Assessing the perception of the childbirth experience in Italian women: A contribution to the adaptation of the childbirth perception questionnaire

Midwifery 28 (2012) 265–274 Contents lists available at ScienceDirect Midwifery journal homepage: www.elsevier.com/midw Assessing the perception of the childbirth experience in Italian women: A contribution to the adaptation of the childbirth perception questionnaire Veronica Bertucci, M.A., Psy.D Student (Psychologist)a, Marilisa Boffo, M.A., PhD student (Psychologist)b, Stefania Mannarini, PhD (Associate Professor)b,n, Andrea Serena, MD (Gynaecologist)a, Carlo Saccardi, MD (Gynaecologist)a, Erich Cosmi, MD, PhD (Researcher)a, Alessandra Andrisani, MD, PhD (Researcher)a, Guido Ambrosini, MD (Associate Professor)a a b Department of Gynecological Sciences and Human Reproduction, University of Padova, Padova 35128, Italy Department of Applied Psychology, University of Padova, Via Venezia 8, Padova 35131, Italy a r t i c l e i n f o abstract Article history: Received 1 October 2010 Received in revised form 18 February 2011 Accepted 22 February 2011 Background: childbirth is a crucial experience in women’s life as it has a substantial psychological, emotional and physical impact. A childbirth positive experience is important to the woman, infant’s health and well-being, and mother–infant relationship. Furthermore, it is useful for the care providers to guarantee the best preparation, health service and support to childbearing women. The Childbirth Perception Questionnaire (CPQ) is a 27-item instrument designed to assess women’s perception of their childbirth experience. Objectives: to provide a first attempt to adapt the Childbirth Perception Questionnaire (CPQ) using a sample of Italian women. The psychometric properties of the scale and the quality of women’s childbirth experience perception were assessed. Furthermore, the potential relation between the childbirth perception and the pain perception was explored. Design: two separate studies were conducted. In Study 1, the factor structure and the reliability of the Italian translation of CPQ were assessed. Also a quantitative analysis of respondents’ mean ratings was conducted. In Study 2 the relation between the CPQ and the Italian Pain Questionnaire (IPQ) was examined. Setting: an inpatient gynaecologic–obstetric unit in a university medical centre in Italy. Participants: 195 women in Study 1 and 92 women in Study 2 completed the questionnaires. Methods: in Study 1 the translated form of CPQ was administered in the 24–48 hours post partum. In Study 2, the participants completed the Italian version of the CPQ and the Italian Pain Questionnaire (IPQ) in the same postpartum time frame. Socio-demographic details and information about women’s obstetric history were collected in both Study 1 and Study 2. Findings: an exploratory factor analysis revealed a 24-item scale with a three-factor structure. The Italian version of the questionnaire was labelled Childbirth Experience Perception Scale (CEPS) and composed of three subscales: Labour and Delivery Perception, Control Perception and Change Perception. The questionnaire presented satisfactory internal consistency’s indexes both in Study 1 (a coefficients range: .66–.83) and in Study 2 (a coefficients range: .70–.86). The analysis of women’s mean scores on CEPS revealed a significant effect of age, social economic status, amniocentesis test, type of childbirth, childbirth preference, and disagreement between actual and preferred childbirth (po.05). A significant correlation between the CEPS and IPQ scales was found (po.05). Conclusion: the current research evidenced that the Italian first adaptation of the CPQ, the Childbirth Experience Perception Scale, may be a valid and reliable measure of childbirth experience perception for use in different women’s health clinical outcome and studies. & 2011 Elsevier Ltd. All rights reserved. Keywords: Childbirth experience Perception Questionnaire Adaptation Introduction Childbearing is one of the most important events in women’s lives. Not only is parturition the transition to motherhood, but n Corresponding author. E-mail address: stefania.mannarini@unipd.it (S. Mannarini). 0266-6138/$ - see front matter & 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2011.02.009 childbirth itself has a substantial physical and emotional impact. For these reasons, the assessment of women’s satisfaction with their perceptions of childbirth is important to both care providers (in offering the best preparation to childbearing women) and to women themselves (due to the implications for the health and well-being of the mother, newborn, and the mother–infant relationship) (Salmon and Drew, 1992; Quine et al., 1993; Slade et al., 1993; Johnston-Robledo, 1998; Robinson et al., 1998; 266 V. Bertucci et al. / Midwifery 28 (2012) 265–274 Lavender et al., 1999; Waldeström, 1999, 2004; Grignaffini et al., 2000; Hodnett, 2002; Goodman et al., 2004; Lundgren, 2004, 2005; Christiaens and Bracke, 2007; Bailey et al., 2008; Bryanton et al., 2008; Conde et al., 2008; Ford and Ayers, 2009; Ip et al., 2009; Kuo et al., 2010; Ngai et al., 2009). In recent years, the importance of measuring woman’s satisfaction with health care has been recognised and has become one of the most frequently reported outcome measures for quality of care and the provision of counselling and psychological support services to new mothers (McDaniel and Nash, 1990; Fitzpatrick, 1991). Satisfaction is a complex concept. It involves both a positive attitude and an affective response to an experience as well as a cognitive evaluation of the emotional response (Hodnett, 2002), which implies the condition of distancing oneself from the event. Furthermore, satisfaction is a multidimensional construct as people may be satisfied with some aspects of an experience and dissatisfied with others, and positive and negative feelings may coexist (Waldeström, 1999). For e.g., being satisfied with care does not necessarily mean