The objective of this paper was to test the psychometric properties of the questionnaire for assessing the childbirth experience (QACE) among Chinese postpartum women.

Research instruments included the demographic characteristics form, the QACE, the Edinburgh Postnatal Depression Scale (EPDS), and the Generalized Anxiety Disorder-7 (GAD-7). The item analysis, confirmatory factor analysis (CFA), known-groups discriminant validity, divergent validity, and internal consistency reliability were assessed for the psychometric properties of QACE.

A total of 235 postpartum women were recruited in this study. Item analysis showed that the critical ratios of all items were greater than 3, and all item-total correlation coefficients were greater than 0.4. The fit indices showed that the original correlated four-factor model of QACE was adequate. In terms of the divergent validity, the QACE subscale and total score were in a significant positive correlation with the EPDS and GAD-7. Regarding reliability, the Cronbach’s alpha of the QACE was 0.812, ranging from 0.611 to 0.844 for total scale and sub-scales, respectively.

The QACE is a valid and reliable tool for measuring childbirth experience among Chinese women sample of postpartum women.

Childbirth is considered a unique and trans-formative moment for every woman [10,11,12]. It involves the process of bringing a new life into the world, which can be both physically and emotionally challenging [10,11,12]. The childbirth experience is a complex and multidimensional construct [38] which refers to a personal life event comprised of interrelated subjective psychological and physiological processes, affected by social, environmental, organizational, and policy contexts [3, 22].

The World Health Organization (WHO) Labour Care Guideline recommends that all women have access to respectful and high-quality maternity care intrapartum care for a positive childbirth experience [30, 39]. Therefore, healthcare providers must provide good-quality, evidence-based, respectful care during labor and childbirth [41].

Childbirth experience is important because having a negative experience is linked to poorer mental health among postpartum women, which includes developing postpartum postpartum mood disorders, post-traumatic stress disorder, and the fear of next childbirth [16, 32, 36]. Furthermore, there is compelling evidence that indicates that improving birth satisfaction contributes to enhancing women's trust in facility-based care, which includes access to quality postnatal care [15, 17, 31]. As such, it is imperative to develop a valid, reliable, and theoretically supported tool to evaluate levels of childbirth experience and formulate effective strategies to improve postpartum care [5].

Several tools have been designed to measure women’s childbirth experience [5], including the Questionnaire for Assessing the Childbirth Experience (QACE), the Childbirth Experience Questionnaire (CEQ), and the Wijma Delivery Expectancy Questionnaire (WDEQ) [20, 21, 25], each with varying focuses and methodologies. Among these instruments, the QACE stands out as a comprehensive tool designed to evaluate the quality of childbirth experiences from the perspective of the birthing individual [7]. The CEQ consists of 25 items in 4 dimensions and was scored using a 4-point Likert scale and a visual analog scale (VAS). Therefore, the CEQ’s complexity and length can deter completion, whereas QACE’s concise format encourages broader participation. While the WDEQ focuses on expectations before childbirth, it may not fully capture the complexities of the childbirth experience itself or the impact of actual experiences on postpartum mental health. Regarding rigorous testing and cross-cultural adaptability, the QACE has undergone extensive validation processes, ensuring that it reliably measures what it intends to assess. Since the founder English -QACE was validated by Carquillat, Vendittelli et al. [7], translations and validations have been carried out in French [9], Persian Farsi [28] and Spain [13], and good psychometric properties of QACE was confirmed. Another advantage is that a shorter completion time, compared to some other tools, QACE can typically be completed in a shorter time frame, making it practical for both respondents and researchers.

That lack of a short assessment tool to examine childbirth satisfaction within a Chinese population resulted in interest in translating and validating a Chinese-QACE (C-QACE). To this end, we aimed to translate and determine the key psychometric properties of a C- QACE, to yield a short and easy-to-administer instrument for use within Chinese populations of postnatal women. The theoretical assumption of this study is that the QACE total and sub-scale scores were significantly positively related to the total and sub-scale scores of EPDS and GAD-7. Validation of a C-QACE will provide an instrument that can be used to measure the effectiveness of interventions designed to improve women's experiences of childbirth, with the ultimate goal of improving the standards of intranasal care provided in China.

This is a cross-sectional study conducted among Chinese postpartum women. This study was divided into two phases (see Fig. 1).

