Transcultural adaptation to the Brazilian Portuguese of the Postpartum Bonding Questionnaire for assessing the postpartum bond between mother and baby

The establishment of the bond between mother and baby in the postpartum period is important for ensuring the physical and psychological health of both. This short communication reports the first phase of the cross-cultural translation and adaptation to the Brazilian context of the Postpartum Bonding Questionnaire (PBQ). Four aspects of equivalence between the original scale and the Portuguese version were evaluated: the conceptual, semantic, operational and item equivalences. Literature review, the study of PBQ history, translation, expert evaluation, back-translation and pretests involving 30 mothers with children aging up to 7 months using a primary healthcare unit were conducted. Each step demonstrated the need for adjustments, which were made during the adaptation process. At the end of the study, a version of PBQ in Brazilian Portuguese equivalent to the original one was obtained, offering promise for national studies on the mother-baby bond, and its influence on health, and for use in health services. Object Attachment; Postnatal Care; Psychiatric Status Rating Scales; Surveys and Questionnaires Correspondence M. L. Baldisserotto Rua Araucaria 141, Rio de Janeiro, RJ 22461-160, Brasil. mlbaldisserotto@gmail.com 1 Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil. 2 Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil. 3 Open University, Milton Keynes, U.K. 4 Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brasil. 5 Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil. COMUNICAÇÃO BREVE BRIEF COMMUNICATION doi: 10.1590/0102-311X00170717 Baldisserotto ML et al. 2 Cad. Saúde Pública 2018; 34(7):e00170717 Introduction The postpartum period evokes changes and adaptations of the women’s psychic, social and physiological systems 1,2. At this point, the normative expectation is that she will develop several skills, and establishing the bond with her baby is one of the most relevant 3,4. Bonding or attachment between mother and baby is defined as an affective relationship involving emotional and physiological processes that manifest through the behaviors, feelings and thoughts of the woman in relation to the child. It ensures that she remains sensitive and available to meet the baby’s needs after birth 3,5. In Brazil, there is no adequate multidimensional instrument to assess the quality of the bond between mother and baby in the postpartum period 6. However, instruments from other language and sociocultural contexts are used 7,8,9. Thus, this study selected the Postpartum Bonding Questionnaire (PBQ) 8 for transcultural translation and adaptation to the Brazilian context. PBQ is a multidimensional, self-completion scale composed of 25 items divided into four dimensions. Each item has six options, ranging from 0 (never) to 5 (always). Factor 1 (impaired bonding) has sensitivity of 93% in the detection of bonding problems and accounts for 34% of the variance of the scale. The second factor (rejection and pathological anger) has a sensitivity of 89% and accounts for 8% of the variance of the scale. Factor 3 (anxiety about the infant) has a sensitivity of 56% and accounts for 3.7% of the test variance. Factor 4 (incipient abuse) shows sensitivity of 28% and accounts for 3.4% of the test variance 8. PBQ is a widely used scale, validated in several countries and easy to apply 10,11,12,13. Although no study confirms its original factorial structure, all indications are that it has good internal consistency 11. This article aims to present the first phase of the translation process and cross-cultural adaptation of the Brazilian version of PBQ.


Introduction
The postpartum period evokes changes and adaptations of the women's psychic, social and physiological systems 1,2 . At this point, the normative expectation is that she will develop several skills, and establishing the bond with her baby is one of the most relevant 3,4 . Bonding or attachment between mother and baby is defined as an affective relationship involving emotional and physiological processes that manifest through the behaviors, feelings and thoughts of the woman in relation to the child. It ensures that she remains sensitive and available to meet the baby's needs after birth 3,5 .
In Brazil, there is no adequate multidimensional instrument to assess the quality of the bond between mother and baby in the postpartum period 6 . However, instruments from other language and sociocultural contexts are used 7,8,9 . Thus, this study selected the Postpartum Bonding Questionnaire (PBQ) 8 for transcultural translation and adaptation to the Brazilian context. PBQ is a multidimensional, self-completion scale composed of 25 items divided into four dimensions. Each item has six options, ranging from 0 (never) to 5 (always). Factor 1 (impaired bonding) has sensitivity of 93% in the detection of bonding problems and accounts for 34% of the variance of the scale. The second factor (rejection and pathological anger) has a sensitivity of 89% and accounts for 8% of the variance of the scale. Factor 3 (anxiety about the infant) has a sensitivity of 56% and accounts for 3.7% of the test variance. Factor 4 (incipient abuse) shows sensitivity of 28% and accounts for 3.4% of the test variance 8 . PBQ is a widely used scale, validated in several countries and easy to apply 10,11,12,13 . Although no study confirms its original factorial structure, all indications are that it has good internal consistency 11 .
This article aims to present the first phase of the translation process and cross-cultural adaptation of the Brazilian version of PBQ.

