Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

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Women's perceptions of social support during labour: Development, reliability and validity of the Birth Companion Support Questionnaire Carmel L. Dunne, PhD (Masters of Nursing (Women's Health), Grad Dip Women's Health Lecturer – Midwifery)a,n, Jennifer Fraser, RN, PhD (Associate Professor, Director of Research Students and Research Development)b, Glenn E. Gardner, PhD, MEdStudies, BAppScience (Advanced Practice Nursing) (Professor of Clinical Nursing)c a b c

Australian Catholic University, McAuley, Banyo Campus Brisbane, PO Box 456, Virginia, Queensland 4014, Australia M02 – Sydney Nursing School, University of Sydney, Sydney, NSW 2006, Australia Queensland University of Technology, Brisbane, Qld, Australia

art ic l e i nf o

a b s t r a c t

Article history: Received 3 June 2013 Received in revised form 15 October 2013 Accepted 16 October 2013

Objective: to develop and test the reliability and validity of a research instrument to measure women's perceptions of social support provided during labour by at least one lay birth companion. Design: a cross-sectional study was carried out from April 2009 to February 2010. Setting: non-tertiary hospital in the outer western region of Brisbane, Australia. Participants: six registered midwives and 10 postnatal women reviewed the instrument. The instrument was then completed by 293 inpatient women who had experienced a vaginal birth. Measurements and findings: the Birth Companion Support Questionnaire (BCSQ) was developed and its reliability and validity were evaluated in this study. An exploratory factor analysis was performed on the final instrument using principal component analysis with an oblique (Promax) rotation. This process suggested two subscales: emotional support and tangible support. The questionnaire was found to be reliable and valid for use in midwifery research. Key conclusions: the BCSQ is an appropriate instrument to measure women's perceptions of lay birth companion support during labour. Implications for practice: this is the first rigorous study to develop and test a measure of social support in labour which is critical at a time when policy makers and health planners need to consider the needs of birthing women and their network of support friends and family. & 2013 Elsevier Ltd. All rights reserved.

Keywords: Birth companion Social support in labour Questionnaire development

Introduction It is now an acceptable practice in most birthing facilities throughout Australia that labouring women will be accompanied to birth suite by one or more birth companions chosen from their intimate and social networks. Throughout history, women across the world birth in the presence of other women to help them cope with the stress of labour and birth (Brodsky, 2006; Fahy, 2006). A number of changes in many western countries saw this traditional practice decline. For example, with women birthing in hospital, they became isolated from the support of family and friends. In an attempt to secure a more supportive experience, women began to demand the presence of a supportive companion; namely their


Corresponding author. E-mail addresses: [email protected] (C.L. Dunne), [email protected] (J. Fraser), [email protected] (G.E. Gardner).

partner. This event became the catalyst for a number of studies focusing on different types of support providers and their contribution to the idea of support during labour. This is evidenced by more than 40 studies that have been conducted over the last 35 years. The overall findings from these studies have revealed that a supportive human presence in the form of partner, female relative or doula enhances women's satisfaction with the birth experience, boosts emotional comfort and decreases anxiety (Sauls, 2002; Hodnett et al., 2003; Rosen, 2004). Despite the substantial amount of research on support during labour, little is known about the impact of non-professional and multiple support people. Research to date has focussed on either mothers' or midwives' perspectives predominantly using qualitative approaches. Price et al. (2007) collected data using in-depth interviews with 16 women in the immediate postpartum period prior to discharge from hospital. Thirteen of the 16 women had additional support people; namely their mothers, female friends and a doula. When interviewed, women said they had chosen family members and

0266-6138/$ - see front matter & 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.midw.2013.10.010

Please cite this article as: Dunne, C.L., et al., Women's perceptions of social support during labour: Development, reliability and validity of the Birth Companion Support Questionnaire. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.10.010i

