Instrumento Postparto 2023

Bully et al.
BMC Pregnancy and Childbirth (2023) 23:610 BMC Pregnancy and Childbirth
https://doi.org/10.1186/s12884-023-05899-6
RESEARCH Open Access
Development and evaluation

of the psychometric properties of a digital
questionnaire for the self‑management
of health and well‑being in the postpartum
period
Paola Bully1,2*, Isabel Artieta‑Pinedo3,4,5, Carmen Paz‑Pascual3,5,6,7, Arturo García‑Álvarez3, Ema-Q Group3 and
Maite Espinosa3
Abstract
Background Despite the fact that the Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030)
recognises the special importance of care for women during the postpartum period, thus highlighting the need
to identify and measure any condition that may affect the welfare of pregnant women in any way, this is one
of the most neglected stages in the health system. Given the absence in our area of global, efficient instruments,
the objective of this study was to design a complete, specific measurement tool with good metric qualities in digital
format for the evaluation of self-reported health and well-being during the puerperium, to conform to what was pro‑
posed by the ICHOM.
Methods A cross-sectional study was carried out to evaluate the psychometric characteristics of a digital measure‑
ment tool. The development of the tool was carried out in 4 steps, following the recommendations of the Interna‑
tional Test Commission. It was tested on 280 puerperas attending primary healthcare appointments in the Basque
Healthcare System (Osakidetza), and they did the newly created survey, answering all the questions that had been
selected as the gold standard. The average age of the women was 34.93 (SD = 4.80). The analysis of the psychomet‑
ric characteristics was based on mixed procedures of expert judgment (a focus group of healthcare professionals,
an item evaluation questionnaire and interviews with users) and quantitative evaluations (EFA, CFA, and correlation
with gold standard, ordinal alpha and McDonald’s omega).
Results The final version of the tool comprised 99 items that evaluate functional state, incontinence, sexuality, breast‑
feeding, adaptation to the role of mother and mental health, and all of these questions can be used globally or par‑
tially. It was found that the scores were valid and reliable, which gives metric guarantees for using the tool in our area.
*Correspondence:
Paola Bully
Paola.bully01@gmail.com
Full list of author information is available at the end of the article
© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
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Bully et al. BMC Pregnancy and Childbirth (2023) 23:610 Page 2 of 15
Conclusions The use of this comprehensive concise tool with good psychometric properties will allow women
to take stock of their situation, assess if they have the necessary resources, in psychological and social terms, and work
together with midwives and other healthcare professionals on the most deficient areas.
Keywords Puerperium, Biopsychosocial needs, Web tool screening, Psychometric properties
Introduction services provided at this stage. Consequently, it is essen-

