Measuring women’s experiences of childbirth using the Birth Satisfaction Scale-Revised (BSS-R)

Birth satisfaction relates to women’s perceptions of their childbirth experience, which consists of personality factors, and evaluations of the quality of care provided and stress experienced. The importance of measuring ‘birth satisfaction’ lies in desire to improve standards of intranatal care provided, through measuring impacts of interventions (i.e., home birth versus hospital birth) and exploring relationships with other important dimensions (i.e., postnatal depression, wellbeing & attachment). With evaluating intranatal care in mind, this paper aims to educate midwives about one particular method of measuring women’s experiences of labour, which involves using the valid and reliable ​Birth Satisfaction Scale-Revised (BSS-R).​ The ​BSS-R​ is a 10-item self-report valid and reliable measure, which is recommended by the International Consortium for Health Outcomes Measurement (ICHOM)​ as the ‘method of choice’ for evaluating women’s ‘birth experience’. Since the ICHOM​ began recommending the ​BSS-R​ as part of its Pregnancy and Childbirth Standard set, the scale (to date) has been used in 39 countries and 134 sites world-wide. If you would like to use the ​BSS-R​, it can be accessed free of charge for clinical, research or educational purposes through contacting (c.hollinsmartin@napier.ac.uk). Key words​: Childbirth, Birth experience; Birth satisfaction; Birth Satisfaction Scale-Revised; Midwives, validation


Key points
(1) 'Birth satisfaction' is a retrospective evaluation of women's labour and birth experiences.
(2) The Birth Satisfaction Scale-Revised ( BSS-R) is a valid and reliable tool for measuring women's levels of 'birth satisfaction'. (

3) The BSS-R is recommended by the International Consortium for Health
Outcomes Measurement (ICHOM) as the 'method of choice' for evaluating women's 'birth experience'.
( www.ichom.org/medical-conditions/pregnancy-and-childbirth/ ) (4) Midwives can use the BSS-R to improve standards of intrapartum care in a wide range of contexts (i.e., clinical, research & education).
(5) The BSS-R has to date been used in projects based in 134 word-wide sites based in 39 countries. (6) The BSS-R can be accessed free of charge through contacting

Introduction
The 10-item Birth Satisfaction Scale-Revised (BSS-R) is a multi-factorial psychometrically robust tool developed for the purpose of measuring women's experiences of labour and childbirth (Hollins Martin and Martin 2014). The

BSS-R is currently recommended by the International Consortium for Health
Outcomes Measurement (ICHOM) as the lead international clinical tool for measuring women's experiences of labour and childbirth (Nijagal et al. 2018) ( www.ichom.org/medical-conditions/pregnancy-and-childbirth/ ) . Since the ICHOM began recommending the BSS-R, it has been used to measure women's 'birth satisfaction' in 39 countries and 134 sites world-wide.

What is birth satisfaction ?
Birth satisfaction is defined as a retrospective maternal evaluation of labour experience (Hollins Martin et al. 2012), with reflective appraisal important because of potential impacts for mother, infant, and family wellbeing (Sawyer et al. 2013). An experience of poor 'birth satisfaction' has aptitude to effect level of mother and infant interaction (Staneva 2013) and subsequent experiences of breastfeeding (Hinic 2016). In addition, experience of a traumatic labour can increase levels of anxiety and fear surrounding planning of future pregnancies (Baxter 2020).
It is important to appreciate that every woman constructs expectations of how her childbirth experience will unfold (Staneva 2013), with individual perceptions subjective and often complex (Dannenbring et al. 1997).
Literature has shown that multiple factors influence maternal experience of labour and childbirth (Hollins Martin and Fleming, 2011), with three main themes identified: (1) Quality of care provision , (2) Personal attributes , and (3) Stress experienced during labour . These three themes are now addressed.
(1) Quality of care provision What midwives instinctively know and the literature shows, is that quality of intrapartum care provided impacts upon women's reported experiences of labour and childbirth (Hollins Martin et al. 2012). Birth satisfaction is influenced by several factors. For example, women place value upon being listened to and being placed at the centre of decision-making processes (Heatley et al. 2015;Mei et al. 2015;Miron-Shatz and Konheim-Kalkstein 2020). Quality and amount of support provided by midwives and allied health care professionals plays a vital role in level of 'birth satisfaction' reported (Luegmair et al. 2018;Dev et al. 2019;Miron-Shatz and Konheim-Kalkstein 2020), with women testifying that they feel more positive about their birth experience when their needs and comforts are considered (Luegmair et al. 2018;Hall et al. 2020).
(2) Personal attributes (i.e., personality & coping skills) Personality and coping skills play a significant role in shaping level of 'birth satisfaction' women report (Johnston et al. 2013;Conrad and Stricker 2018).
Literature shows that women who take a proactive role to educate and prepare themselves for labour, report more positive birth experiences (Howarth et al. 2011;Hinic 2017; Miron-Shatz and Konheim-Kalkstein 2020), cope better during labour (Howarth et al. 2011), experience reduced levels of stress (Hinic 2017), and suffer less pain (McCrea and Wright 1999;Howarth et al. 2011). 'Birth satisfaction' is reported to be higher when women have choice and control in relation to methods of pain relief and style of delivery (Çalik et al. 2018;Deliktas Demirci et al. 2019). More recent research reports that unplanned Caesarean Section (CS) is associated with reduced 'birth satisfaction', with having an advocate for support improving experience (Konheim-Kalkstein and Miron-Shatz 2019). What is clear, is that women with high levels of 'birth satisfaction' report having felt empowered with choice and control over aspects surrounding their labour and birth (Cook and Loomis, 2012).
(3) Stress experienced during labour Stress experienced during labour profoundly influences women's reported levels of 'birth satisfaction', with literature linking medical interventions and associated injury as one influence on reports (Çalik et al. 2018;Johansson and Finnbogadóttir 2019;Fumagalli et al. 2020;Kempe and Vikström-Bolin 2020). For example, women with intact perineum's report more positive experiences (Fumagalli et al. 2020). In relation to midwives efforts to improve 'birth satisfaction', reducing stress and its 'fight/flight' response is important.
To view factors that have potential to increase level of reported 'birth satisfaction' (see Figure 1 ).

