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 HealthLecturer – Midwifery)a,n, Jennifer Fraser, RN, PhD (Associate Professor, Director of ResearchStudents and Research Development)b, Glenn E. Gardner, PhD, MEdStudies, BAppScience(Advanced Practice Nursing) (Professor of Clinical Nursing)c

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

a r t i c l e i n f o

Article history:Received 3 June 2013Received in revised form15 October 2013Accepted 16 October 2013

Keywords:Birth companionSocial support in labourQuestionnaire development

a b s t r a c t

Objective: to develop and test the reliability and validity of a research instrument to measure women'sperceptions 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 instrumentwas then completed by 293 inpatient women who had experienced a vaginal birth.Measurements and findings: the Birth Companion Support Questionnaire (BCSQ) was developed and itsreliability and validity were evaluated in this study. An exploratory factor analysis was performed on thefinal instrument using principal component analysis with an oblique (Promax) rotation. This processsuggested two subscales: emotional support and tangible support. The questionnaire was found to bereliable and valid for use in midwifery research.Key conclusions: the BCSQ is an appropriate instrument to measure women's perceptions of lay birthcompanion support during labour.Implications for practice: this is the first rigorous study to develop and test a measure of social support inlabour which is critical at a time when policy makers and health planners need to consider the needs ofbirthing women and their network of support friends and family.

& 2013 Elsevier Ltd. All rights reserved.

Introduction

It is now an acceptable practice in most birthing facilitiesthroughout Australia that labouring women will be accompaniedto birth suite by one or more birth companions chosen from theirintimate and social networks. Throughout history, women acrossthe world birth in the presence of other women to help them copewith the stress of labour and birth (Brodsky, 2006; Fahy, 2006). Anumber of changes in many western countries saw this traditionalpractice decline. For example, with women birthing in hospital,they became isolated from the support of family and friends. In anattempt to secure a more supportive experience, women began todemand the presence of a supportive companion; namely their

partner. This event became the catalyst for a number of studiesfocusing on different types of support providers and their con-tribution to the idea of support during labour. This is evidenced bymore than 40 studies that have been conducted over the last 35years. The overall findings from these studies have revealed that asupportive human presence in the form of partner, female relativeor 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 amountof research on support during labour, little is known about theimpact of non-professional and multiple support people.

Research to date has focussed on either mothers' or midwives'perspectives predominantly using qualitative approaches. Priceet al. (2007) collected data using in-depth interviews with 16women in the immediate postpartum period prior to dischargefrom hospital. Thirteen of the 16 women had additional supportpeople; namely their mothers, female friends and a doula. Wheninterviewed, women said they had chosen family members and

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

n Corresponding author.E-mail addresses: lynne.dunne@acu.edu.au (C.L. Dunne), jfraser@sydney.edu.au

(J. Fraser), ge.gardiner@qut.edu.au (G.E. Gardner).

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

Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

close friends. The researchers revealed these women chose indi-viduals they felt connected to in day-to-day life, expressing theirneed for individualised support, comfort, control and familybonding (Price et al., 2007).

On the other hand, midwives and nurses have reported thatmultiple birth companions are a source of conflict for women intheir care, rather than support. For example, Spear (2006) con-ducted a telephone survey of 154 obstetric nurse managers in thesouth-eastern hospital obstetric units of Alabama, Louisiana,Virginia, West Virginia, South Carolina, Kentucky, Mississippi,Florida, Georgia, and Tennessee. Findings from the survey revealedthat some nurses exercised their own judgement about who couldaccompany women in labour, and turned a blind eye to a twoperson only policy. However some nurses reported actuallyattempting to limit the number of support people and would askthem to leave claiming it was be detrimental to the health andwelfare of the labouring woman (Spear, 2006). In another quali-tative study, midwives talked about attempting to limit thenumber of companions with one midwife arguing that womenaccompanied by a large number of support people were actuallyunsupported and that the labour and birth process was treated asa ‘viewing’ (Maher, 2004, p. 277).

Advantages and disadvantages of having multiple birth com-panions in hospital units are not well understood although theredoes seem to be conflict between women and hospital staff(Maher, 2004; Kettlei and Perkins, 2006; Spear, 2006; Priceet al., 2007). What we do know is that more research is neededto identify women's perceptions and experiences. This is impera-tive as there is an expectation for women to be accompanied bytheir friends and families in most maternity services today. Thepurpose of the study presented herein was to develop and test theBirth Companion Support Questionnaire (BCSQ) as a self-reportmeasure of women's perceptions of support provided duringlabour and birth by one or more people from their intimate andsocial networks.

