Postpartum Service Quality: Validation of a Multidimensional Model
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Abstract
The objective of this article is to validate a multidimensional model for evaluating postpartum maternal service quality in public hospitals in Hidalgo, Mexico. A mixed-methods approach with an exploratory sequential design (DEXPLOS) was used: the qualitative phase identified six dimensions and supported the construction of a 24-item instrument; the quantitative phase included content validity, internal consistency, EFA, CFA, and multiple regression. The results show a confirmatory factorial model with adequate fit (CFI = 0.938; RMSEA = 0.066). The findings indicate that multiple regression explained 85.6% of the variance in perceived quality, with higher coefficients for emotional support, communication, and warning-sign education. The originality lies in providing a validated model to evaluate postpartum care and guide technological innovation strategies centered on the patient’s experience. Limitations include non-probability sampling and application in a single Mexican state.
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References
Afulani, P. A., Oboke, E. N., Ongeri, L., Weiss, S. J., Lyndon, A., & Berry Mendes, W. (2021). Understanding disparities in person-centred maternity care: The potential role of provider implicit and explicit bias. Health Policy and Planning, 36(3), 298–311. https://doi.org/10.1093/heapol/czaa190
Aiken, L. R. (1980). Content validity and reliability of single items or questionnaires. Educational and Psychological Measurement, 40(4), 955–959. https://doi.org/10.1177/001316448004000419
Aranda, Z., Caamal, V., Montaño, M., Bernal, D., & Meneses, S. (2024). Exploring how non-clinical factors in childbirth care shape users’ experiences in public health facilities in rural Chiapas, Mexico: A qualitative study using the WHO health systems responsiveness framework. BMC Pregnancy and Childbirth, 24(1), 173. https://doi.org/10.1186/s12884-024-06357-7
Arias, M. P., Wang, E., Leitner, K., Sannah, T., Keegan, M., Delferro, J., . . . Hamm, R. (2022). The impact on postpartum care by telehealth: A retrospective cohort study. American Journal of Obstetrics & Gynecology MFM, 4(3). https://doi.org/10.1016/j.ajogmf.2022.100611
Baart, A., Brunsveld Reinders, A., Pijnappel, L., de Haan, M., & de Man-van Ginkel, J. (2025). Continuity of care as central theme in perinatal care: A systematic review. Midwifery, 141(104273). https://doi.org/10.1016/j.midw.2024.104273
Bujang, M., Omar, E., & Baharum, N. (2018). A review on sample size determination for Cronbach’s alpha test: A simple guide for researchers. Malaysian Journal of Medical Sciences, 25(6), 85–99. https://doi.org/10.21315/mjms2018.25.6.9
Contreras-Sánchez, S., Doubova, S., Mejía-Chávez, M., Infante-Castañeda, C., & Pérez-Cuevas, R. (2022). Factores asociados a la falta de control posnatal materno [Factors associated with a lack of postnatal care]. Revista Médica del Instituto Mexicano del Seguro Social, 60(1), 4–11.
Creamer, E. (2022). An introduction to fully integrated mixed methods research (2nd ed.). SAGE Publications, Inc. https://doi.org/10.4135/9781071802823
Creswell, J., & Plano Clark, V. (2018). Designing and conducting mixed methods research (3rd ed.). SAGE Publications, Inc.
Cronbach, L. (1951). Coefficient alpha and the internal structure of tests. Psychometrika, 16(3), 297-334. https://doi.org/10.1007/BF02310555
DiStefano, C., & Morgan, G. (2014). A comparison of diagonal weighted least squares robust estimation techniques for ordinal data. Structural Equation Modeling, 21(3), 425–438. https://doi.org/10.1080/10705511.2014.915373
Doubova, S., Leslie, H., Pérez-Cuevas, R., Kruk, M., & Arsenault, C. (2024). Users’ perception of quality as a driver of private healthcare use in Mexico: Insights from the People’s Voice survey. PLOS ONE, 19(6), e0306179. https://doi.org/10.1371/journal.pone.0306179
Escobar, J., & Cuervo, A. (2008). Validez de contenido y juicio de expertos: Una aproximación a su utilización. Avances en Medición, 6, 27–36. Retrieved from http://revistas.um.es/advances/article/view/48161
Fetters, M. (2020). The mixed methods research workbook: Activities for designing, implementing, and publishing projects. SAGE Publications, Inc. https://doi.org/10.4135/9781071909713
Flora, D., & Curran, P. (2004). An empirical evaluation of alternative methods of estimation for confirmatory factor analysis with ordinal data. Psychological Methods, 9(4), 466–491. https://doi.org/10.1037/1082-989X.9.4.466
Galle, A., Moran, A., Bonet, M., Graham, K., Muzigaba, M., Portela, A., . . . Moller, A.-B. (2023). Measures to assess quality of postnatal care: A scoping review. PLOS Global Public Health, 3(2), e0001384. Retrieved from https://doi.org/10.1371/journal.pgph.0001384
GmbH. (2026). ATLAS.ti [Qualitative data analysis software]. Retrieved from https://atlasti.com
Hayes, A., & Coutts, J. (2020). Use omega rather than Cronbach’s alpha for estimating reliability. But…. Communication Methods and Measures, 14(1), 1–24. https://doi.org/10.1080/19312458.2020.1718629
INEGI, I. (2022). Estadísticas de mortalidad materna 2018–2022. Retrieved from https://www.inegi.org.mx/sistemas/olap/Proyectos/bd/continuas/mortalidad/MortalidadGeneral.asp
Instituto Mexicano del Seguro Social [IMSS]. (2019). Vigilancia y atención amigable en el trabajo de parto en embarazo de bajo riesgo (IMSS-052-19) [Guía de práctica clínica]. Retrieved from https://www.imss.gob.mx/sites/all/statics/guiasclinicas/052GER.pdf
International Organization for Standardization [ISO]. (2015). ISO 9000:2015(es) Sistemas de gestión de la calidad — Fundamentos y vocabulario. Retrieved from https://www.iso.org/obp/ui#iso:std:iso:9000:ed-4:v1:es
Jamovi: Computer software. (2025). Retrieved from https://www.jamovi.org
Jonkisz, A., Karniej, P., & Krasowska, D. (2022). The SERVQUAL method as an assessment tool of the quality of medical services in selected Asian countries. International Journal of Environmental Research and Public Health, 19(13). https://doi.org/10.3390/ijerph19137831
Kline, R. B. (2023). Principles and practice of structural equation modeling (5th ed.). The Guilford Press.