Psychometric validation of the BSS-R
The 10-item BSS-R is a reliable and valid tool (Hollins Martin and Martin, 2014), in response to applying robust psychometric principles. To assess factor structure, validity, and reliability of a proto 30-item BSS (Hollins Martin and Fleming 2011) and to develop a short-form version of the tool, survey data was collected in Scotland (UK) from (n=228) postnatal women (Hollins . Qualitative validation of survey data was undertaken from primary free-text data gathered from (n=207)

How to score the 10-item BSS-R
Postnatal women respond to the 10-items on the BSS-R on a 5-point Likert scale, which is based upon level of agreement or disagreement with each of the statements placed. A score of 40 represents highest possible 'birth satisfaction' and 0 the lowest, with no cut-off scores. An example of how to complete Item 3 follows: When clinicians and researchers gather data using scales, ordinarily they calculate means and significant differences between groups. For example, and in the case of the BSS-R, significant differences in mean scores between groups of primigravidas and women of multiparity, or those who have experienced CS compared with Spontaneous Vertex Delivery (SVD). In addition, the BSS-R can be used to compare group mean 'birth satisfaction' scores between women of various ages, who have received different methods of pain relief and/or have delivered at home, in a midwifery led unit, or a hospital. It is recommended that clinicians and researchers triangulate findings through conducting a qualitative thematic analysis of comments written by participants' under each BSS-R item, with data used to elaborate and explain cause and effect. Through analysing BSS-R survey data, areas of achievement can be acknowledged and rewarded, and conversely areas of improvement identified and where possible rectified. In response, commendations can be awarded and/or plans put in place to improve and re-measure implemented improvements or interventions.

Translations and validations of the 10-item BSS-R
Since the ICHOM started recommending the 10-item BSS-R as the measure of choice for evaluating 'birth experience' world-wide (Nijagal et al. 2018

Examples of 10-item BSS-R use
A systematic review reports that the 10-item BSS-R is an easy to administer instrument for measuring women's 'birth satisfaction' (Alfaro Blazquez et al. 2017). Also and in addition to the ICHOM , the WWU Munster for medical data models recommends the 10-item BSS-R as the measure of choice in Germany (Dugas 2019). So far and to date, the 10-item BSS-R has been used in a diverse range of clinical settings. What follows are examples of some studies that have reported use of the 10-item BSS-R .
Currently the 10-item BSS-R is being used in a multi-site trial in Sweden to assess women's intranatal satisfaction at 2 months post lateral episiotomy or no episiotomy (Bergendahl et al. 2019). The 10-item BSS-R has been used to evidence that women who deliver in birth centres report higher levels of 'birth satisfaction', which has had impact upon restructuring of maternity services (Breman et al. 2019). The 10-item BSS-R has been used to assess women's perceptions of quality of intrapartum care received and its effects upon anxiety, control, and stress in relation to breastfeeding (Hinic 2016

Conclusion
In summary, the 10-item BSS-R is a valid and reliable measure that can be used by clinicians and researchers to evaluate postnatal women's levels of 'birth satisfaction'. If you are considering its use, the 10-item BSS-R is available free of charge both nationally and internationally, and is recommended by the ICHOM ( www.ichom.org/medical-conditions/pregnancy-and-childbirth/ ) as the measure of choice for assessing women's experiences of labour and childbirth. Data collected can be used to evaluate global quality of intranatal care provision, and also to identify individual successes and potential areas for improvement within clinical areas. Data collected can form baselines against which future care can be compared. Data gathered may also be correlated with findings from other validated scales (e.g., those that measure wellbeing, coping, depression etc.). CJHM and CRM continue to work with teams world-wide to provide advice about translation and validation of population specific versions of the 10-item BSS-R , with its free availability enabling clinical and research teams to progress maternity care provision at an international level. If you would like to translate and validate a context specific 10-item BSS-R , or use it to improve quality of maternity care provision, please contact us at (c.hollinsmartin@napier.ac.uk).