Psychometric properties of a Persian version of respectful maternity care questionnaire

Pregnancy and childbirth can be considered an important time for women and their family. Despite the importance of this period, increasing maternal mortality rates and adverse consequences of pregnancy are general public health concerns. Reducing the complications of pregnancy in women and infants is one of the goals in the Third Millennium Development in which promoting prenatal care, birth and respectful care is one way to achieve this important goal [1, 2]. Providing a high-quality and respectful care during pregnancy is one of the ways to reduce the complications of pregnancy in women and newborns, as disrespectful behavior by health care providers constitutes one of the barriers to attending health care facilities and receiving professional care [2]. Respectful maternity care throughout labour and birth has been recommended in the WHO guideline for having a positive childbirth experience [3]. The absence of respectful maternity care is being increasingly recognized as a deterrent to utilization and quality of maternity care [4]. In the last two decades, women have been encouraged to give birth in health care facilities to ensure access to skilled health care professionals. However, access to quality services is not guaranteed for many women; particularly for poor women. Disrespectful and undignified care is prevalent in many countries globally, and this not only disrespects their human rights but is also a significant barrier to accessing intrapartum care services [4]. In addition, health care systems in many parts of the world, which permit the health care provider to control the birthing process, may expose obviously healthy pregnant women to unnecessary medical interventions that interfere with the physiological process of childbirth [3]. The evidence suggests that women may decline to look for care when they have previously experienced disrespectful care and mistreatment, and may also discourage others from seeking care [5, 6].

Respectful Maternity care is a kind of client-centered care, based on respect for women’s independence, expectations, authority, values, culture, and dignity. According to WHO recommendations, “Respectful maternity care refers to care organized for and provided to all women in a manner that maintains their dignity, privacy and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labour and childbirth” [3] This type of care is unique to each individual and his or her family, as each individual has a different family, cultural, social, and ideological background. Therefore, attention to individual differences is crucial in this type of care. According to the Human Rights Declaration, respectful care is an inalienable right of every woman [1, 2, 7‐10]. The purpose of implementing respectful care is to: raise awareness and demand respectful care for clients, launch a national commitment to institutionalize maternal care as a standard of care and to mobilize communities and service providers to provide respectful care as a natural right of clients [10]. Respectful care measures are also taken to eliminate disrespect of, and abuse of clients. Several forms of abuse have been previously reported for women in hospital labour wards, including physical abuse (e.g. slapping), lack of privacy during examinations, disclosure of patients’ secrets, disrespectful care, discrimination in providing services and utilization of hospital facilities, unnecessary episiotomies without the mothers’ permission, and throwing infants on mother’s abdomen [10]. Sheferaw et al. conducted a seven-week study to determine the validity and reliability of the Respectful Care Questionnaire in postpartum women. The Cronbach alpha reliability coefficient of the tool (questionnaire) was reported as 84% [2]. Despite the importance of this issue among vulnerable groups of society and the need for this type of care in the health system, there are very few tools for evaluating and implementing respectful care in Iran, such as the study carried out by Taavoni et al. [11]. In the study by Taavoni et al., one of the original versions of the 59-item Respectful Care Questionnaire was used among women who referred to the post-partum ward of a hospital in Tehran. The present study aimed to determine the psychometric properties and localization of the RMC Respectful Care questionnaire in Iran.

The results of the data analysis with 150 women revealed that the mean age of participants was 28.9 ± 6.2. The women’s age ranged between 15 and 43, and 86% of them were less than 35 years old. Many of the women (42.7%) and their spouses (43.3%) had not completed high school, and 27.3 and 32% of women and their spouses were illiterate, respectively. Most of the women (91.9%) were housewives, and their husbands were self-employed (39.3%). The majority of women (77.7%) reported insufficient income for living cost (Table 1). In terms of the mode of birth, 63% of women delivered by Cesarean Section (CS) and 37% had Normal Vaginal Birth (NVB).

Given the importance of respectful care in different communities, and the lack of studies in this field in Iran, the present study conducted to determine the validity and reliability of the Persian version of the Sheferaw’s Respectful Maternity Care. The target population in the present study was postpartum women who were transferred to the postpartum ward. One of the reasons for choosing the Sheferaw’s tool (15 items) was the low number of items used in this questionnaire, to minimize the study burden on our target population of postpartum mothers. Sheferaw conducted a study in Ethiopia on 509 postpartum women within 7 days after birth. Data were collected using a 37-item questionnaire, with an in-person interview. After analyzing the findings, the final questionnaire with 15 items was presented as a Likert scale. The reliability of this tool was assessed using Cronbach’s alpha coefficient (0.85). The results of the psychometric evaluation of Sheferaw’s tool in the present study revealed that its dimensions and related items could not be used in its original form in the study population in Iran. The use of factor analysis on the items reported that: items Number 9,10, 14, and 15 had factor loading on number one, items number 6, 8, 11, and 13 had factor loading on number two, items 3, 4, and 5 had factor loading on number 3, and items number 12, 2 and 1 had factor loading on number 4. For the present study, item No. 7 was removed as it had no effect on any of the other items, and the number of items was reduced to 14. The dimensions of the items were named as 4 dimensions: Abusive Care, Effective Care, Friendly Care, and Respectful Communication. Cronbach’s alpha for subscales was used to calculate the reliability of the four dimensions, with values of 0.757, 0.717, 0.765, and 0.710, respectively, indicating a good and acceptable Cronbach’s alpha.