feeling positive and satisfied with the entire childbirth experience, but it may contribute to overall childbirth perception. Satisfaction with childbirth may be conceptualised as the positive appraisal of distinct aspects of the childbirth perception. In fact, the perceived quality of the birth experience encompasses more than satisfaction with the care-giving service or the pain experienced. It is a psychological perception that includes practical and relational aspects. Furthermore, a number of potential variables can influence the perceived quality of the birth experience (expectancies, feelings, external variables, personal variables, previous experiences, etc.). Bradamat and Driedger, 1993. Along this theoretical definition of childbirth perception, the measurement of the satisfaction with different aspects of the birth experience may be operationalised as the measurement of a woman’s overall perception of the event. The majority of self-report questionnaires currently used to assess women’s perception of childbirth have been developed and standardised on the English-speaking population (e.g., Marut and Mercer, 1979; Padawer et al., 1988; Salmon et al., 1990; Slade et al., 1993; Mackey, 1995; Fawcett and Knauth, 1996; Smith, 2001). When researchers from other countries conduct a study on this topic, such measures are translated into the target language and directly administered to the non-English speaking sample, based on the assumption that the construct of childbirth perception is unaffected by culture (Christiaens and Bracke, 2007). Concerning the Italian language, we have verified the lack of such a measure in the literature: neither the adaptation of an existing instrument nor the development of a new instrument was found. For this reason, the primary purpose of the current study was to explore whether the theoretical constructs defined by the designers of the Childbirth Perception Questionnaire (CPQ) (Padawer et al., 1988) could be verified in the Italian context and to provide a first attempt to adapt this instrument using a sample of Italian women. We selected the CPQ among the other existing instruments that measure various aspects of the childbirth perception (e.g., Questionnaire Measuring Attitudes About Labour and Delivery (QMAALD), Marut and Mercer, 1979; Fawcett and Knauth, 1996; Birth Experience Questionnaire, Salmon et al., 1990; Women’s Views of Birth Labour Satisfaction Questionnaire (WOMBLSQ), Smith, 2001; Childbirth Experience and Satisfaction Questionnaire (CESQ), Costa et al., 2004; Mackey Childbirth Satisfaction Rating Scale, Goodman et al., 2004; Satisfaction with Childbirth Experience (SWCBE), Oweis, 2009) as one of the most interesting and suitable for evaluating the childbirth perception. As far as the multidimensionality of the childbirth experience is concerned, a review of the literature has suggested a range of potential aspects of a woman’s perception of her childbirth experience (Waldeström, 1999; Hodnett, 2002; Goodman et al., 2004; Christiaens and Bracke, 2007; Bryanton et al., 2008; Conde et al., 2008; Oweis, 2009), and many questionnaires have been developed to measure these aspects. In Table 1, a review of the main self-report instruments that measure the childbirth experience is presented. The characteristics, conceptualisation, psychometric properties, utility and context of development for each scale are reported. On the basis of the content of the items of each scale, we summarise the various childbirth aspects taken into account. Every questionnaire considers some aspects of the birth experience and omits others. The first reason the CPQ was selected was due to its capacity to reflect the most relevant aspects of the childbirth experience perception and to provide a sufficiently comprehensive picture of this perception. In particular, a unique feature of the CPQ is its concern with female sexuality and body image from the woman’s perspective of herself and of the couple. We considered this aspect relevant in measuring the psychological change that occurs during the pregnancy, labour and childbirth, as childbirth is a process that produces an effect on the woman’s self- and couple perception from the beginning of pregnancy and long after the childbirth. A second reason the CPQ was selected is that it can be simply and briefly administered in a 24–48-hour postpartum time frame due to its relatively small number of items. On the other hand, the CPQ presents some weaknesses: it is one of the oldest scales, and it lacks refined studies of its dimensionality. According to the main objective of the present study, we organised the research into two studies. In Study 1, the dimensionality and internal reliability of the Italian translation of CPQ were assessed, followed by an analysis of the potential effects of socio-demographic and obstetric variables on the women’s mean scores. In Study 2, the relation between childbirth perception and pain perception was examined by means of the correlation between the CPQ and the Italian Pain Questionnaire (IPQ, De Benedettis et al., 1988). Study 1 Study 1 was designed to evaluate the dimensional structure and the psychometric properties of the Italian version of the CPQ with a sample of Italian birthing women. Methods and participants All participants were recruited in an inpatient gynaecologic– obstetric unit of a university medical centre in Padova between September 2007 and June 2009. Respondents were included on the basis of the same criteria used by the authors of the American version of the questionnaire (Padawer et al., 1988): (1) nulliparous women; (2) 18 years of age or older; (3) Italian native; (4) childbirth occurred after the 37th week of pregnancy. Excluded from the study were women who experienced the birth of twins, serious maternal pregnancy complications, maternal intensive care and neonatal intensive care. Furthermore, women who had a psychiatric history or presented with a psychological disease during the pregnancy were excluded. Participants