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Qualitative Study of the Experience of Caring for Women During Labor and Birth During the First Wave of the COVID-19 Pandemic

Shannon d simonovich, nichelle m bush, lucy mueller wiesemann, maría pineros-leano.

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Correspondence Shannon D. Simonovich, PhD, RN, School of Nursing, College of Science and Health, DePaul University, 990 W. Fullerton, Suite 4400, Chicago, IL 60614.

Accepted 2022 Dec 21; Issue date 2023 May.

Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

To examine the experiences of labor and delivery (L&D) nurses and certified nurse-midwives who cared for women during labor and birth in the United States during the first wave of the COVID-19 pandemic.

Subgroup analysis of a larger study with a qualitative descriptive design.

Telephone interviews.

Participants

The parent study included 100 nurses across various specialty areas who provided patient care during the first wave of COVID-19 in the United States. Our subgroup analysis included 19 participants: L&D nurses ( n  = 11) and certified nurse-midwives ( n  = 8).

Semistructured interview guide.

Participants described their experiences providing patient care in L&D settings during the first wave of the COVID-19 pandemic. We identified five major themes: Separation of COVID-19–Positive Mothers and Newborns , Isolation of Women in Active Labor , Disparities in Access to Care , Barriers to Communication , and Effect on the Mental Health of Members of the Care Team .

Our findings captured the experiences of maternity care team members who worked during the COVID-19 pandemic when standards of quality maternity care were compromised. The challenges of caring for COVID-19–positive mothers, including isolation during active labor and infant removal from mothers at birth, affected their psychological well-being and their mental health and must now be addressed to prevent burnout and turnover.

Keywords: birth, COVID-19, nursing research, pregnancy, qualitative

Addressing the possible mental health needs of maternity care team members who cared for COVID-19–positive mothers is a priority.

The COVID-19 pandemic has affected global health, with more than 645 million confirmed cases and more than 6.6 million deaths ( World Health Organization, 2022 ), and has raised significant concerns about care delivery ( Alcendor, 2020 ; Razai et al., 2021 ). Nurses have experienced resignations, shortages of personal protective equipment, and overt safety concerns ( Patel et al., 2021 ; Simonovich et al., 2022 ). Even before the COVID-19 pandemic, researchers described inadequate working conditions, including low pay and heavy workloads among nurses ( Han et al., 2015 ). These working conditions worsened during the pandemic, and most nurses in the United States experienced a shortage of personal protective equipment, which made their jobs riskier and affected their ability to provide patient care ( Llop-Gironés et al., 2021 ).

The role of maternity care teams is to safeguard and optimize the health outcomes of a vulnerable population. In a metasynthesis of eight qualitative research studies, Shorey and Chan (2020) examined the experiences and needs of pregnant women, midwives, and nurses who worked in maternity wards during epidemics and pandemics. They reported that participants were negatively affected by previous infectious disease outbreaks; participants described psychological responses, challenges, coping, and support ( Shorey & Chan, 2020 ). Altman et al. (2021) investigated how COVID-19 affected the experiences of pregnant patients and registered nurses who worked in perinatal settings in Washington State. Participants described how adaptations to care were inadequate to meet their needs and left them with a desire for more support. Similarly, in a cross-sectional survey study of the experiences of labor and delivery (L&D) nurses during COVID-19, George et al. (2021) reported substantial effects on roles, responsibilities, and adaptations necessary during the pandemic.

Narrative documentation of the experiences of nurses and midwives who provided care during the emergence of the COVID-19 pandemic is needed.

Research studies published to date indicate that the pandemic detrimentally affected the care provided by nurses to women during pregnancy and the postpartum period. However, rich descriptions of the experiences of L&D nurses and certified nurse-midwives (CNMs) during the emergence of COVID-19, when outbreaks overwhelmed the nation’s medical systems and vaccines were not developed, remain limited. Therefore, the purpose of this qualitative study was to examine the experiences of L&D nurses and CNMs who cared for women during labor and birth in the United States during the first wave of the COVID-19 pandemic.

The current study was a subgroup analysis of a larger study in which we used a qualitative descriptive design with individual interviews. The interview data used in our study originated from a study of 100 nurses across various specialty areas who provided patient care during the first wave of COVID-19 in the United States, including emergency, acute, community-based, and L&D care ( Simonovich et al., 2021 ). We selected these specialty areas based on the expertise of the members of the research team. The research team developed a broad interview protocol to examine commonalities among all participants and to conduct subgroup analyses for each nursing specialty area represented.

We used thematic network analysis to construct a conceptual framework of the participants’ experiences ( Attride-Stirling, 2001 ), and we used the Consolidated Criteria for Reporting Qualitative Studies checklist to thoroughly describe the study design and analysis ( Tong et al., 2007 ). A thematic network is a web-like illustration that summarizes the main themes across texts and is a robust and highly sensitive tool to systemize and present the results of qualitative analyses ( Attride-Stirling, 2001 ). Once a thematic network is developed by a research team, it serves as an illustrative tool and organizing principle for the formal interpretation of the texts ( Attride-Stirling, 2001 ). We intentionally applied a theory-generating design in which we used no specific theory to create the interview guide, purposive sampling techniques to target specific subgroups of nurses, and standardization of interviews across all participants to enhance the validity of findings and to ensure that the results represented the true experiences of participants ( Cypress, 2017 ).

Setting and Participants

After approval from DePaul University’s institutional review board, the study team recruited nurses and advanced practice registered nurses (APRNs) who worked in the United States. For the parent study, we used purposive recruitment measures via social media and the research team members’ personal and professional networks to encourage participation of nurses and APRNs from racial and ethnic minority groups ( Webber-Ritchey, 2021 ). We conducted individual interviews from May to September 2020 to elicit each participant’s experiences related to the first wave of COVID-19. To be eligible for the study, prospective participants self-identified as registered nurses or APRNs who practiced in the United States, provided patient care from March 2020 forward, and agreed to be interviewed in English.

