Nurs Midwifery Stud. 2016 June; 5(2):e29952.

Published online 2016 May 21.

doi: 10.17795/nmsjournal29952.

Research Article

Evaluation of Mackey Childbirth Satisfaction Rating Scale in Iran:

What Are the Psychometric Properties?
Zahra Moudi,1,* and Mahmoud Tavousi2
1
Pregnancy Health Research Center, School of Nursing and Midwifery, Zahedan University of Medical Sciences, Zahedan, IR Iran
2
Health Metrics Research Center, Iranian Institute for Health Sciences Research, Academic Center for Education, Culture and Research, Tehran, IR Iran
*
Corresponding author: Zahra Moudi, Pregnancy Health Research Center, Zahedan University of Medical Sciences, Zahedan, IR Iran. Tel: +98-5433442482, Fax: +98-
5433442481, E-mail: [email protected]

Received 2015 May 17; Revised 2015 December 28; Accepted 2016 January 02.

Abstract

Background: With the integration of the evaluation of patient satisfaction in the overall assessment of healthcare services,
au- thorities can be assured about the alignment of these services with patient needs and the suitability of care provided at the
local level.
Objectives: This study was conducted in 2013 in Zahedan, Iran, in order to assess the psychometric properties of the Iranian
version of the mackey childbirth satisfaction rating scale (MCSRS).
Patients and Methods: For this study, a methodological design was used. After translating the MCSRS and confirming its
initial validity, the questionnaires were distributed among women with uncomplicated pregnancies and no prior history of
cesarean sec- tion. The participants had given birth to healthy, full-term, singletons (with cephalic presentation) via normal
vaginal delivery at hospitals within the past six months. Cronbach’s alpha and test-retest (via the intraclass correlation coefficient)
were applied to ana- lyze the internal consistency and reliability of the scale. Moreover, the validity of the scale was tested via
exploratory factor analysis, confirmatory factor analysis, and convergent validity.
Results: The MCSRS consists of six subscales. Through the process of validation, two partner-related items (“partner” subscale) of
the scale were excluded due to cultural barriers and hospital policies. Cronbach’s alpha for the total scale was 0.78. It ranged
between
0.70 and 0.86 for five subscales, and was 0.31 for the “baby” subscale. Factor analysis confirmed the subscales of “nurse,”
“physician,” and “baby,” which were identified in the original scale. However, in the translated version, the “self” subscale was
divided into two separate dimensions. The six subscales explained 70.37% of the variance. Confirmatory factor analysis indicated
a good fitness for the new model. Convergent validity showed a significant correlation between the MCSRS and the SERVQUAL scale
(r = 0.72, P < 0.001). Moreover, the Farsi version of the MCSRS showed excellent repeatability (r = 0.81 - 0.96 for individual
subscales and r = 0.96 for the entire scale).
Conclusions: The study findings indicated the Farsi version of the MCSRS is a reliable and valid instrument. However, according
to the reliability assessment and factor analysis, the “baby” and “self” subscales need further revisions.

Keywords: Patient Satisfaction, Childbirth, Psychometric Tests

1. Background

Today, service providers have widely acknowledged the importance of the patient perspective as a proper mea-
sure that can be used to review and improve the process of healthcare provision (1). In fact, understanding of the
perspectives of patients can provide us a new opportunity for assessing the quality of the services provided and cus-
tomer satisfaction (2, 3).
Studies have shown that customer dissatisfaction may lead to complaints, refusal of services, change of health- care
providers, and even negative words from dissatisfied clients (4). Additionally, the disappointment of mothers in
childbirth services could cause negative psychological out-
comes such as post-traumatic stress disorder, reluctance to
consider future pregnancies, inclination towards elective cesarean section and abortion, negative mother-infant in-
teractions, and inability to establish an effective relation- ship with a partner (5-8).
As demonstrated in a study by Williams, service providers can assure the provision of proper care by de- signing
and delivering healthcare services based on the experiences and perceptions of healthcare recipients (in- cluding
evaluation of satisfaction) (9). In fact, with the integration of patient satisfaction evaluation in the over- all service
assessment, patients, including underprivileged citizens with no choice but to use public services, can be involved in
the analysis of care provision. Consequently, healthcare authorities can ascertain service quality and ac- ceptability, and
improve healthcare outcomes for mothers
 Copyright © 2016, Kashan University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial
4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided
the original work is properly cited.

