The Journal of Maternal-Fetal & Neonatal Medicine

ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepage: https://www.tandfonline.com/loi/ijmf20

Psychometric properties of the Mackey Childbirth

Satisfaction Rating Scale cross-culturally adapted
to Brazilian Portuguese

Fernanda Lopes, Nelson Carvas Júnior, Mary Uchiyama Nakamura & Roseli
M. Y. Nomura

To cite this article: Fernanda Lopes, Nelson Carvas Júnior, Mary Uchiyama Nakamura & Roseli
M. Y. Nomura (2019): Psychometric properties of the Mackey Childbirth Satisfaction Rating
Scale cross-culturally adapted to Brazilian Portuguese, The Journal of Maternal-Fetal & Neonatal
Medicine, DOI: 10.1080/14767058.2019.1660763

To link to this article: https://doi.org/10.1080/14767058.2019.1660763

Published online: 12 Sep 2019.

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THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE
https://doi.org/10.1080/14767058.2019.1660763

ORIGINAL ARTICLE

Psychometric properties of the Mackey Childbirth Satisfaction Rating Scale

cross-culturally adapted to Brazilian Portuguese

niorb, Mary Uchiyama Nakamuraa and Roseli M. Y. Nomuraa
Fernanda Lopesa, Nelson Carvas Ju
a
Department of Obstetrics, Escola Paulista de Medicina, Universidade Federal de S~ao Paulo (UNIFESP), S~ao Paulo, Brazil; bInstituto de
Assist^encia M
edica Ao Servidor P
ublico Estadual (IAMSPE), S~ao Paulo, Brazil

ABSTRACT ARTICLE HISTORY

Objective: To analyze the psychometric properties of the Brazilian version of Mackey Childbirth Received 18 September 2018
Satisfaction Rating Scale (MCSRS). Accepted 23 August 2019
Methods: The MCSRS questionnaire was applied to postpartum mothers before discharge at
KEYWORDS
low-risk maternity hospital in Brazil. The inclusion criteria were maternal age between 18 and
Childbirth; patient
34 years, delivery of a live infant, and gestational age at birth over 36 weeks. In analyzing psy- satisfaction; psychometric
chometric properties, dimensionality was evaluated by exploratory factor analysis and reliability behavior; questionnaires;
by Cronbach’s alpha and McDonald’s omega. validation studies
Results: Fifty-three questionnaires were filled out by the postpartum mothers for an analysis of
psychometric properties. Of the participants, 84.9% had vaginal deliveries; and 58.5% had deliv-
eries by obstetricians and 41.5% by midwives. Two latent dimensions model was significantly
better than those obtained with the single-factor model (Dc233 ¼ 145.9, p < .001). The first
dimension explains 35% of the variance related to the items covering care giving, and the
second explains 17% of the variance related to self-satisfaction and satisfaction with the partner.
High communality was found for factor 1 (0.36–0.71) and factor 2 (0.28–0.50). For factors 1 and
2, Cronbach’s alpha was 0.96 and 0.92, and McDonalds’ omega was 0.96 and 0.89, respectively.
The reliability coefficient omega for the overall reliability of the questionnaire was 0.97.
Conclusion: The psychometric properties of the Brazilian version of the MCSRS yielded two
dimensions related to professional care giving and family. This version demonstrated good reli-
ability and is thus a potential instrument to promote improvement of childbirth care in the
country. Nonetheless, confirmation of the structural model of the tool should be sought.

