Translation,cultural adaptation,and psychometric validation of the Malay version of the Disrespect and Mistreatment During Childbirth Questionnaire

Abstract

Mistreatment during childbirth, including neglect, verbal abuse, and non-consented procedures, undermines respectful maternity care and negatively affects maternal health outcomes. Despite growing recognition of this issue, no culturally validated instrument has been available to assess mistreatment during childbirth in the Malaysian context. This study aimed to translate, culturally adapt, and psychometrically validate the Malay version of the Disrespect and Mistreatment during Childbirth Questionnaire (DMCQ). A cross-sectional study was conducted among postpartum women within 12 months of delivery attending health facilities in Kelantan. The original DMCQ underwent forward–backward translation and expert harmonization to ensure conceptual and cultural equivalence. Content and face validity were assessed by maternal health experts and postpartum women, while construct validity was examined using exploratory and confirmatory factor analyses, followed by internal consistency reliability testing. All items demonstrated excellent content validity and clear comprehension during face validation. Exploratory factor analysis supported a five-factor structure comprising negative interactions with healthcare providers, separation from the newborn, medical intrusiveness, verbal mistreatment, and pain experience. Confirmatory factor analysis indicated acceptable model fit (χ²(140) = 197.07, CFI = 0.955, TLI = 0.945, RMSEA = 0.054). Internal consistency ranged from moderate to high across domains, with theoretically important items retained despite lower factor loadings. Overall, the Malay DMCQ demonstrated acceptable psychometric properties as a foundational tool for assessing mistreatment during childbirth in Malaysia and provides a culturally appropriate basis for future research, monitoring, and quality improvement efforts.

Keywords

content validation face validation mistreatment during childbirth psychometric validation respectful maternity care and translation

Significance for public health

Mistreatment during childbirth undermines women’s dignity, autonomy, and trust in healthcare services, posing a serious barrier to achieving respectful maternity care. In Malaysia, limited research and the absence of a validated local tool have hindered systematic assessment of women’s experiences during facility-based childbirth. This study provides the first culturally adapted and psychometrically validated Malay version of the Disrespect and Mistreatment during Childbirth Questionnaire (DMCQ). The validated tool enables healthcare providers, researchers, and policymakers to quantify and monitor mistreatment, identify high-risk practices, and evaluate interventions promoting respectful care. By centering women’s voices in measuring negative experiences such as verbal abuse, unnecessary procedures, and mother–infant separation, the Malay DMCQ contributes to improving quality of maternal services and accountability within the healthcare system. Ultimately, it supports national and global efforts to ensure safe, dignified, and equitable childbirth experiences for all women.

Introduction

Mistreatment during childbirth encompasses any form of disrespect, abuse, or neglect experienced by women during labour and delivery in healthcare facilities. It includes actions that violate a woman’s dignity, autonomy, or safety, ranging from verbal abuse and discrimination to neglect or non-consented procedures.¹ This issue is increasingly recognized as a global barrier to quality maternity care, contributing to poor maternal outcomes and eroding trust in healthcare systems.²

Bohren et al. proposed a typology of mistreatment that includes seven categories: physical abuse, verbal abuse, sexual abuse, stigma and discrimination, failure to meet professional standards, provider-patient rapport, and systemic constraints.³ While tools like labour observation and community survey have been developed to assess mistreatment globally,^3,4 definitions and measurement approaches vary across cultural contexts. For example, terms such as “obstetric violence” are more commonly used in Latin America, reflecting distinct systemic challenges, while normalization of mistreatment in other regions is linked to entrenched gender norms.^5,6

Globally, disparities in terminology and methodology hinder comparative research and policy-making. A standardized, culturally relevant framework is essential for understanding the extent of mistreatment and improving maternal healthcare systems.⁷

In Malaysia, evidence of mistreatment exists, especially in studies on maternal near-miss and severe maternal morbidity, where women have reported poor communication, judgemental attitudes, and delays in care.^8,9 These experiences align with broader mistreatment constructs, yet dedicated research on this topic remains limited. This gaps are particularly concerning in light of persistent maternal mortality rates and anecdotal reports of home births due to distrust in healthcare facilities.¹⁰