Translation and validation process of the QACE. Note: QACE, Questionnaire for Assessing the Childbirth Experience; FT-1, Forward translation version-1; FT-2, Forward translation version-; BT-1, Backward translation version-; BT-2, Backward translation version-2; EPDS = Edinburgh Postnatal Depression Scale; GAD-7 = Generalized Anxiety Disorder-7

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The permission for the translation of QACE was obtained from Dr. Guittier via email. The translation process is according to the Beaton guideline [2]. The Translation and validation process of the QACE see Fig. 1. And the Chinese-QACE see Table 1.

According to the criteria required for factorial analysis, with ten to twenty subjects per item [19]. Because the QACE includes 13 items, a sample size of 130 to 260 participants was considered adequate [7].

Participants were recruited from the postpartum clinic of a tertiary hospital in Sichuan province between May 2023 and August 2023, in China. Inclusion criteria comprised of: (a) being aged 18–50 years, and (b) being able to read and write in Chinese. Exclusion criteria consisted of: (a) stillbirth and (b) provided insufficient data, including ① incomplete questionnaire responses: participants who fail to answer a certain percentage (e.g., more than 20%) of the items in the instrument. ② Demographic or contextual information missing in the survey. ③ Participants who withdraw from the study before completing all necessary assessments due to various reasons.

The questionnaires were completed in paper form, which facilitated data collection and participant preference. The paper form was administered by healthcare professionals, which ensured that they were well-equipped to interact with participants and accurately collect data. The questionnaires were completed approximately six to eight weeks after birth. In our study, we approached a total of 240 women to participate. The recruitment was conducted through clinical settings, namely obstetric clinics. Out of those approached, 5 women declined to participate, primarily due to time constraints and lack of interest. Finally, 235 women were included in the data analysis.

Demographic characteristics form

Basic demographics included age (year), postpartum period (day), education level, marital status, number of pregnancies, parity, pregnancy mode, history of cesarean section, type of delivery, feeding pattern, pregnancy complication, neonatal complications, and maternity wards.

The questionnaire for assessing the childbirth experience (QACE)

The QACE comprises 13 items and is divided into four subscales, emotional status, relationship with staff, first moments with the newborn, and feelings at one month postpartum [7]. The score range for each of the dimensions is 1–4, where higher scores indicate worse experiences. This scale was coded in the answer format of the 4-point Likert scale, as follows: 1 (totally), 2 (in part), 3 (not so much), and 4 (not at all) for items 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 [1]. The ratings of negatively worded statements were reverse-scored (items 1, 12, 13) so that the higher scores reflected a negative childbirth experience [10,11,12].

The Edinburgh Postnatal Depression Scale (EPDS)

The EPDS is a self-report questionnaire evaluating the symptoms of perinatal depression [14]. The Chinese version of EPDS was reported to have acceptable internal consistency (α = 0.78), with cut-off points that aid in the identification of postnatal depression among women [40]. In the current study, the Cronbach’s alpha of the EPDS was 0.844.

The Generalized Anxiety Disorder-7 (GAD-7)

The GAD-7 is a seven-item self-report scale for measuring anxiety disorder [27]. Total scores can be categorized as, normal (0–4), mild (5–9), moderate (10–14), or severe (15–21) [27]. The Chinese version of GAD-7 was found to have a very good internal reliability (α = 0.88) [23]. In this study, the Cronbach’s alpha of the GAD-7 was 0.899.

All data analyses were carried out using IBM SPSS Statistics for Windows, Version 29.0. All statistical tests were two-tailed and a p-value of less than 0.05 was considered statistically significant. To describe the demographic characteristics of participants, the frequency (percentage) was used for categorical variables and the mean (standard deviation) was used for continuous variables. Critical ratio (CR) and correlation coefficient were used based on item analysis [29]. In general, an item that has an absolute value of (CR) less than 3 or an item-total correlation coefficient less than 0.4 should be deleted [24]. Confirmatory Factor Analysis (CFA) was used to evaluate construct validity. The evaluation indices for confirmatory factor analysis included the relative chi-square/degrees of freedom (χ²/df), root mean square error of approximation (RMSEA), comparative fit index (CFI), non-normed fit index (NNFI), Tucker-Lewis index (TLI), and incremental fit index (IFI). A χ.²/df ratio of less than 5 is considered indicative of a good fit. For other goodness-of-fit indices, values that suggest a good fit while CFI and TLI values below 0.90 should lead the researcher to strongly suspect(reject) the solution, CFI and TLI values in the range of 0.90 and 0.95 may be indicative of acceptable model fit [6]. The known-groups discriminant validity was assessed by examining differences in the total scores of the QACE about demographic characteristics of known groups. Independent samples t-tests and one-way analysis of variance (ANOVA) were conducted to compare the QACE total scores across different groups. Divergent validity was tested using Pearson’s correlation coefficients between the QACE total score and sub-scales, and EPDS and GAD-7. The higher scores of QACE reflected a more negative childbirth experience [18, 34]. The internal consistency reliability of the QACE was assessed based on Cronbach’s alpha coefficients and Spearman-Brown coefficient for the entire scale and each sub-scale, and threshold values above 0.60 were considered as accepted reliability [4, 18].