Postpartum care has been described as the most tial to have valid, reliable instruments that will enable
neglected aspect of maternity services and gener- the health system to gather information as a basis for
ally, fewer resources are devoted to it than to prenatal improving and monitoring postpartum services, but
care or delivery [1–3]. In our health system, if there is which will also enable women to assess their own health
no particular condition that requires special attention, and seek resources to meet their needs [10].
visits to the midwife are usually limited to two, one in In line with the above, the International Consortium
the first 10 days after the birth and the other a month for Health Outcomes Measurement (ICHOM) car-
after that [4]. Consequently, attention to health from a ried out a study aimed at defining a minimum set of
comprehensive perspective and centered on the needs appropriate outcome measures at international level to
of women, which includes the promotion of health and evaluate and improve perinatal care, including a post-
its follow-up, is impeded. This happens despite the fact partum period up to six months [11]. The outcome
that it is a crucial stage, since the health of the baby and measures proposed as the most important according to
even the rest of the family will depend on the current the ICHOM are survival, morbidity, patient satisfaction
and future health of the mother, in the short and long with care, and health and well-being reported by the
term [3]. patients themselves. Among the health and well-being
The main objectives of care for women in the post- results reported by patients, the areas classified as most
partum period are to identify risks, problems and com- important for women are (1) health-related quality of
plications, promote the health of the mother and the life (HRQOL), (2) incontinence, (3) pain in sexual rela-
newborn, and support parents in the new situation of tions, (4) confidence and success in breastfeeding, (5)
having a baby [5]. Along with the available resources, transition and adaptation to the role of mother, and (6)
Maternal Education (ME) focuses on addressing some mental health [11].
of these objectives, especially those related to the pro- It is indisputable that there are large numbers of
motion of health and preparation for motherhood. tools available for the postpartum period, aimed at
However, until now and at least in our area, matters identifying signs and symptoms of a physical and psy-
related to postpartum are treated at an inappropri- chological nature. There are instruments – self-admin-
ate time for women in ME sessions, between weeks 32 istered or requiring administration by a professional
and 42, which means that the information is almost – to identify aspects such as depression and/or anxiety
ignored. Possibly due to this, one of the demands of the [12–16], evaluate urinary incontinence [17], efficacy
women themselves [6, 7] is to adapt ME to the needs with breastfeeding [18–20], quality of life [21–24],
of this period, giving it greater continuity and provid- fatigue [25], quality of sleep [26], quality of sexual rela-
ing relevant information at each stage. Puerperal in our tions [27], social support [28], and the mother–child
area also want the health system to allow them to have bond [29, 30].
the autonomy to manage their own health and that of However, there are no well-validated self-report
their babies [8, 9]. instruments that give comprehensive, efficient cover-
Likewise, the Global Strategy for Women’s, Children’s age of the 6 areas identified by the ICHOM as being
and Adolescents’ Health (2016–2030) recognises the important for women. This means that the only pos-
special importance of care for women during the post- sible way to measure the results reported by patients
partum period, highlighting the need to identify and in the postpartum period, covering the 6 areas, is to
measure not only serious morbidity, but also any another use a combination of tools [31, 32], as the ICHOM
condition that may affect women’s well-being in some itself suggests. This means carrying out a fragmen-
way or prevent them from progressing in their recov- tary evaluation and analysis of women’s health, which
ery and adapting to motherhood [10]. They also recom- is not the ideal method for approaching health from a
mend follow-up tools with solid data that will serve as a thorough, person-centred perspective. It is not a use-
basis for decision-making and greater transparency and ful basis for providing comprehensive family and com-
accountability in the health system as a way to transform munity healthcare (such as consensual care plans, care
management, distance monitoring or searches for Two bibliographical searches were carried out of Eng-
social resources and support networks); nor does it lish and Spanish databases: PubMed, Web of Science,
help women themselves to manage their own health. Embase, CINAHL, PsychLIT, PsycINFO, PsicoDoc,
Given the absence in our area of global, efficient IBECS, Cochrane library plus and Google Scholar.
instruments, the objective of this study was to design In the first search, articles related to postpartum health
a complete, specific measurement tool with good met- needs were looked for with the aim of identifying rel-
ric qualities in digital format for the evaluation of self- evant constructs and defining them. The search terms we
reported health and well-being during the puerperium, decided to use were those referring to psychosocial and
to conform to what was proposed by the ICHOM. This health factors of priority for women (functional status,
instrument or dossier of scales that have optimized the depression, anxiety, social support, breastfeeding, sexual
various instruments that measure these issues sepa- activity, parental auoefficacy, etc.), as well as those relat-
rately can be used globally or partially, making use of 1 ing to the specific period (postpartum, post-delivery,
or more sections separately. It is housed in the EMAe‑ postnatal, puerperium…) both in free text and in con-
Health app, which we have created using a collabora- trolled language. This work was checked by a group of
tive research process [33] in which women, healthcare midwives belonging to the research team, and they evalu-
professionals, managers and researchers have par- ated its fit for the area where the study was being carried
ticipated. EMAeHealth has, among other things, an out.
area for self-management of health, which enables The second search looked for instruments that meas-
women to evaluate their own needs, as a basis for mak- ured the previously identified constructs, with a double
ing informed and/or shared decisions regarding their aim: 1) to operationalize them by generating a pool of
health and that of their families. This digital tool was items and 2) to choose the gold standard. To the terms
designed as a complement to Maternal Education (ME), used in the first search were added those referring to
with resources that facilitate its accessibility, continuity tools (tool, instrument, questionnaire, survey, test, data
and adaptation to the health needs of each woman. collection, measure…) and their metric properties (valid-
This article describes how the instrument was devel- ity, reliability, psychometric, etc.). The “consensus-based
oped to assess the priority health and well-being needs of standards for the selection of health measurement instru-
women in the postpartum period, and analyzes its psy- ments (COSMIN)” checklist was used to evaluate the
chometric properties. quality of the metric properties of the existing tools. This
checklist describes the validity (content, construct and
Method criteria), reliability (internal consistency, reproducibility,
Design measurement error), and responsiveness of a question-
This study is part of a larger body of research in which naire [35].
the perceptions and needs of women during pregnancy,
childbirth and postpartum were analysed, as well as the 2) Review of the constructs and items by a committee of
resources available to them for adapting to each moment experts.
of the process. The protocol is now available for consulta-
tion [34]. A multidisciplinary team was formed, with 4 primary
It is a cross-sectional study designed to evaluate of the care midwives, 3 puerperal and paediatric nurses, 1
metric characteristics of a digital tool for detecting health paediatrician, 3 psychologists, 3 methodologists (a psy-
needs in the postpartum, and it was carried out between chometrist and 2 researchers in health sciences) and 2
September 2019 and June 2022 in the Basque Health puerperal women. In order to avoid bias, the purpose of
Service (Osakidetza). This is a public health service that the tool to be developed and the definition of the aspects
serves a population of just over two million inhabit- to be evaluated were explained in writing. Each of the 192