Moudi Z and Tavousi M

and newborns (10).

Customer satisfaction is a complex and multi- dimensional concept. Assessment of customer satisfaction with the
provided care, especially childbirth services, can be both objective (by evaluating real events) and sub- jective (by
evaluating healthcare services based on the customers’ preferences, values, and expectations) (7, 11).
Fulfillment and discrepancy theories have been em- ployed to explain patient satisfaction. In fulfillment the- ory,
satisfaction is explained by the patients’ contentment with the outcomes, while prior expectations are not taken into
account. On the other hand, discrepancy theory fo- cuses on the deviation of healthcare services from expec- tations
and desires that have been internalized in an indi- vidual (11, 12).
Some scholars have applied a qualitative approach to assess women’s perspectives on satisfaction with child- birth
experiences (13-15). However, since standardization, comparability, and generalizability of qualitative results are not
feasible, there is a strong need for a psychometri- cally valid instrument.
Several questionnaires have been designed to measure childbirth satisfaction (6, 7, 11, 16-18). However, based on a
literature review of Iranian studies, these instruments have not been adapted for an Iranian population. For this
reason, a valid and reliable instrument is required to cap- ture mothers’ perspectives and evaluate different dimen-
sions and components of childbirth experiences and satis- faction. Therefore, the mackey childbirth satisfaction rat- ing
scale (MCSRS) was chosen for analysis in this study (6).
MCSRS was designed by Mackey and Goodman by examining multiple factors affecting childbirth satisfac- tion
(6). This instrument is a 34-item scale, which measures childbirth satisfaction and consists of six sub- scales:
"self " (9 items; no.3-11), "nurse" (9 items; no.
17,19,21,23,25,27,29,31,33), "partner" (2 items; no. 12,13), "baby" (3 items; no. 14-16), "physician" (8 items; no.
18,20,22,24,26,28,30,32), and "overall childbirth satisfac- tion" (3 items; no. 1-2,34).
Respondents express their satisfaction or dissatisfac- tion with each item on a five-point Likert scale: 1 = very
dissatisfied, 2 = dissatisfied, 3 = neither satisfied nor dis- satisfied, 4 = satisfied, and 5 = very satisfied. This scale has
demonstrated robust psychometric properties in the United States (6) and other countries, with internal relia- bility
coefficients of 0.90, 0.97, 0.70, 0.83, 0.93, and 0.94 for the subscales of “self,” “partner,” “baby,” “physician,” “over- all
childbirth satisfaction,” and “total score,” respectively (18-20). Additionally, MCSRS facilitates a qualitative assess- ment of
the mothers’ perspectives. The features of this tool allow researchers to identify and compare mothers’ con-
cerns across different regions. Though this tool has been
validated in a number of countries (6, 18-20), its applicabil- ity in the Iranian population has not been yet determined.

2. Objectives

The purpose of the current study was to analyze the re- liability and validity of the MCSRS in Iran.

3. Patients and Methods

3.1. The Iranian Version of MCSRS

Permission was obtained from Marlene C. Mackey via e-mail to develop the Iranian version of the MCSRS. The
English version of this scale was translated into Farsi by a health professional with a M.Sc. in midwifery and who was
fluent in English. Afterwards, the Farsi version was back- translated into English by two translators fluent in English and
Farsi. One of the translators was a general practitioner and the other held a PhD degree in the English language and
linguistics; neither of the translators had prior knowl- edge of the questionnaire.
The original scale and the translated Farsi version were reviewed by the original author (PhD in reproduc- tive
health) and an external expert in social sciences (who was bilingual and fluent in English) to compare the scales and
resolve any discrepancies. Subsequently, psychomet- ric tests, including face validity, exploratory factor analy- sis (EFA),
confirmatory factor analysis (21), convergent va- lidity, internal consistency, and reliability were performed on the Farsi
scale, consisting of five factors and 32 items.

3.2. Participants and Setting

A study with a methodological design was conducted in Zahedan, Iran in 2013. The city was stratified into three
areas, based on socioeconomic and cultural factors. Then, three healthcare centers in the northern area, two health- care
centers in the central area, and two centers in the southern area of the city were selected for the study. Over- all in Iran,
healthcare centers provide basic services for children, including immunization. Since immunization is not accessible
outside healthcare facilities, a represen- tative sample of women, who had given birth at different hospitals within the
past six months, was recruited by re- viewing the immunization records of the centers.
The inclusion criteria were as follows: 1) uncompli- cated pregnancy; 2) singleton birth with cephalic presenta-
tion; 3) no prior history of cesarean section; and 4) normal vaginal delivery of a healthy infant at the hospital.
The questionnaires were completed through face-to- face interviews. In addition, demographic information of
the mothers and neonates, e.g., parity, age, education level,

2 Nurs Midwifery Stud. 2016; 5(2):e29952.

Moudi Z and Tavousi M

gestational age, and infant’s weight, and type of hospital were gathered.