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close friends. The researchers revealed these women chose individuals they felt connected to in day-to-day life, expressing their need for individualised support, comfort, control and family bonding (Price et al., 2007). On the other hand, midwives and nurses have reported that multiple birth companions are a source of conflict for women in their care, rather than support. For example, Spear (2006) conducted a telephone survey of 154 obstetric nurse managers in the south-eastern hospital obstetric units of Alabama, Louisiana, Virginia, West Virginia, South Carolina, Kentucky, Mississippi, Florida, Georgia, and Tennessee. Findings from the survey revealed that some nurses exercised their own judgement about who could accompany women in labour, and turned a blind eye to a two person only policy. However some nurses reported actually attempting to limit the number of support people and would ask them to leave claiming it was be detrimental to the health and welfare of the labouring woman (Spear, 2006). In another qualitative study, midwives talked about attempting to limit the number of companions with one midwife arguing that women accompanied by a large number of support people were actually unsupported and that the labour and birth process was treated as a ‘viewing’ (Maher, 2004, p. 277). Advantages and disadvantages of having multiple birth companions in hospital units are not well understood although there does seem to be conflict between women and hospital staff (Maher, 2004; Kettlei and Perkins, 2006; Spear, 2006; Price et al., 2007). What we do know is that more research is needed to identify women's perceptions and experiences. This is imperative as there is an expectation for women to be accompanied by their friends and families in most maternity services today. The purpose of the study presented herein was to develop and test the Birth Companion Support Questionnaire (BCSQ) as a self-report measure of women's perceptions of support provided during labour and birth by one or more people from their intimate and social networks.

The LSQ was designed for self-administration by nurses. It contained 27 items across the four subscales previously mentioned using a six-point Likert-type scale response format. The items used from Saks' (1998) study related to behaviours of support people that she considered were of questionable benefit and included behaviours that distracted the woman from the effort of labour and those that intimated that her labour was taking too long. The final version of the BCSQ contains 17 items designed to measure support with a four-point Likert-type ordinal response format with anchors of 0 (not at all), 1 (a little), 2 (most of the time) and 3 (all of the time). Lozano et al. (2008) maintained that the fundamental psychometric properties of a scale—reliability and validity—are enhanced when four to seven response categories are used. A four-point response format was chosen, rather than the six-point response format used in the LSQ, to allow for more discrimination in responses. The Likert-type scale with an even number of response points used in the BCSQ did not allow for a neutral category, which often results in the modal response (Annett, 2002), but required the participants to have a negative or positive judgement/opinion about the support (Totten et al., 1999; Netemeyer et al., 2003). The BCSQ was designed to allow women to rate how frequently supportive behaviours were provided by each support person present during labour. The women were asked to identify in the space provided on the questionnaire their relationship to each of their support people; for example, partner, mother or sister. The women with multiple support people nominated who support person one, two, three or four were when completing the questionnaire. At the conclusion of the questionnaire, the women with more than one support person were asked to indicate, by ticking the appropriate box, which support person provided them with the most support. The scores were summed to give a total range from 0 to 51; higher scores representing more social support. Content validity testing

Methods Study design This cross sectional design aimed to adapt an existing instrument that measured social support in labour, for use in measuring maternal perception of at least one lay birth support person during labour. The Sauls' (2004) Labor Support Questionnaire (LSQ) was used primarily as it had been generated from the theoretical literature relating to labour support and from other tools that measured elements of labour support. Additional items from Saks' (1998) measure of social support were tested but found to be inconsistent for use in measuring perception of non-professional support persons. Specifically, items from the existing measures that measured functional and supportive behaviour of birth companions were adapted as presented in Table 1. The LSQ (Sauls, 2004) was designed to measure nurses' perceptions of professional labour support. Guided by Lazarus and Folkman (1984), Sauls (2004, p. 125) defined labour support as (i) emotional support—the ability to subjectively participate and share in the labouring woman's feelings, (ii) tangible—the carrying out of tasks to meet the physical needs of the woman, (iii) informational—the practice of exchanging information to meet the labouring woman's knowledge needs and (iv) advocacy—a process of acting on the labouring woman's behalf to ensure she remains at the centre of the decision making. Permission was sought and gained by the author to adapt items from the LSQ in the development and testing of the BCSQ.