ants and that currently has 7 hospitals where women items from the initial pool was evaluated individually for
give birth. Each hospital coordinates with a set of pri- (A) its relevance to a positive postpartum experience and
mary healthcare centres for pregnancy and postpartum (B) its fit to the reference population. They also checked
follow-up. (C) the clarity of the items and (D) the relevance of the
response scales, giving them a score of 0 to 10 in each
Procedure aspect. An average was estimated for each item and those
The postpartum health needs detection questionnaire that did not obtain a score of 8 or higher in relevance and
was created in four steps: fit to the population were eliminated. Any questions that
were still considered important and suitable, but did not
1) Focused review of the scientific literature. obtain averages equal to or higher than 9 points in clarity
and relevance on the answer scale were reformulated. considered, such as age, parity, nationality (Spanish/immi-
Finally, using an open question, the experts assessed the grant), level of education (low/medium/high) or paid
need to include new questions or answer categories. The employment (yes/no). Following the same procedure for
resulting questionnaire was piloted with a sample of 12 gathering information as in the pilot, registered healthcare
women, who reported on their perception of the rele- professionals asked 443 women to take part in the study,
vance, fit and clarity of each of the items. while another 64 were added by other healthcare profes-
sionals or through informal contact between participants.
3) Preliminary analysis of the properties of the instrument. A preliminary analysis of the information gathered was
carried out in order to refine the data and check compli-
In this phase, the web layout of the pilot questionnaire ance with the basic assumptions of the GLM. After that,
was created and the gold standards selected for each con- the fit of the models resulting from the EFAs of step 3 was
struct were administered to a sample of 100 puerperas. tested through confirmatory factor analysis (CFA). Given
The women were recruited by their midwife in postpar- the ordinal nature of the items, the estimation method
tum check-ups. They were offered the option of receiving used was diagonally weighted least squares (DWLS)
a link to the questionnaire in digital format. They were using a polychoric correlation matrix. The evaluation of
also encouraged to share the link with other women in fit of the model to the data was based on the value of the
the same situation. All pregnant women over 18 who chi-square/df ratio, together with information provided
spoke enough Spanish to understand and answer the by the comparative fit index (CFI), the root mean square
questions presented could be included. When the woman error of approximation (RMSEA) and its standardiza-
accessed the link, she received information about the tion (SRMR). Models with chi-square/df ratio results less
characteristics of the study, the type of use that would be than 5, equal to or greater than 0.90 in CFI and equal to
made of the data (for research purposes only) and about or less than 0.10 in RMSEA and SRMR were considered
the possibility of withdrawing from the study at any time acceptable [38, 39]. The pattern of correlation with other
without this compromising her standard of care. The variables to obtain evidence of external convergence was
questionnaire was only filled in if informed consent was analysed using Spearman’s rank correlation coefficient
given. (rs). Finally, the analysis of the internal consistency of the
Once the information was gathered, an analysis was sections was carried out using the coefficients ordinal
carried out to evaluate the presence and patterns of alpha (ordinal α) and McDonald’s omega (ω). As a cri-
absent results, atypical results and compliance with the terion to determine the presence of a possible source of
basic assumptions underlying the general linear model distress, we propose using scores above the 75th percen-
(GLM). Next, the descriptive statistics of each item tile value for risk factors and below the 25th percentile
were calculated (% cases chosen in each option, mean, for protective factors. The statistical program R (v.4.0.2)
standard deviation, asymmetry and kurtosis). For the was used.
analysis of the internal structure, decision-making tech-
niques were used for the optimal number of factors to be Results
extracted within each construct, and exploratory factorial The main results of the four phases completed before
analyses (EFA) were carried out. The internal consistency reaching the optimized version of the questionnaire are
of each section was also calculated, as well as how much described below:
this indicator would vary if each item were removed. If
items had low levels of inclusion factor, and their removal Phase 1. Focused search of the scientific literature
increased the internal consistency of the section, they After the first search, it was established that, in addition
were eliminated. to the characteristics and evolution of the birth (newborn
weight and state of health, type of delivery and surgical
4) Management and analysis of the metric properties of procedures performed, e.g. episiotomy), the variables
the final version. that best determine well-being during the postpartum
period could be classified into the 6 groups proposed
The findings in the pilot (high commonalities, no cross- by the ICHOM. These comprised: (1) functional status/
loadings, strong primary loadings per factor, high num- quality of life related to health: possible complications
ber of indicators per factor and no missing results), and (e.g. haemorrhages, diarrhoea or fever) pain and ability
the moderate length of each section of the questionnaire to perform daily activities, all of which are aspects linked
(15 items maximum), suggest that a sample size over 200 to physical recovery in the puerperium [3, 40, 41]. (2)
offers sufficient statistical power for the CFA of data [36, Incontinence as a sequela in the late postpartum period
37]. In addition, the possible effect of other variables was [41, 42]. (3) Recovery of sexual activity and satisfaction
[43, 44]. (4) Successful breastfeeding [18]. (5) Transition number of items than at the beginning (see Table 1, col-
and adaptation to the role of mother: evolution/confi- umn 2) and 2 new items were added to the questions on
dence in parenting and the satisfaction of the newborn’s alarm signals. Finally, the content of 5 items was reformu-
needs [45]. (6) Mental health: aspects related to body lated or qualified to increase their clarity and the number
dissatisfaction, lack of sleep [46] and moods/postnatal of possible responses to each item was homogenised, so
depression [41, 47]. that they were all a Likert scale with five alternatives.
The second search focused on tools for the evaluation After this version was given to the group of 12 women,
of these aspects. As a result of this process, it was con- a key question was added to the scales of pain, inconti-
cluded that there was a need to create a new, complete, nence, sexual activity, practice and self-efficacy with
updated tool that would be suitable for our social and breastfeeding, sleep problems and emotional difficulties/
health environment online. depression, so that the respondents would not have to
Table 1 presents the sections that were established as answer all the questions if they did not have that prob-
most relevant, and the first column shows the number of lem. Additionally, the research team carried out a second
items that were initially generated to operationalize each check of the eliminated items, in case they considered it
section. necessary to reinstate any questions, and the decisions
In addition, the questionnaires that would be used as made previously were reaffirmed.
gold standards were chosen to determine the conver-
gent validity of the instrument. These, together with their Phase 3: Preliminary analysis of the properties
psychometric properties in our sample, are presented in of the instrument
Table 2: To evaluate the comprehensibility, readability, duration
and initial properties of the final questionnaire (compris-
Phase 2. Review of the constructs and items ing 62.75% of the initial items), it was formatted and a
by a committee of experts pilot was carried out with 100 postpartum women.
After the review by the committee, the 81 items that The results showed that it was likely to be used, since
obtained a median score of less than 8 in “Relevance” it takes around 25–30 min to complete it in its entirety
were eliminated, leaving almost all the scales with a lower and much less if the scales are used separately. Moreover,
Table 1 Evolution of the number and distribution of the items

