1981, p.
20). Perceptions are influenced by past experiences, education, cultural patterns, and
current interests, needs, and goals. King cites accurate perceptions as the “first step
toward mutual goal setting and toward exploring means to move toward those goals”
(King, 1981, p. 24).

In this study, the variables of birth planning, childbirth education, and satisfaction
with childbirth are the concepts of interest. King’s theory of goal attainment can be
employed to illustrate the relationships among these variables (see Figure l). The

personal system of greatest interest in this study is that of the client, the expectant

l3

 

Satisfaction with
the birth experience

 

 

 

 

.—.-._o~

Expectant , -. \
i Primiparous ’ ’- Health Care ‘

 

 

- ' i Provider i
'. Woman 1 I
‘ \ ‘2. , ., /
\. i".—.'.z~\\.°c. /

\' 1’ \ IR... \\ V...
\. ’, ’-\.. .. ‘ ... /
\R I .’. \. ‘ “31/
.‘.‘ I . ’ ..\\ ‘ _, ’ .‘
---.--

1 Significant
‘\ Other ’1’

I'.
Q ’ .

‘ ’

 

Figure 1 : Birth Planning, Childbirth Education, and Satisfaction within
King’s Theory of Goal Attainment

l4

mother. The client’s significant other and the health care provider are other separate
personal systems (depicted by circles in Figure 1). Each system is open and in constant
interaction with the others, as represented by the permeable dotted lines. Each individual
has his or her own perception of reality based on the influences of past experiences,
knowledge, and cultural background.

The interaction of the expectant parents and the health care provider during the
prenatal period was the focus of this study, and is an interpersonal system as described by
King (1981). The interaction is depicted by the area of overlapping circles in Figure 1.

If perceptions are accurate and an effective interaction takes place, a transaction results.
The transaction in this study, resulting from the interaction of the expectant mother, her
significant other, and the health care provider, is the development and use of a birth plan
(see Figure 1).

The effect of several variables of the interaction were explored in this study.
Variables included whether the expectant mother had CBE or not, whether there was any
birth planning, or whether birth planning was written or verbal. Each of the variables
was hypothesized to have the potential to influence the interaction and the occurrence of
a transaction, and to result in varying degrees of satisfaction with the birth experience.
CBE classes can provide an informational framework for the expectant parents which
can affect their perceptions of the interaction. CBE can also prepare the expectant
parents for effective communication with other health care providers, enhance decision
making skills, and promote the development of a birth plan, which was the transaction of

interest in this study.

15

If an effective interaction takes place, a birth plan, either written or verbal, is
developed. During the transaction of developing a birth plan, the expectant mother and
the provider communicate with each other to mutually establish goals, clarify roles, and
identify strategies to increase the ability of the mother to c0pe with the stresses of the
upcoming labor and delivery based on her individual preferences and desires. Although
not addressed in this study, the woman’s significant other may also be involved in the
interaction. Birth planning can enhance the abilities of the involved individuals to
perform their functions and roles during the birth process. Through the development and
use of a birth plan, goals for the childbirth experience can be achieved, potentially
resulting in greater satisfaction with the childbirth experience.

LEW

There is little current literature that examines birth plans, satisfaction with
childbirth, or CBE, and the majority of literature related to these variables is descriptive
and anecdotal in nature. Therefore, scant empirical knowledge about birth plans,
satisfaction with childbirth, or CBE exists. No research was found that directly
addressed the possible relationships among these variables. The empirical findings from
available literature are summarized, and the theoretical and methodological limitations
are discussed. Finally, the rationale for this study is presented based on consideration of
the gaps in knowledge which currently exist.

Binhflam
Few research studies were found that examined the preparation and use of birth

plans. Ekeocha and Jackson (1985) and Moore and Hopper (1995) both conducted

I6

evaluative research concerned with examining the effectiveness of using specific
documents as birth plans in each of their respective practice environments. Springer
(1996) investigated the relationship between preparation of a birth plan and anxiety prior
to delivery. No research was available that discussed the relationship of birth planning or
CBE to satisfaction.

Ekeocha and Jackson’s (1985) study was conducted in 1982 at the Huddersfield
Maternity Unit in England, and Moore and Hopper’s (1995) study was done in the South
Western Sydney (Australia) Area Health Service in 1993. In each of these studies, 100
women who had completed a birth plan were asked to evaluate the use of the plan.
Subjects were interviewed within the first few days after delivery, and were asked to
complete a questionnaire about the use of the birth plan. Subjects in both studies
included primiparous and multiparous women with vaginal and Cesarean deliveries.

Results of Ekeocha and Jackson’s (1985) evaluation included that most women
found the birth plan “helpful” and “reassuring” (p. 98). Although different birth planning
documents were used in the two studies (Ekeocha & Jackson, 1985; Moore & Hopper,
1995), similar findings emerged. Numerous advantages of using birth plans were found.
First, the researchers found that use of a birth plan increased the patients’ knowledge and
understanding of the labor and delivery process, and made them more aware of their
options for care. Communication between the expectant mother and hospital staff was
improved, and mothers felt more comfortable asking questions and expressing their
needs and preferences. Use of a birth plan encouraged discussion during the antepartum

period about possible complications and procedures, which facilitated explanations and

l7

enhanced decision making abilities during labor when the parents were more stressed.
Birth plan preparation and use were perceived to demonstrate a desire by the providers to
recognize the wishes of their clients, thus promoting an atmosphere of respect with the
expectant parents. Improved communication, that emerged from birth plan use, resulted
in the development of mutual partnerships, and helped establish a balance of power
between parents and providers. The conclusion was made by Ekeocha and Jackson that a
birth plan may have it greatest potential impact during labor “when the woman feels she
will be at her most vulnerable and least able to make decisions” (p. 100). Based on their
findings, Moore and Hopper advocated the use of a birth plan as an educational and
empowerment strategy, especially for women who had never attended CBE classes.

The third study, by Springer (1996), related birth planning to its effect on anxiety
prior to labor. Forty-five primiparous women were randomly assigned to an
experimental group (21 women) that completed a written birth plan developed by the
researcher, or a control group (24 women) that did not have a birth plan. The results
comparing state and trait anxiety levels in the two groups at the completion of their CBE
class series showed no significant differences between the birth planning and non-birth
planning women.

There were several limitations identified in these studies of birth plans. In the
study by Ekeocha and Jackson (1985), there was no definition of the birth plan concept,
nor was there a discussion of the literature. Only Springer (1996) provided a theoretical
framework from which to examine the concepts of interest. The actual birth plan

document was provided, with the exception of Springer. The birth plan used by Ekeocha

l8

and Jackson included only 16 items or options for care, which may have significantly
restricted the potential choices for expectant parents, thus limiting the effectiveness of
the plan. Moore and Hopper’s (1995 ) birth plan was more inclusive of possible care
options, with a listing of about 50 choices. Each study differed greatly in the level of
participation in CBE by the subjects. Moore and Hopper reported 41% CBE subjects, all
women in Springer’s study had CBE, and no indication of CBE status was described in
Ekeocha and Jackson’s research.

There were also concerns in each of the studies about the representativeness of
the samples. Springer (1996) had subjects who were predominantly Caucasian, married,
and well-educated, while Moore and Hopper (1995 ) studied young, low-income, poorly-
educated women delivering in two public hospitals. Ekeocha and Jackson (1985)
included no demographic or descriptive information about their sample, except for
primiparous or multiparous status. Springer had a small sample size, which the
investigator suggested as a reason for the lack of statistical significance of the results.
Additionally, the research by Ekeocha and Jackson (1985) and Moore and Hopper (1995)
was directed at evaluation of a specific birth plan form, so no control groups were used
for comparison. Also, in each of the studies, self—selection of the subjects was a
limitation that was not addressed.

Only Springer’s (1996) study was conducted in the United States, while Ekeocha
and Jackson’s (1985) research and Moore and Hopper’s (1995) study were done in
England and Australia, respectively. Although the health care systems in England and

Australia are very similar to that in the U. S., the findings of these studies (Ekeocha &

19

Jackson, 1985; Moore & Hopper, 1995) cannot necessarily be applied to health care
delivery in an American population. However, it must also be noted that there was not
any other literature from the U. S. that could be used to explore the topic of the
effectiveness of birth planning.

Other methodological limitations were also found. No mention was made of
informed consent of the participants or protection of the subjects’ confidentiality, and
little description was given of the methods used for administering the interview or
questionnaire in Ekeocha and Jackson’s (1985 ) study. Springer ( 1996) provided
adequate information about the instrument used to measure anxiety in the subjects, but
little detail was provided about the actual instrument used for evaluation in either of the
other studies. However, the major methodological limitation found was in Springer’s
(1996) study, in which anxiety was measured at the conclusion of CBE classes, remote
from the labor and delivery experience. The author discussed potential adverse effects of
anxiety on labor outcomes and the role of a birth plan in reducing anxiety, but failed to
assess the subjects’ anxiety levels during labor. Because of the timing of the
measurement of anxiety, there was in effect, no evaluation of the relationship between
the use of a birth plan and levels of perceived anxiety during the actual birth experience,
when birth plans exert their most impact.

Satisfaction with the childbirth experience was the variable about which the most
literature could be found. Although numerous authors discussed satisfaction, little

research has been done to obtain empirical evidence. Few definitions of satisfaction

 

20
were offered, and most researchers attempted to identify factors associated with
satisfaction rather than describing the concept or developing a theoretical perspective
from which to examine it. Bramadat and Driedger (1993) also proposed that it is
important to differentiate between the assessment of overall, global satisfaction and the
measurement of particular aspects of satisfaction with the childbirth experience.

Another theoretical problem that has been identified with the investigation of
satisfaction with childbirth is that some studies have used a pain model in their research
(Crowe & von Baeyer, 1989; Lowe, 1991, 1996). In a review of childbirth satisfaction by
Humenick (1981), a model of mastery was proposed as the key to evaluating this
concept. Humenick concluded that women considered childbirth to be an important
psychological task in which they wanted to be active participants. In a study by
Humenick and Bugen (1981), this theory was tested and supported. In the remainder of
the review of childbirth satisfaction literature, those studies using only the pain model
will be excluded from the discussion.

As mentioned earlier, most studies were concerned with identifying factors
related to satisfaction. These factors cannot be ignored when examining this concept.
The components of satisfaction that have been supported by most of the literature will
therefore be presented here. The perception of control, or the mastery model, was
supported by Bramadat and Driedger (1993), who identified self-control and COpIng with
pain, and control over the environment as separate dimensions of this aspect of
satisfaction. Feeling in control was also found to be an important aspect of satisfaction

by other researchers (Bryanton et al., 1993; Callister, 1993; Green et al., 1990). The

 

21

congruence between a woman’s expectations of her delivery and the reality of the
experience also affected her overall perception of satisfaction (Bramadat & Driedger,
1993; Green et al., 1990; Seguin et al., 1989). Brown and Lumley (1994), Seguin et al.
(1989), and Simkin (1991) identified having an active say in making decisions as a factor
highly related to a positive experience. Not having appropriate information was
negatively correlated with satisfaction measures (Brown & Lumley; Seguin et al.).
Virtually all satisfaction literature mentioned feeling cared about, respected, and
supported by providers as another factor. Green et al. and Seguin et al. reported that
women felt less satisfied when more interventions were used. Overall, Simkin (1991)
concluded that women’s long-term satisfaction was associated more with “the way they
conduct themselves and the way they are treated than with the actual clinical features of
their labor” (p. 209).

Each of the authors presented their study with varying degrees of detail about
their samples, methods, instruments, and other aspects of their research. The specific
details of each study are not as important as some of the larger issues of methodological
concerns that were discussed in some of the literature. Rather than enumerating the
limitations of individual studies, the problems in the research designed to measure
satisfaction with childbirth will be addressed in aggregate.

Bramadat and Driedger (1993) discussed the difficulty in measuring an undefined
concept, with most studies failing to give an actual definition of satisfaction. Lumley
(1985) questioned the manner in which assessments were made, whether satisfaction was

measured by monitoring complaints, by single or multiple questions, with rating scales,

22

or with open or closed-ended questions. The lack of demonstrated reliability and validity
of measurement tools was also identified as a limitation (Bramadat & Driedger; Seguin
et al., 1989). It was suggested that appropriate weighting of various components of
satisfaction according to the importance that women placed on each should be
considered (Bramadat & Driedger, 1993).

