Validitas PAI

National Taipei University of Nursing and Health Sciences
College of Nursing
Graduate Institute of Nurse-Midwifery
Master Thesis
Indonesia Version of Prenatal Attachment Inventory (PAI):
A Preliminary Study
Endang Koni Suryaningsih
Advisor: Chien-Huei Kao, C.N.M., R.N., PhD
May 2015
Acknowledgment
I thank all who in one way or another contributed in the completion of this thesis. First, I give
thanks to Allah SWT for protection and ability to do this work.
I am so grateful to the International Cooperation and Development Fund (ICDF) Scholarship,

Taiwan, for making it possible for me to study here. I give deep thanks to the Professors and
lecturers at the Nurse-Midwifery programmed my project manager, the librarians, and other
workers of the faculty.
My special and heartily thanks to my supervisor, Professor Chen-Huei Kao who encouraged
and directed me. Her challenges brought this work towards a completion. It is with her
supervision that this work came into existence. For any faults I take full responsibility.
Besides my advisor, I would like to thank the rest of my thesis committee: Prof. Meei-Ling
Gau, and Prof. Ting-Ting Lee for their encouragement, insightful comments, and valuable
inputs.
I am also deeply thankful to my Indonesian friends in NTUNHS, my beloved roommate,

thank you for your presence in my life. Then, thank you for my research assistances. Their
names cannot be disclosed, but I want to acknowledge and appreciate their help during my
research. Their information has helped me complete this thesis.
I also thank my family who encouraged me and prayed for me throughout the time of my
research, to my parents in law who take care of my son during my study. This thesis is
heartily dedicated to my mother who took the lead to heaven before the beginning of my
study.
Finally, I would like to thank my husband. He was gave me the wings to flew, and he always
there cheering me up and stood by me through the good times and bad. The last one, I
dedicated this accomplishment for my little prince, Azam, who always being my energizer in
day and night, when up and down, to finish this paper on time to going back to him again to
tell a fairytale in every single night.
May the Almighty God richly bless all of You.
i
Abstract
Aims and objectives To translate the Prenatal Attachment Inventory (PAI) into Indonesian
and assess its psychometric properties.
Background The PAI measures maternal affectionate attachment. This scale displays the
most appropriate indicators associated with attachment and has been widely adopted in
different countries and different fields for measuring the maternal-fetal attachment.
Methods and Design The PAI was translated into Indonesian using the translation and
back-translation according to Brislin’s guidelines and the translation result was reviewed by a
committee. The judgment of the expert panel was established to determine the content
validity using Content Validity Index (CVI). In round 1, the experts scored each item based
on a four-point Likert scae. In round 2, the same experts reevaluated the revised item based
on the recommendation in round 1. Then I-CVI and S-CVI/UA were applied. To generate
support the construct validity of criterion-referenced measures, the contrasting group
approach was used. The convenience sample from the accessible population of 130 pregnant
women in five health centers in Yogyakarta, Indonesia was used. Sixty pregnant women less
than 20 weeks’ gestation and sixty pregnant women after 30 weeks’ gestation agreed to
participate in this study. A test of internal consistency was statistically performed to
determine the reliability of this method. Independent t-test and one-way ANOVA were also
performed to explore the scores among its variables.
Results The Indonesian version of PAI (IPAI) contains 21 items and possesses high internal
consistency; the Cronbach’s alpha coefficient was .937. There was a significant difference
between the groups in the total score (p < .05), with women in late pregnancy having the
higher scores.
Conclusions The findings suggest that the Indonesian version of PAI (IPAI) is a reliable and
valid instrument for measuring the levels of attachment and affectionate ties between mothers
and their unborn babies.
Implications Valid instrument is available to either midwife or nurse researchers who are
exploring prenatal attachment. The IPAI provides midwives with a useful tool to explore the
information regarding the maternal-fetal attachment and promote maternal well-being during
child bearing.
Keywords: Indonesia, Prenatal Attachment Inventory, content validity, reliability
i
Contents
Page
Abstract i
Content ii
Content of Figure iv
Content of Table v
Appendices vi
Chapter I Introduction
1-1. Background 1
1-2. Problem statement 2
1-3. Purpose of the study 5
1-4. Significant of the study 5
Chapter II Literature Review

2-1. Brief history of maternal-fetal attachment 7
2-2. Definition of maternal-fetal attachment and related 9
factors
2-3. The studies related to maternal-fetal attachment 14
2-4. Prenatal Attachment Inventory (PAI) 16
2-5. Translation and Back Translation 19
2-6. Content Validity 23
2-7. Construct validity 25
2-8. Reliability Test 27
2-9. Introduction of Indonesia and Yogyakarta 28
Chapter III Research Methodology

3-1. Study Design 32
3-2. Study Setting 32
3-3. Sampling and Sample Size 33
ii
3-4. Inclusion and Exclusion Criteria 34
3-5. Research Tools 34
3-6. Data Collection Processes 39
3-7. Data Analysis 42
3-8. Ethical Consideration 42
Chapter IV Results
4-1. The demographic information of the respondents 44
4-2. The Indonesian version of PAI 46
4-2-1. Translation and back translation 47
4-2-2. Validation tests of Indonesian version of PAI 48
4-2-3. Reliability test of Indonesian version of PAI 55
Chapter V Discussion
5-1. Translation and back translation 57
5-2. Validation of Indonesian version of PAI 58
5-3. The reliability of Indonesian version of PAI 59
Chapter VI Conclusion and Recommendation

6-1. Conclusion 60
6-2. Limitation 61
6-3. Implications of this study 61
6-4. Recommendations 62
References 64
iii
Figure
Page
Figure 2.1. The Map of Indonesia and Yogyakarta 28
Figure 3.1. Flow chart of data collection 41
iv
Tables
Page
Table 3.1. Total health center and participants in this study 33
Table 3.2. The example of four criteria on a 4-point Likert scale 38
Table 4.1 Demographic information of this study from two groups 46
Table 4.2. Rated by expert for content validity in the first round 50
Table 4.3. Final Rated by expert for content validity in the second round 53
Table 4.4. Mean, standard deviation and Independent t-test between two
groups in total score 54
Table 4.5. Reliability test 56
v
APPENDICES
Page
Appendix I Original Instrument of PAI 69
Appendix II Time Schedule 71
Appendix III Permission to use Instrument and Grant to use the Instrument 72
Appendix IV Background of two translatorsInstrument 75
Appendix V Background of the Three experts 76
Appendix VI Cover letter for experts panels 78
Appendix VII Response form from expert 80
Appendix VIII Institutional Review Board (IRB) 85
Appendix IX Consent form for respondent (English and Indonesian) 86
Appendix X Demographic Information (English and Indonesian) 88
Appendix XI Translation and back translation result 92
Appendix XII Final Instrument based on committee review 94
Appendix XIII Individually rating of three experts 95
Appendix XIV The final result of Indonesian version of PAI 102
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1
An Indonesian Version of Prenatal Attachment Inventory (PAI)
Chapter I
Introduction
This chapter introduces the study by describing the background of this research, problem
statement, purpose of study, and significance of the study.
1-1. Background of This Research
Attachment refers to the sustained affection developed between two individuals (Damato,
2004). Attachment theory can clarify many aspects of interpersonal relationship, both
between parents and children and among adults, and has become popular focus inquiry in
relationship studies over the past 20 years (Simpson & Rholes, 2010). The importance of
keeping mothers and infants together and encouraging their interaction was supported by
research studies (Brandon, Pitts, Denton, Stringer, & Evans, 2009; Cranleys, 1981; Muller,
1993). The relationship between a mother and her infant start to develop before an infant is
born (Alhusen, 2008). This relationship provides infants with a sense of security and
happiness and serves as a basis for their future interpersonal relationship (Muller, 1994). In
addition, attachment is a dynamic process that is established in infancy and can influence
one’s entire life (Chen, Chen, Sung, Kuo, & Wang, 2011). When an infant does not have
someone to attach to, he or she feels emotional pain (Koenig, Chesla, & Kenedy, 2003).
Therefore, attachment theory implies that infant have the ability to send messages when they
experience pain or pressure, and parents have the ability to sense these communications
(Koenig et al., 2003).

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1-2. Problem Statement
Children are the backbone for the nation’s next generation and its future human capital
(Muti'ah, 2009). To create a better succeeding generation, it depends on women as mothers
who will be taking care of their children and this important role has begun since pregnancy
stage (Muller, 1993; Muti'ah, 2009).
Based on Indonesia’s Child Protection Committee (ICPC) (2010), the number of
consultation for child abuse (under 15 years old) has been increasing over the year. In 2007,
the consultation was about 1,510 numbers of cases. One year later (2008), that was increased
about 1,826 numbers of cases. Subsequently, in 2010 it increased extremely, to 21 million of
cases. From 21 million of cases, approximately 292 of children who died the main abuser
70% are their mothers (Merdeka, 2010). These mothers release their mental violence feeling
to their children because of some reasons. First, the mothers have severe stress, depression,
and anxiety. It was contributed to the mother’s psychological condition (Moncher, 1996;
Zevalnkink, Walvaren, & Bradley, 1999). Second, the cause of their stress is more stimulated
by economic condition (Hastuti, 2014). Third, the mothers have no role model from their
mothers to coping positive attachment when they was a child. In other word, they have
negative childhood experience in their family (Alhusen, 2008). Fourth, mother who has failed
established strong maternal-fetal attachment during pregnancy, and tend to be a main abuser
to their children (Moncher, 1996; Zevalnkink et al., 1999). This means maternal-fetal
attachment needs considerably important basis of a secure maternal-fetal relationship
(Zevalnkink et al., 1999).

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This maternal-fetal relationship recognized as the emotional tie between mother and
fetal that occurred during pregnancy (Sandbrook, 2009). Strong maternal-fetal attachment
which is reflected by high score of maternal-fetal attachment scale and it has been associated
with constructive health practices during pregnancy, and will encourage the mothers to
always protect their fetal from harm, expressing their love since the babies are unborn, until
their babies grow up (Alhusen, 2008; Lindgren, 2001; Sandbrook, 2009).
It has been clear that exploring the quality of maternal- fetal attachment to examine the
mother’s psychological problem in their pregnant was necessary. It was also to encourage
mother’s positive behavior toward promote mother’s psychological health that would be
affecting the interaction between mothers and their children in the future (Yarcheski, Mahon,
Yarcheski, Hanks, & Cannela, 2009). Therefore, valid and reliable instrument to measure
maternal-fetal attachment was needed.
In Indonesia, little has been known about the attachment between expected mother and
the fetal, however did not emphasize maternal-fetal attachment, much has been focus on
postnatal stage (Dewi, 2013; Muti'ah, 2009; Zevalnkink et al., 1999). At the same time, when
considering maternal attachment, much of the focus has been on the postpartum period (Gau.,
1996). However, maternal fetal attachment actually starts during pregnancy. On the other
hand, from the text of review where women consider pregnancy an equally important period
that initiates and leads into healthy maternal-child attachment after birth (Anand & Hima,
2012; Muller, 1994).

4
Beck (1999) mentioned that maternal-fetal attachment scales consist of Maternal Fetal
attachment Scale (MFAS), Prenatal Attachment Inventory (PAI), Paternal Fetal Attachment
Scale (PFAS), Prenatal Self-Evaluation Questionnaire, Cognitive Adaptation to Stressful
Events (CASE) Instrument and Maternal Antenatal Attachment Scale (MAAS). Other
investigators mentioned the three most commonly used maternal-fetal attachment tools are
MFAS (Cranley, 1981), MAAS (Condon, 1993), and PAI (Bergha & Simonsa, 2009; Muller,
1993; Sandbrook, 2009). Since its development, many researchers into prenatal attachment
have used Cranley and Condon’s questionnaire as a measuring tool. However, the
inconsistency was found. Some studies showing conflicting result in their validation (Condon
& Corkindale, 1997; Muller, 1993; Sandbrook, 2009).
Otherwise, the PAI (Muller, 1993) was chosen for the current study because some
reasons. First, the PAI emphasizes affiliation rather than behaviors which is a broader
definition than that underlined by Cranley (Gau & Lee, 2003). Second, the psychometric
properties of the PAI remain quite adequate and it has been proofed by many studies (Beck,
1999; Bergha & Simonsa, 2009; Condon & Corkindale, 1997; Gau & Lee, 2003; Muller,
1994a; Muller, 1996; Sandbrook, 2009; Siddiqui & Hagglof, 1999). Third, the PAI
instrument has been adopted across different countries including Korea, French, and Italia
(Chen, Chen, Sung, Kuo, & Wang, 2011; Jurgens, Levy-Rueff, Goffinet, Golse, &
Beauquier-Macotta, 2010; Kuo et al., 2013; Siddiqui & Hagglof, 1999; Vedova, Dabrassi, &
Imbasciati, 2008; Wilson, 1990). Therefore, PAI to measure the maternal-fetal attachment is
give explanation for this research. Furthermore, lack of research and no available
maternal-fetal attachment instrument was the most reason researcher to conduct the first ever
Indonesian study to provide the Indonesian version of Prenatal Attachment Inventory.

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1-3. The Purposes of This Study
This study will be coverage three purposes:
1. Translate the Prenatal Attachment Inventory (PAI) into Indonesian.
2. Identify the validity of Indonesian version of PAI by using content validity index and
construct validity.
3. Identify the internal consistency of Indonesian version of PAI by using Cronbach’s
Alpha.
1-4. Significance of This Study
Maternal-fetal attachment was appealing construct because of the intuitive idea that
many of the problems of mothers and children could be solved if approached at the earliest
point in the relationship. Pregnancy was proposed as the first phase in the development of
maternal-fetal attachment and the process of developing attachment between maternal and
fetal has begins during pregnancy (Chen et al., 2011; Osa, Bustos, & Fernandez, 2010;
Vedova et al., 2008). Since health professionals play an important role in improving social
health and providing pregnancy services for mothers in public health centers, it is proposed
that maternal-fetal attachment behaviors be taught and practiced in public health centers and
in physicians’ and midwives’ offices, and that mothers be encouraged to apply these
behaviors to increase their mental and physical health. That is mean, health professionals are
also urging changes in prenatal care to promote maternal-fetal attachment (Muller, 1989),
therefore, exploring the prenatal attachment is very crucial information to health care
provider. Subsequent, the best intervention to improving attachment during pregnancy will
applied.
6
Furthermore, maternal-fetal attachment instrument can be used to predict maternal-fetal
interaction after birth. One study found a significant association between maternal total score
of prenatal attachment and postnatal behavior. Mothers who displayed more prenatal
attachment were also more involved during postnatal interaction and stimulated their infants
(Abasi, Tahmabesi, Zafari, Gholamreza., & Takami, 2012). The significant correlation
between levels of attachment and depression in the last trimester of pregnancy also have been
found (Condon & Corkindale, 1997; Lindgren, 2001).
Maternal-fetal attachment instrument can help caregivers early detect the problems
about expected mothers and their fetal attachment to prevent future problem. This instrument
wills establish a guide for caregivers to identify mothers with poor maternal-fetal attachment
score and help them to improve the outcome of pregnancy. Good develop the instrument to
measure maternal fetal attachment among pregnant woman in Indonesia was required. The
relevance of this instrument for clinical obstetrics, gynecology and reproductive psychology
was accepted (Bergha & Simonsa, 2009).