Nº Items
Sections Initial After experts’ After pilot with 12 After analysis with 100 Final
opinions women women
1) Functional state
1.1 Alarm signals 9 11 12 12 12
1.2 Pain 7 7 8 8 8
1.3 Functionality/QOL 5 4 4 4 4
2) Incontinence 6 1 1 1 1
3) Sexuality
3.1Activity/satisfaction 35 14 15 15 11
3.2 Contraception 3 3 3 3 1
4) Breastfeeding
4.1 Knowledge 9 9 9 9 6
4.2. Practice 20 15 15 15 13
4.2 Self-confidence 30 6 6 6 6
5) Adaptation to role of mother
5.1Parental self-efficacy 20 11 11 11 11
5.2 Perceived social support 12 9 9 9 6
6) Mental health
6.1 Self-image 10 7 8 8 8
6.2 Sleep problems 14 6 7 7 6
6.3 Depression 7 7 7 7 6
Total 194 117 115 115 99
Table 2 Gold standards and their psychometric properties in our sample

Fit of the original theoretical model
Sections Nº items χ2; p; χ2/df CFI TLI RMSEA (90% CI) SRMR
1) Functional state
SF-12 v2 [48] 12 251.46; < .01; 4.83 .98 .97 .11 (.10-.13) .10
2) Incontinence
ICIQ [49] 4 2.21; .33; 1.10 .99 .99 .04 (.00-.32) .03
3) Sexuality
SFQ [50] 14 49.36; < .01; 1.90 .97 .96 .10 (.06–0.16) .10
4) Breastfeeding
PBSES [51] 20 181.79; < .01; 3.56 .99 .98 .10 (.09-.12) .10
5) Adaptation to role of mother
PSOC [52] 17 334.06; < .01; 2.85 .98 .97 .08 (.07-.09) .07
MOS-SSS [53] 20 495.55; < .01; 3.26 .99 .99 .09 (.08-.10) .05
6) Mental health
EDI [54] 10 143.51; < .01; 4.48 .99 .99 .11 (.09-.13) .07
ISI [55] 7 369.75; < .01; 2.46 .99 .97 .09 (.00-.19) .09
EPDS [56] 10 116.78; < .01; 3.43 .99 .98 .09 (.07-.11) .10
ne not estimable
most of the respondents considered it easy to understand Functional state Alarm signals This is a one-dimen-
and interesting. sional scale (χ2 2 = 30.96, df = 27, p = 0.273, χ2/df = 1.15,
Based on the findings of the exploratory and inter- CFI = 0.96, TLI = 0.95, RMSEA (90% CI) = 0.02 (0.00-.
nal consistency factor analyses, it was decided that all 05), SRMR = 0.12) made up of 11 binary items (see
the elements would be kept, pending further evidence Table 4). Its internal consistency is around what was
regarding their function. expected, given the heterogeneity of its content (ordinal
α = 0.67; ω = 0.47).
Phase 4: Management and analysis of the metric
properties of the refined version Positive response to any of the items is indicative
Characteristics of the participants of potential problems that may require specialized
Of the 443 women invited to participate by the attention.
research team, 348 women answered at least one ques-
tion, and 216 (48.75%) completed the entire ques- Pain This is a scale made up of 8 items: 1 binary that
tionnaire. A further 64 were completed by puerperal acts as a key question; and 7 politomic ones to locate
women contacted through other healthcare workers the origin and intensity of the pain (see Table 5). These
or through informal contact between participants. 7 elements are adjusted to both bidimensional models
Finally, 280 puerperal women with a mean age of 34.93 (χ2 = 14.49, df = 13, p = 0.340, χ2/df = 1.11, CFI = 0.96,
(SD = 4.74) gave their consent and answered all the TLI = 0.94, RMSEA (90% CI) = 0.03 (. 00-0.09),
questions. The characteristics of the participants can SRMR = 0.07). 3 belong to the section on specific post-
be seen in Table 3. partum pain and 4 to more non-specific or general pain.
After checking for the absence of patterns of missing The internal consistency of the subsection on specific
results and impossible results in the data, we proceeded pain is good (ordinal α = 0.73; ω = 0.71) while that of non-
to make a formal description of each item (Arithme- specific pain is lower, as expected for its content (ordinal
tic Mean (M) and its 95% confidence interval (95%CI), α = 0.51; ω = 0.50).
standard deviation (SD), asymmetry index (AI) and kur-
tosis index (Ku.)), and evaluate the internal structure,
reliability and convergent validity of each of the sections Scores of 3 or higher on the sum of specific pain or
that make up the questionnaire. general pain items are considered high.
Table 3 Characteristics of the participants Functionality/QOL This is a one-dimension scale

n (%)
(χ2 = 8.76, df = 2, p = 0.003, χ2/df = 4.38, CFI = 0.92, TLI = 0.91,
RMSEA (90% CI) = 0.01 (0.00-0.12), SRMR = 0.02) made
Age up of 4 items (see Table 6), with high internal consistency
< 30 20 (7.1) (ordinal α = 0.82; ω = 0.86) and high correlation with the
30–34 92 (32.9) scores obtained in the SF-12 v2, used as the gold standard
35–39 103 (36.8) (rs = 0.71).
> = 40 38 (13.6)
Nationality Scores of 12 or higher on this functionality scale are
Spanish 253 (90.4) considered indicative of difficulties.
Foreign 27 (9.6)
Educational level Incontinence This is a very simple scale, made up of one
Without schooling/Primary 5 (1.8) single item; its formal description is shown in Table 7.
Secondary/Vocational training 16 (5.5) This item has a high correlation with the scores obtained
Sixth form/Further Education 91 (32.5) in the ICIQ (rs = 0.94). It is unnecessary to calculate the
University degree 175 (62.3) internal consistency or the factor loading.
Paid employment The presence of incontinence is considered an aspect
Yes 228 (81.4) that may impair the quality of life and therefore require
No 52 (18.6) specific attention.
Type of birth
Normal vaginal 179 (63.9) Sexuality This is a scale made up of 12 items: 1 binary
Vaginal assisted with suction cups, forceps or spatulas 53 (18.9) that acts as a key question and is used to indicate whether
Breech 1 (0.4) the woman has resumed sexual activity; 10 politomic
Caesarean 45 (16.1) questions, of which 6 are used to find out the degree of
Other 2 (0.7) satisfaction with sexuality; and 4 questions to locate the
Nº babies born in this delivery possible origin of sexual discomfort, plus 1 additional
1 273 (97.5) question to evaluate knowledge about contraception (see
2 7 (2.5) Table 8). The 10 elements that measure sexual satisfaction
Parity fit the proposed bidimensional model very well (χ2 = 34.80,
Primiparous 184 (65.7) df = 33, p = 0.382, χ2/df = 1.11, CFI = 0.99, TLI = 0.99,
2 or more 96 (34.3) RMSEA (90%CI) = 0.03 (0.00-0.09), SRMR = 0.06). The
Epidural anaesthesia during birth internal consistency of both the subsection of satisfaction
Yes 250 (89.3) (ordinal α = 0.93; ω = 0.91) and of pain (ordinal α = 0.89;
No 30 (10.7) ω = 0.87) are very good. The link of the scores with the
Episiotomy gold standard in the pain subsection was moderate and
Yes 82 (29.3) inverse (rs = -0.36) and with the satisfaction subsection it
No 198 (70.7) was high and positive (rs = 0.76).
Tearing during the birth Scores of 15 or less are considered indicative of dissat-
Yes 136 (48.6) isfaction with sexual activity.
No 144 (51.4)
Complications during the birth Breastfeeding This is a section made up of 25 items,
No 193 (68.9) divided into the subsections Knowledge, Practice and
Yes, fever 39 (13.9) Self-confidence in breastfeeding.
Yes, high blood pressure 6 (2.1)
Yes, postpartum haemorrhage that required transfusion, 2 (0.7) Knowledge about Breastfeeding This is a one-dimen-
and/or ICU admission sional scale (χ2 = 17.53, df = 9, p = 0.042, χ2/df = 1.95,
Yes, manual placenta extraction 8 (2.9) CFI = 0.99, TLI = 0.99, RMSEA (90%CI) = 0.08 (0.02-0.13),
Yes, other complications 32 (11.4) SRMR = 0.06) made up of 6 politomic questions with 5
dDays since delivery, M (SD) 45.3 (16.8) response alternatives that evaluate some beliefs regarding
breastfeeding (see Table 9). The internal consistency was
Table 4 Characteristics of the items that measure alarm signals in the postpartum period
Min–max M SD AI Ku λij
Vaginal bleeding more abundant than a period 0–1 0.05 0.22 4.14 15.28 .24
Vaginal discharge/secretion with bad smell 0–1 0.06 0.23 3.83 12.75 .36
Temperature higher than 38ºC (fever) in the last 12 h 0–1 0.00 0.00 .ne
Temperature higher than 38ºC (fever) now 0–1 0.00 0.00 .ne
Feelings of extreme tiredness 0–1 0.20 0.40 1.47 0.18 .46
Feelings of dizziness or faintness sometimes after the birth 0–1 0.23 0.42 1.29 -0.33 .38
One or both breasts hard or swollen even after breastfeeding 0–1 0.15 0.35 2.01 2.03 .77
Red marks on the breast 0–1 0.08 0.27 3.14 7.93 .60
Cracks in one or both nipples 0–1 0.22 0.42 1.34 -0.20 .59
Difficulties in seeing, flashes or other sudden changes in vision 0–1 0.08 0.28 3.05 7.37 .43
Constipation 0–1 0.45 0.50 0.20 -1.98 .23
λij saturation or factor loading, ne not estimable
Table 5 Characteristics of items that measure pain in specific areas of the body
Do you have pain in any part of your body? 0–1 0.44 0.50 0.25 -1.95 na
The genital and/or anal area 0–4 0.90 0.96 1.06 0.83 .34
One or both breasts 0–4 0.67 0.97 1.54 2.12 .84
One or both nipples 0–4 0.85 1.11 1.22 0.60 .81
The abdominal area (stomach) 0–4 0.61 0.79 1.01 0.05 .17
Head 0–4 0.50 0.89 1.88 2.89 .59
One leg, accompanied by local swelling, heat and red‑ 0–4 0.12 0.44 4.24 20.19 .70
ness
Other parts of the body 0–4 0.70 1.04 1.48 1.42 .32
λij saturation or factor loading, na not applicable
Table 6 Characteristics of the items that measure functionality