were approached by a psychologist within the 24–48 hours post partum during a regular daily visit in the postpartum ward. The same 24–48 hours time frame was used by the designers of the scale (Padawer et al., 1988). After a brief explanation of the study, women were informed that their participation was voluntary and their responses confidential. In total, 200 women met the Table 1 Review of measures of the childbirth experience. Authors CHARACTERISTICS Name Acronym No. of items Response options Subscales Reliability Validity Utility Context Hodnett and SimmonsTropea (1987) Padawer et al. (1988) Salmon et al. (1990) Wijma et al. (1998) Czarnocka and Slade (2000) Smith (2001) Questionnaire measuring attitude about labour and deliveryy Labour agentry Scaley Childbirth perception questionnairey Birth experience questionnairen Wijma delivery expectancy/experience questionnairey,n Perception of labour and delivery scale QMAALD 29 5-point Likert scale Delivery experience;Labour experience;Delivery outcomes; Partner participation; Awareness; LAS 29 7-point Likert scale – CPQ 27 6-point Likert scale Women’s physical appearance/sexuality during pregnancy, childbirth and after the birth; Childbirth mode and women’s conduct during the labour and childbirth; Interaction with the partner during childbirth. – 20 7-point Likert scale Fulfillment and achievement; Emotional feeling. W-DEQ 33 6-point Likert scale – PLDS 24 10-point Likert scale Staff support during childbirth; Pain and distress during childbirth; Fear for safety of self and baby. Women’s views of birth labour satisfaction questionnairey WOMBLSQ 30 7-point Likert scale Professional support; Expectations; Home assessment; Holding baby; Support from husband; Pain in labour; Pain after childbirth; Continuity; Environment; Control. X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X V. Bertucci et al. / Midwifery 28 (2012) 265–274 CHILDBIRTH ASPECTS Sexuality/physical appearance Labour Birth Self-control Pregnancy Pain/distress Fear/worry Quality of care Relaxation Partner/significant others Baby Childbirth general experience Marut and Mercer (1979) X X IC (a range: .76–.87) IC (a range: .91–.98) IC (a range: .58–.82) IC (a range: .54–.83) EFA Research USA EFA; CV; DV Research Canada – Research/clinical USA EFA Research Canada X X X X IC (a range: .89–99) Split half-reliability (range: .87–1.00) CV Research/clinical European (Sweden) IC (a range: .78–.87) IC (a range: .62–.91) EFA Research/Clinical European (UK) EFA; CV Research European (UK) 267 268 Table 1 (continued ) Authors CHARACTERISTICS Name Acronym No. of items Response options Subcales Reliability Validity Utility Context Costa et al. (2004) Oweis (2009) Oweis (2009) Redshaw et al. (2009) Ford et al. (2009) Mackey childbirth satisfaction rating scale CSRS 34 5-point Likert scale Self; Partner; Baby; Nurse; Physician; Overall labour and childbirth evaluation. Childbirth experience and satisfaction questionnairey QESP 104 4-point Likert scale Conditions and care provided; Positive experience; Negative experience; Relaxation; Social support; Partner’s support; Worries; Postpartum. Satisfaction with childbirth experiencey SWCBE 32 5-point Likert scale – Women’s perceptions of control during childbirthy PCCB 23 5-point Likert scale – Oxford worries about labour scale OWLS-9 9 4-point Likert scale Interventions; Uncertainty; Labour and distress. Support and control in birthy SCIB 33 5-point Likert scale Internal control; External control; Support. X X X X X X X X X X X X X X X X X X X X X X X X IC (a range: . 83–.97) IC (a range: .79–.94) Split-half reliability (range .56–.93) EAF; CV Research/clinical European (Portugal) IC (a ¼ .88) – Research Middle East (Jordan) X CV Research USA X X X X IC (a ¼ .86) IC (a range: .64–.88) IC (a range: .86–.95) – Research Middle east (Jordan) EFA; DV Research/clinical European (UK) EFA Research European (UK) X IC¼ internal consistency; EAF ¼exploratory factor analysis; CV ¼convergent/divergent validity; DV ¼discriminant validity. X ¼Presence of the childbirth aspect. n y The questionnaire presents pre-and postpartum versions. The questionnaire presents a total scale score. X X V. Bertucci et al. / Midwifery 28 (2012) 265–274 CHILDBIRTH ASPECTS Sexuality/physical appearance Labour Birth Self-control Pregnancy Pain/distress Fear/worry Quality of care Relaxation Partner/significant others Baby Childbirth general experience Goodman et al. (2004) 269 V. Bertucci et al. / Midwifery 28 (2012) 265–274 eligibility criteria, and 195 (97.5%) agreed to participate in the study and completed the questionnaires. After the informed consent procedures approved by the university and hospital ethical review boards, the women were first administered a detailed socio-demographic questionnaire that included the following variables: age, marital status, education and social economic status. Education was measured by the degrees or certification attained. The social economic status (SES—Hollingshead, 1975) was determined on the basis of the participants’ profession/occupational status. The questionnaire included information about the women’s obstetric history such as mode of birth (vaginal, vaginal with epidural, elective caesarean), prenatal screenings (number of gynecological visits and scans, amniocentesis, chorionic villi sampling) and participation in antenatal birth preparation classes. Furthermore, in the 24–48 hours postpartum period, women were asked which mode of birth they would have preferred. The women then completed the translated Italian version of the Childbirth Perception Questionnaire (CPQ) (Padawer et al., 1988). The CPQ is a 27-item self-report questionnaire that was developed to rate women’s satisfaction with their birth experience with respect to the degree to which it is positive or negative. The questionnaire consists of the following three subscales: (a) women’s physical appearance/sexuality during pregnancy, birth, and after the birth (five items); (b) mode of birth (caesarean, vaginal, vaginal