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Chapter II
Literature Review
To achieve the purposes of this study, researcher has been conducted the literature
review in where include brief history of maternal-fetal attachment, maternal-fetal attachment
definitions, factors relating to maternal-fetal attachment, prenatal attachment inventory scale,
and translation and back translation.
2-1.Brief History about Maternal-fetal Attachment
Theory of attachment at the first time proposed by John Bowlby’s (1958), therefore, he
is called as a “father” of attachment theory. Bowlby’s theory explained why children suffered
both physically and psychologically when separated from their mothers, even though their
physical needs were met. He identified similarities between the behaviors of separated human
infants and those of separated young animals. Bowlby (1958) suggested that, infant responses
are translated into a repertoire of attachment behaviors (such as crying, calling, reaching, and
clinging) with the set goal of bringing an adult into proximity and obtaining safety and
security with the infant (Muller, 1989). The proximity to the adult provides the infant with
feelings of security as well as meeting physical needs.
The loss of change of primary caretaker would lead first to increased attachment
behaviors in an attempt to form a new attachment. If a new attachment figure is absent,
physical and psychological suffering would occur (Bowlby, 1958). This theory of attachment
was an amalgam of concepts from cybernetics, information processing, developmental
psychology, and psychoanalysis, focusing on the infant’s goal to secure maternal response
(Bowlby, 1958).
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Ainsworth (1969) defined attachment a secure base from which an infant can explore the
world. In addition, she formulated the concept of maternal sensitivity to infant signals and its
role in the development of maternal-infant attachment patterns (Aisworth, 1969; Bretherton,
1992). Bowlby's and Ainsworth's conceptualized human attachment as a system of
evolutionary behaviors beginning at birth and persisting through adulthood, motivated by or
toward fear, affection, exploration, and care giving (Walsh, 2010).
The ideas now guiding attachment theory have a long developmental history. There has
been increased recognition over the past 20 years that the relationship between a mother and
her child starts to develop before a child is born; that is, while the child is a fetus. However,
the significance of this phenomenon is not as well studied as maternal-fetal attachment
(Ainsworth, 1969; Bowlby, 1958; Bretherton, 1992) because of the difficulty in measuring
maternal-fetal attachment (Alhusen, 2008).
The difficulty has been led nurse researcher, Mecca Cranley (1981) as the first one who
developed antenatal attachment scale (maternal-fetal attachment scale or MFAS). She also
emphasizes in the literature review about multidimensional model composed of six aspects of
maternal fetal attachment and she is created the theoretical construct of maternal-fetal
attachment, and suggested during the nine months of gestation, both physical developments
of the fetus and transformation of a woman into a mother are occurring (Alhusen, 2008).
Meanwhile, an Australian researcher, John Condon (1993), found Cranley’s work
insufficient in the description of MFA. Therefore, it has been led him to developed maternal
attachment antenatal scale (MAAS), and recent conceptualization of prenatal attachment has
attempted to combine these behavioral, cognitive, and emotional approaches in this working
9
definition: “Prenatal attachment is an abstract concept, representing the relationship between
a parent and fetus, and potentially present before pregnancy (Brandon et al., 2009).
Then, Müller (1993),another prenatal nurse researcher, who utilized Cranley’s construct
of maternal-fetal attachment, found this strategy of conceptualizing the phenomenon to be so
focused on behaviors that it excluded the thoughts and fantasies, she believed the growing
affiliation between mother and fetus, and she also developed prenatal attachment inventory
(PAI) to measure maternal-fetal attachment. All of their scales are derived from attachment
theory which is proposed by Bowlby (1958).
2-2. Definition of Maternal-fetal Attachment and Related Factors
Attachment has had many different definitions. In this study, in order to reach
understanding about maternal-fetal attachment, it is important to recognize about
maternal-fetal attachment definitions and factors relating with it. There are many definitions
of maternal-fetal attachment. It could be described as following:
1. First, according to Cranley (1981), maternal-fetal attachment defined as the extent to
which women engage in behaviors that represent an affiliation and interaction with their
unborn child.
2. Second, Muller (1993) defined the maternal-attachment as the unique, affectionate
relationship that develops between a woman and her fetal during pregnancy.
3. Third, Condon defined the maternal-fetal attachment is the emotional tie or bond which
normally develops between the pregnant women and her unborn fetal.
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Based on the definitions of maternal and fetal attachment, it could be understood that
attachment is an affection bond between maternal and their fetal. Attachment and the
development of a relationship with the unborn child are keys element in the successful
psychological adjustment to pregnancy experience as maternal identity in adaptation to
motherhood (Bergha & Simonsa, 2009; Muller, 1993; Ustunsoz, Guvenc, Akyuz, & Oflaz,
2010a). Maternal-fetal attachment may require the entire nine months developing. Sandbrook
(1969) mentioned that attachment is a reciprocal relationship between mothers and their fetal.
Abasi et al. (2012) found maternal-fetal attachment plays an important role in the health of
pregnant women, because it will encourage the mother’s behavior during pregnancy, then it
will lead the mother’s psychological and physical wellbeing.
Otherwise, there are some factors relating to maternal-fetal attachment. Many variables
have been associated with increases in maternal-fetal attachment (Alhusen, 2008; Canella;
Chang, Park, & Chung, 2004; Condon & Corkindale, 1997; Cranley, 1981; Abasi, 2012;
Lerum & LoBiondo-Wood, 1989; Muller, 1989; Muller, 1993; Nishikawa & Sakakibara,
2013; Ö hman, 2014; Osa et al., 2010; Ross, 2012; Sandbrook, 2009; Siddiqui & Hagglof,
1999; Siddiqui, Hagglof, & Eisemann, 2000; Ustunsoz et al., 2010a; Ustunsoz, Guvenc,
Akyuz, & Oflaz, 2010b; Yarcheski et al., 2009; Yilmaz & Beji, 2013).
The first factor is maternal age. Lerum & LoBiondo-Wood (1989) invited 80
participants and the subject’s age range from 19-32 years old, and his result the correlation
between maternal age and maternal-fetal attachment was not significant. Other studies also
found the same outcome (Lindgren, 2001; Ustunsoz et al., 2010a). Then, the second factor is
parity. As Hagglof (1999) found, primipara mothers has expressed more fantasy and sharing
11
pleasure when compare to multipara. Therefore, high score of maternal-fetal attachment has
obtained from primipara mothers than multipara. Then, the same researchers mentioned,
primipara mothers were more preoccupied with their pregnancy and with the growing fetus,
otherwise, multipara focused more on environmental events, such as job situation, or
financial security. This was supported by other study. Lerum & LoBiondo-Wood (1989)
found that primipara expressed pride in their pregnant appearance, enjoy the attention of
other people and engaged more in fantasy and preparation for the arrival of the baby. Those
researchers concluded, maternal-fetal attachment score on primipara higher than multipara.
The same result also found by other researchers (Ustunsoz et al., 2010a). Otherwise, Muller
(1993) found the contradicted outcome. She mentioned, no relationship was found between
the number of previous children and either maternal-fetal attachment scale (MFAS) or
prenatal attachment inventory (PAI). That outcome supports attachment as a feeling about an
individual which can and should be separated, and there would be stronger feelings of
attachment in those women who had previous experience as a mother (Muller, 1989).
The third factor contributed to the maternal-fetal attachment is education level of mother.
However, there was contradicting result concerning mothers’ education level to the
maternal-fetal attachment. Authors found (Chen et al., 2011) that mothers’ education play a
role in maternal-fetal attachment. The reason is the higher level of mothers’ education as
equal as higher capacity of mothers for learning and ability to absorb more knowledge and
information about pregnancy. It was contradicted by other study. Muller (1993) described,
there was no correlated with mothers’ education level and maternal-fetal attachment.
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The fourth factor is obstetric risk, including high-risk pregnancy. High-risk pregnancy is
a label applied to a pregnancy in which there is a significant possibility of fetal demise, fetal
anomaly, life-threatening illness on the newborn, or serious health risk for the expectant
mothers (Gau, 1996). The categories of the high-risk pregnancy are: heart disease, severe
anemia (HB less than 9Gr %), hypertension, diabetes mellitus, hyperemesis-gravidarum,
asthma, thyroid disease, habitual abortion (abortion more than 3 times before) (Kuehn, 1986).
Researchers invited fifty-three women experiencing normal pregnancies and thirty-two
women with high-risk pregnancies to completed prenatal attachment tool and a questionnaire
providing data specific to the current pregnancy during the third trimester (Kemp & Page,
1987). They found no significant differences in the scores of the normal and high-risk groups
on prenatal attachment, which means, high-risk pregnant women attached as well to their
fetus as the low-risk pregnant women (Kemp & Page, 1987). Other studies mentioned the
same result (Gau, 1996; Kuehn, 1986; Mercer, Ferketich, May, DeJoseph, & Sollid, 1988).
The fifth factor that contributes to maternal-fetal attachment is the gestational week. A
consistent increase in scores on prenatal attachment measures over the course of the
pregnancy have been found by two researchers (Helen, Doan, & Zimerman, 2008), in line to
other researchers, that fetal maternal attachment is progressive in nature and recommended
that maternal-fetal attachment study be conducted in the second or third trimester rather than
in the first trimester (Yarcheski et al., 2009). Muller (1993) described, the correlation of
gestational age and PAI scores was small, perhaps because all women beyond 20th week of
gestation, then, the scores on the total maternal-fetal attachment scale were high signiﬁcantly
for women tested in the later phase of pregnancy (Damato, 2003; SjoGren, Edman, Widstrom,
Mathiesen, & Uvnas-Moberg, 2004). It was congruent with other study, Lerum &
13
LoBiondo-Wood (1989) stated, that prenatal attachment developed in an orderly sequential
way during the course of pregnancy. In the first trimester relatively low levels of prenatal
attachment were observed, increasing after quickening, then, progressing to attachment (e.g.,
talking to the fetus, having pet names for the fetus) and “nesting” behaviors in the second and
third trimesters.
The sixth factor that related with maternal-fetal attachment is quickening experience. In
pregnancy terms, quickening is the moment in pregnancy when the pregnant woman starts to
feel or perceive fetal movements in the uterus (Wikipedia, 2015). The first natural sensation
of quickening may feel like a light tapping, or the fluttering of a butterfly. These sensations
eventually become stronger and more regular as the pregnancy progresses. Sometimes, the
first movements are miss-attributed to gas or hunger pangs. Usually, quickening occurs
naturally at about the middle of a pregnancy. A woman pregnant for the first time (i.e., a
primigravida woman) typically feels fetal movements at about 18–20 weeks, whereas a
woman who has been pregnant more than once (i.e., a multipara woman) will typically feel
movements around 15–17 weeks (Lerum & LoBiondo-Wood, 1989). However, some authors
found the increased on maternal-fetal attachment over the course of the pregnancy have
correlation with fetal movement sensation that felt by mothers, thus, maternal-fetal
attachment scores are higher after awareness of fetal movement (Helen et al., 2008).
Conducted the measurement of attachment in the second or third trimester is give reason for
carried out the study (Yarcheski et al., 2009). It was supported by previous research (Lerum
& LoBiondo-Wood, 1989), mentioned women who have felt fetal movement has
significantly higher of maternal-fetal attachment than for those who have yet to experience
quickening.
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The previous fetal loss is the seventh factor that contributes to the maternal-fetal
attachment score. Fetal loss is a traumatic event that can profoundly affect the lives of parents
(Alhusen, 2008). Examples of prenatal loss includes: miscarriage, ectopic pregnancy,
stillbirth or neonatal death within the first 28 days of life, and other losses (Armstrong &
Hutti, 1997; Callister, 2006). Armstrong & Hutti (1997) mentioned, with prenatal loss,
parents may grieve for many years. When these couples become pregnant again, they may
continue mourning their lost child while simultaneously attempting to develop bonds of
attachment with their new unborn infant. Still the same researchers, they recruited 31
expectant mothers and 16 of them had experienced miscarriage in the 2nd trimester, stillbirth,
or early neonatal death during a previous pregnancy. Anxiety was measured using the
Pregnancy Outcome Questionnaire; prenatal attachment was measured using the Prenatal
Attachment Inventory (Amstrong & Hutti, 1997). This study found, women who experienced
a previous pregnancy loss had a higher level of anxiety related to concerns about the
pregnancy and decreased prenatal attachment with the child. Consequently, she has lower
score of maternal-fetal attachment scale rather than the mother who have no prenatal loss
experience before. It has supported by other studies (Alhusen, 2008; Sandbrook, 2009).
2-3. Studies Related to Maternal-fetal Attachment
Since attachment theory was published at the first time by Bowlby in 1958, it has been
guide many researchers to investigate the attachment between mothers and their unborn
babies or and their infant. Moreover, since Cranley (1981) as the first researcher who
published the instrument to measure maternal-fetal attachment, following by Condon (1993)
and Muller (1993). Their instruments have been widely adopted in many countries. However,
researcher conduct literature of review focus on prenatal attachment inventory scale that has
15
been adopted in some countries during five years back (2008-2014) by using data base such
as CINAHL Plus, Pub Med, and Google Scholarship. The key words are: “prenatal
attachment inventory”, “maternal-attachment inventory”, “translation”, “validation”, and
“version”. It has been found five studies appropriate with, but only two can be accessed.
The first study is to assessed prenatal attachment in a sample of Italian women (Vedova
et al., 2008). This study invited 214 low-risk pregnant women as their participant to
self-administered Italian version of Prenatal Attachment Inventory tool. The participant
should be eligible with inclusion criteria such as over 18 years old, gestational age of over 20
weeks, have no abortion experience before, and normal pregnancy. To evaluate the internal
consistency of the PAI, Cronbach Alpha coefficient was calculated, and ANOVA was carried
out to determine whether PAI scores varied according to the women’s age, educational level,
and occupation. One way ANOVA showed no statistical significant differences in the PAI
scores to the women’s age (p= .718), educational levels (p= .216), or occupation (p= .098).
Pearson’s correlation showed that the PAI scores correlated positively with gestational weeks
(r= .147, p<.05) and correlated negatively with the length of relationship (r= - 0.208, p< .01),
while not correlating with number of previous children (p= .969).Then, in order to test the
factor structure of the PAI, Principal Axis Factoring was carried out. In conclusion, the result
of this study found the 21-item PAI Italian version which seemed to be a reliable and valid
instrument to use in research involving pregnant women in Italia.
The second study is psychometric properties of the French version of the prenatal
attachment inventory (Jurgens et al., 2010). The aim of the study was to provide
psychometric data concerning the Prenatal Attachment Inventory when administered to

16
healthy pregnant women. This study was using the same instrument with current research is
prenatal attachment inventory by Muller (1993). The 112 participants were determined based
on inclusion criteria which were recruited between 34th and 38th week of gestation, were
social and medical data were assessed by self-reported. The translation of the scale into
French followed established guidelines, including appropriate use of independent back
translation. Then, to measure the reliability, researcher used Cronbach’s alpha coefficient.
Results of a confirmatory factor analysis confirmed that the data fitted well to the one factor
model of the PAI. This validation showed that the French version of the PAI has
psychometric characteristics similar to the original version. The small size of the sample and
the impossibility to compare this scale to another tool has been mentioned as the major
limitation of this research.
The differences between two studies above are the instrument has been applied in the
different countries (Italia and French), and the participants came from different gestational
age. First study recruited participants from 20th gestation of week; otherwise the second
study invited participants during 34th and 36th week. Two studies have applied
back-translation process as method to prepare the instrument from English language to their
own language.
2-4. Prenatal Attachment Inventory (PAI)
Prenatal Attachment Inventory (Muller, 1993) was derived from Maternal
Fetal-Attachment Scale (Cranley, 1981). The PAI was emphasizes to affiliation rather than
behavior as like described in MFAS (see Appendix I). Muller, in 1992, reviewed and
assessed the validity derived from Cranleys’ instrument; she found the use of that instrument
17
gave inconsistent and conflicting results. She provided as an example of the inconsistency of
the results when three researchers explore the effects of anxiety on maternal-fetal attachment
(Sandbrook, 2009).
Other instrument to measure maternal fetal attachment is Maternal Antenatal
Attachment Scale (MAAS) by Condon (1993). This items consist of 19 questions, and used in
later research by Condon & Corkindale (1997), found that invalidating some results
(Sandbrook, 2009). It has also been criticized for not representing the attachment experiences
of multiparous women. In 1993, Muller produced Prenatal Attachment Inventory (PAI)
which emphasized affiliation and emotional attachment. It to be used concurrently with
Cranleys’ tool (MFAS) and also this tool based on the assumptions proposed by the
proponent of attachment theory (Bowlby, 1958; Siddiqui & Hagglof, 1999). The instrument
is designed to measure from the mothers’ perspective, the affectionate relationship that
develop between a mother and her unborn baby and not merely the experience of pregnancy
as a physical state or her appreciation of the task concerning motherhood (M. E. Muller,
1993).
The PAI and MFAS scores were correlated at .72 level and factor analysis revealed that
prenatal attachment was one-dimensional (Muller, 1993). Muller develops the PAI in line
with the pregnancy adaptation and attachment literatures, identifying 48 items. These 48
substances were reviewed by an expert panel of 11 theoreticians, obstetrics, nurses, and
pregnant women to establish content validity (Muller, 1993). The experts rated items on a
four- point scale from ‘not relevant’ to ‘quite relevant’, resulting in a 29-item instrument and
the last revision of PAI produce 21-item (Muller, 1994).