Another major area of concern in measuring satisfaction was the timing of the
assessment. In the immediate postpartum period, women experience overwhelming
ranges of emotion and levels of energy, making completion of a questionnaire or
interview a challenge at best. Additionally, if the researcher is a care provider, patients
may feel pressured to respond positively. The feelings of relief and elation of a healthy
childbirth outcome may also affect the patient’s responses. In contrast, a mother who has
an experience that does not meet her expectations, may suffer a grieving response and be
in the denial stage during the early postpartum (Lumley, 1985). Although there have
been criticisms about doing satisfaction assessments at four to six weeks or longer after
delivery, several researchers have shown that women’s perceptions of satisfaction change
very little over that time period (Bramadat & Driedger, 1993; Simkin, 1991). Some
researchers question whether women can accurately recall details of their deliveries after
the immediate postpartum period. Githens, Glass, Sloan, and Entrnan (1993) concluded
in their research that women had an 89% agreement with their medical records for a
period of four to six years. Simkin (1991) found that most women had vivid recall of
their delivery experiences, even after 15 to 20 years, and that long-term satisfaction was a

stable measure.

 

23

Other limitations of research were that most studies used convenience samples,
which may or may not have been representative of the childbearing population, therefore
preventing generalization of findings. The sample sizes varied greatly depending on the
nature and methods of the particular study. In most studies, there were no control or
comparison groups, and no random assignment to treatment.

Childbirth Edugation

The discussion of research literature about the effectiveness of CBE is necessarily
brief, since only one study was found that actually empirically investigated CBE
(Lumley & Brown, 1993). All other CBE literature was descriptive, and offered no
empirical data.

The study by Lumley and Brown (1993) involved a survey of all women who
delivered in a two week period in 1989 in Victoria, Australia. The purpose of the study
was to describe women who attended CBE classes and those who did not, and compare
them and their childbirth experiences. Almost 84% of their sample did have CBE, so
their comparison group was small. No differences were found between the two groups in
their satisfaction with their delivery experiences.

The limitations with this study (Lumley & Brown, 1993) were some of those that
have already been discussed. There were no definitions of the concepts of CBE or
satisfaction, nor was there any use of a theoretical framework. The instrument used was
described, but no demonstrated reliability or validity measures were provided. Again,
another limitation that may be cited is that the study was done in Australia, and findings

cannot necessarily be generalized to the current study population. However, as

A

"T

24

previously stated, the health care system in Australia is very similar to that in the United
States, so application of findings may be appropriate.
1 ' h' ' 'n ' r n

Through the discussion of existing literature, it is apparent that there is a
continued need for research addressing the variables in this study. Studies of birth plans
have evaluated specific documents, and have not provided information about the general
concept of a birth plan or its effect on measures of satisfaction with childbirth. In most
satisfaction research, many theoretical and methodological concerns were identified,
presenting many opportunities for additional research to augment the empirical data that
is currently available. The CBE research is so scarce, that almost any topic associated
with CBE is ripe for investigation.

Existing literature on birth planning has identified that various components which
have been associated with satisfaction are also associated with birth plans. CBE
similarly has been explored as a factor affecting many different aspects of the childbirth
experience, including satisfaction. However, there are no studies that have tried to
demonstrate the possible relationships among these three variables.

In this study, the relationships among birth planning, CBE, and satisfaction with
the childbirth experience were examined. CBE was hypothesized to have an indirect or
interactive effect on satisfaction by providing general knowledge and promoting the
development of a birth plan with the expectant woman’s health care provider. Birth
planning, however, was proposed as having a more direct effect on satisfaction, since

appropriate birth planning provides for more individualization of strategies and goals for

25

the experience for the expectant woman. By addressing the client’s specific needs and
desires more directly, the potential for achieving greater satisfaction with the childbirth
experience can be enhanced through birth planning.

Although little empirical data exist demonstrating the true effectiveness of CBE,
the curriculum of CBE classes includes topics that impact many aspects of the childbirth
experience. CBE provides a foundation of knowledge, teaches coping strategies for pain,
and educates participants about the options available for childbirth. Birth planning can
be encouraged in CBE classes, and expectant parents can be assisted to develop skills to
communicate more effectively with health care providers. Through more effective
communication and interactions with health care providers, expectant parents can be
empowered to develop and use birth plans, which can increase the likelihood that their
goals for their childbirth experience can be attained.

Birth plans have been hypothesized to have an more direct effect on satisfaction
with the childbirth experience, because of the influence birth plans can have on the
various components of satisfaction. Research literature has supported the associations
between many aspects and consequences of birth planning and satisfaction with the birth
experience. The discrepancy between expectations and the reality of the experience, as
presented by Bramadat and Driedger (1993) and Simkin (1991), can be influenced by the
use of a birth plan. Prenatal birth planning can result in more realistic expectations, and
a greater understanding about the possible complications and the use of various
procedures. Feeling cared about and respected, having open communication, and being

provided with appropriate information have all been associated with women’s

26

perceptions of feeling in control, which has in turn been linked with satisfaction
(Bryanton et al., 1993; Callister, 1993; Green et al., 1990; Mackey, 1995). The use of
interventions was suggested by a few researchers to correlate with dissatisfaction (Green
et al., 1990; Seguin et al., 1989); however, Green et al. explained further that it is not the
interventions per se that effect satisfaction, but the perception by the mother that the
right thing was done. With enhanced knowledge and decision making skills, the
woman’s ability to participate in choosing the “right thing” is increased. Each of these
factors are integral components of birth planning, and because these factors have been
shown to be linked with satisfaction, the appropriate preparation and use of a birth plan
can be proposed as a strategy to enhance childbirth satisfaction.

Although measurement of individual aspects of satisfaction can be done,
Bramadat and Driedger (1993) concluded that “the overall measure of satisfaction was a
sensitive measure of the various dimensions” (p. 23). In this study, the measures of
satisfaction included overall feelings of satisfaction, and some measures of perception of
personal control, since control emerged as one of the factors most highly related to
satisfaction.

Existing research does provide some data about CBE, birth planning, and
satisfaction with the childbirth experience, and suggests that there are associations
among these variables. According to Humenick’s (1981) mastery model, childbirth
satisfaction can be promoted by encouraging expectant mothers to “become informed, set
realistic goals, learn coping skills for pain management, prepare for active participation

in decision making, and develop an adequate support system” (p. 81). Each of these

27

aspects of satisfaction are potential products of CBE and birth planning, which provided
the inspiration and rationale for this study.
Methods
Researgh Design

This descriptive study used a nonexperimental, cross-sectional design. The
purpose was to investigate and describe the relationships of prenatal birth planning and
CBE to a primiparous woman’s satisfaction with her childbirth experience. This study is
one part of a larger study on the outcomes of childbirth education by Tiedje, Omar,
Schiffman, Wright, McCann, Metzger, and Buzzitta (1996), which was done in
cooperation with Expectant Parents’ Organization, the local CBE class provider. The
purpose of the overall project was twofold: (a) to describe who had taken childbirth
education classes (first phase), and (b) to examine outcomes for women who had taken
CBE classes from the provider and for a comparison group of women who had not had
classes (second phase). This study is a portion of the second phase of the overall
research project.

The investigators in the overall study were four faculty members of the Michigan
State University College of Nursing, two graduate nursing students, and the director of
the local CBE organization. The four faculty investigators were responsible for the entire
study, and the two graduate students, including the investigator for this study, were
involved as co—investigators in planning and conducting the overall project. The director
of the CBE organization was involved in the planning of the project and provided clerical

support, including scheduling of interviews, central collection and storage of survey

28

forms, data entry, and mailing gift certificates to subjects on completion of interviews.
Sample

The sample consisted of a convenience sample of women who delivered between
May 15, 1996 and September 15, 1996 at one tertiary care center and one smaller
community hospital in the mid-Michigan area. Subjects met the following criteria: (a)
primiparous women with surviving infant, (b) able to understand and speak English, (c)
able to be reached by telephone at six weeks postpartum, and ((1) gave consent to
participate. The final sample consisted of 50 CBE women, 45 non—CBE women, and 4
clinic waiting room CBE women. Because the clinic waiting room CBE group was
insufficient in number and the class structure was not consistent with the definition of
CBE in this study, the subjects were excluded from analysis for this study.

The final sample in this study consisted of 95 women: 50 women with CBE and
45 without CBE. There were 18 (19%) women with written birth plans, and 61 (64%)
with verbal-only birth plans, totaling 79 (83%) women who had some form of birth plan.
The remaining 16 (17%) women reported having no birth plan of any type. Of the 18
women who reported having written birth plans, 15 (83%) had CBE, the remaining 3
(17%) did not attend CBE classes. For the 61 women with verbal-only birth plans, 27
(44%) had CBE and 34 (56%) did not. The 16 women who reported having no birth plan
were divided equally between the CBE and non-CBE groups, with eight in each group.

Instrumentation
The interview schedule developed for the primary study is included in Appendix

A. The questions included information about the intrapartum and postpartum periods,

29

including physical factors, psychosocial factors, pain control, relationship with
significant others, infant outcomes, and other factors such as resources used and
demographics. Many of the questions had been used previously on postpartum
questionnaires administered through the CBE organization, while other questions were
developed specifically for this study.

The satisfaction measures used for this study (items 30 through 39, Appendix A)
were from the PSEQ (Ledennan et al., 1981) which was developed to provide a
quantifiable measure of factors associated with maternal adaptation. This subscale of the
PSEQ was designed “to reflect the mother’s sense of gratification and accomplishment
versus disappointment from childbirth” (Lederman et al., 1981, p. 205). The coefficient
alphas of this subscale in Ledennan’s study (1981) were 0.80 and 0.87 at 3 days and 6
weeks postpartum, respectively. The reliability coefficients for each of the eight
subscales were higher at both measurement occasions than the intercorrelations among
the subscales, indicating that each of the eight different subscales provided unique
information. No other specific information addressing content validity was available.

The satisfaction subscale from the PSEQ was found to be a reliable measure for
satisfaction with the birth experience as defined in the present study. There were a total
of 88 cases for which there were responses for all 10 items. An overall alpha of .75 and a
standardized item alpha of .75 were obtained for the scale. The mean inter-item

correlation for the scale was .23.

 

30
r i n fi iti n
Bitthilans

Preparation and existence of a birth plan was operationalized by direct
questioning in the interview (items 6 and 7, Appendix A). Subjects were asked if they
had a written birth plan, and if they talked to their doctor or nurse in the office or clinic
where they received prenatal care about their options and preferences before their
delivery. Subjects who answered “Yes” to either of these questions were identified as
having a birth plan, while subjects answering “No” to both questions were identified as
being in the non-birth planning group. The birth planning group was further subdivided
into written birth plan and verbal only birth plan groups.

Participation in childbirth education classes was also operationalized by direct
questioning (item 2, Appendix A). If the subject responded that she had attended CBE
classes, additional questions were asked to determine if the classes were in the traditional
(evenings or weekends) format, or if she attended clinic waiting room classes. The
subject was also asked how many classes she had missed. If the subject answered “no”
to having CBE classes, the interview proceeded directly to questions about the childbirth
experience.

i ' ' 'l b‘ ri

Satisfaction with childbirth was operationalized by using 10 questions from the

Postpartum Self-Evaluation Questionnaire (PSEQ) which was developed by Lederman,

Weingarten, and Ledennan (1981) to measure components of maternal adaptation during

31
the postpartum period (see items 30 through 39, p. 5, Appendix A). These questions
comprised one of eight subscales of the PSEQ, and were developed specifically to
measure the mother’s gratification from her labor and delivery experience. Although
gratification and satisfaction can not be assumed to represent the same concept, they are
highly related and can be measured in a similar fashion. Questions from the PSEQ
gratification subscale include “Giving birth was satisfying to me”, “Overall, my labor
and delivery was a good experience”, and “I feel joyful when I remember the birth of the
baby”. Because of the content of these and other questions in the subscale (see Appendix
A), this tool was identified as being an appropriate measure for satisfaction as defined in
this study. The satisfaction scale was scored using a 5-point Likert scale ranging from 5
(W) to 1 (not at all true). Items 32, 34, 35, and 36 were reverse scored since they
were worded negatively. Overall satisfaction scores were obtained by computing a mean
score for the 10 items from the PSEQ. A higher score indicated a more positive
perception of satisfaction with the childbirth experience.
Btgcedure
WW
Subjects for the second phase of the overall project were recruited through CBE
classes and through the hospital in which they delivered. At the time of recruitment,
potential subjects were informed that a gift certificate would be mailed to them on
completion of the phone interview.

