1.1Mindfulness-Based Intervention in Postpartum Depression (MBI – PPD)

MBI - PPD refers to Mindfulness-Based Intervention in Postpartum Depression. Pregnant and postpartum women have a high probability of suffering from depression due to the drastic hormone changes they experience during and after pregnancy, and this affect emotional responses. Indeed, pregnant and postpartum women frequently suffer from postpartum depression (PPD), leaving them emotionally handicapped. Women who develop PPD are often unable to handle a normal mother-infant relationship, and some of these women may even have suicidal ideations or consider harming their newborn. Therefore, to relieve their depression, these women need professional medical assistance and other supports, such as mindfulness practices.

Mindfulness involves maintaining attention and awareness of the present moment and accepting what’s going on in the present moment without judgment (Bodhi2011; Kabat-Zinn2003,2006); to achieve a peaceful state of mind. Bishop et al. (2004) similarly described mindfulness as the self-regulation of attention in order to achieve non-elaborative awareness of present experiences. Many previous studies have demonstrated that mindfulness can reduce anxiety (Anderson et al., 2007) and depression (Shapiro et al.2005).

With the rapid development of technology, Electronic Mental Health (EMH) services have recently been embraced as a non-pharmacological treatment trend. These services provide professional functions and relevant information through online social media to help users alleviate mental health problems. With the increasing popularity of smartphones and tablets, the mobile health (mHealth) service model is becoming most popular EMH model. Improving and reducing the risk of postpartum depression in women as well as effectively combining EMH with mindfulness are two of the most important goals of EMH services.

This study was performed using the EMH APP, a mindfulness-based intervention system named We’ll. This system (1) promotes social support and mindfulness exercises for mothers and (2) provides effective opportunities for self-examination using the Motherhood Self-Efficacy Scale (PMP S-E) (Barnes and Adamson-Macedo2007a) in order to relieve and prevent postpartum depression and associated emotional problems.

1.2Parenting Self-efficacy

Self-efficacy is defined as how an individual perceives their ability to perform a specific task or behavior (Bandura1997a). Self-efficacy has also been defined as (1) the judgement of one’s own ability to perform a task and (2) the ability to successfully develop and implement a plan of action (Bandura1986). Whether a person believes that they have the requisite abilities to successfully complete a specific task (Coleman and Karraker1997) is the core of self-efficacy theory (Bandura1977). Self-efficacy affects peoples’ thoughts, feelings, and behaviors (Schwarzer1992) and is therefore a major determinant of human motivations.

Parental self-efficacy refers to parents’ perception of their abilities to care for and cultivate their children’s growth and development (Coleman and Karraker1997; (Kuhn and Carter2006; Teti and Gelfand1991a). Parental self-efficacy, defined as a belief in one’s ability to successfully address parenting challenges (Hess et al.2004), is an important mechanism which guides mothers’ interactions with hospitalized babies. Parents must possess qualities related to a strong sense of self-efficacy in order to be successful at parenting. Parental self-efficacy is influenced by a number of factors, including characteristics of parents and children as well as external factors related to the social environment (Hess et al.2004). Determining whether a woman feels competent in various aspects of parenting should enable healthcare professionals to better manage and support pregnant and postpartum mothers (Barnes and Adamson-Macedo2007b).

One of the biggest sources of postpartum psychological stress is a mother’s (accurate or inaccurate) belief that she lacks child rearing skills (Miles et al.1993; Miles and Holditch1997). Mothers are effective at performing and managing various tasks in parenting roles. Sexual beliefs also play a key role in the theory of self-efficacy (Bandura1997b). Self-efficacy in parenting can help predict long-term outcomes and potential risk factors for dysfunctional mother-child relationships (Aarnoudse et al., 2009; Jones and Prinz2005; Melnyk et al.2001a). Parents’ self-efficacy and parenting abilities are regulated by how well they understand their baby’s condition and emotional state (Pedrini et al., 2018). For these reasons, parental self-efficacy has been classified as a target for direct postnatal intervention (Benzies, Magill-Evans, Hayden, and Ballantyne2013). Beliefs about parenting self-efficacy mediate the effects of depression, social support, and infant temperament on parenting behaviors (Teti and Gelfand1991b) In fact, interventions aimed at encouraging mother-child interactions have positively impacted mothers, particularly when it comes to reducing maternal stress (Melnyk et al. 2006; Kaaresen, Rønning Ulvund and Da2006) and improving their confidence in dealing with children (Ohgi et al. 2004). These improvements can in turn help alleviate postpartum depression.