A review of the literature on psychometric studies of respectful care tools revealed that despite the importance of respectful care, especially in postpartum women, this area of ​​research has received little attention from researchers in Iran. Therefore, the results of the few studies conducted in this field in Iran were compared. The only Iranian study available to the researchers in this study was the Taavoni et al. study in 2018, during which a new questionnaire of respectful care was designed, and the validity and reliability of the tool was determined. In their study, they used a questionnaire with 59 items in 7 dimensions, administered to women referred to health care centers for postpartum services. Their study showed that the QRMCQI¹ instrument had an appropriate Cronbach’s alpha (0.93%) and the other items were within an acceptable range. Comparison of the present study with the Taavoni study clarified that the two studies were different in terms of the sample size under study and the instrument being measured. Given that the present study was designed with the primary aim of evaluating respectful care in the birth and postpartum ward, it seems that the tool used here, compared to the QRMCQI tool, as used immediately after birth, acted as revealing more accurate information compared to the results of Taavoni’s study as women become more aware of the actions taken during and after the birth, which reduces the incidence of information bias and recall bias [11]. On the other hand, due to the greater need of women for respectful care during childbirth and postpartum care (due to unnecessary and repeated examinations, lack of privacy and hormonal changes after childbirth, psychological changes in maternal and newborns), it seems that more attention should be paid to the respectful care immediately after childbirth in Iran [12‐15]. Based on these principles and considering the psychological conditions and length of hospitalization of mothers, the low number of items in the relevant questionnaires, and its quickness, ease and low cost to implement, it seems that it is a useful tool. To our knowledge this is the first tool with all these criteria to be evaluated in Iran.

Another study by Rubashkin et al. in 2017 used an online survey on 501 mothers aged 18 to 45 years with an experience of natural childbirth or Cesarean section who had children aged less than 5 years. The research tool was a researcher-made questionnaire containing 111 questions in different dimensions. The results showed that the tool had a Context validity of 98%. Compared to the tool used in the present study, it had the same differences of Taavoni’s study regarding the number of items asked, the different community, the likelihood of bias, and the time taken to complete the questionnaire [16].

In the current study, confirmatory and then exploratory analyses were used to determine the construct validity of the instrument. The results of the current study are not in accordance with the results of Sheferaw’s study regarding the items of each dimension as well as the internal reliability (in the original form of the tool). One of the main reasons for this difference could be the option to select “I don’t know” at the center of the Likert scale (with score 3). In the Likert scale, the “do not know” option is expected to lead to a normal distribution and to avoid polarization of responses. There was no option for abstaining answers in the tool under study. According to AMEE GUIDE No. 87, the “No Comments” option should have been left out of the options [17]. Consideration of this in future studies can help to improve the tool. The present study is potentially the very first to validate this tool in Iran with a high sample size.

The limited generalizability of the results to the population under study is one of the limitations of this study. Our validation of this scale is only generalizable to women who attend public hospitals indicating specific socio-demographic characteristics, because the private hospitals did not agree to participate in the current study. The general health condition of participants at the time of filling the questionnaires was another limitation. Finally, another limitation of this study may have been social desirability bias stemming from women’s reluctance to truthfully answer the questions, if they were concerned that their answers could affect the quality of their health care.

The revised RMC questionnaire included four subscales of Abusive Care, Effective Care, Friendly Care, and Respectful Communication in 14 items which explained a large proportion of the variance. The revised RMC questionnaire in Iran would be an appropriate tool for evaluating respectful care in women who have given birth, as it includes a low number of questions, examines four dimensions of respectful care, and has a high internal reliability in the Iranian population. This revised questionnaire therefore could be used as a valid tool in all health and medical centers to measure the level of respectful care, as one of the pillars of clients’ rights, and consequently would result in improvement of the quality of care, the services provided and the satisfaction of clients. Due to the importance of respectful care in improving the health care system and outcomes, and the limited number of relevant studies in Iran, further research in different communities are recommended.