The mean age of the women was 31.30 years (SD = 3.38). The majority of women (71.5%) had a senior high school diploma. A summary of the demographic data is shown in Table 2. And the responses of participants for the QACE see Table 3.

Item analysis was conducted by comparing the proportion of correct responses between the high-scoring group (upper 27%) and the low-scoring group (lower 27%). In the current study, the low-scoring group in QACE consisted of 69 participants, while the high-scoring group included 78 participants. Table 4 presents the demographic characteristics of the participants involved in the item analysis. Critical ratios of all items were greater than 3 (ranging from 5.521 to 12.579) and significant (P < 0.01) between the low score group and high score group (see Table 4). All item-total correlation coefficients were greater than 0.4 (ranging from 0.442 to 0.651) and significant (P < 0.01) (see Table 5). The participants of missing demographic data were included in the item analysis.

The Kaiser–Meyer–Olkin (KMO) was 0.785, and the Bartlett spherical test statistic was 1093.304 (P < 0.001). The fit indices showed that the modified four-factor model of QACE was adequate: χ2 = 101.717; df = 61; χ2/df = 1.700; RMSEA = 0.055; CFI = 0.959; NNFI = 0.907; TLI = 0.947; IFI = 0.960. The four-factor model can be viewed in Fig. 2. The participants of missing demographic data were included in the CFA.

Confirmatory factor analysis of the modified four-factor model

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All variables were not related to the QACE total score (see Table 2).

The QACE subscale and total score were in a significant positive correlation with the EPDS and GAD-7 (see Table Table 6).

The Cronbach’s alpha of the QACE total score was 0.812, and the subscales ranged from 0.611 to 0.844 (see Table 7).

The present study aimed to translate English-QACE to Chinese-QACE and the testing of the psychometrics of this tool among Chinese women. The study's validity hinges on the standardized translation process employed. A rigorous translation method is crucial to ensure the cultural relevance and conceptual equivalence of items. Additionally, the involvement of bilingual experts in both content and language could enhance the accuracy of the translation. The result of this research showed that it is a valid and reliable tool for identifying the experience during childbirth. The QACE provides valuable insights into various aspects of the childbirth experience, which can significantly inform clinical practice in several ways: (1) enhancing patient-centered care: by assessing women's perceptions and experiences during childbirth, healthcare providers can better understand individual needs and preferences. This information can lead to more tailored care plans and improved communication between patients and providers. (2) identifying areas for improvement: the questionnaire can help identify specific areas where the childbirth experience may be lacking, such as pain management, emotional support, or communication with healthcare staff. This allows healthcare facilities to target interventions and improve overall service quality. (3) supporting mental health: understanding the childbirth experience can also shed light on potential psychological impacts, such as postpartum depression or anxiety. Identifying women who may need additional support can facilitate timely interventions. In general, the validation of the Chinese QACE has significant implications for clinicians and policymakers. It can serve as a tool for identifying women at risk of negative childbirth experiences, allowing for timely interventions.

The results of item analysis indicate that the Chinese-QACE had good discrimination (all values of the CR ≥ 3) and high homogeneity (all item-total correlation coefficients ≥ 0.4). The findings from the CFA indicate that the modified four-factor measurement model demonstrates a good fit to the data, consistent with studies conducted in Persian Farsi [28] and Spain [10,11,12]. Residual correlation refers to the correlation between the error terms of two or more observed variables after accounting for their common variance through the model [26]. In the current study, high modification indices for items 1 and 2, and items 12 and 13 would suggest that a residual correlation could improve the model fit.

