Satisfaction with perinatal care providers and the childbirth experience: the moderating role of body mass index

Abstract

Background

Satisfaction with birth and healthcare provider experiences have long-term effects for maternal health. Research has shown that mothers who report more trust, respect, and self-efficacy in their relationship with their healthcare providers are more likely to report positive birthing experiences. Further, individuals with obesity, including pregnant mothers, are more likely to experience weight-related stigma from healthcare providers which may negatively impact satisfaction with this relationship. Thus, the current study examines maternal pre-pregnancy body mass index (BMI) as a moderator between birth and provider satisfaction.

Methods

A sample of 94 women (ages 16–38) were recruited during pregnancy. Participants completed surveys about their satisfaction with their birth experience, provider satisfaction, height, weight, and demographics including age and education. A moderation analysis was used to examine pre-pregnancy BMI as a moderator between birth and provider satisfaction.

Results

Results show that provider satisfaction is positively associated with birth satisfaction among mothers with moderate (overweight) to high (obese) pre-pregnancy BMI scores in our sample.

Conclusions

Findings suggest that strengthening the patient-provider relationship may promote satisfaction with birth experiences.

Background

Satisfaction with one’s childbirth experience has implications for maternal mental health and the early mother-infant relationship, with previous work showing higher rates of birth satisfaction linked to lower rates of postpartum depression and anxiety symptoms as well as higher rates of breastfeeding [1, 2]. Birth satisfaction is highly subjective, and there are many factors that may contribute to how satisfied an individual feels after giving birth including feelings of preparedness for childbirth, the physical environment of delivery, promptness of care, emotional support, interpersonal behavior with providers, and perceived provider competency [3, 4]. Research suggests that birth experiences are highly influenced by the quality of interactions and interpersonal relationships with providers, with feelings of trust, respect, self-efficacy, and involvement in medical decision-making [5, 6] as important influences on patient satisfaction. However, relationships with healthcare providers are susceptible to poor communication, incongruent provider-patient expectations, and negative interpersonal interactions [4], even when such missteps are unintentional. Specifically, such experiences may be particularly salient for individuals with overweight or obesity.

Weight-related stigma is one such factor that can pose barriers to quality relationships with healthcare providers. Individuals with overweight or obesity are at risk for both implicit and explicit weight bias from healthcare providers [7], and weight bias is especially salient for pregnant mothers. In a sample of pregnant and postpartum women, nearly one in five participants reported experiences of weight stigma in healthcare settings, and 28.4% with pre-pregnancy obesity reported their healthcare providers as a source of weight stigma [8]. Previous work has also found healthcare providers asked fewer lifestyle questions and used fewer statements of approval and/or concern when speaking to mothers with higher pre-pregnancy BMIs compared to women with “healthy” weights [9]. Additionally, qualitative interviews have found that pregnant women with obesity had more negative statements about their prenatal healthcare providers, reported feeling judged by providers, and received little information about how their obesity could affect their pregnancy [10]. In addition to the weight-related stigma faced by pregnant women with obesity, higher maternal BMI has been associated with adverse pregnancy and birth outcomes including gestational diabetes, postpartum hemorrhage, and a greater need for intensive care [11], which may also contribute to reduced satisfaction with the birth experience. When considering the compounding effects of these negative birth outcomes and higher rates of stigmatization for individuals with larger bodies, it is possible that the strength of the relationship between provider satisfaction and birth satisfaction differs for those with overweight or obesity. Given the influence of birth satisfaction on postnatal psychological functioning and the mother-infant relationship, it is important to understand how the birth experience may be impacted by provider relationships, particularly for individuals with overweight or obesity who are already at risk of experiencing stigmatization and other medical complications.

Using a prospective design with a diverse and low-income clinic cohort, the current study examines the relationship between women’s satisfaction with their healthcare provider and satisfaction with their birthing experience, while specifically exploring differences in this relationship as it relates to maternal obesity measured through self-reported pre-pregnancy BMI.

