Umbilical cord clamping time and maternal satisfaction

3 Objective: Clamping of the umbilical cord is part of the third stage of delivery. The 4 WHO recommends delayed clamping for its contribution to the adaptation of the 5 newborn and prevention of anaemia. In Spain, there are variable practices of this 6 intervention and no evidence about its effect on maternal satisfaction. The purpose of 7 the present study is to evaluate the effect of the moment of clamping the umbilical cord, 8 as well as different sociodemographic and obstetric factors, on maternal satisfaction. 9 Design: Pragmatic non-drug intervention study with simple random assignment of 10 participating mothers to intervention groups (Clinical Trials Nº: NCT03624335). 11 Setting: A public, university-level


Introduction
Clamping the umbilical cord after birth is part of the third stage of care in childbirth, and there are two options 1 : early clamping (EC) before the first minute of life and delayed clamping (DC), after the first minute and which can be prolonged until the cord stops beating.The first option involves active management of the birth, and the second, physiological or expectant management.In Spain there is variability in the performance of this practice, with midwives having a higher probability than gynaecologists of performing a DC (OR = 14.05,IC95%: 8.41-23.49)and, in general, professionals over 50 years of age perform the clamping like this less frequently (OR = 0.24, IC95%: 0.11-0.52) 2 .
Studies in low per capita income countries show that the DC produces both nutritional and haematological benefit in the new born 3,4,5. .In Spain, the research carried out focuses on describing the relationship between clamping time and the presence of indicators of foetal distress in umbilical cord blood 6,7,8 .It should be noted that with the exception of a study carried out in Turkey 9 , none of the investigations includes patient-reported outcomes (PRO) among the study variables.PROs, such as maternal satisfaction, are as important as any other clinical or physiological outcome in health research 10 .. By paying attention to patient feedback on their perception of the care received, it is possible to reduce readmission rates and/or improve disease prognosis 11,12 .In Spain, previous studies on maternal satisfaction with birth suggest that there is a relationship between the level of satisfaction with birth, the fulfilment of previous expectations and the care received in the maternity ward 13,14 .
The aim of this study is to evaluate the effect of different sociodemographic and obstetric factors, including the timing of cord clamping, on maternal satisfaction with the birth experience, in the context of our healthcare scenario.

Method
This research is included in the CORDON Study (Clinical Trials Nº: NCT03624335) 15 which deals with the influence of umbilical cord clamping time on secondary neonatal morbidity, iron deposits in the neonate and infant, and associated maternal repercussions, and took the form of a pragmatic intervention study without drugs, carried out at the Hospital Universitario de La Plana (Castellón, Spain).The participants in the study were recruited consecutively after obtaining informed consent and were assigned in a simple random fashion to one of two intervention groups, according to the time the umbilical cord was clamped: Early clamping group (before the first minute of life) and, Delayed clamping group (when the umbilical cord stopped beating after the first minute of life).Randomisation was carried out by calculating the probability of a Bernoulli event for an estimated proportion of 0.5 with BM Statistics SPSS v.19.The inclusion criteria applied were gestational age between 35 and 42 weeks, obstetric history of controlled pregnancy, singleton pregnancy and vaginal delivery (orthostatic/instrumental), and language understanding of the questionnaires administered.The exclusion criteria applied were those that discourage DC: acute foetal distress, neonatal depression, thick meconial fluid, maternal infectious pathology (HIV, hepatitis B, hepatitis C), and maternal antibody-mediated pathology.Data were collected using two instruments: The Mackey Childbirth Satisfaction Rating Scale (MCSRS), which measures women's degree of satisfaction with the birth experience, in its validated Spanish version 13 , contains 36 items grouped into six factors: obstetrician, midwife, dilation, expulsion, newborn and accompanying and comfort.Additionally, an ad hoc form was administered on sociodemographic data, degree of knowledge about the moment of clamping and type of breastfeeding.The data were processed in the statistical package R version 3.5.2.A descriptive analysis of the sample and satisfaction was performed first.As the main variables studied did not meet the condition of normality, non-parametric tests were used to analyse the data using the following tests: i) Mann-Whitney for comparison of the mean of two groups, ii) Kruskal-Wallis for comparison of the mean of three or more groups, iii) Chi-square for comparison of two qualitative variables and, iv) Spearman for comparison of two quantitative variables.Satisfaction on the MCSRS scale was assessed from two perspectives 13 : "global" and "final".To determine the weight of each factor, exploratory factor analysis was carried out following Mas Pons et al 13 , using the maximum likelihood method, for the extraction of factors and the varimax method for the rotation of factors.The Kaiser-Meyer-Olkin test and the Bartlett sphericity test were used to check the suitability of the factor analysis for the available data.The study did not change the delivery care procedures in our maternity hospital and was approved by the Clinical Research Ethics Committee of the Hospital Universitario de La Plana.