In the parent study, prospective participants contacted the study team via e-mail. Each prospective participant completed an initial screening survey via e-mail to ascertain sociodemographic characteristics, nursing background, and appropriateness for the study ( Webber-Ritchey, 2021 ). After screening, we sent each participant the study protocol information sheet for review and scheduled the telephone interview. At the initiation of each telephone interview, the information sheet was read verbatim, and oral consent was obtained before the recording of the semistructured interview began. We provided a digital $50 gift card to each study participant for renumeration. We used a 13-item interview protocol to ask probing questions related to the following specific topics: experiences of providing care during the beginning of the COVID-19 pandemic; preparation for caring for COVID-19 patients at the individual, leadership, and institutional levels; coping and support related to caring for COVID-19 patients; and COVID-19 implications for nursing practice, education, and policy ( Simonovich et al., 2021 ). Specific items included, “Tell us about your experience beginning with when you first learned of COVID-19,” “How did your institution prepare you to work with COVID-19 patients?” and “How do you feel taking care of COVID-19 patients?” Members of the research team who self-identified as Black, White, Asian, and Hispanic conducted the interviews with participants of the same race as much as possible because racial and ethnic concordance between patients and their health care providers has been shown to foster trust and improve communication ( Robert Wood Johnson Foundation, 2022 ). Interviews ranged from 20 to 45 minutes depending on the participants’ responses. We did not take field notes during the interviews, and we met weekly during data collection to discuss study progress. Each interview was audio-recorded on two identical devices and uploaded to a secure cloud-based account for storage. Each audio-recorded interview was submitted to online software for computer-based transcription. After transcription into text, trained graduate research assistants verified each transcript.

For the purposes of this subgroup analysis, only the interviews with participants employed in L&D settings were used. The research team met formally from January 2021 to June 2022. We individually reviewed the 19 interview transcripts, created preliminary thematic networks for discussion, and then presented and discussed each thematic network. We developed final collaborative thematic networks for five themes based on consensus. Under the supervision of the first author (S.D.S.), the second author (N.M.B.) completed the formal coding of the interview data into the identified themes using a web application for mixed-methods research. The themes were derived directly from the data, and we noted no minor or diverse themes. We did not contact participants to confirm findings. In this article, we present illustrative quotes without participant identifiers because the goal in obtaining a diverse sample was to reflect the shared voice of the study participants rather than to highlight differences by race, ethnicity, or specific role on the care team. The first author (S.D.S.) and second author (N.M.B.) used IBM SPSS 27 for quantitative analysis of the demographic characteristics of the participants.

Participant Characteristics

The characteristics of our participants ( n  = 19) are presented in Table 1 . Eleven L&D nurses and eight CNMs completed the study protocol. Their average age was 36 years (range = 27–57 years). All participants identified as female. Nine participants identified as White (47.4%), five identified as Black (26.3%), two identified as Asian (10.5 %), two identified as multiracial (10.5%), and one identified as American Indian (5.3 %). In addition, three participants identified as Hispanic (15.8%). In sum, approximately 68% of participants identified as members of a minority racial or ethnic group. Most participants had master’s degrees (52.6%) and an average of more than 8 years of nursing experience. Eight participants were employed in academic medical centers (42.1%), six participants worked at independent community hospitals (31.6%), and five were employed at multicenter hospital systems (26.3%).

Participant Characteristics ( N  = 19)

Note . DNP = doctor of nursing practice; PhD = doctor of philosophy.

Thematic network analysis of interviews with participants revealed five overarching themes: Separation of COVID-19–Positive Mothers and Newborns , Isolation of Women in Active Labor , Disparities in Access to Care , Barriers to Communication , and Effect on the Mental Health of Members of the Care Team . See Figure 1 for a visual depiction of the study themes. Selected illustrative quotes for each theme are presented in Table 2 .

Depiction of thematic network analysis findings.

Key Themes and Illustrative Quotes

Separation of COVID-19–Positive Mothers and Newborns

Participants described the physical removal of newborns from their mothers at birth under the theme Separation of COVID-19–Positive Mothers and Newborns . During the first wave of the COVID-19 pandemic, pregnant women were tested for COVID-19 before or upon admission to the L&D unit. Health care systems across the country created policies to remove newborns from COVID-19–positive mothers immediately after birth to protect newborns from contracting the virus. Many participants felt conflicted by this practice, distressed, and worried about the harm it may cause in relation to the emotional well-being of the mother, the bonding of the dyad, and breastfeeding. They described the physical and emotional challenges of removing newborns, especially from mothers who previously experienced perinatal loss:

It’s really frustrating, especially if . . . you have somebody that [had] a prenatal death before, and it’s like you have to separate mom . . . because she’s COVID positive . . . mom wears her mask and [is] an asymptomatic carrier. But still, you have to be separated . . . The mom, in the end, is the one who loses . . . because she’s not able to hold her baby or breastfeed her baby.

Participants described significant emotional challenges with separating newborns from their mothers immediately after birth and inconsistencies in the implementation of related policies. With policies changing rapidly, traumatic mistakes occurred. One participant recalled that she informed a COVID-19–positive mother that her newborn would be removed directly after birth. However, an error was made by the physician who attended the vaginal birth and briefly forgot the separation policy:

[Upon] delivery, the OB [obstetrician] . . . lifted the child to place it on mom’s stomach. And when [COVID-19–positive] mom reached out to touch her baby, he [remembered and] told her, “I’m sorry, they’re telling me I can’t give you your baby.” And that’s when he cut the cord and gave the baby to us. That mom shrieked so loudly that it was a shriek of pain, a pain of loss. So at that moment, I was able to realize we’re no longer deal[ing] with the happy . . . . Whatever vision that mom had in her head of a perfect delivery [had] gone to the wayside. . . . So for me, it was vitally important to make sure we [could] get mom and baby connected as much as [possible]. . . . We decided to give her a teddy bear that had the same weight as the baby. So every time I fed the baby, the mom was instructed to grab her teddy bear and hug the teddy bear tight. And as I would rock the baby to sleep, she could rock the teddy bear to sleep too.

The participants noted that these negative birth experiences of separation may have had long-lasting effects for mothers and their newborns because of the interrupted bonding for the mother–newborn dyads during the critical first hours of life.

Isolation of Women in Active Labor

The theme Isolation of Women in Active Labor represented the physical distancing of the care team from the woman during labor. During the first wave of the pandemic, participants reported that women in labor were isolated upon admission to L&D while awaiting the results of their COVID-19 testing. Isolation continued for the duration of labor for COVID-19–positive patients and, in some cases, for COVID-19–negative patients as well. Participants described inconsistencies in the way hospitals approached the isolation of patients in labor. Generally, care team members were advised to reduce the time spent at the bedside to protect themselves from contracting COVID-19, and participants described physically distancing themselves from women in active labor. Some participants chose to not distance themselves despite hospital policy, and one described how she prioritized the need to support women who were in labor alone: “I know I need to . . . be in there. . . . These women are by themselves [and they] didn’t plan to be [alone during their births].” Another participant described her decision not to isolate COVID-19–positive patients in labor:

I’m not keeping my distance with patients. . . . Women need a lot of emotional support in labor or through miscarriages. I mean, we see that so much. And to stand at the doorway and talk to someone is so impersonal and . . . to see laboring COVID patients with no family member. . . . Labor is so emotionally taxing. They need someone there. And so I do find myself saying, I think their emotional needs are higher than my risk of getting infected.

