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). Since the ICHOM began recommending the BSS-R, it has been used to measure women's ‘birth satisfaction’ in 39 countries and 134 sites worldwide (at the time of print).
The BSS-R is co-owned by Caroline J Hollins Martin (CJHM) and Colin R Martin (CRM) who are both available to provide advice regarding its use. Country specific BSS-R scales are held in an electronic site based at Edinburgh Napier University (ENU), with the ICHOM directing potential users to CJHM who monitors and maintains the site.
What is birth satisfaction?
Birth satisfaction is defined as a retrospective maternal evaluation of labour experience (Hollins Martin et al, 2012), with reflective appraisal being 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.
| BSS-R | Country | Number |
|---|---|---|
| 1 | Ghana (Africa) | 2 |
| 2 | Nigeria (Africa) | 1 |
| 3 | Australia | 8 |
| 4 | Belgium | 3 |
| 5 | Brazil | 6 |
| 6 | Canada | 4 |
| 7 | Croatia | 1 |
| 8 | Denmark | 1 |
| 9 | Finland | 1 |
| 10 | France | 1 |
| 11 | Germany | 1 |
| 12 | Greece | 2 |
| 13 | India | 11 |
| 14 | Iran | 6 |
| 15 | Ireland (Southern) | 1 |
| 16 | Ireland (Northern) | 1 |
| 17 | Israel | 1 |
| 18 | Italy | 2 |
| 19 | Kuwait | 1 |
| 20 | Lithuania | 1 |
| 21 | Malaysia | 3 |
| 22 | Mexico | 1 |
| 23 | Nepal | 1 |
| 24 | Netherlands | 6 |
| 25 | Pakistan | 1 |
| 26 | Palestine | 3 |
| 27 | Poland | 2 |
| 28 | Portugal | 2 |
| 29 | Saudi Arabia | 2 |
| 30 | Slovakia | 4 |
| 31 | Slovenia | 1 |
| 32 | Spain | 3 |
| 33 | South Korea | 1 |
| 34 | Sweden | 2 |
| 35 | Tanzania | 1 |
| 36 | Thailand | 2 |
| 37 | Turkey | 10 |
| 38 | UK | 12 |
| 39 | US | 22 |
| Total | 134 |
Key: green shading represents countries yet to produce validated scales; grey represents countries with a population specific validated BSS-R
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 healthcare 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).
Personal attributes (ie personality and 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, 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 (c-section) is associated with reduced ‘birth satisfaction’, as well as 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).
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 from (n=228) postnatal women (Hollins Martin and Martin, 2015). Qualitative validation of survey data was undertaken from primary free-text data gathered from (n=207) childbearing women. This data was concurrently analysed with first-hand narratives of birth satisfaction accounted for in 19 qualitative papers. From these findings, it was concluded that the initial 30-item BSS accounted for all of the underpinning qualitative data (Hollins Martin et al, 2012).
To validate a shorter version of the 30-item BSS, factor structure and reliability was statistically assessed. Key psychometric properties of the proto 30-item BSS was evaluated using exploratory factor analysis and structural equation modelling techniques (Hollins Martin and Martin, 2014). Post-psychometric analysis, the 30-item BSS was reconfigured into the 10-item BSS-R, with data confirming the three prior clustered sub-scales of quality of care provision, women's personal attributes and stress experienced during labour (Hollins Martin and Martin, 2014). Post-statistical validation, the 10-item BSS-R was considered a robust tool for measuring women's ‘birth satisfaction’ (Hollins Martin and Martin, 2014).
What is the 10-item BSS-R?
The 10-item BSS-R is comprised of three sub-scales which measure distinct but correlated domains of 1) quality of care provision (four-items) 2) women's personal attributes (two-items) and 3) stress experienced during labour (four-items). To view BSS-R items, see Table 2.
| Quality of care provision (four-items) |
|---|
|
|
| Participants respond on a five-point Likert scale based on level of agreement/disagreement with each of the statements placed, with a possible range of scores between 0−40. A score of 0 on the BSS-R represents least ‘birth satisfaction’ and 40 the most. |
| Strongly Agree |
| Agree |
| Neither Agree or Disagree |
| Disagree |
| Strongly Disagree |
| To obtain a copy of the 10-item BBS-R and marking grid, contact Professor Caroline J Hollins Martin (c.hollinsmartin@napier.ac.uk) |
How to score the 10-item BSS-R
Postnatal women respond to the 10-items on the BSS-R on a five-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 zero the lowest, with no cut-off scores.
An example of how to complete item three 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 a c-section compared with spontaneous vertex delivery. 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’ worldwide (Nijagal et al, 2018), several translations and validations of the scale have been produced for use in specified populations. In sequential order, the 10-item BSS-R has been translated and validated for use in the US (Fleming et al, 2016; Martin et al, 2017a), Greece (Vardavaki et al, 2015), Australia (Jefford et al, 2018), Turkey (Göncü Serhatlıoglu et al, 2018), Spain (Romero-Gonzalez et al, 2019), Israel (Skvirsky et al, 2019), Italy (Nespoli et al, 2018), Iran (Omani-Samani et al, 2019) and Slovakia (Škodová et al, 2019), with many more versions still in production. All adaptations of the 10-item BSS-R are held in an electronic site based at ENU.
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 two 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). Konheim-Kalkstein and Miron-Shatz (2019) used the six-item BSS-R Indicator (BSS-RI), which is a shortened version of the BSS-R (Martin et al, 2017b), in a study that explored the impact of unplanned c-section upon women's levels of reported ‘birth satisfaction’. Rahimi-Kian et al (2018) used the 10-item BSS-R to test effects of ice-pack application on pain and ‘birth satisfaction’.
Škodová et al (2019) are currently using the 10-item BSS-R in Slovakia to explore relationships between ‘birth satisfaction’ and mode of delivery, socioeconomic factors, and psychological variables. Lee et al (2018) used the 10-item BSS-R in Australia to assess ‘birth satisfaction’ in relation to two differing styles of labour management. Turnbull et al (2019) are currently conducting a trial to identify differences between using ‘CTG and ECG’ versus ‘CTG alone’ during labour, and the overall effects on ‘birth satisfaction’ post-emergency c-section. Hamm et al (2019) led an obstetric cohort study in the UK which showed that black race, c-section and increasing labour length are risk factors for women reporting lower levels of ‘birth satisfaction’ when labour has been induced. Above are just a few examples to illustrate how midwives can use the 10-item BSS-R in clinical practice and research.
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’. 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 (eg those that measure wellbeing, coping, depression etc). CJHM and CRM continue to work with teams worldwide 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.