The theoretical justifications are based on conceptual overlap and emotional balance between item 1 and item 2. Both items, “I felt worried” and “I felt secure”, address aspects of emotional status, which can lead to similar response patterns. Individuals may interpret these items in a way that leads to shared variance. The relationship between feelings of worry and security often exists in emotional contexts [33]. High levels of worry might naturally correlate with low levels of feeling secure, which could justify allowing a residual correlation [37]. Allowing the residual correlation between items measuring emotional status—such as"I felt worried"and"I felt secure"—can enhance model fit and reflect the nuanced relationships within the emotional constructs. Item 12 and item 13 belong to the same dimension, namely, feelings at one month postpartum. The theoretical justification lies in the conceptual similarity between the two items, both of which pertain to the negative emotional experiences that new mothers may encounter during the postpartum period [8]. This conceptual overlap indicates that it is reasonable to anticipate a certain degree of correlation between them.

Concerning divergent validity, due to higher scores of QACE indicate more negative experiences [10,11,12], namely, women with a higher score of QACE tend to have a higher score of depression and anxiety [1]. As anticipated, the Chinese-QACE total and sub-scale scores were significantly positively related to postpartum depression and anxiety, which endorses the divergent validity of the Chinese-QACE. Previous studies have documented that poor experiences in antenatal care are linked to higher rates of postpartum mental health issues [35]. The connection drawn between higher QACE scores and increased levels of depression and anxiety suggests that the QACE may effectively capture adverse experiences during antenatal care.

As to the internal consistency of the sub-scales of QACE, Cronbach's alpha coefficients were ranging 0.70 to 0.84, 0.77 to 0.82, and 0.69 to 0.86 in Switzerland [7], Persian Farsi [28] and French [9], respectively. In the Chinese –QACE, similarly to previous findings, Cronbach's alpha of the total scale was 0.812, and the subscales ranged from 0.611 to 0.844. all values were above the threshold of 0.6, which illustrated that the Chinese-QACE had accepted reliability in terms of internal consistency [4].

This study has several limitations that are important to note. The study's focus on a single tertiary hospital in Sichuan province raises significant concerns about the external validity of the results. While findings may accurately reflect the experiences of women in this specific region, they may not be representative of antenatal care experiences across other provinces in China, which may have different healthcare systems, cultural norms, and socioeconomic factors. Secondly, most postpartum mothers visited only once in the postpartum clinic between 6–8 weeks, which limited the opportunity to assess the two-week test–retest reliability of the QACE. Hence, future research should focus on the relatively large sample size and determine the test–retest reliability. Additionally, exploring the tool's applicability across different populations within China, such as rural versus urban women, can provide a more comprehensive understanding of its utility.

QACE:

Questionnaire for Assessing the Childbirth Experience

EPDS:

Edinburgh Postnatal Depression Scale

GAD-7:

Generalized Anxiety Disorder-7

CFA:

Confirmatory Factor Analysis

WHO:

World Health Organization

CEQ:

Childbirth Experience Questionnaire

WDEQ:

Wijma Delivery Expectancy Questionnaire

C-QACE:

Chinese Version of Questionnaire for Assessing the Childbirth Experience

VAS:

Visual Analog Scale

CR:

Critical ratio

χ²/df:

Relative Chi-square/Degrees of Freedom

RMSEA:

Root mean square error of approximation

CFI:

Comparative Fit Index

NNFI:

Non-normed Fit Index

TLI:

Tucker-Lewis index

IFI:

Incremental Fit Index

ANOVA:

One-way Analysis of Variance

KMO:

Kaiser–Meyer–Olkin

SD:

Standard Deviation

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All authors approved the study. Xiaoying Zhong, Linqian He, Xinru Liu and Bangjun Wang: Conceptualization; Methodology; Software; Data curation; Formal analysis; Validation; Investigation; Writing - review & editing; Writing - original draft. Xixi Li and Changqing Pan: Writing - review & editing; Supervision; Project administration. Lin Peng: Supervision and data curation.

Correspondence to Xinru Liu or Bangjun Wang.

The studies involving human participants were reviewed and approved by [Mianyang Central Hospital of Ethics Committee] (ID: S202303111-02).

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The authors declare no competing interests.

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