To better support pregnant and postpartum mothers, a tool which can effectively measure their understanding of and ability to care for their baby is needed. Perceptions of their ability and sensitivity to various levels and tasks in parenting. In addition, knowing whether mothers consider themselves to be competent childcare providers will enable health care professionals to determine which mothers require further intervention and support (Hsiao et al. 2016).

1.3PMP S-E

The Perceived Maternal Parenting Self-Efficacy (PMP S-E) tool, developed by Barnes and Adamson-Macedo (2007a), is a self-report questionnaire which assesses maternal self-efficancy and focuses on mothers of at-risk infants. Initial validation studies on the PMP S-E tool showed high internal consistency and sufficient retest reliability, indicating that the psychometric characteristics of the questionnaire are adequate (Barnes and Adamson-Macedo2007b). The PMP S-E was also shown to be reliable and effective in assessing general self-efficacy levels of UK-born, neonatal mothers (Hsiao et al. 2016). The PMP S-E is consistent with the recognized Bandurian theory of self-efficancy. That is to say, the PMP S-E is a domain-specific tool because it explicitly refers to specific parenting tasks and activities. Thus, it is a highly predictive of actual behavior (Bandura1977). In addition, as the PMP S-E was developed to assess parental self-efficacy during the early stages of neonatal development, it is consistent with a family-centered approach to care (Westrup2015; Als et al. (2012; Bracht et al.2013; Montirosso, Del Prete et al.2012). The PMP S-E is critical to the ethical behavior of clinical research; however, the PMP S-E scale has not yet been translated into Chinese.

1.4Research Objective

The primary objective of this study was to translate the PMP S-E tool into Chinese and then evaluate the effectiveness and reliability of the Chinese version of the tool. There are no similar Chinese instruments specifically formulated for mothers of neonates; therefore, the results of this study may benefit clinical and research applications.

2.1Procedures

The study was conducted in the Department of Obstetrics and Gynecology of Chang Gung Memorial Hospital, Taipei, and included 300 mothers. To be included in our study, mothers had to meet the following selection criteria: (1) had given birth to a healthy baby within the past month and (2) were fluent in Mandarin (listening, speaking, reading and writing). All mothers provided written, informed consent prior to being included in this study. Mothers who had given birth to a baby with genetic or congenital abnormalities were not included. All mothers included in this study were asked to complete the PMP S-E questionnaire and other questionnaires. All questionnaires were completed anonymously.

2.2The Chinese Adaptation of the PMP S-E

The PMP S-E questionnaire was translated into Chinese and then back-translated into English. Briefly, in translating the English version of PMP S-E, two bilingual, native-Chinese speakers completed two independent translations. Both translators were medical doctoral students with academic and clinical backgrounds. After translation, the translators consulted with each other and with a translation expert and then further revised Chinese version of the PMP S-E tool based on discussion and feedback. Subsequently, two new translators who were unfamiliar with the original PMP S-E translated the Chinese version back into English to ensure that the content of both versions of the PMP S-E was consistent. The Chinese text was then reviewed by two additional expert translators and two other translators who specialized in the neonatal field before an updated translation was prepared.

To evaluate the surface validity of the Chinese PMP S-E tool, questionnaire items were administered to 30 relatively healthy mothers of hospitalized newborns. These mothers were asked to assess the significance of each item and to consider whether each item was relevant in a neonatal context. We also had these mothers complete the PMP S-E to ensure that questionnaire items were clear and easy to understand. Finally, the 30 mothers were asked if they had questions about the format, layout, description, or answer scale of the questionnaire. The interviewer then wrote a detailed report, which noted any difficulties these 30 mothers had in completing the questionnaire and included suggestions for additional revisions to the Chinese version of the PMP S-E. Following this, the final version of the Chinese PMP S-E was completed and submitted to the expert committee.

2.3Measures

The Perceived Maternal Parenting Self-Efficacy (PMP S-E) scale is a 20-item self-report questionnaire which measures the parental self-efficacy of new mothers (Barnes and Adamson-Macedo2007a). The questionnaire requires mothers to answer questions using a four-point Likert scale which includes responses that range from “strongly disagree” to “strongly agree”. (In other words, the questionnaire asks mothers to rate how strongly they agree with given parenting skills statements.) The range of total scores for all items is between 20 and 80, whereby higher scores ​​indicate a stronger sense of parental self-efficacy. The initial confirmatory study included four subscales: (1) care-taking procedures (4 items), which refers to the ability of mothers to perform specific activities and tasks (e.g. feeding); (2) evoking behaviour (7 items), which refers to how mothers perceive their ability to change their infant’s behavior; (3) reading behaviour or signalling (6 items), which refers to how mothers perceive their ability to understand and recognize their infant’s behavioural changes; (4) situational beliefs (3 items), which refers to how mothers perceive their ability to judge overall interactions with their baby. The PMP S-E was analysed using a sample of 165 mothers who had given birth to relatively healthy neonates at NICU. Our results showed that the Chinese PMP S-E had high internal consistency for both the overall scale (Cronbach’s alpha = 0.91) and for each subscale (Cronbach’s alpha ranged from 0.72 to 0.89). Furthermore, over a 10-day interval, test–retest reliability was also high for both the overall score (r = .96; p < .001) and subscale scores (care-taking procedures: r = .92, p = .01; evoking behaviour: r = .92, p = .01; reading behaviour or signaling: r = .93, p = .01; situational beliefs: r = .88, p = .01).

