Qualität und Sicherheit in der Gesundheitsversorgung / Quality and Safety in Health Care| Volume 166, P8-17, November 2021

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# Assessment of the quality of woman-centred midwifery care from the mothers’ perspective: A structural analysis of cross-sectional survey data

Open AccessPublished:August 30, 2021

## Abstract

### Objective

Development and psychometric evaluation of a multidimensional model and assessment scales measuring core aspects of the quality of woman-centred midwifery care processes in Germany.

### Design & Participants

201 women, who received midwifery care during their pregnancy in 2018, were enrolled 6 to 18 months after birth. Data were assessed in a retrospective cross-sectional survey in Germany.

### Measurements

Established scales that are used in health care were adapted to the context of woman-centred midwifery care: Shared Decision-Making (SDM-Q-9-M), Empathy (CARE-M), Internal Team Participation (TEAM-M) and Professional Competence (PC-M). Confirmatory factor analyses were adapted to prove (a) the homogeneity of the single scales and (b) the multidimensional structure of the entire item pool.

### Findings

Appropriate to good model fit was confirmed for both the single assessments (CFI ≥ .96; SRMR ≤ .032) and the multidimensional model (CFI = .96; SRMR = .049). Minor model modifications reflecting local item dependencies had to be considered for the scales SDM-Q-9-M, TEAM-M, and PC-M. For the CARE-M scale, Participatory Communication proved to be a separate, second structural component.

### Conclusions

Shared Decision-Making, Empathy, Internal Team Participation, and Professional Competence constitute core components of woman-centred midwifery care processes. A multi-dimensional assessment is now available measuring women's experiences with midwifery care. The assessment provides an essential component to master the complex challenge of measuring the quality of midwifery care inside and outside the hospital by means of a standardised and validated assessment.

## Zusammenfassung

### Zielsetzung

Entwicklung und psychometrische Evaluation eines multidimensionalen Modells und von Skalen zur Erhebung zentraler Merkmale der Prozessqualität der frauenzentrierten Hebammenversorgung in Deutschland aus Perspektive der Mütter.

### Methodik

201 Mütter, die während der Schwangerschaft im Jahr 2018 Hebammenleistungen in Anspruch genommen hatten, wurden 6 bis 18 Monate nach der Geburt in die Studie aufgenommen. Die Daten wurden im Rahmen einer retrospektiven Querschnitterhebung in Deutschland erhoben. Etablierte Skalen, die in der Gesundheitsversorgung Verwendung finden, wurden an den Kontext der frauenzentrierten Hebammenversorgung angepasst: Shared Decision-Making (SDM-Q-9-M), Empathie (CARE-M), interne Teambeteiligung (TEAM-M) und Professionelle Kompetenz (PC-M). Die Homogenität der einzelnen Skalen und die multidimensionale Struktur des gesamten Item-Pools wurden mittels konfirmatorischer Faktorenanalysen analysiert.

### Ergebnisse

Sowohl für die einzelnen Skalen (CFI ≥ .96; SRMR ≤ .032) als auch für das multidimensionale Modell (CFI = .96; SRMR = .049) zeigte sich ein angemessener bis guter Modellfit. Geringfügige Modellmodifikationen, die lokale Itemabhängigkeiten widerspiegeln, mussten für die Skalen SDM-Q-9-M, TEAM-M und PC-M berücksichtigt werden. Für die Skala CARE-M erwies sich die Partizipative Kommunikation als separate zweite Strukturkomponente.

### Diskussion

Shared Decision-Making, Empathie, interne Teamarbeit sowie professionelle Kompetenz stellen Kernkomponenten der frauenzentrierten Hebammenversorgung dar. Ein multidimensionales Assessment ist nun verfügbar, das die Erfahrungen von Frauen in der Hebammenversorgung erfasst. Das Assessment stellt einen wesentlichen Baustein dar, um der komplexen Herausforderung einer standardisierten und validierten Messung der Qualität der Hebammenbetreuung innerhalb und außerhalb des klinischen Kontextes zu begegnen.

## Schlüsselwörter

#### Abbreviations:

AVE (Average Variance Extracted), CARE-8-M (Scale for measuring the Midwife's Empathy), CARE-PM-M (Structural component measuring Participatory Communication), CFA (Confirmatory Factor Analysis), CFI (Comparative Fit Index), CI (Confidence Interval), df (Degrees of Freedom), FR (Factor Reliability), IR (Indicator Reliability), PC-M (Scale for measuring Professional Competence), rit (Corrected item-total correlation), RMSEA (Root Mean Square of Approximation), SDM-Q-9-M (Scale for measuring Shared Decision-Making), SRMR (Standardized Root Mean Square Residual), TEAM-M (Scale for measuring Internal Team Participation), TLI (Tucker-Lewis Index), WHO (World Health Organization)

## Background

Midwives accompany and support pregnant women, women in childbirth, and women who have recently given birth. Midwifery care takes place in an interdisciplinary context with the aim of integrated, coordinated, woman-centred care [

International Confederation of Midwives, Definition of Midwifery. https://www.internationalmidwives.org/assets/files/definitions-files/2018/06/eng-definition_midwifery.pdf, 2017.(accessed 09 Jun 2021).

]. In doing so, they pursue individual and flexible care which is tailored to the respective needs of the woman in order to guarantee the health and rights of women and their newborns at every stage of care. In Germany, the scope of midwifery care is legally defined. It includes independent and comprehensive counselling, care and observation of women during pregnancy, childbirth, puerperium and breastfeeding. Furthermore, the independent management of physiological births and the examination, care and monitoring of newborns and infants is the responsibility of midwives (§ 1 HebG). Physicians are obliged to ensure that a midwife is consulted during birth (§ 4 HebG). In general, according to the Social Security Code V, all legally insured women in Germany are entitled to midwifery care (§ 134a SGB V). Accordingly, midwives are assigned a central role in “providing safe, effective, and efficient high-quality health services” [

WHO Regional Office for Europe, European strategic directions for strengthening nursing and midwifery towards Health 2020 goals. https://www.euro.who.int/__data/assets/pdf_file/0004/274306/European-strategic-directions-strengthening-nursing-midwifery-Health2020_en-REV1.pdf?ua = 1, 2015.(accessed 09 Jun 2021).

]. To ensure professional woman-centred care, it is important to make the quality of the midwifery care processes measurable. This helps to efficiently identify deficits but also strengths in the care of women and their newborns.

