What is the BSS-R ?

The Birth Satisfaction Scale-Revised (BSS-R) is a 10-item multi-factorial psychometrically robust tool developed and co-owned by Professor Caroline J Hollins Martin and Prof Colin R Martin (see Table 1).


Table 1: The 10 item BSS-R©


Subscales:

• Quality of care provision (4-items)
• Women’s personal attributes (2-items)
• Stress experienced during labour (4-items)


Items:
(1) I came through childbirth virtually unscathed.
(2) I thought my labour was excessively long.
(3) The delivery room staff encouraged me to make decisions about how I wanted my birth to progress.
(4) I felt very anxious during my labour and birth.
(5) I felt well supported by staff during my labour and birth.
(6) The staff communicated well with me during labour.
(7) I found giving birth a distressing experience.
(8) I felt out of control during my birth experience.
(9) I was not distressed at all during labour.
(10) The delivery room was clean and hygienic.


Scoring:

Participants respond on a 5-point Likert scale based on level of agreement/disagreement with each of the statements placed, with a possible range of scores between 0-40. A score of 0 on the BSS-R represents least ‘birth satisfaction’ and 40 most.

• Strongly Agree
• Agree
• Neither Agree or Disagree
• Disagree
• Strongly Disagree


Obtain a copy of the BSS-R:
If you would like to use the BSS-R©, it is free to use, but requires permission. Please email us and we will send you a copy.

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The Birth Satisfaction Scale-Revised (BSS-R) is easily scored.

The Birth Satisfaction Scale-Revised (BSS-R) is easily scored. A score of 0 represents no birth satisfaction and 40 most (range 0-40). Each item is scored on a descending rating from ‘Strongly Agree’ with a score of ‘4’ to ‘Strongly ‘Disagree’ with a score of ‘0’. However, items 2, 4, 7, 8 are reverse scored. The following scoring grid details the score that should be given for each individual item.

BSS-R Item Strongly Agree Agree Neither Disagree Strongly Disagree
Item 1 4 3 2 1 0
Item 2 0 1 2 3 4
Item 3 4 3 2 1 0
Item 4 0 1 2 3 4
Item 5 4 3 2 1 0
Item 6 4 3 2 1 0
Item 7 0 1 2 3 4
Item 8 0 1 2 3 4
Item 9 4 3 2 1 0
Item 10 4 3 2 1 0

The BSS-R comprises the following three sub-scales:

 

Sub-scale

Sub-scale items

Score range

Stress experienced during labour

1, 2, 7, 9

0 – 16

Women’s personal attributes

4, 8

0 – 8

Quality of care provision

3, 5, 6, 10

0 – 16

 

The BSS-R is free for use in clinical practice, routine outcomes measurement, and clinical research but requires permission from the developer. Please contact:


The BSS-R was selected in 2016

The BSS-R is the lead international clinical measure of birth satisfaction and is used to assess women’s perceptions of care provided and experiences of care provided during labour and childbirth. The BSS-R is recommended as the method of choice for assessing women’s birth experience by the International Consortium for Health Outcome Measurement (ICHOM): (link to ICHOM section, which follows on from this & also to: www.ichom.org/medical-conditions/pregnancy-and-childbirth/

The BSS-R is a robust, valid and reliable multi-dimensional psychometric instrument for measuring postnatal women’s birth satisfaction. To view the paper that reports development and psychometric properties of the BSS-R:

Reference

Hollins-Martin, C.J., Martin, C. (2014). Development and psychometric properties of the Birth Satisfaction Scale-Revised (BSS-R). Midwifery.
30: 610-619.

Link to reference: www.sciencedirect.com/science/article/abs/pii/S0266613813002982

The 10-item BSS-R has been translated and used in 34 countries across Europe, North America, South America, Asia and the Middle East, by clinicians and researchers to evaluate and ultimately improve maternity service provision. To date,100+ international sites have used the BSS-R to effect positive impacts accounted in many major clinical reports. Several translations and validations have been carried out, with many more in progress.
If you would like to use the BSS-R, please contact us.

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The ICHOM

The BSS-R is recommended as the ‘method of choice’ for assessing birth experience by the International Consortium for Health Outcome Measurement (ICHOM) (see Figure 1):

Figure 1: The International Consortium for Health Outcome Measures (ICHOM) adopted the BSS-R into its standard set for pregnancy and childbirth in 2016.

Available at: www.ichom.org/medical-conditions/pregnancy-and-childbirth/

The 10-item BSS-R is a multi-factorial psychometrically robust tool developed by Professor Caroline J. Hollins Martin and Prof Colin R. Martin (Hollins Martin & Martin, 2014). Since its adoption by the International Consortium for Health Outcome Measurement (Nijagal et al., 2018), the BSS-R is recommended as the key clinical measure of birth experience globally:

Access: www.ichom.org/medical-conditions/pregnancy-and-childbirth/

Reference
Hollins-Martin, C.J., Martin, C. (2014). Development and psychometric properties of the Birth Satisfaction Scale-Revised (BSS-R). Midwifery.
30: 610-619. http://dx.doi.org/10.1016/j.midw.2013.10.006

Link to reference: www.sciencedirect.com/science/article/abs/pii/S0266613813002982

Reference
Nijagal, A.M., Wissig, S., Stowell, C., Olson, E., Amer-Wahlin, I. et al. (2018). Standardized outcome measures for pregnancy and childbirth, an ICHOM proposal. BMC Health Services Research. 18: 953.

Link: https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-018-3732-3

If you would like to use the BSS-R, please contact us.

