Original Research ajog.

org

OBSTETRICS
The maternal childbirth experience more than a decade
after delivery
Carla M. Bossano, MD; Kelly M. Townsend, MS; Alexandra C. Walton, BS; Joan L. Blomquist, MD; Victoria L. Handa, MD, MHS

BACKGROUND: Maternal satisfaction with the birth experience is
multidimensional and influenced by many factors, including mode of
delivery. To date, few studies have investigated maternal satisfaction
outside of the immediate postpartum period.
OBJECTIVE: This study investigated whether differences in satis-
faction based on mode of delivery are observed more than a decade
after delivery.
STUDY DESIGN: This was a planned, supplementary analysis of data
collected for the Mothers Outcomes after Delivery study, a longitudinal
cohort study of pelvic floor disorders in parous women and their associ-
ation with mode of delivery. Obstetric and demographic data were ob-
tained through patient surveys and obstetrical chart review. Maternal
satisfaction with childbirth experience was assessed via the Salmon
questionnaire, administered to Mothers Outcomes after Delivery study
participants >10 years from their first delivery. This validated question-
naire yields 3 scores: fulfillment, distress, and difficulty. These 3 scores
were compared by mode of delivery (cesarean prior to labor, cesarean
during labor, spontaneous vaginal delivery, and operative vaginal delivery).
In addition, the impact of race, age, education level, parity, episiotomy,
labor induction, and duration of second stage of labor on maternal
satisfaction were examined.
RESULTS: Among 576 women, 10.1-17.5 years from delivery, sig-
nificant differences in satisfaction scores were noted by delivery mode.
Salmon scale scores differed between women delivering by cesarean and
those delivering vaginally: women delivering vaginally reported greater
fulfillment (0.40 [e0.37 to 0.92] vs 0.15 [e0.88 to 0.66], P < .001) and
less distress (e0.34 [e0.88 to 0.38] vs 0.20 [e0.70 to 0.93], P < .001)
than those who delivered by cesarean. Women who delivered by cesarean
prior to labor reported the greatest median fulfillment scores and the
lowest median difficulty scores. Median distress scores were lowest
among those who delivered by spontaneous vaginal birth. Among women
who underwent cesarean delivery, labor induction and prolonged second
stage were associated with higher difficulty scores. These factors did not
affect satisfaction scores among women who delivered vaginally. Among
women who delivered vaginally, operative vaginal delivery was associated
with less favorable scores across all 3 scores.
CONCLUSION: Maternal satisfaction with childbirth is influenced by
mode of delivery. The birth experience leaves an impression on women
more than a decade after delivery.
Key words: childbirth experience, maternal perception of childbirth,
mode of delivery, patient satisfaction, Salmon questionnaire

Introduction realization of preferred mode of delivery, experience. In this research, we take

Maternal satisfaction with the birth
experience is multidimensional and
inuenced by a variety of factors,
including mode of delivery.1-4 Prior
research has suggested that childbirth is
perceived differently by women who
deliver by cesarean vs vaginal birth.
Several studies reported that women
who undergo cesarean delivery have a
more negative birth experience,3,5-7
while others reported minimal or no
effect of mode of delivery on maternal
satisfaction and instead attribute the
differences in satisfaction to other fac-
tors such as perceived maternal control,
Cite this article as: Bossano CM, Townsend KM, Walton
AC, et al. The maternal childbirth experience more than a
decade after delivery. Am J Obstet Gynecol
2017;217:342.e1-8.
0002-9378/$36.00
2017 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2017.04.027
and support during labor.8-10 Other
factors shown to play a role in maternal
satisfaction include separation from the
newborn, communication with pro-
viders, neonatal intensive care admis-
sions, and pain control.3,4,8,11
Whether a womans birth experience
is positive or negative has implications
beyond the delivery event. Posttraumatic
stress disorder related to a traumatic
birth experience has been described.12,13
A negative birth experience may increase
the risk of postpartum depression, as
well.14 Furthermore, women who have a
negative birth experience have a longer
interval to their second delivery and
fewer subsequent deliveries.15
Prior research on maternal birth
experience has primarily been limited to
the period immediately surrounding
delivery. Less is known about whether
immediate perceptions of birth persist
and have a long-term impact on a
womans impressions of her birth
advantage of a unique opportunity to
investigate maternal satisfaction in a
cohort of women remote from delivery.
Our primary objective is to investigate
the extent to which maternal satisfaction
with childbirth differs by mode of de-
livery >10 years after childbirth. A sec-
ond objective is to identify other aspects
of childbirth that have a long-term in-
uence on maternal satisfaction.
Materials and Methods
This was a planned, supplementary
analysis of data collected for the
Mothers Outcomes after Delivery
(MOAD) study,16 a longitudinal cohort
study. The parent study is an investiga-
tion of pelvic oor disorders after
childbirth. The goal of this supplemen-
tary study was to investigate the maternal
birth experience. Investigators from
Johns Hopkins Medical Institutions and
Greater Baltimore Medical Center con-
ducted and designed the study. The