Synopsis provided to her [8]. In fact, it is an important indicator

The Brazilian version of the scale of women’s satisfac-
tion with childbirth demonstrated good reliability and
will help to improve the care provided to women.
Introduction
A childbirth experience has an importance on the
woman’s well-being and health [1] as well as on her
satisfaction with it. The influential factors of the
experience [2], therefore, should be identified and
their multidimensionality verified [3–5]. They may sub-
sequently be used to define levels of satisfaction,
which are broadly viewed as a reflection of expecta-
tions, preferences [6], and the reality of caregiving [7].
More specifically, a woman’s satisfaction with child-
birth is primarily related to her access to health care
and her evaluation of the quality of the health services
of the latter [9,10]. Other factors associated with the
satisfaction construct include psychosocial aspects and
the mother–infant bonding in postpartum [11,12].
Childbirth satisfaction is analyzed from different
perspectives in studies using questionnaires to outline
women’s profiles in the various spheres of biopsycho-
social and cultural contexts. However, the question-
naires developed in a foreign language and culture to
measure women’s satisfaction with childbirth need to
be culturally adapted and then validated. The tool val-
idation process requires high methodological rigor to
ensure tool veracity and similarity of the different ver-
sions while maintaining linguistic conformity to cur-
rent social realities [13]. Guidelines are proposed and
usually followed in the cross-cultural adaptation pro-
cess [14,15]; and the psychometric properties should
be investigated and can be evaluated through factor
analysis [16].

CONTACT Roseli M. Y. Nomura roseli.nomura@hotmail.com Department of Obstetrics, Escola Paulista de Medicina, Universidade Federal de S~ao
Paulo (UNIFESP), Rua Napole~ao de Barros, 875, S~ao Paulo, Brazil
ß 2019 Informa UK Limited, trading as Taylor & Francis Group
2 F. LOPES ET AL.

Table 1. Demographic data, childbirth quantitative variables, The MCSRS is a 34-item questionnaire which evalu-
and data on the newborn extracted from the population used ates a postpartum mother’s satisfaction with child-
in the EFA of the Brazilian Portuguese version of the MCSRS.
birth. It comprises the following six subscales: self (9
Variable Result
items: Q3–Q11); partner (2 items: Q12, Q13); newborn
Maternal age, years, mean (SD) 25.0 (4.4)
Maternal ethnicity, n (%) baby (3 items: Q14–Q16); nurses (9 items: Q17, Q19,
White 10 (18.9) Q21, Q23, Q25, Q27, Q29, Q31, Q33); doctors (8 items:
African 12 (22.6)
Other 31 (58.5) Q18, Q20, Q22, Q24, Q26, Q28, Q30, Q32); and an
Marital status, n (%) overall childbirth assessment (3 items: Q1, Q2, Q34).
Cohabiting or married 49 (92.5)
Single 4 (7.5) The degree of satisfaction or dissatisfaction with
Education, n (%) aspects of childbirth was indicated on a 5-point Likert
Elementary school 6 (11.3)
High school 35 (66.0)
scale with the following options: (1) very dissatisfied;
College 12 (22.6) (2) dissatisfied; (3) neither satisfied nor dissatisfied; (4)
Parity, n (%)
Nulliparous 28 (52.8)
satisfied; (5) very satisfied. The sum of the score
Multiparous 25 (47.2) obtained in the items of the subscales gives the score
Gestational age, weeks, mean (SD) 39.7 (1.2) of each one.
Sex of the newborn, n (%)
Male 23 (43.4) The translation into Brazilian Portuguese of the ori-
Female 30 (56.6) ginal scale in English was done by a bilingual transla-
Birth weight, grams, mean (SD) 3347.0 (401.8)
Apgar score, n (%) tor, a medical doctor residing in the USA and
1st minute  7 52 (98.1) specialized in gynecology and obstetrics. The transla-
5th minute  7 53 (100.0)
tion was a conceptual rather than a verbatim render-
ing of the questionnaire. The backward translation
Recent studies have reported the validation of the into English was written by an Anglophone translator
MCSRS in different languages and cultures [7,17,18]. born in Hartford, CT, to reveal misinterpretations or
Yet, there are no specific tools in Brazilian Portuguese misnomers in the forward translation into Brazilian
to assess satisfaction with childbirth. The MCSRS, cov- Portuguese, as suggested by the back-translation
ering the most important factors related to satisfac- methodology [14]. Content validity was carried out by
tion, labor, and delivery, can fill that void. The a group of 10 judges and face validity was obtained
purpose of this study was to validate the construct of by administering the questionnaire to 10 postpartum
a tool to determine the satisfaction of women with mothers to check for item comprehension.
childbirth and to determine the psychometric proper- Subsequently, psychometric testing – including
ties of the Brazilian Portuguese version of MCSRS. exploratory factor analysis (EFA) and reliability tests –
was carried out for the Brazilian Portuguese version of
Materials and methods the scale. The questionnaire was administered in a
face-to-face interview. In addition, demographic data
This is a prospective study approved by the local on the mothers and neonates – such as parity, age,
Human Research Ethics Committee (CAAE: educational level, gestational age, and infant’s age –
51125515.7.0000.5505). The participants were informed were gathered.
of the objectives of the study and they were assured
of its confidentiality. Finally, a written informed con-
sent was obtained from every woman. Statistical analysis
This study was carried out at a low-risk maternity To analyze the dimensionality of the 34 items of the
hospital in S~ao Paulo, Brazil, during August 2016 to tool, three strategies were adopted, which were imple-
November 2016. The questionnaire was applied mented by the Psych package (version 1.6.9): scree
through an interview to 53 postpartum mothers who plot, parallel analysis, and the very simple structure
met the following inclusion criteria: age between 18 procedure. The FA routine, available in the psych
and 34 years; delivery of a live infant; gestational age package, was employed for performing exploratory
at birth over 36 weeks; and comprehension of the factor analysis. Given the ordinal nature of the items,
questionnaire. The scale was filled out by participants utilization of the polychoric correlation matrix with the
before the hospital discharge. Authorization for devel- use of the maximum likelihood estimator and the obli-
oping the Brazilian Portuguese version of the MCSRS min oblique rotation was preferred. Oblique rotation
was sought from and granted by the author, Marlene was justifiably employed because it allows for a poten-
C. Mackey. tial correlation between two latent factors. The cutoff