During the last 4 weeks … Min–max M SD AI Ku λij
My physical condition has limited me in performing basic baby-care tasks (e.g. breastfeeding, bathing, 1–5 1.81 1.11 1.29 0.82 .80
changing diapers.)
My physical condition has limited me in moderate efforts such as moving a table, sweeping or mopping 1–5 2.13 1.20 0.74 -0.46 .93
the house or walking for more than an hour
To what extent has pain made it difficult to carry out your usual activities? 1–5 1.91 1.03 1.12 0.52 .79
How often has your state of health made it difficult to carry out social activities (such as visiting friends 1–5 2.00 1.02 0.66 -0.36 .59
or family)?
λij saturation or factor loading
Table 7 Characteristics of the item that measures incontinence

Do you have leakage of urine, gas or faeces? 0–1 0.23 0.42 1.32 -0.26 na
Table 8 Characteristics of the items that measure sexuality

Have you resumed sexual activity (alone or as a couple)? 0–1 0.30 0.46 -0.90 -1.19 na
I have felt pain or discomfort……
When touching or stroking the vulva and the perineum, during sexual stimulation 1–5 2.69 1.13 0.33 -0.33 .69
At the moment of vaginal penetration 1–5 2.66 1.18 0.25 -0.65 .95
During vaginal penetration 1–5 1.82 1.10 1.23 0.61 .96
When vaginal penetration is over 1–5 3.10 2.30 0.64 -0.82 .78
During the last 4 weeks, rate your degree of satisfaction with…
Sexual desire or interest 1–5 3.58 1.15 -0.77 -0.05 .78
Intensity of sexual excitement 1–5 3.27 1.11 -0.21 -0.78 .93
Quality of your orgasms 1–5 3.25 1.10 -0.15 -0.99 .82
Disinhibition and surrender to sexual pleasure during sexual intercourse 1–5 3.08 1.07 0.10 -0.96 .78
Your concentration during sexual activity 1–5 4.29 0.92 -1.34 1.61 .84
Ease of lubrication during sexual activity 1–5 2.82 1.49 0.09 -1.43 .81
I know all the options available to avoid pregnancy at this moment 1–5 1.70 0.46 -0.90 -1.19 na
Table 9 Characteristics of the items linked to breastfeeding