342.e1 American Journal of Obstetrics & Gynecology SEPTEMBER 2017

ajog.org
study was approved by the institutional
review board at all participating in-
stitutions and written informed consent
was obtained from all participants.
Recruitment for participation in
the MOAD study was previously
described.16 To summarize, eligible par-
ticipants were identied via obstetric
diagnoses 5-10 years after the partici-
pants rst delivery. Given the primary
goal of the parent study, recruitment was
based on delivery type. The recruitment
strategy specied that 60% of the study
population would have delivered their
rst child by cesarean; women who
delivered vaginally and those delivered
by cesarean were matched for maternal
age and years since delivery. Once po-
tential participants were identied, hos-
pital records were reviewed to verify
eligibility and delivery type. Enrolled
participants attend annual study visits
that include an annual health question-
naire. Recruitment for this study was
completed in 2015 and enrolled partici-
pants were followed up annually
thereafter.
Maternal satisfaction with childbirth
was assessed with the Salmon question-
naire,2 included in the annual health
questionnaire during the sixth year of
study participation. At this time point,
participants were at least 10 years from
their rst delivery. Some study partici-
pants were multiparous at the time of
data collection. These women were asked
to assess their satisfaction with regard to
their rst delivery. The Salmon ques-
tionnaire is a validated instrument that
consists of 20 items with the following
instruction: For each description below,
please check the value from 1-5 that best
describes how you felt during the whole
birthing process, including the rst
hours after birth. Each of the 20 de-
scriptors (Appendix) is rated on a 5-
point Likert scale: (1) not at all; (2) a
little bit; (3) moderately; (4) quite a bit;
or (5) extremely. The Salmon question-
naire is scored across 3 domains: fulll-
ment, distress, and difculty. Each score
is calculated by summing the values for
relevant items and then normalizing the
scores. For each scale score, we calcu-
lated median and interquartile range
stratied by delivery group.
OBSTETRICS
Women were grouped by delivery
type. Each delivery was classied as
either a vaginal birth or cesarean birth.
Cesarean births were further classied as
having occurred prior to or during labor.
This classication was based on infor-
mation abstracted from the hospital re-
cord. Vaginal births were further
classied as operative (ie, assisted with
forceps or vacuum) or spontaneous.
Additional maternal characteristics
were also considered: age, age at the time
of rst delivery, interval (in years) be-
tween rst delivery and study enroll-
ment, parity, years between rst and
second delivery (if applicable), race,
and educational attainment. Race and
educational attainment were self-
reported. Obstetrical data were derived
from abstraction of the delivery record
for each participant. Abstracted data
included labor induction, duration of
the second stage of labor (the time from
complete dilation to delivery), episi-
otomy, and indication for cesarean. The
second stage was classied as prolonged
if >2 hours.
Maternal and obstetrical characteris-
tics were compared across delivery
groups using median and interquartile
range for continuous data and frequency
and percent for categorical data. Statis-
