Validation of the Women’s Views of Birth Labor Satisfaction Questionnaire (WOMBLSQ4) in the Spanish Population

International Journal of Environmental Research and Public Health Article Validation of the Women’s Views of Birth Labor Satisfaction Questionnaire (WOMBLSQ4) in the Spanish Population María Dolores Pozo-Cano 1, Adelina Martín-Salvador 2,* , MaríaÁngeles Pérez-Morente 3,*, Encarnación Martínez-García1, Juan de Dios Luna del Castillo 4, María Gázquez-López 5, Rafael Fernández-Castillo 1and Inmaculada García-García1 1Faculty of Health Sciences, University of Granada, 18071 Granada, Spain; [email protected] (M.D.P.-C.); [email protected] (E.M.-G.); [email protected] (R.F.-C.); [email protected] (I.G.-G.) 2Faculty of Health Sciences, University of Granada, 52005 Melilla, Spain 3Faculty of Health Sciences, University of Jaen, 23071 Jaen, Spain 4Faculty of Medicine, University of Granada, 18071 Granada, Spain; [email protected] 5Faculty of Health Sciences, University of Granada, 51001 Ceuta, Spain; [email protected] *Correspondence: [email protected] (A.M.-S.); [email protected] (M.Á.P.-M.) Received: 4 June 2020; Accepted: 31 July 2020; Published: 2 August 2020   Abstract: The satisfaction of women with the birth experience has implications for the health and wellness of the women themselves and also of their newborn baby. The objectives of this study were to determine the factor structure of the Women’s Views of Birth Labor Satisfaction Questionnaire (WOMBLSQ4) questionnaire on satisfaction with the attention received during birth delivery in Spanish women and to compare the level of satisfaction of pregnant women during the birth process with that in other studies that validated this instrument. A cross-sectional study using a self-completed questionnaire of 385 Spanish-speaking puerperal women who gave birth in the Public University Hospitals of Granada (Spain) was conducted. An exploratory factor analysis of the WOMBLSQ4 questionnaire was performed to identify the best fit model. Those items that showed commonalities higher than 0.50 were kept in the questionnaire. Using the principal components method, nine factors with eigenvalues greater than one were extracted after merging pain-related factors into a single item. These factors explain 90% of the global variance, indicating the high internal consistency of the full scale. In the model resulting from the WOMBLSQ4 questionnaire, its nine dimensions measure the levels of satisfaction of puerperal women with childbirth care. Average scores somewhat higher than those of the original questionnaire and close to those achieved in the study carried out in Madrid (Spain) were obtained. In clinical practice, this scale may be relevant for measuring the levels of satisfaction during childbirth of Spanish-speaking women. Keywords: validation study; satisfaction questionnaire; birth attention; patient satisfaction 1. Introduction The birth of a child is one of the most significant events in the lives of women and their families. Knowing the level of satisfaction regarding the care received during the birth and postpartum periods is of special interest as it may help to improve the quality of health systems [ 1 ]. In Western countries, these experiences are becoming less frequent due to the drop in birth rates observed in many of them, especially in southern European countries, and it is hoped that the birth experience can become as rewarding as possible, despite not being free of serious consequences for the health of women and their newborns [1–3]. Int. J. Environ. Res. Public Health 2020,17, 5582; doi:10.3390/ijerph17155582 www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2020,17, 5582 2 of 16 Many authors have explained the importance of women’s satisfaction with the birth process, because it influences such important aspects as the maintenance of breastfeeding [ 4 ], which is crucial for the health of mothers and newborns [5,6]. When women experience unsatisfactory or traumatic births, their memories will be of pain, anger, fear, or sadness, and they may even suffer from post-traumatic stress disorders or may not remember anything about the delivery process [ 7 – 9 ]. Furthermore, a bad experience in a previous delivery increases the anxiety and fear in subsequent deliveries [ 10 , 11 ]. The proximity of childbirth activates memories of previous traumatic experiences and abuse as well as psychiatric disorders in women that can trigger a fear of vaginal childbirth and increase the demand for caesarean births, thus increasing the risks to maternal and perinatal health [12]. This is why, at present, the perceived