Figure 1. Scree plot and parallel analysis (dashed lines in red) for determining the dimensionality of the Brazilian Portuguese ver-
sion of the MCSRS.
point of 0.4 was used to take into account the factor
loadings of each item on the factors. For the reliability
analysis of the two subscales which were found,
Cronbach’s alpha and McDonald’s omega were used.
The statistical significance was set at p < .05.
Results
Fifty-three questionnaires were filled out by the post-
partum mothers for an analysis of psychometric prop-
erties. The characteristics of the population and the
newborns are displayed in Table 1. Of the participants,
84.9% had vaginal deliveries; and 58.5% had deliveries
by obstetricians and 41.5% by midwives.
In determining tool dimensionality, the scree plot,
shown in Figure 1, indicates that the first value of the
correlation matrix is considerably higher than the
others. Both the Kaiser criterion (eigenvalue above 1,
identified by the horizontal line in the graph) and the
abrupt change in the difference between their eigen-
value (the elbow method) and the parallel analysis
(identified by the dotted lines) suggest that a bi-
dimensional structure is the most adequate for
the instrument.
The very simple structure (VSS) analysis is shown in
Figure 2. It is the factorial solution which, overall,
improves the adjustment of the correlation matrix and
maintains the factor loading of the items on a single
factor or on few latent factors. The more complex sol-
utions show no improvement, suggesting that the fac-
torial structure of the tool is, in fact, simple. The v2
test, based on the likelihood ratio of the different
models, found that the model with two latent factors
was significantly better than the single-factor model
THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 3
(Dv2 ¼ 145.9, p < .001); however, the addition of more
latent factors did not entail significant improvement in
the adjustment of the model by such a criterion
(Dv2 ¼ 45.3, p ¼ .06). Hence, the solution with two
latent factors was used, notwithstanding the fact that
the solution with a single factor was not
entirely inadequate.
Exploratory factor analysis was demonstrated in the
pattern matrix which was found (Table 2). The first fac-
tor explains 35% of the variance of the items in the
model, while the second factor explains 17%. The total
percentage of the variance explained by the two fac-
tors is relatively high (52%). The factor loadings are all
above the cutoff point on a single factor, entailing a
considerably high communality for most items
(0.36–0.71 for factor 1 and 0.50–0.28 for factor 2). The
correlation between factors also points to the import-
ance of the rotation strategy utilized, for it is neither
strong enough to suggest that there is, in fact, only a
single factor, nor small enough to make the orthog-
onal solution acceptable.
The first dimension comprised the subscales of sat-
isfaction with the baby (Q14–Q16), the nurses (Q17,
Q19, Q21, Q23, Q25, Q27, Q29, Q31, Q33), the doctors
(Q18, Q20, Q22, Q24, Q26, Q28, Q30, Q32), and overall
satisfaction (Q34). The second dimension was made
up of items from the subscales of overall (Q1, Q2),
self-satisfaction (Q3–Q11), and satisfaction with the
partner (Q12, Q13).
The reliability analysis of the two subscales can be
seen in Table 3, and the final score obtained in the
studied population is presented in Table 4. The results
about subscales originally described are also pre-
sented in this table.
4 F. LOPES ET AL.

