Women’s assessment of the care received during labor and birth is an important component in the process of evaluation of the quality of care. Therefore, studies that aim to assess the patient’s views are necessary for monitoring and improving the quality of childbirth care offered [1, 2].

Positive assessment by women of the care received during labor and birth is associated with positive outcomes in the physical and mental health of the mother and infant, such as increased breastfeeding rate, better bonding between mother and newborn, and lower rates of future abortion. However, a negative assessment is associated with unfavorable outcomes such as psychological problems in the postpartum period (postnatal depression and post-traumatic stress disorder), preference for cesarean section, negative feelings and thoughts about the infant, and breastfeeding problems [3–5]. For these reasons, the women’s assessment about the childbirth care provided have been increasingly considered important feedback for policy makers, managers, and other professionals involved in maternal health care [1, 6].

The assessment by women of the care received is associated with the process and procedures adopted in assistance as well as women’s social, economic, and subjective characteristics. Furthermore, expectations and feelings about pregnancy may influence the way puerperal women assess childbirth care received [7–9].

Since 1996, the WHO recommendations have been published in the guide “Care in Normal Birth: A Practical Guide”, a series of practices and procedures to be adopted or avoided in the conduction of normal labor and birth for providing quality childbirth assistance. WHO has classified these practices into four categories according to their usefulness, effectiveness, and risks, based on the opinion of expert groups and according to the best scientific evidence. Category A comprises those obstetric practices which are demonstrably useful and should be encouraged; category B includes practices which are harmful or clearly ineffective and should be eliminated. Category C includes practices with insufficient evidence to support a clear recommendation that should be used with caution while further research is conducted. Category D practices are those that are often used inappropriately [10].

With the aim to improve care during labor and birth in Brazil, in the 2011 the Ministry of Health (MoH) launched a new program which included a number of actions to be taken within the National Health System to ensure that women have access to labor and childbirth assistance from the perspective of humanization. The changes in the childbirth care model proposed were based on two pillars: dignified and respectful treatment of women, their families, and the newborn; and adoption of good practices recommended by the World Health Organization (WHO) known to be beneficial for monitoring normal labor and birth [11].

The aim of this study is to evaluate the association between adoption of good practices in care during normal labor and birth, as recommended by WHO (category A) and assessment by women of the care received, using data from a nationwide survey and research.

This study is an under sample of the larger study “Birth in Brazil”, a national hospital-based research with countrywide representation consisting of 23,894 mothers and their newborns, conducted between February 2011 and October 2012 in Brazil. All the authors were part of the team that conducted this survey and research. The sampling was carried out considering three stages of selection: all hospitals which had 500 or more births per year in 2007 were selected, classified according to Brazil’s five macro-regions (North, Northeast, Southeast, South and Mid-west), municipality (capital or interior), and type of hospital (private, public and mixed). Subsequently the number of days needed to reach the fixed sample of 90 women who had recently given birth in each hospital was calculated. Finally, these 90 women were selected from each hospital remaining in the sample. A total of 1356 (5.7 %) postnatal women selected were replaced, 203 owing to early hospital discharge and 1153 owing to refusal to participate. A detailed description of the “Birth in Brazil” methodology is given elsewhere [12].

This study found that 90 % of women assessed as excellent or good several aspects of their relationship with the team of caregivers, such as privacy in the birthing place, the empathic support of professionals, clarity of information received, and time to ask the staff questions. Approximately 2.5 % assessed each of these aspects as very poor (Table 2).

In addition, the better the opinion of each woman with respect to these practices, the more favorable her assessment of the care received. This pattern was seen for all variables related to the relationship with the caregiver team. Compared to women who had assessed empathic and respectful support from professionals as excellent, those who had assessed this variable as regular, poor, or very poor were approximately 47 times more likely (OR = 46.81, CI = 20.65–106.12) to rate their care as regular and 257 times more likely (OR = 257.14, CI = 66.22–998.46) to assess care as poor or very poor (Table 3).

Women who did not have a companion present during labor and birth had a 3.51 times greater likelihood (OR = 3.51, CI = 1:11–11:12) of assessing the care received as poor or very poor compared with those who had a companion with them at all times. The other examined good practices in category A (free nutrition, freedom of movement, nonpharmacological analgesia for pain, breastfeeding in the childbirth room, skin-to-skin contact after birth, and free choice of a companion) had no statistical association with the outcome (Table 3).

This study demonstrated that a good relationship established between women and their health care team during labor and birth is a decisive factor for positive assessment of the care received. The lack of association with more objective aspects of care, such as the carrying out of certain procedures, may be due to the fact that these have less relevance in the assessment process by mothers. Many studies have reported that more subjective aspects of care, usually related to how the medical team interacts with the mother, actually have more weight in positive assessment of care than practices related to the objectives of care procedures [16, 17].

