The index

The QMNCFi is a 44-item structured index developed to measure women’s perceptions of care quality during pregnancy, childbirth, and the postnatal period [8]. It covers five domains: effective practices, organization of care, values, philosophy, and provider roles [9]. Items use multiple response formats, including a 4-point Likert-type scale, with an additional “not applicable” option for specific items, binary responses (Yes/No), ternary responses (Yes/No/Not sure), and both single- and multiple-choice options. A brief socio-demographic section precedes the index to support contextualization and interpretation. Initially developed in English, the index has demonstrated construct validity and reliability in the United Kingdom, India, Ghana, and Australia in a single multi-country study [10]. To date, no Arabic version of the index has been implemented.

Cross-cultural adaptation process

The cross-cultural adaptation of the QMNCFi into Arabic followed a six-stage process based on internationally recognized guidelines [4,5,18] (see S1 Fig in Supporting Information).

This approach incorporated both translation and cultural adaptation to achieve semantic, conceptual, and experiential equivalence: semantic (accurate translation of words and sentences), conceptual (shared meaning across contexts), and experiential (similar user experience). Two research teams from five countries collaborated using a unified protocol. Stages included forward translation, synthesis, back translation, expert committee review, pre-final testing, and finalization. Documentation was maintained using standardized templates and protocols established by the QMNC Research Alliance (www.qmnc.org) to ensure consistency.

Team 1 (Palestine, Norway, Scotland) led forward translation, synthesis, back translation, and expert review. Team 2 (KSA and Northern Ireland) contributed to pre-final testing and finalization. Methodological decisions regarding terminology, response options, and cultural adaptations were discussed in joint meetings until consensus was achieved.

Ethical considerations

This study involved the cross-cultural adaptation of a validated maternal health index with direct participation from postpartum women. All procedures adhered to the Declaration of Helsinki (2024 revision) [22]. No personal identifiers were collected, and data were de-identified prior to analysis.

Informed consent was obtained orally and documented through an electronic “I agree” checkbox. Participants were informed of their right to decline or withdraw without consequences.

Ethical approvals were obtained from Birzeit University (Ref: BZUPNH2139), the Palestinian Ministry of Health (Ref: 162/1255/2025), Queen’s University Belfast (Ref: MHLS 24_152), and the Institutional Review Board of the Maternity & Children’s Hospital in Al Ahsa (Ref: 390924-EP-2024).

Additional information regarding ethical, cultural, and scientific considerations related to inclusivity in global research is provided in the Supporting Information (S3 File).

Translation and cross-cultural adaptation outcomes

Stages 1–4 (forward translation, synthesis, back translation, and expert committee review) were led by Team 1, while both teams contributed to testing and finalization. A small number of clinical terms, including “Primary caregiver,” “professional advice,” and “health facility,” lacked direct Arabic equivalents or varied by context. These were resolved through comparison of translations, expert review, and user feedback.

Linguistic adaptations

A country-identifying item was added within the demographic section to allow distinction between data collection sites and alignment with national classifications. For example, Palestine and KSA required different income categories and currency formats. These changes did not alter the 44 core QMNCFi items.

Contextual adaptations

In Stage 5, 48 postpartum women participated in cognitive interviews (28 in Palestine, 20 in KSA). Most items were understood as intended. Interview duration differed between sites, averaging approximately one hour in Palestine and approximately 15 minutes in KSA. This variation likely reflected differences in interview mode (remote versus face-to-face), participant engagement, and site logistics rather than item clarity, providing insight into operational differences across settings.

Women varied in age, education, delivery mode, and place of birth. Interviews identified wording issues requiring contextual adjustment. The inter-rater agreement reached 99.1%, calculated as percentage agreement between independent reviewer ratings, exceeding the predefined 80% benchmark recommended by Sousa and Rojjanasrirat (2011), indicating high clarity and cultural fit (S2 File).

Cultural-sensitivity adaptations

Participant feedback led to targeted refinements. In Palestine, one participant considered the phrase “demonstrated good clinical skills” overly formal. The wording was revised to reflect everyday language while preserving the original meaning. Another participant reported that the family-respect item was not applicable because she gave birth alone, leading to the addition of a “not applicable” option without affecting scoring.

Five participants expressed discomfort with an alcohol-related information item, explaining that responses reflected cultural or religious norms rather than care experiences. The item was retained to preserve conceptual comparability, while a “not applicable” response option was introduced, illustrating how cultural sensitivity was balanced with framework consistency.

In KSA, participants requested clarification of educational materials. Examples such as “booklet” and “pamphlet” were added to improve comprehension. Routing questions about home-based care were also revised to better reflect mixed care pathways.

Comparative synthesis between sites

Palestinian participants mainly highlighted language formality and contextual applicability, whereas KSA participants focused on clarification examples and routing logic. This comparison suggests that adaptation needs were driven more by healthcare system context and communication patterns than by language alone, reinforcing the importance of contextual adaptation even within shared-language settings.

All refinements were minor and maintained conceptual integrity and scoring structure. Refinements included adding a country identifier, aligning demographic categories, clarifying items with context-relevant examples, and adding “not applicable” where appropriate. These changes ensured that the index retained its meaning, improved clarity, and remained culturally relevant in both Palestine and KSA without compromising the original construct. Final revisions were reviewed and approved by both teams. The final Arabic version was then considered ready for psychometric validation.