Methods

Study design

This cross sectional design aimed to adapt an existing instru-ment that measured social support in labour, for use in measuringmaternal perception of at least one lay birth support person duringlabour. The Sauls' (2004) Labor Support Questionnaire (LSQ) wasused primarily as it had been generated from the theoreticalliterature relating to labour support and from other tools thatmeasured elements of labour support. Additional items from Saks'(1998) measure of social support were tested but found to beinconsistent for use in measuring perception of non-professionalsupport persons. Specifically, items from the existing measuresthat measured functional and supportive behaviour of birthcompanions were adapted as presented in Table 1.

The LSQ (Sauls, 2004) was designed to measure nurses'perceptions of professional labour support. Guided by Lazarusand Folkman (1984), Sauls (2004, p. 125) defined labour support as(i) emotional support—the ability to subjectively participate andshare in the labouring woman's feelings, (ii) tangible—the carryingout of tasks to meet the physical needs of the woman, (iii)informational—the practice of exchanging information to meetthe labouring woman's knowledge needs and (iv) advocacy—aprocess of acting on the labouring woman's behalf to ensure sheremains at the centre of the decision making. Permission wassought and gained by the author to adapt items from the LSQ inthe development and testing of the BCSQ.

The LSQ was designed for self-administration by nurses. Itcontained 27 items across the four subscales previously mentionedusing a six-point Likert-type scale response format.

The items used from Saks' (1998) study related to behaviours ofsupport people that she considered were of questionable benefitand included behaviours that distracted the woman from theeffort of labour and those that intimated that her labour wastaking too long.

The final version of the BCSQ contains 17 items designed tomeasure support with a four-point Likert-type ordinal responseformat with anchors of 0 (not at all), 1 (a little), 2 (most of thetime) and 3 (all of the time). Lozano et al. (2008) maintained thatthe fundamental psychometric properties of a scale—reliabilityand validity—are enhanced when four to seven response cate-gories are used. A four-point response format was chosen, ratherthan the six-point response format used in the LSQ, to allow formore discrimination in responses. The Likert-type scale with aneven number of response points used in the BCSQ did not allow fora neutral category, which often results in the modal response(Annett, 2002), but required the participants to have a negative orpositive judgement/opinion about the support (Totten et al., 1999;Netemeyer et al., 2003).

The BCSQ was designed to allow women to rate how frequentlysupportive behaviours were provided by each support personpresent during labour. The women were asked to identify in thespace provided on the questionnaire their relationship to each oftheir support people; for example, partner, mother or sister. Thewomen with multiple support people nominated who supportperson one, two, three or four were when completing the ques-tionnaire. At the conclusion of the questionnaire, the women withmore than one support person were asked to indicate, by tickingthe appropriate box, which support person provided them withthe most support. The scores were summed to give a total rangefrom 0 to 51; higher scores representing more social support.

Content validity testing

The 17-item BCSQ initially underwent review by an expertpanel of six midwives who received (a) a letter outlining the study,(b) review criteria, and (c) a copy of Sauls' (2004) published articleon the development and psychometric analysis of the LSQ. Themidwives were invited to evaluate the items using a 4-pointLikert-type scale ranging from (1) not relevant, to (4) relevantand concise. The midwives were also asked to propose ways inwhich items could be reworded to enhance relevance and tosuggest any items that should be included. Items that requiredrewording were changed. On the basis of these results theresulting 17-item questionnaire was then pilot tested to examinereliability prior to administering the questionnaire to a largersample.

Face validity and test–retest reliability evaluation

Face validity which is an assessment of how the potentialparticipants view the instrument (Waltz et al., 2010) was con-ducted with a convenience sample of 10 postnatal women from ahospital postnatal ward in Queensland, Australia. At the time ofgaining consent, the researcher checked the participants' will-ingness to be telephoned to complete the questionnaire again.

The women were asked to give feedback on readability, clarityof the questions, the time involved in completing the question-naire and ease of filling it out. The questionnaires were completedby women in the hospital room. At the time of collection theywere invited to provide verbal feedback. The combined results ofcontent validity and face validity were used to make minorwording changes to two items prior to testing in the main study.

