Development and psychometric validation of the Indonesian versions of the Postpartum Blues and Maternal Self-Efficacy Scales

Study design and setting

This study employed a two-phase mixed-methods approach conducted from January to March 2024 in the working area of the Health Centre in Batam City, Indonesia. Phase 1 focused on instrument development and cultural adaptation, while Phase 2 involved psychometric validation through a cross-sectional study design.

Phase 1: Instrument development

Cultural adaptation process

For the Indonesian versions of the Postpartum Blues Questionnaire (PBQ) and the Maternal Self-Efficacy Questionnaire (MSEQ), the cultural adaptation process was carried out with attention to detail using systematic steps to maintain translation accuracy and cultural relevance. Established global guidelines informed the adaptation process, especially the ones put forth by the World Health Organization (WHO) focusing on instrument adaptation with multicultural equivalences such as semantics, idioms, culture, and logic (Dun et al., 2021; Kanaan et al., 2022; Pai et al., 2025).

An even blend of clinical and cultural expertise was brought together in one panel to address the various dimensions of relevance, appropriateness, and meaning for items, which was comprised of one obstetrician, a clinical psychologist, a midwife, and a maternal health nurse. This blend took into account the clinical as well as the multicultural aspects of the postpartum period in Indonesia (Pizza et al., 2024; Santana et al., 2023).

The adaptation process steps are as follows:

This form of assessing frameworks ensured that the Indonesian adaptation of PBQ and MSEQ maintained the fundamental constructs of the original instruments as well as their validity and reliability in the context of postpartum mothers in Indonesia (Aloraini, 2022; Jafari et al., 2023; Santos et al., 2024).

Development of the Postpartum Blues Scale (PBQ-32)

The Postpartum Blues Scale (PBQ-32) was developed to identify emotional, physical, and psychosocial symptoms commonly experienced by Indonesian mothers in the early postpartum period. The initial phase of development involved a comprehensive review of international literature and clinical instruments related to postpartum mood disturbances. From this process, an initial pool of 35 items was constructed, reflecting key symptoms and themes relevant to postpartum blues. To ensure cultural relevance and clarity, the 35-item draft underwent expert review and content validation. Feedback from perinatal mental health professionals and maternal health experts guided the refinement of item wording and conceptual grouping. This draft was then used in a pilot study to explore item performance within an Indonesian population (Ika Novita; Sari & Sansuwito, 2025).

Based on both expert evaluation and preliminary empirical findings, three items were excluded due to cultural incongruity and low item-total correlations. The final PBQ-32 consists of 32 items, organized into six conceptual dimensions:

Each item is rated on a four-point Likert scale (0 = never, 1 = rarely, 2 = sometimes, 3 = often), yielding a total score ranging from 0 to 96. Higher scores reflect more severe symptoms of postpartum blues. The following score categories were used for interpretation:

Development of the Maternal Self-Efficacy Scale (MSEQ-20)

The Maternal Self-Efficacy Scale (MSEQ-20) was developed to measure a mother’s perceived confidence in carrying out essential caregiving tasks during the early postpartum period. The scale consists of 20 items, organized into four conceptual domains that reflect fundamental aspects of maternal competence:

Each item is rated on a 5-point Likert scale, ranging from 1 (very incapable) to 5 (very capable), resulting in a total score between 20 and 100. Higher scores reflect stronger perceived maternal self-efficacy. For interpretive purposes, total scores are categorized as follows:

Phase 2: Psychometric validation

Participants and sampling

Participants were recruited using a consecutive sampling method from five community health service areas (villages) within the jurisdiction of a public health centre (Puskesmas) in Batam, Indonesia. A total of 30 postpartum mothers were enrolled in this phase of the study.

Inclusion criteria were:

Exclusion criteria included:

This sample was deemed appropriate for initial psychometric testing and cultural pre-validation, based on guidance from methodological literature supporting sample sizes of 5–10 participants per item in exploratory phases, particularly in early-stage scale validation studies.