### The concept of woman-centred midwifery care

Measuring the quality of midwifery care requires a theoretical foundation and should consider the concept of woman-centred care. Fontein-Kuipers et al. [
• Fontein-Kuipers Y.
• Groot de R.
• van Staa A.
Woman-centered care 2.0: Bringing the concept into focus.
] elaborated a comprehensive conceptual foundation of this concept based on a systematic literature research. Different ways of applying the concept of woman-centred care and the lack of an explicit definition of the concept were found to be major obstacles in practical settings [
• Fontein-Kuipers Y.
• Groot de R.
• van Staa A.
Woman-centered care 2.0: Bringing the concept into focus.
]. Identifying a consensual definition is seen as a central prerequisite to ensure the adequate use of the concept in the midwifery context [
• Fontein-Kuipers Y.
• Groot de R.
• van Staa A.
Woman-centered care 2.0: Bringing the concept into focus.
]. However, the insufficient evidence concerning appropriate woman-centred care and its implementation within care processes provide a central challenge in defining and assessing the quality of midwifery care.
The WHO's framework for improving the quality of maternal and newborn care in health facilities aims at defining consistent criteria at the levels of structural, process, and outcome quality [

WHO, Standards for improving quality of maternal and newborn care in health facilities. https://apps.who.int/iris/bitstream/handle/10665/249155/9789241511216-eng.pdf;jsessionid = B4A2CB77555D98944BE7D7A084FC6CB2?sequence = 1, 2016.(accessed 09 Jun 2021).

] (see Figure 1). This model underlines the complexity of midwifery care processes and takes up core elements of woman-centred care (e.g. woman-midwife relationship, mental health, shared decision-making, cooperation and communication) according to Fontein-Kuipers et al. [
• Fontein-Kuipers Y.
• Groot de R.
• van Staa A.
Woman-centered care 2.0: Bringing the concept into focus.
]. Additionally, it highlights the fact that solely evaluating the provided care services is not sufficient to fully assess the quality of midwifery care (also outside the clinical setting). The woman's perspective on the provided care is defined as a relevant criterion for quality assessment both at the level of the process (experience of care) and the outcomes (woman-centred outcomes) [

WHO, Standards for improving quality of maternal and newborn care in health facilities. https://apps.who.int/iris/bitstream/handle/10665/249155/9789241511216-eng.pdf;jsessionid = B4A2CB77555D98944BE7D7A084FC6CB2?sequence = 1, 2016.(accessed 09 Jun 2021).

]. This is in line with the theoretical foundation of woman-centred care according to Fontein-Kuipers et al. [
• Fontein-Kuipers Y.
• Groot de R.
• van Staa A.
Woman-centered care 2.0: Bringing the concept into focus.
]: The focus is not only on clinical parameters but also on biopsychosocial aspects reported by the women.

### Woman's subjective perspective on quality of midwifery care

Women receiving care mainly evaluate the quality of the care processes and general satisfaction within the context of quality of care. Indicators of clinical outcome quality are less relevant if women assess the quality of care [
• Grande G.
• Romppel M.
The Truth is in the Eye of the Beholder? Quality in Rehabilitation from the Patientś Perspective.
]. Results of studies on women's expectations and their subjective quality concepts are in accordance with aspects of process quality described in the framework (e.g. evidence-based practice, emotional support, respect and dignity, effective communication, competent and motivated human resources) [
• Ayerle G.M.
• Mattern E.
Women's expectations of a midwife.
,
• Hunter A.
• Devane D.
• Houghton C.
• et al.
Woman-centred care during pregnancy and birth in Ireland: thematic analysis of women's and clinicians’ experiences.
,
• Renfrew M.J.
• Bastos M.H.
• et al.
Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care.
]. Women strongly emphasize the interpersonal, empathic relationship between midwife and women [
• Ayerle G.M.
• Mattern E.
Women's expectations of a midwife.
], and the opportunity of making participatory decisions [
• Hunter A.
• Devane D.
• Houghton C.
• et al.
Woman-centred care during pregnancy and birth in Ireland: thematic analysis of women's and clinicians’ experiences.
]. Furthermore, women prioritize continuity and coordinated care. Women want midwives to cooperate with physicians, other midwives and hospital staff when necessary [
• Homer C.S.E.
• Passant L.
• Brodie P.M.
• et al.
The role of the midwife in Australia: views of women and midwives.
]. The integrated consideration of the requirements of the WHO framework, woman-centred care and the subjective quality concept may prove to be useful and form the basis for the operationalization of woman's perspective for assessing the quality of woman-centred care processes.
The present study strives to transfer the standards of patient-centred care (Patient-Reported Experience Measures (PREMs)) to key characteristics in the field midwifery care. PREMs reflect women's subjective assessment of characteristics during the care process [
• Beattie M.
• Murphy D.J.
• Atherton I.
• et al.
Instruments to measure patient experience of healthcare quality in hospitals: a systematic review.
]. The utility PREMs may be at three levels in midwifery care:
• 1.
woman's level: alignment of care with women's experiences and needs in terms of woman-centred care and strengthening patient safety.
• 2.
provider level: individual performance feedback from midwives to evaluate and optimize their own care practices.
• 3.
system level: stronger inclusion of PREMs in midwifery care as supplementary indicators in the context of quality assurance of comprehensive care for women.

### Reference to the concept of patient centred care

The identified requirements for midwifery care are in accordance with the basic principles of patient-centred care. According to Langberg et al. [
• Langberg E.M.
• Dyhr L.
• Davidsen A.S.
Development of the concept of patient-centredness - A systematic review.
] the identified components for the midwifery care can be classified on 3 levels:
• woman (e.g. consideration of woman's preferences, values and behaviour, emotional support, involvement of family members)
• woman-midwife relationship (e.g. trusting, empathic communication, information, shared decision-making, perceived expertise of the midwife)
• coherence of care (e.g. continuity and coordinated care)
These factors have proven to be relevant in various fields of health care science. For example, the predictive value of the constructs Shared Decision-Making, Empathy, and Internal Team Participation on the outcomes of patient satisfaction (61% predicted total variance) and treatment acceptance (67% predicted total variance) in medical rehabilitation has been confirmed [
• Quaschning K.
• Körner M.
• Wirtz M.
Analyzing the effects of shared decision-making, empathy and team interaction on patient satisfaction and treatment acceptance in medical rehabilitation using a structural equation modeling approach.
]. Shared Decision-Making is positively related to patient satisfaction, health outcomes, and cost-effectiveness [
• Barry M.J.
• Edgman-Levitan S.
Shared decision making--pinnacle of patient-centered care.
]. Shared Decision-Making has been defined as a guiding goal for midwives in the midwifery care contract according to § 134a SGB V in Germany. Furthermore study results indicate that a competent midwife (e. g. evidence-based expertise) enhances trust in the woman-midwife relationship [
• Homer C.S.E.
• Passant L.
• Brodie P.M.
• et al.
The role of the midwife in Australia: views of women and midwives.
,
• Kaye D.K.
• Kakaire O.
• Nakimuli A.
• et al.
Male involvement during pregnancy and childbirth: men's perceptions, practices and experiences during the care for women who developed childbirth complications in Mulago Hospital, Uganda.
]. At the womans’ level, emotional support is fostered by midwives’ empathy. In particular, midwives’ sensitivity is needed to appropriately address women's preferences, values, and behaviours. Both the concept of woman-centred care [
• Fontein-Kuipers Y.
• Groot de R.
• van Staa A.
Woman-centered care 2.0: Bringing the concept into focus.
] and the WHO framework [

WHO, Standards for improving quality of maternal and newborn care in health facilities. https://apps.who.int/iris/bitstream/handle/10665/249155/9789241511216-eng.pdf;jsessionid = B4A2CB77555D98944BE7D7A084FC6CB2?sequence = 1, 2016.(accessed 09 Jun 2021).