tical signicance between delivery
groups was determined using Kruskal-
Wallis and c2 tests. Differences in scale
scores between groups were compared in
multivariate linear regression models.
Separate models were created for cesar-
ean and vaginal birth groups, modeling
each Salmon scale score as a function of
maternal characteristics and obstetrical
characteristics specic to the delivery
group. All multivariable models
included age at rst delivery, parity, race,
education, induction of labor, and pro-
longed second stage. Among women
delivered by cesarean, we also considered
the association between each score and
labor prior to cesarean; among women
delivered vaginally, we considered oper-
ative vaginal birth and episiotomy. All
analysis was performed using statistical
software (SAS, Version 9.4; SAS Institute
Inc, Cary, NC). The Figure was also
created using statistical software (R,
Version 3.2.1; R Foundation for
SEPTEMBER 2017 American Journal of Obstetrics & Gynecology
Original Research
Statistical Computing, Vienna, Austria).
In all analyses, P < .05 was considered
statistically signicant.
Results
At the time of this analysis, 742 partici-
pants completed the sixth year of the
MOAD study and the Salmon ques-
tionnaire was completed by 593 (80%) of
these women. Seventeen women were
excluded secondary to incomplete data,
leaving 576 for analysis.
At the time of survey completion,
women were 10.1-17.5 years from rst
delivery and 74% were parous (Table 1).
The modes of delivery were as follows:
64 (11%) cesarean prior to labor, 281
(49%) cesarean during labor, 174 (30%)
spontaneous vaginal delivery, and 57
(10%) operative vaginal delivery. In-
dications for the cesarean prior to labor
group included malpresentation (n
32, 50%), fetal macrosomia (n 15,
23%), concerns about fetal well-being
(n 3, 5%), and other diagnoses (n
14, 22%). Indications in the cesarean
during labor group included arrest of
dilation (n 92, 33%), failure to
descend (n 77, 27%), concerns about
fetal well-being (n 34, 12%), malpre-
sentation (n 26, 9%), and other di-
agnoses (n 52, 19%). For the cesarean
during labor group, 33 (12%) had an
unsuccessful trial of labor induction, 24
(9%) were in early labor at the time of
cesarean, and 224 (80%) were in the
active phase of labor.
Characteristics of the 4 delivery
groups are described in Table 1. There
were no statistically signicant differ-
ences between the groups with regard to
current age, age at rst delivery, years
since rst delivery, parity, years between
rst and second delivery, race, or edu-
cation. Differences were noted with re-
gard to labor induction, episiotomy, and
duration of second stage among the
groups (where applicable).
Salmon scale scores (fulllment,
distress, and difculty) differed between
women delivering by cesarean vs vagi-
nally. Women delivering vaginally re-
ported greater median fulllment (0.40
[e0.37 to 0.92] vs 0.15 [e0.88 to 0.66],
P < .001) and less median distress
(e0.34 [e0.88 to 0.38] vs 0.20 [e0.70 to
342.e2
 Original Research
342.e3 American Journal of Obstetrics & Gynecology SEPTEMBER 2017

TABLE 1
Characteristics of study participants by delivery type, N [ 576
Mode of deliverya
Cesarean Vaginal
Cesarean during labor, Spontaneous, P valueb P valueb
Characteristic No labor, N 64 N 281 N 174 Operative, N 57 (4 categories) (cesarean vs vaginal)
Current age, y 45 [42e49] 45 [41e48] 45 [41e48] 46 [43e49] .12 .27