In low- and middle-income country (LMIC) settings, the availability of culturally valid measurement instruments is a necessary prerequisite for meaningful epidemiological and policy-oriented research on maternal care. Without culturally validated tools, estimates of mistreatment prevalence and associated risk factors are vulnerable to measurement error, construct misclassification, and limiting interpretability for epidemiological inference and policy.¹¹ Such errors can obscure the true magnitude and nature of mistreatment, leading to misleading conclusions and ineffective policy responses.¹² Cross-cultural measurement research has consistently demonstrated that instruments developed in one setting cannot be assumed to function equivalently in another without systematic adaptation and revalidation.^13,14 Psychometric validation therefore represents a foundational step rather than a preliminary one, ensuring that subsequent research and quality improvement initiatives are grounded in accurate and contextually appropriate measurement.^14,15

Recently, Suttora et al. developed and validated the Disrespect and Mistreatment during Childbirth Questionnaire (DMCQ) in Italy, providing a theory-driven, multidimensional instrument grounded in Bohren’s typology of mistreatment.¹⁶ The DMCQ captures five core domains of mistreatment during childbirth: negative interactions with healthcare providers, separation from the newborn, medical intrusiveness, verbal mistreatment, and pain experience. While the original DMCQ demonstrated robust psychometric properties, its applicability across different cultural and health system contexts requires careful translation, cultural adaptation, and revalidation.

To date, no validated Malay-language instrument exists to assess disrespect and mistreatment during childbirth. A culturally adapted and psychometrically sound tool is therefore essential to enable accurate measurement, inform policy development, and support efforts to improve respectful maternity care in Malaysia. Accordingly, this study aim to translate and validate the Malay version of Disrespect and Mistreatment during Childbirth Questionnaire (DMCQ), addressing a critical gap in maternal health research and providing a foundation for future research, monitoring, and intervention planning.

Materials and methods

Study design and population

A cross-sectional study was conducted from January to July 2025 among postpartum women in randomly selected maternal and child health (MCH) clinics across two districts in Kelantan, Malaysia. Eligible participants were women aged 18 years and above, within 12 months postpartum, proficient in Malay, and attending MCH clinics. The sample size was calculated for both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA). For EFA, the sample size was determined based on the guideline of five participants per item for the 20-item scale, requiring at least 100 participants. After accounting for a 10% non-response rate, the final target sample size was set at 111 participants to ensure adequacy. For CFA, the RMSEA-based sample size calculator by Arifin (2025) was applied using RMSEA = 0.05, 20 items, 5 factors 80% power, and a 5% significance level. The minimum required sample size was 126, increased to 140 after accounting for a 10% non-response rate.

A multistage sampling strategy was employed. Two districts (Tumpat and Bachok District) were selected via simple random sampling. From each district, three MCH clinics were randomly chosen. Proportionate stratified sampling was applied based on the average daily postpartum attendance at each clinic to allocate the final sample. The questionnaire was self-administered and offered in paper-based format to maximize accessibility and feasibility in local clinic settings.

Questionnaire and translation process

The DMCQ is a 20-item questionnaire rated on a 7-point Likert scale (1 = very low, 7 = very high), covering five domains: Negative Interaction with Healthcare Providers (4-items), Separation from Newborn (5-items), Medical Intrusiveness (5-items), Verbal Mistreatment (3-items), and Pain Experience (3-items).¹⁶

The translation followed the guidelines proposed by Beaton et al. (2000) and Sousa and Rojjanasrirat (2011). First, two independent bilingual translators (one medically trained and one non-medical) translated the English version of the DMCQ into Malay. These two versions were synthesized into a reconciled version through consensus discussion. Then two new bilingual translators who were blinded to the original version performed a back-translation into English. An expert committee comprising translators and researchers reviewed all versions, harmonized discrepancies, and finalized the pre-final Malay version. Pretesting included content and face validity assessment.

Content validation was assessed by seven maternal health experts (public health, academia, obstetrics, family medicine, and midwifery) who rated item relevance on a four-point Likert scale. Item- and Scale-level Content Validity Indices (I-CVI, S-CVI/Ave, and S-CVI/UA) were calculated, with values meeting established criteria for excellent content validity.^17–19

Face validity was assessed with 30 postpartum women from the selected clinics, who rated the clarity and comprehensibility of each item on a four-point scale (1 = not clear to 4 = very clear). Item- and scale-level Face Validity Indices (I-FVI, S-FVI/Ave, and S-FVI/UA) were calculated, with values indicating satisfactory face validity.^20,21 Item-by-item correspondence between the original English DMCQ and the Malay version, together with the item retention decisions informed by exploratory and confirmatory factor analyses, is presented in Supplementary Table S3.