The 17-item BCSQ initially underwent review by an expert panel of six midwives who received (a) a letter outlining the study, (b) review criteria, and (c) a copy of Sauls' (2004) published article on the development and psychometric analysis of the LSQ. The midwives were invited to evaluate the items using a 4-point Likert-type scale ranging from (1) not relevant, to (4) relevant and concise. The midwives were also asked to propose ways in which items could be reworded to enhance relevance and to suggest any items that should be included. Items that required rewording were changed. On the basis of these results the resulting 17-item questionnaire was then pilot tested to examine reliability prior to administering the questionnaire to a larger sample. Face validity and test–retest reliability evaluation Face validity which is an assessment of how the potential participants view the instrument (Waltz et al., 2010) was conducted with a convenience sample of 10 postnatal women from a hospital postnatal ward in Queensland, Australia. At the time of gaining consent, the researcher checked the participants' willingness to be telephoned to complete the questionnaire again. The women were asked to give feedback on readability, clarity of the questions, the time involved in completing the questionnaire and ease of filling it out. The questionnaires were completed by women in the hospital room. At the time of collection they were invited to provide verbal feedback. The combined results of content validity and face validity were used to make minor wording changes to two items prior to testing in the main study.

Please cite this article as: Dunne, C.L., et al., Women's perceptions of social support during labour: Development, reliability and validity of the Birth Companion Support Questionnaire. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.10.010i

C.L. Dunne et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎


Table 1 Comparative items from Sauls (2004) Labor Support Questionnaire and Birth Companion Support Questionnaire. Labor Support Questionnaire (Sauls)

Birth Companion Support Questionnaire

Provides encouragement during the labour process, such as ‘you're doing a great job’, and Praised my efforts, like ‘great job’ ‘well done’ ‘that's very good’ Provides massages between contractions to help the woman relax such as: backrubs, leg rubs Assisted me with coping techniques (coping techniques may include providing massages, encouraging you to walk around) Reinforces previous instructions such as breathing, relaxation, or pushing techniques Reinforced coping techniques I was using (may include relaxation techniques, breathing techniques) Shows concern for labouring woman. Made me feel they were there for me Instructs the woman on breathing, relaxation and pushing techniques, if needed Helped me to follow the advice/coping techniques suggested by the midwife (may include walking around, using the shower) Acts on the client's behalf to insure her birth plan is followed Supported my decisions (e.g., to change position, to seek pain relief) Listens to and respects the client's opinion and wishes concerning her birth plan Listened to and respected my wishes in relation to my birth plan Maintains eye contact with the woman during conversations and during her contractions, Provided eye contact when praising my efforts when culturally appropriate Provides distraction techniques, such as: light social conversation, having her watch TV or Provided distraction techniques in the early phase of labour (e.g., light listening to music, during the early phase of labour if appropriate. social conversation, playing cards) Provides physical comfort through the use of hot/cold therapy such as, compresses, warm Offered me physical comfort through touch (touch may include holding blanket to relieve discomforts of labour your hand, wiping your face, rubbing your back) Demonstrates understanding and caring Made me feel respected and admired Made me feel that my labour and birth were taking too long* Got distracted by watching TV or chatting to others* n

On the basis of Saks (1998) study of social support during labour.

A pilot study was conducted to assist with instrument testing and to forewarn the researcher about potential problems in the research process (Gardner et al., 2003; Leona et al., 2011). The pilot study also allowed for the assessing of the temporal stability of the questionnaire using test–retest reliability. A period of two weeks to a month between tests is recommended for a ‘pencil and paper’ measure, particularly if there is a chance that genuine changes may take place in the underlying construct within a short period of time (Aday and Cornelius, 2006; Waltz et al., 2010). The questionnaires were completed over the telephone two weeks apart. Wilcoxon Signed Ranks test revealed that there was no significant statistical difference between the underlying distribution of scores at Time 1 and Time 2.