Results
Out of a total of 250 mothers recruited, 62 were excluded (Fig. 1).Table 1 shows the sociodemographic and obstetric data of the mothers included, according to the clamping group to which they were assigned.The maximum and minimum values, and the median (Mna) of Apgar at the first minute and at 5 minutes of life were 4 and 10, Mna = 9, and 8 to 10, Mna = 10, respectively.The minimum and maximum duration of the dilation period was 60 and 660 minutes, respectively, with a median of 180 minutes.And the minimum and maximum duration of the expulsion period was 3 and 477 minutes, respectively, with a median of 51 minutes.
The average overall and final satisfaction of the pregnant women in relation to the birth experience was 4.5 (SD = 0.37) and 4.8 (SD = 0.48), respectively.Most mothers expressed values of satisfaction above 4/5 Mnasatisfacción global= 5,0, Mnasatisfacción final= 4,6 It is observed that although similar values were obtained from both perspectives, they are more dispersed in the "global satisfaction" perspective (Rangosatisfacción global = 3,0, Rangosatisfacción final= 2,11).
With regard to the sociodemographic variables, no significant differences were obtained between the degree of satisfaction of the mothers according to the level of study or place of origin (Table 2) in any of the perspectives analysed, while it varied significantly with the age of the pregnant woman (p=0.0398,R = -0.1529) in the "final satisfaction" perspective (Fig. 2).Both the global and final satisfaction were independent of all the obstetric variables evaluated with the exception of spontaneous amniorrhexis (p = 0.0206) in the final perspective), and in the global perspective, duration of expulsion (p = 0.0065), type of termination of labour (p = 0.0413), and Apgar score at the first minute (p = 0.0011) (Table 2).
With regard to the time of cord clamping, no significant differences were observed between the EC or DC and the overall or final satisfaction, although in general, the values of satisfaction of the mothers with the DC were moderately higher, with a lower degree of dispersion (Fig. 3a).In the regression carried out between the satisfaction and the clamping time, a value of R2 = 0.0156 (p = 0.093) was obtained (Fig. 3b).No significant differences were observed in the satisfaction in relation to the mother's previous knowledge about clamping strategies (Table 2).
The factorial analysis identified the six factors of the MCSRS 12 scale, differentiating the weights of each factor moderately among themselves, depending on whether the set of participating mothers is analysed, or by arm of the study (Table 3).
For the group of pregnant women with EC and DC, the Kaiser-Meyer-Olkin test showed a value of 0.74 and 0.68, respectively, with Bartlett's sphericity test being significant in both cases (p<0.0001).

