Background
Methods
Measure development
Stage 1: literature review
Stage 2: item generation
Stage 3: cognitive interviews
Design and participants
Statistical analysis
Data preparation
Exploratory factor analysis
Confirmatory factor analysis
Divergent validity
Convergent validity
Known-groups discriminant validity
Internal consistency
Results
Descriptive results
Item | Mean | SD | Min. | Max. | Skew | Kurtosis | |
---|---|---|---|---|---|---|---|
Pregnancy scale
| |||||||
EMC1 |
I felt I had the right number of antenatal checks with a midwife/doctor
| 3.29 | 1.03 | 0 | 4 | −1.61 | 1.88 |
EMC2 | I did not have enough choice about my care during pregnancy (e.g. who you saw, where and when) | 2.50 | 1.33 | 0 | 4 | −0.30 | −1.19 |
EMC3 |
My care provider(s) gave me all the information I needed
| 3.21 | 1.02 | 0 | 4 | −1.38 | 1.22 |
EMC4 |
I always saw the same midwife/doctor for my antenatal checks
| 2.17 | 1.60 | 0 | 4 | −0.19 | −1.60 |
EMC5 | I was not able to contact my midwife or other health professional when I needed to | 3.02 | 1.25 | 0 | 4 | −1.00 | −0.25 |
EMC6 | I was not always treated with respect and kindness by health professionals | 3.18 | 1.34 | 0 | 4 | −1.42 | 0.51 |
EMC7 |
Health professionals did not always talk to me in a way I could understand
| 3.48 | 0.90 | 0 | 4 | −1.78 | 2.44 |
EMC8 |
Antenatal appointments were too short to discuss any concerns about my pregnancy
| 3.27 | 1.07 | 0 | 4 | −1.39 | 1.01 |
EMC9 | I was able to speak to a health professional about any worries or sensitive issues. | 3.27 | 1.08 | 0 | 4 | −1.69 | 2.22 |
EMC10 |
I was not involved enough in decisions about my antenatal care
| 3.19 | 1.11 | 0 | 4 | −1.09 | −0.01 |
EMC11 | I felt listened to when I talked to my care provider about my pregnancy and birth | 3.21 | 1.07 | 0 | 4 | −1.54 | 1.80 |
EMC12 |
I was happy with the number of health professionals who cared for me during my pregnancy
| 3.06 | 1.14 | 0 | 4 | −1.10 | 0.23 |
EMC13 |
I was not given enough explanations about the antenatal scans and tests
| 3.16 | 1.15 | 0 | 4 | −1.25 | 0.53 |
EMC14 |
I was not given enough information to make decisions about my antenatal care
| 3.26 | 1.09 | 0 | 4 | −1.34 | 0.79 |
EMC15 | Seeing different midwives/doctors for antenatal care did not matter to me | 1.95 | 1.30 | 0 | 4 | 0.14 | −1.17 |
EMC16 |
I would have liked more antenatal checks and scans
| 2.24 | 1.32 | 0 | 4 | −0.14 | −1.14 |
EMC17 | During pregnancy I was given enough information about where I could give birth to my baby (e.g. home, hospital, midwife unit) | 3.09 | 1.07 | 0 | 4 | −1.01 | 0.06 |
EMC18 | Health professionals always treated me as an individual | 3.36 | 0.91 | 0 | 4 | −1.72 | 3.01 |
EMC19 |
During pregnancy, I did not feel well cared for by health professionals
| 3.43 | 0.99 | 0 | 4 | −1.92 | 3.07 |
EMC20 |
Overall, I was very pleased with the care I received in pregnancy
| 3.40 | 0.89 | 0 | 4 | −1.86 | 3.73 |
Labour and birth scale
| |||||||
EMC21 | Before my labour and birth I was well informed by my midwife/doctor about what would happen | 3.25 | 0.97 | 0 | 4 | −1.39 | 1.46 |
EMC22 |
Staff communicated well with me during labour and birth
| 3.37 | 1.00 | 0 | 4 | −1.72 | 2.27 |
EMC23 | My choices for labour and birth were not always respected | 3.21 | 1.15 | 0 | 4 | −1.43 | 1.13 |
EMC24 |
I needed more staff support during labour and birth
| 3.16 | 1.23 | 0 | 4 | −1.28 | 0.41 |
EMC25 |
Everything was explained to me well during labour and birth
| 3.29 | 0.99 | 0 | 4 | −1.50 | 1.59 |
EMC26 |
I was treated as an individual by staff
| 3.50 | 0.85 | 0 | 4 | −2.11 | 4.68 |
EMC27 |
I was not involved enough in decisions about procedures that were carried out
(
e.g.