CBEsubjects, Women who attended CBE in the traditional setting (a series of

classes held in the evening or on weekends) were asked to participate in the study when

32

they were near the end of the class series. One of the investigators attended a class
session and explained the purpose of the study to the class participants. Any woman who
was willing to participate was asked to sign the informed consent (see Appendix B), and
include her expected due date. Women who agreed to participate were contacted again
by a representative of the CBE organization at an estimated two weeks after their
delivery (based on their expected date of delivery), to confirm continued consent to
participate, and to schedule the phone interview at approximately six weeks postpartum.
Most of the primiparous women in the CBE classes who were asked to participate signed
consent forms, but not all were contacted to participate in the study. Based on expected
due dates, CBE women were contacted during June, July, August, and September to
schedule interviews, until adequate numbers of subjects in this group were obtained. No
records were kept to determine the total number of women who were approached in this
group, so an overall response rate could not be determined. However, of those women
who had signed consent forms and were subsequently contacted and scheduled for
interviews, only three women did not complete the interview, resulting in a response rate
of 94%.

WW Women who had not had CBE classes were identified during
their delivery hospital stay by the investigator of the present study and three other
selected staff nurses. When a delivered woman was identified as having had no CBE
classes and meeting the other selection criteria, she was approached, the study was
explained to her, and she was asked if she was willing to participate. Signed consent (see

Appendix B) was obtained from women who agreed to participate. Date of delivery was

33
recorded on the consent form. The woman was then called by the CBE provider within
approximately two weeks after delivery, continued consent to participate was confirmed,
and the phone interview at approximately six weeks postpartum was scheduled.

Overall, for this group, there were 78 eligible women who were approached and
asked to participate in the study. Eight of these women declined participation, yielding
an initial response rate of 89. %. Of the remaining 70 women, there were 19 who were
unable to be contacted after discharge from the hospital, due to incorrect phone numbers,
unretumed calls or messages, or disconnection of phone service. Of those women who
were scheduled for interviews, only six did not complete the survey, resulting in a
response rate of 88%. This yielded an overall response rate of 59% based on the entire
eligible non-CBE group (46 women who completed the interview out of the 78 who were
identified as being eligible).

Wm:

The four faculty investigators and the two graduate nursing students conducted all
of the phone interviews. Prior to beginning interviews with study subjects, several
training sessions were held to practice interviewing techniques, to develop a list of
definitions to be used for clarification of respondents’ questions during the interviews,
and to review standard recording procedures.

Subjects were mailed a copy of the questionnaire about two weeks before the
scheduled date of the interview, and they were given the name of the nurse who would be
calling them. Subjects were then called on the telephone at the scheduled time. If the

woman was unable to complete the interview at the time of the initial call, another time

 

 

Sc.

em]
bin
for 1
Inc

$3115

{5011]
“Om:
1105511
gTOUpg

34

was arranged. If the woman could not be reached, several other attempts were made to
reach her and complete the interview. If at the time of the interview the woman no
longer consented to participate, or if the woman was unable to be reached after several
attempts, she was dropped from the study. For subjects who completed the interview, a
gift certificate for a local store was mailed to them by the CBE provider within 2 weeks
of completion of the interview.

Data Analysis

Data from this study were analyzed using the Statistical Package for the Social
Sciences (SPSS) computer software program. The sociodemographic data were
summarized using frequencies, percents, means, and standard deviations to describe the
sample. Demographic data of interest included age, marital status, race, education,
employment, and household income. The sample was divided into subgroups (based on
birth planning and non-birth planning, and CBE and non-CBE), and data were analyzed
for each group to identify any systematic differences between the groups. A significance
level of p<.05 was used in all analyses. Satisfaction measures data from the PSEQ
satisfaction subscale were summarized using means and standard deviations.

The first two research questions were concerned with differences between two
groups. Question one asked if there was a difference in satisfaction between primiparous
women with and without a birth plan (written at verbal). Question two addressed
possible differences in satisfaction between written and verbal-only birth planning
groups. The independent samples t-test was used to determine if there were statistical

differences in satisfaction between the two groups in each instance.

 

 

 

efit

USEI

iflV

akc

in

incl

adm

Onb'“
Slud} Ii

locked]

35

The third research question explored the possible existence of an interaction
effect between CBE and birth planning on satisfaction. A factorial (2 X 2) ANOVA was
used to determine if an interaction effect was present in this sample.

P e ti n m n

For the overall study, approval by the University Committee on Research
Involving Human Subjects (UCRIHS) was obtained (see Appendix C). Approval was
also obtained through the Institutional Research Review Committee (see Appendix C) for
subjects from the tertiary care hospital. The Obstetrics and Gynecology Department and
the Family Medicine Department at that institution were also asked for permission to
include patients in the study. Approval from each of these departments was obtained
(Appendix C). Verbal approval for inclusion in the project was obtained from
administrative representatives at the community hospital that was involved.

There were no identified risks to the subjects involved in the study; however,
participants were informed that if they were uncomfortable with any of the questions in
the interview, they did not have to answer them, and that they could stop the interview at
any time. Subjects were informed that the principal investigators would be available to
address any concerns or issues by phone at the number that was provided to each of
them.

Study participants’ confidentiality was protected by identifying them by number
only when data from the surveys were entered into the computer. All documents in the

SIUdy that could lead to identification of individual subjects were stored initially in a

locked file drawer at the CBE provider’s office, and will be transferred for long-term

 

 

in
Die
COII

Skid“

 

36

storage to a locked file drawer in the office of one of the principal investigators at the
Michigan State University College of Nursing.

For the analysis of data in this portion of the study, only data that was pertinent to
this study was received from the data file available from the larger study. Subjects were

identified by code number only.

As, sumptigns and Limitations
W

In this study, it was assumed that the subjects understood the questions during the
phone interviews and that they answered truthfully. It was also assumed that the nurse
interviewers recorded the subjects’ answers correctly, and that data were subsequently
entered accurately into the computer.

The first limitation of this study was that a convenience sample was used, in
which only women who voluntarily agreed to participate were included. With this type
of non-probability sampling, there was no way to determine if there were any systematic
differences between women who agreed to participate and those who refused. The study
also included only first-time mothers, so generalizations can not be made to a population
of pregnant women, since multiparous women (mothers with other children) may differ
from primiparous women in respect to birth planning and satisfaction with childbirth.
The CBE group consisted of only women who had attended CBE classes given by one
community childbirth education provider, which limits the application of findings in this

study to women who had CBE from other sources.

 

 

 

com
MS!
and
or 11
con

013

yea-
W61
lime
non.
.l’tars

anal}:

37

In establishing the presence of birth planning, no specific questioning was done to
determine the extent of the birth planning that had been done. Subjects were asked only
if they had a written birth plan, or if they had talked to their doctor or nurse about their
options and preferences (verbal birth plan). Subjects were identified as being in the birth
planning group if they answered “Yes” to either or both questions. No evaluation was
made to determine if various aspects of the birth planning process were included, such as
discussion of all available options, cultural practices and preferences, possible
complications of labor and delivery and rationale for treatment, and other aspects of care.
Assessment was not done to determine if the woman was counseled about her own role
and the roles of others, such as her partner or the nurse, in the labor and delivery process
or in decision making. No attempt was made to discern the level of birth planning on a
continuum from minimal to maximal, which may have affected the subject’s perceptions
of satisfaction with the birth experience.

Results
ngggtaphigs
The birth planning group had a mean age of 24.84 years, ranging from 15 to 40
years old. Other characteristics of the birth planning group included that the subjects
were predominantly Caucasian, had at least a high school education, worked at least part-
time, had an annual household income of greater than $20,000, and were married. The
non-birth planning group subjects were an average of 26.94 years old (range 19 to 38
years), and shared similar demographic characteristics. The comparison groups were

analyzed for differences in demographic factors, and were found to have no significant

38

differences in age, education, race, employment, income, or marital status. Although not

statistically significant, the non-birth planning group subjects were slightly older and

were employed full-time. There were 10 (13%) of the birth planning subjects but none

of the non-birth planning subjects with less than a high school education. Tables 1 and 2

summarize the characteristics of the sample when divided on the basis of whether or not

they had a birth plan (written or verbal), irrespective of CBE attendance.

 

 

 

 

 

 

 

 

Table l
14,-...qu . a! '10. g .ioonfrBi ’Inn' : on... ' o
Circuits
Research question 1 Birth Plan Group Non-Birth Plan Group
(11:79) (rt-=16)
Variable Mean 512 Mean SQ
Age (in years) 24.84 5.91 26.94 5.50
Education (years completed) 13.70 2.34 14.00 2.03
Research question 2 Written Birth Plan Verbal-Only Birth
(a=18) Plan (a=61)
Variable Mean 51; Mean 52
Age (in years) 25.44 5.22 24.66 6.13
Education (years completed) 14.28 2.61 13.52 2.25

 

Tables 1 and 3 show the demographic characteristics of the subset of the sample

that had birth plans when divided on the basis of written birth planning or verbal-only

birth planning, again irrespective of CBE attendance. When comparing written and

 

Table

Dim

39

Table 2

   

Birth plan (11:79) Non-birth plan (11:1 6)

 

 

 

 

 

 

Characteristic no. % no. %
Race:
Caucasian 61 77 12 75
Non-Caucasian 1 8 23 4 25
Education:
_<_ 11 years 10 13 0 0
12 years (high school) 23 29 7 44
13-15 years 18 23 3 19
2 16 years 28 35 6 37
Employment:
None 30 39 5 31
Part-time 16 20 1 6
Full-time 32 4 1 10 63
Missing data: 1 from BP group
Annual income: (in dollars)
< 5,000 3 4 I 7
5,000-9,999 5 7 O O
10,000—14,999 7 10 0 0
15,000-19,999 4 6 O 0
20,000-29,999 1 0 1 5 3 22
30,000-39,999 8 12 1 7
40,000-49,999 7 1 0 2 14
_>_ 50,000 24 35 7 50
Missing data: 11 from BPgroup
_. 2 from non-8P group
Marital status:
Never married 22 30 2 l4
Engaged 0 0 1 7
Cohabiting 4 5 1 7
Separated 1 l 0 0
Married 47 64 10 72

MiSSing data: 5 from BP group
2 from non-8P group

—._

40

Table 3

hi hrcrisi fWri nndVrbl-nl 'rt Plnnin r

   

Written birth plan Verbal-only birth plan

 

 

 

 

 

 

01:18) (tr-‘61)
Characteristic no. % no. %
Race:
Caucasian 15 83 46 75
Non-Caucasian 3 17 l 5 25
Education:
5 11 years 2 11 8 13
12 years (high school) 3 17 20 33
13-15 years 4 22 14 23
_>_ 16 years 9 50 19 31
Employment:
None 6 33 24 40
Part-time 1 6 15 25
Full-time 1 l 61 21 35
Missing data: 1 from verbal-only group
Annual income: (in dollars)‘
< 5,000 O 0 3 6
5,000-9,999 0 0 5 1 0
10,000- 14,999 1 6 6 1 1
15,000-19,999 2 12 2 4
20,000-29,999 O 0 l 0 1 9
30,000-39,999 5 3 l 3 6
40,000-49,999 1 6 6 1 l
_>_ 50,000 7 44 17 33
Missing data: 2 from written group
_ 9 from verbal-only group
Marital status:
Never married 2 12 20 35
Engaged 0 O 0 0
Cohabiting 0 0 4 7
Separated 0 0 1 2
Married 15 88 32 56

341581113 data: 1 from written group
4 from verbal-only gmuP

‘X’=14.94, rz<.04

 

 

It:

41

verbal-only birth plan groups, although not statistically different, women with written
birth plans tended to be slightly older, have more education, and worked full-time. Only
one significant difference was found between the two groups; women with written birth
plans had higher annual household incomes, with 81% of them reporting incomes of
greater than $30,000, while only 50% of the verbal-only group had annual household
incomes of greater than $30,000.
Res lt R 1 th se r ti n

The results of this study are presented by addressing each of the original research
questions. Each of the research questions examined the association of different factors
of birth planning and CBE as they relate to the outcome measure of satisfaction with the
birth experience. Results of each analysis are presented separately.

e ' n 1

The first research question asked if prenatal birth planning (written or verbal) was
associated with a primiparous woman’s overall satisfaction with her childbirth
experience irrespective of CBE. Satisfaction scores ranged from 2.78 to 5.00 for the
birth planning group, and from 2.6 to 4.9 for the non-birth planning women. Table 4
shows the means and standard deviations of the satisfaction scores for women with any
birth plan, written or verbal, and for women with no birth plan. Mean scores
indicated both groups had high levels of satisfaction. Levene’s test for equality of
variances demonstrated that the variances were equal in the two groups. T-test
results indicated that there was no significant difference in the mean satisfaction

scores for women with or without birth plans, (t (93) = .35, a5). Therefore, there

 

W35

\Vilt'

bin

Tal

and

ltb‘e

42
was not evidence in this sample to support the hypothesis that any birth planning,

whether written or verbal, would result in higher levels of satisfaction with the

birth experience.