Figure 2. Very simple structure analysis for determining the dimensionality of the Brazilian Portuguese version of the MCSRS.

Table 2. Exploratory factor analysis of the application of the Table 3. Cronbach alpha reliability coefficients and
Brazilian Portuguese version of the MCSRS. McDonald’s omega for factors 1, 2 and total in the application
Variable Factor 1 Factor 2 Communality (h2) Singularity (u2) of the Brazilian Portuguese version of the MCSRS.
Factor 1 Factor1 Factor2 Total
Q32 0.90 0.14 0.71 0.29 Alpha 0.96 0.92 –
Q24 0.86 0.09 0.68 0.32 Omega 0.96 0.89 0.97
Q30 0.85 0.02 0.70 0.30
Q26 0.82 0.14 0.58 0.42
Q17 0.80 0.09 0.58 0.42
Q22 0.79 0.08 0.57 0.43 Table 4. Scores obtained in the subscales originally described
Q18 0.78 0.03 0.59 0.41 and in the factors found in the exploratory factor analysis of
Q20 0.77 0.01 0.61 0.39
Q28 0.77 0.09 0.55 0.45 the application of the Brazilian Portuguese version of
Q23 0.77 0.13 0.70 0.30 the MCSRS.
Q33 0.77 0.03 0.61 0.39 Maximum
Q27 0.75 0.12 0.66 0.34 Subscales score Mean SD Median Min Max
Q31 0.72 0.17 0.65 0.35
Q21 0.67 0.11 0.52 0.48 Self 45 33.2 7.9 35 10 45
Q29 0.64 0.18 0.54 0.46 Partner 10 9.0 1.7 10 2 10
Q19 0.63 0.19 0.54 0.46 Newborn baby 15 13.1 2.1 14 7 15
Q25 0.60 0.14 0.45 0.55 Nurse 45 39.3 5.6 41 23 45
Q15 0.57 0.28 0.55 0.45 Doctor 40 33.9 6.7 35 8 40
Q16 0.57 0.20 0.47 0.53 Overall childbirth assessment 15 12.5 2.3 13 3 15
Q34 0.52 0.28 0.47 0.53 Total (34 items) 170 141 19.2 145 90 169
Q14 0.50 0.18 0.36 0.64 Subscales obtained after EFA
Factor 2 Factor 1 105 90.8 13.4 94 57 105
Q5 0.22 0.78 0.50 0.50 Factor 2 65 50.2 10.1 53 22 64
Q11 0.04 0.73 0.50 0.50
Q9 0.02 0.73 0.54 0.46
Q6 0.18 0.66 0.58 0.42 Discussion
Q8 0.08 0.65 0.38 0.62
Q7 0.21 0.65 0.58 0.42 The analysis of the psychometric properties of the
Q10 0.07 0.64 0.38 0.62 MCSRS translated into and adapted to the Brazilian
Q13 0.21 0.60 0.51 0.49
Q2 0.14 0.50 0.33 0.67 Portuguese revealed two dimensions in the sampled
Q12 0.24 0.48 0.39 0.61 target population. The two dimensions represent fac-
Q4 0.22 0.46 0.34 0.66
Q3 0.17 0.45 0.30 0.70 tor 1 professional care (satisfaction with nurses, doc-
Q1 0.14 0.45 0.28 0.72 tors, the baby, and overall experience) and factor 2
Loads factorial 11.93 5.79
Factor 1 1.00 0.44 family (self-satisfaction and satisfaction with the part-
Factor 2 0.44 1.00 ner). The MCSRS, which was developed in the USA [3],
was the target of studies conducted in other countries,

