Cross-cultural adaptation and psychometric validation of the Italian version of the Perinatal Missed Care Survey

In the quiet, high-stakes hours of labor and birth, a midwife's attention is a finite resource, stretched thin by the needs of multiple patients, the urgency of changing conditions, and the sheer volume of tasks that must be completed. Sometimes, despite the best intentions and the highest level of skill, a piece of essential care is left undone, delayed, or only partially finished. This phenomenon, known as missed care, is not merely a matter of a forgotten task; it is a critical indicator of how safe and effective a maternity service truly is. When vital steps in the care of a mother or her newborn are skipped, the consequences can ripple outward, affecting the health of both and the quality of the birth experience. To understand where these gaps occur and why they happen, researchers have developed tools to measure them, much like a doctor uses a thermometer to check for fever. One such tool, originally created in the United States, is a survey designed to ask midwives which parts of their daily routine are most often missed and what organizational pressures cause those omissions. However, healthcare systems vary wildly from country to country, and a tool built for one system cannot simply be copied and pasted into another without careful adjustment.

This study focused on adapting that American survey for use in Italy, a country with its own unique healthcare structure, cultural norms, and clinical practices. The researchers, a team of experts from the University of Parma and the Azienda Ospedaliero-Universitaria di Parma, began by translating the English questions into Italian. But translation is only the first step; the goal was to ensure the questions made sense in the context of Italian hospitals, where the way care is organized and the language used might differ significantly from the United States. They gathered a panel of experienced Italian midwives to review every single question, asking if it was relevant, clear, and applicable to their daily work. This process led to the removal of three specific questions that did not fit the Italian reality, such as one that described a structural feature of the American healthcare system that simply does not exist in Italy. The remaining questions were refined until the team was confident they accurately captured the essence of missed care within the Italian National Health Service.

Once the survey was ready, the researchers distributed it to 423 midwives working across Italy, from the northern regions to the islands in the south. These women represented a wide range of experience, from those just starting their careers to veterans with decades of practice, and they worked in various settings, from small clinics to large hospitals delivering hundreds of babies a year. The researchers split this group into two parts to test the survey's reliability. They first used the larger group to explore the data and see what patterns emerged, and then they used the smaller, independent group to confirm that those patterns held true. This two-step approach ensured that the results were not just a fluke of one specific group of people but reflected a stable reality across the profession.

The analysis revealed that the Italian version of the survey works well and is built on a solid foundation. When the researchers looked at the questions about missed care activities, the answers naturally grouped into three distinct categories. The first group covered general obstetric and midwifery care, such as reviewing medical histories, ensuring patient comfort, and managing pain. The second group focused on active clinical surveillance, which includes the critical, continuous monitoring of the mother and baby, such as watching for signs of distress in the fetal heart rate or recognizing sudden changes in the mother's condition. The third group dealt with postpartum care and communication, encompassing tasks like helping with breastfeeding, assessing the mother after birth, and ensuring the care team is informed of any critical findings. The data showed that midwives could reliably distinguish between these different types of care, and the survey proved to be a consistent tool for measuring them.

The second part of the survey asked about the reasons why care might be missed. Here, the answers clustered into four main areas: the work environment and how care is organized, the quality of teamwork and communication, patient-related factors like complexity or language barriers, and the overall workload and staffing levels. While these categories were distinct, the researchers found that they often overlapped in the real world. In the Italian system, for instance, a shortage of staff often leads to a chaotic work environment, which in turn strains teamwork and makes it harder to manage complex patients. The survey captured this interconnectedness, showing that these factors do not exist in isolation but rather feed into one another, creating a complex web of challenges that can lead to missed care.

The study confirmed that the survey is a reliable instrument, meaning that if you ask the same midwife the same questions at different times, or if you ask different midwives in similar situations, the results are consistent. The internal consistency of the tool was high, indicating that the questions within each category were measuring the same underlying concept. Furthermore, when the researchers tested the survey on the second group of midwives, the same patterns emerged, proving that the structure of the tool is stable and can be trusted to produce the same results in different settings. This stability is crucial because it means the survey can be used to compare different hospitals, track improvements over time, and identify specific areas where a maternity unit might need support.

One of the most significant findings was that the survey successfully identified the specific organizational factors that contribute to missed care in Italy. It highlighted that issues like unclear assignments, frequent interruptions, and a lack of necessary equipment are not just background noise but are central drivers of why care gets missed. The tool also showed that the pressure of high patient volumes and the complexity of the cases midwives face are deeply intertwined with staffing levels. By separating these factors, the survey allows hospital administrators and policymakers to see exactly where the bottlenecks are. Instead of guessing whether a problem is due to tired staff or a lack of equipment, they can use the data to pinpoint the exact cause and design targeted solutions.

The researchers noted that while the survey is robust, it is not without its limitations. Because the study was a snapshot in time, it could not track how these factors change over the long term or how they might respond to specific interventions. Additionally, the survey relies on the self-reported experiences of midwives, which, while valuable, is a subjective measure. The authors acknowledged that future research would need to look at how the survey scores relate to actual health outcomes for mothers and babies, and whether the tool works equally well across all different types of hospitals and regions. Despite these caveats, the study provides a strong, evidence-based foundation for understanding missed care in the Italian context.

Ultimately, this work offers a practical and powerful tool for improving the safety and quality of maternity care in Italy. By giving midwives and hospital leaders a clear, standardized way to measure what is being missed and why, the survey opens the door to meaningful change. It moves the conversation from vague concerns about "being busy" to specific, actionable data about where the system is failing. Whether it is used to benchmark one hospital against another, to audit current practices, or to evaluate the success of a new quality improvement initiative, the Italian version of the Perinatal Missed Care Survey provides the evidence needed to build safer, more effective maternity services. The study confirms that with the right tools, the invisible gaps in care can be made visible, allowing the healthcare system to address them directly and ensure that every mother and baby receives the full, essential care they deserve.