Examining the content validity of the Birthing Unit Design Spatial Evaluation Tool (BUDSET) within a woman-centred framework

Background: The environment for birth influences women in labour. Optimal birthing environments have the potential to facilitate normal labour and birth. The measurement of optimal birth units is currently not possible as there are no tools. An audit tool, the Birth Unit Design Spatial Evaluation Tool (BUDSET), was developed to assess the optimality of birthing environments. The BUDSET is based upon four domains (Fear Cascade; Facility; Aesthetics; Support), each comprising design principles which are further differentiated into specific assessable design items. In the process of developing measurement tools, content validity must be established. Aim: To establish the content validity of the BUDSET from the perspective of women and midwives. Design: Mixed-methods study with a survey assessing agreement with BUDSET items and indepth interviews. Survey results were analysed using an Item-level content validity index (ICVI) and a Survey-level validity index (S-CVI). Interview data were analysed using a directed content analysis approach. Settings: The study was conducted in two locations; a major maternity hospital and a midwifery research centre, in Australia. Participants: 10 women and 2 midwifery academics Findings: The survey revealed content-related validity varied according to the BUDSET domain with the domains of Facility and Support established as content valid by most participants. The domains of the Fear Cascade and Aesthetic were less strong particularly among pregnant women. Interview data analysis provided content valid evidence of both the Fear Cascade and Aesthetic domains. A further four subthemes of Fear Cascade were also identified. These were, foreign space, medical-hospital-emergency, being sterile/clinical, and protecting the woman from the environment. Content validity evidence for facility and support domains was also established. Conclusion: This study has established the BUDSET is content-valid for assessing the optimality of birthing environments. Some further refinement of the tool is now possible.