Cross-cultural adaptation and psychometric properties of the Chinese version of the Person-Centered Maternity Care Scale

Background Increasing evidence show that women across the world face unacceptable mistreatment during childbirth. Person-centered maternity care is fundamental and essential to quality of healthcare services. The aim of this study was to translate and determine the psychometric properties of the Person-Centered Maternity Care (PCMC) Scale among Chinese postpartum women. Methods A cross-sectional study was conducted among 1235 post-partum women in China. The cross-cultural adaptation process followed the Beaton intercultural debugging guidelines. A total of 1235 women were included to establish the psychometric properties of the PCMC. A demographic characteristics form and the PCMC were used for data collection. The psychometric properties of the PCMC were evaluated by examining item analysis, exploratory factor analysis, known-groups discriminant validity, and internal consistency. Results The number of extracted common factors was limited to three (dignity & respect, communication & autonomy, supportive care), explaining a total variance of 40.8%. Regarding internal consistency, the Cronbach’s alpha coefficient and split-half reliability of the full PCMC score were 0.989 and 0.852, respectively. Conclusions The Chinese version of the PCMC is a reliable and valid tool to assess person-centered care during childbirth in China.


Background
Childbirth is one of the most significant and unique individual life events across the life course [1,2], with around 9.56 million women in China giving birth in 2022 [3].The World Health Organization (WHO) notes that person-centered maternity care is a fundamental and essential component of quality of care [4], and that all women should have access to high-quality maternity services [5][6][7].Person-centered maternity care refers to care during childbirth that is respectful and responsive to individual women and their families' preferences, needs, and values [8].
A significant body of evidence shows that women across the world face unacceptable mistreatment during childbirth [9].A recent WHO-led study [10,11] in four countries showed that more than one-third of women experienced mistreatment during childbirth in health facilities, including physical and verbal abuse, stigma and discrimination, failure to meet professional standards of care, and so on.Person-centered maternity care is important because having a negative experience is associated with disparities in adverse pregnancy and birth outcomes [12][13][14], as well as poorer mental health among postpartum women [15], such as postpartum depression, anxiety, and Post-traumatic Stress Disorder (PTSD) [16].Furthermore, evidence suggests that improving person-centered maternity care enhances women's trust in facility-based care while decreasing patient complaints and medical disputes [17,18].As such, it is imperative to have a good, valid, and reliable instrument for assessing levels of person-centered maternity care to inform effective strategies to improve maternal health services [6,19,20].
Several instruments have been developed to measure experience of care during the childbirth.Among these existing tools, are the revised Childbirth Experience Questionnaire (CEQ 2.0) [21], the Wijma Delivery Expectancy Questionnaire version A and B (WDEQ-A and WDEQ-B) [22,23], which have been used by several researchers in China.The Person-Centered Maternity Care (PCMC) Scale is however the most comprehensive multidimensional measure of women's person-centered experiences during childbirth compared to these measures [24,25].The Person-Centered Maternity Care (PCMC) Scale was developed based on a review of the literature and informed by the WHO Quality of Care Standards for improving Maternal and Newborn Health, resulting in a 30-item PCMC in Kenya [8].
To date, the PCMC has been translated and validated has been validated across multiple settings including low-, middle-, and high-income countries [4,26], including in India [27], the United States [26], Turkey [24], and Cambodia [28], Sri Lanka [29], Nigeria [30], and Ethiopia [31,32] where it has been found to have good psychometric properties.No study has, however, been conducted to assess the validity and reliability of PCMC in China.The purpose of this study is therefore to translate and determine the reliability and validity of the Chinese version of the PCMC with postpartum women in China.

Study design and participants
This is a descriptive, cross-sectional study.This investigation was divided into two phases (Fig. 1).In phase 1, the PCMC was translated to Chinese using the Beaton intercultural debugging guide [33].In phase 2, the reliability and validity of the Chinese version of the PCMC were assessed through a cross-sectional survey.

Translation process
Considering some items in the original scale are not relevant to the Chinese context (such as item 29: "Was there water in the facility?"And item 30 "Was there electricity in the facility?"At present, there is water and electricity in all Chinese facilities),the present study used the 35-item version of the PCMC that was validated in the United States.The US-PCMC is divided into three domains: communication and autonomy, responsive and supportive care, and dignity and respect [26].The full PCMC score is standardized to range from 0 to 100, with higher scores indicating a more positive birth experience.Permission to translate and validate the PCMC was obtained from the original developers of the scale.The cross-cultural adaptation process followed the Beaton intercultural debugging guidelines, which comprised of forward and backward translations, scrutiny by an expert committee, and preliminary pilot testing [33] ( see Table 1).pling was used to select (n=30) postnatal women to participate in a preliminary survey that resulted in the final Chinese-PCMC.These pilot participants were asked if they had an unclear understanding of the content, and none declared that they did.