] locate Empathy in the context of process quality. Moreover, the cooperation of midwives with regionally responsible health services in the sense of continuous and coordinated care is enshrined in the quality agreement according to §134a SGB V. Hence, cooperation represents a relevant aspect regarding the level of coherence of care.

### Aim of the present study

The aim of the present study is to make the quality of the midwifery care processes measurable from the woman's perspective. To the best of our knowledge, currently no approved questionnaire exists assessing the woman-centred care process in midwifery care from the perspective of woman in a multidimensional, reliable, and valid manner. Existing quality indicators or assessments are either routinely used in clinical obstetrics to evaluate the outcome, but do not reflect the complexity of the care processes by midwives adequately [

Institute for Quality Assurance and Transparency in Health Care (2019) Description of the quality indicators and key figures according to QSKH-RL: Obstetrics. 2018, Berlin.

]. Instruments primarily focus on the measurement of women's satisfaction with midwifery care, vary in their construct definition and possess differing psychometric characteristics [
• Sawyer A.
• Ayers S.
• Abbott J.
• et al.
Measures of satisfaction with care during labour and birth: a comparative review.
]. In order to measure the quality of midwifery woman-centred care in- and outside the hospital, a standardised and valid assessment instrument will be developed assessing the quality of the care processes in accordance with the synthesis of theoretical approaches described above. In a first step, established and valid instruments measuring Shared Decision-Making (SDM-Q-9 [
• Kriston L.
• Scholl I.
• Hölzel L.
• et al.
The 9-item Shared Decision Making Questionnaire (SDM-Q-9). Development and psychometric properties in a primary care sample.
]), Empathy (CARE [
• Mercer S.W.
• Maxwell M.
• Heaney D.
• et al.
The consultation and relational empathy (CARE) measure: development and preliminary validation and reliability of an empathy-based consultation process measure.
]), Internal Team Participation (TEAM [

M. Körner, Entwicklung und Evaluation eines Trainingsprogramms zur Partizipativen Entscheidungsfindung in der medizinischen Rehabilitation (PEFIT): Abschlussbericht, Universität Freiburg, Freiburg. http://www.forschung-patientenorientierung.de/files/abschlussbericht_endfassung_juni_2012_pefit.pdf, 2012.(accessed 09 Jun 2021).

]), and Professional Competence (PC [
• Gericke C.A.
• Schiffhorst G.
• Busse R.
• et al.
A Validated Questionnaire for Measuring Patient Satisfaction in General and Specialist Ambulatory Medical Care: the Qualiskope-A.
]) are adapted for recording the quality of the care processes of midwifery care. Second, the homogeneity of adapted scales SDM-Q-9-M, CARE-M, TEAM-M, and PC-M will be evaluated in scale specific analyses. Third, a comprehensive multidimensional model will be analysed to determine the associations of the constructs characterising the quality of the midwifery care processes.

## Methods

### Participants

The cross-sectional survey was carried out from June to July 2019 and surveyed mothers’ experience of pregnancy of the child born in 2018. The inclusion criteria were (1) majority age (≥ 18), (2) giving birth(s) in 2018, and (3) use of midwifery services during pregnancy. The child was born 6 to 18 months ago. The hyperlink of the digital questionnaire, a letter of invitation, and the information for participants were sent by post to 2,368 families from a district in Germany from the register of residents. All participants completed a digital informed consent form. Sociodemographic data and information on aspects of childbirth were collected.

### Assessment instruments

#### 9-item Shared Decision-Making Questionnaire (SDM-Q-9)

The instrument 9-item Shared Decision-Making Questionnaire (SDM-Q-9) (Cronbach́s $∝=.94$) was used to measure the extent to which women receiving care during pregnancy are involved in decision-making processes [
• Kriston L.
• Scholl I.
• Hölzel L.
• et al.
The 9-item Shared Decision Making Questionnaire (SDM-Q-9). Development and psychometric properties in a primary care sample.
]. The generic, one-dimensional scale includes 9 items which are scored on a 6-point Likert scale from 0 = “Does not apply at all” to 5 = “Fully applies”. Higher scores are associated with a higher degree of involvement of the woman in decision-making processes, e.g. “My midwife helped me to understand all the information.” (SDM-M-5) [
• Kriston L.
• Scholl I.
• Hölzel L.
• et al.
The 9-item Shared Decision Making Questionnaire (SDM-Q-9). Development and psychometric properties in a primary care sample.
].

#### Consultation and Relational Empathy (CARE)

The degree of empathy among midwives from the perspective of the woman was recorded using the German version of the validated instrument Consultation and Relational Empathy (CARE; Cronbach's $∝$: .92- .94. [
• Mercer S.W.
• Maxwell M.
• Heaney D.
• et al.
The consultation and relational empathy (CARE) measure: development and preliminary validation and reliability of an empathy-based consultation process measure.
,
• Neumann M.
• Wirtz M.
• Bollschweiler E.
• et al.
Evaluation of the Psychometric Properties of the German Version of the ”Consultation and Relational Empathy“ (CARE) Measure at the Example of Inpatient Cancer Patients (Psychometric evaluation of the German version of the ”Consultation and Relational Empathy“ (CARE) measure at the example of cancer patients).
]). The one-dimensional CARE scale includes 10 items which relate the perception of the woman in terms of the midwife's understanding and reaction to the concerns and fears of the woman under care, e.g. “Was the midwife interested in you as a whole person?” (CARE-M-4). The women answered the items on a 5-point scale from 1 = ”fully applies“ to 5 = ”does not apply at all“.

#### Team Scale (TEAM)

The Team Scale (Cronbach's $∝=.88$) was used to measure interaction and internal participation in the team (midwife and attending physicians during pregnancy) [

M. Körner, Entwicklung und Evaluation eines Trainingsprogramms zur Partizipativen Entscheidungsfindung in der medizinischen Rehabilitation (PEFIT): Abschlussbericht, Universität Freiburg, Freiburg. http://www.forschung-patientenorientierung.de/files/abschlussbericht_endfassung_juni_2012_pefit.pdf, 2012.(accessed 09 Jun 2021).

]. The 6 items represent the areas Internal Communication, Coordination, Cooperation, and Climate in the Team: e.g. ”My midwife and my attending physician work hand in hand“ (TEAM-M-1). The 4-point scale (1 = ”does not apply at all“ to 4 = ”applies completely“) was adapted to a 6-point Likert scale for the present study (1 = ”does not apply at all“ to 6 = ”fully applies“). Extreme scale endpoints were added to minimize expected ceiling/floor effects and to achieve better reliability [
• Lozano L.M.
• García-Cueto E.
• Muñiz J.
Effect of the Number of Response Categories on the Reliability and Validity of Rating Scales.
].

