This methodological study was conducted from May 2019 to February 2020. The Prenatal Quality of Care questionnaire was administered to 350 mothers who had recently given birth 2.1. Sampling
2.1.1. Sample size
Face validity had a sample size of 20 individuals, qualitative content validity had a sample size of 13 experts, quantitative content validity had a sample size of 15 experts, and test-retest reliability had a sample size of 50 individuals.
Three hundred fifty questionnaires were distributed during the validity phase. A total of 342 questionnaires were returned, resulting in a response rate of 97.71 percent. Due to confounding information and a large number of missing values, 13 questionnaires were excluded after a review of the 342 questionnaires collected. Finally, 329 samples were subjected to the analysis.
The patients were chosen using the convenience sampling method. Inclusion criteria included being over the age of 18, being familiar with the Persian language, not having severe mental disorders or dementia, and not having had a pregnancy terminated due to premature rupture of the membranes. Mothers with cognitive disorders, active psychological disorders, and underlying diseases such as chronic hypertension, diabetes mellitus, kidney, heart, lung, blood, and liver diseases, as well as known obstetric and medical problems affecting pregnancy status, pregnancy outcomes, and maternal-neonatal health, were excluded from the study.
2.2. Translation and adaptation
The Persian version of the QPCQ was derived from the original English version developed by Wendy Sword and Maureen Heaman for the QPCQ committee at McMaster University in Canada. On the other hand, the forward and backward translations were not repeated in the present study as we were not allowed. After making the necessary arrangements with Mr. Wendy Sword, we obtained permission to use this questionnaire in Iran. Furthermore, the necessary agreement was obtained to proceed with the validation process of this questionnaire in Iran. Wendy Sword delivered us the final 46-question Persian version of the questionnaire.
2.3. Measures
Demographic and Clinical Variables
Mothers were asked for information about their age, occupation, education level, number of children, BMI, number of pregnancies, history of abortion, desire to have children, type of current delivery, and admission history.
Quality of Prenatal Care Questionnaire (QPCQ)
Heaman et al. created the Quality of Prenatal Care Questionnaire (QPCQ) to assess the quality of prenatal care [13]. The QPCQ is a 46-item self-reported questionnaire for women after 36 weeks of pregnancy or within the first 5 days after delivery. This questionnaire consists of 46 items divided into six subscales. The questions are scored on a 5-point Likert scale, with 1 being strongly disagree and 5 being strongly agree. The subscales are 1) information Sharing, 2) anticipatory Guidance, 3) sufficient Time, 4) approachability, 5) aAvailability, and 6) support and respect (Table 1). The scores of questions 8, 15, 23, 28, and 40 are reversed. The scores of the QPCQ (46 questions) are between 1 and 5 [12, 13, 16]. The total score of the QPCQ is calculated by adding the subscale scores. The higher the score, the better the prenatal care. Heaman et al. confirmed the validity of the Canadian version of the questionnaire with a Cronbach's alpha of 0.96 and an intraclass correlation coefficient of 0.88. Sword et al. showed Cronbach's alpha of 0.97 in the French version [14] and 0.97 in the Australian version [12].
World Health Organization Quality of Life-BREF (WHOQOL- BREF)
The World Health Organization developed and used this questionnaire to assess individuals’ perceptions of their health and quality of life. This questionnaire contains 26 questions divided into four domains: 1) Physical Health Domain, 2) Psychological Domain, 3) Social Relationship Domain, and 4) Environmental Domain. Each item has a score ranging from 1 to 5. (not at all, low, medium, high, and extremely high). Reverse scoring is used for questions 3, 4, and 25. To interpret this scale correctly, the short version's scores must be converted to the long version's scores, and then the quality of life in each domain must be interpreted from zero to 100. In Iran, Cronbach's alpha coefficient of 0.78 has been reported for this questionnaire [17].