18
The PAI is a self-report scale consisted of 21 Likert-type items ranging from 1 (‘almost
never’) to 4 (‘almost always’). Total score ranged from 21-84, with higher scores indicating
higher levels of prenatal attachment (Muller, 1994b). The assessment of validity and
reliability of PAI was based on a sample of 336 low-risk pregnant women (M. E. Muller,
1993). Most of the women were Caucasian, well-educated, middle-class and primipara. The
reliability was assessed by internal consistency (Cronbach’s Alpha .81). Construct validity
was assessed with regards to constructs taken from the attachment model and pregnancy
adaptation literature. The PAI scores exhibited a significant correlation with maternal
adjustment to pregnancy (Muller, 1993). Concurrent validity was tested by correlating PAI
scores with the Maternal Fetal Attachment Scale. The tools were strongly correlated
(p= .001). The PAI scores increased with weeks of gestation decreased with length of
marriage and years of education and did not correlate with the number of previous children.
(Gau & Lee, 2003; Muller, 1993; Muller, 1996; Siddiqui & Hagglof, 1999). After Muller
(1993), there are no other researchers who develop the new instrument of maternal-fetal
attachment
Bruno and Hugglof (1999) explained that maternal prenatal attachment during the third
trimester of pregnancy is associated with the postnatal maternal involvement. In related but
separate study described, in pregnancy, the expectant mother develops a loving relationship
with her fetal, which Muller define as prenatal attachment (Sandbrook, 2009). It has been
found that maternal-fetal attachment develops throughout pregnancy and facilitates
behavioral changes in the woman that are protective to ensure the fetal has the right
environment to promote the development and birth of a healthy baby (Sandbrook, 2009). The
19
literature of review has shown that predictors of maternal-fetal attachment are social support,
anxiety, self-esteem, depression, gestational age, prenatal testing, planned pregnancy,
mothers’ age, parity, ethnicity, marital status, income education, and high risk (Yarcheski et
al., 2009).
2-5. Translation and Back Translation
The increasing in diverse populations worldwide, the need for cross-cultural, and
multinational research indicate a great need for clinicians and researchers to have access to
reliable and valid instruments or measures cross-validated among diverse cultural segments
of the population and or in other languages. Therefore, the guidelines for conduct the study
have been established (Sousa & Rojjanasrirat, 2010; Squires et al., 2013; WHO, 2014). Based
on World Health Organization (WHO, 2014), the aim of the process of translation and
adaptation instruments is to accomplish different language versions of the English instrument
that are conceptually equivalent in each of the target countries or cultures. Besides, the
instrument should be equally natural and acceptable and should practically perform in the
same way.
The accepted procedure to accomplish these aims is the use of the back-translation
method (Brislin, 1986). In related but separated study also found the same (Wilson, 1990).
Furthermore, the translation and back-translation method as a well-known method for cross
cultural research, it is also assuring functionally equivalent translation of an instrument the
method of backs-translation was employed in order to assess the adequacy as well as the
reliability and validity of the translated instrument (Beaton, Bombardier, Guillemin, & Ferraz,
20
1998; Beaton, Bombardier, Guillemin, & Ferraz, 2000; Brislin, 1986; Guillemin, Bombardier,
& Beaton, 1993; WHO, 2014).
The translation of this instrument follows a methodological sequence, made by the
following steps according to Brislin’s model: a) translation, b) back-translation, c)committee
review, d) penels’ judgement. As described follow:
1. Forward translation
In this process, the original instrument is translated first by a translator from the source
language (SL) to the target language (TL). According to Brislin (1986), translations are of
higher quality when undertaken by at least two independent translators. This allows for the
detection of errors and divergent interpretations of ambiguous items in the original. The
quality will be even higher if each translation is undertaken by teams rather than single
individuals, who are more likely to introduce personal idiosyncrasies. However, this may be
difficult and unrealistic to find more human resource for capable translator; thus, other
alternatives will used only one translator who qualified based on eligible criteria as like
recommended by some other researchers (Brislin, 1986; Maneesriwongul & Dixon, 2004).
They are recommended that the translator either for first translator or back-translator should
preferably translate into their mother tongue. Besides, the translator expected to be able to
produce target language items readily understandable by the eventual set of respondents who
are part of the data-gathering stage of the research project. Brislin (1986) emphasize that
translator preferably translate into their mother tongue.
2. Back-translation
In this process, translation instrument (TL) then will back-translate to the source language
(SL2) by second translator (back-translator). This process has been shown to help improve
21
the quality of the final version. Unlike some of the first translators, back-translators should
preferably not be aware of the intent and concepts underlying the material. Back-translators
without a prior knowledge of the intent of the original instrument is free of biases and
expectations and their back-translation may reveal unexpected meanings or interpretations in
the final version. Other suggested is the translator preferably a health professional, familiar
with terminology of the area covered by the instrument (WHO, 2014).
They should be knowledgeable of the source language-speaking culture but his or her
mother tongue should be the primary language of the target culture. The qualifications and
characteristics of the translators are also important. Guillemin et al. (1993) suggested that,
translators should preferably translate into their mother tongue also to choosing the translator
who is familiar with survey practice and familiar with medical issues around incontinence,
also who is familiar with quality of life in the target culture (language). Finally, researchers
suggested that in back-translation process, each first translation should be back-translated
independently from each other (Beaton et al., 2000; Guillemin et al., 1993; Sousa &
Rojjanasrirat, 2010). In addition, the two translators must have distinct backgrounds. In
writing or modifying items, the suggested guidelines and rationales according to Brislin
(1986) are:
a. Use short simple sentences of less than sixteen words. Sentences longer than sixteen words,
ideas become difficult to disentangle, with lack of clarity regarding which subordinate
clause refers to which idea. This guideline does not have to lead to short items. Items can
be composed of more than one sentence, each sentence following the suggested
sixteen-word limit;
22
b. Employ the active rather than the passive voice. With the active voice, the translator can
more easily identify the subject, verb, object, and can match adjectives and adverbs to the
appropriate nouns and verbs;
c. Repeat nouns instead of using pronouns. Avoid metaphors and colloquialisms. Such
phrases are least likely to have equivalents in the target language;
d. Avoid the subjunctive, for example verb forms with "could," "would," "should." The
rationale here is very pragmatic: other languages rarely have readily available terms for the
various forms of the English subjunctive. Researchers who use the subjunctive force the
translator to make the best guess or the best approximation. Assuring clear communication
is the researcher's job, and it should not be carelessly delegated to translators;
e. Add sentences to provide context for key ideas ;
f. Avoid adverbs and prepositions telling "where" or "when"(e.g. frequently, beyond, upper)
g.Avoid possessive forms where possible;
h.Use specific rather than general terms;
i. Avoid words indicating vagueness regarding some event or Thing. Use wording familiar to
the translators;
j. Avoid sentences with two different verbs if the verbs suggest two different actions.
3. Committee review
The aim of this technique is to found discrepancies between two instruments and to build
the equivalency from two instruments. The key point of this process is to evaluate similarity
of the instructions, items and response format regarding wording, sentence structure, meaning
and relevance. These approaches will establish the initial conceptual, semantic and content
equivalence of the translated instrument. Conceptual equivalence refers to the degree to

23
which a concept of the items of the instrument exists in both the source and target cultures.
Semantic equivalence refers to sentence structure, colloquialisms or idioms that ensure that
the meaning of the text or idea of the items of the instrument in the source language is present
in the target language. Finally, content equivalence refers to the relevance and pertinence of
the text or idea of the items of the instrument in each culture (Sousa & Rojjanasrirat, 2010).
To gain the aim of this technique, constitute a committee will be present to compare source
and final versions. The committee may resolve problems by considering the material.
Gullemin et al. (1993) mentioned that membership of committee should be multidisciplinary.
This committee will conducting the small group discussion to review, comparing and adjust
both the instruments based on wording, sentence structure, meaning and relevance and to
ensure that the final item is understood as having a meaning equivalent to that of the source
item (Beaton et al., 2000; Sousa, Hartman, Miller, & Carroll, 2009)
2-6. Content Validity
Since validity is a crucial factor in the selection or application the instrument, content
validity approach was applied in this study. Content validity determinates the content
representativeness or content relevant of the elements or item of an instrument (Lynn, 1986).
In line, Polit & Beck (2006) noted, when a new scale is developed, researchers have to
following rigorous scale development procedures are expected to provide extensive
information about the scale’s reliability and validity. Then, researcher noticed frequently
definition of content validity as follows:
1) “…the degree to which an instrument has an appropriate sample of items for the construct
being measured (Polit & Beck, 2004, p.423).

24
2) “...whether or not the items sampled for inclusion on the tool adequately represent the
domain of content addressed by the instrument”(Waltz, Strickland, & Lenz, 2005, p.155)
3) “…the extent to which an instrument adequately samples the research domain of interest
when attempting to measure phenomena”( Schmidt & Schaefer, 2003, p.509).
There is general agreement in these definitions that content validity concern the degree to
which a sample of items, taken together, constitute an adequate operational definition of a
construct (Polit & Beck, 2006; Polit, Beck, & Owen, 2007b). Furthermore, among nurse
researchers, the most widely reported measure of content validity is the content validity index,
or CVI. The CVI has been used for many years, and is most often attributed to an education
(Polit & Beck, 2006; Polit et al., 2007b).
Then, as noted by Lynn (1986), researcher could use two methods to type of CVI, there
are: the content validity index for item and the content validity index for scales. The two CVI
will be defined as follow:
1. Content validity index for items (I-CVI)
To compute the I-CVI, a panel of content experts is asked to rate each scale items in
terms of its relevance the underlying construct. Lynn (1986) advised a minimum of three
experts, but indicated than more than 10 were probably was necessary. By tradition and based
on the advice of early writers such as Lynn, as well as Waltz and Bausell (1981), these item
rating are typically on a 4-point ordinal scale. The frequently use of ordinal scale are: 1 = not
relevant; 2 = unable to assess relevance; 3 = relevant but needs minor alteration; 4 = very
relevant. Then, for each item, the I-CVI is computed as the number of experts giving a rating
of either 3 or 4 (thus dichotomizing the ordinal scale into relevant and not relevant). Divided
by the total number of expert. Next to, Lynn (1986) recommended that if a panel of five or
25
fewer experts, all must agree on the content validity for their rating to be considered a
reasonable representation of the universe of possible rating. That is mean; the I-CVI should
be 1.00 when there are five or fewer judges. When there are six or more judges, the standard
can be relaxed, but Lynn (1986) suggested I-CVIs no lower than.78. Finally, researcher use
I-CVI to guide the items in revising, deleting or substituting items.
2. Content validity index for scales (S-CVI)
The S-CVI defines as the proportion of items on an instrument that achieved a rating of
3 or 4 by all the content experts. When there are more than two experts, one approach method
for computing S-CVI is the I-CVI for each item on the scale, and then calculate the average
I-CVI across the items, refers to S-CVI/Ave. However, another approach method for
computing S-CVI is the proportion of items on a scale that achieves a relevance rating of 3 or
4 by all the experts refers to S-CVI/ Universal agreement or S-CVI/UA. In as much as
S-CVI/Ave and S-CVI/UA can yield different values. These two approaches can be applied
in the study by considering the number of experts. For instance, if the researcher concern
with so many raters, the content validity would be depressed if they used the S-CVI/UA
approach that demand 100% agreement, therefore researcher considered to apply S-CVI/Ave
approach method (Polit et al., 2007b). Finally, one final issue concern an acceptable standard
for the S-CVI, previous researchers have recommended have minimum S-CVI of .80 (Polit,
Beck, & Owen, 2007a).
2-7. Construct Validity
This type of validity is especially important for measures of affect. The primary concern
in assessing construct validity is the extent to which relationships among items included in
26
the measure are consistent with the theory and concepts as operationally defined (Waltz,
Strickland, & Lenz, 2005). Activities undertaken to obtain evidence for construct validity
include:
 Examining item interrelationships
 Investigations of the type and extent of the relationship between scores and exyternal
variables
 Studies of the relationship between scores and other tools or methods intended to
measure the same concepts
 Examining relationships between scores and others measures of different constructs
 Hypothesis testing of effects of specific interventions on scores
 Comparison of scores of known groups of respondents
 Testing hypotheses about expected differences in scores across specific groups of
respondents
 Ascertaining similarities and differences in responses given by members of distinct
subgroups of respondents.
Construct validity is usually determined using of the contrasted group approach. In this
approach, the researcher identifies two groups of individuals who are known to be extremely
high and extremely low in the characteristic being measured by the instrument. The
instrument is then administered to both the high and low groups, and the difference in the
scores obtain by each are examined. If the instrument is sensitive to individual differences in
the trait being measured, the mean performance of these two groups should differ
significantly. Whether or not the two groups differ is assessed by use of an appropriate
statistical procedure such as the t test or an analysis-of variance test.