with epidural analgesia) and women’s conduct during the labour and birth (13 items), and (c) interaction with the partner during birth (nine items). Respondents indicate the extent of their agreement or disagreement with each item using a six-point Likert scale ((1) agree completely to (6) disagree completely). Scores for each subscale are obtained by summing the women’s responses across the items for that scale, with negatively worded items reverse-scored. The higher the total score, the more negatively the birth experience is perceived, with a possible score of 27–162. Because we used the same sampling and procedure criteria as the designers of CPQ, we applied the same scoring procedure as well. Cronbach’s alpha reliability coefficients for the three subscales in the American version were .58 (satisfaction with sexuality), .82 (satisfaction with childbirth), and .75 (satisfaction with partner interaction) (Padawer et al., 1988). Before administering the questionnaire, a back translation was carried out. Guidelines were developed by the International Committee of Psychologists of the International Test Commission (van de Vijver and Hambleton, 1996) for back translations. According to these guidelines, the questionnaire was translated into Italian by a native English speaker and a native Italian speaker. These two versions were independently translated back into English by two Italian experts in English language and obstetrics and gynaecology. Comparisons and discussion of differences between these four versions resulted in no item changes. All four experts who worked on the back translation agreed on the appropriateness and clarity of the scale contents. Statistical analysis To determine whether the birth dimensions defined by the designers of the CPQ could be found in the Italian context, an exploratory factor analysis (EFA) was performed on the 27-item CPQ. The number of factors extracted was determined by considering the three-factor structure of the original version of the questionnaire and the factor solutions with eigenvalue indexes 41.00 (Kaiser, 1960) and with at least the threshold of 5% of variance explained. A principal component analysis (PCA) factor extraction procedure was used. A Promax oblique factor rotation procedure was chosen because it was anticipated that the extracted components may be correlated (e.g., Floyd and Widman, 1995). The items were retained within a factor when a minimum factor loading strength of .35 was achieved (e.g., Comrey and Lee, 1992; Floyd and Widman, 1995). Once we verified whether the instrument’s original theoretical constructs could be adapted to the Italian context, the analysis of internal consistency of each factor was planned by calculating Cronbach’s a coefficient (Cronbach, 1951). Then, the item-deleted Cronbach’s coefficients were calculated in order to evaluate the contribution of each single item to its factor reliability. Secondary to the psychometric evaluation of the instrument, a quantitative analysis of women’s mean scores was conducted. To provide potential effects of the socio-demographic and obstetric variables on childbirth perception, Student’s t-test and one-way ANOVA were used. Statistical significance was set at p o.05. Findings Socio-demographic details The 195 participants ranged in age from 25 to 40 years, with a mean age of 32.65 (SD 3.62). Participants’ highest education attained was as follows: 14 (7.2%) women completed middle school education, 81 (41.5%) completed high school, and the remaining 100 (51.3%) completed a university degree. A total of 133 (68.2%) of the participants belonged to a middle social economic status, whereas 25 (12.8%) pertained to a low–middle to low status and 37 (19%) belonged to high–middle to high status. Sixty-five (33.3%) women were not married but in a relationship, 127 (65.1%) were married and the remaining 3 (1.5%) were separated. The obstetric history of the study sample is reported in Table 2. Psychometric properties of the questionnaire The PCA with Promax oblique factor rotation identified the threefactor solution with eigenvalue indexes 41.00, which cumulatively explained 38.85% of the total variance. Items with loadings greater than .35 are shown in Table 3. According to the criteria of selection, three items were dropped: items 14, 18 and 23 showed factor loadings o.35 (factor loadings¼.33, .27 and .32, respectively). Item Table 2 Obstetric history of the study sample. n (%) Mode of birth Vaginal caesarean section Vaginal with epidural 76 (39%) 67 (26.7%) 52 (34.4%) Childbirth preference Vaginal caesarean section Vaginal with epidural 52 (26.9%) 27 (14%) 114 (59.1%) Gynecologic visits Up to 5 6 7–9 More than 10 21 (10.8%) 55 (28.2%) 80 (41%) 39 (20%) Scans number 3 4 5–6 More than 6 30 52 62 51 Amniocentesis test Yes 34 (17.2%) Chorionic villi sampling Yes 27 (13.8%) Childbirth preparation classes Yes (15.4%) (26.7%) (31.8%) (26.2%) 126 (64.6%) 270 V. Bertucci et al. / Midwifery 28 (2012) 265–274 Table 3 Three-factor solution with 24 items of the Italian version of the questionnaire: Childbirth Experience Perception Scale (CEPS). Promax rotated factor loadings for each item. Item 1 2 3 4 5 6 7 8 9 10 11 12 13 15 16 17 19 20 21 22 24 25 26 27 CEPS Labour and Delivery Perception Control Perception Change Perception .15 .15 .26 .19 .27 .29 .11 .00 .33 .38  .07 .51 .40  .03 .05  .03 .74 .78 .69 .27 .75 .70 .72 .51 .17 .24 .06 .24 .08 .73 .65 .58 .59 .35 .68 .55 .38 .66 .49 .31 .19 .17 .03 .02 .13 .15  .00  .10 .50 .55 .68 .40 .78 .17 .17 .24 .21  .03 .11 .16 .00 .03 .11 .42 .25 .26 .05 .57 .34 .21 .37 .25 Factor loadings 4 .35 are reported in bold. 14 pertained to disappointment about the birth experience, item 18 was concerning a decrease of self-confidence in the woman after the birth, and item 23 addressed possible harm to the partner relationship due to the labour experience. Item 12 (I was satisfied with how much control I had over decisions made during labour and childbirth) (see Table 3) presented factor loading indexes 