Evolution of women satisfaction with labor pain management: a real-time study across nine maternity units

Evolution of women satisfaction with labor pain management: a real-time study across nine maternity units | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evolution of women satisfaction with labor pain management: a real-time study across nine maternity units Corinne Dupont, Laurent Gaucher, René Ecochard, Carole Vuillerot, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7459726/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background A lack of consideration of labor pain by caregivers was a factor in women' dissatisfaction with their childbirth experience. The aim of this study was to measure changes in women' satisfaction with caregivers' consideration of their pain, to identify the environmental factors modifying the perception of pain and to measure their satisfaction about the moment of relief pain and the information received about pain support and management. Methods A multicentre prospective cohort study was conducted in nine French maternity units. Women admitted for vaginal birth of a singleton fetus at ≥ 37 weeks of gestation were included. Data were collected every two hours throughout labor using self-reported questionnaires assessing pain management satisfaction, environmental factors, and received information. Cervical dilatation and analgesia use were recorded. Satisfaction scores were analysed according to cervical dilatation and epidural analgesia status. Factors influencing pain perception were identified based on reported occurrences. Results Of the 225 women who agreed to participate, 215 received epidural analgesia. Their satisfaction scores remained consistently high throughout labor, averaging around 9.5/10. In women without epidural analgesia (n = 10), satisfaction declined after 6–7 cm of dilatation. On admission, 37.3% of all women reported pain-intensifying factors, mainly physical discomfort, sound and lighting, and staff unavailability. Two hours post-delivery, pain-intensifying factors were delayed pain relief, disturbing sound environment, and insufficient information on mobility and the possibility of drinking during labor. Conclusion Women satisfaction were high, especially after epidural analgesia. Modifiable factors such as timeliness of relief, environmental conditions, and autonomy warrant targeted interventions. childbirth experience pain physical environment Figures Figure 1 Figure 2 Figure 3 Background The World Health Organization highlights the importance of ensuring a positive experience for all women ( 1 ). While most women report childbirth as a positive event, a significant proportion experience it negatively, with far-reaching psychological and physical consequences. These include postpartum depression ( 2 ) post-traumatic stress disorder ( 3 , 4 ), sexual dysfunction ( 3 ), difficulties in breastfeeding ( 5 ) and reluctance toward future pregnancies ( 6 ). Fear stemming from a traumatic birth can also increase the preference for caesarean delivery in subsequent pregnancies ( 7 , 8 ). Overall, childbirth experience is a key determinant of maternal and neonatal outcomes in the short term ( 9 , 10 ). Among the contributors to negative experience, labor pain remains one of the most significant. However, the intensity of pain is not the sole determinant of satisfaction. Evidence consistently shows that the timing and delivery of pain relief, and more crucially, the extent to which caregivers are perceived to acknowledge women’s pain, shape how labor is experienced. A systematic review has underlined that analgesia alone does not ensure a positive experience unless it is accompanied by empathy and support ( 11 ). When women feel that their requests for pain relief are dismissed or not prioritised, their perception of care deteriorates. These perceptions weigh more heavily on satisfaction than the effectiveness of the medical intervention itself ( 12 ) ( 13 ). Insufficient attention to labor pain by caregivers has been reported as a key driver of dissatisfaction ( 14 ), and recent evidence has drawn a direct link between such dissatisfaction and the development of postpartum post-traumatic stress disorder ( 13 ) ( 15 ) . Despite growing awareness, the literature still lacks studies capturing how women’s satisfaction with pain management evolves during labor itself. Most available data assess outcomes retrospectively or focus solely on pain intensity in relation to treatment. The dynamic, real-time evolution of satisfaction in response to caregiver behaviour, environment, and communication remains unexplored. This study addresses these gaps. The primary objective was to assess changes in women’ satisfaction with how caregivers considered their pain throughout labor. Secondary objectives were to identify modifiable environmental factors influencing pain perception and to evaluate satisfaction with the timing and clarity of information provided on pain relief. Methods Study Design and Setting This was a prospective, multicentre, observational cohort study conducted across nine maternity units of varying levels (Type I to III, i.e. with or without neonatal units) within the AURORE Perinatal Network in France. These facilities were selected to ensure diversity in type, status (public or private), and volume of activity, providing a sample broadly representative of the general obstetric population. Inclusions took place between February 3, 2022 and October 12, 2023, a period influenced by the COVID-19 pandemic, which occasionally impacted staff availability (Appendice I). Participants Eligible participants were woman admitted in labor for vaginal delivery of a singleton, viable fetus in cephalic presentation, at ≥ 37 weeks of gestation, regardless of cervical dilatation at admission. Women who declined participation or were unable to understand French were excluded. Information about the study was displayed in antenatal clinic waiting rooms from January 2022. Additionally, obstetricians, anaesthetists, and midwives introduced the study during final prenatal consultations and answered participants’ questions. Informed written consent was obtained prior to inclusion. Data Collection Procedures Data were collected using three structured questionnaires (Appendice II- IV) developed in collaboration with a methodologist (CV) and a steering committee (CD LG LB RE), and tested for clarity with five women and the user association Collectif inter associatif autour de la Naissance ( https://ciane.net/ ): Labor Questionnaire Administered on admission and then every two hours during labor, jointly completed by the woman. The primary outcome was assessed by a self-rated satisfaction score (0 = not at all, 10 = perfectly) concerning how well the caregiver addressed labor pain. It also included questions on factors affecting and intensifying pain perception. Women blinded their responses with self-adhesive strips to ensure privacy. Postpartum Questionnaire Completed by the woman in the delivery room after birth, also sealed to maintain confidentiality. It explored satisfaction with the clarity of information about pain relief options, opportunity to discuss those options, and timing of relief (rated as too early, at the right time, late, or too late). It also included questions on mobility and hydration during labor. Medical Questionnaire Completed by the midwife post-delivery to document obstetric characteristics, interventions, and outcomes. Outcomes The primary outcome was self-reported satisfaction score (0–10) evaluating how caregivers responded to pain, measured every two hours from admission to delivery. Secondary outcomes included: The proportion of women reporting environmental or contextual factors that increase pain perception during labor. The number and types of environmental factors that altered pain perception during labor Satisfaction with the timing and clarity of pain relief information, assessed within two hours after birth. Study size The number of participants was not fixed a priori. All eligible and consenting women admitted to one of the nine partner maternity hospitals between February 2022 and October 2023 were included. Statistical Analysis All analyses were performed using R version 4.4.2 (2024-10-31; The R Foundation for Statistical Computing, Vienna, Austria). A descriptive analysis was conducted to characterize the study population. Qualitative variables were expressed as frequencies and percentages, while quantitative variables were summarized using mean and standard deviation or median and interquartile range, depending on the distribution of the data. The normality of distributions was assessed using the Shapiro-Wilk test. Satisfaction with pain management was evaluated using a numeric scale ranging from 0 to 10, at multiple time points during labor according to cervical dilatation. For each time point, data on cervical dilation and use of epidural analgesia were extracted. Two distinct curves were constructed: one for women who ultimately received epidural analgesia and another for those who did not. The data were reshaped to a long format and merged by participant ID and time point. Mean satisfaction and 95% confidence intervals were computed by centimeter of dilation. To avoid extreme values, satisfaction scores were truncated at 10. Smoothing curves (loess method) were plotted separately for women with and without epidural analgesia, across cervical dilation from 0 to 10 cm. Environmental conditions were assessed every two hours, from admission to the birth room until childbirth. The mean score attributed to the ambiance and physical environment was analyzed at each time point to evaluate their impact on pain perception. The pain threshold considered significant was set at 7 on a visual analog scale (VAS)( 16 ). To identify factors that either intensified or alleviated the perception of pain, responses from women were analyzed. The total number of mentions for each factor was recorded, along with the proportion of women who reported being affected. To refine the analysis, the proportion of citations was also calculated relative to the total number of comments collected. Participants with fewer than three recorded time points or missing data for the primary outcome were excluded from the final analysis. No formal sample size calculation was performed. Results Over the observation period, 13,034 deliveries occurred across the nine participating maternity units. A total of 312 women (2.4%) consent to participated and completed the labor questionnaire at least once. Of these, 87 were excluded from analysis due to incomplete data (n = 3) or labor duration too short to allow at least three satisfaction assessments (n = 84, including 65 labors under four hours and 19 with insufficient time points). The final study population comprised 225 women. Participants were recruited from both private (52.9%) and public (47.1%) institutions. Most were included from Type II maternity units (60.9%), followed by Type I (26.2%) and Type III (5.8%) (Table 1 ). Table 1 Distribution of women included according to type of maternity hospital and status Status Women N = 225 n (%) Type III university Public 13 ( 5 , 8 ) Type II Public 76 ( 33 , 8 ) Private 61 ( 27 , 1 ) Type I Private 58 (25,78) Public 17 (7.56) Sociodemographic and obstetric characteristics are presented in Table 2 . The majority of women were primiparous (68.9%) and had completed higher education (69.3%). Nearly all gave birth vaginally (88.9%), and 95.6% received epidural analgesia (Table 2 ). Table 2 Characteristics of included women N = 225 n (%) Country of birth Metropolitan France 201 (89,3) Other country 12 (5.3) Overseas department or region 3 (1.3) Level of education School 4 (1.8) High school 48 (21.3) Baccalaureat + 2 years 58 ( 25 , 8 ) Baccalaureat > 2 years 98 (43,6) Preparing for birth and parenthood 157 (68.8) Early prenatal interview 95 (42.2) Primiparous 155 (68.9) Hospitalization during pregnancy 16 (7.1) Mode of delivery Emergency cesarean section during labor 13 (5.8) Non-emergency cesarean section during labor 11 (4.9) Instrumental extraction 59 (26.2) Spontaneus vaginal delivery 141 (62.7) Episiotomy 22 (9.8) Perineal laceration No 59 (26.2) 1st and 2nd degree 133 (59.1) 3rd et 4th degree 6 (2.7) Epidural analgesia 215 (95.6) Among women who received epidural analgesia (n = 215), satisfaction scores remained consistently high throughout labor, with minimal variation across dilation levels (Fig. 1 ). In contrast, for women without epidural analgesia (n = 10), satisfaction appeared stable until 6–7 cm, after which a marked decline was observed (Fig. 2 ). Confidence intervals were wider in the non-epidural group due to smaller sample size, but remained below the satisfaction cap of 10 points. Self-reported discomfort related to environment and setting remained low and stable throughout labor, with average scores of 3.0/10 at H0, 2.8/10 at H2, and 2.6/10 at H4 (p = 0.2, Wilcoxon paired rank test). On admission, 37, 3% of women reported environmental factors whose worsening their pain perception and 18.7% (42/225) with a score VAS ≥ 7. The most frequently cited factors worsening pain perception were physical or positional discomfort, sound, and lighting. Staff availability was noted by only five participants (Table 3 ). Table 3 Factors reported by women during labor as intensifying the perception of their pain (n = 225) Factors Women reported factors N = 225 Among women with a score VAS ≥ 7 N = 84 Number of reported factors 84 (37,3%) 42 (50,0%) Physical or installation discomfort 33 16 Sound environment 22 12 Light environment 13 8 Availability of staff 5 4 Temperature 4 2 Place (corridor ou small room) 3 0 Moving in and out of the room 2 0 Stress, fear 2 0 Unknown persons present 0 0 Free-text comments collected within two hours post-delivery revealed that 24.4% (55/225) of women identified at least one factor that increased their pain. Most frequent were unrelieved pain (n = 17), noise (n = 14), and discomfort related to positioning or monitoring equipment (n = 13) (Table 4 .a). Conversely, 92.9% (209/225) of women identified at least one factor that reduced their pain perception. Caregiver presence and support were most frequently mentioned (37.3%), followed by pain relief measures (12.0%) and room characteristics (9.3%) (Table 4 .b). Table 4 a Factors emerging from the free comments section reported by women as intensifying the perception of their pain Factors Number of comments % of women (N = 225) % of comments (N = 61) No 156 69,3 / Unrelieved pain 17 7,6 12,4 Sound environment 14 6,2 10,2 Discomfort related to equipment, position, stretcher, monitoring, APD, not drinking, temperature 13 5,8 9,5 Room, Place 7 3,1 5,1 Fatigue, Vomiting, Time management 5 2,2 3,6 Staff (questions, lack of pain management) 3 1,3 2,2 Light environment 2 0,9 1,5 Table 4 b Factors emerging from the free comments section reported by women as reducing the perception of their pain Factors Number of comments % of women (N = 225) % of comments (N = 191) No 97 43,1 / Staff (support, listening) 84 37,3 61,2 Pain management 27 12,0 19,7 Room Place 21 9,3 15,3 Light environment 19 8,4 13,8 Calm, soothing atmosphere 11 4,9 8,0 Bath, shower, ball 10 4,4 7,3 Support (co- parent) 10 4,4 7,3 Position 5 2,2 3,6 Sound environment 4 1,8 2,9 Nearly all women (≥ 92%) expressed satisfaction with the clarity of information provided on pain relief and the opportunities they had to discuss their preferences. However, satisfaction regarding the timing of pain relief was lower, that is 80.9% considered it timely, while 19.1% reported it was administered too late (Fig. 3 ). Additionally, 12.1% of women confirmed that they received information about mobility and the possibility of drinking during labor. Discussion Main findings Among women who received epidural analgesia, satisfaction remained high through labor until childbirth. Among the few who did not receive an epidural, satisfaction declined strongly around cervical dilation of 6 to 7 cm. Although environmental conditions were not rated as highly impactful overall, specific elements, such as physical discomfort, noise, lighting, and perceived staff unavailability, were consistently reported as intensifying the perception of pain. Furthermore, while most women were satisfied with the information provided regarding pain relief options, nearly one in five felt that relief came too late. These findings underline the importance of responsiveness and communication in shaping the childbirth experience. Strengths and limitations This study has several strengths. It was conducted in a diverse sample of maternity units varying in size, type and status, and included women whose sociodemographic profiles largely mirrored national data ( 18 ), albeit with an over-representation of women from higher socio-economic backgrounds and primiparous women (69% versus 41.3% in the national survey) ( 18 ). This skew was inherent to the study design, which required a labor duration sufficient to allow repeated measures. A key innovation lies in the real-time assessment of satisfaction, using sealed questionnaires to ensure honest reporting without caregiver influence. To our knowledge, this is the first study to track satisfaction trajectories in real-time across multiple labor phases. A comparable study, conducted in Taiwan in 2008, focused on labor fatigue but did not measure satisfaction or pain perception ( 17 ). Limitations include the relatively small number of women without epidural analgesia, which restricted subgroup comparisons. Data collection was also affected by external constraints, including the COVID-19 context and a national midwives’ strike, which limited recruitment, especially in Type III hospitals. Our population had a higher level of education than the general population ( 18 ), as is generally described ( 19 ). Finally, the exclusion of women with labor durations under four hours may have biased the sample toward longer, potentially more difficult labors. Interpretation Our results reinforce existing evidence that a woman’s perception of caregiver attentiveness is more strongly associated with satisfaction than the effectiveness of analgesia alone since the score at the start of labor was also high without epidural analgesia ( 11 )( 12 )( 13 ). The stability of satisfaction scores among women with epidural analgesia throughout labor confirms the known efficacy of this method but also reflects the psychological reassurance provided by timely intervention ( 14 ). For women without epidural analgesia, pain and cortisol increased substantially throughout labor ( 20 ). A critical transitional phase shortly before complete cervical dilation has been documented in women’s experiential studies ( 21 ). Recent findings have established a link between unaddressed pain-related concerns and postpartum post-traumatic stress disorder ( 13 , 15 ), highlighting the stakes of caregiver responsiveness. Non-pharmacological pain relief methods, such as massage, acupressure, hydrotherapy, and breathing techniques, are recommended for labor ( 22 )( 23 )( 24 )( 25 ), yet remain underused. Their implementation often depends on caregiver training and time availability, resources which are often limited during high workload periods ( 26 ). The discrepancy between women’s expectations and the reality of care, particularly regarding the timing of relief and freedom of movement, suggests a need for better antenatal preparation. Despite efforts to inform women, antenatal classes remain heterogeneous in content, especially regarding pain anticipation and management ( 27 )( 28 )( 29 ). The difficulty in preparing primiparous women for an unfamiliar intensity of pain has also been described elsewhere and may partially explain the gap in satisfaction ( 28 ). Environmental factors, although often secondary in standard obstetric protocols, emerged as meaningful in our study. Over one-third of participants reported that ambient conditions negatively affected their perception of pain. These findings echo previous reports that both physical (light, noise, mobility) and relational (supportive presence) conditions influence women's emotional and physical experience during labor, irrespective of delivery mode ( 30 ) ( 31 ). Birthing environments that allow women to personalise their experience through control over light, sound, movement and hydration, have been shown to improve maternal outcomes and should be prioritized ( 30 ). Implication for Practice This study highlights several modifiable elements of labor care. First, ensuring timely pain relief, for all women, and be very supportive of women without epidural analgesia, in particular in active phase of the first stage, requires better use of pharmacological and non-pharmacological options, with appropriate caregiver training. Second, maternity teams should be sensitized to environmental discomforts, which are often underestimated but significantly