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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 validityof the Birth Companion Support Questionnaire. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.10.010i

A pilot study was conducted to assist with instrument testingand to forewarn the researcher about potential problems in theresearch process (Gardner et al., 2003; Leona et al., 2011). The pilotstudy also allowed for the assessing of the temporal stability of thequestionnaire using test–retest reliability. A period of two weeksto a month between tests is recommended for a ‘pencil and paper’measure, particularly if there is a chance that genuine changesmay take place in the underlying construct within a short periodof time (Aday and Cornelius, 2006; Waltz et al., 2010). Thequestionnaires were completed over the telephone two weeksapart. Wilcoxon Signed Ranks test revealed that there was nosignificant statistical difference between the underlying distribu-tion of scores at Time 1 and Time 2.

Sample and setting

A convenience sample of 293 women, who had been supportedby one or more people from their social network, was recruitedfrom the postnatal ward in a public metropolitan hospital with abirth rate of approximately 2500 per annum, located in South-EastQueensland, Australia. Guided by the ratio of 15 participants pervariable this sample size was adequate to perform an exploratoryfactor analysis (EFA) (Pett et al., 2003; Field, 2005). Approval toconduct the research was granted by the Human Rights EthicsCommittees (HREC) of the University and relevant Health ServiceDistrict.

Midwifery staff in the birth suite and the postnatal ward wereasked to assist by giving the Patient Information Consent Forms(PICFs) to eligible women. Contact was made with the potentialparticipants in the ward in the first 48 hours after the birth, thisensured the questionnaires were completed before dischargewhich maximised response rate and minimised recall bias. Theresearcher, although an employee of the agency was not clinicallyinvolved in the participants' care, and timely discharge or anyother aspect of postnatal care was not reliant upon participation inthe research. The researcher had no pre-existing or ongoingrelationship with the participants. The participants completedand returned the questionnaire between April 2009 andFebruary 2010.

Inclusion criteriaParticipation in the study was dependent upon the women

meeting the following criteria: (a) age at least 16 years, (b) able toread and understand English, (c) spontaneous onset of labour after36 completed weeks gestation, (d) accompanied to birth suite byone or more people, (e) gave birth vaginally, (h) had an EdinburghPostnatal Depression Score (Cox et al., 1987) (completed in the firsttrimester) of 12 or less, (i) not enroled in a caseload midwiferymodel, (j) infant was not admitted to special care nursery for on-going care, and (k) able to give informed consent.

Socio-demographic questionnaire

Socio-demographic items included age, marital status, parity,ethnicity, income level, education level.

Strategies to reduce bias

Instructions and items were designed to be clear and unambig-uous. To ensure participants read and processed items carefully,some items were worded negatively. Participants were assured ofconfidentiality and were asked to complete the questionnairewhen alone and not in the presence of support people to reducethe risk of socially desirable responding.

Data analysis

Analysis was performed using SPSS 17.0. Data were enteredtwice for verification. Descriptive statistics were used to summar-ise demographics and to check for violation of assumptionsregarding normal distribution. A significance level of 0.05 wasused to designate statistical significance. Negatively worded itemswere reverse scored prior to analysis.

Test of internal consistency was Cronbach's alpha. Cronbach'salpha values for the total scale and subscales above 0.7 areconsidered acceptable, with 0.8 being preferable (Pallant, 2007).Inter-item correlations were also calculated to further verifyinternal consistency. Correlations in the range of 0.02–0.04 aredesirable as lower correlations would indicate lack of homogeneitywhereas higher values signify item redundancy (Briggs and Cheek,1986; Floyd and Widaman, 1995). Item analysis including inter-

Table 1Comparative 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‘that's very good’

Praised my efforts, like ‘great job’ ‘well done’

Provides massages between contractions to help the woman relax such as: backrubs, leg rubs Assisted me with coping techniques (coping techniques may includeproviding massages, encouraging you to walk around)

Reinforces previous instructions such as breathing, relaxation, or pushing techniques Reinforced coping techniques I was using (may include relaxationtechniques, breathing techniques)

Shows concern for labouring woman. Made me feel they were there for meInstructs 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 planMaintains eye contact with the woman during conversations and during her contractions,when culturally appropriate

Provided eye contact when praising my efforts

Provides distraction techniques, such as: light social conversation, having her watch TV orlistening to music, during the early phase of labour if appropriate.

Provided distraction techniques in the early phase of labour (e.g., lightsocial conversation, playing cards)

Provides physical comfort through the use of hot/cold therapy such as, compresses, warmblanket to relieve discomforts of labour

Offered me physical comfort through touch (touch may include holdingyour hand, wiping your face, rubbing your back)

Demonstrates understanding and caring Made me feel respected and admiredMade 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.