4.35 on both factor one and factor two. This item was included in the second factor because its factor loading index was higher for this factor and its content was most related to the second factor. The factor structure presented a new arrangement of items. By reading the items of every factor as a group, in line with the main objective of the current study, we intuitively labelled the three dimensions Labour and Delivery Perception (nine items), Control Perception (eight items) and Change Perception (seven items) (Table 3). The sum of these dimensions composes the quality of the overall birth perception, as described by the Italian label of the instrument: Childbirth Experience Perception Scale (CEPS). After the Italian structure of the scale was determined, the internal reliability consistency index was calculated. Cronbach’s alpha coefficients for the 24-item Italian version of the questionnaire and for each subscale are presented in Table 4. The coefficients of the three subscales and of the total CEPS present satisfactory values ranging from .66 to .83. For every factor, the item deleted analysis was executed. This procedure demonstrated that if each item was removed from the subscale, the Cronbach’s alpha index would have decreased, indicating that the items were highly relevant for the scale’s reliability. Quantitative analysis of women’s responses Through the use of t-test and one-way ANOVA, it was possible to identify eventual relations between the socio-demographic and obstetric variables and the birth experience perception. Women who were between 25 and 33 years old presented significantly lower ratings on the Labour and Delivery Perception Table 4 Cronbach’s a coefficient with item deleted analysis. Labour and Delivery Perception (nine items) a ¼ .82 Control Perception (eight items) a ¼ .79 Item Item a Item a 6 7 8 9 11 12 15 16 .742 .752 .771 .774 .758 .779 .751 .781 1 2 3 4 5 17 22 .632 .618 .612 .647 .578 .650 .647 10 13 19 20 21 24 25 26 27 a .828 .832 .781 .778 .795 .777 .787 .785 .809 Childbirth Experience Change Perception (seven items) a ¼ .66 Perception Scale (CEPS) (24 items) a ¼ .83 subscale (mean¼18.03, SD¼6.014) than those who were between 34 and 40 years old (mean¼19.91, SD¼6.867; t¼  2.028, p¼.044). This suggests that the younger women perceived birth more positively than the older women. As the study qualification did not produce statistically significant effect, the variable social economic status was used as a control of the socio-cultural level. The one-way ANOVA evidenced a statistically significant difference in mean Control Perception scores between mothers who belonged to the low–middle to low social economic level (mean ¼22.68, SD¼7.186; F¼3.661, p o.05) and those who belonged to the middle social economic level (mean¼19.29, SD¼6.21) and to the high–middle to high level (mean¼18.32, SD ¼1.16). Among the obstetric variables, the amniocentesis screening produced an effect on the women’s CEPS total score, and particularly on the Labour and Delivery Perception subscale. Women who underwent the amniocentesis test seemed to have a worse perception of their birth experience (mean¼53.68, SD¼12.017) than women who did not (mean¼48.58, SD¼12.219; t¼ 2.217, p¼.028). In particular, ladies who proceeded with the amniocentesis had more negative perceptions of the labour and birth (mean¼ 20.74, SD¼7.111) than those who did not (mean¼18.38, SD¼6.215; t¼–1.958, p¼.05). Another obstetric variable presented a statistically significant effect on birth experience perception: the mode of birth. The mean Control Perception scores differed at a significant level between women who delivered naturally (mean ¼17.97, SD¼6.123; F¼ 3.606, p o.05) and those who delivered through caesarean section (mean¼20.49, SD¼ 7.159) or with epidural analgesia (mean¼20.60, SD¼6.156). The birth preference expressed by the women between the 24–48 hours after giving birth also affected childbirth perception. Ladies who chose caesarean section as their favourite mode of birth were the least satisfied with their perceptions of control during the birth (mean ¼23.63, SD¼7.006), followed by women who preferred a vaginal birth with epidural analgesia (mean¼19.83, SD ¼6.137). Those who presented the most positive feelings about their sense of control during the birth were the ladies who selected the vaginal birth as their favourite (mean¼16.85, SD ¼6.169; F ¼10.662, po.001). In addition, the birth preference evidenced a statistically significant effect on women’s mean scores for the CEPS total score. Once again, the highlight was on the contraposition of perceptions between the group that chose the vaginal birth (mean¼44.9, SD¼11.862), which presented the best birth experience, and the groups that chose the caesarean section (mean¼54.59, SD¼11.82) or the vaginal mode of birth with epidural analgesia (mean¼50.24, SD¼12.133; F¼ 6.435, p¼.002). 271 V. Bertucci et al. / Midwifery 28 (2012) 265–274 According to the abovementioned results, a new variable was created that calculated the difference between the actual mode of birth and the preference expressed by women in the 24–48 hours after it. The agreement between mode of birth preference produced an effect on the women’s mean score ratings on the whole Childbirth Experience Perception Scale, and in particular on the Labour and Delivery Perception subscale. Women who delivered through and preferred the same type of childbirth presented more positive perceptions of their childbirth (mean¼47.19, SD¼12.51; t¼ 2.434, p¼ .016) and of the moment of labour and birth (mean¼17.55, SD¼5.821) than those who disagreed with the mode of birth they underwent (mean CEPS¼51.47, SD¼ 11.901; mean Labour and Delivery Perception¼ 19.84, SD¼6.795; t¼  2.507, p¼ .013). Study 2 Study 2 was designed to assess the relation between perceived pain and birth perception by means of the correlation analysis between CEPS and a measure of the perception of pain intensity, the Italian Pain Questionnaire (IPQ) (De Benedettis et al., 1988). This pain