affect the birth experience. Light, noise, physical positioning and freedom of movement are all actionable factors. Caregivers should also explicitly inform women during antenatal care about the likely timeline and limitations of analgesia delivery. Doing so may prevent the frustration expressed by the one in five women who felt that their pain relief was administered too late. Implication for Research Further research is needed to identify the most effective formats and content for antenatal education focused on pain management prior to epidural analgesia, especially for first-time mothers. Qualitative studies could also explore how women understand and internalize pain, expectations, and environmental cues during labor. Future research should aim to evaluate interventions that integrate environmental personalization and emotional support with clinical pain relief strategies ( 32 ). Additionally, expanding this type of study to include shorter labor and a broader range of cultural and linguistic profiles would enhance generalizability and equity in perinatal care research. Conclusion Women satisfaction with pain management during labor was high overall, particularly after epidural analgesia, while modifiable factors such as delay relief, environmental discomfort, and limited autonomy remained sources of dissatisfaction. Future efforts should focus on improving early labor support, enhancing environmental conditions, and preparing women more effectively through antenatal education. Declarations Ethics approval and consent to participate The protocol was submitted for approval to the Ethics Committee of the Hospices Civils de Lyon, which issued a favorable opinion on 8 June 2021 (N°21-127). As this is non-interventional research involving human subjects (MR004), the CNIL (N° 2205025 v0) has been informed of the study's compliance. This research was conducted in accordance with the Declaration of Helsinki. Consent for publication All authors have read and approved the manuscript and agree with its submission Availability of data and materials Data and materials were availability Competing interests The authors declare no competing interests. Funding This work was supported by APICIL Authors' contributions CD, LG, LB conceived, designed the cohort study, contributed to the methodological framework. CD drafted the initial version of the manuscript with support from LG and CC. LG, performed the statistical analyses, with support and validation from RE RE, CV contributed to the methodological framework AE contributed to the design of the study and questionnaires MC was responsible for data collection and management, ensured the accuracy and integrity of the dataset DC contributed to the design of the study All authors have contributed to different sections of the paper, provided input to its overall direction and content, and reviewed the paper to its final version. Acknowledgements Thanks to Valette Elsa, Moreon Christelle, Houdinet Nathalie, Etienne Elisa, Almodovar Alain, Vey Noélie, Petitbon Sylvie, Moreau Nathalie, Trenchat Béatrice, CLamote Diamantina, Gerard-Landry Mildrey, Gelsomino Lea, Serventon Adeline, Albasini Valérie, Antoine Armelle for supporting in situ inclusions and to the midwives who completed the medical questionnaire and to those who completed the questionnaire. References WHO recommendations Intrapartum care for a positive childbirth experience [Internet]. 2018. Available from: https://iris.who.int/bitstream/handle/10665/260178/9789241550215-eng.pdf?sequence=1 Urbanová E, Škodová Z, Bašková M. The Association between Birth Satisfaction and the Risk of Postpartum Depression. Int J Environ Res Public Health. 2021 Oct 5;18(19):10458. Ayers S, Eagle A, Waring H. The effects of childbirth-related post-traumatic stress disorder on women and their relationships: a qualitative study. Psychol Health Med. 2006 Nov;11(4):389–98. Ertan D, Hingray C, Burlacu E, Sterlé A, El-Hage W. Post-traumatic stress disorder following childbirth. BMC Psychiatry. 2021 Mar 16;21(1):155. Brown A, Jordan S. Impact of birth complications on breastfeeding duration: an internet survey. J Adv Nurs. 2013 Apr;69(4):828–39. Gottvall K, Waldenström U. Does a traumatic birth experience have an impact on future reproduction? BJOG. 2002 Mar;109(3):254–60. Suwanrath C, Chunuan S, Matemanosak P, Pinjaroen S. Why do pregnant women prefer cesarean birth? A qualitative study in a tertiary care center in Southern Thailand. BMC Pregnancy Childbirth. 2021 Jan 6;21(1):23. Eide KT, Morken NH, Bærøe K. Maternal reasons for requesting planned cesarean section in Norway: a qualitative study. BMC Pregnancy Childbirth. 2019 Mar 29;19(1):102. Chabbert M, Panagiotou D, Wendland J. Predictive factors of women’s subjective perception of childbirth experience: a systematic review of the literature. J Reprod Infant Psychol. 2021 Feb;39(1):43–66. Nilvér H, Wessberg A, Dencker A, Hagberg H, Wennerholm UB, Fadl H, et al. Women’s childbirth experiences in the Swedish Post-term Induction Study (SWEPIS): a multicentre, randomised, controlled trial. BMJ Open. 2021 Apr 7;11(4):e042340. Taheri M, Takian A, Taghizadeh Z, Jafari N, Sarafraz N. Creating a positive perception of childbirth experience: systematic review and meta-analysis of prenatal and intrapartum interventions. Reprod Health. 2018 May 2;15(1):73. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin No. 209: Obstetric Analgesia and Anesthesia. Obstet Gynecol. 2019 Mar;133(3):e208–25. Leavy E, Cortet M, Huissoud C, Desplanches T, Sormani J, Viaux-Savelon S, et al. Disrespect during childbirth and postpartum mental health: a French cohort study. BMC Pregnancy Childbirth. 2023 Apr 12;23(1):241. Joensuu J, Saarijärvi H, Rouhe H, Gissler M, Ulander VM, Heinonen S, et al. Maternal childbirth experience and pain relief methods: a retrospective 7-year cohort study of 85 488 parturients in Finland. BMJ Open. 2022 May 9;12(5):e061186. Leavy E, Cortet M, Huissoud C, Desplanches T, Sormani J, Viaux-Savelon S, et al. Disrespect during childbirth and postpartum mental health: a French cohort study. BMC Pregnancy Childbirth. 2023 Apr 12;23(1):241. Jensen MP, Chen C, Brugger AM. Interpretation of visual analog scale ratings and change scores: a reanalysis of two clinical trials of postoperative pain. J Pain. 2003 Sep;4(7):407–14. Tzeng YL, Chao YMY, Kuo SY, Teng YK. Childbirth-related fatigue trajectories during labour. J Adv Nurs. 2008 Aug;63(3):240–9. SPF. Enquête nationale périnatale. Rapport 2021. Les naissances, le suivi à deux mois et les établissements [Internet]. [cited 2025 May 1]. Available from: https://www.santepubliquefrance.fr/import/enquete-nationale-perinatale.-rapport-2021.-les-naissances-le-suivi-a-deux-mois-et-les-etablissements Tolonen H, Helakorpi S, Talala K, Helasoja V, Martelin T, Prättälä R. 25-year trends and socio-demographic differences in response rates: Finnish adult health behaviour survey. Eur J Epidemiol. 2006;21(6):409–15. Alehagen S, Wijma B, Lundberg U, Wijma K. Fear, pain and stress hormones during childbirth. J Psychosom Obstet Gynaecol. 2005 Sep;26(3):153–65. Network analysis and trajectories of maternal emotional symptoms during labor | BMC Psychology | Full Text [Internet]. [cited 2025 Aug 1]. Available from: https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-025-02713-0 Zuarez-Easton S, Erez O, Zafran N, Carmeli J, Garmi G, Salim R. Pharmacologic and nonpharmacologic options for pain relief during labor: an expert review. Am J Obstet Gynecol. 2023 May;228(5S):S1246–59. Smith CA, Collins CT, Levett KM, Armour M, Dahlen HG, Tan AL, et al. Acupuncture or acupressure for pain management during labour. Cochrane Database Syst Rev. 2020 Feb 7;2(2):CD009232. Smith CA, Levett KM, Collins CT, Armour M, Dahlen HG, Suganuma M. Relaxation techniques for pain management in labour. Cochrane Database Syst Rev. 2018 Mar 28;3(3):CD009514. Smith CA, Levett KM, Collins CT, Dahlen HG, Ee CC, Suganuma M. Massage, reflexology and other manual methods for pain management in labour. Cochrane Database Syst Rev. 2018 Mar 28;3(3):CD009290. Turner L, Griffiths P, Kitson-Reynolds E. Midwifery and nurse staffing of inpatient maternity services – A systematic scoping review of associations with outcomes and quality of care. Midwifery. 2021 Dec 1;103:103118. Leutenegger V, Grylka-Baeschlin S, Wieber F, Daly D, Pehlke-Milde J. The effectiveness of skilled breathing and relaxation techniques during antenatal education on maternal and neonatal outcomes: a systematic review. BMC Pregnancy Childbirth. 2022 Nov 19;22(1):856. Athinaidou AM, Vounatsou E, Pappa I, Harizopoulou VC, Sarantaki A. Influence of Antenatal Education on Birth Outcomes: A Systematic Review Focusing on Primiparous Women. Cureus. 2024 Jul;16(7):e64508. Alizadeh-Dibazari Z, Abdolalipour S, Mirghafourvand M. The effect of prenatal education on fear of childbirth, pain intensity during labour and childbirth experience: a scoping review using systematic approach and meta-analysis. BMC Pregnancy Childbirth. 2023 Jul 27;23(1):541. Chen LL, Pan WL, Mu PF, Gau ML. Birth environment interventions and outcomes: A scoping review. Birth. 2023 Dec;50(4):735–48. Le Lous M, Beridot C, Baxter JSH, Huaulme A, Vasconcelos F, Stoyanov D, et al. Physical environment of the operating room during cesarean section: A systematic review. Eur J Obstet Gynecol Reprod Biol. 2023 Sep;288:1–6. Landeiro F, Silva M, Moura CV e, Martins C, Miller P, Ferraz S, et al. Human-centered design and maternity care: is this a possible interplay?—a systematic review. BMC Pregnancy Childbirth. 2025 Mar 8;25:261. Additional Declarations No competing interests reported. Supplementary Files Appendice.