3.3. Evaluation of the Validity of MCSRS

3.3.1. Content Validity
The translated Farsi version of the questionnaire with a
34-item scale was examined for its content validity. A small group of four midwives who had worked in the hospital and
a scholar confirmed the content validity of the instru- ment.

3.3.2. Face Validity

To confirm the face validity of the MCSRS, a draft of the questionnaire was presented to 10 mothers for clarity and
wording adjustments, to ensure the questionnaire would suit the target population.

3.3.3. Exploratory Factor Analysis (EFA)

Since we aimed to apply the questionnaire in a differ- ent culture (with diverse medical beliefs and practices), use
of EFA, which assumes no prior hypothesis about the dimensionality of a given set of items, was advisable (22).
Therefore, according to Polit and Beck, the original and new factor analyses were compared with respect to factor
structure and loading.
For EFA, a total of 513 questionnaires were completed by the mothers. In accordance with Polit and Beck, EFA via
conventional methods (principal component analysis) was applied to identify the factors. Bartlett’s test of spheric- ity
and the kaiser-meyer-olkin (KMO) test were also per- formed to analyze the magnitude of inter-correlations and
sampling adequacy (22).
In this study, only factors with eigenvalues of more than one were retained (22). Orthogonal (varimax) rota- tion
was used to obtain the factor structure of the scale. Factors with a value of 0.4 or greater were considered desir- able. As
Polit and Lake noted, factor loadings exceeding 0.7 indicate an overlapping variance of at least 50% between the item
and the factor and are, therefore, desirable for in- terpretation (23).

3.3.4. Confirmatory Factor Analysis (CFA)

EFA was applied to extract the factors, while CFA was used to indicate the fitness of the extracted model in this
study (21). In fact, via CFA, the theoretical relationships be- tween the constructs within any given model can be as-
sessed.
We assessed the model via maximum likelihood esti- mation, using Lisrel 8.8 for Windows to determine which
model best fit the data. In the literature, various sug-
gestions have been made regarding the number, type,
and cut-off values for goodness of fit required for CFA. In the present study, we applied several goodness-of-fit
indicators, including relative/normed Chi-square (χ2 /df ), normed fit index (NFI), non-normed fit index (NNFI), root
mean square error of approximation (RMSEA), compara- tive fit index (CFI), and standardized root mean square
residual (SRMR) (24).
Overall, if NFI, NNFI, and CFI values range between 0.90 and 0.95, the model has an adequate fit. Values above 0.95
indicate a good fit, while values below 0.90 represent a poor fit of the model. For RMSEA, values above 1.0 should be
rejected, while values below 0.06 indicate a good fit of the model. For χ2 /df, values below 5.0 indicate an ade- quate
fit, while values below 3.0 represent a good fit of the model. Also, for SRMR, values below 0.08 indicate an ade- quate fit,
whereas values below 0.05 represent a good fit of the model (25, 26).

3.3.5. Convergent Validity

Convergent validity analyzes the correlation between two different methods that measure the same trait (22). Ac-
cording to previous studies, different features of health- care quality (e.g., safety, mother’s relationship with care- givers,
and the structural aspect) influence maternal satis- faction with childbirth services (15, 27).
In the present analysis, we hypothesized that scores on childbirth satisfaction would be positively correlated with
scores on childbirth care quality. Therefore, the SERVQUAL scale for the assessment of service quality was adapted to
confirm the probable positive correlation between child- birth satisfaction and quality of midwifery care (conver- gent
validity). Based on the findings, correlation values of
0.29, 0.3 - 0.49, and ≥ 0.5 were considered small, moder-
ate, and strong, respectively (28). The SERVQUAL scale was developed in 1988 by Parasuraman, Zeithaml, and Berry to
measure the functional quality of healthcare services. Subsequently, the applicability of this scale was assessed in
hospital environments (29). The dimensions of the SERVQUAL scale are as follows: 1) tangibles: facilities, equip- ment,
and appearance of personnel; 2) reliability: ability to perform the promised service dependably; 3) responsive- ness:
willingness to help customers and provide prompt services; 4) assurance: knowledge and courtesy of employ- ees and
their ability to inspire trust and confidence; and
5) empathy: caring, individualized attention of the firm to the clients.
The SERVQUAL scale consists of 22 items, scored on a five-point Likert scale: 1 = very dissatisfied, 2 = dissatisfied, 3
= neither satisfied nor dissatisfied, 4 = satisfied, and 5 = very satisfied. This scale was previously translated into Farsi (α
= 93%) (30, 31) and has been frequently used in Iran (32, 33).
In this study, 100 mothers were asked to complete the MC-