In one systematic review, Hodnett [17] found four factors associated with satisfaction during childbirth: the pregnant woman’s expectations for childbirth, the quantity and quality of support received from the medical staff by the woman, the quality of the patient relationship with the medical team, and the woman’s involvement in decisions about childbirth. According to this author, these four factors seem to outweigh factors of age, socioeconomic status, skin color, birth preparedness, physical environment, pain, immobility, and medical interventions. Therefore, the behavior and the doctor and patient relationship seem to have more weight and are more associated with satisfaction than the other variables [17].

Corroborating with this line of reasoning, the information and explanations received during labor and birth are important for good assessment of care because these help with the woman’s autonomy related to childbirth. If a woman is not informed about the progress of her labor and any procedures that will be carried out, she cannot participate in the choices made, and therefore only receives passive childbirth care. Studies demonstrate that a feeling that women are protagonists during childbirth is associated with high levels of positive care assessment [18, 19].

A relevant aspect of this study is the importance of a companion’s presence throughout labor and birth for a positive evaluation of care. Others studies also report this factor as being significant for a perception of quality care by mothers [20–22].

Another important issue is the discrepancy founded between the low prevalence of good practices for normal labor and birth and the high prevalence of positive assessment by mothers of the care received. It is necessary to discuss the reasons that may lead women to positively assess childbirth care that is not in accordance with the ones recommended by the MoH and WHO. One of the possible causes for this gap would be the lack of information that pregnant women have about what constitutes quality assistance during childbirth. Studies have pointed out that in Southeaster Brazil, prenatal care does not provide information about good practices and the rights of women [23, 24]. Because of this, most women do not know their rights and the procedures that comprise optimal care. Therefore, it would not be possible for women to accurately assess their care if they are unfamiliar with what is considered to be good quality childbirth care. This fact has been pointed out as one of the limitations of this type of study, in which patients are asked to assess their care when they are unfamiliar with good standards of practice and care [6].

Added to the issue of women who are given insufficient information is their expectations about childbirth, which also influence how childbirth care is assessed [25, 26]. In their study of the women’s expectations and experiences related to childbirth, Dias and Deslandes [27] found reports of verbal abuse, abandonment, and delayed care, suggesting that many women classified the care received as good only because they did not experience any violence [27]. So it could be that the expectations of these women are so low that even when poor care is received, they will positively assess the assistance.

Another factor reported in the literature that may be associated with these discrepancy is the tendency for women to assess the care received during labor and childbirth more positively than it actually was [3]. Van Teijlingen et al. [6] called this trend “gratitude bias”. According to these authors, this bias permeates and hinders many studies that investigate the assessment and satisfaction of mothers with childbirth care received. These authors suggest that some women cannot negatively rate their care because they consider such an act to be ingratitude for the positive outcome of the childbirth [6].

A number of methodological issues need to be took in account before considering the implications of the results of this study. Firstly, due to the low prevalence of women in some categories of assessment of care received, some OR’s had a high confidence interval (CI), which compromises the accuracy of these measures of association. Secondly, the absence of any control variable related to the women’s expectations in relation to the care received during labor and childbirth made impossible an analysis in depth of the associations.

In spite of the above, the fact that care assessment was measured outside of the hospital and, on average, 1 year after childbirth, helped to reduce the gratitude bias and is a strength of our research. Because studies recommend that this type of question should be made postpartum after hospital discharge because women may feel embarrassed and afraid of reprisals from the health care team while still in the hospital. In addition, the critical sense of women in relation to assistance received during labor and birth tends to increase with time [3, 6]. Furthermore, as far as we know, this is the first study of its kind in Brazil.

In this study, the way women assessed their care during labor and birth was influenced by good practices related to how they were treated by the medical team (privacy in the birthing place, time available to ask questions and receive explanations), clarity of information received, the empathic and respectful support of health care providers, and the presence of a companion during labor and birth. This result shows the importance of the relationship between the team of caregivers and the woman, for a positive experience of childbirth.

Our study did not find associations between care assessment and good practices related to the objective aspects of care: nonpharmacological analgesia, free nutrition, free movement, initiation of breastfeeding in the childbirth room, and skin-to-skin contact immediately after birth. This fact may be explained by the gratitude bias, the women’s lack of information, and low expectations for labor and birth assistance. However, we cannot ignore the possibility that perhaps the subjective aspects of childbirth care have more relevance to women, according to our findings and those of other researches.

The relationship between the caregiver team and the mother has great impact on the way she will experience the process of labor and birth. An attentive and welcoming staff, with good listening and communication skills, can help to improve the quality of care. Therefore, this study points to the need to invest in training health care professionals so as to improve these qualities and skills, in view of the goal to develop care guided by the concept of humanization, which respects the woman’s dignity, rights, and autonomy.