#### Facet Professional Competence (PC) of Qualiskope-A Questionnaire

The Qualiskope-A Questionnaire is a standardized, patient-centred instrument which enables a differentiated analysis of major aspects of process-related patient satisfaction [
• Gericke C.A.
• Schiffhorst G.
• Busse R.
• et al.
A Validated Questionnaire for Measuring Patient Satisfaction in General and Specialist Ambulatory Medical Care: the Qualiskope-A.
]. The construct Professional Competence was adapted from the Qualiskope-A Questionnaire (Cronbach's $∝ ≥.88$), e.g. ”The midwife is a specialist in her field“. (PC-M-5). The 6 items comprise a 6-point Likert scale (1 = ”does not apply at all“ to 6 = ”fully applies“).
The aspect ”involvement of the partner“ must be regarded as an important midwife-specific task. This is confirmed by the results of a Swedish cross-sectional survey from 2009 to 2010 [
• Hildingsson I.
• Christensson K.
Swedish women's expectations about antenatal care and change over time - a comparative study of two cohorts of women.
]. A newly generated item was added to the scale ”The midwife was open to include people who are important to me in the care“(PC-M-1).
All adaptations of the applied scales to the midwife context are documented in Appendix A, Additional File A. The adaptation was based on the German language versions (see Appendix A, Additional File A and Table 3 for English translations, please note, due to translation some characteristics of the items might have changed. The German scales are available in Appendix A, Additional File C). Scale adaptation was based on the specific characteristics of woman-centred care by midwives. For example, dealing with a disease or coping with the disease is not primarily the focus of midwifery care. Hence, e.g. item 9 of the CARE scale “Did the doctor help you find a way to deal with your illness” was modified into “Did you find the midwife's preparation for birth and parenthood helpful for yourself?” (CARE-M-9). Cognitive interviews (N = 5 mothers) were used to test the comprehensibility of the adapted scales and the changed wording as well as the fit to the German care context.
Validated German versions were used for all assessment instruments [
• Kriston L.
• Scholl I.
• Hölzel L.
• et al.
The 9-item Shared Decision Making Questionnaire (SDM-Q-9). Development and psychometric properties in a primary care sample.
,

M. Körner, Entwicklung und Evaluation eines Trainingsprogramms zur Partizipativen Entscheidungsfindung in der medizinischen Rehabilitation (PEFIT): Abschlussbericht, Universität Freiburg, Freiburg. http://www.forschung-patientenorientierung.de/files/abschlussbericht_endfassung_juni_2012_pefit.pdf, 2012.(accessed 09 Jun 2021).

,
• Gericke C.A.
• Schiffhorst G.
• Busse R.
• et al.
A Validated Questionnaire for Measuring Patient Satisfaction in General and Specialist Ambulatory Medical Care: the Qualiskope-A.
,
• Neumann M.
• Wirtz M.
• Bollschweiler E.
• et al.
Evaluation of the Psychometric Properties of the German Version of the ”Consultation and Relational Empathy“ (CARE) Measure at the Example of Inpatient Cancer Patients (Psychometric evaluation of the German version of the ”Consultation and Relational Empathy“ (CARE) measure at the example of cancer patients).
].

### Statistical Analysis

Descriptive and inferential statistical calculations were performed using IBM SPSS Statistics 23.0. In order to avoid systematic bias due to missing data missing values were imputed using the expectation-maximization algorithm [
• Wirtz M.
On the Problem of Missing Data: How to Identify and Reduce the Impact of Missing Data on Findings of Data Analysis (On the problem of missing data: How to identify and reduce the impact of missing data on findings of data analysis).
].
Confirmatory factor analyses (CFA) were conducted using the maximum likelihood estimation method implemented in AMOS 23.0 [
• Kline R.B.
Principles and practice of structural equation modeling, 4 th. Methodology in the social sciences.
]. According to the classical test theory, it is assumed that a single latent construct can predict the variance of the scale items except for the independent error component [
• Kline R.B.
Principles and practice of structural equation modeling, 4 th. Methodology in the social sciences.
]. The fit of the empirical and estimated variance-covariance matrix was checked by measures of the exact and approximate model fit. The χ2-test represents the most rigorous form of model testing. Non-significant χ2–values (fit criterion: p(χ2) > .05) indicate whether the entire information in the empirical variance-covariance matrix is predicted by the model [
• Kline R.B.
Principles and practice of structural equation modeling, 4 th. Methodology in the social sciences.
]. The root mean square error of approximation (RMSEA) indicates the amount of variance-covariance information which cannot be predicted by the model. Because RMSEA is known to be overly sensitive in indicating model misfit in cases of small number of degrees of freedom (df) and sample size (N ≤ 250) [
• Kline R.B.
Principles and practice of structural equation modeling, 4 th. Methodology in the social sciences.
], the standardized root mean square residual (SRMR), indicating the standardized difference between the predicted and the observed correlation (< .08 good fit [
• Kline R.B.
Principles and practice of structural equation modeling, 4 th. Methodology in the social sciences.
]) will be considered as major indicator of absolute model fit. The Comparative Fit Index (CFI) and the Tucker-Lewis Index (TLI) represent the proportion of information which can be explained by the assumed model in reference to a global zero model (assuming completely uncorrelated analysis variables). The cut-off value for an acceptable fit for incremental indices is > .95 [
• Kline R.B.
Principles and practice of structural equation modeling, 4 th. Methodology in the social sciences.
].
To check the local goodness of fit, the indicator reliability of the individual items (IR; criterion: IR ≥ .40), the average variance extracted (AVE; criterion: AVE ≥ .50), and the factor reliability (FR; criterion: FR ≥ .60) were determined [
• Kline R.B.
Principles and practice of structural equation modeling, 4 th. Methodology in the social sciences.
]. The Fornell-Larcker criterion served as a measure of discriminant validity [
• Kline R.B.
Principles and practice of structural equation modeling, 4 th. Methodology in the social sciences.
]. The modelled constructs can only be reliably separated if each latent construct is more strongly linked on average to its items than to the other latent constructs.