satisfaction regarding care received during the birth is considered an essential indicator to measure quality of care [ 13 ]. Hodnett describes the personal expectations of pregnant women, the support and quality of the relationship with health professionals, especially midwives, and the participation of women in decision making as the most influential elements [14]. There are various instruments that measure the satisfaction of women with childbirth [ 2 , 15 – 22 ]. The Women’s Views of Birth Labor Satisfaction Questionnaire (WOMBLSQ4) [ 23 ] has been used extensively in the recent literature and identifies women’s satisfaction with their birth labor and delivery experiences, as well as the pain relief received during and after. It was developed in the United Kingdom by Smith and has been translated into French and validated to be applied to French-speaking women in University Hospitals in Geneva (Switzerland), and into Spanish, where Mar í n-Morales et al. did the same with women who gave birth in hospitals in Madrid (Spain) [23–25]. In the Autonomous Community of Andalusia (Spain), the Public Health System is committed to achieving excellence in healthcare. This is understood as a comprehensive concept involving multiple variables, among which citizen satisfaction is an inalienable element [ 26 ]. Birth care is focused on women, providing them with personalized care and promoting their autonomy and their role in decision-making [27]. The version translated into Spanish also presents discrepancies in the number of factors with respect to the original version and its translation into French due to significant convergence problems that make it necessary to eliminate the “control” factor, thus leaving the scale in nine dimensions. In order to assess the satisfaction of Andalusian mothers in the process of birth labor and to check the structure of the instrument, the WOMBLSQ4 scale was translated into Spanish and validated. The objectives of this study are to determine the factor structure of the WOMBLSQ4 questionnaire on satisfaction with the care received during birth in Spanish women and to compare the level of satisfaction of pregnant women during the birth process with other studies that validated this instrument. 2. Materials and Methods 2.1. Sample and Data Collection A cross-sectional study was carried out between January and March 2019 in puerperal women who had given birth in the Public University Hospitals of the city of Granada (Spain). In the year prior, an average of 5000 deliveries had taken place at both hospitals. Through intentional sampling, 385 Spanish-speaking puerperal women aged 18 years old or older were selected by collaborating with midwives in the studio. The included women voluntarily agreed to participate and signed an informed consent self-completed questionnaire that was delivered in a sealed envelope and later collected by the principal investigator. Those who did not understand Spanish and had elective caesarean births were excluded. Postpartumsurveyswere administered to450women, ofwhom 15refusedto completethem, 40did not deliver babies, and 10 did not provide informed consent. The questionnaires that were complete Int. J. Environ. Res. Public Health 2020,17, 5582 3 of 16 for all items were considered valid. The final sample consisted of 385 women, which constitutes a response rate of 85.5%. 2.2. Materials To evaluate women’s satisfaction with care received during delivery, the final version of the WOMBLSQ4 scale was used, which consists of 32 questions with Likert-type responses and 10 dimensions: professional support during the birth (5 questions), expectations of delivery (4 questions), assessment at home at the beginning of birth labor (3 questions), first contact with the newborn (3 questions), support of the husband/partner during labor (3 questions), pain relief during labor (3 questions), pain relief immediately after delivery (3 questions), continuity (2 questions), environment during delivery (2 questions), and control (2 questions). The measure of general satisfaction involved two questions [ 23 ]. The factorial validity of the scale was confirmed, as well as an adequate global reliability (Cronbach’s alpha 0.89), and the validity of the subscales was also shown (Cronbach’s alpha values ranged between 0.62 and 0.91). The score for each dimension was obtained by adding the values obtained in each question (some of them with an inverse score), and later on, the result was transformed so that the minimum possible score was 0 and the maximum possible one was 100 (total satisfaction in the dimension) [ 23 – 25 ]. Higher scores indicated