Table 4

M’s ,n. entire. D-.v'ti ns ofStis .oci _ 'h h irthE oi-rr‘n - re

 

 

 

Satisfaction scores [1 Mean 512
Research question 1
Birth planning 79 4.40 .56
Non-birth planning 16 4.35 .55
Research question 2
Written birth planning 18 4.46 .47
Verbal-only birth planning 61 4.39 .59

 

W2.

The second research question asked if there was a difference in overall
satisfaction with childbirth between primiparous women who had a mitten birth
plan and primiparous women who had only a 16112511 birth plan irrespective of CBE.
Satisfaction scores ranged from 3.6 to 5.0 for the written birth plan group, and from
2.78 to 5.0 for the verbal-only birth plan group. Table 4 shows the means and
standard deviations of the satisfaction scores for women with written birth plans
and for women with verbal-only birth plans. Both groups reported high mean

levels of satisfaction. Levene’s test for equality of variances demonstrated that the

 

varia
Sign
and ‘
foun
rest]

\trb

PU
(D
I)
(p

l

allfill
“0”]
"15311
Plant
nosb

”ten

43

variances were equal in the two groups. T-test results indicated that there was no
significant difference between the mean satisfaction scores for women with written
and verbal-only birth planning, (1 (77) = .46, £15,). In this analysis, evidence was not
found in this sample to support the hypothesis that written birth planning would
result in higher levels of satisfaction with the birth experience as compared to
verbal-only birth planning.
Euaeanfitghuaaunii

The third research question asked if there was an interaction between
attendance at childbirth education classes and birth planning on a primiparous
woman’s overall satisfaction with the childbirth experience. Table 5 shows the
mean satisfaction scores of CBE and non-CBE with birth planning and non-birth
planning groups. All scores indicated high mean levels of satisfaction. Although
no significant results were found to support the hypothesis that CBE would have an

interaction effect with birth planning on satisfaction scores, (E (l) = 2.14, 115), it is

 

 

 

Table 5
mm; 1 ° f i wi ‘ oaih EXD; ' ‘ or: f 3111311111 :0 3E
CBE Non-CBE
Birth planning 4.47 4.32
(n=42) (n=37)
Non-birth planning 4.20 4.50

(n=8) (n=8)

44

interesting to note that the lowest mean satisfaction score (4.20) was for the
CBE/non-birth planning group, and the highest mean satisfaction score (4.50) was
for the non-CBE/non-birth planning group.
chat Findings

Data were also analyzed for differences in satisfaction scores based on other
factors of the labor as measured by additional questions included in the survey used
for the overall study, but not included originally as part of this study. Some very
interesting differences were found in mean satisfaction scores based on several
factors. Results of t-tests are displayed in Table 6. For those women who
perceived that their birth had gone as planned, the mean satisfaction score was
significantly higher than for those who felt their birth had not gone as planned. In
response to the question “Do you feel your preferences were respected by the
doctors/nurses in the hospital during your labor and delivery?”, there were 91
subjects who answered “Yes”, while only 4 women answered negatively. Although
the mean satisfaction scores for these two groups were not statistically different,
the mean satisfaction score for the “non-respected” group was only 3.92, the lowest
mean satisfaction score found in any comparison group. Lack of significance could
be due to the small number of women who comprised this group. Satisfaction
scores were also statistically lower for women who experienced Cesarean section
deliveries and those who had epidural anesthesia (see Table 6). There were no
differences in satisfaction scores for women based on induction of labor, use of

pain medication, fetal heart rate monitoring, use of forceps or vacuum extractor, or

 

 

If? [’5’

II

I}

45

use of episiotomy. Because of the lack of significant findings, the summary

statistics for these comparisons are not presented in this discussion.

Table 6

dar iti ns nd ~tes An 1 se f tisf tion wit th irth
x rien cor L b r-relt Vari ls

 

Variable _It Mean $2 t (df)

 

 

 

 

 

[2

Birth went as planned

Yes 56 4.57 .42 3.73 (60.94)

No 39 4.14 .63 .000
Preferences were respected

Yes 91 4.41 .54 1.76 (93)

No 4 3.92 .92 .081
Cesarean delivery

Yes 20 4.09 .54 -2.8 (93)

No 75 4.47 .54 .006
Epidural anesthesia

Yes 74 4.32 .57 -2.67 (40.17)

No 21 4.64 .45 .011

Discussion

Iatatpretation gf Findings

The summary characteristics of the sample in the present study
demonstrated heterogeneity in demographics (age, education, race, socioeconomic

status, and marital status) which are consistent with the population in the mid-

46

Michigan community in which the study was done. However, in each of the
comparison groups, the demographic characteristics overall were similar in their
distribution among groups. Only primiparous women were included in the study,
which represented only a portion of the women delivering in the community. It is
difficult to compare this sample to the samples used in other research because, as
previously discussed, some samples were not described at all and comparison
groups were lacking in much of the research about birth planning, CBE, and
childbirth satisfaction. When examining the samples in research studies
specifically addressing birth plans, it is again inappropriate to compare findings
about demographic characteristics since they were either incompletely presented
(Ekeocha & Jackson, 1985) or were dissimilar to this study sample (Moore &
Hopper, 1995; Springer, 1996).

In this study of 95 subjects, 19% had written birth plans, 64% had verbal-
only birth plans, and 17% had no birth plans. Again it is impossible to evaluate
these findings to validate if they are “typical” of expectant primiparous women,
since none of the existing literature presented data about the numbers of women
who voluntarily engaged in birth planning.

No differences were found in satisfaction scores for any of the comparison
groups used to answer the research questions, possibly due somewhat to the lack of
variability within the sample. Satisfaction scores were on average quite high,
ranging from 2.6 to 5.0, with an overall mean for all subjects of 4.39 and a median

of 4.50 on a scale of 1 to 5, with 5 indicating high levels of satisfaction with the

47

childbirth experience. Women’s satisfaction has been shown to be highly affected
by how they were treated during their labor experience and if they felt they were
respected (Green et al., 1990; Simkin, 1991). For the subjects in this study, only
four women felt that their preferences were not respected, and although the
satisfaction scores were not statistically different from those women who reported
feeling respected, those who were not respected had lower mean satisfaction scores
(3.92 compared to 4.41). Therefore, the high levels of satisfaction with the
childbirth experience which were found in this study may be reflective of the
quality of care provided to women delivering in the hospitals in the study
community. With or without CBE or birth planning, women found their childbirth
experiences to be very satisfying, suggesting that they were treated with respect,
and that they felt they received the care they desired and needed. This also
suggests that women received care that met their expectations for their experiences.
Another factor that may have contributed to the high satisfaction scores was
the population of women who were used as subjects. Satisfaction with childbirth
has the potential to be confounded by the outcome of the experience, whether a
healthy mother and baby resulted from the delivery or not. It is necessary to note
that all women in the study had surviving infants, which excluded deliveries with
extremely poor outcomes. Additionally, the sample was one of convenience, which
prevents conclusions to be drawn about the women who refused to participate. It is
possible that women who were dissatisfied with their care refused to participate, or

were not contacted, leaving only those with higher satisfaction levels to respond to

48

the survey.

One of the limitations identified as having the greatest potential impact on
the study findings, was that there was not a more in-depth assessment of the extent
of the birth planning that was done for each of the subjects. As discussed in birth
planning literature, there are many components of birth planning, including
education (Carty & Tier, 1989; Ekeocha & Jackson, 1985; Moore et al., 1995),
evaluation of values, cultural practices, and goals (Carty & Tier, 1989; Ekeocha &
Jackson, 1985; Way, 1996), improvement of communication and establishment of a
mutual partnership in decision making (Carty & Tier, 1989; Ekeocha & Jackson,
1985; Moore et al., 1995; Way, 1996), and others. Subjects were asked only if they
had a written birth plan or if they had discussed their options and preferences with
their health care provider during the prenatal period. If there had been more direct
and specific evaluation of the level of birth planning, the presence of the various
components of birth planning, and the perceived effectiveness of the process, there
may have been a difference in satisfaction scores for those women who had
complete and effective birth planning as compared to those with incomplete or no
birth plans.

When examining the data related to the interaction effect of CBE and birth
planning on satisfaction with childbirth, it was very surprising to find that the
women with the highest satisfaction scores were those with no CBE and no birth
planning, although these results were not statistically significant. Demographic

characteristics and features of the labor process experienced by this group (if—8)

 

 

____;

VVCI

\VEI

yea:
thar
beir
wor
or 11

ICSU

Clip;

Satis
inte
low

bin!

The
labc

ofl‘a

1993

“birth

49

were explored to find some explanation for this unexpected finding. Demographics
were essentially the same as the rest of the sample, with the typical subject in this
group being about 27 years old, Caucasian, married, had slightly more than 14
years of education, worked full-time, and had an annual household income of more
than $20,000. No common features of the labor experience were identifiable as
being correlated with their high satisfaction scores. One could postulate that
women who were not educated about the childbirth process through CBE classes,
or those that never really “planned” the experience, would have fewer expectations,
resulting in higher satisfaction scores related to less disappointment with
expectations that were not met.

For those women who had CBE but did not have a birth plan, the mean
satisfaction score was the lowest of the comparison groups in the analysis of the
interaction of CBE and birth planning. Although not statistically different, these
lower scores may possibly be attributed to the fact that the women in the CBE/non-
birth planning group had knowledge of various options of care, but never discussed
which options were mutually acceptable to themselves and their care providers.
The lower satisfaction scores may be a result of unmet expectations during the
labor and delivery process, where the woman wanted certain options that were not
offered by her provider.

In several discussions of birth planning in the literature, authors (Lothian,
1993; Moore & Hopper, 1995; Zwelling, 1996) mentioned the possibility that

“birth planning” was something that some hospitals and health care providers

50

offered to present the illusion that expectant parents were given choices in their
birth experiences. Lothian discussed that the only real option that many expectant
women have is where they will deliver and who their provider will be. These
concepts may have had some effect on the outcome of this study. Most women
were highly satisfied with their birth experiences, which may in part have resulted
from the way they were socialized and educated prior to their deliveries. Most
women are educated about their childbirth options, either through CBE, their
providers, or friends and family members. This routine education concerning
childbirth is directed in most cases toward the usual “options”. In actual practice
(based on 18 years of clinical labor and delivery practice by this author), few
women actually request special options for their labor and delivery care. When
women have been socialized to the childbirth experience in this manner, it is much
easier to meet a woman’s expectations for her childbirth when it is the usual and
standard practice that she is expecting as her “option” for childbirth.

The measures that were used to arrive at satisfaction scores may also have
resulted in the lack of differences in satisfaction among the birth planning and non-
birth planning, and CBE and non-CBE groups. Questions from the satisfaction
scale included a few measures of global satisfaction with the experience, such as
“Overall my labor and delivery was a good experience” and “I feel disappointed in
the delivery experience I had” (reverse scored). Many other questions however,
measured other perceptions, such as feelings that the delivery made the woman

proud of herself, or gave her feelings of accomplishment, or that giving birth was

51

satisfying to her. Additional questions in the scale addressed her perceptions of her
own performance in labor or her tolerance of the labor pain. Although these
aspects of the labor and delivery experience have been found to be associated with
satisfaction with childbirth, perhaps these measures are not directly related to CBE
and birth planning, and do not adequately reflect the effect that birth planning or
CBE have on a primiparous woman’s satisfaction with her birth experience.

One other benefit of birth planning that was supported in the literature, was
that birth planning increased the clients’ decision making abilities Oikeocha &
Jackson, 1985; Moore et al., 1995; Springer, 1996). Active participation in
decision making was, according to several authors (Brown & Lumley, 1994; Seguin
et al., 1989; Simkin, 1991), highly related to satisfaction with the birth experience.
In this study, decision making ability and participation in the process were not
concepts that were explored as outcomes of the birth planning process, or as
components of the satisfaction scale. This may also have had an effect on the lack
of differences in satisfaction scores for birth planning and non-birth planning
groups. If participation in decision making had been assessed, women who felt
more involved in decision making may have demonstrated greater satisfaction with
their experiences.

The remainder of this discussion related to the study findings does not
address the questions that were originally proposed for this study, however, the
additional findings do have bearing on the interpretation of the associations among

birth planning, CBE, and satisfaction with the birth experience. The use of various

52

procedures, types of analgesia and anesthesia, and the method of delivery, whether
vaginal or Cesarean section, have been suggested as factors that influence overall
childbirth satisfaction (Green et al., 1990; Seguin et al., 1989). This was supported,
in part, by the results of this study. Differences in satisfaction were found for
women who had Cesarean section deliveries and those who had epidural
anesthesia. Other procedural factors such as induction of labor, use of pain
medication, fetal heart rate monitoring, use of forceps or vacuum extractor, or use
of episiotomy were not found to affect satisfaction. The lower satisfaction scores
for the Cesarean section group could be attributed to the feelings of loss the women
may have experienced by not having a “normal” delivery, and the sense of failure
that many women express that they “failed” to deliver vaginally. Lower
satisfaction scores for women with Cesarean deliveries may also suggest that their
expectations for a spontaneous vaginal delivery were unmet.