Inclusion criteria Participation in the study was dependent upon the women meeting the following criteria: (a) age at least 16 years, (b) able to read and understand English, (c) spontaneous onset of labour after 36 completed weeks gestation, (d) accompanied to birth suite by one or more people, (e) gave birth vaginally, (h) had an Edinburgh Postnatal Depression Score (Cox et al., 1987) (completed in the first trimester) of 12 or less, (i) not enroled in a caseload midwifery model, (j) infant was not admitted to special care nursery for ongoing care, and (k) able to give informed consent. Socio-demographic questionnaire Socio-demographic items included age, marital status, parity, ethnicity, income level, education level.

Sample and setting

Strategies to reduce bias

A convenience sample of 293 women, who had been supported by one or more people from their social network, was recruited from the postnatal ward in a public metropolitan hospital with a birth rate of approximately 2500 per annum, located in South-East Queensland, Australia. Guided by the ratio of 15 participants per variable this sample size was adequate to perform an exploratory factor analysis (EFA) (Pett et al., 2003; Field, 2005). Approval to conduct the research was granted by the Human Rights Ethics Committees (HREC) of the University and relevant Health Service District. Midwifery staff in the birth suite and the postnatal ward were asked to assist by giving the Patient Information Consent Forms (PICFs) to eligible women. Contact was made with the potential participants in the ward in the first 48 hours after the birth, this ensured the questionnaires were completed before discharge which maximised response rate and minimised recall bias. The researcher, although an employee of the agency was not clinically involved in the participants' care, and timely discharge or any other aspect of postnatal care was not reliant upon participation in the research. The researcher had no pre-existing or ongoing relationship with the participants. The participants completed and returned the questionnaire between April 2009 and February 2010.

Instructions and items were designed to be clear and unambiguous. To ensure participants read and processed items carefully, some items were worded negatively. Participants were assured of confidentiality and were asked to complete the questionnaire when alone and not in the presence of support people to reduce the risk of socially desirable responding. Data analysis Analysis was performed using SPSS 17.0. Data were entered twice for verification. Descriptive statistics were used to summarise demographics and to check for violation of assumptions regarding normal distribution. A significance level of 0.05 was used to designate statistical significance. Negatively worded items were reverse scored prior to analysis. Test of internal consistency was Cronbach's alpha. Cronbach's alpha values for the total scale and subscales above 0.7 are considered acceptable, with 0.8 being preferable (Pallant, 2007). Inter-item correlations were also calculated to further verify internal consistency. Correlations in the range of 0.02–0.04 are desirable as lower correlations would indicate lack of homogeneity whereas higher values signify item redundancy (Briggs and Cheek, 1986; Floyd and Widaman, 1995). Item analysis including inter-

Please cite this article as: Dunne, C.L., et al., Women's perceptions of social support during labour: Development, reliability and validity of the Birth Companion Support Questionnaire. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.10.010i

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item and corrected-item total correlations were conducted to determine if lack of homogeneity and redundancy of items were present. Values for Cronbach's alpha if-item-deleted were also scrutinised in order to optimise internal consistency. To explore construct validity, exploratory factor analysis (EFA) was conducted using principal component analysis (PCA) with promax rotation to investigate the interrelationships among the set of variables that make up the BCSQ. The oblique rotation method was employed because there is a reasonable belief in health sciences that constructs of interest, although being conceptually different, are often interrelated (Pett et al., 2003; Field, 2005). Three statistical standards were used to determine the number of factors to retain: Kaiser's criterion (eigenvalue greater than one), Horn's (1965) parallel analysis and item factor loading greater than 0.32.