## Results

### Demographics

2,368 women received a written invitation to participate in the study. Of these, a total of 209 women (8.8%) completed the survey on the midwifery care processes during pregnancy. 8 cases (3.8%) were excluded from the analysis due to more than 5 missing values in the items of all scales used (> 16% missing values). Cases with less than 6 missing values were imputed using the expectation maximization algorithm (N = 33; 15.8%) [
• Wirtz M.
On the Problem of Missing Data: How to Identify and Reduce the Impact of Missing Data on Findings of Data Analysis (On the problem of missing data: How to identify and reduce the impact of missing data on findings of data analysis).
]. In total, N = 201 complete cases (96.2%) were included in the analysis (see Table 1).
Table 1Characteristics of the sample (N = 201).
MS.D.
Age32.83.6
Frequencies (n)(%)
Age
< 30 years3919.4
30 – 35 years11155.2
>35 years5125.4
Nationality
German19496.5
Another nationality73.5
Education
Secondary (general) & specialized school9949.2
Grammar or high school9949.2
Other31.6
Completed vocational training, higher education
Apprenticeship5627.9
Vocational school3115.4
Technical school3115.4
Engineering school21.0
University, college7336.3
Other84.0
Marital status
Married, lives with spouse15677.6
Separated/divorced/widowed/single mother4522.4
Insurance status
Statutory insurance17285.6
Private insurance2914.4
Net-household income (monthly)
500 to less than 2,000 €/month2713.4
2,000 to less than 5, 000 €/month15275.7
≥ 5,000 €/month2210.9
Birth experience
Primipara11657.7
Two children born6532.3
Three or more children born2010.0
Premature birth
Yes126.0
No18994.0
High-risk pregnancy
Yes4421.9
No15476.6
Mode of childbirth
Vaginal spontaneous birth14873.6
Intended caesarean birth178.5
Unscheduled caesarean section/

emergency caesarean-section
3617.9
M = mean, S.D. = standard deviation

### CFA of single assessment scales

#### SDM-Q-9-M Scale

The original one-dimensional model structure of the adapted SDM-Q-9-M scale proved to be invalid due to the measures of global fit (see Table 2, line “original model”).
Table 2Measures of global fit for all estimated single CFA-models (N = 201).
χ2dfχ2/dfpCFITLIRMSEA [90%-CI]SRMR
acceptable fit threshold

good fit threshold
< 3

< 2
≥.05≥ .95

≥. 97
≥ .95

≥ .97
≤ .08

≤ .05

≤ .08
SDM-Q-9-M(idwifery)
Original model216.44278.02 < .001.91.89.187 [.17; .21].045
Modified model74.80243.12 < .001.98.97.103 [.08; .13].025
CARE-M
Original model276.01357.89 < .001.88.84.186 [.17; .21].067
Modified model117.99333.58 < .001.96.94.113 [.09; .14].032
TEAM-M
Original model16.0853.22.007.99.98.105 [.05; .17].016
PC-M
Model with parcelled PC-M item pairs; CFI=Comparative Fit Index; TLI=Tucker-Lewis Index, RMSEA=Root Mean Square of Approximation, SRMR=Standardized Root Mean Square Residual.
Original model196.13209.81 < .001.82.75.210 [.18; .24].071
Modified model38.59201.93.008.98.97.068 [.04; .10].030
Multidimensional Model
Model with parcelled PC-M item pairs; CFI=Comparative Fit Index; TLI=Tucker-Lewis Index, RMSEA=Root Mean Square of Approximation, SRMR=Standardized Root Mean Square Residual.
657.063631.81 < .001.96.95.064 [.06; .07].049
* Model with parcelled PC-M item pairs;CFI = Comparative Fit Index; TLI = Tucker-Lewis Index, RMSEA = Root Mean Square of Approximation, SRMR = Standardized Root Mean Square Residual.
The analysis of residual correlations showed violations due to local item dependencies (medium to high local dependence, r ≥ .43) of three item pairs. SDM-M-1 (”has expressly informed that a decision must be taken“) and SDM-M-2 (“desired to participation in decision making”) address aspects of Decision Making. SDM-M-3 (”information different options“) and SDM-M-4 (”explanation assets and drawbacks of the options“) refer to the Available Options. Deciding between Options is reflected by SDM-M-7 (”joint consideration of options“) and SDM-M-8 (”joint selection of the option“). Defining these dependencies as latent model components led to a satisfactory to good model fit (see Table 2, line ”modified model“). The value of SRMR equal to .025 indicates an appropriate model-fit (SRMR ≤ .08 [
• Kline R.B.
Principles and practice of structural equation modeling, 4 th. Methodology in the social sciences.
]). The measures of local fit confirmed that the latent construct can be reliably measured by the indicators. More than 40% of the variance of each manifest item was shared with the latent variable Shared Decision-Making [
• Kline R.B.
Principles and practice of structural equation modeling, 4 th. Methodology in the social sciences.
]. In addition, FR = .96 and AVE = .74 exceeded the critical threshold of .60 and .50, respectively [
• Kline R.B.
Principles and practice of structural equation modeling, 4 th. Methodology in the social sciences.
] (see Table 3). Thus, after taking the local dependencies reflecting the subaspects Decision Making, Considering Options, and Deciding between Options into account, a single second order construct Shared Decision-Making allows to model the information in the SDM-Q-9-M items appropriately.
Table 3Measures of local fit for the CFA of the single and the multidimensional scale structure and relevant item properties (N = 201)
Critical Ratio (C. R.) for all items ≥ 9
.
SDM-Q-9-M (0=completely disagree all, 5=completely agree)
ItemMS.D.$rit$IR
SDM-M-1 – has expressly informed that a decision must be taken3.491.60.73.50FR: .96
SDM-M-2 – desired participation in decision making3.591.45.81.63AVE: .74
SDM-M-3 – information different options4.031.40.89.82α .96
SDM-M-4 – explanation assets & drawbacks of the options3.871.46.92.89
SDM-M-5 – helped to understand all information4.121.34.85.79
SDM-M-6 – asked which option I preferred3.911.50.91.89
SDM-M-7 – joint consideration of options3.661.58.88.80
SDM-M-8 – joint selection of the option3.381.66.80.65
SDM-M-9 – agreement for further care3.771.60.85.72
CARE-8-M (1=fully applies, 5=does not apply at all)
ItemMS.D.$rit$IR
CARE-M-1 – making you feel at ease1.260.68.81.71FR: .96
CARE-M-2 – letting you tell your “story“1.270.65.82.71AVE: .73
CARE-M-3 – really listening1.350.65.83.71α: .96
CARE-M-4 – being interested in you as whole person1.330.68.87.80
CARE-M-5 – fully understanding your concerns1.430.76.80.67
CARE-M-6 – showing care and compassion1.340.72.92.88
CARE-M-7 – being positive1.320.71.83.73
CARE-M-8 – explaining things clearly1.410.80.80.68
CARE-PM-M (1=fully applies, 5=does not apply at all)
ItemMS.D.$rit$IR
CARE-M-9 – helpful birth preparation1.611.02.82.86FR: .90
CARE-M-10 – making a plan of action with you1.861.13.82.78AVE: .82

α: .90
TEAM-M (1=does not apply at all, 6=fully applies)
ItemMS.D.$rit$IR
TEAM-M-1 – work hand in hand2.871.88.90.73FR: .96
TEAM-M-2 – good agreements among themselves2.951.89.95.93AVE: .85
TEAM-M-3 – coordinated information3.311.84.87.76α: .97
TEAM-M-4 – good communication between each other2.861.89.94.95
TEAM-M-5 – deferential interaction3.552.00.85.86
PC-M
Model with parcelled PC-M item pairs
(1=does not apply at all, 6=fully applies)
ItemMS.D.$rit$IR
PC-M-1 – involves important persons in care5.381.11.61.47FR: .87
PC-M-2 – has taken thorough care of my health5.281.02.77.63AVE: .57
PC-M-3 – cooperates well with other professions4.481.49