OBSTETRICS
Age at first delivery, y 33 [30e37] 32 [29e35] 31 [29e36] 33 [30e36] .18 .87
Time from first delivery, y 12 [11e14] 13 [11e14] 13 [12e14] 13 [12e15] .14 .057
Parity .24 .16
2 59% (38) 59% (165) 53% (93) 44% (25)
3 13% (8) 17% (49) 22% (38) 19% (11)
c
Time between first and second delivery, y 2.5 [1.8e3.9] 2.7 [2.0e3.6] 2.5 [2.0e3.6] 2.4 [1.9e2.8] .25 .29
African American race 5% (3) 15% (41) 10% (18) 7% (4) .07 .23
Education .93 .56
College degree 39% (25) 43% (121) 45% (79) 44% (25)
Graduate degree 37% (24) 37% (103) 37% (64) 40% (23)
Labor induction n/a 51% (144) 29% (51) 40% (23) <.001 .018
Prolonged second stage of labor >2 h n/a 25% (70) 18% (31) 49% (28) <.001 .14
Duration of second stage of labor, h d
n/a 3.0 [2.4e3.9] 1.1 [0.7e1.8] 1.9 [1.2e2.5] <.001 <.001
e
Episiotomy n/a n/a 49% (86) 72% (41) .003 n/a
Domain-specific Salmon score
Fulfillment 0.53 [e0.56 to 0.92] 0.02 [e0.88 to 0.53] 0.47 [e0.24 to 0.92] 0.15 [e0.88 to 0.78] <.001 <.001
Distress e0.16 [e0.88 to 0.65] 0.20 [e0.52 to 1.11] e0.52 [e0.88 to 0.20] 0.02 [e0.52 to 0.93] <.001 <.001
Difficulty e0.43 [e1.03 to 0.17] 0.17 [e0.43 to 0.77] e0.13 [e0.73 to 0.47] 0.47 [e0.43 to 1.07] <.001 .30
Values are median [interquartile range] for continuous variables and percent (frequency) for categorical variables.
n/a, not applicable.
a
Participants are classified by mode of delivery for first birth (among those who are multiparous); b Wilcoxon rank sum test for continuous variables and c2 test for categorical variables; c Reported for multiparous women only; d Reported only for women who
experienced second stage of labor (including 84 women who delivered by cesarean delivery); e Reported only for women who delivered vaginally.
Bossano et al. Maternal childbirth experience >10 years after delivery. Am J Obstet Gynecol 2017.

ajog.org
ajog.org OBSTETRICS Original Research

FIGURE
Box plots representing Salmon satisfaction scores by route of delivery

Any Labor, cesarean during labor; No Labor, cesarean prior to labor; Op Del, operative vaginal delivery; SVD, spontaneous vaginal delivery.
Bossano et al. Maternal childbirth experience >10 years after delivery. Am J Obstet Gynecol 2017.

0.93], P <.001) than those who delivered
by cesarean. Further comparison across
the 4 delivery groups are summarized
(Figure and Table 1). Women who
delivered by cesarean prior to labor re-
ported the greatest median fulllment
scores and the lowest median difculty
scores. Median distress scores were
lowest among those who delivered by
spontaneous vaginal birth.
Differences in Salmon scores between
birth groups were further examined in
multivariable analyses (Tables 2 and 3).
Among women who delivered by cesar-
ean, a prolonged second stage of labor
and labor induction were both associ-
ated with signicantly increased mean
difculty score (representing a percep-
tion of a more difcult birth). Women
who underwent cesarean prior to labor
had more favorable scores for all 3 scales
(higher fulllment, lower distress, and
lower difculty), although these associ-
ations were not statistically signicant in
a multivariable model. Finally, we also
observed more favorable scores for all 3
scales with increasing maternal age at
rst delivery.
Among women who delivered vagi-
nally, the most notable nding was that
operative intervention was associated
with a less favorable birth experience:
lower fulllment, greater distress, and
greater difculty, on average. Also, mean
difculty score was signicantly higher
in women with a prolonged second stage
in the univariate analysis, but this did not
persist after controlling for maternal and
obstetric characteristics (including
operative vaginal delivery). Neither
episiotomy nor labor induction signi-
cantly affected satisfaction scores. An
interesting observation among women
who delivered their rst child vaginally
was that parous women reported on
average higher fulllment and lower
distress for their rst delivery when
compared to nulliparous women.
Finally, we also observed more favorable
scores for the fulllment and distress
scores with increasing maternal age at
rst delivery.
Comment
These results demonstrate that more
than a decade later, delivery events have a
profound impact on a mothers view of