Although it is contrary to customary practice in L&D to isolate women in labor, these interviews describe that the practice took place across the United States during the first wave of the COVID-19 pandemic.

Participants reported that L&D care was disrupted during COVID-19 and included separation of mothers and newborns, disparities in quality of care, and increased barriers to communication.

Disparities in Access to Care

Participants said they witnessed factors that inhibited equitable access to quality care among pregnant patients from underserved populations as represented by the third theme, Disparities in Access to Care . Participants described the disparities that affected some pregnant people during COVID-19, such as lack of social support and inadequate access to medical supplies, and how these matters contributed to inequitable birth experiences:

[COVID-19] has all shed so much light on how dysfunctional our system is. . . . Our population is very, very much underserved. And so those disparities that exist that combined with the antiracism movement as well, I think, like, the fact that those two things are coincided is super important and hopefully move the needle a little bit or a lot. . . . [As a] nurse-midwife . . . I think being even more of a patient advocate and thinking through how the whole person is sitting in front of you, and that it’s not just her pregnant belly but also like, did she just lose her job? What stress is going on in her life? Being an advocate in terms of . . . supporting . .. if a patient is positive, working with the peds [pediatrics] team in terms of isolation with the baby. . . . Patients need more advocacy and more support.

Another participant shared the following:

One disparity point is that we’ve been trying to keep pregnant people out of the office as much as possible. And to do that, [patients] need to be able to take their blood pressure at home. And so people who can afford a blood pressure cuff don’t have to come in as much. People who can’t afford a blood pressure cuff have to come in for all their appointments. So their exposure to the virus is much worse compared to people who could pay 30 dollars for a blood pressure cuff. So should institutions be giving away free blood pressure cuffs? Yes.

Participants also described discrimination against young pregnant people, lack of resources for care and home-monitoring devices for low-income patients, and the need for more respectful interactions with pregnant patients from all backgrounds. Participants universally described how the COVID-19 pandemic worsened disparities in the care of pregnant patients.

Barriers to Communication

The theme Barriers to Communication represented circumstances that interrupted communication between L&D patients and the maternity care team. Participants described how implementation of COVID-19 hospital policies restricted communication and connection with women in labor:

[I was] very uncomfortable as a nurse. In L&D, we’re in our patients’ rooms every 15 to 30 minutes. We’re very close to our patients. We cannot keep 6-foot distance, especially if the woman is pushing, you know, we’re [in] the middle of a delivery.

Participants reported barriers to communication as a concern that affected the quality of care and “injected uncertainty into the patient–provider relationship.” One participant described how wearing a mask impaired communication:

I am a very facial expression kind of person. And so the fact that people can’t see my face, I think is a little bit of a communication barrier. . . . I had a patient a couple of weeks ago who [was] from Ukraine, and her English is good, but it wasn’t great, and she could not understand people when they have masks on because she couldn’t see their mouths.

The interviews revealed that COVID-19 policies around mandatory masking of patients and care team members and social distancing created barriers to communication and changed the level of connection between patients and the L&D care team.

Effect on the Mental Health of Members of the Care Team

Participants described how providing care during labor and birth during the first wave of the COVID-19 pandemic affected them mentally, which was represented by the theme Effect on the Mental Health of Members of the Care Team. Participants described how placing themselves at risk of contracting an infectious disease that remained largely unknown was a significant stressor and source of anxiety. They reported concern for their own personal safety, the safety of their families, and the safety of L&D patients: “I feel like the mental, the psychological part is just the number one for us in the health care field. . . . It’s . . . the fear of the unknown . . . it just throws everyone over the edge.”

At the time of the interviews, knowledge regarding the sequelae of the COVID-19 disease process remained largely unknown and was a source of fear for participants who were concerned they would be infected while at work: “I actually . . . considered reaching out to one of my primary docs [doctors] because I thought I needed Xanax or something because I had chest pain and anxiety. Full-blown anxiety, which I [had] never experienced.” They worried about contracting COVID-19 and becoming ill:

Because of the unknown and the rabbit hole that I’ll go down . . . I don’t [want to] freak myself out going down the rabbit hole. . . . Like, is it even worth it because what we know changes every day? So I feel like to protect my own feelings and emotions, I just have to keep going.

During the first wave of the COVID-19 pandemic, the high degree of uncertainty around the virus and its transmission led to heightened fear in L&D nurses and CNMs who provided direct patient care. All of the participants were fearful of work exposure and the potential transmission of the virus to their own families.

The findings from our study show the challenging experiences of participants during the first wave of COVID-19. Overall, participants perceived that the COVID-19 pandemic negatively affected the quality of care provided in L&D settings. These findings are consistent with the work of George et al. (2021) , who described changes in roles and responsibilities and the adaptation required of L&D nurses during the COVID-19 pandemic. Research shows that disrupted care to patients results in poor outcomes and that less time at the bedside and delays in care are associated with negative labor and birth outcomes ( Simpson & Lyndon, 2017 ). Overall, the participants expressed frustration with the changes in policies and practices that took place during the pandemic. Most participants felt that the changes brought about by COVID-19 were difficult and troubling, and they worried about their patients who experienced labor alone without the presence of family members and were separated from their newborns.

Although the interviews were not diagnostic in nature, all of our participants described common symptoms of anxiety. Fernández-Castillo et al. (2021) described similar findings when they interviewed nurses in intensive care units in Spain during COVID-19. The nurses in their study sample described a high degree of anxiety symptoms that affected their daily living activities and their sleeping patterns ( Fernández-Castillo et al., 2021 ). Jun and Rosemberg (2022) explored the shared professional experiences of nurses who worked in hospitals during the first surge of COVID-19 in the United States. Similar to our findings regarding mental health concerns, they reported that fear was the primary response described by their participants regardless of work experience ( Jun & Rosemberg, 2022 ). These findings across multiple subgroups of nurses indicate that mental health screening should be available for all nurses who provided patient care during the pandemic. Diagnostic screening tools, such as the General Anxiety Disorder seven-item survey for anxiety ( Anxiety & Depression Association of America, n.d. ) and the Patient Health Questionnaire nine-item survey for depression ( American Psychological Association, n.d. ) are available for free online and may serve as important tools for nurses to self-monitor symptoms and identify the need for further mental health support. It is necessary to put resources in place to ameliorate physical and emotional burnout, particularly among nurses, who are among the most essential group of workers.

