Research Article: Adaptation of the Childbirth Experience Questionnaire (CEQ) in China: A multisite cross-sectional study

Date Published: April 24, 2019

Publisher: Public Library of Science

Author(s): Xiu Zhu, Yan Wang, Hong Zhou, Liqian Qiu, Ruyan Pang, Jonathan E. Handelzalts.


The childbirth experience of women represents a significant aspect of quality care. Due to the lack of a reliable Chinese language tool for assessing childbirth experiences, examples must be adapted from other countries. The aim of this study was to translate an English version of the Childbirth Experience Questionnaire (CEQ) into Chinese and adapt this tool to the Chinese context.

A questionnaire validation study was conducted. A forward-backward translation procedure involving the developer of the CEQ was conducted. The data were collected in postnatal wards at 50 birth facilities in 4 regions of Zhejiang Province, China. Women who gave birth vaginally at the investigated facilities during the study period completed an online questionnaire that included the Chinese version of the CEQ (CEQ-C), demographic information and clinical information. Psychometric analyses were performed to assess the internal and content consistency. After subdividing the sample into subsamples, an exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were applied to examine the structural validity. Known-group comparisons were performed to assess the discriminant validity.

Overall, 1747 women participated in this study. The content validity index (CVI) of the CEQ was 0.92. Based on the comments of the experts combined with the statistical results, we removed 3 items related to pain, sense of control and sense of security and changed 3 items to different dimensions. The CFA supported the four dimensions of the CEQ-C (standard root mean square residual (SRMR) = 0.037, root mean square error of approximation (RMSEA) = 0.036, comparative fit index (CFI) = 0.966, and Tucker-Lewis index (TLI) = 0.959). Cronbach’s alpha of the CEQ-C was 0.88, and McDonald’s omega value was 0.91. The duration of labor, delivery mode, parity, oxytocin augmentation, pain management, companionship, prenatal education and pain experienced exerted significant effects on the women’s childbirth experiences.

Although some items performed differently in our analysis comparing the English and Chinese versions of the CEQ, the CEQ-C is reliable and valid. Additionally, the CEQ-C is an easy-to-use and promising tool for measuring childbirth experiences among Chinese women in facility settings that can be used to improve the quality of intrapartum care. Efforts are needed to provide women with respectful, evidence-based intrapartum care to facilitate positive childbirth experiences.

Partial Text

As progress in reducing maternal mortality is achieved, a new and broader focus encompassing the quality of maternity care is needed.[1] This need is particularly relevant in areas with low maternal mortality and high coverage in terms of antenatal care and facility childbirth, where the content of care (insufficient or excessive intervention) and women’s satisfaction should take precedence.[2] Women’s experiences with childbirth represent a vital outcome indicator of intrapartum care and have both immediate and long-term effects on future reproduction.[3,4] Person-centered care for positive childbirth experiences is currently a global trend, and the WHO has issued guidelines recognizing a “positive childbirth experience” as a significant end point for all women undergoing labor.[5] An understanding of this issue may help clinicians identify maternal needs and aspects of care that potentially require improvement.

This study consisted of two phases. In Phase I, a Chinese version of the CEQ (CEQ-C) was produced, and 94 postpartum women completed two pretests (34 women in the first round and 60 women in the second round) to test its content validity. In Phase II, a field study involving 1747 women was conducted to test the construct validity and reliability.

As shown in the present study, the adjusted CEQ-C is reliable and valid tool for assessing childbirth experiences among Chinese women in a facility setting. Its reliability was revealed by a Cronbach’s alpha of 0.88 and a McDonald’s omega value of 0.91, and strong correlations between the individual items and the overall score were observed. The EFA supported the four dimensions (professional support, own capacity, perceived safety, and participation), and this adjusted model was approved by the CFA.

Three main strengths of this study were identified. First, to the best of our knowledge, this study is the first to administer the CEQ in a facility setting rather than a community setting, and more importantly, this study is the first to quantitatively assess childbirth experiences in China. The present study proved that the CEQ-C could be used in facilities to avoid a poor response rate in community settings. We applied some strategies to reduce the possibility that the responses of people who completed these questionnaires in a facility were conditioned by this circumstance to the best of our abilities. First, while conducting the study, trained nurses obtained full informed consent from the participants, and all participants provided oral consent to complete the study. Second, we used online questionnaires to allow the women to complete and submit the questionnaires on their smartphones in a private setting. Third, we informed the women that the staff at the facilities were blinded to the data. Finally, we allowed the women to complete the questionnaire immediately before discharge to prevent their participation from affecting the health care they received. A second strength of this study is its large sample size of 1,747 women from 50 facilities across 4 regions. Third, the forward and backward translation process involved the creator of the CEQ, which helped achieve equivalence with the original version.

In summary, a Chinese version of the CEQ (CEQ-C) was produced and a psychometric validation of this instrument was conducted in the present study. The CEQ-C was a reliable and valid tool that was administered to assess childbirth experiences in mainland China. The present study supports the use of the CEQ-C in health facility settings, providing an efficient and cost-effective way for health care providers to rapidly obtain an overview of the quality of intrapartum care from women’s perspectives, identify the needs of women and improve the quality of maternity care. In addition, the adjusted CEQ-C might facilitate future research investigating childbirth experiences in China and allow comparative studies to be conducted between Western and Eastern settings. However, our sample might be inconsistent with the general population; therefore, caution is required when applying the findings of the present study.




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