Statistical analysis

Following content and face validation, a sequential Exploratory Factor Analysis (EFA)–Confirmatory Factor Analysis (CFA) approach was employed. Because factor structures may shift following translation and cultural adaptation, an exploratory phase was first conducted to identify an interpretable factor structure in the target population, which was subsequently tested as a hypothesised measurement model using CFA.^11,13

The analyses were performed using R software and SPSS AMOS version 29. In addition to the DMCQ domains, descriptive data such as maternal age, ethnicity, education level, marital status, occupation, and monthly household income were collected to characterise the study population.

Data suitability for factor analysis was confirmed using the Kaiser–Meyer–Olkin measure and Bartlett’s test of sphericity, with KMO values ≥ 0.60 considered acceptable and Bartlett’s test required to be statistically significant (p < 0.05). Given evidence of non-normality, exploratory factor analysis was performed using principal axis factoring with oblimin rotation. Factors and items were retained based on eigenvalues > 1.0, conceptual interpretability, and factor loadings ≥ 0.30, while items with communalities < 0.20 or substantial cross-loadings were carefully evaluated. This process resulted in a stable factor structure that was subsequently tested using confirmatory factor analysis.

Confirmatory factor analysis was conducted to assess the construct validity of the translated DMCQ using robust maximum likelihood estimation to account for non-normality. The model was specified with five correlated latent factors: Verbal Mistreatment, Negative Interaction with Healthcare Providers, Separation from Newborn, Medical Intrusiveness, and Pain Experience. Model fit was primarily evaluated using the Comparative Fit Index (CFI), Tucker–Lewis Index (TLI), ≥ 0.90 (preferably ≥ 0.95), Root Mean Square Error of Approximation (RMSEA) ≤ 0.08 (≤0.06 indicating good fit), and Standardized Root Mean Square Residual (SRMR) ≤ 0.08, with information criteria were reported for completeness. Convergent validity and internal consistency were examined using composite reliability, McDonald’s omega, with values ≥ 0.70 considered acceptable, and average variance extracted (AVE) ≥ 0.50 indicating adequate convergent validity. Discriminant validity was assessed by comparing the square root of AVE with inter-factor correlations, with discriminant validity supported when square root of AVE exceeded the corresponding correlations. External convergent validity was not examined in this study due to the absence of validated Malay-language instruments assessing related or unrelated constructs for comparison.

Ethical considerations

This study received ethical approval from the Human Research Ethics Committee of Universiti Sains Malaysia (USM/JEPeM/KK/25010114) and the Medical Research and Ethics Committee of the Ministry of Health Malaysia (NMRR ID-25-004210GX0(IIR). All participants were informed about the study’s objectives, procedures, potential risks, and benefits prior to participation. Written informed consent was obtained from all participants. Participation was entirely voluntary, and respondents were assured of their right to withdraw at any time without consequence. Strict confidentiality was maintained throughout the study; no personal identifiers were collected, and all data were securely stored and accessible only to the research team. Findings were reported in aggregate to ensure anonymity and protect participant privacy.

Results

Psychometric validation of the DMCQ

Content and face validity

Content validation assessed the relevance of each item in the translated Malay DMCQ. All 20 items achieved an Item-level Content Validity Index (I-CVI) of 1.00. The Scale-level Content Validity Index based on average agreement (S-CVI/Ave) was 1.00 (95% CI: 1.00, 1.00), and the Scale-level Universal Agreement (S-CVI/UA) was 1.00 (95% CI: 0.84, 1.00).

Quantitative face validation demonstrated high clarity and comprehensibility of the Malay DMCQ. The Item-Level Face Validity Index (I-FVI) was 1.00 for all 20 items, and the Scale-Level Face Validity Index based on average agreement (S-FVI/Ave) exceeded 0.95 for both clarity and comprehension.

Exploratory factor analysis

Exploratory factor analysis was conducted among 111 postpartum women, who were predominantly Malay and married, with a mean age of 30.31 years (SD = 5.01). Detailed sociodemographic characteristics are presented in Supplementary Table S1.