2.4Statistical Analysis

To test the validity of the factor structure included in the original English verification study (Barnes and Adamson-Macedo2007b), Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) were conducted. In accordance with recommendations on scale development and validation studies (Cabrera-Nguyen2010; Worthington and Whittaker, 2006), we randomly split our study population in order to conduct EFA and CFA on different samples. Specifically, we first performed EFA on half of the study population (i.e. the calibration sample), and we then performed CFA on the other half of the study population (i.e. the validation sample) to test the factor structure derived from EFA. The following indices and thresholds were used to determine the goodness of fit of the model: a Root Mean Square Error of Approximation (RMSEA) smaller than 0.08, Comparative Fit Index (CFI) and Non-Normed Fit Index (NNFI) values greater than 0.90, and a ratio of Chi-square value to degrees of freedom (chi2/df) less than 3.0. Exploratory Factor Analysis (EFA) with varimax rotation was used to determine the factor structure of the PMP S-E. The Kaiser–Meyer–Olkin (KMO) test was performed to verify sampling adequacy for this analysis, and Barlett׳s Test of Sphericity was performed to assess the degree of intercorrelation between variables. Factor extraction was determined using Kaiser’s criterion (eigen values ≥ 1). For this, a factor loading greater than 0.5 was considered to indicate that the item contributed sufficiently to its factor. Cronbach’s alpha coefficients were calculated to determine the internal consistency for both the overall scale and its factors, whereby values ≥ 0.70 were considered adequate. All statistical analyses were performed using SPSS 21.0 and LISREL 8.80 software. Statistical significance was set at p = .05.

Overall, we observed large variability in perceptions of maternal self-efficacy, with PMP S-E scores ranging from 20–80. Figure 1 shows the distribution of scores. For the overall study, the mean self-efficacy score of the sample was 59.24 (SD = 8.957); the median was 59; and the mode was 59. The large spread of scores suggests that the PMP S-E tool had a reasonable degree of discrimination. Skewness was not significant at the 2% level, indicating that PSP S-E scores were normally distributed.

Distribution of PSP-SE scores

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3.1Construct Validity of the Chinses PMP S-E

After splitting the study population into two samples, EFA was conducted on one sample (validation sample) to determine the optimal factor structure of the Chinese version of the PMP S-E (Table 1). The eigen values of the four factors in this analysis were all greater than 1 and explained 71.5% of the total variability. The factors were easily interpretable and were labelled according to item content, as follows: evoking behaviours (which explained 52.6% of variance); reading behavior or signalling (which explained 6.6% of variance), situational beliefs (which explained 6.5% of variance), and care-taking procedures (which explained 5.8% of variance). None of the items showed loadings below the cut-off value (0.5), and none of the items loaded onto more than one factor. This indicates that (1) all items were relevant to the measurement of the parenting self-efficacy construct and (2) all factors were distinct. The fit of the EFA-derived model was then tested by performing CFA on the second sample (calibration sample). As shown in Fig. 2, the fit of the model to the data was excellent (RMSEA = 0.053; CFI = 0.99; NNFI = 0.99; chi²/df = 1.833, p < .001).

CFA validation of EFA-derived factor structure. Model was developed using a Chinese sample

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3.2Internal Consistency of the Chinses PMP S-E

The Chronbach’s alpha value (α = 0.953) we obtained confirmed that the overall scale had high internal consistency. As reported in Table 1, alpha values were low when any item was removed from the scale. Cronbach’s alpha values for the subscales were as follows: reading behaviour or signalling (α = 0.888); evoking behaviour (α = 0.919); situational beliefs (α = 0.767); care-taking procedures (α = 0.816).

