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RESEARCH ARTICLE Open Access
Measuring women’s childbirth experiences:a systematic review for identification andanalysis of validated instrumentsHelena Nilvér1* , Cecily Begley1,2 and Marie Berg1,3
Abstract
Background: Women’s childbirth experience can have immediate as well as long-term positive or negative effectson their life, well-being and health. When evaluating and drawing conclusions from research results, women’sexperiences of childbirth should be one aspect to consider. Researchers and clinicians need help in finding andselecting the most suitable instrument for their purpose. The aim of this study was therefore to systematicallyidentify and present validated instruments measuring women’s childbirth experience.
Methods: A systematic review was conducted in January 2016 with a comprehensive search in the bibliographicdatabases PubMed, CINAHL, Scopus, The Cochrane Library and PsycINFO. Included instruments measured women’schildbirth experiences. Papers were assessed independently by two reviewers for inclusion, and quality assessmentof included instruments was made by two reviewers independently and in pairs using Terwee et al’s criteria forevaluation of psychometric properties.
Results: In total 5189 citations were screened, of which 5106 were excluded by title and abstract. Eighty-threefull-text papers were reviewed, and 37 papers were excluded, resulting in 46 included papers representing 36instruments. These instruments demonstrated a wide range in purpose and content as well as in the quality ofpsychometric properties.
Conclusions: This systematic review provides an overview of existing instruments measuring women’s childbirthexperiences and can support researchers to identify appropriate instruments to be used, and maybe adapted, intheir specific contexts and research purpose.
BackgroundChildbirth experiences can have immediate as well aslong-term positive or negative effects on life, well-beingand health [1]. A positive experience can be rememberedas an empowering life event [1–3] connected to personalgrowth and self-knowledge affecting the transition tomotherhood [4]. A negative birth experience increases therisk of negative health outcomes, such as postpartumdepression [5] and future fear of giving birth [6], that canlead to a request for caesarean birth in future pregnancies
[7, 8], and have an impact on future reproduction [9, 10].The memory of a birth can vary over time for the woman,with either more positive or negative memories beingrecalled at a later period after birth compared to directlyafter [3, 11]. Furthermore childbirth, as experienced bythe woman giving birth, can vary considerably from how acaregiver or relative may experience the same event. Theperson beside the woman may focus on more tangible,observable aspects and underestimate psychological as-pects. It is therefore important that women are askedfor their experiences [12]. Women have the right to adignified, respectful, and humane health care duringchildbirth. Mistreatment of women in childbirth is aviolation of women’s fundamental human rights [13].
* Correspondence: [email protected] of Health and Care Sciences, Sahlgrenska Academy, University ofGothenburg, Gothenburg, SwedenFull list of author information is available at the end of the article
Such mistreatment can occur both in the interactionbetween the woman and health care provider as throughsystematic failures in health facilities and health systemlevels. Therefor there is need of reliable and validated in-struments to highlight women’s experiences and promoterespectful and supportive care [14].Studies on women’s childbirth experiences have been
using different surrogate terms and related concepts suchas ‘childbirth satisfaction’, ‘satisfaction with care’, ‘experi-ences of control’ or ‘of support’, ‘experience of relationshipwith caregivers’ and ‘experience of pain’ [15]. Women’ssatisfaction with childbirth is multidimensional and affectsthe childbirth experience [16]. When evaluating and draw-ing conclusions from care in labour and birth, women’sexperiences of childbirth should be one outcome of con-siderable importance to measure. This requires the use ofreliable and valid instruments adapted to the purpose. Asresearchers might select and use different terms related toeach other when studying women’s childbirth experiences,we have chosen to include instruments that use surrogateterms and related concepts in this review.For an instrument to receive good levels of reliability and
validity, extensive development and testing of psychometricproperties is needed [17]. Without valid psychometricproperties, conclusions drawn may be false and lead toinvalid conclusions on the concept [18].No review specifically focusing on instruments meas-
uring women’s childbirth experiences has been found,but there are two reviews evaluating instruments meas-uring ‘maternal childbirth satisfaction’ [19, 20]. Perrimanand Davis identified and reviewed 4 instruments measur-ing maternal satisfaction with continuity of maternitycare models in before, during and after labour and birth.The papers describing the instruments primarily com-pared outcomes rather than describing the developmentof the tool [19]. Sawyer et al. identified and reviewed 9multi-item instruments specifically studying maternalsatisfaction with care given during labour and birth [20].In an attempt to give researchers and clinicians anoverview, we performed a systematic review to identifyand present validated instruments measuring women’schildbirth experience.
MethodsA systematic review is a rigorous method of researchthat follows a systematic procedure to enable a sum-mary of all findings from multiple studies on a specifictopic. The start point is a rigorous search process forcapturing the entire body of scientific studies [21]. Asresearchers might select and use different terms relatedto each other when studying women’s childbirth experi-ence [15], we have chosen to use a broad definition anduse surrogate terms and related concepts in this review,
e.g. childbirth satisfaction, control, support, fear. TheCochrane guideline was used as guidance [21].
Eligibility criteriaFirst a review protocol was developed (see Additional file1).Inclusion and exclusion criteria were established in advanceand documented in the review protocol. Criteria for inclu-sion in this review were as follows:
� Papers should describe the development or testpsychometric properties of an instrument.
� Instruments assessing both pregnancy, childbirthand the postpartum period are included if one ormore dimensions are related to women’s childbirthexperiences, and this could be assessed as a separatescale.
� Papers reporting original research, published inpeer-reviewed journal.
� Reviews were included to enable us to find originalpapers.
� Papers published in English or French were includedas the researchers could understand these languages.
Dissertations, non-original research, or conferencepapers were excluded.
Search strategyThe search strategy was designed and developed followingconsultation with a healthcare librarian. Before the finalsearch all authors commented and agreed on the searchstring that was adapted for the individual databases (seeAdditional file 2). The final search took place in January2016 in the electronic databases of PubMed, Scopus,CINAHL, Cochrane Library and PsycINFO. No restrictionin the dates of publishing was made.In total 8074 citations were identified (PubMed n = 2785,
CINAHL n = 1140, PsycINFO n = 558, Scopus n = 3426and Cochrane n = 165). For the initial screening all thesearch results were imported into reference managementsoftware (EndNote) and duplicates were removed, leaving5106 titles and abstract to be screened for inclusion. First,papers clearly irrelevant to our topic, such as papers asses-sing childhood development, contraceptives etc., wereremoved by one of us (HN). The remaining 809 titles andabstract were assessed independently by two researchers(HN and an assistant, JC). This identified 266 residualpapers which were assessed independently by two of the re-viewers (HN and MB) to include papers for more in-depthfull text assessment. Sixty-nine papers were retrieved in fulltext and assessed for eligibility criteria by two reviewers in-dependently (HN and CB, or MB and CB, or HN and MB).Any potential conflicts were solved by the third reviewer.
Nilvér et al. BMC Pregnancy and Childbirth (2017) 17:203 Page 2 of 19
Fourteen additional studies were found through search ofreference lists of included papers and were assessed in full-text by two independent reviewers for eligibility criteria(HN and MB). Three of these papers were included afterassessment in full text. In total 83 papers were thusassessed in full text of which 37 did not fulfil the inclusioncriteria and were excluded with reason (see Table 1). Thenames of each instrument were then searched in PubMedand CINAHL to retrieve further potential papers related tothe specific instrument. No further papers on the develop-ment or testing of psychometric properties of the identifiedinstruments were found. The flow of selection for studiesare shown in Fig. 1.
Quality assessment of included instrumentsAs the aim of this review was to identify and assess instru-ments measuring women’s childbirth experiences, thefocus was not on the quality of the studies of the includedarticles but to identify psychometric properties of identi-fied instruments. This was done using criteria specified byTerwee et al. [17] which refer to the following properties;Content validity, Internal consistency, Criterion validity,Construct validity, Reproducibility agreement, Reproduci-bility reliability, Responsiveness, Floor and ceiling effects,and Interpretability. The properties were evaluated as; + =positive rating, ? = indeterminate rating, − = negative rat-ing, and 0 = no information available. Terwee et al. em-phasise the importance of a clear design and method, andthat the sample size needs to be greater than 50 subjectsin every subgroup of the analysis [17]. In addition to qual-ity assessment of these properties we added another twocriteria. The first one considers the need for the instru-ment and, for a positive rating, a search for existing instru-ments had to have been done, demonstrating the need todevelop and test a new instrument. The second ratingitem added is related to face validity. For a positive rating,members of the target population should have been askedabout the appropriateness of the questionnaire and ofeach question.This rating of the measurement properties was per-
formed independently by two review authors (HN andMB, or HN and CB, or MB and CB). When ratingsdiffered between the pairs, it was discussed and, whenconflict remained, the third reviewer was included in thediscussion to reach consensus. An overview of the resultsof the quality rating of psychometric properties ofincluded instruments is displayed in Table 2. The last col-umn in the table gives the total figure awarded to eachtool, based on a mark of 1 for each ‘+’, and 0.5 for one ormore ‘?’ grades. This is only a rough guide to the overallquality of the instrument and must be interpreted withcaution. For example, two tools that both received a markof 6 may be of very different quality, depending on thecriteria that were awarded the points.