Preliminary assessment indicated that the data were suitable for factor analysis, with a Kaiser–Meyer–Olkin (KMO) value of 0.70 and a significant Bartlett’s test of sphericity (χ² = 1296.26, p < 0.001). A five-factor solution was retained based on eigenvalues greater than 1.0, scree plot inspection, and conceptual interpretability, accounting for 59.7% of the total variance. The extracted factors were interpreted as Verbal Mistreatment (VM), Negative Interaction with Healthcare Providers (NI), Separation from Newborn (SN), Medical Intrusiveness (MI), and Pain Experience (P).

As shown in Table 1, most items demonstrated factor loadings

\geq

0.30 and communalities

\geq

0.25. Item within the Negative Interaction with Healthcare Providers, Verbal Mistreatment, and Pain experience domains showed consistently strong loadings and communalities. Several items within the Medical Intrusiveness and Separation from Newborn domains exhibited lower factor loadings (MI 10, MI 12, SN 6, and P 20). One item, SN 8 (“I wished for greater contact with my newborn”) was removed due to low factor loading and cross-loading, resulting in a refined 19-item, five factor structure.

Table 1.

Factor loadings, communalities, and cronbach’s alpha for the malay DMCQ items based on exploratory factor analysis (EFA).

Factor	Item	Factor loading	Communality	Cronbach’s alpha [( $α)$ , 95% CI]
Negative Interactions with Healthcare Providers	NI 1	0.929	0.872	0.953 (0.936,0.965)
	NI 2	0.932	0.866
	NI 3	0.879	0.856
	NI 4	0.921	0.859
Separation from Newborns	SN 5	0.521	0.360	0.692 (0.570,0.767)
Separation from Newborns	SN 6R	0.365	0.124
	SN 7	0.835	0.749
	SN 9	0.763	0.630
Medical Intrusiveness	MI 10	0.205	0.129	0.707 (0.552, 0.752)
	MI 11	0.706	0.512
	MI 12	0.253	0.112
	MI 13	0.707	0.609
	MI 14	0.811	0.676
Verbal Mistreatment	VM 15	0.666	0.567	0.930 (0.836,0.915)
	VM 16	0.988	0.955
	VM 17	0.838	0.775
Pain Experience	P 18	0.887	0.813	0.700 (0.561, 0.771)
	P 19	0.819	0.723
	P 20	0.300	0.153

Notes. Factor loadings $\geq$ 0.30 were considered acceptable. Cronbach’s $α$ values (0.69 – 0.95) indicated acceptable to excellent reliability. Lower-loading items (MI 10, P 20) were retained for theoretical relevance to mistreatment domains.

Inter-factor correlations ranged from -0.14 to 0.30, indicating limited overlap between domains. Internal consistency estimates (Cronbach’s

α

) ranged from 0.692 to 0.953 across domains, reflecting acceptable to excellent reliability (Table 2).

Table 2.

Model fit indices across competing CFA models.

Model	χ² (df)	CFI	TLI	RMSEA [90% CI]	SRMR	AIC	BIC	Δχ² (df), p
Model 1 (baseline)	225.53 (142)	0.934	0.920	0.065 [0.048–0.080]	0.073	9115.5	9256.7	–
Model 2 (VM 16 ∼∼ VM 17)	211.09 (141)	0.944	0.933	0.060 [0.042–0.076]	0.070	9103.1	9247.2	Δχ²(1)=14.11, p<0.001
Model 3 (VM 16 ∼∼ VM 17; MI 11 ∼∼ MI 13)	197.07 (140)	0.955	0.945	0.054 [0.035–0.071]	0.071	9091.1	9238.2	Δχ²(1)=19.85, p<0.001

Note. ² $χ$ = chi-square test of model fit; df = degrees of freedom; CFI = Comparative Fit Index; TLI = Tucker-Lewis Index; RMSEA = Root Mean Square Error of Approximation; SRMR = Standardized Root Mean Square Residual; AIC = Akaike Information Criterion; BIC = Bayesian Information Criterion; $Δ χ$ ²(df) =, p = chi-square difference test for model comparison. Model 1 represent baseline model. Model 2 and Model 3 were sequentially modified based on modification indices by allowing correlated residuals between VM 16 and VM 17, and subsequently between MI 11 and MI 13, to improve model fit.

Confirmatory factor analysis

Confirmatory factor analysis (CFA) was conducted among 140 postpartum women to test the five-factor measurement model derived from the exploratory analysis, comprising 19 items across verbal mistreatment, negative interactions with healthcare providers, separation from newborn, medical intrusiveness, and pain experience. The retained 19-item Malay DMCQ used in the CFA model is detailed in Supplementary File S1. Sociodemographic characteristics of the CFA sample are presented in Supplementary Table S2.