Sample size
The sample size was calculated according to the criteria required for factorial analysis, with ten to twenty subjects per item [34].Given the US-PCMC includes 35 items, a sample size of 350 to 700 participants was considered adequate.A total of 1300 women agreed to participate in the study.but 65 participants were excluded because their data was insufficient or unreliable.A sample of 1235 women were therefore included in the data analysis.

Demographic characteristics form
The following demographic data were collected: age, ethnic group, religion, education level, marital status, parity, mode of delivery, type of maternity wards (double room and single room for Labor, Delivery, Recovery), pregnancy complications, and neonatal complications.Person-Centered Maternity Care Scale (PCMC).The 35-item PCMC scaled translated into Chinese was administered in the survey.

Data collection
Women who gave birth in the preceding six to eight weeks in the postpartum clinics of two tertiary hospitals in Sichuan Province, China, were recruited  between December 2022 and January 2023.(Although the recommended time period for postnatal checkups is within the first six weeks after giving birth, most Chinese women visit postpartum clinics at six to eight weeks postpartum).A paper questionnaire was used to collect the data.Participants were informed of the study when they were in the waiting room.Those who agreed to participate signed the informed consent form, and completed the questionnaires by themselves before been seen for postnatal care.

Data analysis
Data analysis was performed using IBM SPSS Statistics for Windows, Version 21.0 and IBM AMOS Statistics for Windows, Version 24.0.All statistical tests were twotailed, and a p-value of less than 0.05 was considered statistically significant.

Demographic characteristics
The variables were summarized using frequency and percentages were for the categorical variables, and mean and standard deviations (SD) for the continuous variables.

Content validity
To evaluate the content validity of the PCMC, ten specialists assessed the necessity of each item using a 3-point rating scale.Scale-Content Validity Index (S-CVI) and Item-Content Validity Index (I-CVI) was calculated [35].

Item analysis
The critical ratio and correlation coefficient methods were used based on item analysis.The item scores on the PCMC were first summed and then arranged in ascending order from high to low.The bottom 27% of the score was classified as the low score group (327 cases) and the top 27% was classified as the high score group (358 cases) [36], and the independent sample for t-test was used to compare the two groups.Pearson correlation coefficients and total scores were then obtained.An absolute critical ratio value of greater than 3 and item-total correlation coefficient greater than 0.4 indicate items have good differentiation [36].

Exploratory factor analysis
This involved first conducting the Kaiser-Meyer-Olkin (KMO) and Bartlett spherical tests.A KMO test value greater than 0.6 and a statistically significant (p<0.001) Bartlett spherical test statistic indicate that the data is suitable for factor analysis [34].The principal component analysis and maximum variance orthogonal rotation method were used to extract common factors, the cumulative total variance of retained factors should be greater than 40% [34].

Known-groups discriminant validity
Known-groups discriminant validity was evaluated by testing for differences in the full PCMC score and subscale scores in relation to known-groups of demographic characteristics [37].The independent sample t-test, oneway analysis of variance (ANOVA), and the Kruskal-Wallis H test were performed to compare the full PCMC score and sub-scale scores between different groups.

Internal consistency
The Cronbach's α coefficient was used to assess the internal consistency of the PCMC.A Cronbach's α coefficient greater than 0.7 was considered acceptable, 0.6-0.699as tolerable, 0.500-0.599as tolerable but low, and less than 0.5 as poor [38].The odd-even split method was used to assess split-half reliability, with this scale's items divided into two parts, and the Spearman-Brown coefficients of odd-even items calculated.

Content validity
The mean age of the specialists was 45.7 years (SD=7.76;range from 39 to 58); The mean working years of the specialists was 23.5 years (SD=9.69;range from 14 to 38); in terms of job title, 80% specialists are deputy chief nurses and 20% specialists are chief nurses.The result of content validity showed that the I-CVI ranged from 0.80 to 1.00 and the S-CVI of 0.950.The result indicated that the experts confirmed the relevance and clarity of the PCMC.

Item analysis
Apart from three items(i.e., coercion, physical abuse, and bribes) , the critical ratios of all items were greater than 3 (range from 3.311 to 31.212) and significant (p<0.01) between the low and high score groups (Table 3).Apart from that of seven items (i.e., customs respected, coercion, birth position of choice, verbal abuse, physical abuse, bribes, and discrimination), the item-total correlation coefficients were greater than 0.4 and significant (p<0.01)(Table 3).Although the critical ratios of items were a little below 3 andt the gap is narrow, we decided to retain all the items in the Chinese-PCMC in view of the literature review and expert advice.