The findings that women without epidural anesthesia were more satisfied
with their childbirth experiences supports the mastery model as presented by
Humenick (1981). Epidural anesthesia, in most cases, provides the most effective
pain relief for labor and delivery, but these findings suggest that relief of pain may
not be the factor that is the most highly related to a woman’s satisfaction with the
childbirth experience. Some of the questions in the satisfaction scale related
specifically to feelings of self—control, such as “I feel good about howl handled
myself during labor and delivery” and “l have regrets about how I did in

labor”(reverse scored). Women who had epidurals may have had lower satisfaction

53

scores because of feelings of “failure” to tolerate labor pain without the use of
anesthesia. Lower satisfaction scores for women with epidural anesthesia may also
have resulted from the epidural experience not being what they had expected,
either by not providing the pain relief they expected, or by producing sensations
(from the epidural itself) that they did not like.

The additional procedural variables, those of induction of labor, use of pain
medication, fetal heart rate monitoring, use of forceps or vacuum extractor, or use
of episiotomy were not found to have an effect on satisfaction with the childbirth
experience. This could be explained, at least in part, by the notion that these
procedures are now considered as the “normal procedures” used during almost all
labors and deliveries. When women have been socialized into accepting these
procedures as a normal part of their labor and delivery expectations, their actual
birth experiences have greater potential to be congruent with their expectations,
thereby not affecting their perception of satisfaction with the birth experience.

When subjects were questioned about whether they felt their births had
gone as planned, a significant difference in satisfaction scores was found between
women who answered “Yes” and those who answered “No”, with those answering
“No” reporting lower satisfaction scores. This finding suggests that women who
felt that their birth experiences were congruent with their expectations were more
satisfied that those whose expectations were not met.

The findings of this research, although unable to give direct evidence in

support of the proposed relationships among CBE, birth planning, and satisfaction

54

with the birth experience, do suggest that a relationship may exist between the
congruence of a woman’s expectations of her birth experience and the actual event,
and her overall satisfaction with her childbirth. Although most women conceivably
plan for a short labor with manageable levels of pain, resulting in a normal
spontaneous delivery, not all labors and deliveries result in this idealistic outcome.

Findings suggest that women who are educated about possible
complications and use of various procedures may enter labor and delivery with a
more realistic plan and expectations, and less potential for disappointment.
Therefore, women should be adequately educated and prepared through childbirth
education classes, counseling, and birth planning for the possibility of a Cesarean
delivery, the use of analgesia and anesthesia, the use of other procedures, and the
circumstances under which each of these interventions would be used. Women
who are appropriately prepared in this manner may have a greater potential to
achieve a more satisfying birth experience, due to having more realistic
expectations, and an experience that meets those expectations to a greater degree.

vi i f n 1

Based on the findings of this research study, the conceptual model adapted
from King’s theory of goal attainment could be revised so that the transaction of
interest would be providing a woman with a childbirth experience congruent with
her expectations. This implies that the expectant woman has realistic expectations
for her childbirth, and the health care team works with her to meet those

expectations, while still providing safe and effective care. CBE and the

deiehp:
expectai
occuire
satisfac
affect t
childbi

birth p

 

includ

._,_ _

parent

lhtir l

10 de
shot
Star

abt
the
3131
ch

Ext

01h:

92m -

55

development of a birth plan would be strategies that could be used to assist
expectant women to develop realistic expectations which could impact the
occurrence of the transaction and, in turn, the achievement of the goal of
satisfaction with the birth experience (See Figure 2). Other factors that can also
affect the transaction are the actions of the health care team members during the
childbirth experience, and the extent of collaboration in the implementation of the
birth plan. Therefore, the original model that guided this study has been revised to
include factors that have the potential to ensure that the interaction of the expectant
parents and the health care team results in a transaction, an experience that meets
their expectations, and greater satisfaction with the birth experience.

Childbirth education can be an effective tool to assist the expectant woman
to develop realistic expectations for her childbirth experience. CBE class content
should include an objective presentation of all available options, not just the usual
standard labor and delivery care. The curriculum should also include a discussion
about developing a birth plan, and the rights of the expectant parents to express
their preferences and desires for their childbirth experience. Through education
about available options and empowering expectant parents to communicate
effectively with their providers, more realistic expectations for the childbirth
experience may result.

Many women do not attend formal CBE classes, and may use a variety of
other sources to obtain information about labor and delivery. Health care providers

can provide or suggest appropriate sources of information for women who do not

 

56

 

Satisfaction with
the birth experience

 

 

 

  

-~.-..~-3;V_LEE-: 'S;-;??:-..-§:-.L?:-':L::13»: , . .F‘? : . i‘ ; “5:": i “:4 '3 ..
3‘3. “-3.... ...,.-‘..",.‘_,. ‘...‘. ‘.'.'r ’.‘.' . .‘._. .'.'.. .‘.'.‘ ..r'. .'-'. in... .‘.','.>.‘.',‘. . . .'..‘.
"r‘l|“‘;;“‘;;"'.:;:x13.};‘3‘U‘Tb

‘i

.-.—o-_

Expectant I

. . I
Primiparous .
Woman ‘

,r-—4;,
\ I
./\

.’ \

.’ \

d

 

l

‘ |

‘ o

. I

\
\

\
\
\
\
\

I
I

I

Significant
other

I-" ’

\
~ 1"
' I
‘ l
‘ I
\

‘ I

I

Figure 2: Revised Birth Planning, Childbi

      

§ Intervening factors: E
§ (HREE I
5 twansconunu'

; inherneunuuws 3
Realistic birth plan
EiCbuhbonmfintaf §
§ heahhinneweanté
iibnphnnenuuhntofé
' tubflbphutat :

ihdhmmy

oooooooooooooooooooooooooooooooo

Health Care “
Provider

I
/

/

/
/

rth Education, and Satisfaction

within King’s Theory of Goal Attainment

W1

IC-

111

sh

of

to]

be

in

011

5X

in

6dr

57

attend CBE classes. Providers should also discuss the labor and delivery process
and available options with their clients, and correct any misinformation the
expectant women may have. Through appropriate education and discussion,
women without formal CBE classes may also be assisted in development of
realistic expectations for their childbirth experiences.

The development of a birth plan can be employed as a strategy to help
women form realistic expectations for their birth experiences. Expectant parents
should be fully educated about the possibilities of a Cesarean delivery and the use
of various procedures, including epidural anesthesia. While discussing these
topics, the provider can explore the clients’ thoughts and feelings about using these
procedures. If more invasive procedures are discussed as possibilities that need to
be included in the birth plan, women may feel less disappointment and more
involved in the decision making process when difficult labor management choices
must be made.

A third factor that may impact the transaction is the extent of collaboration
of the members of the health care team. Although the original model only includes
one health care provider, the primary delivering practitioner, satisfying birth
experiences also can be affected by the numerous health care providers that interact
with the expectant parents during the birth. The delivering provider, childbirth
educators, nurses in the hospital, resident physicians, and others must collaborate
and be willing to accept birth planning options, and incorporate the expectant

parents’ individual preferences into the care they provide. Frequently various

58

health care providers have different values and personal feelings that may cause
conflicts among the providers and the expectant parents. Through collaboration
and communication among members of the health care team, these differences can
be addressed, allowing more flexibility in the options that are available for
childbirth.

The final, and potentially the most important factor that can affect the
occurrence of a transaction, is implementation of a realistic and effective birth plan
during the labor and delivery process. In some cases, due to emergent conditions,
the birth plan cannot be implemented. Although the development of complications
of pregnancy may result in less satisfaction with the birth experience, a birth plan
that is encouraged by childbirth educators, developed by the expectant couple and
their primary provider, but ignored by the labor and delivery nursing staff or other
providers, can potentially result in even greater dissatisfaction with the experience.
Expectant parents may develop a realistic birth plan with expectations of
implementing their plan, and may be dissatisfied with their experience if their
preferences are not respected by members of the health care team.

f Pr ° i

Advanced practice nurses (APNs) who provide primary care to childbearing
women may include family nurse practitioners, certified nurse midwives, OB/GYN
or women’s health nurse practitioners, and clinical nurse specialists. APNs in each
of these roles have many opportunities to positively affect the satisfaction a woman

experiences with her pregnancy and childbirth. Although there were not significant

 

 

 

ha'
otf
as 1

Pro

“'0“

dish

59

results in this study that support the proposed associations among birth planning,
CBE, and satisfaction with the birth experience, implications for advanced nursing
practice can still be drawn based on the conceptual model and the study findings.
In the conceptual model based on King’s theory of goal attainment, the
primary health care provider can be the APN. During the interaction between the

APN, the expectant woman, and her significant other, effective communication can

 

occur, and realistic expectations for the childbirth experience can be developed.
Through professional activities related to the various role characteristics of an
APN, more interactions with expectant parents could potentially result in
transactions, and in turn, satisfaction with the birth experience could be ensured.

The APN can provide health care services to the expectant woman
throughout the childbearing cycle. However, the findings of this study can be
applied most directly to nursing practice during the antepartum period and the
intrapartum and immediate postpartum periods. APNs have a unique opportunity
to provide direct care, including prenatal care and low risk delivery services that
have traditionally been provided by physicians, as well as providing numerous
other professional services that are more within the realm of nursing practice, such
as education, client advocacy, care coordination, and collaboration with other
providers.

In the nursing process, the APN begins her relationship with an expectant
woman by assessing the client’s health and emotional needs, her strengths, values,

desires, and goals for her pregnancy. By beginning early in the prenatal period to

6O

convey a sense of respect, caring, and mutuality, the APN can develop a trusting
relationship with the client and her significant others. As the pregnancy progresses,
the APN can explore further with the client her desires, cultural practices, and
expectations for the childbirth experience. These are all important aspects of
effective birth planning during the antenatal period, helping the expectant woman
to develop a more realistic set of expectations for her childbirth experience.

As a clinician and practitioner, the APN can give direct care during the
antepartum period, as well as functioning as the delivering practitioner, in the case
of the certified nurse midwife. APNs are particularly well equipped to deal with
not only the physical aspects of care, but also the psychological and spiritual
aspects of the pregnancy and childbirth experience. By helping expectant parents
anticipate the changes, both physical and emotional, that occur with pregnancy and
the birth of a child, the transition to parenthood can be facilitated. After a thorough
assessment of the pregnant client’s physical and psychological needs, the APN can
use her planning skills to develop an appropriate plan of care, including a birth
plan, in cooperation with the expectant mother. By helping the expectant woman
to develop a realistic plan and expectations, the likelihood of having a satisfying
birth experience that is congruent with expectations is potentially increased.

Early screening and detection of risks factors, and appropriate care or
referral to specialized providers is another function of an APN in the antepartum
period. When referral to other providers is necessary, the APN can facilitate the

referral by coordinating necessary care, and collaborating with the other

 

 

 

 

practi
referr
a po:
client
accorc
APN t.
and he
APN’s
efl‘ectii
can be
dtiiVer
Plattit

0f the

EXper

Pater
Vario
DIOCei

an 11113
prObIEm
Cilt‘m dbl

61

practitioners to ensure continuity of care. When possible, the APN can make
referrals to providers who are willing to follow the established birth plan as much
as possible, while still providing the level of high risk care appropriate to the
client’s condition. When pregnancy complications preclude provision of care
according to a previously established birth plan, it is especially important for the
APN to discuss the rationale for expected procedures with the expectant woman,
and help her to express her feelings related to the changes. Through the use of the
APN’s counseling skills, the client can be assisted to develop coping skills to
effectively deal with the stresses of a complicated pregnancy. A revised birth plan
can be formulated to include the necessary procedures, including Cesarean section
delivery , while still preserving, as much as possible, the desires and cultural
practices of the client. By developing a revised plan of care within the constraints
of the necessary high risk care, the expectant mother still has the potential to
experience a childbirth that meets her expectations.