such as Spain [7,17], Iran [18], Egypt, Syria, and
Lebanon [19].
In validating the MCSRS for Spanish [7], the psycho-
metric properties were assessed by EFA with the add-
ition of two new items related to support received
from the midwife and the obstetrician and to alterna-
tive methods of pain relief and traditional relaxation
and breathing techniques. In this Spanish version,
which included only cases of vaginal delivery, six fac-
tors were identified, accounting for 69.4% of item vari-
ance. The factors found were the following: factor 1,
obstetrician; factor 2, midwife; factor 3, dilation; factor
4, expulsion; factor 5, newborn baby; factor 6, patient
companion and comfort. The subscales which refer to
the obstetrician and the midwife, when combined,
explain nearly 40% of the variance, and the original
dimension of self-satisfaction gave way to two new
factors: dilation and expulsion. In this study, the first
factor, related to professional caregiving, includes the
obstetrician and the midwife and it explains 35% of
item variance. According to the authors [7], the
obstetrician and the newborn baby factors coincide
with the original scale of Goodman and Mackey [3]. In
this study, only two factors were extracted and they
account for 52% of item variance, a comparatively
high percentage.
In Spain, the validation carried out by Caballero
et al. [17] analyzed the psychometric properties
through EFA and confirmatory factor analysis (CFA). To
expand scale use, unplanned cesarean deliveries were
included alongside vaginal deliveries. They revealed
five different internal structures, adjusted models of
two to six factors as follows: model 1, family and care;
model 2, family, midwife, and gynecologist; model 3,
self-satisfaction, family, midwife, and gynecologist;
model 4, labor, delivery, family, midwife, and gyne-
cologist; and model 5, labor, delivery, baby, partner,
midwife, and gynecologist. The six-factor model was
deemed the best for application in clinical practice.
In Iran, the MCSRS was validated for Farsi with 32
items and five subscales [18]. The subscale referring to
the husband/partner and consisting of two items was
excluded due to local cultural barriers and hospital
policies. The questionnaire was administered to
women who had had a vaginal delivery and had no
history of cesarean sections. Factor analysis found
three subscales (baby, doctors, and nurses) which cor-
respond to Goodman and Mackey [3] original sub-
scale. The subscale referring to self-satisfaction was
divided into two dimensions (self-control and mid-
wives) and one item of the overall satisfaction sub-
scale was placed in the subscale of nurses [18]. Six
THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 5
factors with self-values higher than 1 were extracted,
and they correspond to 70.4% of the variance; the
CFA confirmed that the new model was good.
In Arabic language, the MCSRS tool was adapted
and administered in hospitals in Damascus, Syria,
Mansoura, Egypt, and Beirut, Lebanon [19]. The scale
had already been adapted in a previous study, but
only 31 items were used, because the questions
related to women’s expectations were not considered.
Both the women who had normal deliveries and those
who had C-sections were included in the study.
Perceived control was directly related to satisfaction,
and variations in the management and provision of
care between the three countries may explain the dif-
ferences in satisfaction levels observed.
In this study, the EFA for the uncovered dimension-
ality was followed by the reliability analysis of the sub-
scales using Cronbach’s alpha and McDonald’s omega.
For the reliability analysis of the two subscales that
were found, Cronbach’s alpha and McDonald’s omega
were used. The reliability coefficients are considerably
high. For the first factor, both alpha and omega are
equivalent; for the second factor, the difference is
wider, with omega indicating lower reliability. When
overall reliability is estimated using the omega coeffi-
cient alone, given that this coefficient takes into