Nurs Midwifery Stud. 2016; 5(2):e29952. 3

Moudi Z and Tavousi M

SRS and the SERVQUAL scales simultaneously to provide ev- idence of convergent validity.

3.4. Evaluation of the Reliability of MCSRS

To analyze the internal consistency of MCSRS, at first, a total of 100 questionnaires were completed by the moth- ers.
Internal consistency was assessed based on Cronbach’s alpha or coefficient alpha. A coefficient alpha of ≥ 0.70 was
considered satisfactory (34). Moreover, the repeatability or stability of the scale was determined through test-retest and
the intraclass correlation coefficient (ICC). As Polit and Beck noted, an r-value of 0.7 is considered high for psycho- logical
variables; also, correlations between such variables are typically in the 0.20 - 0.40 range (22).
The final questionnaire was completed by 14 mothers. Ten to fourteen days later, these mothers were asked to
complete the questionnaire again. The correlation coeffi- cient and Pearson’s r were calculated to test the repeatabil- ity
of the scale. According to Polit and Lake, a reliability co- efficient above 0.70 was considered satisfactory (23).
For statistical analysis, SPSS version 13.0 and Lisrel 8.8 for Windows were utilized. The normality of the data was first
checked, and square transformation was applied for the data related to two MCSRS subscales (i.e., “self” and “nurse”).

3.5. Ethical Considerations

Permission was obtained from Zahedan University of Medical Sciences, Zahedan, Iran (April 22, 2013; approval No.
5760). The participants were informed about the ob- jectives of the study and were assured about the confiden- tiality of
the data. The subjects could withdraw from the study at any time if they desired. Finally, women who were willing to
participate in the study completed the question- naires.

4. Results

4.1. Descriptive Statistics

A total of 513 questionnaires were completed by the mothers. The majority of women (69.4%) had given birth at
teaching hospitals, while 30.6% had delivered at non- teaching hospitals. The mean age of the mothers was 27.28
± 5.83 years (range: 15 - 45 years). Also, the majority of the
participants were multiparous (73.7%), while almost 26.3%
were primiparous.
Approximately 8.4% of the participants were illiterate,
16.4% had basic education, and 21.4% had university de- grees. The mean gestational age of infants was 38.58 ± 1.26
weeks (range: 34 - 42 weeks). Also, the mean birth weight of infants was 3137.79 ± 395.23 g (range: 1500 - 4500 g).
4.2. Content and Face Validity
Due to cultural barriers and hospital policies, fathers are not allowed to be present in labor wards in Iran. There- fore,
two partner-related items (“partner” subscale) were excluded from the translated version. After the final form of the
questionnaire was approved by consensus, it was used for psychometric evaluations.

