2.1. The Hungarian Context of Pregnancy and the Postnatal Period
An expectant woman, as well as the life of the foetus from the moment of conception, enjoy special legal protection and support, as articulated in The Fundamental Law of Hungary (25 April 2011) and related statutes and decrees. Besides declaring these rights, their enforcement should also be ensured by both the health care system and the expectant parents themselves. Free prenatal and intranatal care provided by the state as well as the expertise and skills of various professionals are especially important because they contribute significantly to the mother’s sense of safety. The Health Act determines the mother’s right to choose the person who may accompany her during labour and birth. A government decree regulates the free choice of institution and doctor as well as the criteria and professional rules of home birth. The decree on prenatal care prescribes that, in addition to the screening tests carried out by physicians and health visitors, professional consultation and communication of a range of self-help and supportive knowledge and methods should be provided within the framework of preparation/education for pregnancy, birth and breastfeeding. The scientific and methodological foundations for this were laid by a Hungarian workgroup introducing and inspiring a family-centred approach and care in obstetrics, which had been adopted by several other fields, institutions and research workshops (
Tiba and Paál 1987;
Tiba and Várfalvi 1989). (See the list of relevant Hungarian laws after the bibliography).
From the mid-1980s onwards, a family-centred approach gained momentum and a movement emerged which became increasingly open to preparing expectant couples for pregnancy, birth, breastfeeding and, in intranatal care, the demands of the mothers and childbearing couples, the physiological and psychological needs of the foetus, stress-free, gentle ways of giving birth and being born, and support for early bonding and breastfeeding on demand (
Tiba and Várfalvi 1989). In 1992, WHO launched the “Baby-Friendly Hospital Initiative”, an approach and movement that had been adopted early in Hungary, first by the University of Debrecen Gynaecology and Obstetrics Clinical Centre.
In 2018, the Hungarian government took a decision on family-friendly measures. The aim is to implement the family-friendly values, the family- and child-friendly approach, as widely as possible, and to create family-friendly measures and regulatory environments for this purpose. The Government agrees with the development concept of domestic maternity care that satisfies the needs of families, increases the birth of a new family, a positive childbirth experience, and the comfort of the childbirth period, and that Hungarian obstetric institutions operate in as family-friendly a way as possible.
Irrespective of how childbirth occurs, it is an essential question whether childbirth experience has an impact on the propensity to have a child in the future. In a related study,
Kisdi (
2016) concludes that the appraisal of birth does not affect future childbearing plans. This issue depends least of all on the actual process of delivery, with future plans being affected rather by the experience of pregnancy and puerperium. According to a survey of childbearing plans in countries of the European Union (
Testa 2006), 40% of respondents said that they had had fewer children than they wished to have when they were 20 years old; (Hungary came sixth; the lowest proportion of those who felt that they could fulfil their plans were found in Denmark, while two-thirds of respondents said that they could achieve the desired number of children in Bulgaria, taking the last position). Among reasons for differences in planned and realized number of children, health issues and problems with the partner figure most frequently, while no reference to childbirth experience has been found.
The reason for childbearing postponement and (often parallelly) failure to have another child/more children is frequently associated with improvement in levels of education. Young people stay at school for increasingly longer periods, which delays events in their personal lives. Nevertheless, the intended number of children is the highest by far among those with tertiary-level education; in fact, it exceeds conspicuously the expected reproduction level even during their academic years. Data from a survey with a sample of 1500 show that the average number of planned children is 2.5 among university students (
Engler 2018). Studies conducted by
Kopp (
2010) revealed that the opening of the scissors for the numbers of desired versus actually delivered children is the widest among those with tertiary-level education, particularly women. While three decades ago an increase in education was normally associated with a decrease in the number of children, today women with secondary and tertiary level education show similar fertility, which is in turn lower (approximately 1.6) than fertility among women who completed a lower level of education (2.4). Women who stay at school for longer periods in order to obtain a degree or diploma usually catch up for the number of children during the shorter fertile period after graduation, which women with lower education began at a younger age (
Kapitány and Spéder 2015). Moreover, it can also be noted that child-raising students are by no means at a disadvantage—on the contrary, their academic activity and attainment exceeds that of their childless peers (
Engler 2017).
