Validity and reliability of the turkish version of “Labor Pain Relief Attitude Questionnaire for Pregnant Women”

1. Introduction

Despite being normal, the pain resulting from uterine contractions during labor is among the most intense and significantly contributes to many women’s apprehension toward childbirth (ElFattah et al., 2015; Ergin and Kömürcü, 2009). The psychological impact of labor pain is indisputable. Numerous women perceive that the aggregate effect of several contractions with decreasing relaxation intervals is more challenging than the intensity of any single contraction. The continuous cycle may exacerbate the perception of pain during childbirth by heightening anxiety and apprehension. Therefore, controlling labor pain is one of the primary goals of care for women in labor (Ergin and Kömürcü, 2009). The severity and perception of labor pain can vary from person to person (Rathfisch, 2012). In addition to being a difficult experience, the stress that occurs when severe labor pain cannot be controlled negatively affects maternal, fetal, and neonatal health. Moreover, labor pain may result in adverse perceptions of labor, extended labor duration, unfavorable labor-related experiences, fetal hypoxia, and diminished contentment. The fear of women about labor also elevates the incidence of elective cesarean deliveries (Lowe, 2002; Nwanodi, 2016). The feeling of labor pain varies for each individual based on their own circumstances, including physiological composition, mental health, cultural context, and social network. Healthcare practitioners must possess a comprehensive awareness of these aspects to provide individualized support and effective pain management strategies during childbirth.

Pregnant women find it difficult to imagine the sensation of labor pain, and even those who have given birth several times struggle to recall their previous labor experiences (Lally et al., 2014). The majority of pregnant women need epidural analgesia to manage labor pain, which is often arranged throughout pregnancy (Schytt and Waldenstrm, 2010). Factors such as pain relief during labor, catastrophizing prenatal pain, fear of labor, external locus of control, history of epidural analgesia, and nulliparity have been associated (Logtenberg et al., 2018; Riley et al., 2011; Schytt and Waldenstrm, 2010; Sitras et al., 2017; Veringa et al., 2011). Pregnant women exhibiting depressive symptoms may possess heightened projections about labor pain and pursue more analgesic intervention, aligning with the adverse outcome expectancies often associated with depression. Cultural norms, the perspectives of a woman’s prenatal care providers, and the effect of her social network—including friends, family, and partner—can all affect her perceptions of labor pain management (Haaga et al., 1991; Robertson, 1996). Cultural attitudes significantly affect women’s perceptions and management of labor pain. Due to enhanced positive emotions and improved coping strategies, women are more inclined to see labor pain as a pleasurable and significant event. Conversely, seeing pain as hazardous may result in heightened anxiety and an augmented need for pain control strategies. Social conventions around childbirth and women’s conventional societal roles may influence this cultural context. Cultural norms, healthcare professionals’ perspectives, and social networks together shape women’s perceptions and experiences of pain management after labor. Enhancing women’s satisfaction with the labor process and their preparedness for childbirth may be achieved via improved education and support systems (Tanrıverdi, 2017a, 2017b).

Self-efficacy during labor is crucial for alleviating labor pain. Consequently, the LPRAQ-p may serve as an effective screening instrument to identify women exhibiting diminished labor self-efficacy and heightened pregnancy-specific distress symptom, who may need supplementary assistance (Hulsbosch et al., 2020). The objective of this research was to translate the LPRAQ-p into Turkish and to provide the scale to the academic literature via a validity and reliability assessment.

2. Material & methods

This study used a methodological descriptive strategy to assess the Turkish validity and reliability of the LPRAQ-p.

3. Results

4. Discussion

The LPRAQ-p was developed by Hulsbosch et al. (2020), and its validity and reliability were established. The scale consisted of a total of six questions initially developed to test the distribution of responses to the scale questions and to examine the factor structures. It is an essential instrument for healthcare practitioners to comprehend pregnant women’s perspectives on labor pain management. By recognizing variables that affect these views, such as psychological distress and prior experiences, practitioners may more effectively customize their support and treatments to address the needs of pregnant women throughout delivery.

In the study, when the answers given by the experts were analyzed for comprehensibility, simplicity, and relational validity of the scale items, it was determined that there was agreement between the scale items and the experts’ opinions (p=0.000) when the answers given by 11 experts were analyzed according to W (Kendall’s W=0.805). Kendall’s W test evaluates the agreement between the measured values of the data. In Kendall’s W test, the values are 0 (no agreement) and 1 (complete agreement). As the value approaches 1, it indicates that the agreement between experts is increasing, and a common consensus is reached. According to the results of this study, the experts reached a consensus on the scale items.

Factor analysis is a method that helps to reveal the real reasons behind a large number of measurable and observable characteristics, that is, hidden dimensions that cannot be observed and measured (Saracli, 2011). According to Saraçlı, although there is no significant difference in the statistical data of Varimax and Equamax rotation methods, there is a complete fit (Tabachnick and Fidell, 2007). In this study, Principal Components Analysis and Varimax Rotation methods were applied to assess the construct validity of the scale.

The item-total score correlations for the scale’s subdimensions varied from 0.439 to 0.769, and their consistency was considered satisfactory based on the criteria for evaluating item-total score correlations. Values of 0.30 and higher are considered adequate for differentiating the measured characteristic. This research’s exploratory factor analysis divided the scale into two components, yielding findings that aligned with those of the scale developed by Hulsbosch et al. (2020). The factor analysis findings indicated a minimum variance value of 0.50, above the 0.40 threshold. Consequently, the scale included two sub-dimensions consistent with the original, and there was no removal or decrease of scale elements.