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 25 Sep, 2025 Editor invited by journal 27 Aug, 2025 Editor assigned by journal 26 Aug, 2025 Submission checks completed at journal 26 Aug, 2025 First submitted to journal 26 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7459726","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":524844763,"identity":"2103bc78-2e82-40bd-88f9-e27d75869d54","order_by":0,"name":"Corinne Dupont","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYJCCA0ikDYMBAwMjmM3eQJSWhDSQFgib5wBRdiUcJqyFv7334eHCHTYMfDdyDz4u/HFe3lwigeEwT8UdBh5p7Hokzhw3ODzzTBqD5I28ZOMZCbcNd84AaTnzjIGHLwGrFgOJNIbDvG1A99zIMZPmSbidYHAj/wNYxJ4Hu8OgWv7DtJwDakmAGMKDX8sBmJYDhLVInDkGUpDMI3nmXbIxT1qy4YYzDxgOzjlzmAeXFv72NubPvG12cnzHgSHGY2Mnb3A8gfHBm4rDcri0wAAPGMEAEyoXny4YYPxBhPpRMApGwSgYMQAAGDxcYHm748EAAAAASUVORK5CYII=","orcid":"","institution":"Université Claude Bernard Lyon 1","correspondingAuthor":true,"prefix":"","firstName":"Corinne","middleName":"","lastName":"Dupont","suffix":""},{"id":524844764,"identity":"0d2e1cc1-b25d-4cfc-a421-b09d68d23417","order_by":1,"name":"Laurent Gaucher","email":"","orcid":"","institution":"Université Claude Bernard Lyon 1","correspondingAuthor":false,"prefix":"","firstName":"Laurent","middleName":"","lastName":"Gaucher","suffix":""},{"id":524844765,"identity":"f25641a1-89d3-42c4-a725-d77944b49b92","order_by":2,"name":"René Ecochard","email":"","orcid":"","institution":"Hospices Civils de Lyon","correspondingAuthor":false,"prefix":"","firstName":"René","middleName":"","lastName":"Ecochard","suffix":""},{"id":524844766,"identity":"3fc4e35b-c041-4914-ba1e-59fb3aab435d","order_by":3,"name":"Carole Vuillerot","email":"","orcid":"","institution":"L'Escale, Hôpital Femme-Mère- Enfant, Hospices Civils de Lyon","correspondingAuthor":false,"prefix":"","firstName":"Carole","middleName":"","lastName":"Vuillerot","suffix":""},{"id":524844767,"identity":"8c95e16a-c532-424a-b6a2-2448f58f6d2a","order_by":4,"name":"Anne Evrard","email":"","orcid":"","institution":"Collectif Interassociatif Autour de la Naissance (CIANE)","correspondingAuthor":false,"prefix":"","firstName":"Anne","middleName":"","lastName":"Evrard","suffix":""},{"id":524844768,"identity":"497eaf10-23d7-47c7-8eab-a96b999b5e4b","order_by":5,"name":"Mireille Chamly","email":"","orcid":"","institution":"Pôle de santé publique Hospices Civils de Lyon","correspondingAuthor":false,"prefix":"","firstName":"Mireille","middleName":"","lastName":"Chamly","suffix":""},{"id":524844770,"identity":"3ca237fc-4d18-40f3-8a7b-93ecf8fb3fe4","order_by":6,"name":"Dominique Chassard","email":"","orcid":"","institution":"Hospices Civils de Lyon","correspondingAuthor":false,"prefix":"","firstName":"Dominique","middleName":"","lastName":"Chassard","suffix":""},{"id":524844773,"identity":"3ac9e810-bddc-4b1e-ae43-ca916e86dc1d","order_by":7,"name":"Lionel Bouvet","email":"","orcid":"","institution":"Hospices Civils de Lyon","correspondingAuthor":false,"prefix":"","firstName":"Lionel","middleName":"","lastName":"Bouvet","suffix":""}],"badges":[],"createdAt":"2025-08-26 07:08:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7459726/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7459726/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":92950126,"identity":"dfb05865-0297-4696-b5e8-a1f48b3dae71","added_by":"auto","created_at":"2025-10-07 13:05:47","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":145022,"visible":true,"origin":"","legend":"","description":"","filename":"DupontCMaternalsatisfactionBMCPregnancyandChildbirthV2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7459726/v1/237f36d5ed23e706b2229bd2.docx"},{"id":92950028,"identity":"7b3d9f03-62d1-4107-b4fa-b9e75cd20a02","added_by":"auto","created_at":"2025-10-07 13:05:35","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":9949,"visible":true,"origin":"","legend":"","description":"","filename":"e4a5b0eedce04af6808435f7439c604b.json","url":"https://assets-eu.researchsquare.com/files/rs-7459726/v1/b7e79480448bedf6a194a2c1.json"},{"id":92949918,"identity":"36fdb7ea-5c88-4007-ba5b-7ec795eb0d25","added_by":"auto","created_at":"2025-10-07 13:05:28","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":116034,"visible":true,"origin":"","legend":"","description":"","filename":"e4a5b0eedce04af6808435f7439c604b1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7459726/v1/99d82b759207f2e788fe285d.xml"},{"id":92950116,"identity":"fad45400-5df3-4b2b-85b7-11b816cae19c","added_by":"auto","created_at":"2025-10-07 13:05:44","extension":"png","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":587,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7459726/v1/7ce00fed40750c0addcb9a9c.png"},{"id":92950120,"identity":"fbc4ed87-72ee-4e86-baf0-c058cd985a3a","added_by":"auto","created_at":"2025-10-07 13:05:45","extension":"jpeg","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":221810,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7459726/v1/b2cf8a52575b4440579cc6e1.jpeg"},{"id":92949927,"identity":"5dbf8aa9-0b62-4c94-9902-bbd3252bab80","added_by":"auto","created_at":"2025-10-07 13:05:29","extension":"jpeg","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":244747,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7459726/v1/0c812cc00102af45ac7dab00.jpeg"},{"id":92949984,"identity":"5cdf3e5a-da84-4eab-b307-0d452a626a16","added_by":"auto","created_at":"2025-10-07 13:05:33","extension":"png","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":509,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7459726/v1/39416ce91b68445b1d7c26da.png"},{"id":92950093,"identity":"791b8bd8-9efa-4f3f-bef3-2fc8c3dbd829","added_by":"auto","created_at":"2025-10-07 13:05:38","extension":"png","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":40101,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7459726/v1/85e023f47e531e50686d0d98.png"},{"id":92949972,"identity":"9427517a-ff44-4ae6-afed-828eeaf2ca32","added_by":"auto","created_at":"2025-10-07 13:05:31","extension":"png","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":47288,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7459726/v1/fe1bd2e3bf66cf363b36c2dd.png"},{"id":92949900,"identity":"72b518ef-0ab1-4b7c-a10c-027f8456298f","added_by":"auto","created_at":"2025-10-07 13:05:25","extension":"xml","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":116948,"visible":true,"origin":"","legend":"","description":"","filename":"e4a5b0eedce04af6808435f7439c604b1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7459726/v1/b755c3db0bb4623d561536f9.xml"},{"id":92949916,"identity":"c1e9c345-c129-4eb6-9aac-17479d3d4d60","added_by":"auto","created_at":"2025-10-07 13:05:27","extension":"html","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":127820,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7459726/v1/d834b6eea2cc39738def55d6.html"},{"id":92950119,"identity":"c247a60a-2496-4644-8872-30065e34498b","added_by":"auto","created_at":"2025-10-07 13:05:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":47240,"visible":true,"origin":"","legend":"\u003cp\u003eVariation in the level of satisfaction of women (CI 95%) with epidural analgesia with regard to the consideration given to their pain by the carers according to their cervical dilatation (n=215)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7459726/v1/a07e2ce3979b58991086fbbc.png"},{"id":92950064,"identity":"068e7a86-d359-453a-a4c3-ace193982a53","added_by":"auto","created_at":"2025-10-07 13:05:37","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":52571,"visible":true,"origin":"","legend":"\u003cp\u003eVariation in the average level of satisfaction (CI 95%) of women without epidural analgesia with regard to the way their pain was taken into account by the carers, according to their cervical dilatation (n=10)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7459726/v1/b3c6ed5affd33eb5bd850d98.png"},{"id":92950118,"identity":"d4683156-fc05-4b33-ae7f-253e9495f1b4","added_by":"auto","created_at":"2025-10-07 13:05:45","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":42569,"visible":true,"origin":"","legend":"\u003cp\u003ePercentage of satisfied women measured within 2 hours of delivery regarding pain support and management (n=225)\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7459726/v1/21a0d59087fac7233f00ca79.png"},{"id":92951747,"identity":"c6a1512d-4216-4b2b-829f-20186f8eb55e","added_by":"auto","created_at":"2025-10-07 13:14:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":769622,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7459726/v1/930d1955-d6cb-4061-bfe3-c9ffb70ce0d8.pdf"},{"id":92950058,"identity":"c380b036-9f65-4b38-a0a9-678f40d5badf","added_by":"auto","created_at":"2025-10-07 13:05:36","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":24311,"visible":true,"origin":"","legend":"","description":"","filename":"Appendice.docx","url":"https://assets-eu.researchsquare.com/files/rs-7459726/v1/90afd6ee1d3ca19a54f52035.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evolution of women satisfaction with labor pain management: a real-time study across nine maternity units","fulltext":[{"header":"Background","content":"\u003cp\u003eThe World Health Organization highlights the importance of ensuring a positive experience for all women (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). While most women report childbirth as a positive event, a significant proportion experience it negatively, with far-reaching psychological and physical consequences. These include postpartum depression (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) post-traumatic stress disorder (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), sexual dysfunction (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), difficulties in breastfeeding (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) and reluctance toward future pregnancies (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Fear stemming from a traumatic birth can also increase the preference for caesarean delivery in subsequent pregnancies (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Overall, childbirth experience is a key determinant of maternal and neonatal outcomes in the short term (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAmong the contributors to negative experience, labor pain remains one of the most significant. However, the intensity of pain is not the sole determinant of satisfaction. Evidence consistently shows that the timing and delivery of pain relief, and more crucially, the extent to which caregivers are perceived to acknowledge women\u0026rsquo;s pain, shape how labor is experienced. A systematic review has underlined that analgesia alone does not ensure a positive experience unless it is accompanied by empathy and support (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). When women feel that their requests for pain relief are dismissed or not prioritised, their perception of care deteriorates. These perceptions weigh more heavily on satisfaction than the effectiveness of the medical intervention itself (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Insufficient attention to labor pain by caregivers has been reported as a key driver of dissatisfaction (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), and recent evidence has drawn a direct link between such dissatisfaction and the development of postpartum post-traumatic stress disorder (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) .