greater satisfaction on the part of the women. For this research, the scale was translated into Spanish by two English language translators and its final content was agreed upon by three midwives with extensive experience in childbirth assistance. The translated questionnaire was piloted to 50 women, and it was demonstrated that the instrument presented an excellent level of comprehension and an adequate completion time since, when collecting it, the participants were asked if they had difficulty completing it, if they understood all the questions, and if it seemed too long. In addition, the following sociodemographic variables were incorporated: age, marital status, educational level, and employment situation. 2.3. Data Analysis A descriptive analysis was performed in which means and standard deviations were calculated for the quantitative variables and frequencies and percentages for the qualitative ones. The factorial structure of the scale was explored by extraction of the main components followed by a Varimax rotation. In the first analysis, the Kaiser–Meyer–Olkin (KMO) sample adequacy measure was calculated, accepting values greater than 0.70 as optimal measures. Subsequently, the Bartlett sphericity test was applied to show significant differences between the items in the correlation and the unit matrix. Next, the communality of each of the items on the scale was studied, and those that showed values less than 0.30 were eliminated, as they were poorly represented in the factorial set obtained. Those factors with eigenvalues greater than 1 were considered, and the percentage of variance explained with the said factors was determined to assess the weight of each one. After the rotation and analysis of the item saturation table, these were assigned to the dimension in which their saturation was highest. Once the items were eliminated, the previous steps were repeated in order to obtain the final factor structure. The internal consistency of each of the subscales was measured using Cronbach’s alpha. Data analysis was performed with the SPSS v. Statistical package. 26.0 (International Busines Machines Corporation (IBM), Armonk, NY, USA) for Windows. 2.4. Ethical Considerations The study complies with the standards of good clinical practice, explicit in the European Directive 2001/20/EC and Law 14/2007 (of 3 July) on biomedical research. The treatment of personal data in health research is governed by the provisions of the Organic Law 3/2018, 5 December, Protection of Personal Data and Guarantee of Digital Rights in Spain. The research protocol obtained a favorable resolution from the Ethics and Research Committee of Health Institutions. Int. J. Environ. Res. Public Health 2020,17, 5582 4 of 16 3. Results The sociodemographic characteristics of the analyzed sample are reflected in Table 1. The mean age of the participants was 31.62 years (SD 5.32), with a range of 18 to 46 years old. Regarding the level of education, almost half (175, 46.2%) had a university-level education. In relation to marital status, the majority were married or had a partner (359, 94.0%). Table 1. Sociodemographic characteristics of the sample. Socio-Demographic Variables x±SD Range Age 31.6 ±5.32 18–46 n% Level of Education (n=379) University 175 46.2 Vocational training 87 23.0 Secondary education 66 17.4 Primary/Elementary/Basic education 51 13.5 Marital Status (n=382) Married or with a partner 359 94.0 Single 23 6.0 Labor Situation (n=384) Employed workers 184 47.9 Housewives 68 17.7 Busines women 26 6.8 Unemployed 92 24.0 Other work circumstances (studying, retired, etc.) 14 3.6 Regarding the labor situation, 184 (47.9%) were employed workers. 3.1. Exploratory Facial Analysis To carry out the factor analysis, firstly, all items on the scale were considered, and a mean KMO sample adequacy of 0.80 was obtained, with the result of the Bartlett sphericity test being statistically significant (p<0.001). Of the 32 items in the original questionnaire, only three showed communalities below 0.50: 25 (I am satisfied with just one or two things about the labor care that I received: 0.441), 31 (I didn’t need a lot of pain relief after the birth: 0.475) and 12 (The way my labor care was provided could not have been improved: 0.476). However, they have not yet been removed from the questionnaire. Using the main components method, nine factors that showed self-values greater than one, explaining 68.0% of the global variance, were extracted. A new dimension (3) was designed— pain during and after delivery—after merging dimensions six (pain during delivery) and seven (pain after delivery) from Smith’s original questionnaire [23]. Table 2shows the Cronbach’s alpha and variance explained by each factor, as well as the saturations of each item, once the Varimax rotation had been performed. Int. J. Environ. Res. Public Health 2020,17, 5582 5 of 16 Table 2. Analysis of each dimension and items on the scale. 