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BSS-R underpinning research


The 10-item BSS-R was developed from a literature review of evidence-based reports of what women perceived improved their birth satisfaction (Hollins Martin & Fleming, 2011).

Reference
Hollins Martin, C.J., Fleming, V. (2011). The Birth Satisfaction Scale (BSS).
International. Journal of Health Care Quality Assurance. 24(2): 124-135.

https://www.emerald.com/insight/publication/issn/0952-6862/vol/24/iss/2

Qualitative validation of the survey was undertaken from primary free-text data gathered from (n=207) childbearing women. This data was concurrently analysed with first-hand narratives of birth satisfaction accounted for in 19 qualitative papers. It was concluded that the initial 30-item BSS accounted for all the data (Hollins Martin et al., 2012):

Reference
Hollins Martin, C.J., Snowden, A., Martin, C.R. (2012). Concurrent analysis: Validation of the domains within the Birth Satisfaction Scale. Journal of Reproductive and Infant Psychology. 30(3): 247-260.
http://dx.doi.org/10.1080/02646838.2012.710833

To assess factor structure, validity, and reliability of the preceding 30-item BSS and to develop a short-form version of the tool, survey data was collected in Scotland from (n=228) postnatal women (Hollins Martin & Martin, 2015):

Reference
Hollins Martin, C.J., Martin, C.R. (2015). A survey of women’s birth experiences in Scotland using the Birth Satisfaction Scale (BSS). European Journal for Person Centered Healthcare. 3(4): 478-486.

Link to reference: http://www.ejpch.org/ejpch/article/view/1019

Post-analysis, the 30-item BSS was reconfigured into the 10-item BSS-R, with data confirming the three prior clustered sub-scales (Hollins Martin & Martin, 2014).

Reference
Hollins-Martin, C.J., Martin, C. (2014). Development and psychometric properties of the Birth Satisfaction Scale-Revised (BSS-R). Midwifery.
30: 610-619.

Link to reference: www.sciencedirect.com/science/article/abs/pii/S0266613813002982

This process of psychometric validation by Hollins Martin and Martin (2014) led to specific categories and a 10-item multi-factorial survey format involving three specific themes:

(1) Quality of care provision (birth environment, sufficient support, relationships with health care professionals) (4-items).
(2) Personal attributes (ability to cope during labour, feeling in control) (2-items).
(3) Stress experienced during labour (obstetric injuries, long labour, distress experienced during labour) (4-items).

Post-validation, the 10-item BSS-R was considered a robust tool for measuring women’s satisfaction with their birth experience. Through utilisation of the 10-item BSS-R and associated survey data gathered, key areas for improvement are identified in clinical settings that provide care to women during labour and childbirth.

Further psychometric validation
Further psychometric validation has been carried out on the United States version of the BSS-R (US-BSS-R) (Barbosa-Leiker et al., 2015):

Reference
Barbosa-Leiker, C., Fleming, S., Hollins Martin, C.J., Martin, C.R. (2015).
Psychometric properties of the Birth Satisfaction Scale-Revised (BSS-R) for US mothers. Journal of Reproductive and Infant Psychology. 33(5): 504-511.

Link to reference: https://www.tandfonline.com/doi/abs/10.1080/02646838.2015.1024211?scroll=top&needAccess=true&journalCode=cjri20

Structural analysis demonstrated that the 10-item BSS-R is equivalent in terms of measurement properties across cultures and language (Martin et al., 2016):

Reference
Martin, C.R., Vardavaki, Z., Hollins Martin, C.J. (2016). Measurement equivalence of the Birth Satisfaction Scale-Revised (BSS-R): Further evidence of construct validity. Journal of Reproductive and Infant Psychology. 34(4): 394-402.

Link to reference: https://www.tandfonline.com/doi/abs/10.1080/02646838.2016.1184747

Working with international partners, a US study (n>2000) proved the 10-item BSS-R to be an exemplar in measurement and structural characteristics (Fleming et al., 2016):

Reference
Fleming, S., Donovan-Batson, C., Barbosa-Leiker, C., Hollins Martin, C.J., Martin, C.R. (2016). Birth Satisfaction Scale/Birth Satisfaction Scale-Revised (BSS/BSS-R): a large scale United States Planned Home Birth and Birth Center Survey. Midwifery. 41: 9-15.

Link to reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5575858/

Further analysis was undertaken on minimum sample size requirements for validation studies (Martin & Hollins Martin, 2017):

Reference
Martin, C.R., Hollins Martin C.J. (2017). Minimum sample size requirements for a validation study of the Birth Satisfaction Scale-Revised (BSS-R). Journal of Nursing and Practice. 1(2): 25-30.

Link: www.napier.ac.uk.pdf

Further analysis was carried out in relation to how sub-scale scores/total score can be used (Martin et al., 2018):

Reference
Martin, C.R., Hollins Martin, C.J., Burduli, E., Barbosa-Leiker, C., Donovan-Batson, C. and Fleming, S.E. (2018). The Birth Satisfaction Scale-Revised (BSS-R): Should the sub-scale scores or the total score be used? Journal of Reproductive and Infant Psychology. 36(5): 530-535.

Link: https://www.ncbi.nlm.nih.gov/pubmed/30058370

Prof Caroline J Hollins Martin and Prof Colin R Martin who initiated the concept and development of the BSS-R©, continue to work with international teams to translate, advise and validate population specific versions of the 10-item BSS-R. This allows clinical teams world-wide to produce a context specific robust tool for use in individualised projects. The purpose of developing country and language specific versions of the 10-item BSS-R is ultimately to create a tool that can be used within contextualised populations to assess and improve quality of intra-natal care provision. If you would like to use the BSS-R, please contact us.

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