In conducting this review, our focus and aim was onidentifying measures and conducting a broad assessmentof their psychometric properties. Given the large numberof instruments found, and their very different foci, it wasnot possible to make clear recommendations as to oneparticular instrument that would suit all purposes. Instead,some general suggestions are made as to the instrumentsthat appear to be emerging as the top ranking tools interms of the quality measurement performed, and theoverall mark given.
Data extraction and analysisThe following data were extracted for each instrument:Name of instrument/acronym, authors (year), country oforigin, aim/motive of instrument, number of items, di-mensions/subscales, response scale, timeframe to answerthe questionnaire, whether or not the questionnaire wasavailable and a short narrative summary of included in-struments. The data extraction was made by the first au-thor (HN) and then checked by the other authors foraccuracy.One of the individual papers was conducted by one
of the authors (MB). To avoid conflict of interest thispaper was assessed for eligibility criteria, and qualityassessment was made, by the two other authors (HNand CB).
ResultsForty-six articles presenting 36 instruments [22–59] meas-uring women’s childbirth experiences were included forquality assessment. Different surrogate terms and relatedconcepts used in identified instruments were described byauthors as: childbirth experience (27.8%), satisfaction withcare/birth/childbirth (36.1%), perception of birth/care(13.9%), control (11.1%), support (8.3%), fear of childbirth(5.6%), childbirth trauma (2.8%), birth memories (2.8%)and childbirth schema (2.8%). In five of the identifiedinstruments we found cultural validation/translation ofthe instrument had been done. Most of the instrumentswere developed and tested in the United States (6) and inthe United Kingdom (6). Further countries representedwere: Canada (4), the Netherlands (4), Turkey (3), Sweden(3), Jordan (3), France (2), Italy (2), Australia (1), Senegal(1), and Norway (1). Number of items in the instrumentsvaried from three to 145. Nine of the instruments wereuni-dimensional, and 27 consisted of several dimensions/subscales. Quality ratings of psychometric properties arepresented in Table 2. Descriptive data of included instru-ments are presented in Table 3, and characteristics inTable 4. Instruments are reported in alphabetical order byfirst author.A few of the tools gained a low quality rating, which
would indicate the need for further development andevaluation of their psychometric properties. These
Nilvér et al. BMC Pregnancy and Childbirth (2017) 17:203 Page 3 of 19
Table 1 Excluded papers with reason
Instrument Reason for exclusion
Bowers BB: Development of an instrument to measure mothers’ perceptionsof professional labor support. Texas Woman’s University; 2001.
Dissertation
Callahan JL, Hynan MT: Identifying mothers at risk for postnatal emotionaldistress: further evidence for the validity of the perinatal posttraumatic stressdisorder questionnaire. J Perinatol 2002; 22(6):448–454.
Focus on postnatal medical complications of infant in relationto mothers health rather than on childbirth experiences
Chen CH, Wang SY: Women’s perceptions of caesarean delivery. Gaoxiong YiXue Ke Xue Za Zhi 1992; 8(5):241–246.
In Chinese
Claudia Uribe T, Aixa Contreras M, Luis Villarroel D: Adaptation and validationof the Maternal Welfare Scale in childbirth situations: Second version forintegral assistance scenarios. Revista Chilena de Obstetricia y Ginecologia2014; 79(3): 154–160.
In Spanish
Claudia Uribe T, Aixa Contreras M, Luis Villarroel D, Soledad Hivera M, PaulinaBravo V, Marieta Cornejo A: Maternal wellbeing during childbirth: Developmentand application of a measurement scale. Revista Chilena de Obstetricia yGinecologia 2008; 73(1):4–10.
In Spanish
Declercq ER, Sakala C, Corry MP, Applebaum S: Listening to Mothers II: Reportof the Second National U.S. Survey of Women’s Childbearing Experiences:Conducted January-February 2006 for Childbirth Connection by HarrisInteractive(R) in partnership with Lamaze International. J Perinat Educ 2007;16(4):9–14.
Not able to distinguish childbirth experience as separate scalefrom rest of questionnaire.
De Holanda CSM, Alchieri JC, Morais FRR, De Oliveira Maranhão TM: Strategiesfor development, follow-up, and assessment of care provided to women inthe pregnancy-postnatal cycle. Revista Panamericana de Salud Publica/PanAmerican Journal of Public Health 2015; 37(6):388–394.
In Portuguese
Drummond J, Rickwood D: Childbirth confidence: validating the ChildbirthSelf-Efficacy Inventory (CBSEI) in an Australian sample. J Adv Nurs 1997;26(3):613–622
Measures expectancies of labour
Denis A, Séjourné N, Callahan S: Étude de validation française de la versioncourte du Maternal Self-report Inventory. L’Encéphale: Revue de psychiatrieclinique biologique et thérapeutique 2013; 39(3):183–188.
Not able to separate childbirth experience from the rest of thequestionnaire.
Hung CH, Hsu YY, Lee SF: Couples’ satisfaction with health care serviceduring labor and delivery. Kaohsiung J Med Sci 1997; 13(4):255–262.
Assess couples’ experience, not able to distinguish women’sexperiences.
Ip WY, Chan D, Chien WT: Chinese version of the Childbirth Self-efficacyInventory. J Adv Nurs 2005, 51(6):625–633.
Measures expectancies of labour
Ip WY, Chung TK, Tang CS: The Chinese Childbirth Self-Efficacy Inventory:the development of a short form. J Clin Nurs 2008; 17(3):333–340.
Measures expectancies of labour
Janssen PA, Dennis C, Reime B: Development and psychometric testingof the Care in Obstetrics: Measure For Testing Satisfaction (COMFORTS)scale. Research in Nursing & Health 2006, 29(1):51–60 10p.
Not able to distinguish childbirth experience so that it canqualify as a scale of its own
Khalatbari J, Ghasemabadi E, Ghorbanshirodi S: Effect of early Skin-to-skincontact of mother and newborn on mother’s satisfaction. Life ScienceJournal 2013; 10(SUPPL.3):423–425.
No psychometric analyses
Kishi R, McElmurry B, Vonderheid S, Altfeld S, McFarlin B, Tashiro J: JapaneseTranslation and Cultural Adaptation of the Listening to Mothers II Questionnaire.J Perinat Educ 2011; 20(1):14–27.
Not able to distinguish childbirth experience from the rest ofthe questionnaire.
Lee ML, Cho JH: [Development of a scale to measure the self concept of cesareansection mothers]. Kanho Hakhoe Chi 1990; 20(2):131–141.
In Korean
Lowe NK: Maternal confidence for labor: development of the Childbirth Self-EfficacyInventory. Res Nurs Health 1993; 16(2):141–149.
Measures expectancies of childbirth
Mas-Pons R, Barona-Vilar C, Carregui-Vilar S, Ibanez-Gil N, Margaix-Fontestad L,Escriba-Aguir V: [Women’s satisfaction with the experience of childbirth: validationof the Mackey Childbirth Satisfaction Rating Scale]. Gac Sanit 2012; 26(3):236–242.