Data collection
The researcher identified the mothers and collected the required samples in different shifts (morning, afternoon, and evening) by obtaining the necessary permits and referring to the departments of obstetrics and gynecology in two public hospitals. The study included all eligible mothers who had a vaginal delivery or a cesarean section and had a maximum of 5 days since their delivery. Samples were collected from May 2019 to February 2020. The questionnaire was completed as a self-report in the presence of the researcher. Interviews were used instead of the self-report method when mothers were unable to complete the questionnaire or were uneducated. We used phone contacts to gather information from those who took part in the test reliability evaluation for the second time.
Ethics
This study is the result of a research project approved by the Research Ethics Committee of Rafsanjan University of Medical Sciences (IR.RUMS.REC.1397.148). Initially, the researcher provided information to mothers concerning the purposes of the study, the confidentiality of information collected, and voluntary participation and withdrawal. The mothers completed and signed informed consent forms. The content of the fact sheet was explained to those who were uneducated.
Statistical analyses
SPSS22 was used for all analyses (SPSS Inc., Chicago, Illinois, United States). The significance level of 0.05 was used in this study.
Validity
Face validity
The face validity of the QPCQ-P was done qualitatively. Twenty mothers were asked to complete the QPCQ-P in this section. Then they gave their opinions about the appropriateness, problem, relevance, and ambiguity of the questionnaire questions. The time it would take to respond to the questionnaire was estimated, and the necessary changes were made to the questionnaire based on the feedback.
Content validity
The QPCQ-P content validity was assessed both qualitatively and quantitatively. To assess qualitative content validity, the QPCQ-P was given to 10 eligible experts (2 PhDs in nursing, 3 masters in midwifery, 2 psychologists, and 3 gynecologists), who were asked to evaluate the questionnaire's quality based on grammar, use of appropriate words, phrases, and scoring, as well as to provide their opinions [18]. The questionnaire was then changed in response to the feedback. To assess the QPCQ-P quantitatively, the CVR and the CVI were used. Fifteen experts were provided with QPCQ-P and asked to assess each item on a three-point scale (1. not necessary, 2. useful, but not necessary, and 3. necessary) [19]. If the number obtained from the Lawshe table is greater than 0.49, the presence of the phrase with the significance level (p <0.05) is necessary and important in this questionnaire [20]. The CVR is calculated using the formula below: where ne is the number of experts who rated the item as “necessary” and N is the total number of experts.
The content validity index (CVI) was used to calculate the three criteria of “simplicity and fluency,” “relevance,” and “transparency” with a score ranging from 1 (lowest) to 4 (highest) [21]. If an item's score is greater than 0.79, it will be kept in the questionnaire. If the CVI score falls between 0.79 and 0.70, the phrase in question should be revised; if it falls below 0.70, the phrase in question will be unacceptable and should be removed [22]. The CVI formula was as follows:
CVI= Total number of raters / number of individuals who gave the question score of 3 or 4
Convergent validity
The correlation between QPCQ-P and WHOQOL-BREF was used to assess convergent validity using the Spearman correlation coefficient. It is assumed that a positive relationship between the QPCQ-P and the WHOQOL-BREF indicates convergent validity (<0.30 low; 0.30 - 0.50: moderate; and> 0.50: high) [23].
Reliability
To assess reliability, the Cronbach's alpha method was used, which is a measure of scale reliability. We considered an alpha of 0.70 or higher to be acceptable [24, 25]. Using consistency alone to assess reliability is frequently insufficient because it provides no information about the consistency of participants' responses (20). As a result, we used test-retest in addition to internal consistency. Cronbach's alpha (0.70) was used to assess internal consistency in our sample, which included 41 mothers. The Internal Correlation Coefficient (ICC) was used to determine the repeatability of QPCQ-P as well as evaluate the reliability of the retest at two-week intervals. To interpret the coefficients, we found values below 0.4 to be unreliable, values between 0.4 and 0.7 to be moderately reliable, and values above 0.7 to be very reliable [22].