The benefits of mother’s milk are long-lasting, even after the baby has been weaned 1–5 4.33 0.87 -1.27 1.52 .78
Breastfeeding increases the mother–child bond 1–5 4.37 0.99 -1.77 2.85 .82
Babies fed with maternal milk grow up healthier than babies fed with artificial milk 1–5 3.29 1.29 -0.29 -0.90 .70
Breast milk is the ideal food for babies 1–5 4.65 0.67 -1.80 2.25 .89
Mother’s milk is easier to digest than artificial milk 1–5 4.14 0.92 -0.60 -0.61 .61
Mother’s milk is better than artificial milk 1–5 4.49 0.81 -1.60 2.31 .84
Are you breastfeeding your baby? 0–1 0.82 0.38 1.69 0.85 na
I’m planning to continue breastfeeding my baby for the next few months 1–5 4.70 0.69 -3.04 11.11 .90
My partner and family motivate me and support me to continue breastfeeding 1–5 4.26 1.03 -1.29 0.77 .68
Feeling good and satisfied motivates me to continue breastfeeding 1–5 4.53 0.82 -2.21 5.52 .84
Keeping the baby healthy is a motivation to continue breastfeeding 1–5 4.89 0.36 -3.38 11.59 .75
I offered my baby artificial milk before 4 months of age 1–5 1.95 1.39 1.31 0.26 .70
I have thought about giving up breastfeeding my baby 1–5 1.74 1.01 1.18 0.49 .90
I have had difficulties with breastfeeding due to the small amount of milk 1–5 1.64 1.17 1.82 2.25 .81
I have had difficulties with breastfeeding due to nipple problems 1–5 2.21 1.33 0.74 -0.69 .53
I have had difficulties with breastfeeding due to my work 1–5 1.70 1.17 1.42 0.74 .85
I have had difficulties with breastfeeding due to family problems 1–5 1.12 0.54 5.07 26.61 .94
I get comfortable to breastfeed my baby 1–5 4.42 0.66 -0.79 0.00 .79
I look for the correct position to breastfeed my baby 1–5 4.32 0.71 -0.94 1.51
I know if my baby is drinking enough milk at the feed 1–5 3.61 1.00 -0.80 0.43 .66
I can breastfeed my baby without using artificial or powdered milk as a supplement 1–5 4.37 1.21 -1.88 2.25 .54
I’m sure that my baby latches onto the breast well during feeding 1–5 4.24 0.83 -1.21 2.07 .74
I can handle breastfeeding satisfactorily 1–5 4.04 1.01 -0.96 0.57 .91
Breastfeeding is a satisfactory experience for me 1–5 4.36 0.98 -1.69 2.60 .69
I can breastfeed my baby with one breast and then switch to the other 1–5 4.17 0.99 -1.15 0.76 .44
high (ordinal α = 0.89; ω = 0.83). The correlation with the Adaptation to role of mother Parental self‑efficacy
PBSES scores was moderate (r = 0.30). This is a one-dimensional scale (χ2 = 270.72, df = 44,
p < 0.001, χ2/df = 6.10, CFI = 0.99, TLI = 0.99, RMSEA
Breastfeeding practice This is a scale made up of 4 first- (90%CI) = 0.12 (0.11-0.14), SRMR = 0.08) made up of 11
order factors: motivation for breastfeeding; personal items (see Table 10) and very high internal consistency
difficulties with breastfeeding; external difficulties with (ordinal α = 0.95; ω = 0.91). The correlation with the total
breastfeeding; and practical breastfeeding, explained by score in the PSOC is moderate (rs = 0.60).
a global second order factor (c2=147.74, df=50, p< .001,
c2/df=1.95, CFI=0.96, TLI=0.95, RMSEA (90%CI) = .09 Scores of 52 or less would be indicative of low per-
(.07-.11), SRMR=0.07) (see Table 9). The internal consist- ceived self-efficacy.
ency of the 12 items that make up the global factor was
high (ordinal α = .85; ω=.76). The correlation with the Perceived social support This is a one-dimen-
PBSES scores is moderate (r=.41). sional scale (χ2 = 54.6, df = 11, p < 0.001, χ2/df = 4.96,
CFI = 0.99, TLI = 0.98, RMSEA (90%CI) = 0.13 (0.11-
Self‑confidence in breastfeeding This is also a one- 0.17), SRMR = 0.08) made up of 11 items (see Table 11)
dimensional scale (c2=10.96, df= 9, p=.278, c2/df=1.21, that present high internal consistency (ordinal α = 0.93;
CFI=0.99, TLI=0.99, RMSEA (90%CI) = .03 (.00-.08), ω = 0.87). The correlation with the total score on the
SRMR=0.04) made up of 6 items (see Table 9) with high MOS-SSS is high (r = 0.80).
internal consistency (ordinal α= .82; ω=.77). The correla-
tion with the PBSES scores is moderate (r=.43) Scores of 24 or lower would be indicative of low per-
ceived social support.
Scores of 22 or less in knowledge and self-efficacy for
breastfeeding and equal to or less than 49 in practice are Mental Health Self‑image This is a scale made up of
considered low. 8 items: 1 binary that acts as a key question and is used
Table 10 Characteristics of the items that measure parental self-efficacy

I am able to keep my baby entertained 1–5 4.08 0.79 -0.74 0.91 .75
I am able to feed my baby 1–5 4.88 0.43 -4.80 29.52 .74
I am able to bath my baby 1–5 4.73 0.74 -3.42 12.57 .54
I can calm my baby when she/he is crying 1–5 4.35 0.70 -0.95 1.29 .95
I am able to calm my baby when she/he is anxious 1–5 4.29 0.72 -0.81 0.78 .96
I can calm my baby when she/he cries continuously 1–5 4.19 0.77 -0.68 0.26 .92
I know when my baby is tired and needs to sleep 1–5 4.19 0.76 -0.69 0.38 .77
I can understand what my baby wants 1–5 3.86 0.69 -0.58 1.60 .80
I think my baby responds well to me when I talk and smile 1–5 4.45 0.74 -1.51 3.08 .84
at her/him
I think my baby and I have good interaction 1–5 4.53 0.70 -1.56 2.73 .90
I can show affection to my baby 1–5 4.91 0.37 -6.23 51.16 .71
Table 11 Characteristics of the items that measure perceived social support

There is a special person I can share sorrows and joys with 0–1 4.61 0.80 -2.33 5.51 .83
My family really try to help me 1–5 4.58 0.87 -2.21 4.54 .86
I get the help and emotional support I need from my family 1–5 4.36 0.98 -1.63 2.20 .94
I can talk about my problems with my family 1–5 4.37 0.99 -1.70 2.44 .92
I have friends I can share sorrows and joys with 1–5 4.32 0.96 -1.37 1.26 .73
There is a special person in my life who worries about my feelings 1–5 4.69 0.70 -2.52 6.30 .82
for seeing whether the woman is satisfied with her cur- general; and 5 politomic questions that evaluate the ori-
rent physical appearance; and 7 politomic ones that eval- gin and type of difficulty (see Table 13) (χ2 = 9.53, df = 4,
uate the degree of discomfort that body dissatisfaction p = 0.049, χ2/df = 2.38, CFI = 0.97, TLI = 0.93, RMSEA
generates (see Table 12) (χ2 = 41.33, df = 14, p < 0.011, χ2/ (90%CI) = 0.10 (0.01-0.19), SRMR = 0.08). The internal con-
df = 2.95, CFI = 0.99, TLI = 0.99, RMSEA (90%CI) = 0.08 sistency is acceptable (ordinal α = 0.73; ω = 0.67). The corre-
(0.05-0.11), SRMR = 0.06). Internal consistency is high lation of scores with ISI was moderate-high (rs = 0.61).
(ordinal α = 0.90; ω = 0.87). The correlation of the scores
with the body dissatisfaction scale of the EDI-3 used as Scores of 19 or higher would indicate dissatisfaction
the gold standard was strong (rs = 0.76). with sleep quality.
Scores of 22 or higher would indicate high body Depression This is a one-dimensional scale made up
dissatisfaction. of 6 items (see Table 14) (χ2 = 9.21, df = 9, p = 0.417, χ2/
df = 1.01, CFI = 0.99, TLI = 0.99, RMSEA (90%CI) = 0.01
Sleep problems This is a scale made up of 6 items: 1 (0.00-0.07), SRMR = 0.05). The internal consistency is
binary that acts as a key question and is used to find out very high (ordinal α = 0.89; ω = 0.83). The correlation of
if the woman feels satisfied with her quality of sleep in scores with the EDPS is very high (rs = 0.82).
Table 12 Characteristics of the items that measure self-image