4.3. Factor Analysis

First, the suitability of the data for EFA was assessed. Bartlett’s test of sphericity was statistically significant (<
0.001), i.e., the null hypothesis, which indicates zero corre- lation among variables, could be rejected; therefore, factor
analysis was considered appropriate. Overall, the KMO test is a more appropriate tool, because it compares the magni-
tude of correlation coefficients with the size of partial cor- relation coefficients (range: 0 - 1). The closer the value is to
one, the better the prospects for factor analysis will be (23). Based on our analysis, the KMO measurement of sam- pling
adequacy was estimated at 0.91. Therefore, the data were amenable to factor analysis, and factor analysis was conducted
accordingly.
Six factors with eigenvalues greater than 1.0 were ex- tracted, accounting for 70.37% of the variance. As pre-
sented in Table 1, three and eight items were attributed to the “baby” and “physician” subscales, respectively, which did
not differ from the original scale. In the Farsi version of the scale, one item of the “overall childbirth satisfaction”
subscale (Overall, how satisfied or dissatisfied are you with your childbirth experience?) was attributed to the “nurse”
subscale (Table 1).
Moreover, data on the “self” subscale were categorized into two separate dimensions. The first dimension in-
cluded items that were solely related to mothers and their inner power, while the second dimension contained items
involving mothers and their interactions with nurses or midwives (Table 1).
The mean values and standard deviations for the “to- tal satisfaction,” “overall childbirth satisfaction,” “self,”
“nurse,” “physician,” and “baby” subscales were 117.83 ±
17.53, 10.10 ± 2.54, 34.42 ± 5.32, 33.69 ± 6.45, 27.16 ± 6.86,
and 12.43 ± 1.96, respectively. The correlation matrix for MCSRS is presented in Table 2. There was a desirable cor-
relation between each item and its matching scale, with coefficients ranging from 0.64 to 0.85, except for one item
(overall, how satisfied or dissatisfied are you with your childbirth experience?) and its corresponding scale (r =
0.6).
The findings indicated the adequate fitness of the model in structural equation modeling. As presented in Table
3, the produced model with six subscales had accept- able indices (χ2 /df = 4.73, RMSEA = 0.085, CFI = 0.96, NFI =

4 Nurs Midwifery Stud. 2016; 5(2):e29952.

Moudi Z and Tavousi M

a,b,c
Table 1. Exploratory Factor Analysis of the Iranian Version of the Mackey Childbirth Satisfaction Rating Scale (Part 1)

Items Factors

Nurse Physician Self Baby Overall Satisfaction

Five Items Four Items

1. Your overall labor experience 0.169 0.124 0.134 0.345 -0.028 0.765

2. Your overall delivery experience 0.230 0.090 0.092 0.257 0.011 0.819

3. Your level of participation in decision-making during labor 0.413 0.172 0.091 0.681 0.112 0.095

4. Your level of participation in decision-making during delivery 0.344 0.126 0.144 0.700 0.118 0.051

5. Your ability to manage your labor contractions 0.158 0.086 0.514 0.503 0.011 0.218

6. Your level of comfort during labor 0.117 0.150 0.163 0.783 0.046 0.180

7. Your level of comfort during delivery 0.147 0.171 0.192 0.775 0.031 0.205

8. The control you had over your emotions during labor 0.090 0.005 0.882 0.109 0.065 0.084

9. The control you had over your emotions during delivery 0.054 -0.005 0.853 0.146 0.109 0.039

10. The control you had over your actions during labor 0.210 -0.013 0.822 0.075 0.109 0.023

11. The control you had over your actions during delivery 0.100 0.004 0.797 0.142 0.137 0.027

*
14 . Your baby’s physical condition at birth 0.145 0.162 0.404 0.128 0.416 -0.356

15. The amount of time that passed before you first held your baby 0.097 0.075 0.131 0.062 0.887 0.016

16. The amount of time that passed before you first fed your baby 0.021 0.128 0.216 0.099 0.865 0.006

17. The physical care you received from the nursing staff during labor and delivery 0.624 0.307 0.107 0.208 0.088 0.113

18. The physical care you received from the medical staff during labor and delivery 0.257 0.779 0.084 0.178 0.146 0.036

19. The technical knowledge, ability, and competence of the nursing staff in labor and delivery 0.702 0.179 0.134 0.038 0.041 0.080

20. The technical knowledge, ability, and competence of the medical staff in labor and delivery 0.245 0.777 0.026 0.065 0.154 0.046

21. The amount of explanation or information received from the nursing staff in labor and delivery 0.741 0.236 0.184 0.177 0.041 -0.105

22. The amount of explanation or information received from the medical staff in labor and delivery 0.296 0.790 0.039 0.014 0.090 0.007

23. The personal interest and attention given to you by the nursing staff in labor and delivery 0.766 0.302 0.098 0.181 0.048 0.118

24. The personal interest and attention given to you by the medical staff in labor and delivery 0.258 0.838 -0.010 0.091 -0.009 0.120

25. The help and support with breathing and relaxation you received from the nursing staff in labor and delivery 0.708 0.313 0.081 0.166 0.024 -0.004

26. The help and support with breathing and relaxation you received from the medical staff in labor and delivery 0.272 0.834 -0.039 0.109 0.048 0.062