Data collection procedures

Eligible postpartum mothers were identified through collaboration with village midwives (bidan desa) and community health workers (kader posyandu). Prior to participation, the study objectives and procedures were clearly explained to each prospective respondent, and written informed consent was obtained in accordance with ethical research guidelines. Data collection was conducted through home visits, during which participants completed the Postpartum Blues Questionnaire (PBQ-32) and the Maternal Self-Efficacy Questionnaire (MSEQ-20). To minimize potential misunderstanding or misinterpretation of items, researchers assisted participants during questionnaire completion. Brief follow-up interviews were carried out to clarify responses and assess comprehension. In addition to questionnaire data, basic demographic information was collected, including age, educational background, occupation, number of children, type of childbirth, socioeconomic status, and perceived level of social support. These procedures were implemented to ensure consistency, ethical integrity, and adherence to best practices in maternal health research.

Content validity

To ensure the cultural and contextual relevance of the PBQ-32 and MSEQ-20 for Indonesian postpartum mothers, content validity was assessed using the Content Validity Index (CVI) approach. A multidisciplinary panel of experts—comprising an obstetrician, a clinical psychologist, a certified midwife, and a maternal health nurse—independently evaluated each item for relevance, clarity, and appropriateness using a four-point scale (1 = not relevant to 4 = highly relevant). The item-level CVI (I-CVI) was calculated as the proportion of experts rating an item as either 3 or 4. A minimum I-CVI value of 0.78 was used as the cut-off for item acceptability. The scale-level CVI (S-CVI/Ave) was obtained by averaging the I-CVI values across all items, with a threshold of ≥ 0.90 considered indicative of strong overall content validity (Polit & Beck, 2006). Items that failed to meet the I-CVI threshold were revised based on expert feedback to improve clarity, cultural sensitivity, and contextual relevance. This iterative review process resulted in finalized versions of the PBQ-32 and MSEQ-20 that demonstrated strong content validity and were linguistically and culturally appropriate for use among Indonesian postpartum women.

Construct validity

Construct validity for the PBQ-32 and MSEQ-20 was examined using exploratory factor analysis (EFA) to explore the underlying factor structure of each instrument. Prior to factor extraction, the suitability of the data was assessed using the Kaiser-Meyer-Olkin (KMO) measure and Bartlett’s Test of Sphericity. A KMO value exceeding 0.70 and a significant result on Bartlett’s test (p < 0.05) indicated that the sample was adequate for factor analysis (Espel-Huynh et al., 2020; GÜLER & Durgu, 2025; Huang et al., 2022). The EFA revealed factor structures that aligned with the theoretical dimensions proposed during instrument development. Items were retained for interpretation if they met the minimum factor loading threshold of 0.40, following standard psychometric criteria (Mueller et al., 2024). This analytic process provided strong empirical support for the construct validity of both instruments, reinforcing their relevance and structural soundness for use in evaluating postpartum mental health in the Indonesian population.

Reliability testing

The internal consistency of the PBQ-32 and MSEQ-20 was evaluated using Cronbach’s alpha, with interpretation based on established thresholds: values ≥ 0.70 were considered acceptable, ≥ 0.80 good, and ≥ 0.90 excellent (Sathvik et al., 2022). Reliability testing was conducted not only for the overall scales but also across each subscale, ensuring a comprehensive psychometric assessment (Hikmah et al., 2023). To further examine item-level performance, item-total correlation coefficients were calculated. Items with correlations below 0.30 were flagged for potential revision or removal to improve internal consistency (Hoque et al., 2021). The results indicated strong reliability for both instruments, with Cronbach’s alpha values exceeding acceptable thresholds for all domains. These findings support the use of the PBQ-32 and MSEQ-20 as reliable tools for assessing postpartum blues and maternal self-efficacy in the Indonesian context. Moreover, the reliability analysis underscores the importance of internal consistency in the development of culturally relevant psychological measurement instruments (Huang et al., 2022; Xu et al., 2024).