.66

.55
α: .86
PC-M-4 – pays attention to whether other professionals need to be involved4.831.37
PC-M-5 – shés a specialist5.560.79.74.66
PC-M-6 – is at the current state of knowledge5.580.81
PC-M-7 – physical birth preparation5.311.10.71.61
PC-M-8 – psychological birth preparation5.271.15
M = mean; S.D. = standard deviation; $rit$ = corrected item-total correlation; IR = indicator reliability; FR = factor reliability; AVE = average variance extracted
* Critical Ratio (C. R.) for all items ≥ 9
** Model with parcelled PC-M item pairs

#### CARE-M Scale

The adapted CARE-M scale measuring Midwife Empathy also showed an insufficient model fit for the original one-dimensional model (see Table 2, line ”original model“). The items CARE-M-9 (”helpful birth preparation“) and CARE-M-10 (”making a plan of action with you“) showed a significantly weaker association with the underlying construct (IR = .39 for both items) than the other 8 scale items. The high local dependency (r = .72) indicated that these two items represent the clearly separable information aspect of Participatory Communication, which was modelled as second latent construct in the modified CFA model. Moreover, a local dependency (r = .29) between the items CARE-M-7 (”being positive“) and CARE-M-8 (”explaining things clearly“) exists, which represents the aspect of communication quality regarding birth preparation. These model modifications yielded an acceptable model fit on global (see Table 2, line ”modified model“) and local level (see Table 3).

#### TEAM-M Scale

The CFA of the one-dimensional measurement model of the TEAM-M scale measuring Internal Team Participation indicated a very good model fit with CFI = .99, TLI = .98, and SRMR = .016 in the original model (see Table 2, line ”original model“). For each manifest indicator, at least 73% of the information was associated with the underlying latent construct (IR ≥.40; FR = .95; AVE = .87 [
• Kline R.B.
Principles and practice of structural equation modeling, 4 th. Methodology in the social sciences.
]) (see Table 3).

#### PC-M Scale

The PC-M scale measuring Professional Competence showed an insufficient data fit in the original one-dimensional model definition (see Table 2, line ”original model“). The analysis of residual correlations (r > .30) indicated that the latent construct Professional Competence reflects a second order factor underlying 3 additional facets (first order factors). These facets are represented by two items each. The item PC-M-3 (”cooperates well with other professions“) and PC-M-4 (”pays attention to whether other professionals need to be involved“) represents the subfacet Cooperation, the items PC-M-5 (”she's a specialist“) and PC-M-6 (”is at the current state of knowledge“) represent the subfacet Evidence-based Practice. Finally, the midwife's efforts to provide Holistic Preparation for birth are measured by the items PC-M-7 (”physical birth preparation“) and PC-M-8 (”psychological birth preparation“). This model modification led to a substantial improvement, and a good model fit could be ensured (see Table 2, line ”modified model“). Good local fit level is indicated by IR (≥. 45 on all 8 items), as well as FR (= .87) and AVE (= .57) (see Table 3).

### Multi-dimensional CFA of the assessment scales

To analyse the multidimensional structure of the adapted assessment scales, a comprehensive multifactorial measurement and structural model was defined. Each scale was defined according to the results of the single scale analyses described above. The measurement and structural model are reported in detail in Appendix A, Additional File B. Appendix A, Additional File D contains the empirical correlation matrix of the 32 items of the multidimensional model. The only substantial unexplained residual component prevailed between item PC-3 (“cooperates well with other professions”) and the latent construct TEAM-M (r = .41). Cooperation between health professions measured by PC-M-3 is an essential component of teamwork. Defining this aspect as additional model component both measures of global fit (CFI = .96, TLI = .95, RMSEA = .064, SRMR = .049) and measures of local fit (IR ≥ .50; FR = .87-.96; AVE: .75-.85) indicated a good model fit (see Table 2, line “multidimensional model” and Appendix A, Additional File B). The data in Table 4 indicate that the individual constructs can be satisfactorily separated in the multivariate model. Only the latent constructs PC-M and CARE-PM-M share a higher proportion of variance with each other than either construct shares with its indicators. For all other construct combinations, the Fornell-Larcker criterion is fulfilled, indicating the appropriate separability of the constructs [
• Wirtz M.
On the Problem of Missing Data: How to Identify and Reduce the Impact of Missing Data on Findings of Data Analysis (On the problem of missing data: How to identify and reduce the impact of missing data on findings of data analysis).
].
Table 4Intercorrelations
All results are significant with p>.001
of the scales and relevant scale properties used in the CFA of the multi-dimensional scale structure (N = 201).
ScalesSDM-Q-9-MCARE-8-MCARE-PM-MTEAM-M
Model with parcelled PC-M item pairs; M=mean; S.D.=standard deviation.
PC-M

α
MS.D.Skewness
SDM-Q-9-M.86
Values in the diagonal: square root of average variance extracted (AVE);
.51
Values above the diagonal: Bivariate correlation of the scales;
.54
Values above the diagonal: Bivariate correlation of the scales;
.41
Values above the diagonal: Bivariate correlation of the scales;
.62
Values above the diagonal: Bivariate correlation of the scales;
.963.751.33-1.20
CARE-8-M.54
Values below the diagonal: Bivariate correlation of the latent constructs;
.85
Values in the diagonal: square root of average variance extracted (AVE);
.63
Values above the diagonal: Bivariate correlation of the scales;
.36
Values above the diagonal: Bivariate correlation of the scales;
.69
Values above the diagonal: Bivariate correlation of the scales;
.961.340.622.57
CARE-PM-M.59
Values below the diagonal: Bivariate correlation of the latent constructs;
.67
Values below the diagonal: Bivariate correlation of the latent constructs;
.75
Values in the diagonal: square root of average variance extracted (AVE);
.42
Values above the diagonal: Bivariate correlation of the scales;
.72
Values above the diagonal: Bivariate correlation of the scales;
.901.741.021.72
TEAM-M
Model with parcelled PC-M item pairs; M=mean; S.D.=standard deviation.
.37
Values below the diagonal: Bivariate correlation of the latent constructs;
.34
Values below the diagonal: Bivariate correlation of the latent constructs;
.38
Values below the diagonal: Bivariate correlation of the latent constructs;
.92
Values in the diagonal: square root of average variance extracted (AVE);
.50
Values above the diagonal: Bivariate correlation of the scales;
.973.111.780.30
PC-M.68
Values below the diagonal: Bivariate correlation of the latent constructs;
.75
Values below the diagonal: Bivariate correlation of the latent constructs;
.80
Values below the diagonal: Bivariate correlation of the latent constructs;
.44
Values below the diagonal: Bivariate correlation of the latent constructs;
.91
Values in the diagonal: square root of average variance extracted (AVE);
.865.240.86-1.73
a All results are significant with p >.001
b Values in the diagonal: square root of average variance extracted (AVE);
c Values above the diagonal: Bivariate correlation of the scales;
d Values below the diagonal: Bivariate correlation of the latent constructs;
* Model with parcelled PC-M item pairs;M = mean; S.D. = standard deviation.
The high correlation of the latent constructs PC-M and CARE-PM-M (r = .80) was also reflected in the high manifest correlation of the scales (r = .72).

