Birth satisfaction scale (BSS)

Abstract

The Birth Satisfaction Scale (BSS), developed by Hollins Martin and Fleming (2009), is a robust psychometric instrument designed to measure a woman’s subjective perception of her recent childbirth experience. The scale was later revised in 2014 (BSS-R) to create a more concise, 10-item version with improved factor structure. Both versions move beyond simple clinical outcomes to capture the complex emotional, psychological, and relational aspects of delivery, which are crucial determinants of maternal mental health and bonding.

The BSS and BSS-R are foundational tools in perinatal research and clinical practice, providing healthcare professionals and researchers with a standardized method for assessing the quality of care provision, personal coping mechanisms, and the level of stress experienced during labor and delivery.

Keywords

Birth satisfaction, childbirth experience, psychometric scale, maternal health, postnatal care, BSS, BSS-R, labor and delivery, quality of care.

Authors

Hollins Martin, C.J., Fleming, V., Martin, C.R.

Purpose

The primary purpose of the Birth Satisfaction Scale (BSS) is to quantitatively assess and evaluate the level of satisfaction a woman reports regarding her experience of giving birth. This objective measurement is intended to help healthcare providers, particularly those in midwifery and obstetrics, identify areas for improving maternity care services. The BSS allows for the systematic comparison of satisfaction levels across different birth settings, care models, and patient demographics.

The development of the revised version, the BSS-R, aimed to enhance clinical utility by providing a shorter, yet equally reliable, measure that maintains strong psychometric properties while minimizing respondent burden in busy clinical environments.

Construct

The BSS measures the subjective experience of birth satisfaction as a multidimensional construct, recognizing that satisfaction is influenced by factors beyond just the health outcome of the mother and baby. The scale originally featured 30 items, which were mapped onto three core domains representing the key facets of the birth experience:

• Quality of Care Provision: This domain relates to the environment, support received from staff and partner, communication, and the relationship with healthcare professionals, including midwives and doctors.
• Women’s Personal Attributes: This domain assesses the mother’s internal state, including her ability to cope, preparation for childbirth, feeling of control during labor, and the immediate relationship/bonding with the newborn baby.
• Stress Experienced During Labour: This domain captures negative experiences such as pain, distress, feelings of being mutilated or injured, perception of long labor, and the impact of obstetric intervention.

The condensed BSS-R (2014) retained these three core factors, demonstrating that these three dimensions are critical and distinct components contributing to overall birth satisfaction.

Validity

Multiple studies have been conducted to establish the validity of both the BSS and the BSS-R. Initial validation studies focused on ensuring that the scale accurately reflected the theoretical domains of birth satisfaction (content and construct validity). Concurrent analysis confirmed the validity of the domains within the original 30-item BSS (Hollins Martin, Snowden & Martin, 2012).

The BSS-R demonstrated strong construct validity, as confirmed through factor analysis (Hollins Martin & Martin, 2014). The BSS has also proven to be cross-culturally valid, with studies, such as the Turkish adaptation (Cetin et al., 2015), confirming its applicability and factor structure in non-Western populations.

Reliability

The reliability of the BSS and BSS-R has been demonstrated through internal consistency measures. The development and psychometric properties of the BSS-R (2014) showed high levels of reliability across its three subscales and the overall score, indicating that the items within each domain consistently measure the same underlying construct. The revised 10-item scale is considered a highly reliable measure suitable for clinical audit and research purposes in midwifery and obstetrics.

Factor Analysis

The original 30-item BSS (2009) was developed based on theoretical and clinical input, and subsequent concurrent analysis confirmed the three-factor structure. The transition to the 10-item Birth Satisfaction Scale-Revised (BSS-R) was underpinned by rigorous factor analysis (Hollins Martin & Martin, 2014) to achieve a parsimonious instrument. The BSS-R consistently loads onto three distinct factors:

1. Quality of Care Provision (4 items)
2. Women’s Personal Attributes (2 items)
3. Stress Experienced During Labour (4 items)

This streamlined structure is supported by strong empirical evidence, ensuring that the BSS-R efficiently captures the multidimensional nature of birth satisfaction with minimal overlap between domains.

Instrument

Test Type: Self-report psychometric scale.

Format: The BSS (30 items) and BSS-R (10 items) utilize a 5-point Likert scale response format, ranging from 1 (I Strongly Disagree) to 5 (I Strongly Agree). Specific items are reverse-scored to account for negatively worded statements.

Language Available: English, Turkish (adaptation), and potentially others through international validation efforts.

Population Group: Women post-childbirth.

Age Group: Adult women of childbearing age.