Demographic characteristics

The demographic characteristics of the participants are presented in Table 1. The study included 30 postpartum mothers, with a mean age of 26.8 years (SD = 4.2). Most participants were aged 20–25 years (40.0%), had a senior high school education (43.3%), and were unemployed (63.3%). Primiparous mothers comprised 56.7% of the sample, and 66.7% had vaginal deliveries. Half reported middle socioeconomic status (50.0%), and 53.3% perceived their social support as inadequate.

Psychometric properties

Postpartum Blues Questionnaire (PBQ-32)

Maternal Self-Efficacy Questionnaire (MSEQ-20)

A summary of the psychometric properties of both instruments is presented in Table 2.

Prevalence and risk factors

Postpartum blues prevalence

In this study, the overall prevalence of postpartum blues among participants was 70%. The severity of symptoms was distributed as follows: 30.0% of mothers reported no symptoms, 40.0% experienced mild symptoms, 20.0% reported moderate symptoms, and 10.0% experienced severe postpartum blues. The detailed distribution of postpartum blues severity is presented in Table 3.

The highest mean subscale scores were:

Most reported symptoms:

The most commonly reported individual symptoms were fatigue (83.3%), anxiety about the baby’s health (80.0%), and mood swings (76.7%).

Maternal self-efficacy levels

The distribution of maternal self-efficacy levels was as follows:

The mean total self-efficacy score was 58.4 (SD = 12.6), indicating generally good confidence among participants. The detailed distribution of maternal self-efficacy levels is presented in Table 4.

Risk factor

This study identified several factors significantly associated with postpartum blues. Women with lower levels of education were more likely to report symptoms of postpartum blues (p = 0.032). Primiparous mothers also showed a higher tendency toward experiencing postpartum blues compared to multiparous counterparts (p = 0.041). Additionally, those who underwent cesarean deliveries had a significantly greater risk (p = 0.045). Social support emerged as a critical factor, with inadequate social support demonstrating a strong positive correlation with postpartum blues (r = 0.68, p = 0.001). Conversely, maternal self-efficacy was found to be significantly and negatively correlated with postpartum blues (r = -0.72, p < 0.001), suggesting that higher perceived maternal competence serves as a protective factor against emotional distress in the early postpartum period. The statistical associations between risk factors and postpartum blues are summarized in Table 5.

Concurrent validity analysis

A significant negative correlation (r = -0.72, p < 0.001) between PBQ-32 and MSEQ-20 scores supports the concurrent validity of both instruments and aligns with theoretical expectations.

Psychometric properties and cultural appropriateness

Evaluating the psychometric properties and cultural suitability of psychological instruments is essential to ensure their reliability and validity across diverse populations. The findings demonstrated strong psychometric performance of the Indonesian Postpartum Blues Questionnaire (PBQ-32) and the Maternal Self-Efficacy Scale (MSEQ-20), both in terms of reliability and cultural appropriateness. The results of the validation study indicated excellent psychometric performance. The PBQ-32 yielded a Cronbach’s alpha of 0.923, while the MSEQ-20 obtained a reliability coefficient of 0.923. Both values exceed the generally accepted threshold of 0.80 for research instruments and approach the 0.90 benchmark considered optimal for clinical use (Sánchez-Meca et al., 2021). These findings support the internal consistency of the two instruments and confirm their applicability in both research and clinical settings in Indonesia.

The adaptation process played a crucial role in ensuring contextual validity. Expert panel reviews involved careful consideration of culturally embedded practices, such as traditional postpartum rituals, the central role of extended family networks, and locally defined maternal expectations. This culturally grounded approach is consistent with the growing consensus in the literature that psychological instruments must be tailored to reflect local social norms and belief systems. For example, studies on maternal mental health in Indonesia have highlighted the significance of social support—particularly within matrilineal or extended family systems—as a key determinant of maternal self-efficacy (Setyowati et al., 2024).