The purpose of this study was to translate the PMP S-E tool into Chinese and evaluate its reliability and validity. Our results provide support for Chinese version of this tool, which can be used by Taiwanese mothers of hospitalized neonates during the neonatal period. We developed a Chinese version of this tool for the following reasons. Firstly, understanding the parental self-efficacy construct can benefit both healthcare providers and recipients in multiple ways. Specifically, it provides information that can be used to empower new parents to make choices that should enhance their ability to care for their babies (10). The PMP S-E also features a unique methodology to help medical professionals screen mothers’ parenting abilities. We recommend using the overall PMP S-E score to gain general insight into self-efficacy level and using the subscales to determine specific types of support that individual mothers may benefit from. The PMP S-E questionnaire only takes 10 min to complete, making it easy to administer in clinical settings. Furthermore, the PMP S-E is unique among measures used to assess parenting self-efficacy in that it was specifically designed for postpartum mothers. The neonatal period is a stressful time, and this stress may affect mothers’ perceptions of their abilities to be successful parents. Thus, the PMP S-E could be useful during this stressful period.

This study addresses the lack of tools to assess self-efficacy among mothers of neonates in Taiwan. An assessment of maternal self-efficacy should allow more effective, family-centered interventions to be implemented in treating mothers with postpartum depression (Westrup2015). This study also confirmedthe multidimensional structure of the PMP S-E. Specifically, EFA clearly identified four factors which pertain to different parenting skills. In addition, the Chinese version of the MBI-PPD S-E includes 20 items. None of the items loaded on more than one factor, and alpha coefficients revealed high internal consistency for each of the four factors. The factor “care-taking procedures” refers to a mother’s perception of her ability to perform tasks related to her baby’s basic needs (e.g. feeding). The factor “evoking behaviours” refers to a mother’s perception of her ability to elicit certain changes in her baby’s behaviour (e.g. soothing). The factor “reading behaviour or signaling” refers to the mother’s perception of her ability to identify and understand the body cues of her baby (e.g. tiredness). The factor “situational beliefs” refers to the mother’s perception of her ability to identify and manage changes in her baby’s behaviour based on emotional cues (e.g. when the baby is upset). The PMP S-E had high internal consistency, and the removal of any item resulted in a larger overall alpha coefficient, indicating that all items are significant components of the parental self-efficacy construct.

Table 2 compares reliability and validity scores for the PMP S-E that were obtained by the current study and by previous studies. For the current study, alpha values were high regardless of whether overall reliability or the reliability of subscales was being assessed. With regard to validity, all of the indicators we employed confirmed that our CFA model had adequate goodness of fit. Furthermore, the amount of variability explained by our EFA model was relatively high. Overall, our findings confirm the nature of the PMP S-E as a “domain-specific” measure of self-efficacy (Barnes and Adamson-Macedo2007a). According to the well-accepted Bandurian theory of self-efficacy (Bandura1997c), “domain-specific” measures refer to specific activities, and this makes them more predictive of parenting competence than general measures of self-efficacy (Bandura1997d). In this sense, the PMP S-E fits well with current approaches to neonatal care that combine technological and pharmacological interventions with interventions that address “relationship-based needs” (Westrup2015; Als et al.2012; McAnulty et al.2010). Effectively assessing mother-baby interactions requires that specific observation and coding procedures be employed (Jones and Prinz2005; Morsbach and Prinz2006). Indeed, attachment representations are the factors with the greatest influence over mother-baby interactions (Fonseca, Nazaré, Canavarro et al.,2013). However, assessments of perceived parental self-efficancy can still be informative. Cognitive processes (i.e. obtaining knowledge, acquiring beliefs, developing values and attitudes) influence the acquisition of new behavioural patterns and the ability to change existing behavioural patterns (Bandura1977). This may explain why parental self-efficacy has been associated with parenting competence (Jones and Prinz2005; Teti and Gelfand1991b; Teti et al.2005).

This is the first study to develop a Chinese translation of a tool that is capable of measuring maternal self-efficacy among mothers of hospitalized neonates. This study was completed using a large sample of Taiwanese mothers of neonates, and our results indicated that the Chinese version of the PMP S-E had good validity, reliability, and consistency. Therefore, this tool is worthy of further testing and application. Given that parental self-efficacy is likely associated with the quality of parent-baby interactions, the PMP S-E questionnaire should greatly benefit clinical and research applications. Improving parent–baby interactions has long-term benefits for the neurodevelopment process of neonates. This study also deepened existing knowledge about parental self-efficacy and provided evidence of its manifestation in Taiwan. Future studies should employ the Chinese version of the MBI-PPD S-E scale developed in this study to further investigate the relationship between parental self-efficacy and postpartum depression, and further investigate the role of mindfulness interventions in improving maternal self-efficacy and alleviating postpartum depression.