breaking waters, epidural, caesarean section)
| 3.28 | 1.06 | 0 | 4 | −1.37 | 1.00 |
EMC28 |
Health professionals left me alone more than I would have liked
| 3.08 | 1.22 | 0 | 4 | −1.08 | −0.13 |
EMC29 |
I felt that my pain relief needs were not managed well
| 3.07 | 1.27 | 0 | 4 | −1.13 | 0.01 |
EMC30 | I had already met the staff who looked after me during labour and birth | 0.76 | 1.33 | 0 | 4 | 1.50 | 0.73 |
EMC31 |
I felt safe in the labour and birth environment
| 3.41 | 0.91 | 0 | 4 | −1.73 | 2.59 |
EMC32 | Staff did not listen to my requests in managing my labour and birth | 3.33 | 1.07 | 0 | 4 | −1.51 | 1.32 |
EMC33 |
The staff could have done more to help me to feel in control of my labour and birth
| 3.10 | 1.28 | 0 | 4 | −1.11 | −0.18 |
EMC34 |
I had confidence and trust in the staff caring for me
| 3.44 | 0.91 | 0 | 4 | −1.82 | 2.87 |
EMC35 | Health professionals helped make labour and birth a really positive experience | 3.17 | 1.04 | 0 | 4 | −1.27 | 1.03 |
EMC36 | The personal care I received could have been better during labour and birth | 3.00 | 1.31 | 0 | 4 | −1.01 | −0.39 |
EMC37 |
I did not mind being looked after by midwives or doctors I had not met before
| 3.00 | 1.08 | 0 | 4 | −1.12 | 0.66 |
EMC38 | The choices I wanted were not available to me | 2.92 | 1.40 | 0 | 4 | −0.87 | − 0.74 |
EMC39 | My labour and birth experience was not as I expected | 2.00 | 1.44 | 0 | 4 | 0.10 | −1.30 |
EMC40 |
I had the best possible care during labour and birth
| 3.37 | 0.95 | 0 | 4 | −1.86 | 3.44 |
Postnatal scale
| |||||||
EMC41 |
I received enough care and attention from staff on the postnatal ward
| 2.72 | 1.23 | 0 | 4 | −0.71 | −0.68 |
EMC42 |
I stayed in hospital as long as I wanted after the birth
| 2.78 | 1.35 | 0 | 4 | −0.76 | −0.74 |
EMC43 | Staff on the postnatal ward did not respond when I needed them | 2.76 | 1.29 | 0 | 4 | −0.55 | −1.11 |
EMC44 | I was not able to make choices about the postnatal care of me and my baby | 2.97 | 1.22 | 0 | 4 | −0.81 | − 0.62 |
EMC45 |
I was treated as an individual by midwives/doctors after the birth
| 3.10 | 1.16 | 0 | 4 | −1.25 | 0.62 |
EMC46 |
After I had given birth, health professionals treated me as though I was no longer important
| 2.98 | 1.27 | 0 | 4 | −0.96 | −0.42 |
EMC47 | I did not know the midwives I saw after bringing my baby home | 1.74 | 1.59 | 0 | 4 | 0.37 | −1.47 |
EMC48 |
I had enough information from health professionals about how to care for my baby