Incorporating culturally relevant elements into psychological assessments has been shown to enhance their interpretability and cross-cultural acceptance. Instruments that reflect local practices and vernacular expressions tend to yield more accurate data and foster stronger engagement from participants (Mandorino et al., 2021). Accordingly, the culturally sensitive adaptation of the PBQ-32 and MSEQ-20 strengthens their utility in assessing postpartum mental health among Indonesian mothers. Taken together, the high reliability scores and the culturally attuned development process underscore the relevance of these instruments for the Indonesian context. Their use holds promise not only for early detection and appropriate intervention in postpartum mental health but also for supporting culturally responsive care and advancing cross-cultural research in maternal health.

Clinical implications and utility

The availability of validated Indonesian versions of the PBQ-32 and MSEQ-20 represents a significant advancement in the landscape of maternal mental health care in Indonesia. As with their English-language counterparts, these instruments can now be integrated into clinical practice to support maternal psychological well-being during the postpartum period. Prevalence estimates of postpartum blues range from 50% to 80% depending on the population studied (Votruba et al., 2023). The finding of a 70% prevalence rate in the current study reinforces the urgency of routine mental health screening, particularly at the level of first-contact healthcare providers (Blackmore et al., 2022).

In low-resource settings, where mental health services are limited, community-based initiatives that strengthen social support and parenting confidence are particularly impactful (Monteiro et al., 2020). Numerous studies have underscored the role of social support in mitigating the onset and severity of postpartum depression and anxiety, especially in settings where cultural constraints and systemic barriers persist (Votruba et al., 2023; Fatin et al., 2022).

The observed strong negative correlation between maternal self-efficacy and postpartum blues (r = -0.72) suggests that enhancing maternal confidence may serve as a protective factor against emotional dysregulation during the postpartum transition (Shi et al., 2024). Mothers commonly face substantial physical, emotional, and social challenges following childbirth. Interventions that bolster parenting confidence and resilience—particularly those grounded in evidence-based practices—have demonstrated efficacy in reducing anxiety and depressive symptoms during the early postpartum period (Pereira et al., 2022).

These findings collectively highlight the importance of pairing routine mental health assessments with comprehensive educational and psychosocial support programs. Such an integrated approach can enhance prevention, enable timely detection, and foster maternal empowerment, thereby yielding more favourable outcomes in maternal mental health (Aldridge et al., 2022). Delivering effective mental health care to expectant and new mothers requires a collaborative effort that brings together healthcare providers, midwives, mental health professionals, and community-based organisations. This multi-sectoral approach ensures broader access and equitable distribution of resources (Blackmore et al., 2022). In the Indonesian context, the culturally adapted PBQ-32 and MSEQ-20 offer reliable and contextually appropriate tools to support these efforts. Their integration into maternal health services has the potential to inform clinical decision-making and policy development, ultimately contributing to improved mental health outcomes for mothers and their infants.

Comparison with international literature

The 70% prevalence of postpartum blues identified within the Indonesian sample aligns closely with findings from international studies, where reported rates range from 39% to 85% (Landman et al., 2024; O’Dea et al., 2023). These results lend further support to the proposition that postpartum blues is a widespread phenomenon among obstetric populations globally. However, the variations in prevalence and symptom severity across different populations suggest that cultural factors—such as symptom expression, diagnostic thresholds, and the availability of social support—play a significant role. In the Indonesian context, the deeply ingrained role of extended family networks appears to be a critical factor influencing the psychosocial experiences of mothers during the postpartum period (O’Dea et al., 2023).

The Indonesian versions of the PBQ-32 and MSEQ-20 maintain psychometric properties that are comparable to those reported in validation studies from other cultural settings. This strengthens the credibility of their reliability and validity. The PBQ-32 yielded a Cronbach’s alpha of 0.923, a result that meets or exceeds the psychometric benchmarks set by previously validated postpartum screening tools. Similarly, the MSEQ-20 produced an internal consistency score of 0.923, consistent with the original maternal self-efficacy scale developed by Teti and Gelfand, and in line with adaptations validated in both Western and non-Western populations (Teti & Gelfand, 1991). These findings affirm the reliability and internal consistency of the Indonesian adaptations, underscoring their potential utility in both clinical assessment and academic research.