\u003c/p\u003e\u003cp\u003eDespite growing awareness, the literature still lacks studies capturing how women\u0026rsquo;s satisfaction with pain management evolves during labor itself. Most available data assess outcomes retrospectively or focus solely on pain intensity in relation to treatment. The dynamic, real-time evolution of satisfaction in response to caregiver behaviour, environment, and communication remains unexplored.\u003c/p\u003e\u003cp\u003eThis study addresses these gaps. The primary objective was to assess changes in women\u0026rsquo; satisfaction with how caregivers considered their pain throughout labor. Secondary objectives were to identify modifiable environmental factors influencing pain perception and to evaluate satisfaction with the timing and clarity of information provided on pain relief.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy Design and Setting\u003c/p\u003e\u003cp\u003eThis was a prospective, multicentre, observational cohort study conducted across nine maternity units of varying levels (Type I to III, i.e. with or without neonatal units) within the AURORE Perinatal Network in France. These facilities were selected to ensure diversity in type, status (public or private), and volume of activity, providing a sample broadly representative of the general obstetric population. Inclusions took place between February 3, 2022 and October 12, 2023, a period influenced by the COVID-19 pandemic, which occasionally impacted staff availability (Appendice I).\u003c/p\u003e\u003cp\u003eParticipants\u003c/p\u003e\u003cp\u003eEligible participants were woman admitted in labor for vaginal delivery of a singleton, viable fetus in cephalic presentation, at \u0026ge;\u0026thinsp;37 weeks of gestation, regardless of cervical dilatation at admission. Women who declined participation or were unable to understand French were excluded.\u003c/p\u003e\u003cp\u003eInformation about the study was displayed in antenatal clinic waiting rooms from January 2022. Additionally, obstetricians, anaesthetists, and midwives introduced the study during final prenatal consultations and answered participants\u0026rsquo; questions. Informed written consent was obtained prior to inclusion.\u003c/p\u003e\u003cp\u003eData Collection Procedures\u003c/p\u003e\u003cp\u003eData were collected using three structured questionnaires (Appendice II- IV) developed in collaboration with a methodologist (CV) and a steering committee (CD LG LB RE), and tested for clarity with five women and the user association \u003cem\u003eCollectif inter associatif autour de la Naissance\u003c/em\u003e ( \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://ciane.net/\u003c/span\u003e\u003cspan address=\"https://ciane.net/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e ):\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eLabor Questionnaire\u003c/strong\u003e\u003cp\u003eAdministered on admission and then every two hours during labor, jointly completed by the woman. The primary outcome was assessed by a self-rated satisfaction score (0\u0026thinsp;=\u0026thinsp;not at all, 10\u0026thinsp;=\u0026thinsp;perfectly) concerning how well the caregiver addressed labor pain. It also included questions on factors affecting and intensifying pain perception. Women blinded their responses with self-adhesive strips to ensure privacy.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003ePostpartum Questionnaire\u003c/strong\u003e\u003cp\u003eCompleted by the woman in the delivery room after birth, also sealed to maintain confidentiality. It explored satisfaction with the clarity of information about pain relief options, opportunity to discuss those options, and timing of relief (rated as too early, at the right time, late, or too late). It also included questions on mobility and hydration during labor.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMedical Questionnaire\u003c/strong\u003e\u003cp\u003eCompleted by the midwife post-delivery to document obstetric characteristics, interventions, and outcomes.\u003c/p\u003e\u003c/p\u003e\u003cp\u003eOutcomes\u003c/p\u003e\u003cp\u003eThe primary outcome was self-reported satisfaction score (0\u0026ndash;10) evaluating how caregivers responded to pain, measured every two hours from admission to delivery.\u003c/p\u003e\u003cp\u003eSecondary outcomes included:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eThe proportion of women reporting environmental or contextual factors that increase pain perception during labor.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe number and types of environmental factors that altered pain perception during labor\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSatisfaction with the timing and clarity of pain relief information, assessed within two hours after birth.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eStudy size\u003c/p\u003e\u003cp\u003eThe number of participants was not fixed a priori. All eligible and consenting women admitted to one of the nine partner maternity hospitals between February 2022 and October 2023 were included.\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eAll analyses were performed using \u003cem\u003eR\u003c/em\u003e version 4.4.2 (2024-10-31; The R Foundation for Statistical Computing, Vienna, Austria).\u003c/p\u003e\u003cp\u003eA descriptive analysis was conducted to characterize the study population. Qualitative variables were expressed as frequencies and percentages, while quantitative variables were summarized using mean and standard deviation or median and interquartile range, depending on the distribution of the data. The normality of distributions was assessed using the Shapiro-Wilk test.\u003c/p\u003e\u003cp\u003eSatisfaction with pain management was evaluated using a numeric scale ranging from 0 to 10, at multiple time points during labor according to cervical dilatation. For each time point, data on cervical dilation and use of epidural analgesia were extracted. Two distinct curves were constructed: one for women who ultimately received epidural analgesia and another for those who did not. The data were reshaped to a long format and merged by participant ID and time point. Mean satisfaction and 95% confidence intervals were computed by centimeter of dilation. To avoid extreme values, satisfaction scores were truncated at 10. Smoothing curves (loess method) were plotted separately for women with and without epidural analgesia, across cervical dilation from 0 to 10 cm.\u003c/p\u003e\u003cp\u003eEnvironmental conditions were assessed every two hours, from admission to the birth room until childbirth. The mean score attributed to the ambiance and physical environment was analyzed at each time point to evaluate their impact on pain perception. The pain threshold considered significant was set at 7 on a visual analog scale (VAS)(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTo identify factors that either intensified or alleviated the perception of pain, responses from women were analyzed. The total number of mentions for each factor was recorded, along with the proportion of women who reported being affected. To refine the analysis, the proportion of citations was also calculated relative to the total number of comments collected.\u003c/p\u003e\u003cp\u003eParticipants with fewer than three recorded time points or missing data for the primary outcome were excluded from the final analysis. No formal sample size calculation was performed.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOver the observation period, 13,034 deliveries occurred across the nine participating maternity units. A total of 312 women (2.4%) consent to participated and completed the labor questionnaire at least once. Of these, 87 were excluded from analysis due to incomplete data (n\u0026thinsp;=\u0026thinsp;3) or labor duration too short to allow at least three satisfaction assessments (n\u0026thinsp;=\u0026thinsp;84, including 65 labors under four hours and 19 with insufficient time points). The final study population comprised 225 women.\u003c/p\u003e\u003cp\u003eParticipants were recruited from both private (52.9%) and public (47.1%) institutions. Most were included from Type II maternity units (60.9%), followed by Type I (26.2%) and Type III (5.8%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDistribution of women included according to type of maternity hospital and status\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStatus\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWomen\u003c/p\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;225\u003c/p\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType III university\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePublic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType II\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePublic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76 (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrivate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61 (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType I\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrivate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e58 (25,78)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePublic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (7.56)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSociodemographic and obstetric characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The majority of women were primiparous (68.9%) and had completed higher education (69.3%). Nearly all gave birth vaginally (88.9%), and 95.6% received epidural analgesia (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of included women\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;225\u003c/p\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCountry of birth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMetropolitan France\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e201 (89,3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther country\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (5.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOverseas department or region\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (1.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLevel of education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSchool\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (1.