questionnaire includes the sensorial, cognitive and affective components of pain perception. We selected a measure of the perception of pain intensity as the pain dimension plays an important role in the birth experience and is strongly associated with the woman’s perception of the birth and of her ability to cope with it (e.g., Slade et al., 1993; Goodman et al., 2004; Christiaens and Bracke, 2007; Conde et al., 2008; Oweis, 2009). Methods A total of 95 women were recruited from the same inpatient gynaecologic–obstetric unit of the university medical centre in Padova in the second half of 2009. The inclusion criteria were the same as those in Study 1. Of the 95 eligible women, 92 (96.84%) agreed to participate in the study and fully completed the questionnaires. Women first completed a brief version of the socio-demographic questionnaire, which included age, education and SES. Mode of birth was the only obstetric variable considered. Then the participants completed the CEPS and the IPQ. To complete the IPQ, women were instructed to consider the labour and birth period as the time frame for assessing the pain perception. The IPQ is the Italian version of the McGill Pain Questionnaire (Melzack, 1975), created and validated for the Italian population (De Benedettis et al., 1993). It is a multidimensional measure of pain perception that is constituted by a semantic scale of 42 pain descriptors divided into four classes: sensorial (PRIr-S), affective (PRIr-A), evaluative (PRIr-E) and mixed (PRIr-M). The sum of these four indexes produces the pain total index (PRIr-T), which describes the overall amount of pain experienced by the subject (De Benedettis et al., 1988, 1993). We administered this scale together with the CEPS and hypothesised a strong correlation among all of the IPQ indexes and the CEPS total score, the Labour and Delivery Perception subscale score and the Control Perception subscale score. We also hypothesised the absence of a significant correlation between the Change Perception subscale and the IPQ indexes because this subscale refers to the experience of pregnancy and psychophysical changes and does not present semantic relation with the pain contents of IPQ. Statistical analysis The internal reliability consistency of the CEPS was re-assessed using Cronbach’s alpha coefficient. Then the Pearson’s correlation coefficient (r) was used to determine the potential relation between the two questionnaires. Findings The socio-demographic characteristics of women were similar to those of Study 1. The mean age was 33.2 (SD 4.27, range 24–48). Of the 92 participants, 7 (7.6%) completed middle school education, 40 (43.5%) completed high school, and 45 (48.9%) completed a university degree. Fifty-nine (64.1%) women came from a middle social economic status, 15 (16.3%) came from a middle to low status and 18 (19.6%) from a middle to high status. Women were all nulliparous: 27 (29.3%) had a vaginal birth, 22 (23.9%) had a vaginal birth with epidural analgesia, and 43 (46.7%) gave birth by caesarean section. In regards to pain relief methods, we took into account epidural analgesia during vaginal birth (22 women). However, the epidural analgesia did not produce an effect on the IPQ measure. This is likely because the pain perception measured by the IPQ not only considers the sensorial aspect of pain, but the emotional and cognitive components as well. The internal reliability analysis confirmed the internal consistency of the three components of the CEPS that emerged in Study 1, with satisfactory Cronbach’s alpha values for all scales: .86 for the total scale, .83 for Labour and Delivery Perception subscale, .84 for Control Perception subscale and .70 for Change Perception subscale. Then, we proceeded with the correlation analysis between CEPS and IPQ; the results are presented in Table 5. As hypothesised, a statistically significant positive correlation was found for both the total scores of the two questionnaires and their subscales (p o.05). Every pain index (PRIr-S, -A -E, -M) was positively correlated with the Labour and Delivery Perception and Control Perception CEPS subscales at a significant level (p o.05). However, the pain indexes did not correlate with the Change Perception subscale, except for the affective index (PRIr-A), which presented a positive relation with the Change dimension of birth perception (p o.01). Discussion The main goal of this study was to examine the Italian dimensional structure and provide a first attempt to adapt the Childbirth Perception Questionnaire (CPQ) using a group of Italian women. This instrument was developed to assess how a woman perceives the childbirth event, taking into account the different aspects that constitute a complex and multidimensional construct such as the birth experience perception. Two separate studies were designed to evaluate the translated version of the CPQ with Italian postpartum women. In Study 1, a principal component analysis (PCA) revealed a three-factor questionnaire with 24 of the 27 original items. Three Table 5 Correlation analysis for IPQ and CEPS (Pearson’s r index). Childbirth Experience Perception Scale (CEPS) Italian Pain Questionnaire (IPQ) PRIr-T PRIr-S PRIr-A PRIr-E PRIr-M Total scale Labour and Delivery Perception Control Perception Change Perception .464nn .394nn .519nn .365nn .351nn .352nn .344nn .325nn .294n .237n .416nn .323nn .472nn .352nn .332nn .199 .152 .322nn .089 .166 PRIr-T ¼total pain index; PRIr-S ¼sensorial pain index; PRIr-E ¼evaluative pain index; PRIr-M ¼ mixed pain index. n Correlation is significant with p o.05. Correlation is significant with p o.01. nn 272 V. Bertucci et al. / Midwifery 28 (2012) 265–274 items were removed from the scale (items 14, 18 and 23). A possible hypothesis of this result is that the birth experience has a positive connotation in the Italian culture (Scopesi and Zanobini, 1997). Both item 14 and item 18 present the birth experience as having negative consequences for both the woman and the couple, contrasting