Methods

Participants and study procedures

The study examined 94 women (ages 16–38) who completed surveys about their satisfaction with their birth experience, provider satisfaction, height, weight, and demographics including age and education. Participants were recruited from two university-affiliated OB-GYN clinics in a metropolitan area in a South-Central U.S. state that serves racially diverse, socioeconomically marginalized, and medically underserved populations. Although the full study spans three years, the data for the current study come from the first and fourth assessments, occurring during the first trimester and two weeks postpartum, respectively. The study received approval from the authors’ Institutional Review Board and all participants provided informed consent before being enrolled. Participants were compensated between $25–50 for each survey assessment within 24 h of completion.

Participants were 25.9 years old on average and 30.9% reported having a high school education or less. Over half (57.4%) of the mothers in the study reported being married or living with a romantic partner. The racial breakdown of the sample included 45.7% of participants identifying as White, 25.5% as Black or African American, 13.8% as Native American or Alaskan Native, and 14.9% as Hispanic (percentages add to more than 100 due to some participants reporting more than one race/ethnicity). Over one-third (37.2%) of mothers reported their current pregnancy as their first, and approximately 89% of participants reported receiving public assistance (e.g., Medicaid).

Measures

Demographics

Participants provided background information including age and education (in years) at their first prenatal appointment (average gestation of 10 weeks).

Body mass index (BMI)

At their first prenatal appointment, participants self-reported their height and weight immediately prior to becoming pregnant. Pre-pregnancy BMI was calculated as weight (lb.) / [height (in.)]² × 703. BMI scores were recoded into clinically relevant groups based on standard BMI classifications: underweight (< 18.5), normal weight (18.5–24.9), overweight (25.0–29.9), and obesity (≥ 30.0). Due to the small sample size in the underweight category (n = 2), individuals in this group were combined with those in the normal weight category, resulting in three final BMI categories for analysis: normal/underweight (BMI < 25.0), overweight (BMI 25.0–29.9), and obese (BMI ≥ 30.0) [12].

Provider satisfaction

At approximately two weeks postpartum, participants answered six questions adapted from the Canadian Maternity Experiences Survey [13] about their level of satisfaction with perinatal care during pregnancy, labor, and birth using a 7-point Likert scale (1 = Very Dissatisfied; 7 = Very Satisfied). Items assessed satisfaction with varying aspects of care, including: “The information given to you by your healthcare providers;” “The compassion and understanding shown by your healthcare providers;” “The competency of your healthcare providers;” “The concern of your healthcare providers for your privacy and dignity;” “The respect shown by your healthcare providers;” and “Your involvement in decision making with your healthcare providers.” Scores were summed for a total score (possible range 6–30), where higher scores indicated greater provider satisfaction. Cronbach’s coefficient alpha showed acceptable internal reliability (α = 0.95).

Birth Satisfaction

At approximately two weeks postpartum, participants also rated their overall childbirth experience using a 7-point Likert scale (1 = Very Negative; 7 = Very Positive) based on previous work on labor and birth experience [14].

Data analytic plan

Descriptive statistics and bivariate associations were calculated for all variables. To examine the strength and direction of the relationship between provider satisfaction and birth experience satisfaction at different levels of pre-pregnancy BMI (i.e., the moderator variable), a moderation analysis was conducted in SPSS using Hayes’s PROCESS Macro Version 3.5 [15] with 5,000 bootstrap resampling with replacement. Conditional effects were probed at three clinically relevant BMI categories: normal/underweight (BMI < 25.0), overweight (BMI 25.0–29.9), and obese (BMI ≥ 30.0) [12]. Analyses controlled for maternal age and education.

Results

On average, women had a pre-pregnancy BMI score of 29.73 (SD = 8.47). The normal/underweight group included 32 participants, the overweight group consisted of 19 participants, and the obese group comprised 43 participants. The average birth experience was positive (M = 5.73, SD = 8.47), and participants reported fairly high levels of satisfaction with their perinatal care providers (M = 25.52, SD = 4.82). Provider satisfaction was positively correlated with birth satisfaction (r = .31), whereas pre-pregnancy BMI categories were negatively correlated with birth satisfaction (r = − .23). Pre-pregnancy BMI categories were not significantly correlated with provider satisfaction (r = − .08).