27
2-8. Reliability Tests
Brown (1997) explained, there are three strategies for estimating reliability: (a)
test-retest reliability (i.e., calculating a reliability estimate by administering a test on two
occasions and calculating the correlation between the two sets of scores), (b) equivalent (or
parallel) forms reliability (i.e., calculating a reliability estimate by administering two forms of
a test and calculating the correlation between the two sets of scores), and (c) internal
consistency reliability (i.e., calculating a reliability estimate based on a single form of a test
administered on a single occasion using one of the many available internal consistency
equations). According to Brown, the internal consistency strategy is the easiest logistically
because it does not require administering the test twice or having two forms of the test
(Brown, 1997) and also it is the most commonly reported reliability estimates in the language
testing literature (Tavakol & Dennick, 2011).
A Cronbach’s alpha score will be gained from calculation result of the questionnaire in
which already fulfilled by eligible participant. Cronbach’s alpha estimate (often symbolized
by the lower case Greek letter α) is used to estimate the proportion of variance that is
systematic or consistent in a set of test scores. It can range from 0.00 (if no variance is
consistent) to 1.00 (if all variance is consistent) with all values between 0.00 and 1.00 also
being possible (Brown, 1997). A low value of alpha could be due to a low number of
questions, poor inter- relatedness between items or heterogeneous constructs. For example if
a low alpha is due to poor correlation between items then some should be revised or
discarded.
28
2-9. Introducing of Indonesia and Province of Yogyakarta
Figure 2.1. The Map of Indonesia and Yogyakarta
The Republic of Indonesia is a sovereign state in Southeast Asia and Oceania. Indonesia
is an archipelago comprising 13,466 islands (Wikipedia, 2014) with the total population of
247,954,000 persons and the average population density is 134 people per square kilometer
(347 per sq. mi) (Indonesia, 2013).It encompasses 33 provinces and 1 Special Administrative
Region (for being governed by a pre-colonial monarchy) with over 238 million people,
making it the world's fourth most populous country. Indonesia's republic form of government
comprises an elected legislature and president. The nation's capital city is Jakarta. The
country shares land borders with Papua New Guinea, East Timor, and Malaysia. Other
29
neighboring countries include Singapore, the Philippines, Australia, Palau, and the Indian
territory of the Andaman and Nicobar Island (Indonesia, 2013).
Education in Indonesia is under the responsibility of the Ministry of Education and
Culture (Kementerian Pendidikan dan Kebudayaan or Kemdikbud) and the Ministry of
Religious Affairs (Kementerian Agama or Kemenag). In Indonesia, all citizens must
undertake nine years of compulsory education which consists of six years at elementary level
and three in secondary level (Wikipedia, 2014).
Total fertility rate in Indonesia was 2.4 birth per women (Indonesia, 2013). It was
represents the number of children that would be born to a woman if she were to live to the
end of her childbearing years and bear children in accordance with current age-specific
fertility rates. Otherwise, Infant mortality rate was 29.29 per 1000 live birth. Then, the
ministry of health is responsible in management of the health sector, which includes health
service, regulation, resource mobilization including human resource development and health
research. It has health minister, who in charge in the ministry of health.
This study was conducted in Yogyakarta (see Figure 2.1). The population of Yogyakarta
is approximately 3,390,000 and the average density is estimated to be 980, 90 persons per
square kilometer, spreading in the area of 3,186 km2. Large majority of the population are
native Javanese. Special Region of Yogyakarta majority of the population is Muslim is equal
to 90.96%, the rest are; Christian, Catholic, Hindu, and Buddhist. The number of health
centers in the city of Yogyakarta reached 18 units in 14 districts in the city.

30
1. Antenatal Visits in Indonesia
Based on Ministry of Health (Kementrian Kesehatan) (2012), antenatal care services are
individual service to prevent the occurrence of adverse problems for both mother and fetus in
order to through labor with a healthy and safe. To reach that goal, healthy physic and
psychology are needed, since it will be influenced the well-being of fetus (Kemenkes, 2012).
In Indonesia, a protocol to antenatal care service has been applying according to Health
Minister (Indonesia, 2012).
The antenatal clinic is divided into three sections; family planning, maternal child health,
and antenatal care. The clinic is administered by a senior doctor. However, the antenatal unit
is administered by a senior midwife. Antenatal care should be covered by the health
professionals: i) weight and height measurements, ii) providing the Ferum (Fe) tablet at least
90 tablets giving during pregnancy with dose one tablet a day, iii) administered Tetanus
Toxoid (TT) immunization at least two times during pregnancy, iv) performing Leopold’s
abdominal palpation to make sure the fetus well-being including fetal heart rate, fetal position
and presentation, re-check engagement of fetal head in the late pregnancy, v) providing urine
and blood laboratory sample test, especially to the mother who has predisposition of high-risk
pregnancy (e.g. diabetes mellitus history, hypertension induced pregnancy), and vi) providing
counseling, information, and education about birth planning, high-risk symptoms, and
prevention for complication related with pregnancy.

31
2. Maternal-fetal Attachment in Indonesia
Information about attachment between mother and infant in Indonesia well provided
(Bidankita, 2011; Bunda, 2014; Khasanah, 2012; Metta, 2014). Otherwise, there was no
relevant evidence published relating to maternal-fetal attachment during pregnancy.
Researcher found one of published work in which conduct the study about attachment
between maternal and toddler in Indonesia (Muti'ah, 2009). She was investigated the
maternal-fetal attachment by using Condon’s instrument to measure the attachment between
mothers and their toddlers. Previous study (Zevalnkink et al., 1999) only measure attachment
in Indonesia by using the instrument of quality of attachment with video type (qualitative
research). Furthermore, universality and generalizability of this study should be raised
(Zevalnkink et al., 1999).

32
Chapter III
Research Methodology
This chapter describes the research design and methodology, including the settings,
sampling and sample determination, inclusion and exclusion criteria, validity, reliability, data
collection, data analysis, and ethical considerations.
3-1. Study design
This study was conducted to produce the instrument for Indonesian version of PAI
(IPAI). The researcher adopted a cross-sectional study design using the instrument to gain
validity and reliability from appropriate sample. The researcher used a quantitative approach
to compare the meaning score of IPAI to two groups of pregnant women. Independent t-test
and one way ANOVA was applied to obtain the validity. Cronbach’s alpha was calculated to
measure the reliability.
3-2. Study setting
The study was conducted in Yogyakarta province. Yogyakarta is a city and the capital of
Yogyakarta Special Region in Java, Indonesia. This study was conducted in five health
centers (PKM) in Yogyakarta; health center of Jetis, health center of Kraton, health center of
Ngampilan, health center of Tegalrejo, and health center of Karangkajen. The five health
centers represent each area in Yogyakarta (North, West, South, Center, and East). The
average number of antenatal visits in health centers Yogyakarta is about 40 to 60 monthly.
These places were representative for this research because there were many clients who come
from different ethnic groups in Indonesia and the environment was supportive. The data
33
collection was set up during August-September 2014 (see Appendix I). The respondent
mapping as shown in table 3.1.
Table 3.1. Total health centers and respondents in this study
No Place 20 weeks gestation 30 weeks gestation
1. PKM* Jetis 15 20
2. PKM Tegalrejo 20 20
3. PKM Kraton 10 5
4. PKM Ngampilan 10 5
5. PKM Karangkajen 10 15
Total 65 65
*PKM= Puskesmas (health center)
3-3. Sampling and sample size

A sampling is the process of selecting a portion of the population to represent the entire
population. In this study, convenience sampling was used to recruit respondents. The
respondents selected were pregnant women who attended antenatal care in health centers in
Yogyakarta. The sampling was taken from mothers less than 20 weeks pregnant and mothers
after 30 weeks pregnant.

34
3-4. Inclusion and Exclusion Criteria
1. Inclusion Criteria
The target population:
 Pregnant women less than 20 weeks’ gestation or pregnant women after 30 weeks
gestation.
 Mothers must be able to read in Indonesian as well. Their ability must be proved when
researchers ask respondents to fill out socio-demographic data in the questionnaire.
 Mothers are willing to participate in the study
2. Exclusion Criteria
 Pregnant women with gestational age ranged 21-29 weeks.
3-5. Research Tools
In this study, there are two tools used: the demographic data sheet, and the Indonesian
version of the PAI. The first tool, the demographic data sheet, was developed by researcher.
The information from the demographic data sheet consisted of two resources. In the first
resource, information was gained from an antenatal care chart, including: age, religion,
ethnicity, education, obstetric status, gestational week, and occupation. In the second resource,
information was obtained from the pregnant woman. To create this resource, researchers
asked whether the woman had already experienced fetal motion during pregnancy.
Furthermore, the second tool was the Indonesian version of the Prenatal Attachment
Inventory. The original instrument of the PAI was designed by Muller (1993) and contains 21
items in the English language. The original questionnaire for the PAI was translated into
Indonesian with permission from Dr. Muller (see Appendix III). All items are summed for a
single score, and the possible range of scores is 21-84. The PAI is a self-reported scale
35
consisting of Likert-type items ranging from 1 (‘almost never’) to 4 (‘almost always’). The
higher the score, the stronger attachment between the mother and her fetus. The development
of this instrument was based on some previous research. Some studies had shown the
correlation of the PAI to the measure of attachment between mother and unborn baby. The
21-item PAI was validated in a Swedish sample of 171 pregnant women by Siddiqui et al
(1999), Cronbach’s alpha coefficient was .86, and the mean was 57.22 (SD = 5.916). In 2003,
Gau and Lee tested the construct validity of the instrument by using confirmatory factor
analysis (CFA) on a sample of 344 pregnant American women in their third trimesters.
Cronbach’s alpha coefficient was .89 and the mean were 63.7.
However, other researchers (Vedova et al., 2008) assessed and administered the PAI to a
sample of 214 low-risk Italian pregnant women. The mean PAI score was 60.91 (SD. =9.280).
Scores ranged from 37 to 83 (possible range 21 to 84). The PAI scores were normally
distributed (Z= .920, p= .366), and the alpha coefficient for the PAI was .87. The 26 items of
maternal attachment inventory, or PAI, also was modified to a Korean version (MAI). Scores
were positively correlated with maternal fetal attachment scores (.10 < r < .48) and maternal
sensitivity scores (.13 < r < .64). The mean MAI score was 94.26 (SD = 9.74). Cronbach’s
alpha coefficient of the total score for the Korean version of the MAI was .94. Then, to
provide an Indonesian version of the Prenatal Attachment Inventory, researcher conducted a
translation and back-translation process by following the guidelines discussed below:

36
1. Translation and back translation
The translation of the instrument was based on literature review (according to Brislin’s
guidelines). One master’s degree holder from Australia, fluent in both English and Bahasa
Indonesia, was asked to translate the English version of the PAI to Indonesian. After the
Indonesian version of the questionnaire was confirmed, another qualified translator was asked
to do the back-translation from Indonesian to English to help improve the quality of the final
version of the instrument. The information regarding the translator’s background can be seen
in Appendix IV. Then, the two translators and researchers met to discuss and to compare
instruments, the original and the back-translation. This committee (the researchers and two
translators) identified the discrepancies and inconsistencies, which needed to be adjusted with
regard to ambiguities of words and culture, based on a study of the literature (Guillemin et al.,
1993). In this process, the back-translator gave some comments and recommendations
regarding the content and culture, based on the Indonesian version, which was produced by
the first translator. The result of this process was the Indonesian version of the PAI.
2. Determination of content validity
To results content validity, researchers conducted two important procedures. First, they
selected a panel of experts. Second, they sent a cover letter and response form. Each
procedure is described below:
a. Selection of a panel of experts
The first procedure to increase the quality of content validity was to solicit expert
opinions on the instrument. Therefore, in this study, three qualified expert panels were invited.
The panels consist of experts from different professional backgrounds in the health field. The
37
criteria for selecting these experts were based on work experience. Three panelists previously
worked in the clinic as nurses and midwifes for several years. They now work as lecturers at
Health College. The experts’ backgrounds can be seen in Appendix V. After identifying
panel members, the researcher sent an e-mail or message at least one week in advance to
provide time for the expert to respond. Then, when an expert decided to accept the
researcher’s request, the cover letter and response form were delivered.
b. Cover letter and response form
Prior to inviting these experts, the researcher sent a cover letter including an explanation
of the purpose of this study, selection criteria for the experts, the measure its scoring, and the
response form. Further information about the cover letter and response form can be seen in
Appendixes VI and VII. The response form contained the expert panel’s feedback. The
experts were asked to evaluate the measure based on four criteria: (1) relevance, (2)
ambiguity, (3) simplicity, and (4) clarity. Each criterion was rated on a scale from 1 to 4
(1=‘not relevant’, 2= ‘item needs some revision’, 3= ‘relevant but needs minor revisions’,
and 4= ‘very relevant’). A Table 3.2, like the one shown below, was added as an example to
the cover letter and response form to guide the expert in the scoring method. Before sending
the instrument to the expert, researcher decided that three experts must agree on each item
and on the total instrument in order for it to be considered valid. The agreement was decided
on the rating score of either 3 or 4. Then, items that do not achieve the minimum agreement
by three experts must be either eliminated from the instrument or revised.

38
Table 3.2. The example of four criteria on a 4-point likert scale
Relevant Clarity Simplicity Ambiguity

1= Not relevant 1= Not clear 1= not simple 1= doubtful
2= Item need some 2= Item need some 2= Item need some 2= Item need some
revision revision revision revision
3= relevant but need 3= clear but need 3= simple but need 3= no doubt but need
minor revision minor revision minor revision minor revision
4= very relevant 4= very clear 4= very simple 4= meaning is clear
In the present study, to determined of content validity, researchers used item-levels
(I-CVIs) and scale-level (S-CVI) approaches. To obtain the content validity index (CVI) for
the relevance, clarity, simplicity and ambiguity of each item (item levels [I-CVIs]), the
number of experts who rated the item as a three or four were counted and divided by the total
number of experts. If the I-CVI was higher than .79, the item was judged appropriate.
Otherwise, if the I-CVI was lower than .79, the item needed to be revised. Then, to achieve
S-CVI, researchers computed the proportion of items on the instrument that achieved a rating
of 3 or 4 by the experts. Furthermore, the method of the universal agreement among experts
(S-CVI/UA), applied in this study. For calculating the S-CVI/UA, researchers conducted
several steps:
a) First,the scale was dichotomized by combining values 3 and 4 together and values 1 and 2
together. The two choice options of “relevant” and “not relevant” were formed for each
item.
b) Second, the number of items considered “relevant” by all the judges was divided by the
total number of items.

39
c. Contrasted group approach
In this study, to measure the construct validity, a contrasted-group approach was
established. The researcher created this, by means to measure the mean differences between
two groups of pregnant women, completed by sixty five respondents with gestational age of
less than 20 weeks and sixty five respondents with gestational age up to 30 weeks. Then, the
reliability of the instrument was required. Cronbach’s alpha was applied to measure the
internal consistency of the instrument. Furthermore, the respondents in this study were
recruited from five health centres in Yogyakarta, Indonesia. After obtaining informed consent,
the women were divided into two groups based on the gestational weeks classification and
then asked to fill the questionaire. Questionaires consisted of the demographic information
form and the Indonesian version of the Prenatal Attachment Inventory. The first classification
was pregnant women with less than 20 weeks of gestation, and the second classification was
pregnant women beyond 30 weeks of gestation.
3-6. Data collection processes

Prior to conducting this project, the researcher contacted the head of the health centers
and explained the purpose of study. After agreement of conducting research and approval
from the Institutional Review Board (IRB) were obtained (see Appendix VIII), the researcher
conducted several briefing sessions with five research assistants on the objectives of the study.
First briefing, researcher was explained the administration of the questionnaire to the research
assistants. Second briefing, the researcher emphasized the quality control issues relating to
biases, fabricated data, missing data, and ethical issues. These were established in an effort to
ensure consistency in the process of data collection.