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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 validityof the Birth Companion Support Questionnaire. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.10.010i

item and corrected-item total correlations were conducted todetermine if lack of homogeneity and redundancy of items werepresent. Values for Cronbach's alpha if-item-deleted were alsoscrutinised in order to optimise internal consistency.

To explore construct validity, exploratory factor analysis (EFA)was conducted using principal component analysis (PCA) withpromax rotation to investigate the interrelationships among theset of variables that make up the BCSQ. The oblique rotationmethod was employed because there is a reasonable belief inhealth sciences that constructs of interest, although being con-ceptually different, are often interrelated (Pett et al., 2003; Field,2005). Three statistical standards were used to determine thenumber of factors to retain: Kaiser's criterion (eigenvalue greaterthan one), Horn's (1965) parallel analysis and item factor loadinggreater than 0.32.

Findings

Participants

Of the 310 women approached to participate in the study, 10refused. The women who refused indicated that they did not havethe time as they were preparing for discharge (n¼6), or were notinterested in participating (n¼4). Three hundred women agreed toparticipate in the study, but seven participants were excluded asthey did not complete or return the questionnaire. Two hundredand ninety three women completed the questionnaire giving aresponse rate of 98%. Of the 293 participants, 162 (55%) wereaccompanied by one person and 131 (45%) were accompanied bytwo or more people.

The 25–29 age group (30%) represented the majority of theparticipants and 28 (9.5%) were 20 years old or less. Of themajority of the women, 238 (81%) were married or defactocompared to the 50 (17%) who were single or the five (2%) whoidentified as ‘other’. 187 (64%) were multiparous women com-pared to 106 (36%) first time mothers.

Internal reliability analysis

Following reliability testing where inter-item correlations wereexamined, only correlations between 0.30 and 0.80 were retainedleaving a 14-item scale. The deleted items were ‘Made me feel thatmy labour and birth was taking too long’, ‘Left me alone to go outsidefrom time to time’, ‘Got distracted by watching TV or chatting toothers’. Following EFA the scale was reduced to 13 items and theCronbach's alpha was 0.80. According to Pallant (2007) internalconsistency estimates for a newly developed instrument should beat least 0.7. The first subscale met this criterion (0.76) whereas thesecond subscale was slightly below (0.66). Both scales wereinspected to determine whether the removal of any items fromthe scales would strengthen Cronbach's alpha, but this was notnecessary.

Construct validity

PCA was used to examine the underlying structures of the 14item BCSQ. The suitability of EFA was determined by preliminaryinspection of the data. The majority of the inter-item correlationswere Z0.3, the Kaiser–Meyer–Olkin value, a measure of sampleadequacy was 0.87 which exceeded the recommended value of0.60 (Kaiser, 1974) and Bartlett's Test of Sphericity (Bartlett, 1954)reached statistical significance (po0.001), supporting the factor-ability of the correlation matrix. The PCA showed three compo-nents with eigenvalues greater than 1 explaining between 8% and35% of the variance. A parallel analysis was conducted revealing

only two components with eigenvalues exceeding the correspond-ing criterion values for a randomly generated data matrix ofsimilar size (293 subjects�14 variables). Therefore two compo-nents were retained for further analysis.

The two-components solution accounted for 42.8% of thevariance with component 1 contributing 33% and component2 contributing 9.8%. Review of the communalities values indicatedthat 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 fromfurther EFA. Using the same steps, the EFA was repeated with theremaining 13 items and two components were retained. This two-component solution accounted for 45.3% of the variance withcomponent 1 contributing 34.8% and component 2 contributing10.5%. To assist interpretation of the two components, promaxrotation was performed.

Components that were above 0.32 were considered to haveloaded because, as a rule of thumb, only variables with loadings of0.32 or above are interpreted (Field, 2005; Tabachnick and Fidell,2007) when the sample size is between five and 10 participantsper variable (Floyd and Widaman, 1995). The rotated solutionshowed a simple structure with seven components loading posi-tively and exclusively at 0.32 or above on Component 1. A twocomponent solution is therefore proposed as shown in Table 2.

However, one component cross loaded at 0.38 on Component1 and 0.33 on Component 2. The other seven items on Component1 appeared to be reflecting the elements of emotional support.Five components loaded positively and exclusively at 0.32 or aboveonto Component 2 and these items were capturing the elements oftangible support. There was a positive correlation of 0.50 betweenComponent 1 and Component 2. Items within the subscales areshown in Table 3.