### Associations of the scales with intensity of care, service utilization, education, and birth experience.

Table 5 shows the descriptive values for the three indicators of frequency of contact during pregnancy with midwives. SDM-Q-9-M and PC-M show higher values with increasing number and duration of appointments. The time of first contact with a midwife is only associated with SDM-Q-9-M.
Table 5Descriptive statistics and Pearson correlation of appointments with midwife during pregnancy (N = 201).
Pearson correlation
AppointmentsMS.D.MedianSDM-Q-9-MCARE-8-MCARE-PM-MTEAM-MPC-M
Number of appointments with midwife during pregnancy
=Excluding telephone and digital contact
3.273.232.00.229
p<.001
.136.038.109.208
p<.01
Duration of appointments with the midwife during pregnancy (minutes)32.4621.3830.00.177
p<.01
.111.126.050.186
p<.01
First contact with midwife (week of pregnancy)19.798.3618.00.163
p<.05
.035.103.025.010
M = mean; S.D. = standard deviation
a  = Excluding telephone and digital contact
* p < .05
** p < .01
*** p < .001
Depending on the education of women and the birth experience (first birth, at least second), there are no differences on the five scales (exception: TEAM-M for birth experience, weak effect size) (see Table 6).
Table 6Mean values (standard deviation) of scales and Cohen’s d for women's education, birth experience, utilization of midwifery services.
NSDM-Q-9-MCARE-8-MCARE-PM-MTEAM-MPC-M
EducationGrammar or high school1023.74 (1.39)1.35 (0.63)1.69 (1.03)3.06 (1.85)5.25 (0.81)
Other993.76 (1.27)1.32 (0.61)1.78 (1.02)3.15 (1.71)5.17 (0.91)
Cohen’s d0.010.050.090.060.09
Birth ExperienceFirst birth1163.672 (1.13)1.39 (0.64)1.83 (1.03)2.89 (1.72)5.14 (0.85)
At least second birth853.86 (1.36)1.27 (0.59)1.62 (1.01)3.41 (1.81)5.31 (0.87)
Cohen’s d0.150.190.210.30
p<.05
0.20
Services
Preventive medical check-upsyes394.33 (0.82)1.16 (0.34)1.44 (0.70)3.86 (1.93)5.58 (0.59)
no1623.61 (1.39)1.38 (0.66)1.81 (1.07)2.93 (1.69)5.12 (0.89)
Cohen’s d0.55
p <.001
0.36
p <.01
0.38
p <.01
0.54
p <.01
0.55
p <.001
Counsellingyes1014.01 (1.02)1.30 (0.49)1.71 (0.97)3.30 (1.80)5.29 (0.76)
No1003.50 (1.55)1.38 (0.72)1.77 (1.08)2.92 (1.72)5.13 (0.95)
Cohen’s d0.39
p <.01
0.130.060.220.19
Support (e. g. pregnancy complaints)yes1404.08 (1.06)1.26 (0.49)1.61 (0.85)3.34 (1.77)4.35 (0.74)
no613.01 (1.58)1.11 (0.82)2.06 (1.30)2.56 (1.68)4.90 (1.03)
Cohen’s d0.86
p <.001
0.39
p<.05
0.42
p<.05
0.45
p <.01
0.66
p <.01
birth preparationyes1553.76 (1.33)1.32 (0.60)1.63 (0.89)3.11 (1.71)5.25 (0.79)
no463.72 (1.37)1.38 (0.69)2.09 (1.33)3.10 (2.01)5.08 (1.07)
Cohen’s d0.030.100.46
p<.05
0.010.20
* p< .05
** p < .01
*** p < .001
Table 6 shows the mean values depending on the utilization of services. The scale values are increased with medium to high effect sizes if preventive medical check-ups and support (e.g. pregnancy complaints) are used.

## Discussion

The aim of the present study was to examine the construct validity of the adapted assessment scales SDM-Q-9-M (Shared Decision-Making), CARE-M (Midwife Empathy), TEAM-M (Internal Team Participation), and PC-M (Professional Competence). In order to measure these constructs identified as central components of the woman-centred midwifery care process, empirically tested assessment scale were chosen that are internationally accepted in the field of patient-centred care. The instruments were selected to allow for the unidimensional measurement of the according constructs in German language. Because we relied on well-established instruments, in particular CARE and SDM-Q-9, the data collected for midwifery care can be related to the data for clinical reference groups from other sectors of health care [
• Gericke C.A.
• Schiffhorst G.
• Busse R.
• et al.
A Validated Questionnaire for Measuring Patient Satisfaction in General and Specialist Ambulatory Medical Care: the Qualiskope-A.
]. The conceptual basis and the evaluation of women-centred care by midwives can be advanced through assessment aligned with established standards in other clinical care settings.
For the CARE-M scale, the construct Participatory Communication (represented by CARE-M-9 (”helping you take control“) and CARE-M-10 (”making a plan of action with you“) proved to be an independent additional structural component which must be considered separately from the main construct Midwife Empathy. This is not consistent with existing study results in other populations (e. g., Neumann et al. [
• Neumann M.
• Wirtz M.
• Bollschweiler E.
• et al.
Evaluation of the Psychometric Properties of the German Version of the ”Consultation and Relational Empathy“ (CARE) Measure at the Example of Inpatient Cancer Patients (Psychometric evaluation of the German version of the ”Consultation and Relational Empathy“ (CARE) measure at the example of cancer patients).
]; oncological patients). Thus, it seems reasonable to assume that in midwifery care Participatory Communication is more distinct from general Empathy reflected in the other 8 CARE-items, as these two focus more directly on birth preparation [
• Wirtz M.
• Boecker M.
• Forkmann T.
• et al.
Evaluation of the ”Consultation and Relational Empathy" (CARE) measure by means of Rasch-analysis at the example of cancer patients.
]. The focus is on the need for Participatory Communication, in which the midwife discusses possible changes in the course of the pregnancy with the woman. This encourages woman to participate in decision making. In the care of oncological patients physicians prepare the patients for a long-term, potentially recurrent, life-threatening disease process, which is associated with high psychological and physical distress.
For the construct Shared Decision-Making all indicators were highly associated with the underlying construct (factor loading ≥ .71). Although, Shared Decision-Making proved to be the dominant information sources reflected by all SDM-Q-9-M items, moderate local dependencies of the items have to be regarded. These local dependencies are in accordance with empirical findings in a study sample of rehabilitation patients [
• Quaschning K.
• Körner M.
• Wirtz M.
Analyzing the effects of shared decision-making, empathy and team interaction on patient satisfaction and treatment acceptance in medical rehabilitation using a structural equation modeling approach.
].
The CFAs of the single assessments (CFI ≥ .96; SRMR ≤ .032) as well as the CFA of the multidimensional model (CFI = .96; SRMR = .049) indicate a satisfactory to good model fit after consideration of local dependencies. Only RMSEA exceeds the limit for sufficient model fit in the CFA for the single scales SDM-Q-9-M, CARE-M, and TEAM-M. For the RMSEA, Kenny et al. [
• Kenny D.A.
• Kaniskan B.
• McCoach D.B.
The Performance of RMSEA in Models With Small Degrees of Freedom.
] proved that the rejection rate (RMSEA >.05) increases with a decreasing number of df and a small sample size. The problem of this effect is also reflected in the estimated 90% confidence interval (CI) [
• Kenny D.A.
• Kaniskan B.
• McCoach D.B.
The Performance of RMSEA in Models With Small Degrees of Freedom.
]. In our study, for example, the 90% CI of the RMSEA of the TEAM-M scale was [.05; .17]: the range comprises values indicating good up to insufficient model-fit. The validity of the alternative measure SRMR is not affected model complexity and sample size: Like all other measures of global fit, SRMR indicates good to appropriate model fit for all final model specifications.
For all adapted assessment scales, Cronbach's α coefficients (≥ .86) proved to be higher than in existing studies. This result suggests that pregnant women perceive the constructs for assessing the quality of care more homogeneously than the samples from previous studies with chronic diseases or patients from medical rehabilitation in Germany.
In contrast to the findings of Eickhorst and colleagues [
• Eickhorst A.
• Schreier A.
• Brand C.
• et al.
Inanspruchnahme von Angeboten der Frühen Hilfen und darüber hinaus durch psychosozial belastete Eltern (Knowledge and use of different support programs in the context of early prevention in relation to family-related psychosocial burden).
], the current study showed no or only a marginal association between the mother's educational qualification and the five assesment scales. In fact, mothers’ educational qualifications were identified as the strongest predictor in terms of predicting knowledge and use of midwifery support and early intervention services. The higher the educational qualification, the better the knowledge and utilization. The relevance of this aspect could not be investigated appropriately in our study. For this purpose, it would have been necessary to record more precisely under which conditions which midwifery services were used. Thus, the findings should not be interpreted as contradictory to those of Eickhorst et al. [
• Eickhorst A.
• Schreier A.
• Brand C.
• et al.
Inanspruchnahme von Angeboten der Frühen Hilfen und darüber hinaus durch psychosozial belastete Eltern (Knowledge and use of different support programs in the context of early prevention in relation to family-related psychosocial burden).
].