Limitations

The study design was cross-sectional in nature, and interviewing each participant at one single point in time limited our ability to capture how their experiences may have changed over time. The themes presented were not discussed or confirmed with participants, which may limit the trustworthiness of the reported findings because no feedback was elicited. However, the themes were credible to the maternity care team members on the research team and contribute valuable narrative experiences to our understanding of maternity care during the emergence of the COVID-19 pandemic in the United States.

Implications for Research and Practice

Researchers can translate our themes into survey items that can be used to describe how challenging experiences (e.g., the separation of mothers and newborns after birth, the isolation of women in active labor, disparities in access to care) affect the mental health of the maternity care team. Results could indicate the need for more emotional and mental health support services for the maternity care workforce across the United States. The experiences of mothers who gave birth during the pandemic, were isolated during active labor, and were separated from their newborns at birth warrant further exploration. Finally, the disparities in access to care described by participants convey the importance of increasing financial and programmatic support for underserved pregnant women during pandemics to ensure equitable pregnancy and postpartum care.

Maternity care team members who provided care during COVID-19 should be screened for anxiety and depression, and mental health resources should be readily available.

Our results suggest a need for reflection on how the COVID-19 pandemic has affected the well-being of the L&D and CNM workforce. The collective trauma endured by maternity care teams and their patients has yet to be properly addressed. Healing is needed for the maternity care team members and the patients who suffered traumatic experiences during COVID-19. A fundamental concern for maternity care is that seasoned nurses who experience the strains of the COVID-19 pandemic will leave the profession, which will further exacerbate the nationwide nursing shortage and contribute to the estimated half-million nursing jobs that will go unfilled by 2030 ( Zhang et al., 2018 ). The lessons learned from the experiences of nurses and CNMs during COVID-19 and past infectious disease outbreaks, such as Ebola, H1N1, and severe acute respiratory syndrome (SARS), suggest that creating policies to enhance emotional well-being and address resilience in nurses can help decrease burnout rates, enable coping skills, and increase retention in the profession ( Shorey & Chan, 2020 ). Health care systems should prioritize sweeping policy changes that holistically support building healthy work environments that promote the mental health and safety of the nursing workforce, including paid leave for mental health concerns and counseling services free of charge.

Our findings strongly support the need for improved access to emotional and mental health support for L&D nurses and CNMs who provided patient care during the first wave of the COVID-19 pandemic. Addressing the possible mental health needs of maternity care team members who experienced the challenge of caring for COVID-19–positive mothers, including the isolation of women in active labor and removal of newborns from their mothers at birth, is a priority.

Acknowledgment

The authors thank Karen M. Tabb, PhD, MSW, and Hsiang Huang, MD, MPH, for methodologic consultation and content expertise.

Conflict of Interest

The authors report no conflicts of interest or relevant financial relationships.

This study was funded by the Illinois Nurses Foundation, the Zeta Sigma Chapter of Sigma Theta Tau International, and the DePaul University College of Science & Health and School of Nursing.

Biographies

Shannon D. Simonovich, PhD, RN, is an associate professor, School of Nursing, College of Science and Health, DePaul University, Chicago, IL.

Nichelle M. Bush, DNP, APRN-FPA, FNP-C, ENP-C CEN, is a family and emergency nurse practitioner and part-time faculty member, School of Nursing, College of Science and Health, DePaul University, Chicago, IL.

Lucy Mueller Wiesemann, DNP, CNM, APN, is a clinical assistant professor and simulation lab educator, School of Nursing, College of Science and Health, DePaul University, Chicago, IL.

María Pineros-Leano, PhD, MSW, MPH, is an assistant professor, School of Social Work, Boston College, Chestnut Hill, MA.

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• Published: 13 July 2022

Maternal childbirth experience and time in labor: a population-based cohort study

• Sara Carlhäll 1 , 2 ,
• Marie Nelson 1 , 2 ,
• Maria Svenvik 2 , 3 ,
• Daniel Axelsson 2 , 4 &
• Marie Blomberg 1 , 2  

Scientific Reports volume  12 , Article number:  11930 ( 2022 ) Cite this article

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• Epidemiology
• Medical research
• Outcomes research
• Population screening
• Preventive medicine
• Public health
• Reproductive signs and symptoms
• Risk factors

A negative childbirth experience may have long term negative effects on maternal health. New international guidelines allow a slower progress of labor in the early active phase. However, a longer time in labor may influence the childbirth experience. In this population-based cohort study including 26,429 women, who gave birth from January 2016 to March 2020, the association between duration of different phases of active labor and childbirth experience was studied. The women assessed their childbirth experience by visual analogue scale (VAS) score. Data was obtained from electronic medical records. The prevalence of negative childbirth experience (VAS 1–3) was 4.9%. A significant association between longer duration of all labor phases and a negative childbirth experience was found for primi- and multipara. The adjusted odds ratio (aOR (95%CI)) of negative childbirth experience and longer time in active labor (above the 90th percentile) in primipara was 2.39 (1.98–2.90) and in multipara 2.23 (1.78–2.79). In primi-and multipara with duration of labor ≥ 12 h or ≥ 6 h the aOR (95%CI) of negative childbirth experience were 2.22 (1.91–2.58) and 1.91 (1.59–2.26) respectively. It is of great importance to identify and optimize the clinical care of women with longer time in labor to reduce the risk of negative childbirth experience and associated adverse long-term effects.

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Introduction.

The woman’s experience of care during childbirth is as important as an optimal clinical care to achieve desired outcomes of childbirth and labor according to the World Health Organization (WHO) 1 . Despite this, a negative childbirth experience has been reported in 5–10% of laboring women 2 , 3 , 4 , 5 which may have long-term effects on maternal health 6 . Posttraumatic stress disorder, postpartum depression and dysfunctional bonding with the newborn have been related to a traumatic childbirth experience 7 , 8 . Furthermore, a negative childbirth experience may lead to secondary fear of childbirth, longer interval to subsequent deliveries and increased risk of future cesarean section (CS) 9 , 10 , 11 , 12 .