2.2. The Experience, Conditions and Impacts of Childbirth
Human factors include the physician’s person and expertise, the midwife’s work, and the presence of supportive family members or other companions.
Kisdi (
2016) examined approximately 70 birth experiences through in-depth interviews. She concluded that the physician’s person, rather than strictly his/her activities and involvement, is crucial with respect to the mother’s sense of safety. Another decisive factor was found to be the presence of the mother’s partner. Most respondents asked their partners to be present, and even when an operation was necessary, it proved to be helpful that the father could witness the event through a glass panel. The partner’s presence and support also manifest hormonally, since it can activate the central oxytocin system, facilitating labour (
Varga 2015). The role of supportive relationships (father, parents, siblings, and friends) is highlighted in the study by
Aune et al. (
2015). According to their results, a stable network makes women emotionally strong, so they are better able to cope with stress, and so the experience of childbirth becomes positive.
Hildingsson et al. (
2011) associate a father’s positive birth experience and, later, the strength of ties between father and child with the degree and quality of engagement experienced during the childbirth process. Some research called attention to the psychological aspect of preparation, supporting efforts to provide psychophysical preparation for expectant women, which has, in addition to obstetrical advantages, positive physiological, psychological and emotional outcomes in the delivery room (
Tiba et al. 1985;
Tiba and Miklósi 1987;
Duncan and Bardacke 2010;
Henriksen et al. 2017;
Abbass-Dick et al. 2020;
Damashek et al. 2020).
The primary aspects of the labour and birth process are duration, degree of pain, methods of pain relief and surgical techniques and the mode of birth (natural or caesarean section), while the involvement of the childbearing woman and her partner in the process is also essential. Involvement during childbirth is also a crucial issue in evaluating this process. Women who were continuously informed by their doctors or midwives, and who were asked about their opinions and consent at each stage, tend to have more favourable memories of the labour and birth process (
Lavender et al. 1999;
Henriksen et al. 2017). Those who were present not as patients but as partners did not feel as if they were in the usual hospital hierarchy. This positive attitude becomes clear already in the early stage of pregnancy: in the course of examinations, consultations and preparation expectant mothers are treated as equals. If, for instance, we focus on the question of artificially increasing the oxytocin level (OT infusion), we can see that methods of its application and giving information on its effects receive little attention. Yet, “maternal OT infusion during labour may reach the brain of the fetus, exposure to OT in the postnatal period gives rise to lifelong effects. These effects include antistress-like effects, such as the lowering of blood pressure and corticosterone levels, an increased pain threshold and weight gain. The effects are sometimes not apparent until adulthood” (
Jonas et al. 2007, p. 61; see also
Varga 2009, p. 468).
Nurses and midwives also have an important role in childbirth experiences. Often women are grateful for their husbands’ and families’ help, but they preferred a nurse’s care. Sometimes, it is felt that doctors and nurses concentrate on technology rather than their care (
Fleming et al. 2011). A midwife can help women with preparing for birth, providing information, increasing understanding, and keeping up communication. As a result, women may develop confidence in the process of labour and birth and in their own ability to give birth (
Lothian 2006). A positive relationship between mother and midwife contributes to the positive experiences (
Karlstörm et al. 2015).
Kitzinger (
2006) notes that hospital protocols and the authoritarian system of this “total” institution also force caregivers working in obstetrics to conform to a well-established hierarchy of relations, which hinders the mother’s otherwise special treatment. In addition to this mechanized, technocratic system, unpredictability and the lack of information also increases the distance between the actors of this inherently natural process (
Soltész et al. 2015). However, childbirth satisfaction is to result from having a sense of control, having expectations met, feeling empowered, confident and supported (
Farahat et al. 2015). Partly because of this, in Central and Eastern Europe the rate of giving informal payment to doctors is high, as in Hungary. According to studies, paying women hope that their obstetrician will be more acceptable and respectful to them and they will get higher quality care. The most important paying factor was the promise of the chosen doctors’ presence at delivery, even if the presence of the chosen obstetrician leads to unnecessary interventions (
Baji et al. 2017).