To calculate Cronbach’s alpha, divide the total variance of the scale by the sum of the variances of the items; this yields the weighted standardized mean of the items’ variances. Each item on the scale may possess an individual Cronbach’s alpha value, or the scale may collectively have an average value. The overall reliability of the questionnaire is shown by the Cronbach’s alpha value obtained for each item. Generally, readings of 0.70 and above are deemed acceptable (Kilic, 2016). Reliability is considered sufficient when Cronbach’s alpha ranges from 0.60 to 0.70 and exceptional when it falls between 0.70 and 0.80. A Cronbach’s alpha around 1 indicates a substantial degree of internal consistency among the scale’s components (Field, 2013). Defective measuring instruments, such as scales with low reliability coefficients, are incapable of reliably yielding identical results across all measurements. To consider test findings credible, the reliability coefficient generally must be 0.70 or above (Devon et al., 2007).

The scale’s reliability in the study was assessed using Cronbach’s alpha values: 0.853 for the perception of women subscale, 0.699 for the social environment subscale, and 0.733 for the total scale score. Hulsbosch et al. (2020) found that the scale as a whole had a Cronbach’s Alpha of 0.75, with the subscale evaluating social surroundings having a value of 0.67 and the subscale measuring perceptions of women having a value of 0.78. In all research, the subscale evaluating social environment demonstrated good reliability (>0.60), whereas the subscale measuring women’s views and the total scale score showed high reliability (>0.70). The results of both studies demonstrate that the scale was very consistent with itself. The results of the research demonstrate that the Turkish version of the scale is valid and reliable.

One of the most frequently used methods in validity and reliability analysis is the test-retest method (Devon et al., 2007). In the study, when the compatibility between the mean test-retest scores of the scale’s perception of women’s sub-dimension, social environment sub-dimension, and the total scale was examined, a positive, strongly significant relationship was found (r=0.849, r=0.812, r=0.868, respectively; p<0.01). This result shows that the scale is not affected by time and always measures the same situation, even if time passes.

In the study, the item-total correlation coefficients of the scale ranged from r=0.85-0.88 for the perception of women subscale and r=0.70-0.83 for the social environment subscale. “In the literature, it is stated that the reliability of items with a coefficient less than 0.50 should be doubted, and in some sources, it is stated that this coefficient should be above 0.30, but most researchers consider 0.20 as the limit (Aksoy et al., 2019).” In this framework, in our study, since the correlation coefficients of the scale items were above 0.20, no item was discarded from the scale, and the scale was found to be compatible with the two-factor model.

Pain during labor is a physiological event. However, when labor pain cannot be controlled, a vicious cycle of fear, anxiety, and pain is formed, negatively affecting the health of the mother, fetus, and newborn, and the progress of labor. Failure to control labor pain causes pregnant women to perceive labor negatively, have negative experiences with labor, and decrease their satisfaction. Another negative effect of pain during labor is that fear of labor and labor pain leads women to have a cesarean section of their own accord. The rates in our country are quite high compared to the cesarean rates included in the World Health Organization and Mother-Friendly Hospital Practice criteria. At this point, it is very important to provide antenatal care to pregnant women and control labor pain in order to control the rates of elective cesarean sections (Gönenç and Terzioğlu, 2020; Taşkın, 2024; Fenwick et al., 2010).

Pharmacological methods used to reduce labor pain cause some unwanted complications in the mother. They may also reach the fetus via the placenta. These include the mother not being able to participate in labor, not remembering what happened during labor, and increasing labor costs in terms of the country’s economy (Gönenç and Terzioğlu, 2020; Ertem and Sevil, 2005).

Based on all these results, the validity and reliability study of LPRAQ-p, which was conducted in our country, will contribute to the determination of the attitudes of pregnant women regarding the use of pharmacological methods in labor pain. Thus, the management of labor pain will be facilitated by providing education and counseling to pregnant women on the subject. Relieving labor pain will positively affect mother and baby health by ensuring that pregnant women have a positive birth experience, tend towards normal birth, and reduce the cesarean section rates in our country.

5. Conclusion and recommendations

The findings of this research indicate that the Turkish LPRAQ-p is a valid and dependable instrument. The scale’s cultural and linguistic suitability was ensured by a comprehensive translation procedure, and its psychometric features were validated by statistical analysis. The two-factor structure effectively reflects pregnant women’s perspectives on labor pain management, maintaining its original shape. The study of internal consistency, shown by Cronbach’s alpha values between 0.699 and 0.853, affirmed the scale’s reliability, while test-retest correlations validated its temporal stability. The Turkish version of the LPRAQ-p is an effective instrument for evaluating pregnant women’s perceptions of labor pain alleviation in Turkey. The use of such equipment in maternal healthcare may enhance the identification and treatment of women requiring more help during labor via personalized programs.

Researchers studying pregnancy and childbirth are hoping to benefit from the scale. However, housewives from rural regions made up the bulk of the study’s respondents. This meant that the research could not provide a full picture of Turkish pregnant women. The results suggest the need for a bigger sample size and more diverse demographics in future research.