Moderation analyses with bootstrapping procedures [13] indicated that while controlling for maternal age and education, pre-pregnancy BMI categories significantly moderated the association between provider satisfaction and birth satisfaction, with a statistically significant interaction term, [Provider satisfaction X BMI], b = 0.103, SE = 0.027, p < .05. Results are presented in Table 1. The overall model was statistically significant, R²_Adjusted = 0.266, F(5, 88) = 6.38, p = .000. Figure 1 displays the results of the simple slopes analysis examining the conditional effects. Greater provider satisfaction was associated with greater birth satisfaction in the obese pre-pregnancy BMI, b = 0.18, 95% CI [0.11, 0.26] and overweight pre-pregnancy BMI, b = 0.08 95% CI [0.03, 0.14] groups. The relationship between provider satisfaction and birth satisfaction was not significant among those with normal/underweight pre-pregnancy BMI, b = -0.02, 95% CI [− 0.09, 0.06].

Table 1 Moderation analyses of the association between provider satisfaction and birth satisfaction by pre-pregnancy body mass index (BMI) categories, controlling for maternal age and education

Fig. 1

Interaction between provider satisfaction and pre-pregnancy body mass index predicting birth satisfaction

Conclusions

Among a diverse, low-income cohort of mothers, findings indicate that satisfaction with the birthing experience was more strongly linked to provider satisfaction among those with overweight or obesity. Interestingly, the association between provider satisfaction and birth satisfaction was not significant among mothers with normal/underweight pre-pregnancy BMIs, as these mothers demonstrated a consistently high level of satisfaction with their birth experience regardless of reported provider satisfaction. These findings highlight the importance of provider satisfaction for mothers with overweight or obesity, as low satisfaction with healthcare providers may be a particularly important risk factor for dissatisfaction with their birth experience.

Limitations of our study include the use of self-report measures, including pre-pregnancy BMI as it does not consider mothers’ age, bone structure, or muscle mass or underlying weight-related psychological constructs that may impact satisfaction. Moreover, the current study is limited in its measurement of provider satisfaction as the questions do not specify a particular provider, and some individuals may see multiple providers throughout pregnancy and at delivery.

Future work may benefit from using measures of internal weight-related psychological functioning, such as internalized weight stigma, as a mediator to better understand the effects of perceived weight biases on provider and birth satisfaction outcomes in pregnant individuals. Further, questions on continuity of care in relation to provider satisfaction should be included to better address the potential of working with multiple providers. Additionally, future work examining the longitudinal relationship between provider satisfaction during pregnancy and birth experience may benefit from exploring the temporal precedence of weight-related stigma and birthing outcomes. Future research should also consider weight-related pregnancy complications that might impact both experiences with providers and the childbirth experience. Lastly, access, cost, and socioeconomic status have been shown to influence perceived maternal satisfaction of the childbirth experience [4] and should be considered when examining this relationship in the future.

Our findings have implications for healthcare providers working with pregnant individuals and suggest potential disparities in perinatal provider relationships among those with overweight or obesity. Results emphasize the importance of prioritizing non-judgmental, supportive approaches to care for all patients regardless of weight, as these relationships may be particularly influential on the birthing experience and subsequent physical and mental health of the mother-infant dyad. Additionally, results suggest the need for perinatal providers to recognize potential weight-related biases and stigma. Specifically, there may be benefit to incorporating training that addresses weight-related biases and helps care teams to build supportive, positive relationships across the healthcare experience, particularly for large healthcare teams where pregnant individuals may see several different providers throughout their care. In sum, positive provider relationships are particularly important for individuals with overweight or obesity to promote satisfaction with their birthing experience and support postpartum health and well-being.