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48 (21.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBaccalaureat\u0026thinsp;+\u0026thinsp;2 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e58 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBaccalaureat\u0026thinsp;\u0026gt;\u0026thinsp;2 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e98 (43,6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreparing for birth and parenthood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e157 (68.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEarly prenatal interview\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e95 (42.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimiparous\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e155 (68.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospitalization during pregnancy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16 (7.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMode of delivery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmergency cesarean section during labor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (5.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-emergency cesarean section during labor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (4.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInstrumental extraction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e59 (26.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSpontaneus vaginal delivery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e141 (62.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEpisiotomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22 (9.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerineal laceration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e59 (26.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1st and 2nd degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e133 (59.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3rd et 4th degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (2.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEpidural analgesia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e215 (95.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAmong women who received epidural analgesia (n\u0026thinsp;=\u0026thinsp;215), satisfaction scores remained consistently high throughout labor, with minimal variation across dilation levels (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In contrast, for women without epidural analgesia (n\u0026thinsp;=\u0026thinsp;10), satisfaction appeared stable until 6\u0026ndash;7 cm, after which a marked decline was observed (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Confidence intervals were wider in the non-epidural group due to smaller sample size, but remained below the satisfaction cap of 10 points.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eSelf-reported discomfort related to environment and setting remained low and stable throughout labor, with average scores of 3.0/10 at H0, 2.8/10 at H2, and 2.6/10 at H4 (p\u0026thinsp;=\u0026thinsp;0.2, Wilcoxon paired rank test). On admission, 37, 3% of women reported environmental factors whose worsening their pain perception and 18.7% (42/225) with a score VAS\u0026thinsp;\u0026ge;\u0026thinsp;7. The most frequently cited factors worsening pain perception were physical or positional discomfort, sound, and lighting. Staff availability was noted by only five participants (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFactors reported by women during labor as intensifying the perception of their pain (n\u0026thinsp;=\u0026thinsp;225)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eFactors\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWomen\u003c/p\u003e\u003cp\u003ereported factors\u003c/p\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;225\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAmong women with a score VAS\u0026thinsp;\u0026ge;\u0026thinsp;7\u003c/p\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;84\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of reported factors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e84 (37,3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42 (50,0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysical or installation discomfort\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSound environment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLight environment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAvailability of staff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTemperature\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlace (corridor ou small room)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMoving in and out of the room\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStress, fear\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnknown persons present\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFree-text comments collected within two hours post-delivery revealed that 24.4% (55/225) of women identified at least one factor that increased their pain. Most frequent were unrelieved pain (n\u0026thinsp;=\u0026thinsp;17), noise (n\u0026thinsp;=\u0026thinsp;14), and discomfort related to positioning or monitoring equipment (n\u0026thinsp;=\u0026thinsp;13) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e4\u003c/span\u003e.a).\u003c/p\u003e\u003cp\u003eConversely, 92.9% (209/225) of women identified at least one factor that reduced their pain perception. Caregiver presence and support were most frequently mentioned (37.3%), followed by pain relief measures (12.0%) and room characteristics (9.3%) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e4\u003c/span\u003e.b).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ea Factors emerging from the free comments section reported by women as intensifying the perception of their pain\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eFactors\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber of comments\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e% of women\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;225)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e% of comments\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;61)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e156\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e69,3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnrelieved pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7,6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12,4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSound environment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6,2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10,2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiscomfort related to equipment, position, stretcher, monitoring, APD, not drinking, temperature\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5,8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9,5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRoom, Place\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3,1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5,1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFatigue, Vomiting, Time management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2,2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3,6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStaff (questions, lack of pain management)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1,3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2,2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLight environment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0,9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1,5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eb Factors emerging from the free comments section reported by women as reducing the perception of their pain\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eFactors\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber of comments\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e% of women\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;225)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e% of comments\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;191)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e43,1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStaff (support, listening)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e37,3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e61,2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePain management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12,0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19,7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRoom Place\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9,3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15,3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLight environment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8,4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13,8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCalm, soothing atmosphere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8,0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBath, shower, ball\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7,3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSupport (co- parent)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7,3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePosition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2,2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3,6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSound environment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1,8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2,9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e Nearly all women (\u0026ge;\u0026thinsp;92%) expressed satisfaction with the clarity of information provided on pain relief and the opportunities they had to discuss their preferences. However, satisfaction regarding the timing of pain relief was lower, that is 80.9% considered it timely, while 19.1% reported it was administered too late (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Additionally, 12.1% of women confirmed that they received information about mobility and the possibility of drinking during labor.