27. The amount of time the nurses spent with you during labor 0.683 0.338 -0.023 0.065 -0.059 0.238

28. The amount of time the doctors spent with you during labor 0.240 0.777 -0.052 0.059 -0.086 0.179

29. The attitude of nurses in labor and delivery 0.759 0.160 0.117 0.208 0.073 -0.072

30. The attitude of physicians in labor and delivery 0.278 0.740 0.054 0.237 0.085 -0.115

31. The nursing staff’s sensitivity to your needs during labor and delivery 0.749 0.345 0.056 0.157 0.007 0.065

32. The medical staff’s sensitivity to your needs during labor and delivery 0.294 0.813 0.041 0.137 0.044 -0.003

33. The overall care you received during labor and delivery 0.745 0.273 0.052 0.103 0.019 0.205

34. Overall, how satisfied or dissatisfied are you with your childbirth experience? 0.579 0.239 0.176 0.193 0.188 0.315
 Eigenvalue 6.11 5.98 3.57 3.08 1.91 1.84

Explained variance, % 19.11 18.69 11.17 9.65 5.99 5.76

a
Kaiser-Meyer-Olkin measure of sampling = 0.91; Bartlett’s test = 12067.46; df = 496 Sig < 0.001.
b
Extraction Method: Principal component analysis.
c
Rotation Method: Varimax with Kaiser normalization.
*
Items 12 and 13 were deleted.

0.94, NNFI = 0.95, and SRMR = 0.067). In addition, the cor- relation matrix between the latent variables in CFA is pre-
sented in Table 4.

4.4. Convergent Validity

Overall, the estimated convergent validity between the MCSRS and SERVQUAL scales was strong (r = 0.72, P < 0.001). As
expected, the results showed a strong and significant correlation among SERVQUAL sub-domains (“reliability,”
“responsibility,” “assurance,” and “empathy”) and MCSRS
subscales (“nurse,” “self,” and “overall satisfaction”), which were related to interpersonal relationships (Table 5).

4.5. Reliability of the Scale

As demonstrated in Table 6, the MCSRS showed excel- lent repeatability. Five factors of the translated version
showed satisfactory internal consistency with Cronbach’s α of > 0.7, except for the “baby” subscale (α = 0.31). More- over,
the items related to each subscale (e.g., “self”) were

Nurs Midwifery Stud. 2016; 5(2):e29952. 5

Moudi Z and Tavousi M

Table 2. The Correlation Matrix for Mackey Childbirth Satisfaction Rating Scale

Self Nurse Physician Baby Overall Childbirth Satisfaction Total Satisfaction

Self 1.00

Nurse 0.48

Physician 0.30 0.63

Baby 0.39 0.23 0.23

Overall childbirth satisfaction 0.53 0.52 0.37 0.12

Total satisfaction 0.71 0.86 0.80 0.42 0.66 1.00

Table 3. Goodness-of-fit Indices for the Confirmatory Factor Analysis of the Mackey Childbirth Satisfaction Rating Scale After Exploratory Factor Analysis (n = 513)

Parameters Results

Indices

Degree of freedom 449

2
χ /df 4.73

Root mean square error of approximation (RMSEA) 0.085

Normed fit index (NFI) 0.94

Non-normed fit index (NNFI) 0.95

Comparative fit index (CFI) 0.95

Incremental fit index (IFI) 0.95

Root mean square residual (RMR) 0.056

Standardized RMR (SRMR) 0.067

Goodness of fit index (GFI) 0.79

a
Latent variables and factors Number of items Factor loading

5 0.60, 0.88, 0.84, 0.80, 0.76

Self
4 0.83, 0.81, 0.70, 0.72
b
Nurse 10 0.83, 0.79, 0.69 , 0.72, 0.67, 0.76, 0.85, 0.76, 0.74, 0.75

Physician 8 0.82, 0.80, 0.82, 0.86, 0.87, 0.78, 0.79, 0.86

Baby 3 0.49, 0.78, 0.89

 Overall childbirth satisfaction 2 0.87, 0.81
a
All factor loadings are significant at P = 0.01.
b
The item “Overall, how satisfied or dissatisfied are you with your childbirth experience?” is related to the “overall childbirth satisfaction” subscale.

subjected to reliability assessment, and the corrected item- to-total correlations were examined.