Findings Participants Of the 310 women approached to participate in the study, 10 refused. The women who refused indicated that they did not have the time as they were preparing for discharge (n ¼ 6), or were not interested in participating (n ¼4). Three hundred women agreed to participate in the study, but seven participants were excluded as they did not complete or return the questionnaire. Two hundred and ninety three women completed the questionnaire giving a response rate of 98%. Of the 293 participants, 162 (55%) were accompanied by one person and 131 (45%) were accompanied by two or more people. The 25–29 age group (30%) represented the majority of the participants and 28 (9.5%) were 20 years old or less. Of the majority of the women, 238 (81%) were married or defacto compared to the 50 (17%) who were single or the five (2%) who identified as ‘other’. 187 (64%) were multiparous women compared to 106 (36%) first time mothers. Internal reliability analysis Following reliability testing where inter-item correlations were examined, only correlations between 0.30 and 0.80 were retained leaving a 14-item scale. The deleted items were ‘Made me feel that my labour and birth was taking too long’, ‘Left me alone to go outside from time to time’, ‘Got distracted by watching TV or chatting to others’. Following EFA the scale was reduced to 13 items and the Cronbach's alpha was 0.80. According to Pallant (2007) internal consistency estimates for a newly developed instrument should be at least 0.7. The first subscale met this criterion (0.76) whereas the second subscale was slightly below (0.66). Both scales were inspected to determine whether the removal of any items from the scales would strengthen Cronbach's alpha, but this was not necessary. Construct validity PCA was used to examine the underlying structures of the 14 item BCSQ. The suitability of EFA was determined by preliminary inspection of the data. The majority of the inter-item correlations were Z0.3, the Kaiser–Meyer–Olkin value, a measure of sample adequacy was 0.87 which exceeded the recommended value of 0.60 (Kaiser, 1974) and Bartlett's Test of Sphericity (Bartlett, 1954) reached statistical significance (p o0.001), supporting the factorability of the correlation matrix. The PCA showed three components with eigenvalues greater than 1 explaining between 8% and 35% of the variance. A parallel analysis was conducted revealing

only two components with eigenvalues exceeding the corresponding criterion values for a randomly generated data matrix of similar size (293 subjects  14 variables). Therefore two components were retained for further analysis. The two-components solution accounted for 42.8% of the variance with component 1 contributing 33% and component 2 contributing 9.8%. Review of the communalities values indicated that all the items except item 5 had an acceptable value Z0.3 (Pallant, 2007). Item five's value was 0.142 and it was deleted from further EFA. Using the same steps, the EFA was repeated with the remaining 13 items and two components were retained. This twocomponent solution accounted for 45.3% of the variance with component 1 contributing 34.8% and component 2 contributing 10.5%. To assist interpretation of the two components, promax rotation was performed. Components that were above 0.32 were considered to have loaded because, as a rule of thumb, only variables with loadings of 0.32 or above are interpreted (Field, 2005; Tabachnick and Fidell, 2007) when the sample size is between five and 10 participants per variable (Floyd and Widaman, 1995). The rotated solution showed a simple structure with seven components loading positively and exclusively at 0.32 or above on Component 1. A two component solution is therefore proposed as shown in Table 2. However, one component cross loaded at 0.38 on Component 1 and 0.33 on Component 2. The other seven items on Component 1 appeared to be reflecting the elements of emotional support. Five components loaded positively and exclusively at 0.32 or above onto Component 2 and these items were capturing the elements of tangible support. There was a positive correlation of 0.50 between Component 1 and Component 2. Items within the subscales are shown in Table 3. The one component that loaded on Component 1 (0.38) and Component 2 (0.33) referred to support people praising the woman's efforts. The item was allocated to Component 1 on the justification of the higher loading on Component 1 and because it was similar to other items which focused on providing emotional support for the woman. Investigation of the Cronbach's alpha for the scale items if an item was deleted was performed revealing only minor changes to the subscale values of α. Deletion of the item would reduce the total scale's alpha to 0.74.