1 Professional Support (Cronbach’sAlpha =0.867, % Variance Explained =14.02) Coefficient * Q19 During labor there was always a carer to explain things so that I could understand. 0.843 Q7 All my labor carers were very supportive. 0.834 Q13 Carers always listened very, very carefully to everything that I had to say. 0.808 Q27 All my carers treated me in the most friendly and courteous manner possible. 0.778 Q32 My carers couldn’t have been more helpful. 0.733 Q12 The way my labor care was provided could not have been improved. 0.556 2 Expectations (Cronbach’s Alpha =0.861, % Variance Explained =9.19) Q17 The delivery went almost completely as I had hoped that it would 0.809 Q11 The labor went nearly exactly as I had hoped that it would. 0.794 Q22 My labor was just about the right length. 0.719 Q1 My labor went totally normally. 0.710 3 Pain During and After the Birth (Cronbach’s Alpha =0.781, % Variance Explained =8.75) Q26 More pain relief would have made my labor easier. (−) 0.719 Q6 I should have been offered something more to relieve the pain I had after my baby was born. (−) 0.702 Q16 I was in a fair bit of pain immediately after the birth. (−) 0.669 Q9 I should have been offered something more to relieve my labor pains. (−) 0.668 Q20 I got excellent pain relief in labor. 0.586 Q31 I didn’t need a lot of pain relief after the birth. 0.399 4 Home Assessment (Cronbach’s Alpha =0.843, % Variance Explained =7.52) Q15 When I thought that my labor had started, I would have liked a carer to come and see me at home to confirm that I had. (−)0.914 Q28 Early home assessment of me in labor would have been very helpful. (−) 0.904 Q8 I should have had a home assessment in early labor. (−) 0.761 5 Support from Husband (Cronbach’s Alpha =0.750, % Variance Explained =6.80) Q2 My birth partner/husband helped me to understand what was going on when I was in labor. 0.937 Q23 My birth partner/husband couldn’t have supported me any better. 0.920 Q29 I could have had a bit more help from my birth partner/husband. (−) 0.511 Int. J. Environ. Res. Public Health 2020,17, 5582 6 of 16 Table 2. Cont. 6 Holding Baby (Cronbach’s Alpha =0.675, % Variance Explained =6.74) Q18 I needed to hold my baby a little earlier than I did. (−) 0.842 Q10 After my baby was born, I was not given him/her quite as soon as I wanted. (−) 0.786 Q3 I got to see my baby at exactly the right time after she/he was born. 0.577 7 Knowledge of Women about Professionals During Childbirth Assistance (Cronbach’s Alpha =0.797, % Variance Explained =5.21) Q24 I knew the carer(s) present at the birth of my baby. 0.855 Q5 At the start of my labor I knew my carers very well. 0.844 8 Environment (Cronbach’s Alpha =0.711, % Variance Explained =4.97) Q4 My birth room was a little impersonal and clinical. (−) 0.810 Q14 The area where I gave birth was very pleasant and relaxing. 0.764 9 Control (Cronbach’s Alpha =0.436, % Variance Explained =4.76) Q21 Everyone seemed to tell me what to do in labor. (−) 0.753 Q30 Labor was just a matter of doing what I was told by my carers. (−) 0.729 Q25 I am satisfied with just one or two things about the labor care that I received. (−) 0.460 * Correlation coefficients of each item with its subscale. Int. J. Environ. Res. Public Health 2020,17, 5582 7 of 16 Item 12 (the way my labor care was provided could not have been improved) showed a saturation of 0.55 and the generalization of its statement could be confusing. Item 25 did not saturate well with respect to the other two (0.46), and due to its statement (I am satisfied with just one or two things about labor care that I received), it did not seem to correspond to the being analyzed. Finally, both items were removed from the questionnaire. Later on, a second analysis was performed with the remaining items, obtaining a sample adequacy of KMO of 0.86 and maintaining statistical significance in the Bartlett sphericity test (p<0.001). This time, only items 3 and 31 showed communalities of less than 0.50, (0.44 and 0.47, respectively), although we decided to keep them in the model. The number of factors extracted by the principal component method with eigenvalues greater than 1 was also nine, which explained 70.0% of the global variance. Table 3represents the saturation level in the rotated components, the corresponding Cronbach’s alphas, and the variance explained by each factor. In Table 3, the dimension of pain again appears to be merged. Item 31 (I didn’t need a lot of pain relief after the birth) has a saturation level close to 0.50 and continues to remain on the scale, although it is poorly associated with the other items, because its contents belong to this dimension. Table 4shows the Cronbach’s alpha values from the validation carried out in this study as well as those from the English version, the French adaptation, and the puerperal period in Madrid (Spain). It can be seen that the Cronbach’s alpha values of this study are in the range of previous studies or, in some cases, even higher. 