40
On the days of data collection, the researcher was present at one of the health centers,
alternating based on the antenatal care schedule, in order to supervise the data collection
process, to ensure the process went according to procedure, and to answer any questions that
might arise from research assistants. The health centers in Yogyakarta generally had antenatal
care twice a week. In approaching the potential subjects, research assistants were to explain
the purpose of the study. If the subjects agreed to participate in this study, they were required
to sign the consent form (see Appendix IX). The participant was then given the questionnaire
of the Indonesian version of the PAI, and the questionnaire requesting their personal
information (see Appendix X). An estimated time of 8-10 minutes was allotted to each
participant to complete all items on the questionnaires. A private room for participants filling
out the questionnaires was provided. This was an effort to remove participants from
distractions.
Since the majority of the pregnant woman attended the health center at the same time in
the morning hours of 9-12, questionnaires were done either before or after antenatal
examinations. Completed questionnaires were collected by research assistants and checked
for missing data. If data was missing, the questionnaires were immediately returned to the
respondents to obtain the absent information. Researchers in this study thanked the
respondents for their cooperation by giving a small gift to them. The entire process of data
collection is summarized in the flow chart below.

41
Researcher contacted the Head of health center

and explained the purpose of study and got
permission from Institutional Review Board
Briefing session with five research assistants to

ensure consistency in the method of data
collection in the five health centers
Got permission from the mothers to participate in

this study and obtained their agreement to be
involved in this research and give the
questionnaire to the participant
Checking and collected the complete

questionnaire by research assistants
Figure 3.1. Flow chart of data collection

42
3-7. Data Analysis

Data analysis is the process of presenting and interpreting data. Quantitative data
analysis involves preparing a summary of the data. Descriptive statistics were used to
describe the participants’ personal information. An independent t-test applied to analyze the
difference means score of PAI between two groups. Analysis was conducted using statistical
packages for social sciences (SPSS) for Windows, version 20.0. The results are presented in
the table.
3-8. Ethical Consideration
The researcher was obtain permission to conduct the study and respected the respondents’
privacy and confidentiality (Collins, 2015) succeeding three aspects as explained as follows:
1. Permission
The researcher applied for and obtained permission to conduct the study from the
Yogyakarta city health department.
2. Informed consent
The researcher and assistance research was explain the nature and purpose study to the
respondents, obtained their informed consent and emphasized that participation was
voluntary, and that they can the right to withdraw from the study at any time without penalty
(Bowling, 2002; 138).

43
3. Privacy and confidentiality
The administration of questionnaire was conducted privately in the specific room and the
researcher assures the respondents that their information was limited as strictly confidential.
Only the researcher and those directly involved with the study will have access to the data.
44
Section IV
Results
This chapter contains the outcome of this study. The contains will be divided into two
sections. The first section described the demographic information of the respondents, and the
second section presented the Indonesian version of PAI.
4-1. Demographic Information of the Respondents
The data collection for this study is sourced from five health centers in Yogyakarta,
Indonesia. The places are the health centers of Jetis, Tegalrejo, Ngampilan, Kraton, and
Mergangsan. In total, 130 respondents participated in this study consisting of 65 pregnant
women less than 20 weeks of gestation as the first group and 65 pregnant women after 30
weeks of gestation as the second group. The demographic profile contains information about
the mother’s age, parity, education level, marital status, occupation, complication during
pregnancy, and previous fetal loss. To examine the difference of the demographic variables
between two groups (first and second group), a chi-square applied. There were no significant
differences between the groups in age, education, parity, marital status, occupation,
complication during pregnancy, and previous fetal loss.
Table 4.1 provides the statistics of demographic information of the respondents based on
the two groups. In the first group, regarding the age, 25-year-old respondents made up 49%
of the demographic, and 26-year-old respondents were up to 51%. The parity of the
respondents was 46% primigravida and 54% multigravida. The education level of the
respondents showed that 22% have graduated from junior high school, 58% have graduated
from senior high school, and 20% have graduated from college. In this group, all respondents
45
were married (100%). The occupation of the respondents showed that 49% were housewives
and 51% were working. Furthermore, in this group, the percentage of respondents who had
no complications during pregnancy was 94% and the percentage of respondents who had no
previous fetus loss was 94% (see Table 4.1).
In the second group, regarding the age, 25-year-old respondents were 48% and
26-year-old respondents were 52%. The parity of the respondents in the second group were
46% primigravida and 54% multigravida. However, the education level of the respondents
showed that 25% have graduated from junior high school, 64% have graduated from senior
high school, and 11% have graduated from college. In this group, 100% participants were
married. Then the occupation of the respondents showed that 60% were housewives and 40%
respondents were working. Finally, the percentage of complication during pregnancy showed
that 97% respondents have no complications, and the percentage of previous fetal loss
showed that 97% respondents have no previous fetal losses (see Table 4.1).
46
Table 4.1. Demographic information of respondents of this study from two groups
First group Second group
.
(less than 20 weeks) (after 30 weeks)
Variable Option n = 65 n = 65 p value
Mother's age ≤ 25 years old 32 (49%) 31 (48%)
≥ 26 years old 33 (51%) 34 (52%) = .86
Parity Primigravida 30 (46%) 30 (46%)

= .22
Multigravida 35 (54%) 35 (54%)
Mother's education
Junior high school 14 (22%) 16(25%)
level
Senior high school 38 (58%) 42 (64%)
College 13(20%) 7 (11%)
Marital Status Have not Married 0 (0%) 0 (0%)

Married 65 (100%) 65(100%)
Occupation Housewives 32 (49%) 39 (60%)

= .21
Working 33(51%) 26 (40%)
Complication
None 61 (94%) 63 (97%)
during pregnancy = .40
Have 4 (6%) 2 (3%)
Previous Fetus loss None 61(94%) 63 (97%)

= .40
Have 4 (6%) 2 (3%)
4-2. The Indonesian version of PAI
The purpose of the present study was to assess the psychometric properties of the
Indonesian version of PAI. Therefore, specific objectives were determined to accomplish the
purpose. The three specific objectives were the translation and back translation, the test to
measure the validity of the instrument, and the procedure to measure the internal consistency
of the instrument.
47
4-2-1. Transalation and Back Translation
The first phase of this study was to translate the instrument from original language
(English) to Bahasa as the target language. This process has three steps. First, forward the
translation from the source language to the target language done by a translator. Second, the
target language (Bahasa) version was translated back to the source language by another
translator. Third, two source language versions will be compared (committee review). The
description for each step, will be defined as follows:
1. Forward Translation
To achieve the forward translation, the researcher invited one translator in this study. The
criteria for selecting a translator was based on recommendations in the study of literature.
The forward translation step resulted (PAI) in Bahasa Indonesia.
2. Back-Translation
To attain the back-translation, the researcher invited another translator in this study. The
criteria for selecting a translator were based on endorsements in this study of texts. To avoid
biases of the translation, two translators work independently, and they also had no prior
knowledge about the instrument. The back translation step resulted as a prenatal attachment
inventory in the English language.
3. Committee Review
To accomplish the committee review, the researcher invited two translators to compare
the instruments between the original instrument and the back-translation instrument. For the
48
period of this process, two translators have had divergent opinions regarding wording and
sentence structure in the items of the instrument. Dissimilarity of wording and sentence
structure has been found on item 4; however, item 4 belongs to “I think that my baby already
has a personality” or, in Bahasa, belongs to “Aku berpikir bahwa bayiku sudah memiliki
sifat.” The term “sifat” expressed “personality,” and according to one of the back translators,
the word “sifat” was unclear to express the term “personality.” Otherwise, to describe the
same purpose, people understand the term “kepribadian” more rather than the term “sifat.”
Finally, the committee agreed to the supernumerary term “sifat” over the term “kepribadian.”
Another differing view in wording between the two translators was recognized. The
translator chose the term “aku” to express “I.” In contrast, as said by one of the back
translators, the word “aku” was not suitable to express “I.” Then one of the back translators
provided another preference word—“Saya” instead of “Aku”—because the term “Saya” is
more polite and more common among people. Finally, the committee agreed to change “Aku”
to “Saya” for the entire item. For the complete transcript of translation, back translation, and
final result from the committee review, finds Appendixes XI and XII.
4-2-2. Validity tests of Indonesian version of PAI
The second phase of this study was to validate the instrument produced from the
translation process. To complete the phase, two important steps are established,content
validity index and contrasted group validity approach.

49
1. Content Validity
To establish the rigorous of content validity, the researcher has to conduct two rounds of
processes to recognize content validity judgment in this study.
a. First Round
In this round, the researcher focused to analyze the results in a rating scale for each item
that was given by the three experts. Based on criteria, the item has a rating of either two or
three and will be revised according to the expert’s comments. The complete evidence
concerning counting the scale by three experts in the first round can be seen at Appendix XIII
and summarized in Table 4.2.

50
Table 4.2. Rated by experts for content validity in the first round
Rating Rating Rating Rating
Items I-CVIs Interpretation
4**** 3*** 2** 1*
1 3 0 0 0 1 Valid
2 3 0 0 0 1 Valid
3 3 0 0 0 1 Valid
4 2 0 1 0 .66 Invalid
5 3 0 0 0 1 Valid
6 2 0 1 0 .66 Invalid
7 3 0 0 0 1 Valid
8 3 0 0 0 1 Valid
9 3 0 0 0 1 Valid
10 2 1 0 0 1 Valid
11 2 1 0 0 1 Valid
12 3 0 0 0 1 Valid
13 3 0 0 0 1 Valid
14 3 0 0 0 1 Valid
15 3 0 0 0 1 Valid
16 3 0 0 0 1 Valid
17 2 1 0 0 1 Valid
18 3 0 0 0 1 Valid
19 2 1 0 0 1 Valid
20 3 0 0 0 1 Valid
21 3 0 0 0 1 Valid
* the number of expert who gave rate 1
**the number of expert who gave rate 2
***the number of expert who gave rate 3
****the number of expert who gave rate 4
51
Two items that have a rating of two (I-CVIs less than.79) and need some revisions were:
1) Item 4 belongs to “I think my baby already has a personality” or, in Bahasa, belongs to
“Saya pikir bayi saya sudah memiliki kepribadian.” This item has been rated two on the
scale of ambiguity by the first expert, while other two experts provide a rating of four on the
same item. The expert’s comment was “The content of this item can be interpreted differently
by readers. Please revise to be ‘Saya pikir bayi saya sudah memiliki pembawaan sifat sejak
dalam kandungan.’”
2) Item 6 belongs to“I know things I do make a difference to the baby” or, in Bahasa, “Saya
tahu hal-hal yang saya lakukan bisa memberikan perubahan pada bayi saya.” This item also
has been rated two on the scale clarity by the first expert, while the other two experts
provided a rating of four on the same item. According to the first expert, this item does not go
directly to the content to be measured. Consequently, a suggestion to review the item was
provided.
The four items that have a rating of three (I-CVIs .79 above) and need minor revisions
were:
1) Item 10 belongs to“I know when the baby is asleep” or “Saya tahu kapan bayi saya
tertidur.” This item has been rated three on the scale clarity by the first expert, while the
other two experts provided a rating of four on the same item. The expert’s suggestion was
unclear to measure the context of item.
2) Item 11 belongs to“I can make my baby move” or “Saya bisa membuat bayi saya
bergerak.” This item has been rated three on the scale clarity by the first expert, while the
52
other two experts provided a rating of four on the same item. The expert’s comment was
“Please modify the item in order to be clearer and easier to be understood by the
respondents.”
3) Item 17 fits into “I know why my baby is moving” or, in Bahasa, belongs to “Saya tahu
kenapa bayi saya bergerak.” This item has been rated three on the scale of ambiguity by the
third expert, while the other two experts provided a rating of four on the same item. The
expert’s comment was “To avoid ambiguity. It might be better if this item has minor
revisions as ‘Saya tahu penyebabnya mengapa bayi saya bergerak’ or in English, “I know
what caused my baby to move.”
4) Item 19 belongs to “I share secrets with the baby” or, in Bahasa, belongs to “Saya
berbagi rahasia dengan bayi saya.” This item also has been rated three on the scale of
simplicity by the second expert, while the other two experts provided a rating of four on the
same item. The expert suggested to make the item simpler.
b. Second round
In the second round, the researcher contacted the same experts to reevaluate the set’s
revised items. The six revised items were item 4, item 6, item 10, item 11, item 17, and item
19. Furthermore, the experts reached an agreement on the scale of a score of four for those
six revised items. While the second-round panel gained a reviewed set of items, the S-CVI
can be computed. Table 4.3 displays the information of final revision for each item and the
calculation of I-CVI and S-CVI. Finally, all the experts approve each item without adding
new items or deleting the original one from the instrument. The final revised Indonesian
version of PAI can be seen at Appendix XIV.

53
Table 4.3. Final Rated by experts for content validity in the second round
Items Rating Rating Rating Rating Interpretation

I-CVIs
4**** 3*** 2** 1*
1 3 0 0 0 1.00 Valid
2 3 0 0 0 1.00 Valid
3 3 0 0 0 1.00 Valid
4 3 0 0 0 1.00 Valid
5 3 0 0 0 1.00 Valid
6 3 0 0 0 1.00 Valid
7 3 0 0 0 1.00 Valid
8 3 0 0 0 1.00 Valid
9 3 0 0 0 1.00 Valid
110 3 0 0 0 1.00 Valid
11 3 0 0 0 1.00 Valid
12 3 0 0 0 1.00 Valid
13 3 0 0 0 1.00 Valid
14 3 0 0 0 1.00 Valid
15 3 0 0 0 1.00 Valid
16 3 0 0 0 1.00 Valid
17 3 0 0 0 1.00 Valid
18 3 0 0 0 1.00 Valid
19 3 0 0 0 1.00 Valid
20 3 0 0 0 1.00 Valid
21 3 0 0 0 1.00 Valid
I-CVI = 1.00
Number of items considered relevant by all the judges = 21
Number of item = 21
S-CVI/UA = 21/21 = 1
* the number of expert who gave rate 1

**the number of expert who gave rate 2
***the number of expert who gave rate 3
****the number of expert who gave rate 4
54
2. Construct validity
To provide the construct validity of the Indonesian version of PAI, this study used
the contrasted group approach. In the contrasted group approach, the researcher
identifies two groups among the pregnant women. The first group consisted of pregnant
women who were less than 20 weeks of gestation, and the second group consisted of
pregnant women after 30 weeks of gestation. Furthermore, the scores were summarized
using descriptive statistics such as mean and standard deviation. Differences between
groups in attachment were analyzed using the independent t-test as shown in Table 4.4.
Table 4.4. Mean, standard deviation and Independent t-test between two groups in total
score
Classification of gestational weeks n Mean SD t value
Gestational weeks less than 20 weeks 65 59.75 7.85

p< .001
Gestational weeks after 30 weeks 65 65.94 3.47
Then mean of score in the first group was 59.75 (SD= 7.85), while in the second
group, it was 65.94 (SD = 3.47). Then a significant level of 5% was applied, and there
was a significant difference between the two groups in the total score (p<.05).
55
4-2-3. The Reliability test of Indonesia version of PAI
The last phase of this study is addressed to identify the internal consistency by using
Cronbach’s alpha. The assessment of reliability of the Indonesian version of PAI was based
on a sample of 130 of pregnant women in two groups consist of sixty-five pregnant women
less than 20 weeks and sixty-five pregnant women after 30 weeks. As contrast-group test, the
respondents in the reliability test were invited from five health centers in Yogyakarta and set
up during Agustus-October 2014 (see Appendix II). In other words, the respondents in this
reliability test have the same places and criteria as the respondents in the validity test. Most
of the respondents graduated from senior high school, and they were housewives, and most of
the respondents were primigravida. The Cronbach’s alpha coefficient for the total PAI was
high (.937), and the minimally changed items were removed (.931-. 932), see Table 4.5.
56
Table 4.5. Reliability test

