title: Midwifery care: development of an instrument to measure quality based on the World Health Organization's classification of care in normal birth.
abstract: OBJECTIVE
  The aim of the study was to develop an instrument to measure midwifery care in relation to World Health Organization's classification of care in normal birth and to test the instrument for content validity and inter-rater reliability.
  
  
  METHODS
  The Delphi method was used for development of the instrument and to elicit evidence of content validity. Six experts from three different geographical regions in Sweden, representing clinically working midwives, lecturers in midwifery and obstetricians, participated in the first part of the study. The instrument was tested for inter-rater reliability in an exploratory study by two midwives and one of the authors. Data were analysed using percentage of agreement level and the Kappa coefficient.
  
  
  RESULTS
  Five expert rounds were needed to reach consensus for content validity. The inter-rater reliability test showed high agreement levels (95.9, 94.2 and 95.7%) and good to very good Kappa coefficients (0.74-1.0). The final instrument consisted of 78 items divided into five sections: background (five items); practices which are demonstrably useful and should be encouraged (55 items); practices which are clearly harmful or ineffective and should be eliminated (five items); practices for which insufficient evidence exists to support a clear recommendation and which should be used with caution while further research clarifies the issue (four items); and finally practices which are frequently used inappropriately (nine items).
  
  
  CONCLUSIONS
  The instrument can be used at a labour ward to measure documented care and quality of midwifery care. The results can be used to identify areas for improvements, to develop guidelines towards evidence-based care and to improve documentation. However, the present study should be regarded as an exploratory study and the feasibility of the instrument remains to be tested in empirical studies.
authors.affiliation: Division for Health and Caring Sciences, Karlstad University, Karlstad, Sweden. fia.bojo@kau.se
authors.forename: Ann-Kristin 'Fia'
authors.initials: AK
authors.lastname: Sandin Bojö
authors.forename: Marie-Louise
authors.initials: ML
authors.lastname: Hall-Lord
authors.forename: Ove
authors.initials: O
authors.lastname: Axelsson
authors.forename: Giggi
authors.initials: G
authors.lastname: Udén
authors.forename: Bodil
authors.initials: B
authors.lastname: Wilde Larsson
mesh_terms: D001291:Attitude of Health Personnel; D036861:Delivery, Obstetric / Q000451:nursing / Q000592:standards; D003697:Delphi Technique; D019317:Evidence-Based Medicine; D006801:Humans; D016389:Maternal-Child Nursing / Q000592:standards; D008880:Midwifery / Q000592:standards; D020380:Needs Assessment; D009721:Nurse Midwives / Q000523:psychology / Q000592:standards; D024802:Nurse's Role; D009731:Nursing Audit / Q000379:methods / Q000592:standards; D015403:Nursing Evaluation Research / Q000379:methods* / Q000592:standards*; D009736:Nursing Process / Q000592:standards; D015588:Observer Variation; D017063:Outcome Assessment, Health Care / Q000379:methods; D017410:Practice Guidelines as Topic; D019984:Quality Indicators, Health Care; D011787:Quality of Health Care; D013548:Sweden; D014944:World Health Organization