Maternal childbirth experience is affected by several factors including maternal age, mode of delivery, postpartum hemorrhage, low Apgar score, induction of labor and obstetric anal sphincter injury 2 , 3 , 6 , 13 . Emergency CS has been described as a significant risk factor for a negative childbirth experience 2 , 4 , 6 , 14 , 15 . The CS rate increases worldwide 16 . To reduce the incidence of emergency CS due to failure to progress, new guidelines on normal labor progression have been published by the WHO 1 and the American College of Obstetricians and Gynecologists (ACOG) 17 , allowing a slower progress in the beginning of the active phase of labor compared with the traditional guidelines by Friedman 18 . However, a long time in labor may increase the risk of a negative childbirth experience, which in turn may lead to a future demand of CS in the following pregnancy 19 , 20 . When a study compared childbirth experience in women randomized to follow either the traditional partograph or new guidelines allowing longer time in labor, women following new guidelines scored lower on positive memories and feeling of control 21 .

The knowledge about maternal childbirth experience in relation to time in active labor is sparce and studies show conflicting results. A few studies have analyzed duration of the active labor in primiparous women, most without taking possible confounders into account, and concluded that prolonged labor was a risk factor for a negative childbirth experience 14 , 19 , 22 . Another study could not confirm that duration of the first stage of labor affected the childbirth experience but found that a longer pushing phase contributed to a negative childbirth experience 23 . Further, in a Swedish single center study the maternal childbirth satisfaction was not affected by the duration of neither the latent nor the active phase of labor 24 .

There are not only conflicting results concerning the impact of time in labor on maternal childbirth experience in the previous literature, but there is also inconsistent data on relevant adjustments related to time in labor as the exposure. Most of these studies are based on single center cohorts, increasing the risk of selection bias.

Thus, this study aimed to evaluate whether the duration of active labor was associated with the women’s self-reported childbirth experience. We hypothesized that longer time in active labor increased the risk of a negative childbirth experience.

Study-design and population

This retrospective population-based cohort study was conducted between January 2016 and March 2020 at all the seven delivery units in the southeast health care region of Sweden. All women giving birth to a singleton infant at or above 37 gestational weeks were included. The women with elective CS, non-cephalic presentation and stillbirth were excluded as well as the women with missing data on childbirth experience and missing labor time estimates before the final analyses.

After delivery, the women were asked by the midwife at the postnatal ward to assess their overall experience of the active phase of childbirth by using a visual analog scale (VAS) ranging from 1 to 10, where 1 is a very negative experience and 10 is a very positive experience. This assessment of satisfaction of childbirth by VAS is a well-established routine in the postnatal care at all participating delivery units included in this study. The VAS scoring is usually completed within 2 days after delivery, before discharge from the postnatal ward and is documented in the women’s electronic medical record. The overall assessment of satisfaction of childbirth by VAS has been validated and is comparable with the Wijma Delivery Experience Questionnaire (W-DEQ) and the Childbirth Experience Questionnaire (CEQ) 24 , 25 , 26 .

Data collection and definitions

Data in this study was obtained from the women’s electronic medical records. The maternal variables that were extracted included the self-reported childbirth experience VAS score, maternal age at time of delivery, early pregnancy body mass index (BMI), parity and gestational age at delivery. Labor and neonatal variables assessed were onset of labor (spontaneous or induction), usage of epidural anesthesia, oxytocin augmentation, mode of birth (non-instrumental vaginal delivery, instrumental vaginal delivery, or emergency CS), obstetric anal sphincter injury, postpartum hemorrhage, Apgar score at five minutes and birth weight. Further, the time estimates for start of active labor, start of pushing contractions, and time of birth were extracted from the electronic medical records.

Maternal BMI was categorized according to the World Health Organization (WHO) classification: < 18.5 kg/m 2 (underweight), 18.5–24.9 kg/m 2 (normal weight), 25.0–29.9 kg/m 2 (overweight), 30–34.9 kg/m 2 (class I obesity), 35.0–39.9 kg/m 2 (class II obesity) and ≥ 40 kg/m 2 (class III obesity).

Primiparous women and multiparous women were analyzed separately. Women with induced labor and a spontaneous onset of labor were included in the analyses as well as women with emergency CS.

The main exposure was duration of labor. The different labor time variables that were analyzed were the duration of the total active labor (from start of the active labor until the time of birth), the active phase in the first stage of labor (from start of the active labor until start of the pushing efforts) and the pushing phase. Start of active labor was defined according to the Swedish nationally recommended definition, which states that at least two out of three of the following criteria must be fulfilled: spontaneous rupture of the membranes, regular painful contractions (2–3/10 min), and the cervix dilated four centimetres or effaced and dilated more than one centimetre. In addition to these criteria, the labor should progress within the following 2 h 27 . The midwife at the delivery ward prospectively documented the time when the active phase and the pushing efforts started and the time of birth. The distribution of total labor duration is presented in a descriptive approach as crude observed data of the 10th, 25th, 50th, 75th and 90th percentiles of time in active labor. For the purpose of this study, prolonged labor was defined based on the Swedish definition of dystocia (cervical dilatation less than 1 cm/hour during the active phase and > 3 h from cervix fully dilated to delivery for primiparous women) 28 and previous similar research, defining prolonged labor ≥ 12 h for primiparous women 14 , 19 and clinically relevant cut offs. The total active labor was defined prolonged if duration was ≥ 12 h in primiparous women and ≥ 6 h in multiparous women. The active phase of the first stage of labor was defined prolonged if duration was ≥ 10 h in primiparous women and ≥ 5 h in multiparous women. The pushing phase was defined prolonged if the duration was ≥ 60 min in primiparous women and ≥ 30 min in multiparous women. These cut offs were similar to the 75th quartiles of time in labor for the present study population; for primiparous women the 75th percentile was 13.0 h and for multiparous women the 75th percentile was 6.2 h (Table S2 ). Incorrect values of the labor time estimates were excluded. The time estimates were regarded incorrect, if they were < 11 min and ≥ 52 h for the total labor, < 10 min or ≥ 48 h for the active phase of first stage of labor and < 1 min and ≥ 4 h for the pushing phase, based the graphical distribution of time in labor excluding the outliers and based on clinical experience. Information on start of the pushing phase was not available for all women.