SEPTEMBER 2017 American Journal of Obstetrics & Gynecology 342.e4

Original Research OBSTETRICS ajog.org

TABLE 2
Univariate and multivariate linear regression results for Salmon scale scores among women delivered
by cesarean, N [ 345
Domain-specific Salmon score, estimate (SE)
Fulfillment Distress Difficulty
a b a b
Variable Univariate Multivariate Univariate Multivariate Univariatea Multivariateb
Age at first delivery, per 5 y 0.13 (0.058)c,d 0.16 (0.064)c e0.12 (0.056)c,d e0.18 (0.062)c e0.20 (0.054)c,d e0.22 (0.057)c
Parity, vs uniparous
2 e0.19 (0.138) 0.00 (0.146) 0.05 (0.134) e0.16 (0.141) 0.28 (0.129)c 0.06 (0.131)
3 e0.22 (0.183) 0.01 (0.195) 0.04 (0.177) e0.24 (0.188) 0.19 (0.171) e0.06 (0.175)
e
Labor stage and duration
No labor 0.36 (0.151)c 0.23 (0.166) e0.32 (0.146)c e0.27 (0.160) e0.43 (0.138)c e0.19 (0.149)
Second stage >2 h e0.17 (0.146) e0.17 (0.149) 0.09 (0.141) 0.05 (0.144) 0.41 (0.134) 0.46 (0.133)c
Labor induction e0.32 (0.115)c e0.24 (0.125) 0.22 (0.112) 0.14 (0.121) 0.47 (0.107)c 0.37 (0.112)c
Coefficients represent mean change in Salmon scale score for each variable.
a
Univariate estimates are generated from multiple models, each with its own interceptetherefore, no univariate intercept is reported; b Multivariable models also control for years from first delivery,
race, and education; c P < .05; d Derived from model containing both time variables: age at first delivery and years from first delivery; e Reference group women with any labor and without
second-stage duration >2 h.
Bossano et al. Maternal childbirth experience >10 years after delivery. Am J Obstet Gynecol 2017.

childbirth. Women who delivered by
cesarean recalled their childbirth expe-
rience as less fullling and more dis-
tressing than those who delivered by
vaginal birth. This is consistent with
prior studies in the immediate post-
partum period, which have reported
more negative birth experiences for
women who deliver via cesarean vs
vaginal delivery.1-3,5-7 Our results sug-
gest that such perceptions endure for at
least a decade after delivery.
Our results also suggest very favorable
satisfaction scores among women who
deliver by cesarean prior to labor. It has
been suggested that satisfaction is
highest when women attain the planned
mode of delivery, regardless of whether
they are planning cesarean or vaginal
delivery. In other words, maternal
perception of involvement with medical
decision making may have a larger in-
uence on maternal satisfaction than the
actual mode of delivery.9 This likely

TABLE 3
Univariate and multivariate linear regression results for Salmon scale scores among women delivered
vaginally, N [ 231
Domain-specific Salmon score, estimate (SE)
Fulfillment Distress Difficulty
Variable Univariatea Multivariateb Univariatea Multivariateb Univariatea Multivariateb
Age at first delivery, per 5 y 0.10 (0.064)c 0.17 (0.070)d e0.08 (0.066)c e0.19 (0.071)d 0.06 (0.073)c 0.00 (0.081)
Parity, vs uniparous
2 0.28 (0.135)d 0.38 (0.147)d e0.26 (0.138) e0.38 (0.149)d e0.10 (0.154) e0.07 (0.169)
3 0.12 (0.165) 0.26 (0.182) e0.26 (0.169) e0.40 (0.184)d e0.17 (0.189) e0.16 (0.209)
Prolonged second stage of labor >2 h e0.01 (0.132) 0.11 (0.139) 0.14 (0.135) e0.02 (0.140) 0.34 (0.148) d
0.19 (0.159)
Operative delivery e0.34 (0.131) d
e0.36 (0.140) d
0.47 (0.133) d
0.47 (0.142) d
0.48 (0.148) d
0.45 (0.161)d
Episiotomy e0.12 (0.115) e0.06 (0.118) 0.16 (0.118) 0.08 (0.120) e0.09 (0.131) e0.22 (0.136)
Labor induction e0.08 (0.123) e0.02 (0.123) e0.08 (0.126) e0.13 (0.125) e0.04 (0.140) e0.06 (0.142)
Coefficients represent mean change in Salmon scale score for each variable.
a
Univariate estimates are generated from multiple models, each with its own interceptetherefore, no univariate intercept is reported; b Multivariable models also control for years from first delivery,
race, and education; c Derived from model containing both time variables: age at first delivery and years from first delivery; d P < .05.
Bossano et al. Maternal childbirth experience >10 years after delivery. Am J Obstet Gynecol 2017.