| 3.10 | 1.06 | 0 | 4 | −1.21 | 0.81 |
EMC49 | I felt comfortable speaking with healthcare professionals about how I was feeling | 3.31 | 0.96 | 0 | 4 | −1.61 | 2.27 |
EMC50 | The health professionals I saw after the birth did not really listen to me | 3.32 | 0.95 | 0 | 4 | −1.45 | 1.61 |
EMC51 | I would have liked to have seen midwives more after the birth | 2.49 | 1.37 | 0 | 4 | −0.45 | −1.03 |
EMC52 |
I was able to build a good relationship with the healthcare professional(s) I saw after coming home
| 2.49 | 1.29 | 0 | 4 | −0.36 | −1.05 |
EMC53 |
I was not given the advice and information I needed by health professionals after my baby was born
| 3.18 | 1.02 | 0 | 4 | −1.17 | 0.58 |
EMC54 |
There was not enough time to talk over my concerns with health professionals
| 3.17 | 1.10 | 0 | 4 | −1.10 | 0.14 |
EMC55 | The advice I received from healthcare professionals about caring for my baby was consistent | 2.67 | 1.28 | 0 | 4 | −0.77 | −0.53 |
EMC56 |
I had all the checks I needed after the birth
| 3.13 | 1.15 | 0 | 4 | −1.33 | 0.76 |
EMC57 |
After the birth of my baby, I knew who to contact if I had questions or concerns
| 3.38 | 0.94 | 0 | 4 | −1.71 | 2.48 |
EMC58 | As a mother of a new baby I did not feel cared for and supported enough by health professionals | 3.25 | 1.01 | 0 | 4 | −1.20 | 0.55 |
EMC59 |
The postnatal care I received did not meet the needs of me and my baby
| 3.19 | 1.13 | 0 | 4 | −1.23 | 0.44 |
EMC60 |
Overall I was very pleased with the quality of my postnatal care
| 3.13 | 0.99 | 0 | 4 | −1.17 | 0.81 |
Exploratory factor analysis
EMC Scale | Parallel analysis N | EFA factors | Initial item N | Final item N |
---|---|---|---|---|
Pregnancy | 6 | 5 (SI loading) | 15 | 12 |
Labour and Childbirth | 3 | 2 (SI loading) | 15 | 12 |
Postnatal | 4 | 3 (miss-spec) | 17 | 12 |
EMC Scale | χ2 (df) |
p
| RMSEA | RMSR | CFI | TLI |
---|---|---|---|---|---|---|
Pregnancy | 47.43 [40] | 0.20 | 0.03 (0.01–0.06) | 0.03 | 0.99 | 0.98 |
Labour and Childbirth | 154.62 (76) | < 0.01 | 0.07 (0.05–0.08) | 0.04 | 0.96 | 0.94 |
Postnatal | 195.22 (88) | < 0.01 | 0.08 (0.06–0.09) | 0.04 | 0.94 | 0.91 |
Scale and sub-scale | Mean | SD | Min. | Max. | Skew | Kurtosis |
---|---|---|---|---|---|---|
Sub-scale
| ||||||
Care appraisal (PR) | 10.00 | 2.31 | 1 | 12 | −1.34 | 1.43 |
Information (PR) | 6.60 | 1.83 | 1 | 8 | −1.05 | −0.13 |
Antenatal communication (PR) | 9.66 | 2.57 | 2 | 12 | − 0.84 | − 0.33 |