Kruk, M., Gage, A., Arsenault, C., Jordan, K., Leslie, H., & Roder-DeWan, S. (2018). High-quality health systems in the Sustainable Development Goals era: Time for a revolution. The Lancet Global Health, 6(11), e1196–e1252. https://doi.org/10.1016/S2214-109X(18)30386-3
Lieber, E., & Weisner, T. (2010). Meeting the practical challenges of mixed methods research. In Handbook of mixed methods in social & behavioral research (pp. 559–579). SAGE.
National Academies of Sciences, Engineering, and Medicine. (2021). The future of nursing 2020–2030: Charting a path to achieve health equity. National Academies Press. https://doi.org/10.17226/25982
Nuwabaine, L., Namulema, A., Sserwanja, Q., Kawuki, J., Amwiine, E., & Amperiize, M. (2024). Factors associated with quality of postnatal care in Kenya: An analysis of the 2022 Kenya DHS. Archives of Public Health, 82(1), 227. https://doi.org/10.1186/s13690-024-01433-y
OCDE/Eurostat. (2018). Manual de Oslo 2018: Guidelines for Collecting, Reporting and Using Data on Innovation, 4th Edition. OECD Publishing. https://doi.org/10.1787/9789264304604-en
OECD. (2023). OECD science, technology and innovation outlook 2023. https://doi.org/10.1787/0b55736e-en
OECD. (2024). Global Trends in Government Innovation 2024: Fostering Human-Centred Public Services. https://doi.org/10.1787/c1bc19c3-en.
Paredes-Cruz, M., Perez-Moran, D., Doubova, S., Arsenault, C., & Quinzaños-Fresnedo, C. (2025). Quality of postnatal care for mothers and neonates in Mexico: Insights from the maternal eCohort study. PLOS ONE, 20(8), e0323039. https://doi.org/10.1371/journal.pone.0323039
Penfield, R., & Giacobbi, P. (2004). Applying a score confidence interval to Aiken’s item content-relevance index. Measurement in Physical Education and Exercise Science, 8(4), 213–225. https://doi.org/10.1207/s15327841mpee0804_3
Repke, L., Birkenmaier, L., & Lechner, C. (2024). Validity in survey research – From research design to measurement instruments. GESIS – Leibniz Institute for the Social Sciences. https://doi.org/10.15465/gesis-sg_en_048
Rivas-Tovar, L. (2025). Normas APA 7.ª edición: estructura, citas y referencias. Instituto Politécnico Nacional. Retrieved from https://www.researchgate.net/publication/357046089_NORMAS_APA_7_EDICION_ESTRUCTURA_CITAS_Y_REFERENCIAS
Secretaría de Salud. (2016, 4 7). Norma Oficial Mexicana NOM-007-SSA2-2016, para la atención de la mujer durante el embarazo, parto y puerperio, y de la persona recién nacida. Retrieved from Diario Oficial de la Federación: https://www.dof.gob.mx/nota_detalle.php?codigo=5432289
Secretaría de Salud. (2026). Mortalidad materna: Semana epidemiológica 03 [Boletín]. Retrieved from Gobierno de México.: https://www.gob.mx/cms/uploads/attachment/file/1052006/MM_2026_SE03_1_.pdf
Sudhinaraset, M., Landrian, A., Golub, G., Cotter, S., & Afulani, P. (2021). Person-centered maternity care and postnatal health: Associations with maternal and newborn health outcomes. The Lancet Regional Health – Americas, 1, 100005. https://doi.org/10.1016/j.xagr.2021.100005
Symon, A., Mortensen, B., Pripp, A., Chhugani, M., Adjorlolo, S., Badzi, C., . . . Cummins, A. (2025). Validating the Quality Maternal and Newborn Care Framework index: A Global Tool for Quality-of-Care Evaluations. Birth, 52: 347-352, 1–15. https://doi.org/10.1111/birt.12895
Tavakol, M., & Dennick, R. (2011). Making sense of Cronbach’s alpha. International Journal of Medical Education, 2, 53–55. https://doi.org/10.5116/ijme.4dfb.8dfd
Tormen, M., Toniolo, B., Pecci, L., Soraci, G., Taliento, C., Greco, P., & Salvioli, S. (2024). Exploring the impact of integrating telehealth in obstetric care: A scoping review. European Journal of Obstetrics & Gynecology and Reproductive Biology, 302, 242-248. https://doi.org/10.1016/j.ejogrb.2024.09.031
World Health Organization. (2022). WHO recommendations on maternal and newborn care for a positive postnatal experience. Retrieved from https://www.who.int/publications/i/item/9789240045989
World Health Organization. (2025). Quality health services. Retrieved from https://www.who.int/news-room/fact-sheets/detail/quality-health-services