# Development and validation of the birth integrity questionnaire for measuring attitudes, maternity care, and perceptions of birth

## TL;DR

This study developed and validated a questionnaire to measure attitudes and experiences related to childbirth and maternity care in Germany.

## Contribution

The Birth Integrity Questionnaire (BI-Q) is a new validated tool for assessing birth experiences and perceptions in European contexts.

## Key findings

- The BI-Q showed high reliability and validity with 65 items across eleven constructs.
- Key factors influencing birth integrity were CONSENT, RESPECT, SUPPORT, and CARE.
- The BI-Q needs re-testing in more diverse samples due to the omission of DISCRIMINATION.

## Abstract

Public health research on maternal health has increasingly focused on care quality, emphasizing subjective evaluations and addressing issues such as obstetric violence and mistreatment during childbirth. In 2014, the WHO called for research to prevent and eliminate mistreatment, advocating for respectful maternity care. While significant research exists in Africa, Asia, and Latin America, research in European settings is lacking. Our Germany-based study on Birth Integrity aims to capture a holistic understanding of the birthing process, encompassing culturally mediated attitudes, actual birth experiences, and perceptions of childbirth.

The Birth Integrity Questionnaire (BI-Q) was developed through construct definition, item development, expert reviews, and cognitive interviews. Psychometric properties were tested using exploratory factor analysis and structural equation modeling with 1,729 participants recruited via an anonymous, openly available, voluntary, non-incentivised online survey. Data analysis included reliability testing and examination of correlations between latent constructs.

The BI-Q demonstrated high reliability and validity, with 65 items across eleven latent constructs. The latent outcome construct of Birth Integrity, consisting of 22 items, was also successfully validated. Key influences on birth integrity included CONSENT, RESPECT, SUPPORT, and CARE. High standards of maternity care in Germany likely explained the lack of significant direct effect from constructs such as FACILITY, PRIVACY, INFORMATION, and RIGHTS, though these had indirect effects. GENDER, MEDICALIZATION, and BIRTH WISHES showed indirect effects as well, whereas DISCRIMINATION was omitted in our model due to statistical reasons.

The BI-Q is a validated and reliable tool for measuring birth integrity. Findings highlight the significant impact of healthcare providers’ actions and attitudes on birth perception, advocating for improved maternity care and prioritizing women’s autonomy. The omission of DISCRIMINATION underscores the need to re-test the BI-Q in more diverse samples.

The online version contains supplementary material available at 10.1186/s12884-025-08331-3.