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMain findings\u003c/p\u003e\u003cp\u003eAmong women who received epidural analgesia, satisfaction remained high through labor until childbirth. Among the few who did not receive an epidural, satisfaction declined strongly around cervical dilation of 6 to 7 cm.\u003c/p\u003e\u003cp\u003eAlthough environmental conditions were not rated as highly impactful overall, specific elements, such as physical discomfort, noise, lighting, and perceived staff unavailability, were consistently reported as intensifying the perception of pain. Furthermore, while most women were satisfied with the information provided regarding pain relief options, nearly one in five felt that relief came too late. These findings underline the importance of responsiveness and communication in shaping the childbirth experience.\u003c/p\u003e\u003cp\u003eStrengths and limitations\u003c/p\u003e\u003cp\u003eThis study has several strengths. It was conducted in a diverse sample of maternity units varying in size, type and status, and included women whose sociodemographic profiles largely mirrored national data (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), albeit with an over-representation of women from higher socio-economic backgrounds and primiparous women (69% versus 41.3% in the national survey) (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). This skew was inherent to the study design, which required a labor duration sufficient to allow repeated measures.\u003c/p\u003e\u003cp\u003eA key innovation lies in the real-time assessment of satisfaction, using sealed questionnaires to ensure honest reporting without caregiver influence. To our knowledge, this is the first study to track satisfaction trajectories in real-time across multiple labor phases. A comparable study, conducted in Taiwan in 2008, focused on labor fatigue but did not measure satisfaction or pain perception (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eLimitations include the relatively small number of women without epidural analgesia, which restricted subgroup comparisons. Data collection was also affected by external constraints, including the COVID-19 context and a national midwives\u0026rsquo; strike, which limited recruitment, especially in Type III hospitals. Our population had a higher level of education than the general population (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), as is generally described (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Finally, the exclusion of women with labor durations under four hours may have biased the sample toward longer, potentially more difficult labors.\u003c/p\u003e\u003cp\u003eInterpretation\u003c/p\u003e\u003cp\u003eOur results reinforce existing evidence that a woman\u0026rsquo;s perception of caregiver attentiveness is more strongly associated with satisfaction than the effectiveness of analgesia alone since the score at the start of labor was also high without epidural analgesia (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The stability of satisfaction scores among women with epidural analgesia throughout labor confirms the known efficacy of this method but also reflects the psychological reassurance provided by timely intervention (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). For women without epidural analgesia, pain and cortisol increased substantially throughout labor (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). A critical transitional phase shortly before complete cervical dilation has been documented in women\u0026rsquo;s experiential studies (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Recent findings have established a link between unaddressed pain-related concerns and postpartum post-traumatic stress disorder (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), highlighting the stakes of caregiver responsiveness. Non-pharmacological pain relief methods, such as massage, acupressure, hydrotherapy, and breathing techniques, are recommended for labor (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), yet remain underused. Their implementation often depends on caregiver training and time availability, resources which are often limited during high workload periods (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe discrepancy between women\u0026rsquo;s expectations and the reality of care, particularly regarding the timing of relief and freedom of movement, suggests a need for better antenatal preparation. Despite efforts to inform women, antenatal classes remain heterogeneous in content, especially regarding pain anticipation and management (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). The difficulty in preparing primiparous women for an unfamiliar intensity of pain has also been described elsewhere and may partially explain the gap in satisfaction (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEnvironmental factors, although often secondary in standard obstetric protocols, emerged as meaningful in our study. Over one-third of participants reported that ambient conditions negatively affected their perception of pain. These findings echo previous reports that both physical (light, noise, mobility) and relational (supportive presence) conditions influence women's emotional and physical experience during labor, irrespective of delivery mode (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Birthing environments that allow women to personalise their experience through control over light, sound, movement and hydration, have been shown to improve maternal outcomes and should be prioritized (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eImplication for Practice\u003c/p\u003e\u003cp\u003eThis study highlights several modifiable elements of labor care. First, ensuring timely pain relief, for all women, and be very supportive of women without epidural analgesia, in particular in active phase of the first stage, requires better use of pharmacological and non-pharmacological options, with appropriate caregiver training. Second, maternity teams should be sensitized to environmental discomforts, which are often underestimated but significantly affect the birth experience. Light, noise, physical positioning and freedom of movement are all actionable factors.\u003c/p\u003e\u003cp\u003eCaregivers should also explicitly inform women during antenatal care about the likely timeline and limitations of analgesia delivery. Doing so may prevent the frustration expressed by the one in five women who felt that their pain relief was administered too late.\u003c/p\u003e\u003cp\u003eImplication for Research\u003c/p\u003e\u003cp\u003eFurther research is needed to identify the most effective formats and content for antenatal education focused on pain management prior to epidural analgesia, especially for first-time mothers. Qualitative studies could also explore how women understand and internalize pain, expectations, and environmental cues during labor. Future research should aim to evaluate interventions that integrate environmental personalization and emotional support with clinical pain relief strategies (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Additionally, expanding this type of study to include shorter labor and a broader range of cultural and linguistic profiles would enhance generalizability and equity in perinatal care research.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWomen satisfaction with pain management during labor was high overall, particularly after epidural analgesia, while modifiable factors such as delay relief, environmental discomfort, and limited autonomy remained sources of dissatisfaction. Future efforts should focus on improving early labor support, enhancing environmental conditions, and preparing women more effectively through antenatal education.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThe protocol was submitted for approval to the Ethics Committee of the Hospices Civils de Lyon, which issued a favorable opinion on 8 June 2021 (N\u0026deg;21-127). As this is non-interventional research involving human subjects (MR004), the CNIL (N\u0026deg; 2205025 v0) has been informed of the study\u0026apos;s compliance. This research was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the manuscript and agree with its submission\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData and materials were availability\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis work was supported by APICIL\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eCD, LG, LB conceived, designed the cohort study, contributed to the methodological framework. CD\u0026nbsp;drafted the initial version of the manuscript with support from LG and CC.\u003c/p\u003e\n\u003cp\u003eLG,\u0026nbsp;performed the statistical analyses, with support and validation from RE\u003c/p\u003e\n\u003cp\u003eRE, CV contributed to the methodological framework\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAE contributed to the design of the study and questionnaires\u003c/p\u003e\n\u003cp\u003eMC\u0026nbsp;was responsible for data collection and management, ensured the accuracy and integrity of the dataset\u003c/p\u003e\n\u003cp\u003eDC contributed to the design of the study\u003c/p\u003e\n\u003cp\u003eAll authors have contributed to different sections of the paper, provided input to its overall direction and content, and reviewed the paper to its final version.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThanks to Valette Elsa, Moreon Christelle, Houdinet Nathalie, Etienne Elisa, Almodovar Alain, Vey No\u0026eacute;lie, Petitbon Sylvie, Moreau Nathalie, Trenchat B\u0026eacute;atrice, CLamote Diamantina, Gerard-Landry Mildrey, Gelsomino Lea, Serventon Adeline, Albasini Val\u0026eacute;rie, Antoine Armelle for supporting in situ inclusions and to the midwives who completed the medical questionnaire and to those who completed the questionnaire.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO recommendations Intrapartum care for a positive childbirth experience [Internet]. 2018. Available from: https://iris.who.int/bitstream/handle/10665/260178/9789241550215-eng.pdf?sequence=1\u003c/li\u003e\n\u003cli\u003eUrbanov\u0026aacute; E, \u0026Scaron;kodov\u0026aacute; Z, Ba\u0026scaron;kov\u0026aacute; M. The Association between Birth Satisfaction and the Risk of Postpartum Depression. Int J Environ Res Public Health. 