Items Mean (SD) Cronbach’s Alpha if Item Deleted
1 2.94 ( .811) .935
2 2.63 ( .831) .934
3 2.74 (1. 136) .932
4 2.33 ( .869) .937
5 2.24 ( .823) .937
6 2.80 ( .939) .933
7 2.70 ( .882) .934
8 2.11 ( .769) .936
9 2.61 ( .920) .935
10 2.31 ( .865) .936
11 2.67 (1.009) .931
12 2.63 ( .831) .934
13 3.00 ( .971) .931
14 2.80 ( .939) .932
15 2.54 ( .840) .935
16 2.76 ( .775) .934
17 2.48 ( .986) .933
18 3.13 ( .802) .936
19 2.80 ( .855) .936
20 2.96 ( .726) .933
21 3.20 ( .737) .933
Cronbach’s Alpha for all item = .937
57
CHAPTER V
Discussion
This chapter is consists of three sections. The translation and back translation process are
presented in the first section, followed by the validity tests of Indonesian version of PAI, then
reliability test well as a discussion of the study results.
5-1. Translation and Back translation
The first purpose of this study is to translate the Prenatal Attachment Inventory (PAI) to
the Indonesian version. The translation and back translation process was successfully
established in this study by two translators following by Brislin’s model. The selection
criterion to choose the eligible translators was based on the study of literature as described in
the chapter two of this study. Then committee reviewed by two translators and researcher
were effectively established to resulted Indonesian version of PAI based on committees’
appraisal. Maneesriwongul in 2004 conducted the studies reviewed in instrument translation
process, of the 47 studies reviewed, 38 used forward-and back translation, and the remaining
nine used only forward translation. Maneesriwongul described the strength and weakness of
each translation process, then the translation and back translation procedure was chosen by
researcher as the most appropriate procedure for this study. Furthermore, translation and back
translation procedure has been widely used to translate research instruments into the language
of culture being studied.
In line with this study, some previous researchers use the same procedures to translate the
instrument from original language into their culture and language. As conducted by Vedova,
58
Debrassi, & Imbasciati in 2008, they used a translation-back translation procedure to translate
the PAI into Italian, while Anand & Hima (2012) was translated and back translated of
maternal fetal attachment scale from English into Tamil Language (India) by two health
professionals who were proficient in Tamil and English.
5-2. Validation of Indonesian version of PAI
The second purpose of this study is to measure the content validity of Indonesian version
of PAI by using content validity index, and measure the construct validity by using contrasted
group approach. Regarding the content validity index, researcher invited three eligible
experts from different educational background. Two experts are nurse and lecturer in nursing
department at Health College, while one expert is midwife and lecturer in midwifery
department at Health College. By using content validity index, in the first round, experts gave
a rating scale for each item (I-CVIs) based on a four criteria (relevance, clarity, simplicity,
and ambiguity), while the second round panel gained an evaluated the revised item, the
S-CVI can be computed to result the final version of Indonesian version of PAI (IPAI). This
study has followed the rigorous scale development procedures to provide extensive
information about scale’s reliability and validity. As recommended by Polit & Beck (2006),
that among nurse researchers, the most widely reported measure of content validity is the
content validity index and it’s often attributed on an education.
As for the construct validity, contrasted group approach established. Researcher
investigated the means scores of Indonesian version of PAI to two difference groups pregnant
woman. The first group belongs to pregnant women less than 20th weeks and the second
group belongs to pregnant women after 30th weeks. In this study, there was a statistically
59
significant difference of PAI score between the groups. The results showed that the women
who were tested at the end of pregnancy displayed a higher attachment to their fetuses than
those who were studied earlier in the pregnancy. This support the preposition that prenatal
attachment is the developmental process defined previously as binding in (Rubin, 1981). In
the first trimester of their pregnancies, women are limited in the ways they can connect with
the fetus inside. A similar finding was reported by Sjogren et al (2004) that there was a
significant difference between the group in the total score (p< .01) in which women in late
pregnancy had a higher score of attachment than women in early pregnancy. In line, Vedova
et al. (2008) found that the PAI scores increased with weeks of gestation. The comparison of
the result from this study with those of previous studies established the consistency result
about prenatal attachment. One means of this finding result is the consistency use of
measurement for measuring prenatal attachment during the late stage of pregnancy. In other
word, the contrasted group approach in this study was provided evidence that the instrument
of Indonesian version of PAI measured the attribute of interest (Waltz, Strickland, & Lenz,
2005).
5-3. The reliability of Indonesian version of PAI
The third purpose of this study was to identify the internal consistency of Indonesian
version of PAI (IPAI) by using Cronbach’s α. The result in this study indicated a high
internal consistency of the Indonesian version of PAI. The alpha coefficient for IPAI total
score was slightly higher than in the study originally based on 29 items that conducted by
Muller in 1993.
.
60
Chapter VI
Conclusion and Recommendations
6-1. Conclusion
The Indonesian version of PAI had been successfully translated into Indonesia and
showed great promises for use in Indonesian childbearing women. In addition, this study
demonstrated how to conduct a content validity study and construct validity study, a crucial
step in scale development. An expert panel was used to evaluate the translation measure.
Experts critique the measured to determine the relevance, clarity, simplicity, and ambiguity
of the items. Although content validity is subjective, using this method can add objectivity.
Using a panel of experts provides the researcher with valuable information to revise a
measure.
Validating a measure is a continuing process. The first validating process is the experts’
judgment by using content validity index (CVI) that consists of two rounds. The first round of
CVI should be evaluating the content validity of the measure. The second round CVI was
reevaluates the content validity from a set of revised items based on the process in the first
round. Furthermore, the second validating process is building contrasted group approach. The
result of the contrasted group approach provided evidence that the instrument of Indonesian
version of PAI measures the attribute of interest. Finally, the result of this study indicated a
high internal consistency of the Indonesian version of PAI.

61
6-2. Limitations of This Study
The diversity of characteristic backgrounds of pregnant women in Indonesia should be
represented by samples of others from different areas. This current study invited pregnant
women only in Yogyakarta. Therefore, researcher did not achieve a random sampling from
different area in Indonesia is the one of limitation in this study.
6-3. Implications of This Study
The readings about bonding attachment after the natal stage were common to discuss in
Indonesia, while the number of studies concerning attachment during the prenatal stage was
very minor. This result study expected has implications in different areas.
1. Implication for policy development
This study provides evidence the importance to apply the PAI into maternity care units.
Therefore, policy maker in clinic setting need to establish regulation to provide this
instrument for pregnant women in the third trimesters to help them to find the attachment
problem between mother and fetal.
2. Implication for midwifery practice
Exploring prenatal attachment could assist health professionals to promote health practice
during pregnancy and could assist the health professionals to detect the problems about
expecting mothers and their fetal attachment to prevent future problems early. This
instrument will establish a guide for caregivers to recognize mothers with a poor
maternal-fetal attachment score and help them improve the outcome of pregnancy. In
addition, the increasing number study in maternal-fetal attachment in Indonesia, will provides
62
further evidence to practice maternity and nursing-care services and to use as a guide to
decide how best to incorporate information about prenatal attachment.
3. Implication for midwifery education
The maternal attachment between mothers and baby are widely discussed in the
curriculum at Health College. Since PAI was available in Indonesian, policy maker in
education setting need to include the material about attachment between mothers and fetal
during pregnancy in the curriculum as their concern.
4. Implication for research
Next researchers could use this valid instrument to explore prenatal attachment between
the mother and fetus since pregnancy. Consequently, there will increase the number of
maternal-fetal study in Indonesia.
6-4. Recommendations
Based on the findings of this study and the conclusion drawn above, the following
recommendations are made.
1. Recommendation for further study
To build the construct validity by using contrasted group approach, researcher are invited
the respondents from five health centers in Yogyakarta. However, Indonesia has a huge
number of pregnant women from different regions conditions, therefore the next researcher
should ascertain whether the Indonesian version of PAI is stable among pregnant woman in
different regions in Indonesia and the next researcher needs to be associated with other
63
instruments to assess the complexity of the topic of maternal-fetal attachment.
2. Recommendation for policy development
Since the validity and reliability of Indonesian version of PAI (IPAI) were performed the
promises result to use among pregnant women in Indonesia, the midwives coordinator in the
basic level of health services could propose this instrument as the pilot project to applied
IPAI as screening attachment for pregnant women in the late stage of pregnancy.
3. Recommendation for education
The conceptual framework of postnatal attachment had been widely applied in the
midwifery school in Indonesia. However, since Prenatal Attachment Inventory present as
Indonesian version, the lecturer have to add the conceptual framework of prenatal attachment
into subject of midwifery care of pregnant women (Asuhan Kebidanan Ibu Hamil) as the
basic knowledge to the midwifery student about maternal-fetal attachment during pregnancy.
4. Recommendation for practice
Since IPAI applied in the maternal-care unit, midwives can use this instrument to investigate
the attachment between mothers and fetuses during pregnancy in order for the midwives or
nurses to provide support to the mothers in establishing adequate emotional bonds to their
unborn babies. In addition, the need for increased awareness and understanding from health
professionals on how women develop their attachment by using this instrument.

64
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Appendix I. Prenatal Attachment Inventory (Original Instrument)

The Prenatal Attachment Inventory
The following sentences describe thoughts, feelings, and situations women
may experience during pregnancy. We are interested in your experiences
duringthepastmonth. Please circle the letter under the word that applies to
you.
almost almost
always often sometimes never
1. I wonder what the baby looks like now..............a. b. c. d.
2. I imagine calling the baby by name.................a. b. c. d.
3. I enjoy feeling the baby move......................a. b. c. d.
4. I think that my baby already has a personality.....a. b. c. d.
5. I let other people put their hands on my
tummy to feel the baby move.........................a. b. c. d.
6. I know things I do make a difference to the baby...a. b. c. d.
7. I plan the things I will do with my baby...........a. b. c. d.
8. I tell others what the baby does inside me.........a. b. c. d.
9. I imagine what part of the baby I'm touching.......a. b. c. d.
10. I know when the baby is asleep.....................a. b. c. d.
11. I can make my baby move............................a. b. c. d.
12. I buy/make things for the baby.....................a. b. c. d.

70
13. I feel love for the baby...........................a. b. c. d.
14. I try to imagine what the baby is doing in there...a. b. c. d.
15. I like to sit with my arms around my tummy.........a. b. c. d.
16. I dream about the baby.............................a. b. c. d.
17. I know why the baby is moving......................a. b. c. d.
18. I stroke the baby through my tummy.................a. b. c. d.
19. I share secrets with the baby......................a. b. c. d.
20. I know the baby hears me...........................a. b. c. d.
21. I get very excited when I think about the baby.....a. b. c. d.
Copyright Mary E. Muller, PhD 1989
Scoring:
A=4, B=3, C=2, D=1. All items are summed for a single score.
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Appendix II. Time Schedule on Thesis Writing
Activity and Times Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15
Choose one problem

Study Literature
Chapter I -III
Proposed seminar
Revised
Obtain IRB
Expert Panels Judgment
Collecting Data
Data Analysis
Chapter IV-VI
Oral Defense
Revised
Print out the Thesis
72
Appendix III. Permission and Grant to Use the Instrument
From : <konnywae@yahoo.co.id>
To : MMuller@CHILDRENSCENTRALCAL.ORG
Mar20 2014 7:13 PM
Dear. DR.Mary E Muller, RN., PhD.

Hello, my name is Endang Koni Suryaningsih, im come from Indonesia. Now I am pursuing
my Master Degree in National Taipei University of Nursing and Health Sciences (NTUNHS)
Taiwan.
It was very challenging to get your email address Doctor, but finally i got it.
I wish to appeal to you grant me permission to use your instruments on Prenatal Attachment
Inventory (PAI), published 1993. I wish to conduct a similar study for my Thesis (Translation
and Validation Muller's 21 Instrument of Prenatal Attachment Inventory in Indonesia : a Pilot
Study) and would therefore be grateful if you can grant me permission to use your
instrument .
Sincerely,
International Graduate Student/
International Nurse Midwifery Master of Science Program
National Taipei University of Nursing and Health Sciences
No.365,Ming-te Road,Peitou District,Taipei City, Taiwan
Hp. +886 984 228 572
73
From: Mary Muller
To : <konnywae@yahoo.co.id>
Mar20 pada 10:59 PM
RE: Ask Permition
Dear Endang Koni Suryaningsih,
I would be very happy to have you use the Prenatal Attachment Inventory in your study. I am
particularly happy that you will translate it and do a pilot study of it. It is not often that people are
that careful with the instruments used for measurement in nursing. In the future, please use my
home email address. That is mxexmuller@aol.com. I will be retiring soon and will always be
reviewing that email. I assume you have a copy of the PAI, but let me know if there is anything else
I can do for you.
Mary E. (Betsy) Muller
Betsy Muller, PhD, WHNP-BC
Clinical Practice Specialist
Children's Hospital, Central California
9300 Valley Children's Place
Madera, CA 93636 (559) 353-6724
>>> Konny Wae <konnywae@yahoo.co.id> 3/20/2014 4:13 AM >>>

74
From : mxexmuller@aol.com
To:konnywae@yahoo.co.id
RE: Ask Permition
Mar24 pada 7:57 PM
Here it is. You may give my email address to anyone who asks you about the Prenatal Attachment
Inventory. If you need the postnatal version, let me know.
Mary E. (Betsy) Muller
 PAI final version .Doc Download

75
Appendix IV. Translator and back-translator’s background
No Translators
1 Forward-translator:Cesa Septiana P. S.SiT., M.Mid.
Education Background :
 (2012) Master of Midwifery at Flinders University, Australia

 (2015) Pursuing PhD at Leeds University, United Kingdom
Occupation:
- 2009-1010 : Pracical in the Pivate Clinic as a midwife

- 2010-present : Health College Instititute in Midwifery Department
Job description :
 Lecturer
 Researcher
 Secretarial courses on midwifery department
2 Back-translator: Ns. Dwi Prihatiningsih, S. Kep., M.Ng.
Education Background :
 (2012) Master of Midwifery at Flinders University, Australia

 (2015) PhD candidate at Flinders University, Australia
Occupation:
- 2007-1010 : Pracical in the hospital as a nurse

- 2010-present : Health College Instititute in Nurse Department and in the
Hospital of Yogyakarta
Job description :
 Lecturer
 Researcher
 Students Affairs
 Head of Nurse Unit Care
76
Appendix V.The background of expert panels
Expert 1 Name: Wantonoro
Educational Background
 (2013) Master of Nursing, Specialist on Clinical Medical Surgery at

Indonesian University, Indonesia
 (2015) PD Candidate at Khon Kaen University, Thailand
Occupation :
 2009 – 2010 : Nurse in Maternity Unit care at PKU Muhammadiyah

Yogyakarta
 2010 – 2011 : Nurse in Fatwamati Hospital, Jakarta
 2011- present : Lecturer at Health College Institute
Job Description :
 Lecturer
 Researcher
 Students Affairs
Expert 2 Name: Ruhyana
 (2010) Master of Nursing, in University of Brunei Darussalam, Brunei
Occupation :
 2002- present : Lecturer at Health College Institute in Nursing Department
Job Description :
 Lecturer
 Researcher
77
Expert 3 Name : Anjarwati
 (2013) Master of Public Health, at Gadjah Mada University, Indonesia
Occupation :
 1999– 2002: Midwife Community at Yogyakarta

 2002- present : Lecturer at Health College Institute in Midwife Department
Job Description :
 Lecturer in Antenatal consentration

 Researcher
 Head of Study Program of Midwifery
78
Appendix VI. Cover Letter for Experts
(Brief Example of Cover Letter in English)
INSTRUCTION- This measure is designed to evaluate the content validity of a measure.