Are you happy with your current physical appearance? 0–1 0.42 0.49 0.31 -1.92 na
I avoid situations where people can see my body (e.g. pool/beach, bathrooms 1–5 2.12 1.26 0.83 -0.46 .82
or changing rooms)
I worry about getting fat 1–5 2.82 1.37 0.16 -1.17 .87
I am afraid that my breasts will lose their shape or firmness 1–5 2.56 1.32 0.35 -1.02 .57
Seeing my body in the mirror makes me feel bad 1–5 2.36 1.28 0.64 -0.61 .92
I think I should go on a diet 1–5 2.92 1.51 0.04 -1.42 .80
I think I have lost most of the weight I gained during pregnancy 1–5 3.47 1.44 -0.52 -1.06 .52
I think my appearance is normal for a woman who has given birth recently 1–5 4.16 1.07 -1.18 0.65 .55
Table 13 Characteristics of items that measure sleep problems

Are you satisfied with your quality of sleep? 0–1 0.52 0.50 0.09 -2.01 na
I wake up in the middle of the night 1–5 4.08 1.17 -1.28 0.81 .50
I have sleep problems due to child-care during the night 1–5 4.32 1.04 -1.53 1.55 .51
I have trouble sleeping due to anxiety related to the baby 1–5 2.13 1.21 0.82 -0.30 .64
I have sleep problems that leave me without energy through‑ 1–5 3.31 1.13 -0.24 -0.56 .63
out the day
I have trouble getting to sleep 1–5 2.34 1.25 0.64 -0.55 .73
Table 14 Characteristics of the items that measure depression