Population Details: Typically administered shortly after birth (e.g., within 6 weeks) to capture accurate recall of the labor and delivery experience.

Test Methodology: Respondents rate their agreement with statements regarding various aspects of their recent birth. Scoring involves summing the responses, with specific items requiring reverse scoring (items 4, 8, 12, 15, 16, 17, 19, 20, 21, 23, 25, and 29 in the BSS). Higher scores indicate greater birth satisfaction.

Keywords

Maternal psychological health, delivery experience, obstetrics, midwifery research, scale development, validation, BSS-R, obstetric intervention.

Authors

Author ORCID Identifier: Not provided in source content.

Affiliation Email addresses: [email protected]

Correspondence Address: Not provided in source content.

Permissions & Fee and Test Year

The scale was initially developed in 2009 (BSS) and revised in 2014 (BSS-R). Information regarding specific permissions and fees for commercial use should be sought directly from the authors, C.J. Hollins Martin and V. Fleming or C.R. Martin. The instrument is widely used in academic research.

The original PDF documentation for the instrument can be downloaded here: http://www.researchgate.net/profile/Caroline_Martin3/publication/50985570_The_birth_satisfaction_scale/links/540ec3f70cf2df04e756f736.pdf and here: http://www.midwifery.org.uk/wp-content/uploads/2013/01/Birth-Satisfaction-Scale.pdf

Reference’s

• Cetin, Fatma Cosar., Sezer, Ayse, Merih, Yeliz Dogan. (2015). The birth satisfaction scale: Turkish adaptation, validation and reliability study; North Clin Istanbul ;2(2):142-150.
• Fair CD, Morrison TE. (2012). The relationship between prenatal control, expectations, experienced control, and birth satisfactionamong primiparous women. Midwifery 28:39–44.
• Goodman P, Mackey MC, Tavakoli AS. (2004). Factors related to childbirth satisfaction. J Adv Nurs ;46:212–9.
• Hollins Martin, C.J. and Fleming, V. (2011). The Birth Satisfaction Scale (BSS). International Journal of Health Care Quality Assurance;24(2),124-135.
• Hollins Martin CJ, Martin CR. (2014). Development and psychometric properties of the Birth Satisfaction Scale-Revised (BSS-R). Midwifery;30:610–9.
• Hollins Martina, Caroline J., Snowdenb, Austyn & Martinb Colin R. (2012). Concurrent analysis: validation of the domains within the Birth Satisfaction Scale. Journal of Reproductive and Infant Psychology ;30(3): 247-260.

Items of the Birth satisfaction scale (BSS)

Birth satisfaction scale (BSS), 2009

1. I coped well with my birth.
2. The delivery room staff encouraged me to make decisions about how I wanted my birth to progress.
3. I was well prepared for my labour, i.e., read a lot of literature and/or attended parenthood education classes.
4. I found giving birth a distressing experience.
5. I came through childbirth virtually unscathed
6. I gave birth to a healthy normal baby.
7. During labour I received outstanding medical care.
8. I received a lot of medical intervention, i.e., induction, forceps, section etc.
9. I had a swift and speedy labour.
10. I felt well supported by my partner during labour and birth.
11. I was encouraged to hold my baby for a substantial amount of time after birth.
12. My birth experience was considerably different from what I intended.
13. I had the same midwife throughout the entire process of labour and delivery.
14. I felt that the delivery room was unthreatening and comfortable.
15. I felt very anxious during my labour and birth.
16. I felt out of control during my birth experience.
17. I felt it was better not to know in advance about the processes of giving birth.
18. I was not distressed at all during labour.
19. I felt mutilated by my birth experience.
20. My baby was avoidably hurt during birth.
21. The staff provided me with insufficient medical care during my birth.
22. I had a natural labour, i.e., minimal medical intervention.
23. I thought my labour was excessively long.
24. I felt well supported by staff during my labour and birth.
25. I was separated from my baby for a considerable period of time after my birth.
26. My birth proceeded as I planned it.
27. The staff communicated well with me during labour.
28. The delivery room was clean and hygienic.
29. Giving birth was incredibly painful.
30. Labour was not as painful as I imagined.

Birth satisfaction scale -Revised (BSS-R), 2014 (10 items)

1. I came through childbirth virtually unscathed.
2. I thought my labour was excessively long.
3. The delivery room staff encouraged me to make decisions about how I wanted my birth to progress.
4. I felt very anxious during my labour and birth.
5. I felt well supported by staff during my labour and birth.
6. The staff communicated well with me during labour.
7. I found giving birth a distressing experience.
8. I felt out of control during my birth experience.
9. I was not distressed at all during labour.
10. The delivery room was clean and hygienic.