Robust maximum likelihood estimation was applied to account for multivariate non-normality. The baseline five-factor model (Model 1) demonstrated acceptable model fit. Two additional models were examined to assess potential improvements in fit. Modification indices were inspected to identify localized areas of model misfit. The largest indices suggested residual covariance between VM 16 and VM 17, which reflect closely related verbal mistreatment experiences. Accordingly, Model 2 allowed this residual correlation. A subsequent inspection indicated additional covariance between MI 11 and MI13, both describing intrusive clinical procedures with overlapping content, leading to Model 3. These modifications were implemented conservatively and were guided by both modification indices and conceptual overlap between items. Comparative model fit indices for Models 1–3 are presented in Table 2, showing incremental improvements in fit across successive models.

Standardized factor loadings and reliability estimates for the final CFA model are presented in Table 3. The final CFA model is illustrated in Supplementary Figure S1. Standardized factor loadings ranged from 0.229 to 0.955. McDonald’s omega coefficients ranged from 0.669 to 0.906 across domains. Average Variance Extracted (AVE) values ranged from 0.364 to 0.708, with lower AVE observed for the Verbal Mistreatment, Separation from Newborn, and Pain Experience domains.

Table 3.

Standardized factor loadings, and reliability estimates for the final CFA model of the malay DMCQ.

Factor	Item	Std. Loading	ω	AVE
Verbal mistreatment (VM)	VM 15	0.928	0.670	0.504
	VM 16	0.627
	VM 17	0.498
Negative Interaction with Healthcare Providers (NI)	NI 1	0.597	0.906	0.708
	NI 2	0.927
	NI 3	0.935
	NI 4	0.955
Medical Intrusiveness (MI)	MI 10	0.456	0.854	0.506
	MI 11	0.887
	MI 12	0.714
	MI 13	0.841
	MI 14	0.739
Separation from Newborn (SN)	SN 5	0.593	0.669	0.364
	SN 6	0.229
	SN 7	0.742
	SN 9	0.755
Pain Experience (P)	P 18	0.845	0.717	0.491
	P 19	0.909
	P 20	0.283

Note. Std. loading = Standardized factor loading; $ω$ = McDonald’s omega (composite reliability); AVE = Average Variance.

Discriminant validity was assessed by comparing the square root of AVE for each construct with inter-factor correlations. In all cases, the square root of AVE exceeded the corresponding inter-factor correlations, supporting discriminant validity. Inter-factor correlations and square root of AVE comparisons are presented in Table 4.

Table 4.

Discriminant validity assessment using square root of AVE and inter-factor correlations.

Construct	$\sqrt$ AVE	VM	NI	MI	SN	P
Verbal Mistreatment (VM)	0.710	0.710
Negative Interactions (NI)	0.841	–0.12	0.841
Medical Intrusiveness (MI)	0.711	0.42	–0.11	0.711
Separation from Newborn (SN)	0.603	0.19	0.07	0.38	0.603
Pain Experience (P)	0.701	0.45	0.01	0.37	0.20	0.701

Note. Values on the diagonal (bold) represent the square root of the AVE for each construct. Off-diagonal values represent inter-factor correlations. Discriminant validity is supported when $\sqrt$ AVE of each construct is greater than its correlations with other constructs.

Discussion

The present study translated, culturally adapted, and psychometrically validated the Malay version of the Disrespect and Mistreatment during Childbirth Questionnaire (DMCQ), originally developed by Suttora et al.¹⁶ The finalized Malay DMCQ comprises 19 items across five domains—negative interactions with healthcare providers, separation from the newborn, medical intrusiveness, verbal mistreatment, and pain experience—reflecting core dimensions of mistreatment described in Bohren’s typology. Overall, the findings provide evidence of acceptable content validity, structural validity, and reliability, supporting the use of the Malay DMCQ as a multidimensional measure of women’s mistreatment experiences during childbirth in Malaysian health facilities.

Translation and cultural adaptation followed a structured and iterative process to ensure semantic and contextual relevance for Malaysian postpartum women. Several items required contextual adaptation to reflect local maternity care experiences, particularly in the Malaysian public health setting. For example, phrases referring to “medical procedures” were refined to encompass common interventions in government hospitals, such as episiotomy, perineal suturing, or repeated vaginal examinations during active labour, which are often performed with minimal explanation²².