Min–max M SD As Cu λij
I have felt lonely 1–5 2.11 1.13 0.65 -0.54 .75

I have cried a lot for no reason 1–5 2.05 1.06 0.67 -0.44 .73
I haven’t been able to concentrate on anything 1–5 2.16 1.10 0.63 -0.43 .82
I have felt as if I wasn’t myself 1–5 2.07 1.16 0.81 -0.34 .82
I have felt like a failure as a mother 1–5 1.77 0.98 1.15 0.72 .76
I have started thinking that I would be better off dead 1–5 1.06 0.33 5.88 37.52 .78
Scores of 14 or higher would indicate the presence of and researchers. This app can easily be linked to the
possible mood disorders. patient’s clinical e-records.
We believe that, if used correctly, it will be an instru-
Discussion ment that will permit the collection of useful data for
When it comes to care of a woman during the postpar- professionals related to postpartum care (e.g. gynae-
tum period, as we mentioned in the introduction, it is cologists, midwives, nurses and physiotherapists) and
of special importance to identify and measure not only other health professionals, but above all that it will be
serious morbidity, but also any other condition that pre- useful for the woman herself, since it will allow for the
vents her from progressing in her recovery and adap- exploration of her physical, social, emotional and sex-
tation to motherhood or that can affect her well-being ual sphere in a short space of time, making it easy for
in some way [10]. In this task, it is essential not only her to make informed decisions about her health dur-
to take into account the results reported by patients or ing the 12 months following delivery.
users of the health service, for example using PROs [57],
but also that the measurement instruments enable the
woman herself to obtain useful information and make Limitations
decisions about her own health and that of her fam- The ICHOM working groups understand that their
ily. Likewise, in the selection of these instruments, in function is not to design new measures of results, but
addition to demonstrating good metric characteristics to agree on a minimum set of well-validated measures,
and documentation for their interpretation [58–60], including the measures reported by patients, that eve-
efficiency at the time of collecting the information is a ryone should use [61]. The purpose is to incorporate
quality that we must not overlook: if there is the option standard sets in patients’ medical e-records, to be able
for selecting a short questionnaire, it should not be to make comparisons at different levels. Currently, our
necessary to submit the patients to endless batteries of instrument has been developed in and for our health,
questions that gather identical information. social or cultural context; therefore, it would not be
In line with this, given the lack of comprehensive, usable without previous adaptation and validation in a
specific evaluation instruments with proven metric different environment. However, this fact is not some-
quality adapted to our environment, a digital instru- thing inherent to our tool but affects all psychometric
ment or dossier of scales made up of 99 items was measurement instruments; in fact, some recommend
developed, which evaluates 6 essential aspects for good deepening evaluative research on the contribution of
psychosocial adjustment and successful coping mecha- PRO instruments to a comparison between providers
nisms during the postpartum period. These aspects are [62] which would contribute to the comparability of
in perfect harmony with the proposal of self-reported results. It might even be thought that, because it is a
measurements by patients (PROs) that ICHOM made context-specific tool, it may have greater potential for
for the collection of health and well-being data in the use as a measurement tool in the clinical environment
postpartum period with a focus on the outcomes that and in research implementation [63].
matter most to patients [11]. It should be noted that it On the other hand, the fact that part of the sample
is a multidimensional self-evaluation instrument which has been selected by means of snowball sampling could
covers the 6 priority areas proposed by the ICHOM increase the representation of more proactive women
and has several advantages: the first is that it can be with a higher level of education. However, measures have
used as a single measure of global or partial evaluation been taken to avoid introducing bias: the overwhelm-
of the mentioned areas, making use of one or more sec- ing majority of the women were selected by 25 midwives
tions separately; the second is that it is short, as in only belonging to public health centres located in various
20 min it evaluates the six areas, which have been com- population areas, both rural and urban, and of different
pared to gold standards equal or similar to those con- socioeconomic and social characteristics. Given that the
tained in the measurement tools proposed by ICHOM; women belonging to the snowball sample were referred
the third is that it has been conceived and validated as by these same women, we can assume that they will come
a self-evaluation instrument by women, so it is useful from equally varied backgrounds. In light of the soci-
for making shared decisions with the appropriate pro- odemographic data, it can be said that the women in our
fessional; and the fourth is that it is designed to be used study are representative of the study population.
in the EMAeHealth app, which was created through a Finally, there is lack of evidence regarding the tempo-
collaborative research process [33], with the partici- ral stability of the scores. Information will probably be
pation of puerperal women, professionals, managers obtained on this aspect in future studies.
Conclusions CNM. Mª Jesús Mulas, CNM. Covadonga Pérez, CNM. Angela Rodríguez,
CNM. Mercedes Sáenz de Santamaría, CNM. Jesús Sánchez, CNM. Gema Vil‑
This digital tool for measuring the priority health issues for lanueva, Senior Systematic Reviewer at Cochrane Response.
women during the postpartum period, which is adapted to
the cultural and health environment where it was designed Authors’ contributions
IA, CP and PB developed the protocol, and were responsible for organiza‑
(public primary gynaecological care), and which is in tion and funding. PB, IA, CP, AG and ME wrote the main manuscript text and
Spanish and has good psychometric properties, is consid- statistical analysis and figures. Ema-Q have read the manuscript to contribute
ered useful and accessible for women and professionals. to it, and have approved the final text.
The psychometric quality of the EMA-postpartum Funding
instrument, together with the advantages it presents in The grant was received from the National Institute of Health Carlos III, file
terms of format and length, would justify its considera- number PI20/00899, within the State R&D&I Plan 2017–2020, and co-financed
by the ISCII (Sub directorate) General Evaluation and Promotion of Fund
tion by the ICHOM as a possible PROM tool, within the Research European Regional Development Fund (FEDER). This study was
Standard Set of Outcome Measures for Pregnancy and co-financed by the Basque Government Department of Health. File n°:
Childbirth, for the Health and Welfare section. However, 2018111087.
a previous psychometric analysis of the properties of the Availability of data and materials
scores derived from EMA-postpartum in other popula- The data sets generated and/or analyzed during the current study are not yet
tions of pregnant women is recommended. publicly available as they are still being processed by the research team for
further publication, but can be made available from the corresponding author
upon reasonable request.
Abbreviations
AI Asymmetry index Declarations
CFA Confirmatory factor analysis
CFI Comparative fit index Ethics approval and consent to participate
COSMIN Consensus-based standards for the selection of health measure‑ The Clinical Research Ethics Committee of Basque Country (PI2019110)
ment instruments approved the study in accordance with the relevant guidelines and regula‑
DF Degrees of freedom tions. Prior to participating in the study, all the participating women were
DWLS Diagonally weighted least squares informed of the study and an informed consent was provided by all the partic‑
EDI-3 Eating disorder inventory-3 ipants for this study. The consent and information sheet had been previously
EFA Exploratory factor analysis approved by the Ethics Committee of Basque Country.
EPDS Edinburgh postnatal depression scale
ICIQ International consultation on incontinence questionnaire Consent for publication
short-form Not applicable.
ICHOM International consortium for health outcomes measurement
K Cohen’s kappa coefficient Competing interests
Ku Kurtosis index The authors declare no competing interests.
LL Lower median limit
M Arithmetic mean Author details
Max Maximum 1
University of the Basque Country, Barrio Sarriena, S/N, 48940 Leioa, Spain.
ME Maternal education 2
Paola Bully Methodological and Statistical Consultant, C/ Barrio La Sota,
Min Minimum Sopuerta 48190, Spain. 3 Osakidetza-Basque Health Service, Biocruces-
MOS-SSS Medical outcomes study-social support survey Bizkaia Health Research Institute, C/ Edificio Biocruces 3. Plaza De Cruces,
Ordinal α Ordinal alpha 48903 Barakaldo, Spain. 4 Primary Care Midwife Zuazo Health Centre, Osi
PBSES Prenatal breast-feeding self-efficacy scale Barakaldo‑Sestao‑Osakidetza, C/ Lurkizaga Kalea, S/N, 48902 Barakaldo, Spain.
PSOC Parental sense of competence 5
School of Nursing, University of the Basque Country, C/ Barrio Sarriena S/N,
RMSEA Root mean square error of approximation Leioa 48940, Spain. 6 Midwifery Training Unit of the Basque Country, Hospital
SD Standard deviation de Basurto-Osakidetza, C/ Montevideo Etorbidea 18, Bilbao 48013, Spain.
SF-12 v2 Short form 12 items health survey version 2 7
Primary Care Midwife Markonzaga Health Centre, OSI Barakaldo-Sestao-
SFQ Sexual function questionnaire Osakidetza, C/ Antonio Trueba Kalea, 17, Sestao 48910, Spain.
SRMR Standardized root mean square residual
TLI Tucker-lewis index Received: 17 April 2023 Accepted: 4 August 2023
UL Upper median limit
λij Standardized factorial weight
95% CI Confidence interval of 95%
ω McDonald’s Omega
χ2 Chi-squared References
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Bully et al.

RESEARCH Open Access

Development and evaluation

Introduction services provided at this stage. Consequently, it is essen-

Table 1 Evolution of the number and distribution of the items

Table 2 Gold standards and their psychometric properties in our sample

Table 3 Characteristics of the participants Functionality/QOL This is a one-dimension scale

Table 6 Characteristics of the items that measure functionality

Table 7 Characteristics of the item that measures incontinence

Table 8 Characteristics of the items that measure sexuality

Table 9 Characteristics of the items linked to breastfeeding

Table 10 Characteristics of the items that measure parental self-efficacy

Table 11 Characteristics of the items that measure perceived social support

Table 12 Characteristics of the items that measure self-image

Table 13 Characteristics of items that measure sleep problems

Table 14 Characteristics of the items that measure depression

I have felt lonely 1–5 2.11 1.13 0.65 -0.54 .75

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