Operational insights and collaborative dynamics

The adaptation process followed established cross-cultural guidance. However, implementation was shaped by operational factors influencing workflow and decision-making.

Ethics approvals and data-sharing requirements differed across sites. Multi-layered approvals in Palestine and Norway contrasted with centralized processes in KSA. Restrictions on cross-border data transfer required sharing anonymized summaries rather than raw data, which preserved compliance but slowed reconciliation.

Differences in researcher experience and supervision structures also affected workflow. One researcher worked within a structured supervisory framework, while another relied more on peer support. These variations highlight how researcher capacity and institutional context can influence implementation consistency in multi-country adaptation studies.

Supervisors contributed complementary expertise in language, maternal health, and methodology. Digital collaboration required explicit documentation and version control to reduce ambiguity and prevent undocumented edits. Standardized reporting templates improved coordination in later stages.

Overall, operational findings indicate that successful same-language adaptation depends not only on linguistic expertise but also on coordinated governance, clear documentation, and collaborative infrastructure across sites.

Equivalence across contexts and the challenge of shared language

Although both settings share Arabic, the findings demonstrate that shared language did not guarantee experiential equivalence. Measurement validity depended on health system context, communication practices, and women’s expectations of care, consistent with equivalence models such as Herdman et al. [20], which distinguish semantic, conceptual, and experiential dimensions of cross-cultural adaptation.

Continuity-of-care items illustrate this challenge. In Palestine, interpretation occurred within a health system characterized by fragmented service delivery and movement restrictions, where continuity was often experienced as discontinuous or provider-dependent. In contrast, participants in KSA interpreted similar items within a more structured referral and postnatal education system. These differences suggest that experiential equivalence is shaped not only by translation accuracy but also by health system organization, clinical communication norms, and women’s expectations of care.

The findings therefore support the argument that linguistic equivalence alone is insufficient when adapting maternity care instruments across heterogeneous health systems. Adaptation must address how women interpret care through local institutional realities, levels of health literacy, and culturally shaped provider-patient interactions.

Translation as an interpretive and negotiated process

Stages 1–4 highlighted that translation was not purely technical but interpretive. Terms lacking direct Arabic equivalents required negotiation between clinical precision and participant comprehension. This reinforces contemporary perspectives that translation represents an interpretive act rather than a literal transfer of wording.

The bilingual composition of the research teams enabled iterative mediation between formal language, spoken dialects, and methodological consistency. Researcher positionality therefore influenced decision-making, as translators and researchers acted simultaneously as linguistic mediators, cultural interpreters, and methodological gatekeepers.

Feedback during cognitive interviews further demonstrated that women interpreted items through personal, cultural, and healthcare experiences. The decision to retain culturally sensitive items (e.g., alcohol-related questions) while adding a “not applicable” option illustrates how adaptation required balancing cultural acceptability with conceptual fidelity to the original framework.

Operational and collaborative influences on adaptation

Operational factors played a substantial role in shaping the adaptation process. Ethics approvals and data governance differed across sites, requiring anonymized data exchange rather than raw-data transfer. While this approach protected compliance, it slowed iterative reconciliation.

Variation in researcher training and supervision structures also affected workflow. These differences highlight that methodological rigor in cross-cultural adaptation depends not only on protocols but also on capacity building, mentorship, and collaboration structures.

Digital collaboration supported continuity but required version control and structured documentation to avoid inconsistencies. These findings suggest that successful multi-country adaptation is not only a linguistic task but also an organizational and governance process.

Methodological and contextual limitations

Methodological limitations include reliance on convenience sampling and a modest qualitative sample size, although this aligns with established recommendations for cognitive interviewing in cross-cultural adaptation research.

Contextual limitations relate to conducting the study in only two Arabic-speaking settings. While Palestine and KSA represent distinct healthcare systems, findings may not capture the full linguistic and institutional diversity across Arab countries.

Translation decisions were achieved through expert consensus. Although consensus improves internal coherence, it also reflects interpretive judgments influenced by researcher perspectives, which should be acknowledged as part of the adaptation process rather than viewed solely as bias.

Implications and future directions

The study demonstrates that adapting health measurement tools within the same language requires careful attention to experiential equivalence and institutional context. Future work should prioritize formal psychometric validation to confirm structural validity, reliability, and cross-country comparability of the Arabic QMNCFi.

Further testing across additional Arabic-speaking regions is needed to evaluate measurement

invariance and determine whether the instrument support regional benchmarking of maternity care experiences.

Beyond this instrument, the findings provide practical lessons for multi-country same-language adaptations, emphasizing early planning for ethics harmonization, shared documentation systems, and structured mentorship guidance.

Synthesis

On completion of all stages, the Arabic QMNCFi achieved semantic, conceptual, and experiential equivalence sufficient for psychometric testing. The central insight of this study is that equivalence emerges through negotiation among language, health systems, and researcher mediation, rather than translation alone. These findings provide a practical foundation for future validation studies and support the use of standardized women-centered maternity care measurement tools across Arabic-speaking contexts.