Please rate each item as follow:
 Please rate the level of relevant on a scale of 1-4, with 4 being the most relevant.
Space is provided for you to comment on the item or to suggest revisions.
 Please rate the level of clarity for each item, also on a four poin scale. Again, please
make comment in the space provided.
 Please rate the level of simplicity on a four likert scale. Please make comment or
advice in the space provided.
 Please rate the level of ambiguity on a four likert scale. Please make comment or
advice in the space provided.
 Finally, evaluate the entire measure by indicating items that should be deleted or
added. Thank you for your time.
1= Not relevant 1= Not clear 1= not simple 1= doubtful
2= Item need some 2= Item need some 2= Item need some 2= Item need some
revision revision revision revision
3= relevant but need 3= clear but need minor 3= simple but need minor 3= no doubt but need
minor revision revision revision minor revision
4= very relevant 4= very clear 4= very simple 4= meaning is clear

Item 1 1234 1234 1234 1234
Comment : Comment : Comment : Comment :
Item 2 1234 1234 1234 1234
Item 3 1234 1234 1234 1234
Item 4 1234 1234 1234 1234
79
Lam : 1 bendel instrument

Hal : Permohonan validasi instrument
Kepada Yth,
Ibu Anjarwati, S.SiT., M.PH
Di Yogyakarta
Dengah hormat,
Saya yang bertanda tangan dibawah ini :
Nama: Endang Koni Suryaningsih
NIM : 662029022
Jurusan : Master of Science (Nurse-Midwifery program)
Memohon kesediaan Ibu untuk melakukan validasi pada instrument yang akan saya gunakan
untuk penelitian dari Tesis yang berjudul “Indonesian Version of Prenatal Attachment
Inventory (PAI): a preliminary study” yang sudah disetujui oleh dosen pembimbing.
Demikian surat permohonan ini saya sampaikan. Atas perhatian dan kesediaannya, saya
ucapkan terimakasih.
Yogyakarta, 15 Juli 2014
Peneliti

80
Appendix VII. Response Form from Experts
Yang bertanda tangan dibawah ini :
Nama : Anjarwati, S.SiT., M.PH
NIP : 05.10.047
Jabatan : Dosen Prodi D III Kebidanan
Telah membaca instrument dari peneliti yang berjudul :
”Indonesian version of Prenatal Attachment Inventory: a preliminary study”
Nama : Endang Koni Suryaningsih

NIM : 662029022
Jurusan : Master of Science (Nurse-Midwifery program)
Setelah memperhatikan instrument, maka masukan peneliti adalah seperti yang tercantum
dalam lampiran.
Demikian surat keterangan ini dibuat untuk semestinya.
Yogyakarta,21 Juli 2014
Validator
Anjarwati, S.SiT., M.PH

81
Jenis Produk : Kuesioner

Judul Poduk : Indonesian Version of Prenatal Attachment Inventory (PAI) : a Preliminary
Study
A. PETU JUK PENGISIAN

1. Lembar ini dimaksudkan untuk evaluasi kuesioner yang telah disusun.
2. Ibu dimohon menilai dan mengevaluasi kuesioner ini dengan memberikan
nilai sesuai criteria yang telah dicantumkan (CVI).
3. Ibu dimohon untuk memberi masukan atau saran pada kolom saran/komentar
yang telah disediakan pada tabel.
4. Jika terdapat kesalahan konsep dan evaluasi pada kuesioner ini mohon
dituliskan pada bagian kolom saran di bawah tabel untuk keperluan perbaikan.
5. Atas kesediaan ibu untuk mengisi lembar angket diucapkan terimakasih.
Keterangan
Skor 4 : Baik
Skor 3 : Cukup
Skor 2 : Kurang
Skor 1 : Sangat Kurang

82
Content validity Index

No Butir Pertanyaan Sesuai Jelas Simpel Ambigu
Saya membayangkan bagaimana rupa bayi saya 1234 1234 1234 1234
1
sekarang Comment : Comment : Comment : Comment :
Saya membayangkan memanggil bayi saya dengan 1234 1234 1234 1234
2
nama Comment : Comment : Comment : Comment :
1234 1234 1234 1234
3 Saya menikmati ketika bayi saya bergerak
Saya berpikir bahwa bayi ku sudah memiliki 1234 1234 1234 1234
4
kepribadian Comment : Comment : Comment : Comment :
Saya mengijinkan orang lain meletakkan tangannya di 1 2 3 4 1234 1234 1234
5
atas perutku untuk merasakan gerakan bayi Comment : Comment : Comment : Comment :
Saya tahu hal-hal (tindakan) yang Saya lakukan bisa 1234 1234 1234 1234
6
memberikan perubahan pada bayi saya Comment : Comment : Comment : Comment :
Saya merencanakan hal-hal yang akan Saya lakukan 1234 1234 1234 1234
7
dengan bayi saya Comment : Comment : Comment : Comment :
Saya mengatakan kepada orang lain apa yang bayi saya 1 2 3 4 1234 1234 1234
8
lakukan di dalam tubuh saya Comment : Comment : Comment : Comment :
Saya membayangkan bagian dari tubuh bayi saya saat 1234 1234 1234 1234
9
Saya menyentuhnya Comment : Comment : Comment : Comment :
1234 1234 1234 1234
10 Saya tahu kapan bayi saya mengantuk
1234 1234 1234 1234
11 Saya bisa membuat bayi saya bergerak
83
1234 1234 1234 1234

12 Saya membeli/membuat barang-barang untuk bayi saya
1234 1234 1234 1234
13 Saya merasa adanya cinta untuk bayi saya
Saya mencoba untuk membayangkan apa yang sedang 1 2 3 4 1234 1234 1234
14
bayi saya lakukan didalam Comment : Comment : Comment : Comment :
1234 1234 1234 1234
15 Saya suka duduk dengan lengan melingkari perut saya
1234 1234 1234 1234
16 Saya bermimpi tentang bayi saya
1234 1234 1234 1234
17 Saya tahu kenapa bayi saya bergerak
1234 1234 1234 1234
18 Saya membelai bayi saya melalui perut saya
1234 1234 1234 1234
19 Saya berbagi rahasia dengan bayi saya
1234 1234 1234 1234
20 Saya tahu bayi saya dapat mendengarkan saya
Saya merasa bersemangat ketika berfikir tentang bayi 1234 1234 1234 1234
21
saya Comment : Comment : Comment : Comment :
Saran dan komentar :
…………………………………………………………………………………………………………………………………………………………
84
Kesimpulan :
Dengan ini, saya menyatakan bahwa Kuesioner Tentang “Indonesia Version of Prenatal Attachment Inventory (PAI) : a Preliminary Study” :
a. Layak digunakan tanpa revisi

b. Layak digunakan dengan revisi
c. Tidak layak digunakan
Yogyakarta, 21 Juli 2014
Validator
Anjarwati, S.SiT., M.PH.

85
An Indonesian VersionAppendix
of Prenatal Attachment
VIII. Inventory
Institutional (PAI)
Review Board
Approval (IRB)
86
Appendix I. Consent Form
(English Version)
My name is Endang Koni Suryaningsih, a Master student at National Taipei University of

Nursing and Health Sciences (NTUNHS), Taiwan.
I am conducting a study on Indonesian Version of Prenatal Attachment Inventory (IPAI):
A preliminary study. This study is intended to fulfill an academic requirement, and the
translation and validation instrument could as well be used to measure maternal fetal
attachmenttowards the improvement of promoting the well-being of pregnant women in
Indonesia.
However, you are urging to independently decide to participate or decline from this study
without recourse, and you may as well withdraw from the interview any time you wish.
If you agree with me, I will ask you few questions relating to pregnancy. This will take little
bit of your time approximately 10 minutes.
The information you will provide me will be made confidential and will not be disclose to a
third party, if you agree, may I kindly urge you to sign or thumb print in the space provided
below.
CONSENT FORM
After been provided with clear explanation of the purpose and the objectives of this
study, I here in voluntarily and independently append my signature or thumb print to attest
my consents to participate in this study.
Participant’s Signature ……….. …………………. Date: -----/--------/2014

87
(Indonesian Version)
Assalamualaikum Wa Rahmatullahi Wa Barakatuh
Perkenalkan, nama saya Endang Koni Suryaningsih, saya Mahasiswa pada Program Master
Jurusan Nurse-Midwifery Master of Science Program di National Taipei University of
Nursing and Health Sciences (NTUNHS), Taiwan.
Saya sedang melaksanakan penelitian dengan judul “Indonesian Version of Prenatal
Attachment Inventory (PAI): A preliminary study. Penelitian ini dimaksudkan untuk
memenuhi kewajiban atau syarat akademik, dan terjemahan serta validasi instrumen yang
akan dilSayakan kelak dapat dipergunakan untuk mengukur bonding attachment antara ibu
dan janin pada masa kehamilan yang diharapkan dapat meningkatkan promosi kesehatan ibu
dan janin dari sisi psikologis di Indonesia.
Meskipun begitu, anda secara bebas memutuskan untuk berkenan menjadi partisipan ataupun
menolaknya, dan anda diperkenankan mengundurkan diri pada saat dilSayakan
pengambilan data kapanpun anda kehendaki.
Jika anda berkenan, saya akan mempersilahkan anda untuk mengisi beberapa pertanyaan
pada kuisioner yang telah kami sediakan dan akan membutuhkan waktu selama kurang lebih
10 menit
Informasi yang anda berikan akan kami jamin kerahasiaannya dan tidak akan kami
sampaikan kepada pihak ketiga, jika anda menyetujui, silahkan untuk menandatangani
persetujuan berikut ini.Wassalamualaikum Wa Rahmatullahi Wa Barakatuh
CONSENT FORM
Setelah diberikan penjelasan secara jelas dari tujuan dan maksud penelitian ini, maka
saya secara sukarela bersedia menjadi responden dalam penelitian ini.
Tandatangan responden………………….…………. Tgl: -----/--------/2014

88
Appendix X. Demographic Information
(English Version)
SOCIO-DEMOGRAPHIC INFORMATION
1. Personal Information
a. Number :………………………….( feel by researcher )
b. LMP :……/………/……G…P…A…..Ah……(feel by officer )
c. Gestational week :
d. Mother’s age :
e. Name (initial) :
f. Education Level : Elementary school ( )
Secondary school ( )
Tertiary school ( )
University ( )
g. Marital Status : Legal ( )

Religion only ( )
h. Interspaced with the last pregnant………year….month.

i. Occupation : Housewife ( )
Employee ( )
Entrepreneur ( )
j. Pregnancy complication : Heart ( )

Asthma ( )
Migraine ( )
Bleeding ( )
Hyperemesis ( )
89
Anemia/HB <9gr% ( )
Other, specify……………………
None ( )
k. Loss experience: Yes ( ) No ( )

If yes, is more than 3times? Yes ( ) No ( )
l. Address :
m. Have been felt the baby’s movement?: Yes ( )
Not yet ( )
90
KUISIONER PRENATAL ATTACHMENT INVENTORY (PAI)/ KEDEKATAN IKATAN

EMOSIONAL ANTARA IBU DAN JANIN SELAMA MASA KEHAMILAN
1. Identitas Pasien
a. Nomor responden :………………………….( diisi peneliti )
b. HPHT :……/………/……G…P…A…..Ah……( diisi petugas )
c. Usia Kehamilan :
d. Umur ibu :
e. Nama (inisial) :
f. Pendidikan :Tidak tamat SD ( )
Tamat SD ( )
Tamat SMP ( )
Tamat SMA ( )
Perguruan Tinggi ( )
g. Status pernikahan : Menikah ( )

Belum menikah ( )
h. Jarak dengan kehamilan terakhir………tahun,….bulan.

i. Pekerjaan : Ibu rumah tangga ( )
Wiraswasta ( )
Pegawai swasta ( )
PNS ( )
j. Komplikasi kehamilan: Penyakit jantung ( )

Asma ( )
Migrain ( )
Perdarahan ( )
91
Mual muntah berlebihan ( )

Anemia/Hb <9gr% ( )
Lain-lain,sebutkan……………………
Tidak ada ( )
k. Pengalaman keguguran: Ya ( ) Tidak ( )

Jika Ya, apakah lebih dari 3x? Ya ( ) Tidak ( )
l. Alamat :
m. Apakah Ibu sudah merasakan gerakan janin?: Ya ( )
Belum ( )
2. Petunjuk pengisian
a. Bacalah kuesioner ini dengan cermat dan teliti sebelum menjawab.
b. Kalimat-kalimat berikut menggambarkan pikiran, perasaan, dan situasi yang
dialami wanita selama kehamilannya. Lingkarilah pada salah satu pilihan yang
Anda alami selama satu bulan kebelakang.
c. Untuk kelancaran dan validnya penelitian ini, Anda tidak perlu bertanya pada
siapapun serta jawablah seluruh pertanyaan secara jujur dan apa adanya.
92
Appendix XI. Forward-translation and back-translation result
Back-translated to original
No Original Instrument Forward translation to Bahasa
language
Aku membayangkan
I wonder what the baby looks I imagine what my baby looks
1 bagaimana rupa bayi saya
like now like now
sekarang
Aku membayangkan
I imagine calling the baby I imagine calling the baby by
2 memanggil bayi saya dengan
by name name
nama
Aku menikmati ketika bayi saya I enjoy feeling when my baby
3 I enjoy feeling the baby move
bergerak moves
I think that my baby already Aku berpikir bahwa bayi ku I think that my baby already
4
has a personality sudah memiliki sifat has a personality
Aku mengijinkan orang lain
I let other people put their I let other people put their
meletakkan tangannya di atas
5 hands on my tummy to feel hands on my tummy to feel the
perutku untuk merasakan
the baby move baby move
gerakan bayi
Aku tahu hal-hal (tindakan)
I know things I do make a yang Saya lakukan bisa I know things (actions) I do
6
difference to the baby memberikan perubahan pada make a difference to my baby
bayi ku
Aku merencanakan hal-hal
I plan the things I will do with I plan the things I will do with
7 yang akan Saya lakukan
my baby my baby
dengan bayi saya
Aku mengatakan kepada orang
I tell others what the baby I tell others what my baby
8 lain apa yang bayi saya
does inside me doing inside me
lakukukan di dalam tubuhku
Aku membayangkan bagian
I imagine what part of the I imagine part of the baby I'm
9 dari tubuh bayi saya saat Saya
baby I'm touching touching
menyentuhnya
I know when the baby is Aku tahu kapan bayi saya
10 I know when my baby is sleepy
asleep mengantuk
Aku bisa membuat bayi saya
11 I can make my baby move I can make my baby move
bergerak
I buy/make things for the Aku membeli/membuat I buy / make things for my
12
baby barang-barang untuk bayi saya baby
Aku merasa adanya cinta untuk I feel the presence of love for
13 I feel love for the baby
bayi saya my baby
Aku mencoba untuk
I try to imagine what the baby membayangkan apa yang I try to imagine what the baby
14
is doing in there sedang bayi saya lSayakan is doing in there
didalam
I like to sit with my arms Aku suka duduk dengan lengan I like to sit with my arms
15
around my tummy melingkari perutku around my tummy
93
Aku bermimpi tentang bayi