During harmonization phase, expert reviewers aligned item wording with local clinical language and norms, expanding the concept of “medical intrusiveness” to include both physical and psychological dimensions of mistreatment commonly encountered in the Malaysian context, including rough handling, compromised privacy, and intimidating communication.²³ In addition, neutral phrasing was recommended to avoid implied blame, such as replacing “dikenakan prosedur” with “dijalankan prosedur”. These refinements enhanced semantic clarity and cultural alignment while preserving the conceptual intent of the original instrument.

Content validity indices demonstrated unanimous expert agreement on item relevance, supporting comprehensive domain coverage and conceptual alignment with the intended construct. In line with COSMIN recommendations, this process ensured fidelity to the original instrument while maintaining cultural appropriateness for the Malaysian context.^14,15,18 As highlighted by Almanasreh et al. (2019), establishing strong content validity is a critical prerequisite for psychometric testing, ensuring that the instrument is not only statistically sound but also conceptually meaningful and contextually relevant for the target population.

Face validity assessment involving postpartum women provided valuable insight into how items were interpreted in real-world settings. While most items were perceived as clear and relevant, qualitative feedback identified minor wording ambiguities, particularly for items describing clinical procedures and newborn separation. Such refinements are consistent with best practices for face validity assessment and cognitive testing, which emphasize the importance of end-user feedback in improving clarity and minimizing response bias.^4,12,21 Subsequent wording adjustments enhanced semantic clarity and cultural resonance, strengthening acceptability and supporting the practical usability of the instrument in both clinical and research settings.²⁴

Retention of theoretically important items

Exploratory factor analysis supported a five-factor structure of the Malay DMCQ that closely aligned with Bohren’s typology of mistreatment during childbirth and the original DMCQ validation. Several items within the Medical Intrusiveness and Separation from Newborn domains demonstrated lower factor loadings during exploratory analysis; nevertheless, these items were retained based on their conceptual relevance to established mistreatment frameworks and their importance in capturing clinically meaningful experiences in Malaysian maternity care. Retention also ensured adequate domain representation for subsequent confirmatory factor analysis, consistent with psychometric practices in early-stage validation of complex and sensitive constructs, where strict reliance on statistical thresholds alone may compromise content validity.^13,25–28

In particular, item SN 6 was retained despite a very low standardized loading (0.229) and a lower AVE for the Separation from Newborn domain (0.364). Although removal of this item would improve AVE, it was retained due to its conceptual importance in capturing early mother–infant contact, a core indicator of respectful maternity care emphasized in WHO and Bohren’s mistreatment frameworks^29,30. Malaysian perinatal care guidelines emphasise early skin-to-skin contact, breastfeeding initiation, and emotional bonding between mother and newborn, while also acknowledging that temporary separation may occur under specific clinical circumstances. These institutional postpartum care practices, which may attenuate statistical associations while retaining substantive relevance³¹. Retention of SN 6 therefore reflects a theory-driven decision prioritizing construct validity and contextual relevance over statistical optimization in early-stage scale validation.

In contrast, SN 8 was excluded from the final model as it demonstrated both low factor loading and cross-loading, indicating limited specificity to the Separation from Newborn construct.²⁷ Conceptually, the item reflects an aspirational desire for increased mother–infant contact rather than a concrete experience of mistreatment, which may explain its diffuse loading pattern.^12,25 Excluding this item enhanced construct clarity and ensured that retained items more precisely captured actionable aspects of disrespect and mistreatment relevant to quality improvement in maternity care.^3,32

At the confirmatory stage, most domains demonstrated acceptable internal consistency, although two domains—Verbal Mistreatment and Separation from Newborn—showed omega values slightly below the conventional 0.70 threshold and AVE values below 0.50, indicating modest convergent validity and suggest that items within these domains may capture related but not identical aspects of mistreatment. Nevertheless, as noted by Fornell and Larcker (1981), AVE represents a conservative estimate of convergent validity, and constructs may still demonstrate adequate convergent validity when composite reliability is acceptable, even if AVE falls below 0.50. Such patterns are common in early-stage validation of multidimensional, context-dependent constructs and have been reported in similar instruments assessing respectful or mistreatment-related maternity care.^25,33–36 These limitations highlight areas for future refinement rather than undermining the overall construct validity of the Malay DMCQ.

