Based on this study, the Finnish translation of the Childbirth Experience Questionnaire (CEQ-FI) is a valid tool for assessing the childbirth experience of Finnish-speaking women. Internal consistency of the questionnaire is good and its repeatability at least moderate, mostly substantial. The questionnaire performed well in known-groups validation as women with known risk factors for a negative experience had lower scores.
Sample size was small due to lower than expected response rate. However, the results were in line with previous studies validating other translations of the CEQ. Other studies have increased the response rate using reminders (4, 7), use of a web questionnaire or administering the questionnaire during hospitalization immediately after delivery (8, 9). However, sending reminders may result in delayed response, which in turn may affect the item responses (15). On the other hand, administering the questionnaire while the woman is still receiving care may also have an effect on the item responses.
The structure of the CEQ has been modified in studies validating other versions, due to cultural and lingual as well as management practice differences. The Spanish study made slight alterations to the wording of the items and moved one item to another domain (4). The Chinese CEQ was translated from the English translation, and three items were completely removed to improve construct validity. Furthermore, three items in Chinese CEQ were moved to another domain. High ceiling effect was observed especially in items regarding labor pain, which the authors attributed to Chinese traditions of accepting intense labor pain as normal and lower analgesia use compared to Western countries (8). The Persian translation was not subject to structural changes, but the item evaluating midwife’s support for partner was seen as irrelevant, as partners are not allowed in deliveries in Iran (9). Contrary to these studies, due to very similar culture in both society and hospital practices in Sweden and Finland, the structure of the questionnaire could easily be retained in its original form. We were also able to translate the questionnaire directly from the original Swedish version and preserve the original wording and structure of the items.
This study was designed with the original Swedish validation study in mind. Primiparity predisposes women to a negative childbirth experience (12), and only primiparous women were included to control this impact, as in the Swedish study. The Spanish validation study nevertheless showed that the CEQ is appropriate also in assessing the childbirth experience of multiparous women. Validation study of the Persian CEQ included only spontaneous vaginal deliveries, and Chinese and Spanish validation studies excluded all cesarean deliveries. In Finland, 15.6% of primiparous women had an emergency cesarean delivery in 2018 (16). Operative delivery is a risk factor for a negative childbirth experience (12), and the validity of the questionnaire is of paramount importance also in this subgroup. In this study, labor induction was not an exclusion criterion unlike in the original Swedish study. Labor induction has become increasingly prevalent: at the time of development of the CEQ in Sweden in 1999, 7.7% of primiparous women were induced (17), whereas 32.8% of primiparous women were subjected to this procedure in Finland during 2018 (16).
Internal consistency of the questionnaire is good regarding the whole questionnaire as well as regarding all domains with the exception of Participation. This was also shown in the original Swedish study describing Cronbach’s alpha of 0.62 for Participation. Similarly, effect sizes of known risk factors for a negative experience were quite small especially regarding Participation in both Finnish and Swedish studies. In the Swedish study, this was thought to be related to small number of items in the domain, and rewording or adding items could increase the value of the domain (6). A revised version of the original questionnaire has since been developed and validated in English (18), Swedish (19) and Persian (9) language versions.
The English validation (of the original CEQ) study compared the questionnaire to previously validated Maternity Survey and showed high correlation (4). No validated tool exists in Finnish, and thus criterion validity of CEQ-FI can not be evaluated. However, as known risk factors significantly decreased the total score and the scores of most domains, CEQ-FI is likely to be able to discriminate a negative birth experience.
Test-retest reliability was assessed by computing weighted kappa coefficient for each item as well as for all domains and the total score, unlike in the English validation study, which did not report item-specific kappa values. Compared to that study, domain-specific and total score agreement was at least as good in our study, and agreement in Participation reached substantial level (moderate in the English study).
CEQ and its translations can be used to evaluate individual childbirth experience. In addition, the total or domain scores may be used for example in comparing the impact of different management practices to maternal experience. On the other hand, the questionnaire may be used in clinical setting for structuring discussions with women who have given birth and may need extra support. CEQ-FI is thus suitable for research and clinical settings and is a valid and reliable tool in assessing childbirth experience in multiple dimensions.