In Spanish
Nilvér et al. BMC Pregnancy and Childbirth (2017) 17:203 Page 4 of 19
included: The Childbirth Trauma Index for adolescents[22] (overall quality mark of 2); The Perception of BirthScale [23, 24] (overall quality marks of 3); Support andControl in Birth [25] (overall quality marks of 4); TheChildbirth Experience Perception Questionnaire [26] andThe Birth satisfaction scale and the Birth satisfactionscale - revised [27–29] (overall quality marks of 4.5); TheBirth Memories and Recall Questionnaire [30], The
labour and delivery satisfaction index [31] (an instru-ment developed and evaluated in 1987, and in need offurther testing and updating of its psychometric proper-ties), the Women’s delivery experience measures [32],and the Childbirth schema scale [33] (overall qualitymarks of 5).In general, we would suggests that tools with marks of
2 to 4.5 are not suitable for use without further testing,
Table 1 Excluded papers with reason (Continued)
Padawer JA, Fagan C, Janoff-Bulman R, Strickland BR, Chorowski M: Women’spsychological adjustment following emergency cesarean versus vaginaldelivery. Psychology of Women Quarterly 1988; 12(1):25–34.
Limited testing and description of psychometric properties.The childbirth Perception Questionnaire is further validatedby Bertucci et al. (2012) which is included in the review
Perriman N, Davis D: Measuring maternal satisfaction with maternity care:A systematic integrative review: What is the most appropriate, reliable andvalid tool that can be used to measure maternal satisfaction with continuityof maternity care? Women Birth 2016.
Review
Redshaw M, Martin C, Rowe R, Hockley C: The Oxford Worries about LabourScale: women’s experience and measurement characteristics of a measureof maternal concern about labour and birth. Psychol Health Med 2009;14(3):354–366
Not experiences of childbirth but on worries about childbirth
Rini EV: The Development and Psychometric Analysis of an Instrument toMeasure a Woman’s Experience of Childbirth. West Virginia University; 2014.
Dissertation
Ross-Davie MC, Cheyne H, Niven C: Measuring the quality and quantity ofprofessional intrapartum support: testing a computerised systematic observationtool in the clinical setting. BMC Pregnancy Childbirth 2013; 13:163.
Not the woman’s perspective
Rudman A, El-Khouri B, Waldenstrom U: Women’s satisfaction with intrapartumcare - a pattern approach. J Adv Nurs 2007, 59(5):474–487.
Compare different dimensions of the childbirth experienceto see how they form different patterns of satisfaction
Salmon P, Miller R, Drew NC: Women’s anticipation and experience of childbirth:the independence of fulfillment, unpleasantness and pain. Br J Med Psychol1990; 63 (Pt 3):255–259.
Compares antenatal anticipations of childbirth to postnatalexperiences of childbirth
Sapountzi-Krepia D, Raftopoulos V, Tzavelas G, Psychogiou M, Callister LC,Vehvilainen-Julkunen K: Mothers’ experiences of maternity services: internalconsistency and test-retest reliability of the Greek translation of the KuopioInstrument for Mothers. Midwifery 2009; 25(6):691–700.
Focus on expectations on childbirth not on experiences
Sawyer A, Ayers S, Abbott J, Gyte G, Rabe H, Duley L: Measures of satisfactionwith care during labour and birth: a comparative review. BMC PregnancyChildbirth 2013; 13:108.
Review
Sinclair M, O’Boyle C: The Childbirth Self-Efficacy Inventory: a replication study.J Adv Nurs 1999; 30(6):1416–1423.
Measures expectancies of childbirth
Stahl K: [Revalidation of a questionnaire assessing women’s satisfaction withmaternity care in hospital]. Psychother Psychosom Med Psychol 2010;60(9–10): 358–367.
In German
Stevens NR, Hamilton NA, Wallston KA: Validation of the multidimensionalhealth locus of control scales for labor and delivery. Res Nurs Health 2011;34(4):282–296
Pregnant women’s expectations
Sweetser L: Satisfaction with childbirth: measurement and causes. Other titles:1976; 45(4):163–180.
No psychometric analyses
Takegata M, Haruna M, Matsuzaki M, Shiraishi M, Murayama R, Okano T, Severinsson E:Translation and validation of the Japanese version of the Wijma Delivery Expectancy/Experience Questionnaire version A. Nurs Health Sci 2013; 15(3):326–332.
Nilvér et al. BMC Pregnancy and Childbirth (2017) 17:203 Page 5 of 19
especially if there is another existing tool that will servethe same purpose. Tools with a mark of 5 may be suit-able if they are the only instrument developed in thattopic area, but not otherwise, and further testing beforeuse is recommended.The majority of tools (20 out of 36, 56%) had marks
of 6 or 6.5, which probably indicates a suitable tool,unless there is a higher quality one in the same area.We suggest that the seven instruments with marks of7 to 9 (Table 2) can be considered valid and reliablealthough, of course, further testing is always welcomeand could improve them further. These included: TheChildbirth Experience Questionnaire [34], The mater-nal satisfaction scale for caesarean section [35], TheResponsiveness in Perinatal and Obstetric Health CareQuestionnaire [36, 37], Pregnancy and maternity carepatients experiences questionnaire [38] and The Child-birth Perception Scale [39]. The tool with the highestquality rating, of 9, was the Wijma Delivery Expect-ancy/experience Questionnaire [40], an instrumentmeasuring fear specific to labour and childbirth withone version used during pregnancy (version A) andone used after childbirth (version B). The Wijma DeliveryExpectancy/experience questionnaire has been used ex-tensively [60–66] and cultural validation and translationshave been made in several countries [67–69]. As this scaleis commonly used for measuring fear of childbirth, and itis properly developed with good psychometric properties,
we recommend this scale for measuring women’s experi-ence of fear in childbirth, when a detailed survey is neces-sary. However, a number of different cut-off points areused to define severe fear of childbirth, resulting in differ-ent prevalence rates, and these should be standardised.
DiscussionThe purpose of this systematic review was to identify andanalyse instruments that measure women’s childbirth ex-periences, and 46 papers representing 36 instrumentswere identified and included. By including surrogate termsand related concepts to the childbirth experiences, abroader and more holistic overview of existing instru-ments was achieved. Identified instruments demonstrateda wide range in purpose and content as well as in thequality of psychometric properties.When choosing between different instruments, one
needs to consider all ratings together as well as taking intoaccount those measurement properties that are mostimportant for a specific application, setting and popula-tion, e.g. practical aspects such as burden for women, andcost and quality aspects regarding the validity and reliabil-ity of the instrument [70]. If the researcher chooses aninappropriate or poor quality measurement instrument,this may lead to bias in the conclusion, resulting in wastedresources and unethical procedures for the women thatparticipated [71]. Rudman [72] concluded that a multi-item instrument including different dimensions of care
Fig. 1 Flow chart of study selection
Nilvér et al. BMC Pregnancy and Childbirth (2017) 17:203 Page 6 of 19
Table
2Qualityratin
gof
psycho
metric
prop
ertieswith
Terw
eeet
al.’scriteria
Instrumen
tPsycom
etric
prop
erties
Total
score
Needforthe
instrumen
tFace
validity
Con
tent
validity
Internal
consist-en
cyCriterion
validity
Con
struct
validity
Reprod
-ucibility
(Agree-m
ent)
Reproc-ucibility
(Reliabi-lity)
Respon
-sivness
Floo
r&
ceiling
effects
Inter-
pretata-bility
TheChildbirthTraumaInde
x[22]
+0
+-
0?
00
00
02.5
TheCh
ildbirth
ExperiencePerceptionQuestionn
aire[26]
++
+-
+0
0?
00
04.5
TheChildbirthExpe
rienceQuestionn
aire
[34]
++
++
0+
0+
0+
07
TheSurvey
ofBang
lade
shiw
omen
’sexpe
riences
ofmaternity
services
[41]
++
++
0+
+0
00
06
TheBirthCom
panion
Supp
ortQuestionn
aire
[42]
++
++
0+
+0
00
06
ThePercep
tionof
BirthScale[23,24]
+0
++
00
00
00
03
TheBirthMem
oriesandRecallQuestionn
aire
[30]
++
++
00
0+
00
05
TheSupp
ortandCon
trol
inBirthqu
estio
nnaire
[25]
++
++
00
00
00
04
Aself-administeredqu
estio
nnaire
toassess
wom
en’s
satisfactionwith
maternity
care
[43]
+0
++
00
++
00
+6
TheScaleforMeasurin
gMaternalSatisfaction-
norm
albirth[44]
++
++
++
00
00
06
TheScaleforM
easuringMaternalSatisfactio
n-caesarean
birth[44]
++
++
++
00
00
06
TheLabo
randDeliveryInde
x[45]
++
+0
0+
++
00
06
TheLabo
urAge
ntry
Scale[46]
+0
++
00
++
+0
06
TheBirthSatisfactionScale-Revised[27–29]
++
++
0?
00
00
04.5
TheEarly
Labo
urExpe
rienceQuestionn
aire
[47]
?0
++
++
0+
00
+6.5
TheLabo
randDeliverySatisfactionInde
x[31]
++
+-
0+
+-
00
05
Wom
en’sde
liveryexpe
riencemeasures[32]
+?
++
0+
00
00
?5
Thematernalsatisfactio
nscaleforcaesarean
section[35]
++
++
0+
0+
00
+7
TheSatisfactionwith
childbirth
experiencequestionnaire[48]
++
++
0+
00
00
+6
Wom
en’sPercep
tionof
Con
trol
durin
gChildbirth[48]
++
++
0+
00
00
+6
TheChildbirthSche
maScale[33]
00
++
0+
+0
00
+5
Satisfactionwith
obstetricalcare
[49]
++
?+
0+
00
0+
+6.5
ThePreterm
BirthExperienceandSatisfactionScale[50]
++
++
0+
0?
?0
+6.5
TheRespon
sivnessin
Perin
atalandObstetricHealth
CareQuestionn
aire
[36,37]
++
++
0+
00
++
+8
Wom
en’sSatisfactionWith
Hospital-Based
Intrapartum
CareScale[51]
++
++
0+
00
00
+6
Patient
Percep
tionScore[52]
++
++
++
00
00
+7
Nilvér et al. BMC Pregnancy and Childbirth (2017) 17:203 Page 7 of 19
Table
2Qualityratin
gof
psycho
metric
prop
ertieswith
Terw
eeet
al.’scriteria
(Con
tinued)
Preg
nancyandmaternity
care
patientsexpe
riences
questio
nnaire
[38]
++
++
0+
++
+0
+9
Wom
en’sview
ofbrith
labo
ursatisfaction
questio
nnaire
[53]
++
++
?+
00
00
+6.5
ThePerceivedCon
trol
inChildbirthScale[54]
+0
++
++
00
00
+6
TheSatisfactionwith
ChildbirthScale[54]
+0
++
++
00
00
+6
ThePreg
nancyandChildbirthQuestionn
aire
[55]
++
++
??
0+
00
+6.5
TheChildbirthPercep
tionScale[39]
++
++
0+
0+
00
+7
TheScaleof
Wom
en’sPercep
tionforSupp
ortive
CareGiven
DuringLabo
r[56]
++
++
0+
00
00
+6
TheDeliveryFear
Scale[57]
++
++
0+
?0
00
+6.5
TheWijm
aDeliveryExpe
ctancy/Experience
Questionn
aire
[40]
++
++
++
0+
+0
+9
TheParentalSatisfactionandQualityIndicatorsof
Perin
atalCareInstrumen
t[58,59]
++
++
0+
00
00
+6
Ratin
g:+=po
sitiv
e,?=interm
ediate,−
=ne
gativ
e,0=no
inform
ationavailable,
N/A
notassessab
le
Nilvér et al. BMC Pregnancy and Childbirth (2017) 17:203 Page 8 of 19
Table
3Descriptivedata
oftheinclud
edinstrumen
ts
Nam
eof
Instrumen
t/Acron
ymAutho
rs(year)
Cou
ntry
Aim
/motiveof
instrumen
tCom
men
ts
TheChildbirthTraumaInde
xforadolescents/CTI[22]
And
erson(2011)
USA
Tode
term
inespecificindicatorspe
rceived
byadolescentsas
influen
cing
birthtrauma.
Develop
edto
aidnu
rses
toassessanddirectcareto
redu
cethepo
ssibilityof
atraum
astressrespon
seor
post-traumatic
stressdisorderam
ongadolescentspo
stpartu
m[22].Further
developm
ent,adaptationandevaluationof
the
psycho
metric
prop
ertiesof
thistoolwou
ldbe
valuable.
TheCh
ildbirth
Experience
PerceptionScale/CEPS
[26]
Bertucciet
al.(2012)
Italy
Toassess
wom
en’spe
rcep
tionof
their
childbirthexpe
rience.
Afurthe
rde
velopm
entof
‘The
childbirthpe
rcep
tion
questionn
aire’[73].Theoriginalqu
estionn
airewas
exclud
edfro
mou
rreviewas
theoriginalpaperd
oesno
tpresent
testing
ofpsycho
metric
prop
erties.Bertu
ccietal.[26]areaw
areof
this,
buttheyconsiderthestreng
thsof
thequ
estionn
aireou
tweigh
thelim
itations
asittakesabroadview
ofvarious
aspectsinto
considerationwhenevaluatingthechildbirth
perceptions.The
psycho
metric
prop
ertiesneed
toto
befurth
erevaluated.The
validity
oftheCh
ildbirth
experienceperceptionscalewas
challeng
edinaletterto
Midwiferyjournal,andtheauthors
replieddefend
ingtheirp
osition
[83,84].
TheChildbirthexpe
rience
questio
nnaire/CEQ
[34]
Den
cker
etal.(2010).
Swed
enTo
assess
different
aspe
ctsof
first-tim
ewom
en’spe
rcep
tionof
theirchildbirth
expe
rience.
Develop
edto
assessdifferent
aspectsof
mothers’childbirth
experiences
inordertoexplorethem
comprehensively.
Sugg
ested\tobe
used
toidentifywom
enwith
negative
childbirth
experiences
andforevaluatingqu
ality
ofcare.
Thedevelopm
ento
fthe
instrumentisclearly
described
andprimaryresults
ofseveralpsychom
etric
prop
ertiesare
presented[34].The
instrumenth
asbeen
validated
inthe
UK[77]andused
inresearch
[85].
Thesurvey
ofBang
lade
shiw
omen
’sexpe
riences
ofmaternity
services/
SBWEM
S[41]
Duffet
al.(2001)
UK
Toevaluate
satisfactionwith
maternity
care
inSylheti-spe
akingBang
lade
shi
wom
en.
Thiscross-cultu
ralinstrum
entwas
madeby
cultu
ral
adaptatio
nandtranslatio
nof
anexistingmeasure.This
papercan
beused
asamod
elandinspiratio
nwhen
developing
instrumentsforu
seinminority
ethn
iccommun
ities
[41].
TheBirthCom
panion
Supp
ort
Questionn
aire/BCSQ
[42]
Dun
ne(2014)
Australia
Tomeasure
wom
en’spe
rcep
tions
ofsocialsupp
ortprovided
durin
glabo
urby
atleaston
elaybirthcompanion
.
Presen
tsafirstrig
orou
sstud
yof
thisinstrumen
tde
velope
dto
beused
inmidwifery
research
[42].
ThePercep
tionof
BirthScale/
POBS
[23,24]
Fawcett&Kn
auth
(1996)
Marut
&Mercer(1979)
USA
Tomeasure
wom
en’spe
rcep
tions
oftheirchildbirthexpe
riences.
Thisqu
estio
nnaire
was
originallyde
velope
dand
adaptedto
measure
thepe
rcep
tionof
wom
enwho
hadvaginalo
run
planne
dcaesareanbirths
in1975
[86]
andfurthe
radaptedby
Marut
andMarcer[24]
in1979.A
ttem
ptshave
been
madeto
adaptandtest
psycho
metric
prop
erties[87,88]be
fore
Fawcettand
Knauth
[23]
in1995
adaptedthescalefurthe
rand
madean
exploratoryfactor
analysis.The
scalene
eds
furthe
rtestsof
itspsycho
metric
prop
erties.
TheBirthMem
oriesandRecall
Questionn
aire/BirthM
ARQ
[30]
Foleyet
al.(2014)
UK
Toexam
inetherelatio
nship
between
mem
oriesof
birthandpo
stnatalm
ood
andpsycho
patholog
y.
Develop
edto
measure
characteristicsof
mem
ories
ofchildbirth
andto
exam
inetherelationshipbetween
mem
oriesforb
irthandmentalhealth
includ
ing
emotionaland
traum
aticmem
ories.With
furth
ertesting
ofreliabilityandvalidity
thisqu
estionn
airecould
becomeausefultoolbo
thinresearch
aswellasin
clinicalpractice[30].
Nilvér et al. BMC Pregnancy and Childbirth (2017) 17:203 Page 9 of 19
Table
3Descriptivedata
oftheinclud
edinstrumen
ts(Con
tinued)
TheSupp
ortandCon
trol
inBirthQuestionn
aire/SCIB
[25]
Ford
etal.(2009)
UK
Tomeasure
supp
ortandcontrolinbirth.
Focuseson
different
dimen
sion
sof
controld
uring
childbirth.
With
furthe
rtestingof
tispsycho
metric
prop
ertiesitcanprovideavalid
andreliablemeasure
toexam
inetherelatio
nships
amon
gsupp
ort,control,
andbirthou
tcom
es[25].Ithasbe
encultu
rally
validated
andtranslated
into
Turkish[78].
Wom
en’ssatisfactionwith
maternity
care/W
SMC[43]
Gerbaud
etal.(2003)
France
Tomeasure
wom
en’ssatisfaction
concerning
maternity
care.
Thisqu
estio
nnaire
isin
Fren
chandmeasure
wom
en’s
satisfactionwith
care
durin
gpreg
nancy,ho
spitalisation
forbirth,andho
mecom
ing.
Itistested
andde
velope
dto
beused
clinicallyandevaluatedcare
[43].
TheScaleforMeasurin
gMaternalSatisfaction-no
rmal
birth/SM
MS-no
rmalbirth[44]
Gun
gor&Beji(2012)
Turkey
Tomeasure
maternalsatisfaction
with
birthin
orde
rto
evaluate
wom
en’sexpe
riences
inlabo
urandtheearly
postpartum
perio
dbe
fore
hospitald
ischarge
.
Thisisascalede
velope
din
twoversions,o
neforno
rmal
birth
andon
eforcaesarean
birth
.The
scales
areconstru
cted
toevaluate
both
theexperienceof
careandtheem
otional
experienceof
childbirth
asameasureof
satisfaction.The
evaluationof
initialpsycho
metric
prop
ertiesarego
odand
with
furth
ertestingthesescales
canbecomeausefultool[44].
TheScaleforMeasurin
gMaternal
Satisfaction-
Caesarean
birth/SM
MS-
caesareanbirth[44]
Gun
gor&Beji(2012)
Turkey
Tomeasure
maternalsatisfaction
with
birthin
orde
rto
evaluate
wom
en’sexpe
riences
inlabo
urandtheearly
postpartum
perio
dbe
fore
hospitald
ischarge
.
Seeabove.
TheLabo
randDeliveryInde
x/LA
DY-X[45]
Gärtner
etal.(2015)
The
Nethe
rland
sAutility
measure
forecon
omic
evaluatio
nsin
perin
atalstud
ies.
Develop
edto
measure
costeffectiven
essof
perin
atalcare
interven
tions
forusein
research
andisableto
discrim
inate
betw
eengrou
ps[45].The
onlyinstrumen
tiden
tifiedthat
measuresecon
omicevaluatio
nsin
perin
atalstud
ies.
TheLabo
urAge
ntry
Scale/LA
S[46]
Hod
nett&Simmon
s-Trop
ea(1987)
Canada
Aninstrumen
tmeasurin
gexpe
ctancies
andexpe
riences
ofpe
rson
alcontrol
durin
gchildbirth.
Sincethisscalewas
develope
din
1987
[46]
ithasbe
enused
instud
iesfro
mabroadrang
eof
coun
triesas
well
asin
different
type
sof
stud
ies[89–96].Alth
ough
widely
used
,further
stud
iesof
thepsycho
metric
prop
ertiesare
recommen
dedto
ensure
itsvalidity
andreliability.
TheBirthSatisfactionScale-
Revised/BSS-R[27–29]
HollinsMartin
&Flem
ing(2011)
HollinsMartin
etal.(2012)
HollinsMartin
&Martin
(2014)
UK
Tomeasure
postnatalw
omen
’sbirth
satisfaction.
Thebirthsatisfactionscale–revised[28]
isafurthe
rde
velopm
entof
theBirthsatisfactionscale[27,29,97].
Therevisedversionof
thescaleisamorerobu
stversion.
They
have
been
used
inresearch
[97–99]andfurthe
rcultu
raltranslatio
nandvalidationhasbe
enmadein
GreeceandtheUS[79,80,100].
TheEarly
Labo
urExperience
Questionn
aire/ELEQ[47]
Janssen&Desmarais(2013)
USA
Tomeasure
wom
en’sexpe
riences
with
theirearly
labo
urcare.
Develop
edto
measure
wom
en’sexpe
rienceandevaluate
care
givenin
thelatent
andearly
phaseof
labo
ur[47,101].
Add
ition
altestingof
psycho
metric
prop
ertieswou
ldstreng
then
thequ
estio
nnaire
furthe
r.
TheLabo
rand
DeliverySatisfaction
Index/LA
DSI[31]
Lomas
etal.(1987)
Canada
Toassessthecaringaspectsof
childbirth
care.
Develop
edforusein
clinicaltrials[31]
andhasbe
enused
inseveralstudies
evaluatin
gcare
given[102–104].Itwas
develope
dandevaluatedin
1987.The
refore
itwou
ldbe
approp
riate
tope
rform
furthe
rtestingandup
datin
gof
itspsycho
metric
prop
erties.
Wom
en’sde
liveryexpe
rience
measures/MFRM
[32]
Mannarin
ietal.(2013)
Italy
Toassess
birthexpe
riences
afterbo
thspon
tane
ousandmed
icallyassisted
concep
tion.
Thestatisticalanalysiswas
madeby
usingtheRash
mod
elwith
thepu
rposeof
definingandvalidatinga
latent
dimen
sion
forbirthpe
rcep
tion[32].
Nilvér et al. BMC Pregnancy and Childbirth (2017) 17:203 Page 10 of 19
Table
3Descriptivedata
oftheinclud
edinstrumen
ts(Con
tinued)
Thematernalsatisfactionscalefor
caesareansection/MSS-caesarean
section[35]
Morganet
al.(1999)
Canada
Tomeasure
maternalsatisfactionin
wom
enun
dergoing
electiveor
non-em
erge
ntcaesareansectionun
der
region
alanaesthe
sia.
Develop
edby
anaesthe
siolog
ists
andtw
oof
the
dimensio
nsaremeasurin
gsatisfactionwith
anaesthetics
andsid
e-effects.Ithasbeen
prop
erlytested
forvalidity
andreliability[35].
TheSatisfactionwith
childbirth
experiencequ
estionn
aire/SWCB
E[48]
Oweis(2009)
Jordan
Noaim/purpo
seof
theinstrumen
tdo
cumen
ted.
Oweis[48]
develope
dtw
oscales
inthesamestud
yto
assess
wom
en’schildbirthexpe
riences
includ
ing
expectatio
ns,satisfactionan
dself-control.Th
ese
twoscales
need
furthe
revaluatio
nof
their
psychom
etric
prop
ertie
s.
Wom
en’sPercep
tionof
Con
trol
durin
gChildbirth/PC
CB[48]
Oweis(2009)
Jordan
Noaim/purpo
seof
theinstrumen
tdo
cumen
ted.
Seeabove.
TheCh
ildbirthSchemaScale/CS
S[33]
Peirce(1994)
US
Toob
tain
anun
derstand
ingof
sche
maform
ationandrevision
with
theknow
nstressor
ofchildbirth.
Develop
edto
gain
unde
rstand
ingof
theun
derlying
structureof
know
nstressorsof
childbirth,by
comparing
thesche
mas
before
andafterbirth[33].Fu
rthe
rdevelop
men
tandad
aptatio
nof
theinstrumen
twou
ldstreng
then
thepsycho
metric
prope
rties.
Satisfactionwith
obstetricalcare/
SSO[49]
Ramanah
(2014)
France
Canada
Sene
gal
Tomeasure
satisfactionin
obstetrical
care
durin
glabo
r,de
liveryandtw
oho
urspo
stpartum
relevant
totheFren
ch-spe
akingcontext.
Thisinstrumen
tistested
inaFren
chspeaking
context
inSenegal,France
andCanada
[49].Further
developm
ent
andevaluatio
nof
thisinstrumentwou
ldstreng
then
the
validity.
ThePreterm
BirthExpe
rienceand
SatisfactionScale/P-BESS
[50]
Sawyer(2014)
UK
Toassess
parents(wom
enandtheir
partne
rs)expe
riences
andsatisfaction
with
care
durin
gvery
preterm
birth
(<32
gestationalw
eeks).
Furth
ertestingof
psycho
metric
prop
ertiesinlargersample
grou
pswouldbe
recommendedas
wellasassessmento
fwhenthemostsuitabletim
eafterb
irthto
administerthe
questionn
airewou
ldbe
[50].
TheRespon
sivnessin
Perin
ataland
ObstetricHealth
CareQuestionn
aire/
ReproQ
[36,37]
Scheerhagenet
al.(2015)
vanderK
ooyet
al.(2014).
The
Nethe
rland
sTo
evaluatin
gmaternalexperiences
ofpe
rinatalcare
services,using
the
eigh
t-do
mainWHOconcep
t.
Thisqu
estio
nnaire
isbasedon
theeigh
t-do
mainWorld
Health
Organ
ization’sRe
spon
sivene
ssmod
el.Th
eque
stionn
aire
hasan
antepa
rtum
versionassessing
theexperiencedu
ringpreg
nancyan
dapo
stpa
rtum
versionassessingwom
en’sexperiences
duringchildbirth
andpo
stpartum
care.Ithasbeen
prop
erlytested
fora
broadvarietyof
psycho
metric
prop
erties[36,37,105].It
hasbeen
used
toevaluate
andcompare
care
[106].
Wom
en’sSatisfactionWith
Hospital-
BasedIntrapartum
CareScale[51]
Shaban
(2014)
Jordan
Tomeasure
wom
en’ssatisfaction
with
intrapartum
care
inJordan,
espe
ciallyto
exam
ineho
wlow-risk,
healthylabo
ringwom
enexpe
rienced
aredu
ringlabo
randbirth.
Develop
edto
provideinform
ationon
wom
en’s
expe
riences
with
theaim
ofhe
lpingcaregiverschange
practices.Further
stud
iesevaluatin
gthepsycho
metric
prop
ertieswou
ldbe
thene
xtstep
[51].
Patient
Percep
tionScore/PP
S[52]
Siassakoset
al.(2009)
UK
Asimpletool
tomeasure
maternal
satisfactionof
operativeabdo
minal
andvaginalb
irth.
Thisisashorttool
adaptedfro
maPatient
percep
tion
scoreused
insim
ulationtraining
ofob
stetric
emergency
situatio
nsandiseasy
tocomplete[107].Itaimsto
capture
patient’sperceptio
nof
operativebirthwith
afocuson
perceivedcommun
ication,respectandsafety.Thisisan
easy
toolthat
issugg
estedby
theauthorsto
beused
onaregu
larb
asisinclinicalsettings
tofocuson
wom
en’s
percep
tions
andim
provecare
[52].
Preg
nancy-
andmaternity-care
patients’expe
riences
questio
nnaire./
PreM
aPEQ
[38]
Sjetne
(2015)
Norway
Tomeasure
wom
en’sexpe
riences
ofpreg
nancyandmaternity
care
inDevelop
edto
collect
wom
en’sexpe
riences
ofthe
maternity
health
care
system
inNorway.Ithasbe
enwelltested
forabroa
dvarie
tyof
psycho
metric
Nilvér et al. BMC Pregnancy and Childbirth (2017) 17:203 Page 11 of 19
Table
3Descriptivedata
oftheinclud
edinstrumen
ts(Con
tinued)
Norway
andothe
rsiteshaving
similar
health
system
.prop
ertie
san
disan
acceptab
leinstrumen
tfor
collectingwom
en’sexpe
riences
ofmaternity
care
[38].
Wom
en’sView
ofBirth
Labo
urSatisfaction
Questionn
aire/W
OMBLSQ
[53]
Smith
(2001)
UK
Tomeasure
maternalsatisfactionwith
care
quality
ofdifferent
mod
elsof
labo
urcare
intheUK.
Thisqu
estio
nnaire
canbe
used
tocompare
mod
els
orsystem
sof
labo
urandcare
durin
gbirth,
giving
anoverallp
icture
ofcare
received
.Itwou
ldstreng
then
thereliabilityandvalidity
iftheinstrumen
twas
furthe
revaluatedandadapted[53].Ithasbe
encultu
rally
translated
andadaptedin
severalcou
ntries[108,109]
andused
instud
ies[110].
Thepe
rceivedCo
ntrolinCh
ildbirthScale/
PCCh
[54]
Steven
s(2012)
USA
Toassess
patient
percep
tions
ofcontrolo
fthechildbirthen
vironm
ent.
Develop
men
tof
twoseparate
scales
inthesamepape
r.Ago
alof
thestud
ywas
toclarify
thetheo
retical
distinctions
amon
gsimilarconstructs
[54].
TheSatisfactionwith
ChildbirthScale/
SWCh[54]
Steven
s(2012)
USA
Toassessglob
alsatisfactionwith
the
childbirth
experience.
Seeabove.
ThePreg
nancyandChildbirth
Questionn
aire/PCQ[55]
Truijens
(2014a)
The
Nethe
rland
sTo
assessqu
ality
ofcaredu
ring
pregnancyanddeliveryas
perceived
bywom
enwho
recentlygave
birth
.
Twoscales,o
nereferringto
preg
nancyandon
ereferring
tobirth
.Furtherresearch
andevaluationof
thepsycho
metric
prop
ertieswou
ldstreng
then
thevalidity
andreliability[55].It
hasbeen
used
instud
ies[111,112].
TheChildbirthPercep
tionScale/
CPS
[39]
Truijens
(2014b
)The
Nethe
rland
sTo
assesses
thepe
rcep
tionof
deliveryandthefirst
postpartum
week.
Develop
edto
compare
wom
en’spe
rcep
tionof
homeand
hospitalbirth[39].Psychom
etric
prop
ertieshave
been
adequate
tested
butfurthertestin
gwou
ldstreng
then
validity
andreliability.
TheScaleof
Wom
en’sPercep
tionfor
Supp
ortiveCareGiven
DuringLabo
r[56]
Uludag&Mete(2015).
Turkey
Tode
term
inewom
en’spe
rcep
tionof
supp
ortivecare
givendu
ringlabo
r.Develop
edto
seeho
wwom
enpe
rceive
care
received
from
nurses
toevaluate
quality
ofcare
[56].Further
evaluatio
nandadaptatio
nof
thepsycho
metric
prop
erties
wou
ldstreng
then
validity
andreliability.
DeliveryFear
Scale/DFS
[57]
Wijm
aet
al.(2002)
Swed
enTo
measure
fear
durin
gtheprocessof
labo
r.Thisistheon
lyscalethat
wehave
iden
tifiedthat
has
been
tested
andevaluatedforpsycho
metric
prop
erties
that
aremeant
tobe
used
durin
glabo
ur[80].The
scale
hasbe
enused
inresearch
[113,114].
TheWijm
aDeliveryExpectancy/Experience
Questionn
aire/W
-DEQ
[40]
Wijm
aet
al.(1998)
Swed
enTo
measure
fear
ofchildbirthdu
ring
preg
nancyandafterchildbirth.
Con
sistsof
twoversions;o
neto
beused
durin
gpreg
nancy
(version
A)andon
eto
beused
afterchildbirth(version
B)[40].Itha
sbe
enused
extensively[60–
66]an
dcultu
ral
validationandtran
slations
have
been
mad
ein
several
coun
tries[67–
69].Itiscommon
lyused
formeasurin
gfear
ofchildbirth,
anditisprope
rlyde
veloped
with
good
psycho
metric
prop
ertie
s.
TheParentalSatisfactionandQuality
Indicatorsof
Perin
atalCareInstrumen
t/PP
C[58,59]
Woo
l,C.(2015a).
Woo
l,C.(2015b).
US
Tomeasure
parentalsatisfactionandqu
ality
indicatorsin
parentselectin
gto
continue
apreg
nancyafterlearning
ofalife-lim
iting
fetald
iagn
osis.
Thisistheon
lyinstrumen
tweiden
tifiedconcerning
this
subject[58,59].Furthe
revaluatio
nof
thepsycho
metric
prop
ertieswou
ldstreng
then
thevalidity
andreliability.
Nilvér et al. BMC Pregnancy and Childbirth (2017) 17:203 Page 12 of 19
Table
4Characteristicsof
includ
edinstrumen
ts
Nam
eof
Instrumen
t/Acron
ymItems
Dim
ension
s/subscales
Respon
seTimeframeto
answ
erthequ
estio
nnaire
Quest-io
nnaire
available
TheChildbirthTraumaInde
xfor
Ado
lescen
ts/CTI[22]
14-item
sNo
4-po
intLikertscaleandratin
gof
birthexpe
riencebe
tween0
and10
1–3days
postpartum
No
TheChildbirthExpe
rience
Percep
tionScale/CEPS[26]
24-item
s3subscales;Labo
urandDelivery
Percep
tion,Con
trol
Percep
tion,and
Chang
ePercep
tion.
6-po
intLikertscale
24–48hpo
stpartum
No
TheChildbirthexpe
rience
questio
nnaire/CEQ
[34]
22-item
s4dimen
sion
s;Owncapacity,
Profession
alsupp
ort,Perceived
safety,and
Participant
4-po
intLikertscaleandVA
S1mon
thpo
stpartum
Yes
Thesurvey
ofBang
ladeshiw
omen’s
experiences
ofmaternityservices/
SBWEM
S[41]
72-items
3subscales;Ante-
(33items),Peri-
(15items),Post-natal(24
items)
Yes/No,Likertscales
and
Multip
lechoice
optio
ns2mon
thpo
stpartum
Yes
theBirthCom
panion
Supp
ort
Questionn
aire/BCS
Q[42]
17-item
s2subscales;Em
otionalsup
port,
tang
iblesupp
ort
4-po
intLikertscale
Onpo
stnatalw
ard
before
discharge
No
ThePercep
tionof
BirthScale/
POBS
[23,24]
25-item
s5subscales;Labo
rExpe
rience,
DeliveryExpe
rience,Delivery
Outcome,Partne
rParticipation,
andAwaren
ess
5-po
intLikertscale
1–2days
afterbirth
No
TheBirthMem
oriesandRecall
Questionn
aire/BirthM
ARQ
[30]
23-itmes
6dimen
sion
s;Em
otionalm
emory,
centralityof
mem
oryto
iden
tity,
Coh
eren
ce,Reliving,
Involuntary
recall,andSensorymem
ory
7-po
intLikertscale
With
in1year
after
giving
birth
Yes
TheSupp
ort
andCon
trol
inBirthQuestionn
aire/SCIB
[25]
33-item
s3subscales;Internalcontrol(10
items),
externalcontrol(11
items),Sup
port
(12items)
5-po
intLikertscale
Onaverage,1year
afterbirth
Yes
Wom
en’ssatisfactionwith
maternity
care/W
SMC[43]
44-item
s11
dimen
sion
sLikertscales
andMultip
lechoice
optio
ns2mon
thpo
stpartum
Yes
TheScaleforMeasurin
gMaternal
Satisfaction-no
rmalbirth/SM
MS-
norm
albirth[44]
43-item
s10
subscales;pe
rcep
tionof
health
profession
als,nu
rsing/midwifery
care
inlabo
ur,com
forting,
inform
ationand
involvem
entin
decision
making,
meetin
gbaby,p
ostpartum
care,hospitalroo
m,
hospitalfacilities,respectforprivacy,
meetin
gexpe
ctations
5-po
intLikertscale
With
in24
hNo
TheScaleforMeasurin
gMaternal
Satisfaction-
Caesarean
birth/SM
MS-
caesareanbirth[44]
42-item
s10
subscales;pe
rcep
tionof
health
profession
als,prep
arationforcaesarean,
comforting,
inform
ationandinvolvem
ent
indecisio
nmaking,meetingbaby,postpartum
care,hospitalroo
m,hospitalfacilities,
respectfor
privacy,meetingexpectations
5-po
intLikertscale
With
in72
hNo
TheLabo
randDeliveryInde
x/LA
DY-X[45]
7-items
7do
mains;A
vailability,Inform
ation,
Needs,Emotionalsup
port,W
orries,Safety,
timeto
firstcontactwith
baby
3-po
intLikertscale
6–8weeks
postpartum
Yes
Nilvér et al. BMC Pregnancy and Childbirth (2017) 17:203 Page 13 of 19
Table
4Characteristicsof
includ
edinstrumen
ts(Con
tinued)
TheLabo
urAge
ntry
Scale/LA
S[46]
29-item
sNo
7-po
intLikertscale
With
in72
hpo
stpartum
No
TheBirthSatisfactionScale-
Revised/BSS-R[27–29]
10-item
s3subscales:Qualityof
care
provision
(4items),w
omen
’spe
rson
alattributes
(2items),stressexpe
rienced
durin
glabo
ur(4
items).
5-po
intLikertscale
With
in10
days
postpartum
Yes
TheEarly
Labo
urExpe
rience
Questionn
aire/ELEQ[47]
22-item
s3subscales:Em
otionalW
ell-Being
(8),
EmotionalD
istress(8),Percep
tionof
Nursing
Care(6)
5-po
intLikertscale
Duringpo
stpartum
stay
atho
spital
Yes
TheLabo
randDelivery
SatisfactionInde
x/LA
DSI[31]
38-item
sNo
6-po
intLikertscale
2days
postpartum
and
4.6weeks
postpartum
Yes
Wom
en’sde
liveryexpe
rience
measures/MFRM
[32]
31-item
s7dimen
sion
s4-po
intLikertscale
24–48hpo
stpartum
No
Thematernalsatisfactionscalefor
caesareansection/MSS-caesarean
section[35]
22-item
s3subscales:Anaesthetic(6
items),
Side
-effects(6
items),A
tmosph
ere
(10items)
7-po
intLikertscale
Not
repo
rted
Yes
TheSatisfactionwith
childbirth
expe
riencequ
estio
nnaire/
SWCBE
[48]
32-item
sNo
5-po
intLikertscale
Not
repo
rted
Yes
Wom
en’sPercep
tionof
Con
trol
durin
gChildbirth/PC
CB[48]
23-item
sNo
5-po
intLikertscale
Not
repo
rted
Yes
TheChildbirthSche
maScale/
CSS
[33]
16-item
pairs
3factors:Em
otions
ofou
tcom
e(6
items),
Sensationof
theworkof
childbirth(4
items),
Time(3items),Preparationforcon
trol(3items)
7-po
intLikertscale
1mon
thbe
fore
and
2weeks
afterbirth
No
Satisfactionwith
obstetrical
care/SSO
[49]
49-items
5dimen
sion
s:Nurse
(14),d
octor(14),
anaesthe
tist(5),en
vironm
ent(9),glob
alsatisfaction(7)
10-point
Likertscale
48hpo
stpartum
Yes
ThePreterm
BirthExpe
rience
andSatisfactionScale/P-BESS
[50]
17-item
s3dimen
sion
s:Staffprofession
alism
and
empathy,Inform
ationandexplanations,
Con
fiden
cein
staff
5-po
intLikertscale
Upto
12mon
ths
postpartum
No
TheRespon
sivnessin
Perin
atal
andObstetricHealth
Care
Questionn
aire/Rep
roQ[36]
40-item
s8do
mains:D
ignity,A
uton
omy,Con
fiden
tiality,
Com
mun
ication,Prom
ptattention,Social
consideration,Basicam
enities,C
hoiceand
continuity.
Not
repo
rted
6weeks
postpartum
Yes
Wom
en’sSatisfactionWith
Hospital-Based
Intrapartum
CareScale[51]
14-item
s3dimen
sion
s:Interpersonalcare
(5ite
ms),
Inform
ationandde
cision
making(4
items),
Physical
birthen
vironm
ent(5
items)
Not
repo
rted
2mon
thspo
stpartum
No
Patient
Percep
tionScore/
PPS[52]
3-items
3items;commun
ication,respectandsafety
5-po
intLikertscale
With
in24
hof
birth
yes
Preg
nancy-
andmaternity-care
patients’experiences
questio
nnaire./
PreM
aPEQ
[38]
145-itemsin
total
4partsin
thequ
estio
nnaire.O
neof
theseis
Birthandhave
3subscales:Person
alrelatio
nships
inthede
liveryward,
Resourcesandorganisatio
nin
thede
liveryward,
Atten
tionto
partne
rin
the
deliveryward.
5po
intLikertscalforsing
leitemsand
inde
xscores
weretransformed
linearly
toascaleof
0–100.
From
17weeks
after
birth
Yes
Nilvér et al. BMC Pregnancy and Childbirth (2017) 17:203 Page 14 of 19
Table
4Characteristicsof
includ
edinstrumen
ts(Con
tinued)
Wom
en’sView
ofBirthLabo
urSatisfactionQuestionn
aire/
WOMBLSQ
[53]
Not
repo
rted
10dimen
sion
sin
additio
nto
gene
ralsatisfaction
Not
repo
rted
With
in10
days
ofbirth
No
Thepe
rceivedCon
trol
inChildbirth
Scale/PC
Ch[54]
12-items
No
6-po
intLikertscale
Priorto
discharge
Yes
TheSatisfactionwith
Childbirth
Scale/SW
Ch[54]
7-items
No
7-po
intLikertscale
Priorto
discharge
Yes
ThePreg
nancyandChildbirth
Questionn
aire/PCQ
[55]
25-item
sTw
oscales:18-itemsreferring
topregnancy,7-items
referring
toperson
altreatmentd
uringdelivery.
5-po
intLikertscale
With
in6weeks
ofbirth
No
TheChildbirthPercep
tionScale/
CPS
[39]
12-item
s2dimen
sion
s;Percep
tionof
delivery(6-item
s),
percep
tionof
firstpo
stpartum
week(6-item
s)4-po
intLikertscale
7days
postpartum
Yes
TheScaleof
Wom
en’sPercep
tion
forSupp
ortiveCareGiven
During
Labo
r[56]
33-item
s3subd
imen
sion
s:Com
fortableBehaviou
rs(15-items),Edu
catio
n(8-item
s),D
isturbing
Behaviou
rs(10items)
4-po
intLikertscale
Not
repo
rted
No
TheDeliveryFear
Scale/DFS
[57]
10-item
sNo
10-point
scale
Duringanymom
ent
oflabo
randde
livery
Yes
TheWijm
aDeliveryExpe
ctancy/
Expe
rienceQuestionn
aire/W
-DEQ
[40]
29-item
sNo
6-po
intLikertscale
Within2hof
birth
and
5weeks
afterb
irth
Yes
TheParentalSatisfactionand
QualityIndicatorsof
Perin
atal
CareInstrumen
t[58,59]
Intra-partum
scale:
37items
Post-natalscale
includ
ean
addit-
ional7
items
3scales:The
Pren
atal,The
Intrapartum,The
PostnatalScale8do
mains:Structure
and
processesof
care,p
hysicalaspectsof
care,
psycho
logicaland
psychiatric
aspe
ctsof
care,
socialaspe
ctsof
care,spiritual,religious,and
existentialaspectsof
care,culturalaspectsof
care,careof
theim
minen
tlydyingpatient,
andethicaland
legalaspectsof
care.
7-po
intLikertscale
Not
repo
rted
No
Nilvér et al. BMC Pregnancy and Childbirth (2017) 17:203 Page 15 of 19
instead of a single global measure, gave a more diverseand richer picture of women’s childbirth experiences butalso led to a more negative picture [72]. To choose theright instrument for clinicians and researchers for theirspecific context is a complex process. In our result wepresent an overview in Tables 1 and 2 of descriptive dataand characteristics of instruments as well as a narrativesummary of the individual instruments, which can aid inthis process.Terwee et al. [17] consider the content validity to be
the single most important psychometric property of thequestionnaire, and state that only if the content validityis adequate can the questionnaire be considered, and theremaining measurement properties become useful. Allinstruments in our review did get a positive rating ofcontent validity. But a more thorough investigationwould still be advisable to see which instruments havethe strongest content validity to aid in choosing anappropriate instrument. Many of the instruments thatwe identified would need further testing of their psycho-metric properties to determine which would be best.This is consistent with the finding of Sawyer et al. [20],who evaluated nine questionnaires about women’s satis-faction during labour and birth, concluding that none ofthe questionnaires had optimal testing of validity andreliability. Most of the instruments in our review didreport on several tests of psychometric properties, butfurther evaluation of validity and reliability was needed.Among the excluded papers (Table 1) there are sev-
eral questionnaires developed that were not includedin this review as they did not report on psychometricproperties [73] or the focus was on a study ratherthan development of the instrument [72, 74]. Beforeusing a specific instrument, we suggest that a thor-ough investigation of the development and testing ofthe instrument should be done to ensure good psy-chometric properties. In the US Food and Drug Ad-ministration’s guidelines on developing new patient-reported outcome measures, they suggest that a newinstrument can be developed by modifying an existingone [18]. As we found a large number of question-naires and instruments, we agree with this suggestion.When conducting studies of psychometric propertiesof an instrument, we recommend applying standardssuch as the COSMIN checklist [75, 76] and Terweeet al.’s criteria [17] in order to enhance the quality ofthe results and to facilitate the researcher to compareand find an instrument with good psychometricproperties.Several of the papers included in our review consisted
of development and validation of existing questionnaires[23, 26, 41]. As well, several of the questionnaires havebeen culturally translated and validated in other lan-guages and cultures [67–69, 77–80].
Methodological considerationsThe attempt with this review was to identify all studiesand instruments that meet the eligibility criteria, but it ispossible that we have missed relevant articles, written inother languages than English and French, or indexed inother databases than those chosen. A limitation of thissearch was that we did not use Terwee et al’s PubMedsearch filter [81] which may have generated more papers.We suggest that this review can be used as a tool for iden-tification of existing instruments, while acknowledgingthat each researcher will have to assess their chosen toolthemselves in the light of the lack of, in most cases, suffi-cient testing. Terwee et al. [82] raised in their discussionof the quality of systematic reviews of health related out-come measurement the need for reviewers to make strongrecommendations. Our review consists of a large numberand wide range of instruments, making it difficult to makethose recommendations, particularly as a more thoroughevaluation of psychometric properties and quality assess-ment of included studies was needed. Nevertheless, wehave made some suggestions in relation to use of toolsdepending on their overall quality score. As we chose toinclude instruments that use surrogate terms and relatedconcepts to women’s childbirth experiences this reviewpresents for researchers and clinicians the diversity of in-struments developed. For assessing methodological qual-ity, the COSMIN checklist has newly been developed. It isa detailed and rigorous checklist [75, 76], useful in futuresystematic literature reviews that have a more narrowedconstruct of interest, so it could be manageable to do amore in-depth assessment of each instrument comprisingboth psychometric properties and methodological qualityof the development process of each instrument.
ConclusionsThis systematic review provides an overview of existinginstruments measuring women’s childbirth experiencesand can support researchers to identify an appropriateinstrument for their research purpose. Most of the instru-ments require further validation and reliability testing.Given the plethora of instruments in use in the literature,and the lack of complete testing for many of them, werecommend that researchers do not develop any morenew tools, but try to test thoroughly, adapt and improvethose that already exist.Researchers and clinicians need help in finding and
selecting the most suitable instrument for their purpose.This makes reviews of measurement instruments import-ant as they aid researchers in finding appropriate, estab-lished and tested instruments instead of developing newones. When different instruments are used to measure thesame construct of interest, e.g. women’s experiences ofcaesarean section, it can become difficult in systematic re-views to compare and statistically report the results. We
Nilvér et al. BMC Pregnancy and Childbirth (2017) 17:203 Page 16 of 19
trust that this review can contribute in helping cliniciansand researchers to find the right instrument for theirspecific context.
Additional files
Additional file 1: Review protocol. (DOCX 17 kb)
Additional file 2: Search strategy. (DOCX 15 kb)
AcknowledgmentsWe thank librarian Tobias Prenler at Gothenburg university library whoprovided support and knowledge in develop and perform the literaturesearch. We thank collaborator Jenny Carlsson (JC), RM, MSc, for co-screeningarticles for initial inclusion/exclusion.
FundingThis study was not funded.
Availability of data and materialsNot applicable.
Authors’ contributionsHN, MB and CB planned the study. HN conducted the literature search andinitial screening of papers. HN and MB screened papers for full textassessment. All authors screened full text articles for inclusion and wereinvolved with quality assessment of included instruments. HN extracteddescriptive data and characteristics of included instruments. This waschecked by MB and CB. HN drafted the manuscript. All authors contributedto the intellectual content, read and approved the final manuscript.
Competing interestsOne of the reviewers, MB, was involved in the development and validationof the Childbirth experience questionnaire [30], one of the instrumentsincluded in the review. The inclusion and quality assessment wheretherefore assessed and evaluated by the other two reviewers (HN and CB).
Consent for publicationNot applicable.
Ethics approval and consent to participateThis is a systematic review of already published primary sources and as suchno further ethical approval was required.
Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims in publishedmaps and institutional affiliations.
Author details1Institute of Health and Care Sciences, Sahlgrenska Academy, University ofGothenburg, Gothenburg, Sweden. 2School of Nursing and Midwifery, TrinityCollege Dublin, Dublin, Ireland. 3Centre for Person-Centred Care (GPCC),University of Gothenburg, Gothenburg, Sweden.
Received: 14 December 2016 Accepted: 26 May 2017
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