Some studies show a strong correlation between antenatal care, childbirth experience and social background. Inequality is appearing among women requiring antenatal care (
Pandey 2004). Often the young, rural, lower-income mothers and less educated women may not benefit from antenatal care services or may drop out due to barriers and low-quality services (
Oyinlola et al. 2018). According to the surveys conducted by
Varga et al. (
2011), decisions on family formation, pregnancy and childbirth conditions are influenced by age, educational background, health, financial situation and social support. Studying young women’s views of childbirth,
Sallay et al. (
2015) found diverse attitudes to giving birth, with influencing background factors such as subjective well-being, religiosity and the respondent’s own experience of being born. While some research shows that socio-economic status has only a slight significant effect on satisfaction (
Mocumbi et al. 2019), other research suggests that women are more satisfied with maternal care living in the countryside, where they did not give informal payment and where the educational level is highest (
Mehata et al. 2017;
Tocchioni et al. 2018).
Most obstetrics divisions aim to ensure that the newborn has bodily contact with the mother as soon as possible, for example by putting the infant on the mother’s abdomen right after delivery so that she can caress her child. However, not all institutions follow this practice, or certain conditions and necessary medical treatments do not allow the mother or newborn to experience it. Nowadays, the imminent need for skin-to-skin contact (imprinting) between mother and child is not considered a condition for early attachment, since it is not supported by scientific evidence that the absence of such contact has a harmful effect on the mother–child relationship (
Gervai 1997). The fulfilment of this objective is also supported by preparing expectant mothers through the transfer of knowledge, methods and practical techniques (
Várfalvi 1999). Childbirth as well as skin-to-skin contact immediately after birth and the initiation of suckling within the first, “golden hour” of life are crucial events (
Moore et al. 2012). Subsequently, when the mother and the newborn are accommodated together, exclusive breastfeeding facilitated within the framework of the rooming-in service promotes the infant’s adaptation and resilience, and successful suckling establishes the basis for his/her healthy physical and mental development. For the mother too, breastfeeding is a natural process, hormonally supported by her body, but numerous affective and cognitive factors may influence the ability and effectiveness of breastfeeding. Nevertheless, the role of early attachment is undebatable; its long-term impact on the child can be detected in the partnerships and parental role he or she would have in adulthood (see, for example,
Diehl et al. 1998;
Feeney and Noller 1990;
Fraley 2002;
Roelofs et al. 2006;
Pace and Zappulla 2011;
Szalai 2014).
Delivery by caesarean often prevents the mother and the newborn from staying actively together. However, this is not the only reason for C-sections being under scrutiny. While WHO defines the optimum rate of caesarean sections as 10–15%, average rates for both Europe as a whole and Hungary are considerably higher than this figure (
Gibbons et al. 2010), and very different around the world (
Sepehri and Guliani 2017;
Harrison et al. 2017;
Boatin et al. 2018). In Hungary, there is a significant increase in the proportion of C-sections: as much as 41% were registered for 2018, compared to 20% of births in 2000. In the same period, the rate of planned interventions grew from 6% to 13%, while the proportion of operative interventions ordered during labour increased from 14% to 26%. The increase in caesarean rates can be explained, among other factors, by an increase in maternal age, previous caesarean births, the obstetrician’s growing professional experience and certain periods of time, such as workdays or December (
Gyarmati et al. 2009). According to other research, the great amount of increase in caesarean section frequency cannot be explained only by classical obstetric risk factors nor the higher maternal age, but is presumably related to changes in provider and midwife attitudes (
Cavallaro et al. 2016;
Póka et al. 2020).