Among items attributed to the “baby” subscale, one item, i.e., “baby’s physical condition at birth” showed a cor-
relation of 0.61 with the total score. Other item-to-total cor- relations for the “baby” subscale ranged from 0.84 to 0.87.
Also, among items related to “overall childbirth satisfac- tion,” only one (“Overall, how satisfied or dissatisfied are you
with your childbirth experience?”) showed a correla- tion of 0.58. The rest of the item-to-total correlations for “overall
childbirth satisfaction” ranged from 0.86 to 0.87.
5. Discussion

The present study is the first comprehensive report on the Iranian version of the MCSRS. The results showed that the
translated version possessed relatively sufficient psy- chometric properties.
Factor analysis confirmed three out of five subscales (i.e., “nurse,” “physician,” and “baby”), which were identi- fied
in the original scale. However, the “self” subscale was divided into two separate dimensions. The first dimension involved
the following four items: “your level of participa-
tion in decision-making during labor,” “your level of par-

6 Nurs Midwifery Stud. 2016; 5(2):e29952.

Moudi Z and Tavousi M

Table 4. The Correlation Matrix Between Latent Variables in Confirmatory Factor Analysis

Overall Childbirth Satisfaction Baby Physician Nurse Self

Five Items Four Items

Overall childbirth satisfaction 1.00

Baby 0.05 1

Physician 0.30 0.24 1

Nurse 0.45 0.22 0.68 1

Self

Five items 0.29 0.42 0.11 0.30 1

Four items 0.61 0.30 0.46 0.63 0.43 1

Table 5. The Correlation Between the SERVQUAL Scale and the Mackey Childbirth Satisfaction Rating Scale (n = 100)

Satisfaction Quality Physician Nurse/Midwife Baby Self Overall Satis-faction Total Mean ± SD
a
Five Items Four Items
a a b c a a
Tangibles 0.39 0.55 0.16 0.22 0.47 0.29 0.56 14.55 ± 2.7
c a b c a a a
Reliability 0.33 0.65 0.13 0.13 0.56 0.51 0.60 17.23 ± 3.9
c a b c a a a
Responsibility 0.32 0.73 0.16 0.22 0.55 0.46 0.65 13.54 ± 3.8
c a c c a a a
Assurance 0.21 0.79 0.28 0.29 0.67 0.54 0.68 13.68 ± 3.8
c a c a a a a
Empathy 0.26 0.81 0.28 0.35 0.67 0.55 0.73 16.71 ± 4.5
c a c c a a
Total 0.31 0.80 0.23 0.27 0.66 0.53 0.73 75.7 ± 16.9

Mean ± SD 23.98 ± 16.9

a
35.03 ± 8.7 11.07 ± 2.5 a
13.31 ± 3.0 19.29 ± 3.4 a
6.69 ± 1.8 a
109.37 ± 19.3
a
P < 0.0001.
b
The Correlation Was Insignificant.
c
P < 0.05.

Table 6. The Results of Test-Retest and Reliability Analysis of the Mackey Childbirth Satisfaction Rating Scale

Subscales Number of Items Mean (SD), N = 14 ICC (95% CI) Sig Internal Reliability (Cronbach’s α),
N = 339

Test Retest

Self 9 37.92 (4.32) 38.50 (4.60) 0.91 0.74 - 0.97 < 0.001 0.70
 Baby 3 12.57 (0.93) 12.50 (1.28) 0.91 0.74 - 0.97 < 0.001 0.31

Nurse 9 38.00 (5.50) 37.71 (4.39) 0.95 0.86 - 0.98 < 0.001 0.86

Physician 8 35.07 (4.08) 35.00 (3.92) 0.97 0.93 - 0.99 < 0.001 0.79

Overall Childbirth Satisfaction 3 11.64 (1.82) 11.92 (1.94) 0.89 0.68 - 0.96 < 0.001 0.70

Total Satisfaction 32 135.21 (13.46) 135.64 (13.51) 0.98 0.94 - 0.99 < 0.001 0.78

ticipation in decision-making during delivery,” “your level of comfort during labor,” and “your level of comfort dur- ing
delivery.” These items showed how nurses interacted with mothers and involved them in the decision-making process.

Based on previous studies, involvement in decision making and control during childbirth are influential fac-
tors in maternal satisfaction (7, 12). In this way, mothers are empowered and actively participate in the childbirth
process. Moreover, mothers feel in control of their envi- ronment, act based on their desires and preferences, meet their
emotional, psychological, and physical needs, and feel comfortable during labor and delivery (35, 36).