Discussion
The results of this study provide new data from the Spanish health system on the satisfaction of mothers with the experience of labour and birth, incorporating the moment of umbilical cord clamping as a condition not studied until now.
According to previous studies, maternal satisfaction in vaginal births is related to various factors such as support and quality of the relationship with health professionals, accompaniment during birth by a chosen person, detailed and understandable information during the process, fulfilment of previous expectations, pain relief, healthy new born, and sociodemographic characteristics of the mother 13,14- 16,17,18,19 .In our study, none of these factors was related to maternal satisfaction, except for the age of the pregnant woman among those of a sociodemographic nature, and spontaneous amniorrhexis, the duration of expulsion, the type of termination of labour and the Apgar score at the first minute, among the obstetric ones.
With respect to the age of the mothers, the Spearman coefficient obtained in the regression analysis with maternal satisfaction, has a low and negative value, suggesting that age, although it influences the satisfaction of the pregnant woman, does so to a minimum degree and inversely, with the younger mothers being more satisfied.Recently, Mazúchovú et al (2020) 20 , showed that the aspect of age is significantly related to the control factor of women in labour and their participation in decision making.Therefore, it is advisable to strengthen interventions in the field of women's participation in decision-making.Hodnett (2002)  21 argues that pain and its relief do not play a major role in the birth experience unless expectations regarding either are not met.Our results support this hypothesis, finding no significant differences in reported satisfaction between mothers who received epidural analgesia and mothers who did not.It is of interest to deepen the research on satisfaction with water dilation, given the scant scientific evidence on this option of pain relief, together with its growing popularity among pregnant women in Spain 22 .
Johansson and Finnbogadóttir 23 (2019) show that the risk factors for a negative birth experience in first-time Swiss mothers are obstetric anal sphincter injuries and the onset of oxytocin augmentation in the first stage of labour.In our study, no significant difference in satisfaction between primiparous and multiparous mothers was detected, although the two conditions mentioned were not present in the studied cohort.No anal sphincter lesions were produced and, in our usual clinical practice, the onset of oxytocin augmentation takes place during the third stage of labour care.
Spontaneous amniorrhexis and a shorter expulsion period were significantly associated with higher maternal satisfaction.In the first case it could be due to the fact that labour starts naturally, and in the second case it could be due to the fact that labour lasts less time.In addition, the Apgar value at the first minute of life was significantly related to greater or lesser satisfaction, with the higher Apgar value of the newborn being observed to be more satisfactory for the mother.
In relation to timing and satisfaction, Calik et al. (2018) 9 report a significantly lower degree of satisfaction (p=0.039) in mothers who received a DC, which is striking since the DC is recommended for its neonatal benefits 24 .Our study finds that DC compared to EC does not lead to lower satisfaction in mothers, and it is even slightly higher.The regression line obtained suggests that the longer the clamping time, the greater the maternal satisfaction.Therefore, if there are no situations that justify an EC with active management of labour, a DC will produce a clinical benefit and will not negatively affect maternal satisfaction with the experience of labour and birth.
The factor analysis carried out identified the same six factors as the validated MCSRS scale adapted to Spanish 12 .These factors as a whole explain, depending on whether they are mothers with EC or DC, 60.9% and 50.3% respectively of the total variance in satisfaction in our study population.Given that for the mothers as a whole this variance is 1.2 times lower than that reported in the validation study of the MCSRS scale 13 , it is possible that in our environment there are other factors conditioning satisfaction in addition to those covered in the instrument used her.In our case, the factors that obtained the greatest weight in the variance explained were "obstetrician" and "midwife".Regardless of whether the relative weight of both is inverted according to mothers in the EC or DC group, the importance of the performance of these two groups of health professionals as determinants of satisfaction continues to be evident. 25, point out that the continuum of care during childbirth by the same professional increases the satisfaction of women and their partners, therefore one would expect that the satisfaction associated with midwives would be greater than that associated with obstetricians, as they have a more limited role in the care of childbirth.In our study, 53% of births were attended exclusively by midwives, so it is striking that in some cases mothers responded to the questions on the "obstetrician" subscale with values other than "3" (recommended neutral value 12 ).There could therefore be some bias arising either from the wording of the question in the questionnaire, or from the answer given (false or premeditated response bias), or social acceptability bias relating to a historical and social over-evaluation of the medical profession compared to other health professions 26,27 .Consequently, this emerges as a limitation of the study and, at the same time, as an opportunity to review the use of the MCSRS instrument, as well as to further investigate the roles of the different physicians involved in this procedure.