In the role of educator, the APN can provide information to the expectant
parents pertaining to their pregnancy, the options that are available to them in
various health care settings, and the risks and benefits of different options and
procedures. Throughout the pregnancy and the childbirth process, the APN can be
an invaluable resource to the pregnant woman to answer questions and address
problems as they may arise. The APN may also be responsible for instructing
clients about the structure of the health care system, and helping them to develop

enhanced communication skills, so interactions with other health care providers

 

 

 

can
orc
“hi
der

1656

“ho

reah:

acht
vhh‘
0ph
Ina
he
10
ab
nu:
San:
SUMQ
eduflhi

haWfiCa

62

can be more effective. APNs can participate in teaching CBE classes themselves,
or can direct expectant women to quality CBE providers in the community in
which they live. As consultants, APNs can collaborate with CBE providers to
develop and revise the curriculum of CBE classes to include the most current,
research-based information. For women who are unable to attend CBE classes,
APNs can direct them to appropriate sources for instructional information. Women
who are well informed, can communicate effectively with providers, and have
realistic expectations for the labor and delivery process may have a greater
potential for having a satisfying childbirth experience.

An APN can also have an impact on satisfaction with childbirth through
activities as a leader, change agent, and patient advocate. Through collaboration
with other health care providers, the APN can promote the acceptance of expanded
options for the childbirth process, including culturally appropriate practices that
may not be familiar to many providers. APNs can share the knowledge they gain
from assessments of clients with nurses and physicians providing delivery services
to advocate for greater flexibility to meet patient needs and desires. In this study,
all but four subjects felt that their preferences were respected by the doctors and
nurses in the hospital, and overall satisfaction scores were very high. Although the
services that are currently provided were found to be highly acceptable to the
subjects in the study, quality of care may always be improved through more
education and expanded awareness of clients’ wishes and cultural differences by

health care providers.

63

A final step in the nursing process is evaluation of the care that was
provided based on the assessment of the client and the plan of care that was
developed. All aspects of care should be evaluated objectively, including the
content of care as well as the process by which the care was delivered. Outcomes
of the childbirth process, including physical outcomes such as maternal and infant
health, and psychological outcomes such as satisfaction with the experience, should
continue to be evaluated to provide data that can be used to further improve care.
Although in this study, significant results were not found to support the
effectiveness of birth planning and CBE in promoting satisfaction with childbirth,
further information is needed to elucidate the possible relationships among these
variables, including the importance of an experience congruent with expectations
as a factor affecting satisfaction.

Finally, the APN must employ research skills to advance the knowledge
base and establish guidelines for care especially as related to birth planning, CBE,
and satisfaction with childbirth. The APN can be directly involved in planning
projects and collecting research data to clarify the associations among these
variables and others. As more data emerge, the APN can help to disseminate
research findings and assist other nurses to utilize these findings to develop new
care practices.

1m i ti f r rc
Although more research is emerging related to CBE, there is still much we

do not know about the effectiveness and outcomes of CBE. Birth planning has

64

been explored by only a few researchers, which leaves many aspects of birth
planning available for further inquiry and discovery. Satisfaction with childbirth
has been examined more closely than the other two variables, but a clear
conceptual definition of “satisfaction with childbirth” has not yet been articulated.
In addition to the lack of a clear definition, there is insufficient evidence to indicate
the factors that are essential to ensure client’s satisfaction with the childbirth
experience.

Study findings revealed that women who felt their births had gone as
planned reported higher satisfaction scores, and women with Cesarean sections and
those with epidurals had lower satisfaction scores. These findings suggest that
satisfaction with the childbirth experience is more directly related to a woman’s
perception of her experience being congruent with her expectations than to CBE or
birth planning. Although CBE and birth planning may be factors that affect the
development of a woman’s expectations, there was not evidence to support the
hypotheses in this study that CBE and birth planning had an association with a
primiparous woman’s overall perception of satisfaction with her childbirth
experience. Therefore, it is recommended that additional research be directed
toward the role of the study variables (CBE and birth planning) in establishing
more realistic expectations of the birth process, and how that affects satisfaction
with the birth experience.

In further research that seeks to clarify the associations among the study

variables, it is also important that a more detailed assessment be made of the birth

65

planning process. Without evaluation of the level and effectiveness of birth
planning, it was difficult in this study to compare the outcome measure of
satisfaction when there was no method to control for variability within the birth
planning process itself. Further research should strive to assess for the various
components of birth planning, including education about options and possible
interventions including Cesarean sections, evaluation of the expectant woman’s
personal and cultural values and practices, and assessment of communication and
decision making skills, and for the perceived effectiveness of the process. In this
way, the level of effectiveness of the birth planning process on a continuum of
minimal to complete birth planning, may be used to compare the degree to which
expectant women develop realistic expectations, and in turn, experience
satisfaction with their childbirth.

In this study, the satisfaction measures were directed toward the woman’s
perceptions of global satisfaction with the experience and her self-evaluation of
performance and pain tolerance. The satisfaction measures that were used may
need to be changed to more appropriately assess for other variables that may be
more directly related to birth satisfaction, such as the woman’s perceptions of
feeling respected, being involved as a mutual partner in decision making, the
degree of implementation of the birth plan, and the congruence of her expectations
to the actual experience.

Additional research on these t0pics can also be expanded to include women

who received CBE from other providers or through other formats, and multiparous

66

as well as primiparous women. It would also be interesting to determine if there
are differences in satisfaction between women who receive their care from
advanced practice nurses and those receiving care from physicians. Use of larger
samples may also be an important factor to enhance the ability to find differences
in satisfaction levels of childbearing women related to their birth experiences. The
majority of women in this study were Caucasian, mid 205 in age, middle income,
and well educated. Although women of ethnic minorities, women of childbearing
age extremes, and those with lower incomes and less education were represented in
the study population, further research is necessary to explore the factors that may
affect satisfaction with childbirth in these women that may be different from the
majority of women in this study.

In the current study, only English-speaking women were recruited as
subjects, thereby restricting, at least in part, the cultural diversity in the sample.
This limited the ability to distinguish the effectiveness of birth planning and CBE
for those women who may have had desires for more non-routine, culturally-based
childbirth practices. It would be interesting, but admittedly difficult considering
the language barrier that would exist, to compare satisfaction with the childbirth
experience for women of other cultures who had CBE and effective birth planning,
to satisfaction levels of those who had none. Study results may have revealed very

different pattems if women of other cultural backgrounds were included.

 

67

Summaty

Existing literature suggests that there may be some associations among birth
planning, CBE, and satisfaction with the birth experience. This study attempted to
find data to support and clarify these associations. In this sample of primiparous
women, no significant differences were found in satisfaction scores based on: (a)
whether or not they had any birth plan, written or verbal, (b) whether or not they
had a written birth plan or a verbal-only birth plan, and (c) whether or not there
was an interaction effect of CBE and birth planning. Although results did not
support the proposed associations, overall, women in this study were found to be
very satisfied with their birth experiences, regardless of their birth planning or CBE
status. Study findings suggested a relationship between the congruence of a
woman’s expectations for her childbirth experience and the actual event, and her
perception of satisfaction. Childbirth is an important social, psychological,
developmental, and physical event which can have long-term consequences for
both parents and their infants. Ensuring a safe and satisfying birth experience for
mothers and their significant others is a challenge which all health care providers
of pregnant women should strive to meet. Through additional research and
continued activities such as assessment, planning, education, patient advocacy,
coordination of care, collaboration, counseling, and evaluation, the APN can
augment the body of knowledge that currently exists concerning the effectiveness
of birth planning and CBE, and their influence on satisfaction with the birth

experience.

APPENDICIES

APPENDIX A

APPENDIX A

Outcomes Interview Schedule

Code if

 

OUTCOMES m'rarwrrzw SCHEDULE

Beforewebeginl‘dliketoaskyoquuutions.

1. Isthisyourfimbaby? YES_ NO—

2. Didyouhavechildbirtheduentioncluseswithymrrbabybornéweehago?
YES_ NO

i—Ifyadidymattendcliniccluses? YES_ NO__

Ifyeghowrnanyappoirmnentsnttheclinicdidyouhave?

Ifyouwenttootlwrchildbirthclassu(evening,Sanrrdays,etc.),

didyouattendallyourCBEclaues? Yes_ NO_

Ifno,howmanyclassesdidyourniss?_

 

 

 

r
IfN0,goontothenextsectionlabeledChildbirth.

CHILDBIRTH
NowMyombabyhubembomwewmddliketohwabMymrchfldbfitharpaiences.

Sonreofthequestionsmayseuntorepentbrfithat‘somwayofmkingmyou‘reheafingthe
questionsinthesameway. Let'sbegin

 

1. YOUR NAME
2. HOSPITAL OF DELIVERY __ 3. DOCTOR/MIDWIFE NAME
4. BABY‘S BIRTHDATE __ S. BABY‘S WEIGHT

 

6. Didyourbirthgoasplanned? YES_NO_
Did you have a written birth plan? YES_ NO—

7. Did you talk to your doctor/nurse in the emu/clinic about your options and preferences
before your delivery? YES_ NO—

68

 

10.

ll.

12.

13.

14.

15.

16.

69

Doyoufedyomprefmwuempectedbythcdoaordmm-indwlmsphddufing

yourlsborand delivery? YES__NO__

Everyhborandddivayisdifi‘erernsndmsyindudeoneormmeofflrcfoflowing
procedure; Pleaseindicsteiftheywerespartofyourexperierusndyourcommmts

aboutthem.

MEDICA‘I'IONS (Morphine, Demerol, Visuril. Nubsin)

Comments

 

 

IV
Comments:

 

FETAL HEART MONITOR
Comments:

 

ANESTHESIA (indicate type)
__ load (for episiotomy)
_ epidunl
_ duramorplr/spinal

other

Comments:

 

EPISIOTO
Comments: ‘

 

INDUCTION OF LABOR
Comments:

 

FORCEPS OR VACUUM EXTRACTOR DELIVERY
Comments:

 

CESAREAN DELIVERY
Comments:

 

 

Elf—BE] E] E [EEK—ii
BEBE

 

70

CHILDBIRTH (confirmed)

Hymaflatdeddildbhthdauqdidthemfumafionywrwdvedindmabmnflwabmm
hdpyouademmdymeaymnneedsfifywwaenminachfldbkthdmgoonmthefoflowing
question).

 

YES FAIRLY SOMEWHAT NOT VERY NOT AT ALL
VERYHELPFUL HELPFUL HELPFUL HELPFUL HELPFUL

5. 4. 3. ' 2.

 

 

l7. Howmanytimesrhdyougotothehoqfitalforfalselabor?

 

18. Whatwuethereuonsyouwanmthehospitalwhenyouwereadminedforddivay?

(Circle as many as apply)
1.2. 3. 4.

Contractions Water broke Induction Other
Ifother, specify what the reason was
19. Howfarwereyoudilatedwhenyougottothehospital? ___centimeters

20. HowlongwuymtlaborfiomdxetimeyomconuactionswereSmimtesapmtothe

 

timeyoudelivered? M
21. Didyouusebreathingandrelaxationtechniques?
_Yes _No
Ifyes, whichones Ifno,goonto
(check all that apply) westion 24)
2. _Relaxation
_slowpaced (abdominal) breathing
_modified paced (chest) breathing

_patternedpacedChe-he-who')breathing
_pushms

23. Ifymusedbresthinyrelaxsfionpleasecommunonhowhdpfidthebreathingand
relaxation techniques were in coping with labor contractions (using the scale below).

 

 

 

YES FAIRLY SOMEWHAT NOT VERY NOT AT ALL
VERY HELPFUL HELPFUL HELPFUL HELPFUL HELPFUL

 

S. 4. 3. 2. 1.

 

 

 

 

71

CHILDBIRTH (confirmed)

24.

25.

26.

27.

28.

29.

Ifyes,inwhatwaywasthispersoninvolved?

OnascaleofO-10,with0being'nopain'and lObeing'painasbadasitcouldposa'bly
be',hownmchwasthcmostpainywexperiencedduringlaborandddiveryz

O 1 2 3 4 S 6 ‘7 8 9 10
Nopain Painasbadasit
could possiblybe

Didyouunderstandyourchoicesrelatedtopainreliefduringlabor?
YES_ NO—

Didyouhaveenoughinformafionmmakethedgcin'maboutwhethaormttohave
medication?
YES_ NO—

Didyouhavemoughinformafionmmakethedmiainnabmnwhethaornotmhavem
epidural?
YES NO __,

Thedecisinnabmnwhetherornottohavemedicafionoranepidtnalwasmade:

Completely by the doctors/muses By you & the doctors/nurses Completely by you
1 3 5

Was your partner/support person involved in your decision for pain relief? By
panner/mpportpersonwemeanthepersonwhohelpedyouthemostinlabormOTthe
doctorormrse).
YES NO—
1. 5.

 

 

 

 

72

mantra (continued)

For the following 12 questions usethe scale below and give me the amber which indicates your
response.

4 3 2 1

Verytrue Fairlytrue Somewhattrue Notverytrue Notatalltrue

30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.