with the Italian view of the birth experience. This conceptual contradiction did not allow the subjects to provide a significant response, justifying the low item factor loadings. As regards item 23, we suggest a similarity with the contents of items 14 and 18, as both items ask the respondent to provide an evaluation of a negative event (‘ruin’) associated with a positive relationship (‘spouse relationship’) that arouses again strong, positive feelings. The contraposition of two opposite experiences that are strongly and emotionally invested and the consequent conceptual confusion did not allow the subjects to express a definitive rate. Even if the American and the Italian versions of the questionnaire presented the same factor number, the arrangement of items appeared to be different. The items distributed into the three different components of the Childbirth Experience Perception Scale (CEPS), labelled: Labour and Delivery Perception, Control Perception and Change Perception. This new arrangement of items may reflect the differences in the birth perception between American and Italian cultures (Scopesi and Zanobini, 1997) as culture largely influences the way women live this particular life event with all of the feelings of pain, control and partner’s cares. In particular, in the Italian form, the Labour and Delivery Perception subscale combines the second and the third factor of the American form of the instrument (mode of birth and woman’s conduct during the labour; interaction with spouse during the birth). This denotes that the perception of labour and birth is not separate from the relationship with the partner, who is strongly present in the woman’s experience of birth. In fact, the presence of a significant other during the moment of labour and/or birth has been found to influence the woman’s feelings and perceptions and to differentiate between Italian and American women (Scopesi and Zanobini, 1997). The Italian second factor (Control Perception) highlights an important aspect of the childbirth dimension as the amount of control perceived by a woman is a strong determinant of the birth perception. Another important difference of the new factor structure concerns the third factor (Change Perception), which includes items from the original first (women’s physical appearance/sexuality during pregnancy, birth and shortly after the birth), second and third factors. However, the interpretation is quite different, highlighting the pregnancy and birth as causes of a possible negative change of women’s physical and psychological aspects. This change involves the individual aspects that may be negatively influenced by the experience of pregnancy and birth, such as the self-image, body image, sphere of sexuality, relationship with their own partner, and presence of the newborn. Furthermore, this factor presents a heterogeneous time perspective as it considers the pregnancy, the birth, the post partum period, and even the future. The aspect of changing over time reflects the fact that motherhood is a process and a transitional state in a woman’s life, demanding a re-organisation of her daily life, her self-perception and her relationship with her partner. The most probable hypothesis for the difference in the American and Italian dimensions of the birth perception is that they may reflect the cultural influence on women’s perceptions of pregnancy and childbearing. This is clearly visible by the cultural sampling differences between the subjects used by Padawer et al. (1988) and those used in the current investigation, even with the same criteria of inclusion. Callister (1995) stated that birth is an intimate and complex transaction whose topic is physiological and whose language is cultural. Culture is amongst the most significant variables that influence a woman’s perception of the childbearing experience (Raines and Morgan, 2000). Therefore, the Italian version of the questionnaire may represent the culturally based birth perception of Italian women. The pain perception, the control exerted, the presence of the partner during the birth, and the environment have been found to generate culturally related perceptions (Scopesi and Zanobini, 1997). However, these cultural differences in the way a woman experiences the birth event do not invalidate the instrument’s reliability, which was confirmed both in Study 1 and in Study 2. The quantitative analysis of women’s ratings revealed the effect of age and social economic level on birth perception. Older women perceive the birth event more negatively. As for the social economic level, lower levels are associated with more negative birth perceptions, in particular for the degree of control perceived during the birth event. The review of literature provides contradictory and limited results. In some studies, satisfaction has been related to older age and higher income whereas the opposite association has been found in other studies (e.g., Quine et al., 1993; Waldeström, 1999; Donaghy et al., 2000; Hodnett, 2002; Goodman et al., 2004; Zasloff et al., 2007). Older first-time mothers may suffer from a biological disadvantage, and thereby perceive a more complicated birth (Zasloff et al., 2007). In regards to social economic level, the degree of information and involvement in the decision making during the birth event may differ for those belonging to the low and high–middle level. The sociocultural level appears to play a role only insofar as it affects caregivers’ attitudes and behaviours toward women, in particular the ability to communicate with women and involve them in decisions about their care (Hodnett, 2002). The negative effect produced on satisfaction scores by the amniocentesis procedure seems to support the idea that medical procedures create discomfort and physical pain for women as well as increased stress and anxiety for the newborn (Verny, 1992). This emotional state may then lead to a worse perception of the childbirth event. In addition to these results, the CEPS evidenced the ability