342.e5 American Journal of Obstetrics & Gynecology SEPTEMBER 2017

ajog.org
explains why the mean satisfaction
scores for women who underwent ce-
sarean prior to labor were more positive
when compared to those who delivered
by cesarean during labor. It also likely
explains the favorable scores for women
who delivered by spontaneous vaginal
delivery. This is consistent with several
studies reporting positive birth experi-
ences for women undergoing elective
cesarean and that suggest other factors
such as maternal control may inuence
maternal satisfaction more than mode of
delivery.1,9,10
We found that labor induction prior
to cesarean delivery had a negative
impact on maternal satisfaction (higher
difculty scores compared to those who
did not have induced labor). In contrast,
labor induction did not impact maternal
satisfaction among those who delivered
vaginally. Thus, the association between
the delivery experience and labor in-
duction appeared to differ for those who
delivered by cesarean vs vaginal birth. We
also found that a prolonged second stage
of labor was associated with greater dif-
culty scores among those who deliver
by cesarean but not by those who deliver
vaginally. Thus, our ndings suggest that
labor induction and the duration of the
second stage are perceived differently by
those who deliver by cesarean vs vaginal
birth.
Although the above observations
provide an interesting insight into
possible factors inuencing maternal
birth experience, it is important to note
that these results represent tendencies
and not individual experiences of
women. Our data show that in every
group there were women whose birth
experience was perceived as negative or
positive in all 3 domains, regardless of
mode of delivery.
At the time of survey completion, 74%
of the participants were parous; parity
did not differ by birth group, nor did
interpregnancy interval among parous
women. We acknowledge that the expe-
rience of subsequent pregnancies might
impact maternal recall of a womans rst
delivery. In the cesarean delivery group,
there was no signicant association be-
tween parity and satisfaction scores.
However, among women who delivered
OBSTETRICS
their rst child vaginally, those with a
second delivery were more likely to
report a lower distress score and a higher
fulllment score for the rst birth. It is
not clear whether the second birth might
inuence a womans perception of her
rst birth or perhaps those who found
the rst birth unfullling or distressing
are less likely to have another child.
A unique aspect of our study is that we
investigated maternal perception of birth
experience >10 years after delivery. A
few prior studies have investigated
longer-term maternal perceptions. In
1991, Simkin17 assessed maternal recall
of birth experience among 20 women
who were 15-20 years after delivery. She
concluded that maternal perception of
birth experience changed little over
time.18 Rijnders et al19 investigated
maternal birth experience 3 years post-
partum in The Netherlands and identi-
ed several risk factors for negative
perceptions including operative vaginal
delivery and unplanned cesarean, inad-
equate pain control, negative description
of care providers, and a nonhome birth.
Bennett20 assessed maternal perception
of delivery 2 years postpartum and noted
that maternal recall about specic events
in labor remained largely accurate over
time; however, women had more nega-
tive views about birth procedures when
more time had elapsed. Similarly,
Maimburg et al21 found that 5 years after
delivery, women recalled their birth
experience more negatively. Moreover,
those women who reported more posi-
tive or equal satisfaction with the birth
experience 5 years postdelivery were
signicantly more likely to have deliv-
ered via spontaneous vaginal delivery
without any interventions.21 The impact
of obstetrical events on maternal satis-
faction, as observed in the current study,
speaks to the importance of ensuring a
good patient experience, as these per-
ceptions endure over long periods of
time.
Our study has several strengths, in
addition to the unique opportunity to
examine outcomes >10 years after birth.