Model refinement during CFA involved freeing a limited number of residual correlations between items with overlapping wording and content. These modifications were applied conservatively and resulted in incremental improvements in model fit, consistent with recommendations that modification indices be used sparingly and guided by substantive rationale rather than statistical optimization alone.^32,37,38 The final model retained a theoretically coherent five-factor structure aligned with Bohren’s typology and the original DMCQ.

The content of the Malay DMCQ aligns closely with emotional and interpersonal aspects of maternity care reported in prior Malaysian studies, including experiences of poor communication, disempowerment, and emotional distress during childbirth.⁸ While satisfaction-based instruments such as the Women’s Views of Birth Postnatal Satisfaction Questionnaire capture general perceptions of postnatal care, they do not systematically assess mistreatment during childbirth.³⁹ By explicitly measuring domains such as lack of consent, verbal abuse, and medical intrusiveness, the Malay DMCQ addresses this gap and complements existing measures.

Internationally, the Malay DMCQ demonstrates conceptual alignment with other validated tools assessing mistreatment and respectful maternity care. Instruments developed in Latin America and other LMIC settings emphasize sociocultural and institutional dimensions of obstetric violence that parallel the medical intrusiveness and negative interaction domains of the DMCQ.⁴⁰ While the DMCQ does not explicitly measure decision-making autonomy, it overlaps conceptually with autonomy-focused instruments through items addressing non-consented care.⁴¹ Compared with person-centered maternity care tools, the DMCQ differs in its explicit focus on identifying negative and potentially harmful experiences during childbirth.^33,42 Comparable instruments, such as those developed in Iran,⁴³ also demonstrated robust psychometric performance but were tailored to their local sociocultural context.

Beyond instrument-level comparisons, the Malay DMCQ aligns with broader methodological advances emphasizing the importance of standardized yet locally adapted tools for measuring mistreatment during childbirth.⁴ Women’s self-reported experiences capture subjective dimensions of mistreatment—such as stigma, unmanaged pain, and lack of companionship—that are often missed by facility-based observations.⁴⁴ As a self-report instrument, the Malay DMCQ centers women’s voices and supports efforts to design contextually responsive respectful maternity care interventions. This is consistent with Sequeira D’Mello et al.,⁴⁵ who emphasized the centrality of women’s narratives and the importance of cultural and linguistic adaptation to ensure the relevance and acceptability of mistreatment measurement tools in LMIC settings.

Implications for public health and maternal care in Malaysia

From a public health perspective, the Malay DMCQ holds significant potential as a monitoring and quality-improvement tool within Malaysian maternity services. By systematically capturing women’s experiences of disrespect and mistreatment during childbirth, the instrument can support routine facility audits, enable monitoring of respectful maternity care practices, and inform the design and intervention of targeted interventions. As a standardized self-report measure, the Malay DMCQ may also serve as a baseline tool for epidemiological surveillance of disrespect and mistreatment and for assessing disparities across facilities, populations subgroups, or regions. Its application can strengthen accountability mechanisms, guide resource allocation, and support policy advocacy aimed at improving quality and equity in maternity care. These applications align with WHO’s call to eliminate disrespect and mistreatment during childbirth as a barrier to safe and dignified maternity care.^2,46

Strengths and limitations

The validation process was rigorous and transparent, involving forward–backward translation, harmonization, expert content review, face validation, and exploratory and confirmatory analyses grounded in established disrespect and mistreatment frameworks. These methodological steps strengthen confidence in the cultural relevance and psychometric robustness of the Malay DMCQ.

However, several limitations should nevertheless be acknowledged. Women’s self-reports of mistreatment are inherently sensitive and may be influenced by recall bias or social desirability bias. The sample size used for exploratory factor analysis was at the lower acceptable limit, and the Kaiser–Meyer–Olkin value of 0.70, while adequate, indicates only moderate shared variance among items and may have contributed to lower factor loadings observed for some items. In addition, two domains demonstrated omega values slightly below the conventional 0.70 threshold, reflecting moderate internal consistency at this early stage of validating multidimensional psychosocial constructs. Although discriminant validity between domains was supported using internal criteria (square root of AVE), external convergent validity with external instruments could not be assessed, as no comparable, validated Malay-language tools measuring comparable constructs of disrespect and mistreatment during childbirth. This limits the ability to examine cross-instrument validity and should be addressed in future studies as additional measures become available.

