Background

Declining birth rate is an issue of international concern as the average global birth rate has reduced from 20.09 per 1000 of the total population in 2007 to 19.4 births per 1000 of the total population in 2014.1 Asia has been one of the most affected regions in the world,2 where birth rates have been consistently declining over the past decade. The reasons for declining birth rates are multi-factorial and include maternal expectations, age, economic status, career and previous negative birth experiences.3-5 However, studies have found that childbirth experience was one of the main factors affecting birth rate.6,7

Childbirth experience is a complex phenomenon that is influenced by social, environmental, organizational and policy factors.8 As each mother perceives and interprets childbirth experience differently, giving birth to their first child can have either a positive or negative effect on new mothers.9 When a woman's experience matches their expectation, childbirth can be a positive experience for them.10,11 This positive childbirth experience can greatly empower a woman's transition into motherhood and promote mother-child and spouse bonding, which may in turn enhance parenting satisfaction.12-14 Social and emotional support received from healthcare professionals and significant others has been seen to enhance positive childbirth experience.15,16

Every mother has their own perceived expectations of childbirth; however, when childbirth experience is vastly different from their expectations, this may lead them to feel like they are "not in control"10^(p.475) and incompetent.11,17 This, in turn, may cause women to experience continuous psychological pain.18-20 Negative experience of childbirth can happen when threat of or actual injury is caused to the mother or the baby, causing fear for their own or their infant's safety.13 Reports of dissatisfaction with a birth experience are associated with both physiological and psychological factors.14 Physiological factors contributing to a negative experience of childbirth include prolonged delivery, emergency caesarean section, excruciating pain and unplanned interventions during delivery such as instrumental delivery, induction and augmentation of labor and obstetric complications.18,19 Psychological factors include a decreased authority to make decisions, unmet maternal expectations, feeling powerless, a lack of caregiver support, a loss of control, anxiety and poor midwifery care.17-21 Social factors, such as a lack of support from their partner or the midwife in the early postpartum period, are also associated with negative childbirth experiences.21 Any of these physiological, psychological and social factors will be considered as perceived negative experience to childbirth for this review.

Going through a negative childbirth experience can result in a longer time interval between having children.22 This could be due to the long period of time taken to recover from the trauma. Previous research has shown that 38% of women who had a negative experience of childbirth avoided having children in the next eight to 10 years compared to 17% who had a positive experience and therefore, had another child.20 Most women who had a negative birth experience specifically requested for a caesarean section instead of a vaginal delivery for their second child.23,24 Choosing a caesarean section instead of having a "natural" childbirth could be viewed as a possible "way out" for a woman who is trying to evade her fears of childbirth instead of facing them.18 Previous negative childbirth experience is found to be the most important factor in explaining the fear of childbirth during pregnancy to one year after birth.11-13,25-30 Emergency caesarean section and vacuum extraction during previous births are factors associated with the fear of future birth.31 A meta-synthesis of literature32 revealed that a negative birth experience could lead women into a turmoil of devastating emotions that have long-term negative repercussions on self-identity and relationships. Support by professionals in recognizing and sensitively responding to these women's psychosocial concerns is recommended. The training of professionals to enhance their awareness and, as such, prevent the trauma is needed to facilitate a smooth transition to motherhood.

Literature has shown that childbirth experience is one of the many factors that may influence birth rate and that many new mothers experience childbirth negatively. The main focus of previous literature remained on examining the risk factors associated with negative childbirth experience. However, the implications of negative childbirth on future reproductive decisions, specifically on future pregnancy and mode of delivery, have not been examined systematically. As such, the aim of this review is to examine the impact of negative childbirth experience on the future reproductive decisions of mothers including not having another child, having a delay in conceiving another child and a request for caesarean section. This is to enable evidence to be synthesized to inform supportive interventions for vulnerable mothers. Hopefully, with supportive interventions from healthcare professionals, negative childbirth experience can be prevented or minimized, and women may make better reproductive decisions, including having more children, which in turn may address the declining birth rate. A search in the Cochrane Collaboration and the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports did not reveal any previous systematic reviews on this topic.

Inclusion criteria

Types of participants

This review will consider studies that include adult women (18 years old or above), both primiparas and multiparas, regardless of education, race, culture and ethnicity who have given birth at term (37-42 weeks) at either private or public hospitals and have had a negative experience of childbirth. Studies involving mothers below 18 years old, preterm birth, mothers who have delivered stillborn babies and mothers with psychiatric or/and psychological conditions will be excluded.

Exposure

Any exposure that leads to a perceived negative experience of childbirth including, but not limited to, physiological (such as prolonged delivery, emergency caesarean section and excruciating pain), psychological (such as feeling powerless) and social factors (such as lack of support) that could impact future reproductive decision will be considered.

Outcomes

The primary outcome is the future reproductive decisions of mothers after suffering a negative experience of childbirth, which will include at least one of these outcomes:

* not having another child

* having a delay (at least five years) in conceiving another child

* a request for caesarean section without medical indication in future births.

These outcomes will be measured using, but will not be not limited to, questionnaires, observations and other methods specified in primary studies.

Types of studies

This component of the review will consider any study design including before and after studies and cross-sectional studies such as surveys, cohort studies, case-control studies descriptive studies and case series.

Search strategy

The search strategy aims to find both published and unpublished studies and papers. The search will be limited to English language reports. A three-step search strategy will be utilized in this review. An initial limited search of PubMed and CINAHL Plus with Full Text will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken (Appendix I). Third, the reference list of all identified reports and articles will be searched for additional studies. There has been a vast advancement in the areas of obstetrics and gynecology and family health over the years, such as emphasis on physiological births, water births, use of different positions during labor, non-pharmacological pain relief and advancement in technology related to pregnancy and birth. Therefore, to include the most current evidence, the search strategy of this review will be limited to the past 20 years from 1996 to 2016.

The databases to be searched include the following:

* CINAHL Plus with Full Text

* PubMed

* Scopus

* Web of Science

* Embase

* PsycINFO.

A federated search engine, MedNar, will be used to search for unpublished studies.

Initial keywords to be used will include caesarean section, delayed pregnancy, delayed future birth, future reproductive decisions, sexual health decisions, reproductive choices, reproductive decisions, fear of birth, negative childbirth experience, unwanted childbirth experience, painful childbirth experience, unforgettable childbirth experience and traumatic childbirth experience.

Assessment of methodological quality

Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (Appendix II). Any disagreements that should arise between the reviewers will be resolved through discussion with a third reviewer.

Data extraction

Quantitative data will be extracted from papers included in the review using the standardized data extraction tools from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (Appendix III). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. For missing information or data that need clarification, the authors of primary study will be contacted.

Data synthesis

Where possible, quantitative research study results will be pooled in a statistical meta-analysis using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument. All results will be double entered. Odds ratio and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible, the findings will be presented in a narrative form.

Acknowledgements

We would like to thank Dr Siti Zubaidah Mordiffi, Assistant Director of Nursing, National University Hospital and Ms Wai Kin Yip, Nurse Educator I, National University Hospital, for their guidance and support.

Appendix I: Search strategy

Appendix II: Appraisal instruments

Appendix III: Data extraction instrument

MAStARI data extraction instrument

References