Sandall et al (2013)
The satisfaction of the mothers related to the care of the birth and accompaniment during it increases in those who started breastfeeding early 28 , and the type of birth conditions the maternal satisfaction with the breastfeeding 29 .Skin-to-skin contact is a simple way of increasing maternal satisfaction, although it is not directly related to the origins of dissatisfaction with birth.Furthermore, this simple technique is known to have benefits for both the woman and the baby, as it improves the effectiveness and increases the frequency and duration of breastfeeding, improves the health and development of the baby and has positive effects on psychological factors such as parental and new born stress 30,31,32,33,34 .In women who have had a caesarean section (planned or emergency) or instrumental delivery (e.g.vacuum extraction), encouraging rapid skin-to-skin contact promotes a more positive birth experience 35 .
Our results show a lack of relationship between type of breastfeeding, skin-to-skin contact and post-delivery or discharge breastfeeding with maternal satisfaction.The importance of breastfeeding in the maternal-infant environment and the lack of conclusive results in the literature suggest the necessity of carrying out studies on maternal satisfaction with birth and delivery together with the satisfaction, quality and duration of breastfeeding.
Delayed umbilical cord clamping in vaginal deliveries is associated with numerous benefits in the neonate, without increasing the risk of neonatal jaundice or maternal haemorrhage 3,36 .In term new-borns, these benefits include a reduced risk of anaemia until at least six months of age, increased cerebral myelin content at four and 12 months, and improvement in fine motor and social skills until four years of age 37,38 .
Preterm infants show a 50% reduction in the risk of intraventricular haemorrhage, a more than 50% reduction in the need for early red blood cell transfusions, a lower risk of late-onset sepsis, and a 30% reduction in hospital mortality when a DC is performed 39,40,41   .There are even indications that this technique is feasible and safe in Caesarean deliveries and is associated with increased maternal satisfaction and comfort of the medical team in a modern delivery environment 42 .If we add to the documented benefits that, according to the evidence of this study, there is no effect on maternal satisfaction with the experience of labour and birth in full-term pregnancies, the general proposal of adopting DC as a standard of care for the care of labour and birth in mothers with a gestational age between 35 and 42 weeks is reinforced.

Conclusion
Maternal satisfaction with the birth experience varies according to the age of the pregnant woman, the occurrence of spontaneous amniorrhexis, the length of the expulsive period, and the value of Apgar at the first minute of life, while it is not affected by the timing of cord clamping.Therefore, this component of the physiological management of childbirth provides additional advantages for the health of the newborn and infant, without having a negative impact on the final maternal perception of the health care received.

Fig. 2 .
Fig. 2. Age of mothers and satisfaction with the birth experience by the final score of the Mackey Childbirth Satisfaction Rating Scale, (N = 181)

Fig. 3 .
Fig. 3. Umbilical cord clamping time and overall satisfaction with the birth experience of 191 mothers participating in the study, by the final score of the Mackey Childbirth Satisfaction Rating Scale (1= very dissatisfied; 5= very satisfied).a) comparison between early and delayed clamping, b) regression using a logarithmic scale on the time axis for better visualization.

Table 1 .
Sociodemographic and obstetric characteristics of the 198 mothers who 285 participated in the study.286

Table 2 .
P-value of the relationship between the global and final satisfaction of the 288 participating mothers with the birth experience and the different socio-demographic and 289 *Score obtained from item 36 on the Mackey Childbirth Satisfaction Rating Scale.** Score resulting from the sum of the values assigned to each item -1 to 36 -on the Mackey Childbirth Satisfaction Rating Scale.

Table 3 .
Variance explained by each factor of the Mackey Childbirth SatisfactionRating Scale (MCSRS) for measuring satisfaction with the birth experience, obtained for the mothers participating in the study by the moment of umbilical cord clamping, and values of the study validating the scale.Flow (CONSORT) of the progress through the phases of the CORDON study of the two groups of participating mothers.