account the multidimensionality of the scale, it is con-
siderably high.
In the Mas-Pons et al. [7] validation for Spanish,
internal consistency assessed by Cronbach’s alpha
received 0.94 for the overall scale and scores oscillating
from 0.72 to 0.96 for the subscales. These results are
similar to those of this study, which had high alpha
scores for the two factors. In the validation for Farsi
[18], Cronbach’s alpha was satisfactory, with 0.78 for
the overall scale and higher than 0.70 for the five sub-
scales, except for the newborn subscale, whose alpha
was 0.31. The reliability of the questionnaire adapted to
Arabic [19], the resulting values are the following: over-
all scale, 0.95; self, 0.93; husband/family, 0.97; baby,
0.83; nurse, 0.95; and doctors, 0.95. In contrast, the val-
idation for Spanish by Caballero et al. [17] used
McDonald’s omega to determine the reliability. The fac-
tors of all models achieved fair omegas ranging from
0.76 to 0.97, which allowed no factor to be rejected for
lack of reliability. This was also observed in this study,
where McDonald’s omega was considerably high.
Similarly, the Brazilian Portuguese version of MCSRS
exhibited good internal consistency with Cronbach’s
alpha coefficients higher than 0.7 in comparison with
the scores obtained in the original version [3] and
with the elevated McDonald omega coefficients [17].
6 F. LOPES ET AL.
In Brazil, the research “Being born in Brazil” [20]
identified factors associated with women’s satisfaction
concerning hospital births, vaginal and cesarean deliv-
eries, and health professionals. The study sample was
made up of more than 15,000 postpartum mothers at
public, private, and both public and private hospitals
nationwide. Hospital care was classified as excellent by
64% of the women in the private sector and by only
43% in the public sector. However, the satisfaction of
women with childbirth was not specifically studied. It
is worth noting that tools must be developed to
assess satisfaction in different contexts and to address
the experience in broad terms.
Women’s satisfaction with childbirth meets the gen-
eral expectations and the experience of each woman,
whose peculiarities should be accepted, reproductive
and sexual rights should be respected, and traditions
and culture should be valued. The public sector in this
country delays implementing the necessary changes in
childbirth care capable of improving women’s satisfac-
tion with the childbirth experience in all its
aspects [21,22].
This study has limitations in connection with the
sample size, which, perhaps, was not large enough to
detect more dimensions. Thus, an analysis of psycho-
metric properties with a larger sample could make it
possible [23]. A statistically representative sample of
the Brazilian population might yield a different num-
ber of dimensions. Another issue is the absence of
other questionnaires validated for Brazilian
Portuguese, preventing a comparison of this version
of the MCSRS with similar scales.
In conclusion, EFA yielded two dimensions in the
Brazilian Portuguese version of the MCSRS adapted to
the sociocultural context. This version demonstrated
good reliability and is thus a potential instrument to
promote improvement of childbirth care in the coun-
try. Nonetheless, confirmation of the structural model
of the tool should be sought.
Acknowledgments
We thank Kathia Sakamoto Reynolds and Maria Luisa Moraes
Barros Flynn for the translation and back-translation of the
questionnaire.
Disclosure statement
No potential conflict of interest was reported by the authors.
Author contributions
RMYN designed the protocol, FL collected the information,
NCJ and FL performed data analysis, RMYN and MUN helped
to interpret the findings, and RMYN and FL wrote the
final text.
Funding
We are grateful to the Fundaç~ao de Amparo a Pesquisa do
Estado de S~ao Paulo (FAPESP) for granting a scholarship to
F. Lopes [n 2015/26225–4].
ORCID
Roseli M. Y. Nomura http://orcid.org/0000-0002-
6471-2125
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