16 I dream about the baby I dream about my baby
saya
I know why the baby is Aku tahu kenapa bayi saya
17 I know why my baby is moving
moving bergerak
I stroke the baby through my Aku membelai bayi saya I stroke my baby through my
18
tummy melalui perutku tummy
Aku berbagi rahasia dengan
19 I share secrets with the baby I share secrets with my baby
bayi saya
Aku tahu bayi saya dapat
20 I know the baby hears me I know my baby hears me
mendengarkanku
Aku merasa bersemangat
I get very excited when I I get very excited when
21 ketika berfikir tentang bayi
think about the baby thinking about my baby
saya
94
Appendix XII. Final Instrument Based on Committee Review
Hampir
Hampir Kadang-
No Items Sering tidak
sering kadang
pernah
Saya membayangkan bagaimana rupa bayi
1 4 3 2 1
saya sekarang
Saya membayangkan memanggil bayi saya
2 4 3 2 1
dengan nama
3 Saya menikmati ketika bayi saya bergerak 4 3 2 1
Saya berpikir bahwa bayi saya sudah memiliki
4 4 3 2 1
kepribadian
Saya mengijinkan orang lain meletakkan
5 tangannya di atas perut saya untuk merasakan 4 3 2 1
gerakan bayi
Saya tahu hal-hal (tindakan) yang Saya
6 lakukan bisa memberikan perubahan pada bayi 4 3 2 1
saya
Saya merencanakan hal-hal yang akan Saya
7 4 3 2 1
lakukan dengan bayi saya
Saya mengatakan kepada orang lain apa yang
8 4 3 2 1
bayi saya lakukan di dalam perut saya
Saya membayangkan bagian dari tubuh bayi
9 4 3 2 1
saya saat Saya menyentuhnya
10 Saya tahu kapan bayi saya tidur 4 3 2 1
Saya bisa berkomunikasi dengan bayi saya
11 4 3 2 1
dengan membuatnya bergerak
Saya membeli/membuat barang-barang untuk
12 4 3 2 1
bayi saya
13 Saya merasa adanya cinta untuk bayi saya 4 3 2 1
Saya mencoba untuk membayangkan apa yang
14 4 3 2 1
sedang bayi saya lakukan didalam
Saya suka duduk dengan lengan melingkari
15 4 3 2 1
perut saya
16 Saya bermimpi tentang bayi saya 4 3 2 1
17 Saya tahu penyebab bayi saya bergerak 4 3 2 1
18 Saya membelai bayi saya melalui perut saya 4 3 2 1
19 Saya berbagi rahasia dengan bayi saya 4 3 2 1
20 Saya tahu bayi saya dapat mendengarkan saya 4 3 2 1
Saya merasa bersemangat ketika berfikir
21 4 3 2 1
tentang bayi saya
95
Appendix XIII. Individually Rating of Three Experts
EXPERT1

No Item
Saya membayangkan bagaimana rupa

1 4 4 4 4
bayi saya sekarang
Saya membayangkan memanggil bayi
2 4 4 4 4
saya dengan nama
Saya menikmati ketika bayi saya
3 4 4 4 4
bergerak
2
Comment: lebih digambarkan
Saya berpikir bahwa bayi saya sudah misal bayiku nanti mungkin
4 4, 4 4
memiliki kepribadian jadi orang yang sabar karena
selama hamil ini saya selalu
merasa aman dan nyaman
Saya mengijinkan orang lain
5 meletakkan tangannya di atas perut 4 4 4 4
saya untuk merasakan gerakan bayi
Saya tahu hal-hal (tindakan) yang 2
6 Saya lakukan bisa memberikan 3 Comment: perubahan 4 4
perubahan pada bayi saya yang bagaimana?
Saya merencanakan hal-hal yang akan
7 4 4 4 4
Saya lakukan dengan bayi saya
Saya mengatakan kepada orang lain
8 apa yang bayi saya lakukan di dalam 4 4 4 4
tubuh saya
96
Saya membayangkan bagian dari

9 tubuh bayi saya saat Saya 4 4 4 4
menyentuhnya
3
4
10 Saya tahu kapan bayi saya mengantuk Comment: Aku tahu kapan 4 4
bayiku tidur
3
Comment:sya sering
11 Saya bisa membuat bayi saya bergerak mengelus bayiku 4 4 4
sehingga dia merespond
engan bergerak
Saya membeli/membuat
12 4 4 4 4
barang-barang untuk bayi saya
Saya merasa adanya cinta untuk bayi
13 4 4 4 4
saya
Saya mencoba untuk membayangkan
14 apa yang sedang bayi saya lakukan 4 4 4 4
didalam
Saya suka duduk dengan lengan
15 4 4 4 4
melingkari perut saya
17 Saya tahu kenapa bayi saya bergerak 4 4 4 4

Saya membelai bayi saya melalui
18 4 4 4 4
perut saya
Saya tahu bayi saya dapat
20 4 4 4 4
mendengarkan saya
97
Saya merasa bersemangat ketika

21 4 4 4 4
berfikir tentang bayi saya
98
EXPERT 2
No Item Relevant Clarity Simplicity Ambiguity

Saya membayangkan bagaimana rupa
1 4 4 4 4
bayi saya sekarang
Saya membayangkan memanggil bayi
2 4 4 4 4
saya dengan nama
Saya menikmati ketika bayi saya
3 4 4 4 4
bergerak
Saya berpikir bahwa bayi saya sudah
4 3 4 4 4
memiliki kepribadian
Saya mengijinkan orang lain meletakkan
5 tangannya di atas perut saya untuk 4 4 4 4
merasakan gerakan bayi
Saya tahu hal-hal (tindakan) yang Saya
6 lakukan bisa memberikan perubahan pada 4 4 4 4
bayi saya
Saya merencanakan hal-hal yang akan
7 4 4 4 4
Saya lakukan dengan bayi saya
Saya mengatakan kepada orang lain apa
8 yang bayi saya lakukan di dalam tubuh 4 4 4 4
saya
Saya membayangkan bagian dari tubuh
9 4 4 4 4
bayi saya saat Saya menyentuhnya
10 Saya tahu kapan bayi saya mengantuk 4 4 4 4
11 Saya bisa membuat bayi saya bergerak 4 4 4 4
Saya membeli/membuat barang-barang
12 4 4 4 4
untuk bayi saya
99

Saya mencoba untuk membayangkan apa
14 4 4 4 4
yang sedang bayi saya lakukan didalam
Saya suka duduk dengan lengan
15 4 4 4 4
17 Saya tahu kenapa bayi saya bergerak 4 4 4 4
Saya membelai bayi saya melalui perut
18 4 4 4 4
saya
3
Comment: Aku sering be
19 Saya berbagi rahasia dengan bayi saya 4 4 4
rbicara banyak hal denga
n bayiku
Saya tahu bayi saya dapat mendengarkan
20 4 4 4 4
saya
Saya merasa bersemangat ketika berfikir
21 4 4 4 4
tentang bayi saya
100
EXPERT 3
No Item Relevant Clarity Simplicity Ambiguity
Saya membayangkan bagaimana rupa bayi saya

1 4 4 4 4
sekarang
Saya membayangkan memanggil bayi saya dengan
2 4 4 4 4
nama
3 Saya menikmati ketika bayi saya bergerak 4 4 4 4
Saya berpikir bahwa bayi saya sudah memiliki
4 4 4 4 4
kepribadian
Saya mengijinkan orang lain meletakkan tangannya
5 4 4 4 4
di atas perut saya untuk merasakan gerakan bayi
Saya tahu hal-hal (tindakan) yang Saya lakukan bisa
6 4 4 4 4
memberikan perubahan pada bayi saya
Saya merencanakan hal-hal yang akan Saya lakukan
7 4 4 4 4
dengan bayi saya
Saya mengatakan kepada orang lain apa yang bayi
8 4 4 4 4
saya lakukan di dalam tubuh saya
Saya membayangkan bagian dari tubuh bayi saya
9 4 4 4 4
saat Saya menyentuhnya
10 Saya tahu kapan bayi saya mengantuk 4 4 4 4
11 Saya bisa membuat bayi saya bergerak 4 4 4 4
Saya membeli/membuat barang-barang untuk bayi
12 4 4 4 4
saya
101
Saya mencoba untuk membayangkan apa yang

14 4 4 4 4
sedang bayi saya lakukan didalam
Saya suka duduk dengan lengan melingkari perut
15 4 4 4 4
saya
3
Comment:
persiapan
16 Saya bermimpi tentang bayi saya 4 4 4
kelahiran bayi
hingga terbawa
mimpi
3
Comment: Bayiku
17 Saya tahu kenapa bayi saya bergerak 4 4 4 bergerak karena
kondisinya sehat
18 Saya membelai bayi saya melalui perut saya 4 4 4 4
20 Saya tahu bayi saya dapat mendengarkan saya 4 4 4 4
Saya merasa bersemangat ketika berfikir tentang
21 4 4 4 4
bayi saya
102
Appendix XIV. The Final result of Indonesian version of PAI
Kalimat di bawah menjelaskan pikiran, perasaan dan situasi yang mungkin terjadi selama
kehamilan. Kami tertarik pada pengalaman
ffhhfyang anda alamidalam 1 bulan terakhir. Berilah
lingkaran pada huruf sesuai dengan yang anda rasakan.
Items Selalu Sering Hampir Hampir

kadang2 tidak
No pernah
1. Saya membayangkan bagaimana rupa 4 3 2 1

bayi sayasekarang
2. Saya membayangkan memanggil bayi 4 3 2 1

saya dengan nama
3. Saya menikmati ketika bayi saya 4 3 2 1

bergerak
4. Saya berpikir bahwa bayi saya sudah 4 3 2 1

memiliki pembawaan kepribadian
sejak dalam kandungan
5. Saya mengijinkan orang lain 4 3 2 1

meletakkan tangannya di atas perutku
untuk merasakan gerakan bayi
6. Saya tahu hal-hal (tindakan) yang 4 3 2 1

Saya lakukan dapat berdampak pada
bayi saya
103
7. Saya merencanakan hal-hal yang 4 3 2 1

akan Saya lakukan dengan bayi saya
8. Saya mengatakan kepada orang lain 4 3 2 1

apa yang bayi sayalakukan di dalam
tubuh saya
9. Saya membayangkan bagian dari 4 3 2 1

tubuh bayi saya saat Saya
menyentuhnya
10. Saya tahu kapan bayi sayatidur 4 3 2 1
11. Saya bisa membuat bayi saya bergerak 4 3 2 1
12. Saya membeli/membuat 4 3 2 1

barang-barang untuk bayi saya
13. Saya merasa adanya cinta untukbayi 4 3 2 1

saya
14. Saya mencoba untuk membayangkan 4 3 2 1

apa yang sedang bayi saya lakukan
didalam
15. Saya suka duduk dengan lengan 4 3 2 1

16. Saya bermimpi tentang bayi saya 4 3 2 1
17. Saya tahu kenapa bayi saya bergerak 4 3 2 1
18. Saya membelai bayi saya melalui 4 3 2 1

104
perut saya
19. Saya berbagi rahasia dengan bayi saya 4 3 2 1
20. Saya tahu bayi saya dapat 4 3 2 1

mendengarkan saya
21. Sayamerasa bersemangat ketika 4 3 2 1

berfikir tentang bayi sa
105
106

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National Taipei University of Nursing and Health Sciences

Indonesia Version of Prenatal Attachment Inventory (PAI):

Endang Koni Suryaningsih

Advisor: Chien-Huei Kao, C.N.M., R.N., PhD

I am so grateful to the International Cooperation and Development Fund (ICDF) Scholarship,

I am also deeply thankful to my Indonesian friends in NTUNHS, my beloved roommate,

Chapter II Literature Review

Chapter III Research Methodology

Chapter VI Conclusion and Recommendation

Figure 2.1. The Map of Indonesia and Yogyakarta 28

Figure 3.1. Flow chart of data collection 41

statement, purpose of study, and significance of the study.

1-1. Background of This Research

(Koenig et al., 2003).

1-2. Problem Statement

(Muti'ah, 2009). To create a better succeeding generation, it depends on women as mothers

stage (Muller, 1993; Muti'ah, 2009).

Based on Indonesia’s Child Protection Committee (ICPC) (2010), the number of

about 1,826 numbers of cases. Subsequently, in 2010 it increased extremely, to 21 million of

attachment needs considerably important basis of a secure maternal-fetal relationship

(Zevalnkink et al., 1999).

their babies grow up (Alhusen, 2008; Lindgren, 2001; Sandbrook, 2009).

maternal-fetal attachment was needed.

2012; Muller, 1994).

Scale (PFAS), Prenatal Self-Evaluation Questionnaire, Cognitive Adaptation to Stressful

& Corkindale, 1997; Muller, 1993; Sandbrook, 2009).

Indonesian study to provide the Indonesian version of Prenatal Attachment Inventory.

1-3. The Purposes of This Study

This study will be coverage three purposes:

1. Translate the Prenatal Attachment Inventory (PAI) into Indonesian.

3. Identify the internal consistency of Indonesian version of PAI by using Cronbach’s

1-4. Significance of This Study

Furthermore, maternal-fetal attachment instrument can be used to predict maternal-fetal

found (Condon & Corkindale, 1997; Lindgren, 2001).

was accepted (Bergha & Simonsa, 2009).

review in where include brief history of maternal-fetal attachment, maternal-fetal attachment

definitions, factors relating to maternal-fetal attachment, prenatal attachment inventory scale,

and translation and back translation.

2-1.Brief History about Maternal-fetal Attachment

feelings of security as well as meeting physical needs.

behaviors in an attempt to form a new attachment. If a new attachment figure is absent,

was an amalgam of concepts from cybernetics, information processing, developmental

role in the development of maternal-infant attachment patterns (Aisworth, 1969; Bretherton,

1992). Bowlby's and Ainsworth's conceptualized human attachment as a system of

evolutionary behaviors beginning at birth and persisting through adulthood, motivated by or

toward fear, affection, exploration, and care giving (Walsh, 2010).

the significance of this phenomenon is not as well studied as maternal-fetal attachment

maternal-fetal attachment (Alhusen, 2008).

Meanwhile, an Australian researcher, John Condon (1993), found Cranley’s work

definition: “Prenatal attachment is an abstract concept, representing the relationship between

of maternal-fetal attachment, found this strategy of conceptualizing the phenomenon to be so

theory which is proposed by Bowlby (1958).

2-2. Definition of Maternal-fetal Attachment and Related Factors

understanding about maternal-fetal attachment, it is important to recognize about

of maternal-fetal attachment. It could be described as following:

1. First, according to Cranley (1981), maternal-fetal attachment defined as the extent to

2. Second, Muller (1993) defined the maternal-attachment as the unique, affectionate

psychological adjustment to pregnancy experience as maternal identity in adaptation to

will lead the mother’s psychological and physical wellbeing.

otherwise, multipara focused more on environmental events, such as job situation, or

researchers concluded, maternal-fetal attachment score on primipara higher than multipara.

Researchers invited fifty-three women experiencing normal pregnancies and thirty-two

LoBiondo-Wood (1989) stated, that prenatal attachment developed in an orderly sequential

(Alhusen, 2008). Examples of prenatal loss includes: miscarriage, ectopic pregnancy,