The one component that loaded on Component 1 (0.38) andComponent 2 (0.33) referred to support people praising thewoman's efforts. The item was allocated to Component 1 on thejustification of the higher loading on Component 1 and because itwas similar to other items which focused on providing emotionalsupport for the woman. Investigation of the Cronbach's alpha forthe scale items if an item was deleted was performed revealingonly minor changes to the subscale values of α. Deletion of theitem would reduce the total scale's alpha to 0.74.

Discussion

This is the first questionnaire to be empirically tested as aninstrument to measure women's perceptions of social supportduring labour. Prior to this instrument, the only validated instru-ments available were those which measured women's perceptionsof support provided by midwives, or LSQ (Sauls, 2004) whichmeasured midwives' ratings of the importance of supportivebehaviours during labour. Preliminary estimates of BCSQ indicateits potential to be a reliable and valid measure of the underlyingtheoretical constructs. The testing indicated 13 of 17 items shouldremain in the instrument and that a two-component solution wasthe best fit for the data using PCA with promax rotation. The twocomponent solution constructs are Emotional Support and Tangi-ble Support.

Although this is an important development and one that willhave important implications for maternity unit policy and plan-ning, a number of limitations are acknowledged. Firstly, theconvenience sample of women came from one maternity sitefeaturing a younger cohort than average. The questionnaire'sproperties were tested on English speaking women only fromwhat could be seen as a homogenous cultural background. Next,one of the main difficulties with developing the questionnaire wasthe scarcity of established measures for comparison. Indeed, the

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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 validityof the Birth Companion Support Questionnaire. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.10.010i

study was instigated due to the lack of validated measures ofwomen's perceptions of social support during labour.

A number of recommendations for future research can bemade. The questionnaire needs to be tested on a larger samplefrom a variety of maternity sites and include women with culturaland socio-demographic diversity. Further testing of the factorsolution is needed. Nevertheless it is important to emphasise thatfactor analysis is an error prone procedure even with adequatesamples and favourable data (Costello and Osborne, 2005). Con-firmatory factor analysis will assist in a more rigorous assessmentof the reliability and construct validity of the instrument.

Conclusion

This is the first rigorous study to develop and test a measure ofsocial support in labour which is critical at a time when policymakers and health planners need to consider the needs of birthingwomen and their friends and families network. Preliminaryevidence of the internal consistency, content and construct valid-ity of BCSQ in assessing women's perceptions of social supportduring labour is an important first step towards improvingservices to meet the demand of young birthing women. It is thebasis of a valid and reliable instrument that offers a better under-standing of women's perceptions of social support during labour.

Conflict of interest

There is no conflict of interest.

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Table 3Subscales of the Birth Companion Support Questionnaire.

Emotional support items Tangible support items

There for me Spoke to midwife about my needsEnjoyed the company Reinforced coping methods I was usingFelt satisfied with support Assisted with coping techniquesListened and respected my wishes Provided distraction in early phaseOffer comfort through touch Helped me to follow advice of the midwifeMade eye contactMade me feel respected

Table 2Pattern and Structure Matrix for PCA with Promax Rotation of Two Factor Solution of BCSQ Items (n¼293).

Item Pattern coefficients Structure coefficients Commonalities

Component 1 Component 2 Component 1 Component 2Emotional support Tangible support Emotional support Tangible support

6. There for me 0.781 �0.045 0.759 0.345 0.57713. Enjoy the company 0.740 �0.034 0.724 0.336 0.52417. Felt satisfied 0.719 �0.096 0.671 0.263 0.45716. Listen and respect 0.664 �0.154 0.587 0.178 0.3627. Offer comfort 0.574 0.107 0.628 0.394 0.40315. Eye contact 0.536* 0.153 0.612 0.421 0.3921. Feel respected 0.478 0.147 0.552 0.386 0.3212. Praised my effort 0.381* 0.332 0.547 0.523 0.38210. Speak to midwife �0.300 0.847 0.123 0.698 0.5548. Reinforce methods 0.017 0.735 0.383 0.743 0.55211. Assist with coping 0.080 0.534* 0.446 0.774 0.6044. Provide distraction 0.069 0.521* 0.329 0.555 0.31214. Follow advice/coping 0.278 0.487 0.521 0.626 0.450

Note: major loadings for each item are in bold.n Items load on the same component of Sauls' (2004) LSQ.

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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 validityof the Birth Companion Support Questionnaire. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.10.010i