We used a multidimensional, validated
questionnaire to assess maternal experi-
ence with delivery. These scaled scores
were then compared to maternal and
SEPTEMBER 2017 American Journal of Obstetrics & Gynecology
Original Research
obstetrical characteristics obtained
through patient questionnaires and
veried through chart abstraction. This
decreased recall bias and veried
important obstetrical details. Our large
sample size and similar demographics
across groups increases the strength of
our ndings, as well.
Our study has limitations. Most
notably, we did not have information
about maternal preference or plan for
vaginal vs cesarean delivery. Information
about maternal preferences and plans
regarding mode of delivery would have
strengthened our study. In addition, we
did not collect information about patient
perception of health care team, support
during labor, antenatal childbirth edu-
cation, or maternal fear regarding
childbirth. Such characteristics were
shown to affect maternal satisfaction
with childbirth.3,4,22 We also acknowl-
edge that our study population was from
a single institution and was 82%
Caucasian, with a high level of educa-
tion. This may limit the generalizability
of our ndings. The Salmon question-
naire was developed in a relatively
afuent Caucasian population; further
research is needed to assess whether this
instrument would adequately capture
the relevant domains of maternal satis-
faction in a less afuent or more
culturally diverse population.
The ndings of our study have
important implications for the health
care of women in childbirth. It is
important to recognize that a womans
perception of her experience is long-
standing. In the immediate postpartum
period, a negative birth experience is
associated with posttraumatic stress
disorder and, in some cases, postpartum
depression.12-14 The long-term impacts
are not known. At a minimum, we
speculate that a womans childbirth
experience may inuence how she en-
gages the health care system for herself
and her family. Given the increasing
emphasis placed on patient-reported
outcomes and patient satisfaction,
obstetrical providers should be aware of
the enduring impact of obstetrical in-
terventions and mode of delivery on
maternal satisfaction with the birth
experience. n
342.e6
Original Research OBSTETRICS
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Author and article information
From the Department of Gynecology and Obstetrics,
Johns Hopkins School of Medicine (Drs Bossano and
Handa, and Ms Walton); Department of Epidemiology,
Johns Hopkins Bloomberg School of Public Health
(Ms Townsend); and Department of Gynecology, Greater
Baltimore Medical Center (Dr Blomquist), Baltimore, MD.
Received Jan. 4, 2017; revised April 13, 2017;
accepted April 16, 2017.
Support provided by the Eunice Kennedy Shriver
National Institute of Child Health and Human Develop-
ment (R01HD056275).
The authors report no conflict of interest.
Presented at the 2016 International Council on
Womens Health Issues Congress, Baltimore, MD, Nov. 6-
9, 2016.
Corresponding author: Carla M. Bossano, MD.
cbossan1@jhmi.edu
ajog.org OBSTETRICS Original Research

Appendix.
Twenty descriptors included in the
Salmon questionnaire.
The stem for all items reads as follows:
For each description below, please check
the value from 1-5 that best describes how
you felt during the whole birthing process,
including the rst hours after birth. Each
of the 20 descriptors is rated on a 5-point
Likert scale: (1) not at all; (2) a little bit; (3)
moderately; (4) quite a bit; or (5)
extremely.
Domain (Fulllment, Distress, Dif-
culty) scores were calculated by
summing the values from pertinent
descriptors marked below. Standard-
ized normal scores were then
calculated.

My childbirth experience made me feel. Fulfillment Distress Difficulty

Disappointed U
Fulfilled U
Enthusiastic U U
Satisfied U
Delighted U
Depressed U
Happy U U
Excited U
Good experience U U
Coped U
Cheated
In control U
Enjoyable U
Relaxed U
Anxious U
Painful U
Easy U
Time going slowly U U
Exhausted U
Confident

SEPTEMBER 2017 American Journal of Obstetrics & Gynecology 342.e8