The main outcome was maternal childbirth experience by VAS score. The VAS score was dichotomized into negative birth experience (VAS 1–3) and not being dissatisfied with childbirth (VAS 4–10). The definition of negative childbirth experience was based on the clinical recommendation at the participating study sites to offer extra psychologic support to the women scoring VAS 1–3 2 . The VAS score was further coded into three groups for descriptive analyses: negative birth experience (VAS 1–3), intermediate birth experience (VAS 4–7) and positive birth experience (VAS 8–10). The classification of positive birth experience as VAS 8–10 was based on the definition used in the national Swedish pregnancy register 29 .

Continuous data is presented as mean and one standard deviation (SD), or median and inter quartile range [IQR] if not normally distributed. Categorical data is presented as number and per cent. Differences in the categorical labor time variables between the VAS groups were analyzed with Chi-square test. The labor time variables were not normally distributed. Kruskal–Wallis test was used to compare median durations of the total active labor, the active phase in first stage of labor and the pushing phase among the three VAS groups. Multivariable logistic regression analyses were used to study the association between time in labor, in percentiles and categorical labor time variables, and binary outcomes; negative birth experience (VAS 1–3) and not being dissatisfied with childbirth (VAS 4–10), presented as crude and adjusted odds ratios (ORs and aORs). In the multivariable analyses, adjustments were made for maternal age, BMI, and fetal birthweight. The reference category for the analyses of the labor time estimates in primiparous and multiparous women was set as 10th–90th percentiles for duration of total active labor. In primiparous women the reference categories were set as < 12 h in total active labor, < 10 h in the active phase in first stage of labor, and < 60 min in the pushing phase. For multiparous women the reference categories were chosen as < 6 h in total active labor, < 5 h in the active phase in first stage of labor, and < 30 min in the pushing phase. The statistical analyses were performed using IBM SPSS version 26 (IMB inc, Armok, NY). A p-value < 0.05 was considered statistically significant.

Sensitivity analyses

Sensitivity analyses were performed to examine the robustness of our findings.

First, we compared the prevalence of maternal characteristics and obstetric outcomes in the women that were excluded from the final study-population due to missing VAS score as well missing information on start of active labor, with the women included in the final study-population (Table S1 ).

Further we performed extended analyses on time in total active labor. Time in active labor was classified in < 25th percentile, 25th–75th percentile and > 75th percentile and sensitivity analyses examined whether the crude ORs for a negative childbirth experience differed compared to the main analyses (Table S2 ).

Sensitivity analyses of time in total active labor, classified in < 10th percentile, 10th–90th percentile and > 90th percentile and crude ORs for a negative childbirth experience in primiparous and multiparous women categorized according to type of onset of labor and mode of birth were done (Table S3 , S4 ).

Ethical approval

The Regional Ethical Review Board in Linköping, Sweden approved this study on October 26th, 2018 (Dnr 2018/337-31) and on January 1st, 2020 (Dnr 2019-04529). All methods were performed in accordance with the relevant guidelines and regulations.

A total number of 26,429 women, with a singleton term pregnancy, who had assessed their childbirth experience by VAS score and with known start of active labor constituted the final study population. Of all 43,953 eligible women, 9.5% (n = 4168) were excluded due to elective cesarean section, non-cephalic presentation and/or stillbirth. Of all 39,785 included women 33.6% (n = 13,356) were excluded due to missing information on VAS and/or start of active labor (Fig.  1 ).

Flow chart of the study population.

In the final study population, 82.7% had a documented VAS score. Overall, 69.7% ( n  = 18,428) of the women had a positive birth experience (VAS 8–10), whereas 4.9% ( n  = 1298) reported a negative birth experience (VAS 1–3).

The maternal characteristics, obstetric interventions, and outcomes in the study-population, categorized according to a positive, intermediate, or negative childbirth experience, are presented in Table 1 . The women who had a negative childbirth experience were statistically significantly older, primiparous, at gestational age ≥ 41 weeks, had induced labor, an infant with Apgar score < 7 at 5 min or with a birthweight of ≥ 4.5 kg, compared with the women in the total study population. Further, the frequencies of epidural anesthesia, oxytocin augmentation, operative vaginal birth or emergency CS, occurrence of obstetric anal sphincter injury and postpartum hemorrhage ≥ 1000 ml were statistically significantly higher among women with a negative childbirth experience (Table 1 , p < 0.05 for all variables, not shown in Table 1 ).

The distribution of labor duration in primiparous and multiparous women according to a positive, intermediate, or negative childbirth experience, is presented by percentiles in Table 2 . When analyzing the distribution of total labor duration in primiparous and multiparous women, according to the different labor duration percentiles, the same pattern emerges regardless of parity. The associations between the labor time categories defining prolonged labor and childbirth experience in primiparous and multiparous women are shown in Table 2 . The proportion of primiparous and multiparous women with prolonged labor phases increased with decreasing VAS scores, indicating a negative childbirth experience (p for homogeneity < 0.001). Almost half of the primiparous women with a negative childbirth experience had a prolonged total active labor (48%) and in multiparous women with a negative childbirth experience 40% had a prolonged total active labor (Table 2 ).

Tables 3 and 4 demonstrate a significant association between duration of labor and risk of negative childbirth experience in primiparous and multiparous women, in all labor time categories that were analyzed. The analyses were adjusted for maternal age, BMI and fetal birthweight (Model 1 in Tables 3 , 4 ). For primiparous women with duration of total active labor above the 90th percentile the risk of a negative birth experience was more than doubled (aOR 2.39 (1.98–2.90), Model 1, Table 3 ). If, on the other hand, duration of total active labor was below the 10th percentile, primiparous women had a significantly reduced risk of a negative childbirth experience (aOR 0.46, 95% CI (0.32–0.69) (Table 3 , Model 1).

In primiparous women with a defined prolonged total labor (≥ 12 h) the risk of a negative childbirth experience was more than twice as high, compared with women with normal duration of labor; aOR 2.11, 95% CI (1.81–2.46). Primiparous women with prolonged active phase (≥ 10 h) had an increased risk for a negative childbirth experience; aOR1.89, 95% CI (1.59–2.24). The risk of negative childbirth experience was also increased (aOR 1.49, 95% CI (1.22–1.83)), if the pushing phase was ≥ 60 min (Table 3 , Model 1).