42.

Over-almylaboranddeliverywasagoodacperience._
Ifeelgoodabmtthowlhandledmyselfdminglaboranddelivery._
Ifeellreactedbadlytothepainoflabor.__;_
Childbirthgavemeafeelingofaccomplishment.__
Ihavercgretsabouthowldidinlabor._
Ifeeldisappointedinthedeliveryatperiencelhad.._'_
Irememberlaborasmrpleasantandfi-ightening.__
Givingbirthwassatisfyingtome._
Ifeeljoyfinlwhenlrememberthebirthofthebaby.__

My recent delivery made me proud of myself.
Iwasawareofwhatwashappeningduringlabor.
Iwasawareofwhatwashappeningduringdelivery.__

Onequestionabmttywroveralllaboranddelivetyexperience. Whatmightyouhave
domtobebetterpreparedforyourlaboranddelivery?

 

 

 

 

 

 

 

 

 

73

crmmsmm (continued)

Forthesefivequestionsabout help/supportdminglaborandathomewithyourbabyusethe
following scale. Give me the mmberwhichindieates your response:

5 4 3 2 1
Verytrue Fairlytrue Somewhattrue Notvery Notatalltrue
true

43. Ifeltencouragementfrommyeoach/wpportperaonduringlabor.__
44. Mycoach/supportpersonwasunderstandingandabletoeahnme._ ‘
45. Ifyour coach/support pers'onhelpedyoudminglaboranddelivery.Mfldidhelshe help?

 

 

 

 

 

 

46. Onelastquestion: How longwaeminthelwspitalafia'ddivay—(Days)? How
longwasthebabyinthehospital (Days)?

TIME AT HOME

‘l'henerttthreequcstionsareaboutyornpartnerorlmsband.
Doyouhaveapartnerorlmsband? Yes_ No_
Ifyoudonmhaveaparmaorlmsband,goontothenmwcfiononbabyeare(pp. 7). If

1 2 3 4 5
Very true Fairly true Somewhat true Not very Not at all true
true

Ifeelclosetomypartnerbecauseofthelaboranddeliveryexperience_
Mypartnerspendstimewiththebaby_
Itishardtotalkwithmypartnerabouttheproblemslhave_

9’9".”

74

BABYCARIUFIRSTWEEK

Cuingforyanbabyandymnsdfafiaddivuyisamndlfingnewthnymneededtoleun
mmmmmwmmrwmmmmmmmzmuckwm
-firstwsekathome,howwellprepareddidyoufeeltoz

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VERYWBL PAIRLYWELL WAT WIVERY NOTATAU.
PREPARE) PREPARE!) PREPARED PREPARED PREPARED
1. Dodailycare(bathing,cordcare,
circumcision care, etc.) 5 4 3 2 1
2. Sootheyourcryingbaby 5 4 3 2 1
3. Understandtheehangesyouare
goingthroughasanewparent 5 4 3 2 1
WW:
4. meoubtwtfeedins.boulcfeedina.or Breastfeeding Bottlefeeding Both
both? 5. 3. 1.
Dnrlngthatfirflweekhnmemleaaeindicate
howpreparedyouwereto:
VERYVIELL PAIRLY'IEJ. MIA? ”VERY ‘ MATALL
PREPARE) PREPARED new mm mm
5. Feedyourbaby 5 4 3 2 l
BEYOND‘I'IIEFIRS‘I‘WEEK
l. Howareyoufeedingyourbabynow?
2. Haveyoutalmnyom‘babytotheemergencyroom? YES—NO—
2a. Ifyes, why:

 

2b. Ifyes,howmanytimes:
3. Haveyoutabnywrbabyforadteck—upataclinicordoctor’soffice? YES_ NO—
3a. Ifyes,howmanytimes?_
4. Huyombabybeenbackinthehospitalsincebirth? YES_ NO—
4a. Ifyes,howmanydayswashelshethere?_
5. Wasthereanytopicthatyouwouldhavelikedmoreinformationonrelatedtotakingeareofyour
baby?

 

 

 

75

ABLE TO 111mm DANG“ SIGNS

Iwillrudyoutwosituationsaboutlifeathomewithbabies. Iwillthenaskyonwhatyouwnulddointhese
situations. Ywdonothaveacopyofdreaesihnflongaojustlistenaslreadthem.

1. Youandbabylnvebeenhomefromthehospitalfioruhours. Yonnoticeyourbdry'sakina’whites

oftheireyesisthecolorofabmna. Althoughahrlheisawake,hedhisbodyfeelslimpwhenyou
pickher/himup. Whatwouldyoudo?

Probe:Whatdoyouthinkmightbcwrong?

2. YorubabyhashadBliquidgreenstoolsinthelastday. Althoughfnssyyesterday,mdayshelhe
aeemsveryabepy. Youhavenotbeenabletokeephedhimawalclongenoughtofeedher/himin
thelasteighthours. Her/hisaoftspotisaunlenin. BerlhiswmperamreileZ. Whatwouldyoudo?

Prochhudoyouminkmightbewrong?

 

76

SELFCARE

Pleasemdiawhowwenpreparedyoufdtmnkingmofywrsdfmdwfolbwingarus. Thinkbackoverthe
timesincethebabywasbom. Howwellprepareddidyoufeelin:

 

my was. FAIRLY WELL WHAT PDT WY 101' AT an.
PRDARED PREPARE!) PREPARED PREPARED PREPARED

 

 

 

 

 

 

 

 

 

 

 

l. Recognizingifyouhadafever 5 4 3 2 1
2. Knowingwhattoexpectfromyour
bleeding/flow 5 4 3 2 l
3. Knowinghowtotakecareofyour
episiotomy(stitches) 1 mo
. m
4. Xnowinghowtospotbreastinfcctions 5 l
5. KnowinghowtocareforyourC-section
incision 5 4 3 2 1 ms
ms
6. Knowinghowtoareforyourbasicneeds
(aleeping,resting,eating,exereise) S 4 3 2 l
7. Xnowingabout'babyblues'andfeeling
depressed S 4 3 2 l

8. Sincethebabywasbom:
8a. HaveywbeentotheERforyomselflYPS_ NO—
Ifyes,howmanytimes?_
8b. HaveyoubeentothedoctorclinicforyourselflYES_ NO—
Ifyes,howmanytimes?_
8c. Haveyoubeenbackinthehospitalnrrselt? YES_ No_
1fyes,howmanydays?__

9. Wumaemympicmuymwmndhavefikedminfomfimabmflrdawdmnkingmofyoundfl

 

 

 

 

77

10

RESOURCE
Indicateallmthatyouhaveusedsinceyoubroughtthebabyhome:

1. Media
_ EPO Manual (or other childbirth education manual)
_Books

_Videos

2. People
__ Friends
__ Relatives
__ Neighbors
__ Childbirth class instructor
__ Doctor/Midwife
_ Public health nurse
__ Lactation consultant
Other (indicate who)

 

3. Community resources
_ Nurseline
__ W1C
__ Family Growth Center
__ Office for Young Children
Other

 

4. Howdidyouknowaboutthecommunity resources?
Childbirth class Blue folder Someplace else

 

 

"T—

4a. If'someplaceelse' pleasetellmewhere

 

78

DEMOGRAPHICS

Please answer the following questions about yourself. Remember, all answers are strictly
confidential.

Howoldareyou?

 

years

Whatisyourdateofbirth? l 1....
mo day yr

Whatisyourcrmentmaritalstatus? (Morethanonenumberrnayapply)

 

1. never married

2. engaged

3. now married

4. cohabitating (living with partner)
5. separated

6. divorced

7. widowed

What rs your race or ethmcrty?

1 European American (white)

2 African American

3. Native American

4. Asian

5 Latino

6 War multiracial

7 Other (fill in)

Whatisthehighestgndeinaehoolyouhavecompleted?

 

(Schoolgradeoryearincollege)
Doyouhaveajob (workforpay)?
1. Yes, part-time (lessthan30hoursaweek)
2. Yes, full-time(30hoursormoreaweelt)
3. No

Haveyoureturnedtoworksincethebabywasborn? YES_ No_

79
12

8. What is your total household income before taxes this year? This should include income for all
thosepeoplein thehousehold whoahareexpenses. (Just tell methenumbermntotheanswer)

Less than $5,000 a year

S$,(X)0 to $9,999 a year

$l0,000 to $14,999 a year

$15,000 to $19,999 a year

820,000 to $29,999 a year

330,000 to $39,999 a year

$40,000 to $49,999 a year

$50,000 or more a year

AFDC/Food Stamps/Work First/or other program
Don't know

 

aprsewswwr

 

9. Beforewcend,I'dlilaetoaskifthereisanythingelsethatreallymadeadifferenceinyour
pregnancy or childbirth experience? One event, conversation, or bit of advice that you have
usedorrernember?

Thankyouverymuch foryourparticipation. WewillbesendingyouaSlOgiftcertificateinabout2
weeks. Pleaseindieatetheaddresstowhereweshouldsendit.

 

NAME

 

STREET ADDRESS

 

CITY, STATE, ZIP CODE

APPENDIX B

APPENDIX B

Informed Consent Forms

Respondent number:
Informed Consent Form

lunderstandiambeingasltedtoparticipateinatelephoneinterviewatsix
weeks following the delivery of my first child. This interview will be
conducted by Dr. Linda Beth Tiedje, RN, PhD, Associate Professor in the
CollegeofNuning at Michigan StateUniversity oranurse from herreseardt
staff. Klagrccmparddpamlwillbecalleduntheteieplnnemduked
questionsaboutmybirdumyfeenngsoffiuhelplreceivedbompeophwho
wereWithmeduringlabor,thepainletpedenced.outcomesform baby,
Wiltaveusedsincedelivery,and(iflhaddtildbiflhcluaea any
thoughtslhavaaboutwhatlhcardinmyclaasesbeforedrebabyw-bom
Thetelephoneintervlew wilitalteaboutSOndnutes. Aflartheinterviewl
willbemailedaflOgiftcerttfimte.

Norisksordiammfortsareupaebdtorasulthomdrisatudy,dthoughitis
sibla thatsorna ofthe csflonsmaymakemeuncomfurtlbie. Ethic

ppenalcanletlheteiep interviewerkncw,andsinceaheisanurae
shewllltalltwithmeandrefermeforneededhelpiinecesaary.

Iunderstand thatpartlcipationin this studylsvoluntaryandrefusing to
participatewill notaBectmyfuturehealthcne. Ialso understandihatlcan
stop participating at any time during the telephone interviews; all I have to
sayis'lwanttostop". lalsounderstandlamfree toonly answer-the
questions I want to. I know I may benefit by discussing my labor and delivery
with a nurse. lnadditionlltncw this studymay helpnursea tobetterplan
childbirth education for other mothers like me.

All informationl givewillbeidentifiedbyacode number-only. After-all the
information has ban collected for this study, any information identifying
names with code numbers will be destroyed. The telephone uttervisws will
bekeptinalockedmembinetwithmesigned consentfonns. Myresponses
will be anonymous in any, report of these reseamh findings.

III should have any questions concerning this study, or wish to withdraw my
cement to participate, I may contact Linda Beth Tiedje, RN at 353-8685.

Signing this consent indicates that I understand and am willing to participate
in the study.

Study participant 0019...”...
Parent (if participant under 18)
Phone number where you can be reached
cc: Participant 80

 

 

8]

SP OW

 

HOSPITAL

PATIENT CONSENT FORM
FOR NEW PROCEDURE, sruov on onus UNDER CLINICAL INVESTIGATION

 

TO:

 

Your Attending Physician is: M.D.ID.O.
Phone Number.

 

1. Sparrow Hospital allows doctors, nurses and other trained people to work on research to
study sickness and health eare, and new ways to treat sickness and give care to
patients. Sometimes research could cause risks to patients in the study such as
becoming sicker. being hurt. or even dying. Some of these risks may be known. others
are not. No promises can be made about how this study will turn out, or if it will help cure
a sickness. Before you decide to be part of a research project or study, you should talk
to your health care provider about all risks of being part of the study. You should also
talk about any other types of treatment, or having no treatment, and the risks of each.
After getting this information, you have the right decide if you want to be part of the
studyornot. ltyou do notwantto be inthe study,therewill not be any penaltyorlossof
benefits to which you otherwise have a right.

2. You are invited to be part of a research study. called 'Childbirth Education: Outcomes
Research', being done by:

Linda Beth TIedje, RN, PhD. Phone: 353-8685
Millie Omar, RN, PhD. 355-8360
Rachel Schiffman, RN, PhD. 353-5072
Jackie Wright, RN, PhD. 353-8677
Alyne McCann, RN, Graduate Assistant (517M359727
Sandy Metzger, RN. Graduate Assistant 483-2615

You can agree to be part of this study or not. If you do not want to be part of this study, it
will not affect your future health care or have any other penalty.