Continuity (PR) | 5.10 | 2.41 | 0 | 8 | −0.38 | − 0.95 |
Antenatal checks (PR) | 5.49 | 1.92 | 0 | 8 | −0.39 | −0.56 |
Care quality (LB) | 22.77 | 5.45 | 0 | 28 | −1.39 | 1.87 |
Care needs (LB) | 14.70 | 5.15 | 0 | 20 | −0.84 | −0.19 |
Adequacy of care (PN) | 11.50 | 4.13 | 0 | 16 | −0.80 | − 0.24 |
HP Communicationa (PN) | 11.98 | 3.55 | 0 | 16 | −0.82 | 0.11 |
Individualised care (PN) | 12.72 | 3.20 | 0 | 16 | −0.99 | 0.73 |
Total scale scores
| ||||||
Pregnancy scale total score | 36.84 | 8.29 | 12 | 48 | −0.66 | − 0.41 |
Labour & birth scale total score | 37.47 | 9.96 | 0 | 48 | −1.18 | 0.92 |
Postnatal scale total score | 36.20 | 9.10 | 5 | 48 | −0.83 | 0.08 |
Six-item scale total (PR) | 19.65 | 4.43 | 3 | 24 | −1.02 | 0.57 |
Confirmatory factor analysis
Model | EMC Scale | Factor N | χ2 (df) |
p
| RMSEA | SRMR | CFI | TLI |
---|---|---|---|---|---|---|---|---|
1 | Pregnancy | 5 | 82.06 [44] | < 0.01 | 0.06 (0.04–0.08) | 0.04 | 0.96 | 0.94 |
2 | Labour and Childbirth | 2 | 133.10 [53] | < 0.01 | 0.08 (0.07–0.10) | 0.05 | 0.94 | 0.93 |
3 | Postnatal | 3 | 133.06 [51] | < 0.01 | 0.09 (0.07–0.10) | 0.06 | 0.93 | 0.91 |
4 | Pregnancy | 1 | 143.84 [54] | < 0.01 | 0.09 (0.07–0.10) | 0.06 | 0.90 | 0.88 |
5 | Labour and Childbirth | 1 | 149.36 [54] | < 0.01 | 0.09 (0.07–0.11) | 0.05 | 0.93 | 0.92 |
6 | Postnatal | 1 | 283.51 [54] | < 0.01 | 0.14 (0.10–0.15) | 0.08 | 0.80 | 0.76 |
EMC Scale | PR.1 | PR.2 | PR.3 | PR.4 | PR.5 | LB.1 | LB.2 | PN.1 | PN.2 | PN.3 | Preg | Lab | Post |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Sub-scales
| |||||||||||||
Care appraisal (PR.1) | 1.00 | ||||||||||||
Information (PR.2) | 0.62 | 1.00 | |||||||||||
Antenatal communication (PR.3) | 0.65 | 0.59 | 1.00 | ||||||||||
Continuity (PR.4) | 0.49 | 0.31 | 0.36 | 1.00 | |||||||||
Antenatal checks (PR.5) | 0.47 | 0.38 | 0.39 | 0.24 | 1.00 | ||||||||
Care quality (LB.1) | 0.45 | 0.34 | 0.39 |
0.17
| 0.35 | 1.00 | |||||||
Care needs (LB.2) | 0.32 | 0.33 | 0.37 |
0.15
| 0.28 | 0.76 | 1.00 | ||||||
Adequacy of care (PN.1) | 0.29 | 0.30 | 0.31 | 0.09* |
0.18
| 0.34 | 0.33 | 1.00 | |||||
HP Communication* (PN.2) | 0.45 | 0.44 | 0.48 | 0.28 | 0.34 | 0.44 | 0.44 | 0.46 | 1.00 | ||||
Individualised care (PN.2) | 0.45 | 0.42 | 0.44 | 0.20 | 0.42 | 0.45 | 0.43 | 0.56 | 0.65 | 1.00 | |||
Totals
| |||||||||||||
Pregnancy total | 0.87 | 0.76 | 0.82 | 0.66 | 0.64 | 0.45 | 0.39 | 0.31 | 0.53 | 0.51 | 1.00 | ||
