# Development and validation of a person-centered antenatal care scale for low- and middle-income countries

## TL;DR

This paper introduces a new tool to measure respectful and responsive antenatal care in low- and middle-income countries.

## Contribution

A validated, person-centered antenatal care scale tailored for low- and middle-income countries is developed and tested.

## Key findings

- The PCANC scale has high reliability (Cronbach’s alpha of 0.90) and validity in Ghana and Kenya.
- The scale includes three subscales: dignity and respect, communication and autonomy, and responsive and supportive care.
- The tool correlates with global measures of care quality and satisfaction, indicating strong criterion validity.

## Abstract

Person-centered antenatal care (PCANC)—antenatal care that is respectful and responsive to people’s needs, values, and preferences—is essential to achieving optimal pregnancy outcomes. Yet, no validated tools exist to comprehensively measure PCANC in low- and middle-income countries (LMICs). We aim to develop and validate a tool to comprehensively measure PCANC relevant to women’s experiences in LMICs.

We followed standard procedures for scale development. This included a literature review to adapt items from a prior scale developed in the United States and to generate new items relevant to LMICs; expert reviews with maternal health experts, health care providers, and women with lived experiences (currently pregnant or previously pregnant) to assess content validity; and cognitive interviews and pretesting with pregnant and postpartum women to evaluate clarity, appropriateness, and relevance of the questions. Questions were iteratively revised at each stage and administered in a survey to 300 pregnant (third trimester) and 300 postpartum women (who gave birth within six months of the interview) in the Upper East Region of Ghana. Following data analysis from the first survey, the questions were revised and administered to 2000 postpartum women in Ghana and Kenya (1000 per country). The survey data were used in psychometric analysis to assess construct and criterion validity, and internal consistency reliability.

Iterative exploratory factor analysis was used to reduce the number of items from over 60 to 36. The 36 items load onto one dominant factor, with three factors having eigenvalues greater than one. Items are grouped into three conceptual domains representing subscales for “dignity and respect,” “communication and autonomy,” and “responsive and supportive care.” The Cronbach’s alpha for the full scale is 0.90, and the subscales are each > 0.7. The summative PCANC scores correlate with global measures of antenatal care quality, satisfaction, and future care location, suggesting good criterion validity.

The PCANC scale has high validity and reliability in the sample of prenatal and postpartum women in Ghana and Kenya. This scale will facilitate efforts to measure and improve respectful and responsive antenatal care in LMICs.