The study sample was predominantly Malay Muslim and drawn from two districts in Kelantan, which may limit the generalizability of the findings to more diverse Malaysian populations. While the Malay DMCQ reflects WHO’s mistreatment typology, it does not fully capture broader forms of institutional neglect, systemic delays, or discrimination that may influence women’s childbirth experiences in other settings. Future adaptations should integrate qualitative methods to broaden content coverage and enhance contextual relevance.

Further validation across different regions and population groups, as well as linkage with maternal and neonatal outcomes, would strengthen the evidence base for the Malay DMCQ. Evaluation of its use in health facility audits, quality-improvement initiatives, and intervention studies would also enhance its utility as a practical tool for improving respectful maternity care in Malaysia.

Conclusion

The Malay version of the Disrespect and Mistreatment during Childbirth Questionnaire (DMCQ) demonstrated acceptable validity and reliability, with a multidimensional structure consistent with WHO’s disrespect and mistreatment typology and international evidence. While some domains showed moderate reliability, the tool captured conceptually important aspects of women’s childbirth experiences, ensuring both psychometric rigor and contextual relevance. The Malay DMCQ offers a practical instrument for assessing mistreatment in Malaysian health facilities and can support respectful maternity care programs, facility audits, and policy advocacy.

Supplemental material

Supplemental material - Translation, cultural adaptation, and psychometric validation of the Malay version of the disrespect and mistreatment during childbirth questionnaire

Supplemental material for Translation, cultural adaptation, and psychometric validation of the Malay version of the Disrespect and Mistreatment during Childbirth Questionnaire by Nionella bt Stephen Sampil, Anis Kausar Ghazali, Tengku Alina Tengku Ismail, Nik Normanieza Nik Man in Journal of Public Health Research

Supplemental material

Supplemental material - Translation, cultural adaptation, and psychometric validation of the Malay version of the disrespect and mistreatment during childbirth questionnaire

Supplemental material

Supplemental material - Translation, cultural adaptation, and psychometric validation of the Malay version of the disrespect and mistreatment during childbirth questionnaire

Supplemental material

Supplemental material - Translation, cultural adaptation, and psychometric validation of the Malay version of the disrespect and mistreatment during childbirth questionnaire

Supplemental material

Supplemental material - Translation, cultural adaptation, and psychometric validation of the Malay version of the disrespect and mistreatment during childbirth questionnaire

Supplemental material for Translation, cultural adaptation, and psychometric validation of the Malay version of the Disrespect and mistreatment during childbirth questionnaire by Nionella bt Stephen Sampil, Anis Kausar Ghazali, Tengku Alina Tengku Ismail, Nik Normanieza Nik Man in Journal of Public Health Research

Footnotes

Acknowledgements

The authors would like to express their sincere appreciation to the Director of Health, Kelantan State Health Department, and the Director-General of Health, Malaysia for their kind permission and support in conducting and publishing this study.

Ethical considerations

This study received ethical clearance from the Human Research Ethics Committee of Universiti Sains Malaysia (USM/JEPeM/KK/25010114) and Medical Research and Ethics Committee of Ministry of Malaysia (NMRR ID-25-004210GX0(IIR) and performed in accordance with the principles of the Declaration of Helsinki.

Consent to participate

Informed consent was obtained in writing. Participation was entirely voluntary, with no coercion, and respondents were assured of their right to withdraw at any time without consequence. Informed consent was obtained for publication of this study.

Author contributions

Conceptualization: NSS, TATI.

Data curation: NSS, TATI, AKG.

Formal analysis: NSS, TATI, AKG.

Investigation: NSS, NNNM.

Methodology: NSS, TATI, AKG.

Project administration: NSS, TATI.

Resources: TATI, AKG, NSS, NNNM.

Software: NSS, TATI, AKG.

Supervision: TATI, AKG.

Validation: AKG, TATI.

Visualization: NSS.

Writing–original draft: NSS.

Writing–review & editing: NSS, TATI, AKG.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: School of Medical Sciences, Universiti Sains Malaysia.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The Malay version of the Disrespect and Mistreatment during Childbirth Questionnaire and the datasets generated and analysed during the current study are provided as Supplementary Information (Supplementary Figure S1, Supplementary File S1, and ).*

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

Please find the following supplemental material available below.

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For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

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