The second dimension of the “self” subscale consisted

Nurs Midwifery Stud. 2016; 5(2):e29952. 7

Moudi Z and Tavousi M

of five items: “your ability to manage your labor contrac- tions,” “the control you had over your emotions during la-
bor,” “the control you had over your emotions during deliv- ery,” “the control you had over your actions during labor,”
and “the control you had over your actions during deliv- ery.” These items primarily showed the mothers’ abilities and
inner power, and consequently, can be referred to as “self-control.” As a result, these five items were categorized as one
single dimension.
In the Farsi version of the scale, the final item of “over- all childbirth satisfaction” was added to the “nurse” sub- scale.
This was due to two factors. First, this rearrange- ment is related to the adjacent place of this item to the “nurse” and
“physician” items. Second, since the major- ity of care services are offered by nurses or midwives, and clients mostly
interact with these care providers, it is un- derstandable that overall satisfaction depends on the func- tionality of these
individuals; consequently, this item was included in the “nurse” subscale.
In accordance with a study by Rahmqvist and Bara (2010), a good correlation was found between the
SERVQUAL scale and the MCSRS (1). Therefore, the Ira- nian version of the MCSRS can be a proper representative of
functional service quality and the level of maternal satisfaction with childbirth experience at hospitals (1, 9,
12, 19, 20). In accordance with previous studies, mothers expected nurses and midwifes (as key maternity care
providers) to be skilled, watchful, and compassionate towards them and their infants and to keep them away from
hazards.
The present findings revealed that the translated Ira- nian version of MCSRS had satisfactory repeatability for all the
scales and subscales. Also, this scale showed significant and satisfactory internal consistency, except for the “baby”
subscale (α = 0.31), which was lower than the acceptable
alpha value (α = 0.70) (34). It should be mentioned that Polit and Beck (2012) considered an r-value between 0.20 and
0.40 to be normal for psychological variables (22).
In terms of the “baby” subscale, the internal consis- tency was 0.49, 0.72, and 0.78 for “your baby’s physical con-
dition at birth,” “the amount of time which passed before you first held your baby,” and “the amount of time which
passed before you first fed your baby,” respectively. We did not face any problems in translating the items, and moth- ers
had no trouble understanding the questions. However, it seems that the items related to the “baby” subscale need to be
reviewed.
As Larsen and Attkisson noted (10), mothers distin- guish between satisfaction and the benefits of curative
treatments (item: “baby’s physical condition at birth”), which can be gained through childbirth care services at
hospitals. Hodnett (2002), in a systemic review, suggested
that mothers with healthy newborns might be dissatisfied with their childbirth experiences and vice versa (12).
Although life-threatening events for the mother and newborn can be minimized through maternity care at hos-
pitals (37), mothers pass judgments on the provided ser- vices, based on certain personal expectations and desires
(Beebe and Humphrey, 2006, Dahlen et al. 2010). Therefore, these expectations should be recognized and considered in
the provision of childbirth services to promote mater- nal satisfaction.

5.2. Limitations
Since satisfaction is dependent on socio-cultural fac- tors, the findings of the present study, conducted in only one
city of Iran, cannot be generalized. Therefore, further research is required to re-evaluate the psychometric prop- erties of
the MCSRS. Also, since no other valid Farsi child- birth satisfaction questionnaire was accessible to the re- searchers, the
MCSRS was not compared with similar scales (especially a context-based scale).
5.3. Conclusion
The translated version of the MCSRS could provide hos- pital authorities with a means to evaluate maternal satis-
faction with childbirth experiences. Therefore, this scale, with its open-ended questions, can show the level of sat-
isfaction or dissatisfaction of mothers with childbirth ser- vices. Moreover, this scale, by showing the differences be-
tween “what is” and “what should be,” can gather feedback from mothers to tailor healthcare services to their expecta-
tions and promote their satisfaction.

Acknowledgments

We would like to thank all the mothers who partici- pated in this study. We also extend our gratitude to local ex-
ecutives at Zahedan University of Medical Sciences for their invaluable help.

Footnotes

Authors’ Contribution: Zahra Moudi wrote the first draft, analyzed the data, and wrote the final manuscript.
Mahmoud Tavousi performed CFA and helped improve the article.
Financial Disclosure: None declared.
Funding/Support: This study was supported by the preg- nancy health research center at Zahedan University of Med- ical
Sciences, Zahedan, Iran (22 April, 2013; approval No.
5760).

8 Nurs Midwifery Stud. 2016; 5(2):e29952.

Moudi Z and Tavousi M

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