Labour & birth total | 0.41 | 0.36 | 0.40 |
0.17
| 0.33 | 0.94 | 0.94 | 0.36 | 0.47 | 0.47 | 0.45 | 1.00 | |
Postnatal total | 0.46 | 0.45 | 0.48 | 0.22 | 0.36 | 0.49 | 0.47 | 0.83 | 0.83 | 0.86 | 0.53 | 0.51 | 1.00 |
Internal consistency
Scale | Sub-scale | N items | Alpha | Alpha (95% CI) |
---|---|---|---|---|
Pregnancy | 12 | 0.847 | 0.82–0.88 | |
Care appraisal | 3 | 0.798 | 0.75–0.84 | |
Information | 2 | 0.672 | 0.59–0.76 | |
Antenatal comm. | 3 | 0.662 | 0.59–0.74 | |
Continuity | 2 | 0.588 | 0.49–0.69 | |
Antenatal checks | 2 | 0.456 | 0.32–0.59 | |
Labour and birth | 12 | 0.904 | 0.89–0.92 | |
Care quality | 7 | 0.867 | 0.84–0.89 | |
Care needs | 5 | 0.811 | 0.77–0.85 | |
Postnatal | 12 | 0.873 | 0.85–0.90 | |
Adequacy of care | 4 | 0.800 | 0.76–0.84 | |
HP Communication | 4 | 0.775 | 0.72–0.82 | |
Individualised care | 4 | 0.753 | 0.70–0.81 |
Divergent validity
EMC Scale and sub-scale |
r
| 95% CI |
p
|
---|---|---|---|
Sub-scale scores
| |||
Care appraisal (PR) | −0.02 | −0.15 - 0.11 | 0.73 |
Information (PR) | 0.04 | −0.09 - 0.17 | 0.55 |
Antenatal communication (PR) | −0.01 | − 0.14 - 0.12 | 0.87 |
Continuity (PR) | −0.01 | − 0.14 - 0.12 | 0.88 |
Antenatal checks (PR) | 0.11 | −0.02 - 0.24 | 0.10 |
Care quality (LB) | 0.11 | −0.02 - 0.24 | 0.09 |
Care needs (LB) | 0.12 | −0.01 - 0.25 | 0.08 |
Adequacy of care (PN) | 0.05 | −0.08 - 0.18 | 0.48 |
HP Communication (PN) | 0.06 | −0.07 - 0.19 | 0.38 |
Individualised care (PN) | 0.09 | −0.05 - 0.21 | 0.21 |
Total scale scores
| |||
Pregnancy scale total score | 0.02 | −0.11 - 0.15 | 0.75 |
Labour & birth scale total score | 0.12 | −0.01 - 0.25 | 0.06 |
Postnatal scale total score | 0.07 | −0.06 - 0.20 | 0.27 |
Convergent validity
EMC Scale and sub-scale |
r
| 95% CI |
p
|
---|---|---|---|
Sub-scale scores
| |||
Care appraisal (PR) | 0.44 | 0.33–0.54 | < 0.01 |
Information (PR) | 0.40 | 0.29–0.51 | < 0.01 |
Antenatal communication (PR) | 0.44 | 0.33–0.54 | < 0.01 |
Continuity (PR) | 0.32 | 0.20–0.44 | < 0.01 |
Antenatal checks (PR) | 0.27 | 0.15–0.39 | < 0.01 |
Care quality (LB) | 0.25 | 0.12–0.37 | < 0.01 |
Care needs (LB) | 0.23 | 0.10–0.35 | < 0.01 |
Adequacy of care (PN) | 0.29 | 0.16–0.40 | < 0.01 |
HP Communication (PN) | 0.29 | 0.17–0.41 | < 0.01 |
Individualised care (PN) | 0.31 | 0.19–0.42 | < 0.01 |
Total scale scores
| |||
Pregnancy scale total score | 0.50 | 0.40–0.60 | < 0.01 |
Labour & birth scale total score | 0.25 | 0.13–0.37 | < 0.01 |