Method
After requesting the authorization from the PBQ authors, the initial stages of the transcultural translation and adaptation process were carried out based on the protocols suggested by Borsa et al. 14 and Reichenheim & Moraes 15 (Figure 1).
For the evaluation of the conceptual and item equivalences, a bibliographic review of the construction process and other cross-cultural translations and adaptations of the PBQ were conducted. In addition, a review of the literature on mother-baby bonding theory and its correspondence with the Brazilian reality was made. This content was discussed with three experts in perinatal mental health with extensive clinical and research experience, who also analyzed the components of the PBQ and its applicability to Brazil.
For evaluation of the semantic equivalences, the original instrument was translated by three professional translators, who are natives in the Portuguese language and English teachers. The synthesis was carried out by the researchers responsible for the adaptation of the instrument. Initially, the different translations were compared, and the discrepancies of meanings, concepts and contexts were analyzed. When there was no difference in meaning, the researchers chose the best translation. In cases in which significant disagreements of meaning occurred, one of the original authors of the instrument was consulted regarding the original meaning of the item.
This step generated the first version of the PBQ, used in a pretest conducted with 16 mothers over 18 years old with babies aging 1-6 months, living in a low-income community, who had appointments in a unit of the Family Health Strategy (FHS) in the city of Rio de Janeiro, Brazil. During the scale administration, when a woman expressed doubt regarding the meaning of an item, the interviewer explained the meaning of the item and asked for suggestions of synonyms. In addition, mothers were asked what they understood by certain items to verify the intended understanding. At the end, each woman was asked her opinion of the questionnaire.
Changes and adjustments were then made to improve the instrument, and a second version was administered to 14 women with babies from 1 to 7 months in the same health unit as the first pretest. Finally, the back-translation was performed by a native translator in British English and presented to one of the authors of the PBQ. The conceptual, item, semantic and operational equivalences of the  Brazilian final version of the PBQ were evaluated by specialists in psychometry and perinatal mental health together with the researchers and one of the authors of the original scale.
This study was conducted according to Resolution n. 196/1996 of the Brazilian National Health Council, which sets the standards for research involving human subjects, issued by the Research Ethics Committee of the Sergio Arouca National School of Public Health, Oswaldo Cruz Foundation, under CAAE 21982613.6.0000.5240. All the participants assigned a free and informed consent.

Results
The literature review and the opinion of the specialists confirmed that both the latent variable and the PBQ scale were relevant to the Brazilian reality. From the initial translation, discrepancies in meaning between the translators in items 4 and 7 were observed. Based on the response of an author of the scale, the word "cuddle" was translated as "ninar" and "winds me up" for "dar nos nervos" (Table 1).
In the first pretest, problems were identified in the understanding of some items. In item 3, the first translation was "Me sinto distante do meu bebê". However, many mothers understood this as only referring to physical distance. In order to emphasize the emotional connotation of this distance, the word "emocionalmente" was included (Table 1). Another item that showed divergence in understandings was item 23, for which the initial translation was: "Sinto que a única solução é outra pessoa cuidar do meu bebê". Many mothers chose the "always" answer, because they had to go back to work and, therefore, had to leave their children with another caregiver or in a daycare setting. The consulted author of the scale explained that, in England, such problem of understanding for the original English language item did not occur. One of the factors that may have influenced this difference is that in Brazil, the return to work for many women occurs a few months after delivery, unlike English's women, who tend to have a longer maternity leave period (Table 1).
One point observed was the difficulty for women to answer the items at six frequency levels. For this, an analogue scale was used for helping the mothers to respond using six frequency levels. In addition, the items were turned into questions, since that scale should be administered by an interviewer.
In the second application of the pretest, the adjustments that had been made improved the understanding of the items by the mother, confirming semantic equivalence with the original scale. The women were able to understand and answer all the questions and found the scale very interesting and easy to understand. Analog-scale response options were able to accurately capture the frequency of each question.
Experts in psychometrics and perinatal mental health considered that the final version of PBQ seems appropriate to assess the bond between mother and baby in the Brazilian context. The reverse translation was approved by one of the PBQ authors.

Conclusion
This initial process of cross-cultural translation and adaptation of PBQ demonstrates the importance of evaluations of conceptual, item, semantic and operational equivalence to obtain an adequate instrument for assessing the postpartum mother and baby bond in the Brazilian context and to ensure equivalence with the original scale. Thus, it allows the generalization and comparability of its results with other sociocultural and language contexts.
At the end of this initial process of transcultural translation and adaptation, a first version of PBQ in Brazilian Portuguese (Table 1) was obtained, which seems to be promising. Studies in progress by the research group will complement the psychometric evaluation steps of the instrument, through the evaluation of test-retest reliability, dimensional structure and construct validity, thus continuing the validation process of PBQ in Brazilian Portuguese 14,15 . This instrument offers potential for future research and for use in perinatal mental health clinics.

Name The Postpartum Bonding Instrument Instrumento de Avaliação do Vínculo Afetivo Mãe-Bebê no Pós-Parto
Instruction Please indicate how often the following are true for you. There are no "right" or "wrong" answers: Choose the answer which seems right in your recent experience.