2021 Oct 5;18(19):10458. \u003c/li\u003e\n\u003cli\u003eAyers S, Eagle A, Waring H. The effects of childbirth-related post-traumatic stress disorder on women and their relationships: a qualitative study. Psychol Health Med. 2006 Nov;11(4):389\u0026ndash;98. \u003c/li\u003e\n\u003cli\u003eErtan D, Hingray C, Burlacu E, Sterl\u0026eacute; A, El-Hage W. Post-traumatic stress disorder following childbirth. BMC Psychiatry. 2021 Mar 16;21(1):155. \u003c/li\u003e\n\u003cli\u003eBrown A, Jordan S. Impact of birth complications on breastfeeding duration: an internet survey. J Adv Nurs. 2013 Apr;69(4):828\u0026ndash;39. \u003c/li\u003e\n\u003cli\u003eGottvall K, Waldenstr\u0026ouml;m U. Does a traumatic birth experience have an impact on future reproduction? BJOG. 2002 Mar;109(3):254\u0026ndash;60. \u003c/li\u003e\n\u003cli\u003eSuwanrath C, Chunuan S, Matemanosak P, Pinjaroen S. Why do pregnant women prefer cesarean birth? A qualitative study in a tertiary care center in Southern Thailand. BMC Pregnancy Childbirth. 2021 Jan 6;21(1):23. \u003c/li\u003e\n\u003cli\u003eEide KT, Morken NH, B\u0026aelig;r\u0026oslash;e K. Maternal reasons for requesting planned cesarean section in Norway: a qualitative study. BMC Pregnancy Childbirth. 2019 Mar 29;19(1):102. \u003c/li\u003e\n\u003cli\u003eChabbert M, Panagiotou D, Wendland J. Predictive factors of women\u0026rsquo;s subjective perception of childbirth experience: a systematic review of the literature. J Reprod Infant Psychol. 2021 Feb;39(1):43\u0026ndash;66. \u003c/li\u003e\n\u003cli\u003eNilv\u0026eacute;r H, Wessberg A, Dencker A, Hagberg H, Wennerholm UB, Fadl H, et al. Women\u0026rsquo;s childbirth experiences in the Swedish Post-term Induction Study (SWEPIS): a multicentre, randomised, controlled trial. BMJ Open. 2021 Apr 7;11(4):e042340. \u003c/li\u003e\n\u003cli\u003eTaheri M, Takian A, Taghizadeh Z, Jafari N, Sarafraz N. Creating a positive perception of childbirth experience: systematic review and meta-analysis of prenatal and intrapartum interventions. Reprod Health. 2018 May 2;15(1):73. \u003c/li\u003e\n\u003cli\u003eAmerican College of Obstetricians and Gynecologists\u0026rsquo; Committee on Practice Bulletins\u0026mdash;Obstetrics. ACOG Practice Bulletin No. 209: Obstetric Analgesia and Anesthesia. Obstet Gynecol. 2019 Mar;133(3):e208\u0026ndash;25. \u003c/li\u003e\n\u003cli\u003eLeavy E, Cortet M, Huissoud C, Desplanches T, Sormani J, Viaux-Savelon S, et al. Disrespect during childbirth and postpartum mental health: a French cohort study. BMC Pregnancy Childbirth. 2023 Apr 12;23(1):241. \u003c/li\u003e\n\u003cli\u003eJoensuu J, Saarij\u0026auml;rvi H, Rouhe H, Gissler M, Ulander VM, Heinonen S, et al. Maternal childbirth experience and pain relief methods: a retrospective 7-year cohort study of 85 488 parturients in Finland. BMJ Open. 2022 May 9;12(5):e061186. \u003c/li\u003e\n\u003cli\u003eLeavy E, Cortet M, Huissoud C, Desplanches T, Sormani J, Viaux-Savelon S, et al. Disrespect during childbirth and postpartum mental health: a French cohort study. BMC Pregnancy Childbirth. 2023 Apr 12;23(1):241. \u003c/li\u003e\n\u003cli\u003eJensen MP, Chen C, Brugger AM. Interpretation of visual analog scale ratings and change scores: a reanalysis of two clinical trials of postoperative pain. J Pain. 2003 Sep;4(7):407\u0026ndash;14. \u003c/li\u003e\n\u003cli\u003eTzeng YL, Chao YMY, Kuo SY, Teng YK. Childbirth-related fatigue trajectories during labour. J Adv Nurs. 2008 Aug;63(3):240\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eSPF. Enqu\u0026ecirc;te nationale p\u0026eacute;rinatale. Rapport 2021. Les naissances, le suivi \u0026agrave; deux mois et les \u0026eacute;tablissements [Internet]. [cited 2025 May 1]. Available from: https://www.santepubliquefrance.fr/import/enquete-nationale-perinatale.-rapport-2021.-les-naissances-le-suivi-a-deux-mois-et-les-etablissements\u003c/li\u003e\n\u003cli\u003eTolonen H, Helakorpi S, Talala K, Helasoja V, Martelin T, Pr\u0026auml;tt\u0026auml;l\u0026auml; R. 25-year trends and socio-demographic differences in response rates: Finnish adult health behaviour survey. Eur J Epidemiol. 2006;21(6):409\u0026ndash;15. \u003c/li\u003e\n\u003cli\u003eAlehagen S, Wijma B, Lundberg U, Wijma K. Fear, pain and stress hormones during childbirth. J Psychosom Obstet Gynaecol. 2005 Sep;26(3):153\u0026ndash;65. \u003c/li\u003e\n\u003cli\u003eNetwork analysis and trajectories of maternal emotional symptoms during labor | BMC Psychology | Full Text [Internet]. [cited 2025 Aug 1]. Available from: https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-025-02713-0\u003c/li\u003e\n\u003cli\u003eZuarez-Easton S, Erez O, Zafran N, Carmeli J, Garmi G, Salim R. Pharmacologic and nonpharmacologic options for pain relief during labor: an expert review. Am J Obstet Gynecol. 2023 May;228(5S):S1246\u0026ndash;59. \u003c/li\u003e\n\u003cli\u003eSmith CA, Collins CT, Levett KM, Armour M, Dahlen HG, Tan AL, et al. Acupuncture or acupressure for pain management during labour. Cochrane Database Syst Rev. 2020 Feb 7;2(2):CD009232. \u003c/li\u003e\n\u003cli\u003eSmith CA, Levett KM, Collins CT, Armour M, Dahlen HG, Suganuma M. Relaxation techniques for pain management in labour. Cochrane Database Syst Rev. 2018 Mar 28;3(3):CD009514. \u003c/li\u003e\n\u003cli\u003eSmith CA, Levett KM, Collins CT, Dahlen HG, Ee CC, Suganuma M. Massage, reflexology and other manual methods for pain management in labour. Cochrane Database Syst Rev. 2018 Mar 28;3(3):CD009290. \u003c/li\u003e\n\u003cli\u003eTurner L, Griffiths P, Kitson-Reynolds E. Midwifery and nurse staffing of inpatient maternity services \u0026ndash; A systematic scoping review of associations with outcomes and quality of care. Midwifery. 2021 Dec 1;103:103118. \u003c/li\u003e\n\u003cli\u003eLeutenegger V, Grylka-Baeschlin S, Wieber F, Daly D, Pehlke-Milde J. The effectiveness of skilled breathing and relaxation techniques during antenatal education on maternal and neonatal outcomes: a systematic review. BMC Pregnancy Childbirth. 2022 Nov 19;22(1):856. \u003c/li\u003e\n\u003cli\u003eAthinaidou AM, Vounatsou E, Pappa I, Harizopoulou VC, Sarantaki A. Influence of Antenatal Education on Birth Outcomes: A Systematic Review Focusing on Primiparous Women. Cureus. 2024 Jul;16(7):e64508. \u003c/li\u003e\n\u003cli\u003eAlizadeh-Dibazari Z, Abdolalipour S, Mirghafourvand M. The effect of prenatal education on fear of childbirth, pain intensity during labour and childbirth experience: a scoping review using systematic approach and meta-analysis. BMC Pregnancy Childbirth. 2023 Jul 27;23(1):541. \u003c/li\u003e\n\u003cli\u003eChen LL, Pan WL, Mu PF, Gau ML. Birth environment interventions and outcomes: A scoping review. Birth. 2023 Dec;50(4):735\u0026ndash;48. \u003c/li\u003e\n\u003cli\u003eLe Lous M, Beridot C, Baxter JSH, Huaulme A, Vasconcelos F, Stoyanov D, et al. Physical environment of the operating room during cesarean section: A systematic review. Eur J Obstet Gynecol Reprod Biol. 2023 Sep;288:1\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eLandeiro F, Silva M, Moura CV e, Martins C, Miller P, Ferraz S, et al. Human-centered design and maternity care: is this a possible interplay?\u0026mdash;a systematic review. BMC Pregnancy Childbirth. 2025 Mar 8;25:261. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"childbirth experience, pain, physical environment","lastPublishedDoi":"10.21203/rs.3.rs-7459726/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7459726/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eA lack of consideration of labor pain by caregivers was a factor in women' dissatisfaction with their childbirth experience. The aim of this study was to measure changes in women' satisfaction with caregivers' consideration of their pain, to identify the environmental factors modifying the perception of pain and to measure their satisfaction about the moment of relief pain and the information received about pain support and management.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA multicentre prospective cohort study was conducted in nine French maternity units. Women admitted for vaginal birth of a singleton fetus at \u0026ge;\u0026thinsp;37 weeks of gestation were included. Data were collected every two hours throughout labor using self-reported questionnaires assessing pain management satisfaction, environmental factors, and received information. Cervical dilatation and analgesia use were recorded. Satisfaction scores were analysed according to cervical dilatation and epidural analgesia status. Factors influencing pain perception were identified based on reported occurrences.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOf the 225 women who agreed to participate, 215 received epidural analgesia. Their satisfaction scores remained consistently high throughout labor, averaging around 9.5/10. In women without epidural analgesia (n\u0026thinsp;=\u0026thinsp;10), satisfaction declined after 6\u0026ndash;7 cm of dilatation. On admission, 37.3% of all women reported pain-intensifying factors, mainly physical discomfort, sound and lighting, and staff unavailability. Two hours post-delivery, pain-intensifying factors were delayed pain relief, disturbing sound environment, and insufficient information on mobility and the possibility of drinking during labor.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eWomen satisfaction were high, especially after epidural analgesia. Modifiable factors such as timeliness of relief, environmental conditions, and autonomy warrant targeted interventions.\u003c/p\u003e","manuscriptTitle":"Evolution of women satisfaction with labor pain management: a real-time study across nine maternity units","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-07 12:52:48","doi":"10.21203/rs.3.rs-7459726/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-09-25T07:20:47+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-27T12:05:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-26T23:36:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-26T23:36:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-08-26T07:01:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"490283ae-863a-4ea4-8d4c-a7a8af9299db","owner":[],"postedDate":"October 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-07T12:52:48+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-07 12:52:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7459726","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7459726","identity":"rs-7459726","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}