to discriminate among the three modes of birth and the birth preference provided by women. Consistent with previous research (Geary et al., 1997; Waldeström, 1999; Schindl et al., 2003; Conde et al., 2008; Pang et al., 2008), those who delivered by caesarean section, or preferred a caesarean section birth, were the most dissatisfied with the birth event. On the other hand, vaginal birth, actual or preferred, seems to positively affect the birth perception, followed by vaginal birth with epidural analgesia. Moreover, when the preference for mode of birth is asked shortly after the birth, the quality of the general birth experience may be impaired. In fact, women who had more negative perceptions of their labour and birth were those who selected a different type of birth from the one they underwent. Once the dimensionality, internal reliability and discriminant validity of the Childbirth Experience Perception Scale were found, the relation between CEPS and the pain perception, as measured by the IPQ, was examined in Study 2. A significant positive correlation with the IPQ was found, suggesting a strong relationship between the birth perception and the pain perception. The correlation hypothesis between the two instruments was confirmed. High levels of pain perception in all four dimensions (sensorial, affective, evaluative and mixed) were related to worse perceptions of the labour and birth and of the women’s amount of control. As expected, the Change Perception dimension did not present a relation with three of the four pain indexes or the total pain index (PRIr-T). The sensorial (PRIr-S), evaluative (PRIr-E) and mixed (PRIr-M) components of pain were not related to the Change dimension because this dimension refers to an evaluation of all pregnancy and birth phases, distancing it from the sensorial V. Bertucci et al. / Midwifery 28 (2012) 265–274 and cognitive aspects of pain and suffering. Only the affective index of pain (PRIr-A) evidenced a positive statistically significant correlation with the Change Perception subscale. A possible hypothesis for this result is that the affective component of pain, which is composed of affective tension, autonomic, fear, and negative emotional impact aspects of pain, might have a deep impact on the psychological adjustment of women during pregnancy and birth. This relation between the affective quality of pain and the Change Perception component of birth experience, namely its emotional aspect, is consistent with the literature (Boudou et al., 2007). The positive relation between the Change dimension and the affective component of pain may suggest that in the postpartum period, the feelings of fear, agony and distress perceived during the pregnancy and the birth induce a psychological change in the woman’s perception of herself and the experience. Pain can be felt as a failure for women who prepared themselves to overcome the labour and birth (Boudou et al., 2007). The more negative is the suffering experience, the more negative is the woman’s change perception after the birth. The clinical relevance of this relation between the birth experience dimension and pain perception is important in the assessment of the woman’s psychological adjustment after the significant life event of the birth of her child. The results of Study 1 and Study 2 evidenced that the three dimensions of the CEPS represent a good measure of the multidimensionality of birth perception and an important clinical indicator of the psychological impact of the birth experience on women’s well-being. Additional research that explores the possible changes of childbirth perceptions after the postpartum period is warranted. To further verify the validity and reliability of the instrument, a confirmatory factor analysis and a test–retest analysis of the scale are recommended. Moreover, the relation between the emotional component of pain perception and the birth experience requires additional research that incorporates a follow-up perspective to examine whether this relation holds over time. The current study presents two important limitations. First, the study used a non-representative convenience sample of nulliparous women from the north-east of Italy. Second, the scale does not contain items regarding the aspect of the quality of care and staff support received during the birth. Further research should include a larger randomly selected sample that is representative of the Italian female population, including multiparous women from all areas of Italy, and introduce items concerning the perception of the quality of care received into the questionnaire. The strengths of the present study include its novelty (because such an instrument does not yet exist in Italy) and its fields of application: both in the obstetric–gynecological field and in the psychological sphere as a screening instrument. The questionnaire could be used to generally assess women’s perception of birth or to screen it to detect areas for further in-depth qualitative enquiry. Examining each subscale score separately may be useful for both hospital personnel and health providers, as it provides a more comprehensive understanding of the various factors of the birth experience. It allows the detection of areas of intervention in order to empower women’s strategies to cope with labour and birth, to maximise feelings of self-confidence, to maintain a greater control during the birth event and to better adjust to the transformations birth induces. Childbirth preparation classes, birth planning, midwife preparation and medical and social support are some of the activities that could be organised ad hoc to the women’s needs and promote the best birth experience (Johnston-Robledo, 1998; Grignaffini et al., 2000; Goodman et al., 2004; Bailey et al., 2008; Ford and Ayers, 2009; Ip et al., 2009; Ngai et al., 2009; Kuo et al., 2010). 273 References Bailey, J.M., Crane, P., Nugent, C.E., 2008. Childbirth education and birth plans. 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