3. The purpose of this research is to study what happens to families of first babies during
their birth and at about six weeks alter delivery. It will compare peOple who have taken
childbirth education classes from Expectant Parents Organization to a group who has
not had classes.

4. The procedure in this project is to call you on the telephone at about six weeks after
delivery and do an interview (ask you questions) about your birth experience. The

10.

11.

12.

13.

82

interview will have questions about your baby’s birth. your feelings about the help you
had from people with you during labor. the pain you had. how you and your baby are
doing. resources (help) used since your delivery. and (if you had childbirth classes)
thoung about what you heard in your classes before you baby was born. The interview
will last about 30 minutes.

A copy of the interview will be mailed to you about a week before you are called on the
phone. This will give you time to look at the questions and think about some of your
answers.

The purpose of the study interview is to find out if childbirth classes help people learn
what they need to know for their birth and for taking care of themselves and their babies
after delivery. It may help identify things that can be used to make childbirth classes
better.

Being part of the study may benefit you by letting you talk about your birth experience
and by helping you resolve some of your feelings about how your birth tumed out. It may
also help you and other parents who take childbirth education classes in the future. After
being interviewed, you will receive a $10 gift certificate.

Participation in the interview should not cause any risks or discomforts, but some
questions may make you uncomfortable when asking you to think and talk about your
birth experience, which may have been painful or frightening.

You can withdraw from the research study at any time without penalty or loss of benefits
to which you have a right. You can stop participating at any time during the interview by
telling the nurse interviewer ‘I want to stop”. You are free to answer only those questions
that you want to answer.

Your doctor may stop your participation in this study at any time. The nurse interviewer
may stop the interview at any time.

New information found during the study which may change your mind about wanting to
be part of the study will be given to you.

All information that you give during the interview will be identified by a code number only.
The telephone interviews and the consent forms will be kept in a locked file cabinet.
After all the information has been collected for the study, any records identifying names
with code numbers will be destroyed. Your answers will be anonymous (no one will know
your answers to any of the questions) in any reporting of the research findings.

If you have questions about the procedure or participation in the interview. you may call:
Dr. Linda Beth TIedje. RN, PhD.
Day Phone: 353—8685

If discomfort occurs as a direct result of the interview procedure used in this research
study, the nurse interviewer will discuss the problem with you, and make referrals for
help if needed. If available. payment from your insurance company will be requested for
referral care and any other medical expenses that result because of the problem. No
other compensation will be made.

14.

15.

83

If such a problem happens as a direct result of the interview procedure used in this
research study, your doctor should be called. You also need to contact:

Linda Beth TIedje, RN, PhD. Phone: 353-8685

If you have any questions about this research, your rights as a research subject, or any
other concerns about being part of this study, you can contact the above.

Participation in this research will not cost you or your health care insurer anything extra.

If you agree to be part of this study and sign this consent, you may participate in this
research study, which will be done by registered nurses.

Your signature below shows that:

(1) this information has been verbally explained to you, and that you have had the
chance to read it and get answers to any questions you have,

(2) you understand and agree to the information,

(3) you want to participate in the project described and know about the risks that may
be involved in this study,

(4) that information will remain confidential, and

(5) that you have been given a full copy of this consent form.

 

 

Witness Signature of Patient

 

Date

lnvestigator’s Statement

I acknowledge that the nature and purpose of the investigational procedure(s), the risks
involved and the possibility of complications or unintended results were fully explained to the
patient by me or my designee before the patient consented.

 

 

Investigator Date

APPENDIX C

 

GTEEU:
RESEARCH
AND
GRADUATE

STUDIES

University Committee a
MwunhMNwmQ
Human Subjects
(UCRIHS)

Michigan Slate University
232 AdmInIslIalIOn Burldrng
East Lansing Michigan
“fiflJDfi

517/355-2180
FAX 517/432-1171

   
 
  
 
 

APPENDIX C

Human Subjects Approvals

MICHIGAN STATE

UNIVERSITY

 

January 6, 1997

TO: Linda Beth Tiedje . .
A—230 Life Sciences BUilding
RE: IRBII: 96-183
TITLE: CHILDBIRTH EDUCATION: OUTCWES RESEARCH
REVISION REQUESTED: 12/13/96
CATEGORY: l—C
APPROVAL DATE: 03/19/96

The University Committee on Research Involving Human Subjects'(UCRIHS)
review of this project is complete. I am pleased to adVise that the
rights and welfare of the human subjects appear to be adequately
protected and methods to obtain informed consent are appropriate.
Egrefore. the UCRIHS approved this progect and any reVisions listed
a ve.

RENEWAL: UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to
continue a preject beyond one year must use the green renewal
form (enclosed with t e original agproval letter or when a
project is renewed) to seek u ate certification. There_is a
maximum of four.such expedite renewals ssible. Investigators
wishin to continue a prOJect beyond the time need to submit it
again or complete reView.

REVISIONS: UCRIHS must review any changes in grocedures involving_human
subjects. rior to initiation of t e change. If this is done at
the time o renewal, please use the green renewal form. To
revise an approved protocol at any other time during the year,
send your written request to the CRIHs Chair, requesting reVised
approval and referenCing the project's IRB # and title.. Include
in your request a description of the change and any reVised
ins ruments, consent forms or advertisements that are applicable.

PROBLEIB/

CRANGRS: Should either of the followin arise during the course of the
work, investigators must noti DCRIHS promptly: (1) roblems
(unexpected side effects¢ comp aints, e c.) involving uman
subjects or (2).changes in the research environment or new
information indicating greater risk to the human sub ects than
existed when the protocol was previously reviewed an approved.

If we can be of any future help, lease do not hesitate to contact us
at (517)355-2180 or FAX (517)4 2— 171. .

Sincerel

  

avid E. Wright, Ph.D
UCRIRS Chair

EW:bed

cc: Sandra Metzger

84

SPARROW

HOSPITAL

 

April 15, 1996

Linda Beth TIedje

Michigan State University
A-230 Life Sciences Buliding
College of Nursing

East Lansing, MI 48824

RE: Childbirth Education: Outcomes Research

Dear MS. TIedje:

I am in receipt of your research application requesting review and approval for the above
mentioned protocol by the Sparrow Hospital institutional Research & Review Committee.

This letter is to inform you that the protocol has been approved under the Sparrow Hospital
Institutional Research & Review Committee Policy on Expedited Status Protocol.

Sincerely,

f. knit:

G orge S. Abela, MD, Chairperson
Institutional Research & Review Committee

 

1215 E. Michigan. P.O. Box 30480. Lansing, MI 48909-7980 ° (517) 483-2700

 

86

TO: OB Executive Committee

FROM: Sandy Metzger, RNC, BSN
OB Nurse Clinician

DATE: March 18, 1996

RE: Research Proposal

The following information is in regard to a research study proposed by Linda Beth Tiedje, RN,
PhD., Associate Professor of the College of Nursing at Michigan State University. The study
involves participation by Expectant Parents Organimtion and Sparrow Hospital. The attached
study proposal describes a research project to study the availability and outcomes of childbirth
education

My involvement in the study will be as a graduate assistant in the project, and is part of my
required course work for the completion of my Masters Degree in Nursing at MSU. The focus of
my graduate thesis will be the relationship between prenatal birth planning and discussion of

' birth options and preferences, and the patient’s perception of confidence and satisfaction in the
birth experience.

The research instruments included in this packet will be revised slightly to include several
questions about the discussion of birth preferences with the care providers during the prenatal
period, and respect for these preferences during labor and delivery.

The entire proposal for this research project is being Submitted for approval to the University
Committee for Research Involving Human Subjects at MSU, the Sparrow Institutional Research
and Review Committee, and the Sparrow Nursing Research Committee.

I would appreciate your consideration for granting the approval of the OB department to include
your patients in the study.

Thank You,

:1 (lie-(Asa . gimme»

Sandra J. Metzger

Approval granted:

 

”ff/M76

37—/S_ 936'

Signature of Family Practice Representative Date

Date

 

 

 

LIST OF REFERENCES

LIST OF REFERENCES

Bramadat, I. J ., & Driedger, M. (1993). Satisfaction with childbirth:
Theories and methods of measurement. Birth, 29 (1), 22-29.

Brown, S., & Lumley, J. (1994). Satisfaction with care in labor and birth:
A survey of 790 Australian women. Birth, 21 (1), 4-13.

Bryanton, J., Fraser-Davey, H., & Sullivan, P. (1993). Women’s

perceptions of nursing support during labor. Wand
Hamming}; (8), 63 8-644.

Callister, L. C. (1993). The role of the nurse in childbirth: Perceptions of
the childbearing woman. i i N r i I' (6), 288-293.

Carty, E. M. ,& Tier, T. ( 1989) Birth planning: Areality- based script for
building confidence. Joana] Q: Nurse-M ide’em,§4 (3), 111- 114.

Crowe, K., & von Baeyer, C. (1989). Predictors of a positive childbirth
experience. BjLLILLB (2), 59—63.

Ekeocha, C. E. 0. ,,&Jackson P. (1985). The ‘birth plan” experience
Br rit1 tish Jgumal 9f £21251;sz an nd €1er egg] ggy, 92, 97-101.

Evans, C. L. S. (1991). Imogene King: A anceptnal framewgrlg for
nursing, Newbury Park, CA: Sage.

Githens, P. 3., Glass, C. A., Sloan, F. A., & Entman, S. S. (1993).
Maternal recall and medical records: An examination of events during pregnancy,
childbirth, and early infancy. Birth, 20 (3), 136-141.

Green, J. M., Coupland, V. A., & Kitzinger, J .V. (1990). Expectations,
experiences, and psychological outcomes of childbirth: A prospective study of 825

women. Biuh, 17(1), 15-23.

Humenick, S. S. (1981). Mastery: The key to childbirth satisfaction? A
review. WW (2), 79-83.

87

88

Humenick, S. S., & Bugen, L. A. (1981). Mastery: The key to childbirth
satisfaction? A study. Birth and the Family lgumal, 8(2), 84-89.

Jannke, S. (1995). Birth plans. Childbirth Instrugtgr Magagine, 5 (3), 26-
29.

King, I. M. (1981). A theorv fgr nursing: Systems, goncepts, process, New
York: Wiley.

Ledennan, R. P., Weingarten, C. G. T., & Lederman, E. (1981).
Postpartum self-evaluation questionnaire: Measures of maternal adaptation. In R. P.
Lederman, B. S. Raff, & P. Carroll (Eds. ), March Qf Bimes Birth Defects
WW5 I m l (6) maximum.

WWW 201-231)
New York: Liss.

Lindell, S. G. (1988, March/April) Education for childbirth. Atime for
change WWWM 108- 111

Lothian, J. A. (1993). Critical dimensions in perinatal education.

5. l . - ’ IIIII I 1 IIIPTI 4. .eI 2 Q I l- , -' LTI 9. 4(1), 20"
27.

Lowe, N K. (1991). Maternal confidence 1n c0ping with labor: A self-
efficacy concept. um I t tri in 2 (6),
457-463.

. Lowe, N. K. (1996). The pain and discomfort of labor and birth. Jo ornu
WWO) 82-92

Lumley, J. (1985). Assessing satisfaction with childbirth. Birth, 12 (3),
141-144.

Lumley, J., & Brown, S. (1993). Attenders and nonattenders at childbirth
education classes in Australia: How do they and their births differ? Br'rth_29 (3),
123-131.

Mackey, M. C. ( 1995). Women’s evaluation of their childbirth
performance. WWW (2), 57-72.

Moore, M., & Hopper, U. (1995). Do birth plans empower woman?
Evaluation of a hospital birth plan. m (1), 29-36.

89

Seguin, M. D., Therrien, R., Champagne, F ., & Larouche, D. (1989). The
components of women’s satisfaction with maternity care. Birth, 16 (3), 109-113.

Simkin, P. (1991). Just another day in a woman’s life? Women’s long-term
perceptions of their first birth experience. Part 1. Birth, 18 (4), 203-210.

Springer, D. (1996). Birth plans: The effect on anxiety in pregnant women.

WWIIO). 20-25.
Way, K. (1996). Effective birth plans. ' n l '1

Educaunnilfl). 10-11.

Zwelling, E. (1996). Childbirth education in the 19903 and beyond.
0. ., o O. -' I - olo: inc. 'On-. all. in (5),425-432.

 

MICHIGAN STATE UNIV. LIBRARIES
IIIII”IIIIIIIIIIIIIIIIIII”IIIIIIIIIIIIIIIHI
31293017120035