### Limitations of the study

The scale analyses are based on retrospective self-reports of the women (6 to 18 months after birth) who were enrolled in the study as voluntary participants (self-selection). Therefore, biasing effects due to general perception (e.g. Halo effects), recall, and selection biases cannot be excluded [
• Higgins J.P.T.
• Thomas J.
• Chandler J.
• et al.
(eds)Cochrane handbook for systematic reviews of interventions.
]. This may contribute to the enhanced homogeneity of scales (Cronbach́s α). Positive birth characteristics (e.g. birth outcome) can lead to spill over effects regarding the retrospective evaluation, and thus to a more positive assessment of the care processes. In addition, women may be hesitant to openly criticize the caregiver. In order to minimize expected ceiling or floor effects, at least five-point Likert scales with extreme endpoints were used. Nevertheless, ceiling effects could not be avoided completely. Similar values are reported by Neumann et al. [
• Neumann M.
• Wirtz M.
• Bollschweiler E.
• et al.
Evaluation of the Psychometric Properties of the German Version of the ”Consultation and Relational Empathy“ (CARE) Measure at the Example of Inpatient Cancer Patients (Psychometric evaluation of the German version of the ”Consultation and Relational Empathy“ (CARE) measure at the example of cancer patients).
].
The population exhaustion rate was only 8.8%. In similar studies, the response rate is about 30% if participation can be rewarded by incentives. Assuming a response rate of 10%, more than 2,000 parents were contacted via the registration offices of one county in order to be able to include N = 200 mothers in our study. Thus, despite the rather low response rate, a sufficient sample size for the psychometric scale analyses was achieved.
Furthermore, the results only apply to the time of care during pregnancy and in the context of German midwifery care. Analyzing factorial stability for the different care situations (prenatal, birth, and postpartum) as well as determining the scales’ sensitivity to change are required [
• Sawyer A.
• Ayers S.
• Abbott J.
• et al.
Measures of satisfaction with care during labour and birth: a comparative review.
].
Future research should also consider the perspective and expectations of the male partners. With regard to the discussion of the role of the modern father, there is evidence that according to culture, fathers are not adequately involved in the lives of their children, especially during pregnancy and birth [
• Longworth M.K.
• Furber C.
• Kirk S.
Fathers’ roles matter too: An ethnographic study examining fathers’ roles and the influences on their roles during labour and birth.
]. In general, men are willing to become aware of their role during the birth process. Previous research identified different passive and active roles that fathers adopt to support and protect their wives during the birth process. Successful performance of these roles depends, among other things, on the quality of communication between fathers and health care professionals. Longworth et al. [
• Longworth M.K.
• Furber C.
• Kirk S.
Fathers’ roles matter too: An ethnographic study examining fathers’ roles and the influences on their roles during labour and birth.
] also identify the midwife as an important authority. Midwives can actively involve fathers by listening and responding to their concerns and needs, while enabling them to take an active or passive role in birth. For this purpose, the item PC-M-1 (”involves important persons in care“) was added and could be confirmed as a homogeneous scale item of the Professional Competence scale (rit = .61; IR = .47).

## Conclusion

Instruments assessing Shared Decision-Making, Midwife Empathy, Internal Team Participation and Professional Competence in medical care could be adapted successfully to the field of German midwifery, to integrate the woman's perspective for quality-based care. The developed and confirmatory tested assessment scales show good to satisfactory psychometric characteristics at item and scale level. The standardised and validated assessment provides an essential component to master the complex challenge of measuring the woman-centred quality of midwifery care inside and outside the hospital.

## Availability of data and materials

The datasets used and analysed during the current study are available from the corresponding author on reasonable request ([email protected]).

## Ethics approval and consent to participate

The Ethics Committee of the German Society of Psychology classified the project as ethically acceptable (MAW 022019). All participants completed a digital informed consent form.

## Funding

The research project took place within the framework of the project “Analysis of midwifery care in rural areas”, which was initiated by the Network for Families and Midwives Ortenaukreis. The project was supported by the German Federal Ministry of Agriculture and Food from 2017-2019 (grant number: 2817LEO15).

## Acknowledgement

We would like to acknowledge all study participants, as well as the Health Department of the Administrative District Offenburg, the Network for Families and Midwives Ortenaukreis and the municipal and town councils of the Ortenau district for their support in the recruitment process.

## Conflict of interest

The authors declare that they have no competing interests.

## CRediT author statement

AAS planned and conducted data collection and analysed and interpreted the data set using confirmatory factor analysis. AAS was major contributed in all steps of the study and in editing the manuscript; MAW contributed to the planning of the study, was involved in all steps of the data analysis and editing and revising the manuscript. All authors read and approved the final manuscript.

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