Data from a ten-year longitudinal study in Hungary (
Gyarmati 2010) show that an approximately four-year increase in the average age of childbearing women has raised the rate of operative intervention by 5%. This can be interpreted with the result that increased maternal age may entail prolonged labour and inefficient uterine contractions. The same study suggests that the relationship between obstetricians’ professional experience and the number of caesarean births may be explained with the composition of the group who can make autonomous decisions on the mode of delivery (more elderly doctors) and accumulated knowledge (more adverse experience with wrong decisions and pregnancy outcomes), and that more experienced obstetricians probably undertake to conduct more complicated deliveries. Based on his research findings, Gyarmati concludes that a further increase in CS rates is predictable. Due to a change in approach (the newborn and the mother can leave hospital only when both of them are healthy), doctors have to meet strong societal demands, which is also reflected in the increasing number of malpractice lawsuits. Preference for CS is also justified by the fact that advanced surgical methods, modern technical devices and experience gained makes this intervention increasingly safe, and the chance of CS causing complications has decreased (or certain problems may manifest much later). Thus, when considered with a view on safe outcomes and when its potential late harmful effects on the mother are ignored, caesarean section seems to be the mode of birth with fewer risks.
Not only caution on the part of doctors, but also childbearing women’s fear, may support preference for this solution. Review studies such as
Sallay et al. (
2015) or
Karlström et al. (
2011) clearly show that women prefer C-sections because of their fear of birth. Women who prefer to give birth with C-section, most likely to try to avoid damage to the body, are also likely to choose the caesarean section because of their ability to plan the time of birth, while some of them believe CS is better, safer and healthier for the mother (
Stoll et al. 2017).
We can raise the question of how these mothers evaluate their caesarean births afterwards (irrespective of whether it was elective, planned, or the outcome of a process that started as a natural birth). In some narratives of childbirth experience, respondents consider caesarean section the same process of “giving birth” as natural delivery and report that it does not impact their birth memories or appraisals negatively or positively (
Kisdi 2016). However,
Malacrida and Boulton (
2012) found in their survey that women who had gone through unplanned C-sections were less likely to experience the rite of passage to motherhood. Furthermore,
Carquillat et al. (
2016) found that women who gave birth by caesarean section (especially emergency CS) reported more negative feelings about their first moments with the newborn, felt less safe, had a more negative relationship with staff, and felt worse in the month after giving birth. The results of
Karlström et al. (
2011) suggest that women who give birth with a chosen caesarean section are not more satisfied with the birth experience compared to women who give birth vaginally, so a caesarean section is not a guarantee of a positive birth experience.
Some studies point out that informal payment strengthens the social selection, and this effect is reflected in the number of planned caesarean sections (
Veroszta and Boros 2020). Mothers give birth in public hospitals, and often an out of pocket paid private doctor at birth undercuts health care access and contributes to increasing social inequalities (
Schaaf and Topp 2019;
Veroszta and Boros 2020). The chances of a caesarean section are also higher among elderly women, those in a better financial position, those with higher education and those living in urban environments, or if complications have developed during pregnancy (
Amjad et al. 2018;
Rydahl et al. 2019).
Yet, how birth is perceived is not based solely on personal experience. Widespread or latent narratives of childbirth (giving birth and being born), as well as dominant patterns of representation in the media greatly influence this impression prior to gaining actual experience. These cultural perceptions in turn may also be decisive in how the woman understands the birth process and what kind of decisions she makes about her own delivery. Prior knowledge on birth may derive from several sources such as (a) experience of a previous delivery, (b) interactions with doctors and health visitors during antenatal care, (c) birth narratives of family members, relatives and friends, (d) often dramatic representations of childbirth experience in the media or (e) social media communities. It is also clear that media as the most effective agents of socialization have a great impact on how the woman experiences childbirth (
Morris and McInerney 2010;
Prot et al. 2015;
Luce et al. 2016). Representations of birth in the media as dramatic, painful and dangerous, its portrayal as an extraordinary life event, the underrepresentation of obstetric nurses, health visitors and midwives and the fact that media content is less likely to reflect uncomplicated birthing may influence expectations of childbirth and promote the medicalization of this natural phenomenon; eventually, it can affect both the process and experience of childbirth.
Generally, data drawn from literature show that childbirth experience is positively impacted by better sociocultural backgrounds and social (family) support, while it is negatively influenced by high-risk pregnancy and caesarean. This study is based on the assumption that a caesarean section has a negative effect on the childbirth experience, and that groups with more favourable sociocultural backgrounds tend to have a higher rate of caesarean births.
Our hypotheses are the following: