Given the significance and utility of the BSS-RI, and the limited availability of short assessment tools to measure birth satisfaction among the Chinese population, there is a need to develop and validate a Chinese-language version of the BSS-RI. The objective of this study is to create a Chinese version of the BSS-RI that can effectively evaluate women’s childbirth experiences in China, thus contributing to the existing body of research in this field. The BSS-RI is a 6-item questionnaire that includes two subscales: Stress Experienced during Childbirth (SE) and Quality of Care (QC). The aim of this study is to validate and adopt the BSS-RI in the Chinese language in China.
This cross-sectional study was conducted among postpartum women who underwent physical examinations six weeks after delivery. Data collection took place between April and August 2023 at three tertiary hospitals in Nantong City, China: The Affiliated Hospital of Nantong University, The Sixth People’s Hospital of Nantong, and The Affiliated Maternity and Child Health Care Hospital of Nantong University. The three hospitals selected for this study are situated in different regions of Nantong City, ensuring a representative sample of postpartum women from across the area. The timing of the study, six weeks postpartum, was chosen to provide a comprehensive assessment of birth satisfaction while minimizing potential threats to care and aligning with established postnatal care practices.
Participants were selected using convenience sampling. In our study, the sample size calculation was based on the formula for cross-sectional studies, considering the snapshot nature of our research. Given the lack of local data on the prevalence of birth satisfaction measured by the BSS-RI, we assumed a prevalence of 60% (P = 0.6) with reference to international validation studies of similar scales. The calculation formula was: N = Z × P(1-P) / e. Where Z = 1.96 (95% confidence level), P = 0.6 (assumed prevalence), and e = 0.05 (margin of error). The calculation yielded a minimum sample size of 368.8. Considering a 10% potential attrition rate, the adjusted required sample size was 406. This study is part of a broader research project titled “Comprehensive Assessment of Physical and Mental Health Among Pregnant Women and New Mothers,” which aims to gather extensive data on various aspects of physical and mental health. Fortunately, our recruitment rate exceeded expectations, and we were able to gather a total of 836 participants for our study, meeting the sample size criteria. However, two participants withdrew from the study, eight had incomplete data, and two provided invalid responses. As a result, the final analysis included 824 participants, resulting in a response rate of 98.56%. To assess test-retest reliability, a random subsample of 30 participants was recruited from the baseline cohort. Retesting was conducted 2 weeks after initial assessment, an interval selected to minimize recall bias while assuming stable birth satisfaction perceptions. The sample size was determined in accordance with COSMIN guidelines for reliability studies, which specify that ≥ 25 subjects provides adequate precision for intraclass correlation coefficient (ICC) estimation.
The inclusion criteria were as follows: (1) Postpartum women aged 18 years or older, (2) Mothers of newborns with no birth defects or severe complications, (3) Willingness to participate in the survey, (4) Ability to communicate effectively in Chinese and understand the questionnaire content, (5) Ability to complete the questionnaire independently. The exclusion criteria were as follows: (1) Presence of mental illnesses, (2) Presence of severe organic diseases (e.g., severe cardiovascular diseases, chronic respiratory diseases, or other conditions that significantly impact physical health).
Before the survey commenced, all participants were informed about the purpose, methods, and significance of the study. They were provided with standardized instructions that included a comprehensive overview of the investigation’s purpose and content. They were also informed that their participation was voluntary, and all responses would be kept confidential. They had the option to withdraw from participation at any time. The entire survey lasted for 10-15 min. The study obtained ethical approval from the Research Ethics Committee of the Affiliated Hospital of Nantong University (approval number: 2022-K150-01).
To ensure that the selection of a limited number of items from the BSS-RI did not significantly impact the measure’s conceptual alignment, we employed a random split-half data selection procedure. This procedure involved dividing the dataset into two random halves: one for exploratory factor analysis (EFA) to identify the underlying factor structure, and the other for confirmatory factor analysis (CFA) to validate the identified structure. This approach is consistent with best practices in instrument development and evaluation.
BSS-RI is an instrument that has been proven to be both reliable and valid in measuring self-reported birth satisfaction, consisting 6 items and dividing into 2 sub-scales: stress of childbearing (BSS-RI-SE) (4 items) and quality of care (BSS-RI-QC) (2 items). Each item is rated on a 3-point Likert scale, where respondents can select from the options of ‘agree’, ‘agree to some degree’, or ‘disagree’. Higher scores indicate higher levels of birth satisfaction, with the scoring system ranging from 0 to 12.
To assess the correlation between the C-BSS-RI and postpartum psychological states, we used the following scales: (1) Maternal Postpartum Stress Scale (MPSS): A 22-item scale measuring postpartum stress, scored on a 5-point Likert scale. (2) Edinburgh Postnatal Depression Scale (EPDS): A 10-item scale evaluating postpartum depression, scored from 0 to 3. (3) Depression Anxiety Stress Scale (DASS-21): A 21-item scale assessing depression, anxiety, and stress, with each sub-scale consisting of 7 items.
We have administered the questionnaires in Chinese to the participants. After obtaining authorization from the original author, the BSS-RI was translated into Chinese using the classic “backward and forward” approach, following the improved Brislin translation model. The forward translation of the English items into Chinese was carried out independently by two bilingual Chinese native psychologists. Then, the researcher and the translator discussed and revised the scale, and reached a consensus to put forward the Chinese version of the scale. Next, the reconciled forward version of the scale was translated back into English by two independent bilingual psychologists who were unfamiliar with the original English version. Finally, the original English version and the back-translated version were compared to one another in accordance with the cross-cultural adaptation guidelines of the scale. The translated versions were carefully examined and evaluated by a panel of six experts, including psychologists, clinical experts, nursing education experts, sociologists, and obstetric nursing experts. The results of the evaluation indicated that the translated versions maintained semantic equivalence with the original version. Afterwards, a total of 30 postpartum women participated in cognitive interviews to assess the comprehensibility of the Chinese version of the BSS-RI. Based on their feedback, revisions were made to improve its clarity and understanding.
In our study, we used Kendall W analysis to assess the concordance among expert reviewers. Additionally, we calculated the Content Validity Index (CVI) to evaluate the relevance and appropriateness of each scale item. The CVI was calculated using a panel of expert reviewers who rated each item on a 4-point Likert scale. The item-level CVI (I-CVI) was calculated by dividing the number of experts who rated the item as 3 or 4 by the total number of experts. The scale-level CVI (S-CVI) is calculated as the average of all I-CVI values. We conducted an EFA to assess the factor structure of the BSS-RI. The data were split into two random halves to ensure that the factor structure was robust and not overfitted to the data. One half was used for EFA, and the other half for CFA. The suitability of the data for factor analysis will be evaluated using the Kaiser-Meyer-Olkin (KMO) measure and Bartlett’s sphericity test. Common factor analysis was chosen because it focuses on explaining the common variance among items, which is more appropriate for identifying latent factors in our study. We performed a CFA using Amos software (version 24.0) to validate the consistency of the model structure with the identified factor structure. The model’s goodness of fit was evaluated using several indices: the Chi-square/Df (χ/Df) ratio, root mean square residual (RMR), root mean square error of approximation (RMSEA), incremental fit index (IFI), normed fit index (NFI), and comparative fit index (CFI). A good model fit was indicated by a Chi-square/Df (χ/Df) ratio less than 3, an RMSEA value less than 0.08, a CFI value greater than 0.90, a TLI value greater than 0.90, and an NFI value greater than 0.90. The CFA results showed a good model fit with χ/Df = 1.511, RMSEA = 0.035, CFI = 0.989, TLI = 0.979, and NFI = 0.968, indicating that the model fits the data well and supports the validity of the C-BSS-RI.. Internal consistency reliability was assessed using Cronbach’s α coefficient, with values exceeding 0.7 deemed acceptable. The test-retest reliability of the C-BSS-RI sub-scale and total scores was assessed by calculating the intraclass correlation coefficient (ICC). This analysis involved comparing the scores obtained at baseline and follow-up within a subset of 30 participants from the baseline sample, selected using convenience sampling. The retesting was conducted 2 weeks after the initial assessment. We hypothesized that the ICC would be above 0.70, indicating good test-retest reliability. Differences in demographic characteristics between the EFA and CFA groups were assessed using the two-sided chi-squared test. Meanwhile, Student’s t-test was employed to evaluate differences in total BSS-RI scores among postpartum women with varying statuses. The correlation between birth satisfaction and postpartum psychological states was assessed using the EPDS, DASS-21, and MPSS scales. Convergent validity was assessed by correlating the C-BSS-RI total scores with a satisfaction question scored on a 1-5 scale (1 = ”very dissatisfied,” 5 = ”very satisfied”). We hypothesized a positive correlation, based on prior research linking positive birth experiences with reduced postpartum distress, and used Pearson’s correlation analysis to evaluate this relationship. Divergent validity was assessed by calculating Pearson’s correlation coefficients between the total and subscale scores of the C-BSS-RI and maternal age. We hypothesized that there would be no significant correlation between the C-BSS-RI scores and maternal age. Known-groups discriminant validity was evaluated by comparing C-BSS-RI scores across different types of delivery using one-way ANOVA. The Bonferroni test was used for post-hoc multiple comparisons. We compared scores among four distinct delivery modes: Natural Vaginal Delivery without Injury (NVD-WI), which refers to deliveries without any form of obstetric intervention or injury, Vaginal Delivery with Injury or Assistance (VD-WIA), which includes deliveries involving perineal tears, episiotomies, or the use of obstetric instruments such as forceps or vacuum extraction, Emergency Cesarean Section, which refers to cesarean deliveries performed due to unforeseen complications during labor, and Elective Cesarean Section, which refers to cesarean deliveries scheduled in advance without complications during labor. We hypothesized that there would be significant differences in C-BSS-RI scores across these groups. Data analysis was conducted using SPSS 25.0 and Amos 24.0. A significance level of 0.05 (two-tailed) was chosen as the threshold for statistical significance.