For multiparous women with duration of total active labor above the 90th percentile, the risk of a negative childbirth experience was more than twice as high (aOR 2.23 (1.78–2.79), Model 1, Table 4 ). Further with a defined prolonged total active labor (≥ 6 h) and prolonged active phase (≥ 5 h) the risk of a negative childbirth experience was increased in multiparous women compared with women with normal duration of labor; aOR 1.91, 95% CI (1.59–2.28) and aOR1.55, 95%CI (1.28–1.88) respectively. A prolonged pushing phase in multiparous women doubled the risk of a negative birth experience aOR 2.05, 95%CI (1.62–2.60) (Table 4 , Model 1).

When the multivariable logistic regression analyses on the association between time in labor and childbirth experience also included adjustments for onset of labor and mode of delivery, the aORs were still statistically significant and only changed marginally (Tables 3 , 4 , Model 2).

The sensitivity analyses comparing the prevalence of maternal characteristics and obstetric outcomes in women with available or missing VAS score as well as women with available or missing start of active labor demonstrated statistically significant differences. More women with gestational age ≥ 42 weeks, induction of labor and cesarean delivery had missing information on start of active labor compared to women with known start of active labor (Table S1 ). A larger proportion of women with missing VAS (7.9%) was also delivered by CS compared to women with known VAS (4.6%).

A dose–response relation between time in active labor and risk of a negative childbirth experience was seen, with statistically significant higher crude ORs for a negative childbirth experience when prolonged time in active labor was defined above the 90th percentile for both primiparous (OR 2.54 95% CI (2.10–3.07)) and multiparous women (OR 2.27 95% CI (1.81–2.83)) compared to the analyses when the 75th percentile of total labor duration was analyzed for primiparous (OR 2.00 95% CI (1.70–2.35) and multiparous women (OR 1.80 95% CI (1.49–2.81) (Table S2 ).

In Tables S3 and S4 the crude OR for negative birth experience for women, categorized according to type of start of labor and mode of delivery in percentiles of labor duration, are presented. Primiparous women with induced labor and labor duration above the 90th percentile, had higher crude OR for negative birth experience; OR 3.60 95% CI (2.42–5.35) compared to women with spontaneous onset of labor and labor duration above the 90th percentile; OR 2.34 95% CI (1.88–2.91) (Table S3 ). When comparing primiparous women with induction and spontaneous onset in labor time categories, the women with prolonged total labor (≥ 12 h) and induced labor had higher crude OR for a negative birth experience; OR 2.70 95% CI (1.88–3.88), than the women with spontaneous start and same categorization of prolonged labor; OR 1.87 95% CI (1.55–2.25) (OR not shown in Table S3 ). No difference was seen between the non-instrumental and instrumental vaginal delivery groups (Table S3 ). For multiparous women no significant differences were seen between women with induced labor and spontaneous start of labor or between women with instrumental and non-instrumental vaginal delivery (Table S4 ). For primi- and multiparous women delivered with CS, no statistically significant differences were seen (Tables S3 , S4 ).

In this large multi-center population-based cohort study, we found a significant association between longer duration of active labor and low VAS score, indicating a negative childbirth experience in both primiparous and multiparous women and the most pronounced risk of a negative childbirth experience was seen for those with induced labor. All different labor phases that were studied were significantly related to the women’s childbirth satisfaction score. The longer duration of total labor, active phase and pushing phase, respectively, the lower both primiparous women and multiparous women rated their childbirth satisfaction score by VAS. The dose–response relation between time in active labor and risk of negative childbirth experience, with statistically significant higher crude ORs for a negative childbirth experience when prolonged labor was defined at or above the 90th percentile compared to the 75th percentile, strengthens the result that there is an association between long time in labor and an overall negative childbirth experience by VAS.

In line with previous research, the women in our cohort with negative childbirth experience were more likely to be primiparous, have induced labor, an infant with Apgar score < 7 at 5 min, oxytocin augmentation, operative vaginal birth or emergency CS, obstetric anal sphincter injury or postpartum hemorrhage 2 , 3 , 13 .

There are some studies that have investigated the relationship between prolonged labor and birth experience, although the definition of prolonged labor was not specified in all studies 30 , 31 . A Swedish study found that nulliparous women with negative birth experience reported longer labors measured in hours than women with positive birth experience 30 . An Iranian study stated that labor dystocia was a strong predictor of low birth satisfaction 31 . Our results are consistent with previous studies concluding that prolonged labor, defined as > 12 h, increased the risk of negative childbirth experience 14 , 19 . However, these studies were conducted at a single center, included smaller study populations, were restricted to primiparous women, and did not study the active phase of first stage of labor and the pushing phase separately 14 , 19 . In contrast to these studies, Fenaroli et al. found that the duration of first stage of labor did not affect the woman’s birthing experience among 111 Italian primiparous women who completed the Wijma Delivery Experience Questionnaire (W-DEQ), however a longer pushing phase contributed to a negative childbirth experience 23 . An association between prolonged second stage of labor and a negative childbirth experience, evaluated more than a decade after delivery was also found in primi- and multiparous American women who delivered by CS but not for those who delivered vaginally 6 . In another single center study including 70 primiparous women, Turkmen et al. showed that the childbirth satisfaction score by Childbirth Experience Questionnaire was not affected by the duration of neither the latent phase nor the active phase of labor 24 . An aspect when studying time in labor and women’s childbirth experiences is that women´s perceptions of start of active labor, the labor phases and time in labor might differ from the established medical definitions 32 , 33 . However, in a Swedish study, women with negative childbirth experiences both reported longer labors measured in hours and experienced longer labors and viewed the length as prolonged compared to women with a positive birth experience 34 .

A major strength of this study is the multicenter population-based design with prospectively recorded data in standardized medical records, which reduces the risk of selection bias and recall bias. There were some statistically significant differences between the women with missing or known start of active labor or VAS. We cannot exclude the possibility that the missing data may have had some influence on the adjusted estimates. To exclude a group of women that differ from the included women will influence the generalizability. There was a higher prevalence of women with gestational age ≥ 42 weeks and induction in the group with unknown start of active labor compared to women with known start of active labor. This might be explained by the fact that a gestational week ≥ 42 is an indication for induction of labor and some women with induction of labor never reach start of active labor before they are delivered by cesarean section due to failure to induce labor. This may also explain why more women with missing start of active labor (11.4%) were delivered by cesarean section than women with available start of active labor (3.6%). However, it is also possible that among the women that were excluded due to unknown start of active labor there were women with emergency CS due to slow progress of labor. Among the women in the final study population the percentage of women with labor duration above the 90th percentile was higher among women with CS compared with women with non-instrumental vaginal delivery. Hence, most likely, if these excluded women would answer similar to the women in the final study population, the estimates would be even more significant if more women with longer labor duration would have been included, following the hypothesis that women with prolonged labor are more likely to have negative birth experience. This strengthens the results.