3.2. Level of Satisfaction in the Different Versions Table 5shows the mean scores in each of the dimensions for the different versions. It can be seen that the three best valued dimensions in the four versions were professional support, support of the husband, and first contact with the newborn. Int. J. Environ. Res. Public Health 2020,17, 5582 8 of 16 Table 3. Analysis of each dimension and items on the scale after the removal of items Q12 and Q25. 1 Professional Support (Cronbach’s Alpha =0.869, % Variance Explained =13.403) Coefficient * Q19 During labor there was always a carer to explain things so that I could understand. 0.836 Q7 All my labor carers were very supportive. 0.830 Q13 Carers always listened very, very carefully to everything that I had to say. 0.801 Q27 All my carers treated me in the most friendly and courteous manner posible. 0.772 Q32 My carers couldn’t have been more helpful. 0.722 2 Expectations (Cronbach’s Alpha =0.861, % Variance Explained =9.817) Q17 The delivery went almost completely as I had hoped that it would. 0.819 Q11 The labor went nearly exactly as I had hoped that it would. 0.808 Q22 My labor was just about the right length. 0.725 Q1 My labor went totally normally. 0.719 3 Pain during and after the Birth (Cronbach’s Alpha =0.749, % Variance Explained =9.085) Q6 I should have been offered something more to relieve the pains I had after my baby was born. (−)0.717 Q26 More pain relief would have made my labor easier. (−) 0.716 Q16 I was in a fair bit of pain immediately after the birth. (−) 0.682 Q9 I should have been offered something more to relieve my labor pains. (−) 0.660 Q20 I got excellent pain relief in labor. 0.575 Q31 I didn’t need a lot of pain relief after the birth. 0.418 4 Home Assessment (Cronbach’s Alpha =0.843, % Variance Explained =8.026) Q15 When I thought that my labor had started, I would have liked a carer to come and see me at home to confirm that I had. (−)0.912 Q28 Early home assessment of me in labor would have been very helpful. (−) 0.903 Q8 I should have had a home assessment in early labor. (−) 0.762 5 Support from Husband (Cronbach’s Alpha =0.750, % Variance Explained =7.209) Q2 My birth partner/husband helped me to understand what was going on when I was in labor. 0.940 Q23 My birth partner/husband couldn’t have supported me any better. 0.927 Q29 I could have had a bit more help from my birth partner/husband. (−) 0.498 Int. J. Environ. Res. Public Health 2020,17, 5582 9 of 16 Table 3. Cont. 6 Holding Baby (Cronbach’s Alpha =0.675, % Variance Explained =7.042) Q18 I needed to hold my baby a little earlier than I did. (−) 0.842 Q10 After my baby was born, I was not given him/her quite as soon as I wanted. (−) 0.784 Q3 I got to see my baby at exactly the right time after she/he was born. 0.579 7 Knowledge of Women about Professionals during Childbirth Assistance (Cronbach’s Alpha = 0.797, % Variance Explained =5.532) Q24 I knew the carer(s) present at the birth of my baby. 0.855 Q5 At the start of my labor I knew my carers very well. 0.847 8 Environment (Cronbach’s Alpha =0.711, % Variance Explained =5.297) Q4 My birth room was a little impersonal and clinical. (−) 0.834 Q14 The area where I gave birth was very pleasant and relaxing. 0.771 9 Control (Cronbach’s Alpha =0.481, % Variance Explained =4.646) Q30 Labor was just a matter of doing what I was told by my carers. (−) 0.789 Q21 Everyone seemed to tell me what to do in labor. (−) 0.778 * Correlation coefficients of each item with its subscale. Int. J. Environ. Res. Public Health 2020,17, 5582 16 of 16 52. Moore, E.R.; Anderson, G.C.; Bergman, N.; Dowswell, T. 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Mart í nez-Garc í a, E.; Pozo-Cano, M.D.; Mart í n-Salvador, A.; P é rez-Morente, M.A.; G á zquez-L ó pez, M.; Medina-Casado, M. Cambio de paradigma en la atenci ó n al parto en España ¿Realidad o ficci ó n? Rev. Paraninfo Digit. 2019,XIII, e091. © 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).