Discussion This is the first questionnaire to be empirically tested as an instrument to measure women's perceptions of social support during labour. Prior to this instrument, the only validated instruments available were those which measured women's perceptions of support provided by midwives, or LSQ (Sauls, 2004) which measured midwives' ratings of the importance of supportive behaviours during labour. Preliminary estimates of BCSQ indicate its potential to be a reliable and valid measure of the underlying theoretical constructs. The testing indicated 13 of 17 items should remain in the instrument and that a two-component solution was the best fit for the data using PCA with promax rotation. The two component solution constructs are Emotional Support and Tangible Support. Although this is an important development and one that will have important implications for maternity unit policy and planning, a number of limitations are acknowledged. Firstly, the convenience sample of women came from one maternity site featuring a younger cohort than average. The questionnaire's properties were tested on English speaking women only from what could be seen as a homogenous cultural background. Next, one of the main difficulties with developing the questionnaire was the scarcity of established measures for comparison. Indeed, the

Please cite this article as: Dunne, C.L., et al., Women's perceptions of social support during labour: Development, reliability and validity of the Birth Companion Support Questionnaire. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.10.010i

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Table 2 Pattern and Structure Matrix for PCA with Promax Rotation of Two Factor Solution of BCSQ Items (n¼ 293). Item

6. There for me 13. Enjoy the company 17. Felt satisfied 16. Listen and respect 7. Offer comfort 15. Eye contact 1. Feel respected 2. Praised my effort 10. Speak to midwife 8. Reinforce methods 11. Assist with coping 4. Provide distraction 14. Follow advice/coping

Pattern coefficients

Structure coefficients

Component 1 Emotional support

Component 2 Tangible support

Component 1 Emotional support

Component 2 Tangible support

0.781 0.740 0.719 0.664 0.574 0.536* 0.478 0.381*  0.300 0.017 0.080 0.069 0.278

 0.045  0.034  0.096  0.154 0.107 0.153 0.147 0.332 0.847 0.735 0.534* 0.521* 0.487

0.759 0.724 0.671 0.587 0.628 0.612 0.552 0.547 0.123 0.383 0.446 0.329 0.521

0.345 0.336 0.263 0.178 0.394 0.421 0.386 0.523 0.698 0.743 0.774 0.555 0.626


0.577 0.524 0.457 0.362 0.403 0.392 0.321 0.382 0.554 0.552 0.604 0.312 0.450

Note: major loadings for each item are in bold. n

Items load on the same component of Sauls' (2004) LSQ.

Table 3 Subscales of the Birth Companion Support Questionnaire. Emotional support items

Tangible support items

There for me Enjoyed the company Felt satisfied with support Listened and respected my wishes Offer comfort through touch Made eye contact Made me feel respected

Spoke to midwife about my needs Reinforced coping methods I was using Assisted with coping techniques Provided distraction in early phase Helped me to follow advice of the midwife

study was instigated due to the lack of validated measures of women's perceptions of social support during labour. A number of recommendations for future research can be made. The questionnaire needs to be tested on a larger sample from a variety of maternity sites and include women with cultural and socio-demographic diversity. Further testing of the factor solution is needed. Nevertheless it is important to emphasise that factor analysis is an error prone procedure even with adequate samples and favourable data (Costello and Osborne, 2005). Confirmatory factor analysis will assist in a more rigorous assessment of the reliability and construct validity of the instrument.

Conclusion This is the first rigorous study to develop and test a measure of social support in labour which is critical at a time when policy makers and health planners need to consider the needs of birthing women and their friends and families network. Preliminary evidence of the internal consistency, content and construct validity of BCSQ in assessing women's perceptions of social support during labour is an important first step towards improving services to meet the demand of young birthing women. It is the basis of a valid and reliable instrument that offers a better understanding of women's perceptions of social support during labour.

Conflict of interest There is no conflict of interest.

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Please cite this article as: Dunne, C.L., et al., Women's perceptions of social support during labour: Development, reliability and validity of the Birth Companion Support Questionnaire. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.10.010i

Women's perceptions of social support during labour: development, reliability and validity of the Birth Companion Support Questionnaire.

to develop and test the reliability and validity of a research instrument to measure women's perceptions of social support provided during labour by a...
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