Postnatal scale total score | 0.35 | 0.23–0.46 | < 0.01 |
Known-groups discriminant validity
Scale and sub-scale | Differentiator |
t
|
p
| 95% CI | ES (d) | d 95% CI | ES Interpretation | ||
---|---|---|---|---|---|---|---|---|---|
Sub-scale scores
| |||||||||
Care appraisal (PR) |
Ethnicity (N = 169/56):
| White UK | BME | ||||||
10.14 (2.26) | 9.55 (2.43) | 1.66 | 0.79 | −0.11–1.29 | 0.26 | − 0.05–0.56 | Small | ||
Information (PR) |
Previous birth (N = 110/115):
| ‘No’ | ‘Yes’ | ||||||
6.35 (1.73) | 6.84 (1.90) | 1.98 | 0.05 | −0.96– −0.01 | 0.27 | 0.01–0.53 | Small | ||
Antenatal communication (PR) |
Delivery type (N = 132/93):
| Normal | Non-normal | ||||||
9.70 (2.53) | 9.22 (2.58) | 2.19 | 0.03 | 0.07–1.44 | 0.30 | 0.03–0.56 | Small | ||
Continuity (PR) |
Asked about mental health (N = 32/190):
| ‘No’ | ‘Yes’ | ||||||
4.38 (2.92) | 5.25 (2.30) | 1.92 | 0.06 | −1.78–0.02 | 0.37 | −0.01–0.74 | Small | ||
Antenatal checks (PR) |
Asked about mental health (N = 32/190):
| ‘No’ | ‘Yes’ | ||||||
5.09 (2.16) | 5.67 (1.88) | 1.29 | 0.19 | −1.20–0.25 | 0.25 | −0.13–0.62 | Small | ||
Care quality (LB) |
Ethnicity (N = 169/56):
| White UK | BME | ||||||
23.30 (5.16) | 21.20 (6.03) | 2.53 | 0.01 | 0.46–3.74 | 0.39 | 0.08–0.70 | Small | ||
Care needs (LB) | Ethnicity (N = 169/56): | White UK | BME | ||||||
15.17 (4.96) | 13.29 (5.49) | 2.39 | 0.02 | 0.33–3.43 | 0.37 | 0.06–0.67 | Small | ||
Adequacy of care (PN) |
Baby health problems (N = 196/27):
| ‘No’ | ‘Yes’ | ||||||
11.67 (5.23) | 10.11 (3.88) | 1.85 | 0.07 | −0.11–3.22 | 0.38 | −0.03–0.78 | Small | ||
Health professional communication (PN) |
Baby health problems (N = 196/27):
| ‘No’ | ‘Yes’ | ||||||
12.17 (4.10) | 10.30 (3.41) | 2.61 | < 0.01 | 0.46–3.29 | 0.54 | 0.13–0.94 | Medium | ||
Individualised care (PN) |
Baby health problems (N = 196/27):
| ‘No’ | ‘Yes’ | ||||||
12.91 (4.26) | 11.07 (2.97) | 2.84 | < 0.01 | 0.56–3.12 | 0.58 | 0.18–0.99 | Medium | ||
Total scale scores
| |||||||||
Pregnancy scale total score |
Asked about mental health:
| ‘No’ | ‘Yes’ | ||||||
35.00 (8.85) | 37.25 (8.18) | 1.42 | 0.16 | −5.37–0.87 | 0.27 | −0.11–0.65 | Small | ||
Labour & birth scale total score |
Ethnicity:
| White UK | BME | ||||||
38.46 (9.51) | 34.48 (10.76) | 2.62 | < 0.01 | 0.99–6.97 | 0.40 | 0.10–0.71 | Small | ||
Postnatal scale total score |
Baby health problems:
| ‘No’ | ‘Yes’ | ||||||
36.76 (12.27) | 31.48 (8.41) | 2.87 | < 0.01 | 1.65–8.90 | 0.59 | 0.18–1.00 | Medium |