To our knowledge, this study has the largest cohort of women with detailed information on maternal characteristics, known time in active labor and assessed childbirth experience, which gave sufficient power to evaluate the association between duration of the different labor phases and childbirth experience and in addition, enabled adjustments for possible confounding factors. If adjustments for all possible known confounders had been done, this might have resulted in different results. However, our purpose with this study was to evaluate the overall effect of time in labor and childbirth-experience focusing on the main groups primiparous and multiparous women, not necessarily to imply causality between the exposure and the outcome. Our approach could be looked upon as both a strength and a limitation.

In contrast to Kempe et al. who only analyzed the mean VAS score in relation to time in labor 14 , we categorized the VAS scores. To categorize the VAS scale into negative and positive childbirth experience and to present the distribution of exposure, time in labor, in percentiles gives a wider dimension of the childbirth experience compared with the mean value. Further, the high response rate of VAS (82.7%), increases the likelihood of representative study samples. The prevalence of negative childbirth experience of 4.9% is similar to the reported prevalence in previous studies 2 , 13 which also strengthens the generalizability of the study results.

The evaluation of the overall childbirth experience by VAS score is an accessible, easy, and valid method that correlates with other birthing experience instruments such as the W-DEQ and the Childbirth Experience Questionnaire 24 , 25 , 26 . The VAS method is used nationwide in Sweden to assess women’s birth experiences a few days after childbirth and the VAS scores are registered in the national Swedish Pregnancy Register 2 , 3 , 14 , 35 . Another advantage of the VAS method is that it is part of the clinical routine and reaches the majority of all parturients and therefore is a good method to study a larger cohort.

On the other hand, the VAS method is a limitation due to its simplified and non-specific measure on childbirth experience overall that does not give a deeper understanding of the multifaceted childbirth experience. Some risk factors for a negative childbirth experience, such as personal experience of pain or support during labor 5 , 19 , 36 , was not documented in the women’s electronic medical records and can thus not be adjusted for in the analyses. This may decrease the validity of the present study. Further, there is no established definition of negative childbirth experience by VAS and another definition might have given different results. However, our definition of an overall negative childbirth experience by a low VAS score (1–3) was based on the current clinical guidelines at the participating study sites to offer extra psychosomatic support to women scoring below 4 and thereby including the women who were the most dissatisfied with their childbirth experience. Another limitation is that the childbirth experience was evaluated within the first 72 h after childbirth, since women’s rating of childbirth might be influenced by the initial positive feelings shortly after birth 37 . A certain amount of time estimates for the different phases of labor were missing, however there is no reason to suspect an association between missing time estimates and VAS that could have biased the results.

The definition of normal labor progression is currently under international debate. The WHO and ACOG has changed their definitions and allow a slower progress in the beginning of the active phase of labor 1 , 17 . The reason for this change has mainly been to reduce the incidence of emergency CS and avoid unnecessary emergency CS due to failure to progress. However, since long time in labor increases the risk of a negative birthing experience, as demonstrated in this study, it may also increase future demands on CS in the following pregnancy due to fear of childbirth 9 , 10 . Since a negative birth experience also may have every day and life-long consequences affecting the bonding with the newborn and the women’s mental health and result in avoidance of a future pregnancy as a result from fear of childbirth, care givers must pay attention to the women with long time in active labor 34 , 38 , 39 . The childbirth experience is multidimensional. Some contributing factors for a negative childbirth experience, like unexpected events such as instrumental delivery, emergency CS, and postpartum hemorrhage, are difficult to prevent, while other factors might be noticed and thus improve the care of women in labor. It is described that women who experienced more pain than expected, did not receive the support by the care givers that they needed, had insufficient continuous information and did not feel included in decisions made during labor were at risk of a negative childbirth experience 5 , 19 , 36 . Reducing the risk of these known factors might compensate for the effect of a longer time in labor. Hence, it might be of extra importance to make sure that women with longer time in labor have enough pain relief and to be aware of a possible need for extra support and guidance during labor. A cesarean delivery due to failure of labor progress might contribute to a negative childbirth experience 2 , 4 , 6 , 14 , 15 . It is therefore important not to terminate labor with CS due to failure of progress before the women have been offered continuous support and the expectations from the women have been ascertained . A Swedish study including 10 women with prolonged labor concluded that emotional support and encouragement by caregivers helped to accept the prolonged labor 40 . Clear information on labor interventions like induction procedure or instrumental delivery may also reduce the risk of negative birth experience 41 .

In conclusion, our data show that a longer time in active labor significantly increases the risk of an overall negative childbirth experience for both primiparous and multiparous women. The most pronounced risk of a negative childbirth experience was seen for those with induced labor. This risk also applies to the active phase of first stage of labor and the pushing phase separately. It is of great importance to identify and optimize the clinical care of women with long time in labor to reduce the risk of negative childbirth experience and associated adverse long-term effects.

Data availability

The data that support the findings of this study are available on request from the corresponding author.

Abbreviations

World Health Organization

Cesarean section

American College of Obstetricians and Gynecologists

Visual analog scale

Body mass index

Adjusted odds ratio

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Acknowledgements

We express our gratitude to all participants and staff involved in this study.

Open access funding provided by Linköping University. Financial support was received from the County Council of Östergötland and Linköping University, Sweden (ALF grants, Region Östergötland) and the Medical Research Council of Southeast Sweden (FORSS; grant number FORSS-909171).

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S.C. and M.B. contributed to the study concept and design. M.N., S.C. and M.B. contributed to the data acquisition. S.C. and M.B. performed the statistical analyses and S.C., M.B., D.A. and MS interpreted the data. S.C. wrote the manuscript. M.B., D.A. and M.S. critically revised the manuscript. All authors gave final approval and agreed to be accountable for all aspects of work ensuring integrity and accuracy. All authors gave final approval and agreed to be accountable for all aspects of work ensuring integrity and accuracy.

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Carlhäll, S., Nelson, M., Svenvik, M. et al. Maternal childbirth experience and time in labor: a population-based cohort study. Sci Rep 12 , 11930 (2022). https://doi.org/10.1038/s41598-022-14711-y

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DOI : https://doi.org/10.1038/s41598-022-14711-y

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