Exploratory factor analysis
Exploratory factor analysis found the KMO value to be 0.828, and the Bartlett spherical test statistic to be 48157.862(p<0.001),thus demonstrating that the data was suitable for factor analysis.We decided to limit the number of extracted common factors was to 3, explaining a total variance of 40.803% (communication & autonomy, 23.353%; supportive care, 11.171%; dignity & respect, 6.279%).Apart from five items (i.e., coercion, birth position of choice, wait time, customs respected, discrimination), the loading value on the corresponding common factor for the remainder of the items was greater than 0.3 (Table 4).

Known-groups discriminant validity
The PCMC total score was related to type of delivery and maternity wards, with higher scores among those who delivered by c-sections and those who delivered in a single room for Labor, Delivery, Recovery compared to those who delivered vaginally and in the general ward respectively (Table 5).

Internal consistency
The Cronbach's alpha coefficient of the full set of PCMC was 0.989, with that of the subscale ranging from 0.669 to 0.840.The Spearman-Brown coefficient of the full PCMC was 0.852, with that of the subscales ranging from 0.449 to 0.798 (Table 6).

Discussion
A growing body of evidence reveals that the mistreatment of pregnant women during facility-based childbirth occurs across the globe [39].The aim of the current study was to evaluate the psychometric properties of PCMC in Chinese postpartum women.The findings showed that the Chinese version of the PCMC had robust validity and reliability for assessing the level of maternity care in the multicultural context of China.
The findings of the item analysis showed that these items, which include customs respected, coercion, birth position of choice, verbal abuse, physical abuse, bribes, and discrimination, exhibited poor discrimination between the low score and high score groups.In terms of exploratory factor analysis, 3 factors explained a total variance of 40.803% that was higher than the recommended value (40%), but the questions on customs respected, coercion, birth position of choice, and discrimination had loading values lower than 0.3.These findings were not consistent with the US validation findings [26], which is likely due to discrepancies in the sample distribution.On the one hand, the site of delivery is affiliated with the Chinese National Health and Family Planning Commission; hence, the quality of health services is higher compared to other primary hospitals.On the other hand, 95% of the participants in the present study were Han nationals with no specific cultural customs.Thus, the items with poor psychometric properties (customs respected, coercion, birth position of choice, verbal abuse, physical abuse, bribes, discrimination) were still retained in view of the literature review and expert advice.
Regarding known-groups discriminant validity, we found that on average, women who had Caesarean sections had a higher PCMC score compared to women who had vaginal deliveries.In the study, 60.6% women has a cesarean delivery and 39.4% had a vaginal delivery.This high c-section rate may be explained by the site of delivery being affiliated with the Regional medical center, with most participants being from southwest China, and having high-risk pregnancy factors, which results in high cesarean section numbers.The higher PCMC scores may be due to a greater attention to the experiences of such patients.It is noteworthy that a statistically significant difference was found in PCMC scores by the type of maternity ward, with women delivering in a single room for labor, delivery, and recovery having higher PCMC than those delivering in double room.A potential explanation may be that the single room promotes birth as a normal family process, leading to a greater level of Person-Centered Maternity Care through privacy provisions and other aspects of Person-Centered Maternity Care [40].Concerning internal consistency, apart from the Cronbach's alpha coefficient of the dignity and respect sub-scale that was tolerable, the Cronbach's alpha coefficient of the full PCMC and other sub-scales exceeded the value of 0.7, which is acceptable.The split-half reliability of the PCMC was also acceptable, indicating stability over time.In general, the result of the current study found that the Chinese version of PCMC had good internal consistency, which is consistent with previous studies [8,24,27].
Although this study used a strong scientific approach with robust methods to translate and investigate the

which was then com- pared to the original PCMC. • Step 3: Scrutiny by an expert committee: Ten experts were invited to evaluate the cultural adaptation of
the Version 2.0 Chinese-PCMC, which served as the foundation for the Version 3.0 pre-final Chinese-PCMC.• Step 4: Preliminary pilot testing: Convenience sam-

Table 2
Demographic characteristics of participants (n=1235)SD Standard deviation, LDR Single room for Labor Delivery, Recovery

Table 3
Items analysis of the Person-centered Maternity Care Scale performance of the PCMC in a Chinese context, there are some limitations.Firstly, the women recruited for this study came from only two tertiary hospitals in Sichuan Province, and were quite homogeneous-mostly of Han nationality and with high education and married.Also, about 61% delivered by c-section.Thus, this sample is not

Table 4
Exploratory factor analysis of the Person-centered Maternity Care ScaleConclusionsThis study demonstrated the robust psychometric properties of the PCMC, revealing that it is a reliable and valid tool for evaluating Person-Centered Maternity Care in a Chinese context.The Person-Centered Maternity Care Scale can now be used by those working with Chinese-speaking populations as an objective and robust measure.Moreover, it will be a valuable tool for understanding aspects of Person-Centered Maternity Care that need to be addressed in interventions as well as aid in the evaluation of interventions.