Furthermore, the strong negative correlation observed between postpartum blues and maternal self-efficacy (r = -0.72) provides evidence of the concurrent validity of the two instruments. This result echoes previous findings, which suggest that higher maternal self-efficacy is associated with reduced symptoms of postpartum depression and anxiety (Matinnia & Yazdi-Ravandi, 2020; Mutiso et al., 2024). These findings also reinforce theoretical frameworks that conceptualise self-efficacy as a protective factor within maternal mental health, capable of buffering emotional distress during the early postpartum period.

Beyond psychometric robustness, cultural factors remain central to understanding the manifestation of postpartum blues. Cross-national research has highlighted the influence of culturally mediated gender roles, rites of postpartum confinement, and societal norms on maternal emotional well-being. In some societies, stigmatisation of mental health concerns may exacerbate distress, while in others, strong communal or familial support structures may serve as protective mechanisms (Bauman et al., 2020; Rodriguez et al., 2023). The current Indonesian findings contribute to this discourse by illustrating how localised systems of care and cultural expectations shape maternal psychological outcomes.

These comparative insights not only confirm the universality of postpartum emotional disturbances but also emphasise the critical importance of culturally sensitive validation processes. The adoption of a cross-cultural lens in mental health assessment, paired with contextually relevant interventions, is essential to improving the accessibility and effectiveness of maternal mental health services across diverse populations.

Limitations and future directions

There are several limitations to this study that should be taken into account when interpreting the results. First, the recruitment was conducted at a single centre with a modest sample size (n = 30), which limits the generalizability of the findings. Future studies should consider involving larger samples from multiple regions in Indonesia to enhance the external validity and representativeness of the results.

Second, the use of a cross-sectional design precludes the ability to examine changes in psychological outcomes over time or assess the predictive validity of the instruments. Longitudinal research is necessary to determine the stability of the PBQ-32 and MSEQ-20 over time and to explore their potential in predicting long-term maternal mental health outcomes.

Third, this validation study focused on the early postpartum period, specifically between days 3 and 10 after childbirth. As maternal psychological responses can evolve throughout the postpartum period, further research should explore how these instruments perform during later stages.

Finally, criterion validity was not fully assessed due to the absence of comparison with internationally recognised tools such as the Edinburgh Postnatal Depression Scale (EPDS). Future studies should incorporate such measures to enable a more comprehensive assessment of concurrent and convergent validity and to strengthen the psychometric credibility of the PBQ-32 and MSEQ-20 in the Indonesian setting.

Recommendations for implementation

Based on the findings of this study, several practical recommendations are proposed to support the effective integration of maternal mental health assessment instruments into the Indonesian healthcare system:

Structured training programs should be developed for midwives, nurses, and other maternal health professionals to ensure accurate administration, scoring, and interpretation of the Postpartum Blues Questionnaire (PBQ-32) and the Maternal Self-Efficacy Scale (MSEQ-20). Capacity building in this area will support informed clinical decision-making and enhance the responsiveness of postpartum care services.

Both instruments should be formally incorporated into existing postpartum care guidelines at the primary healthcare level. Routine screening using these tools—particularly during the early postpartum period—can facilitate the early identification of emotional distress and self-efficacy deficits, allowing for timely and appropriate interventions.

Data generated from the PBQ-32 and MSEQ-20 can inform the development of targeted maternal mental health interventions, particularly for mothers identified as high-risk due to low self-efficacy or insufficient social support. Interventions should be culturally tailored to address local norms, family dynamics, and traditional practices in postpartum care.

Future research should include longitudinal studies to evaluate the predictive validity and long-term clinical utility of both instruments. Such studies will be essential to assess how scores evolve and to determine their effectiveness in forecasting maternal mental health outcomes, thereby guiding more sustainable and evidence-based practices in maternal care.

Theoretical implications

The validation of the Indonesian versions of the PBQ-32 and MSEQ-20 supports key psychological frameworks. The strong negative correlation between maternal self-efficacy and postpartum blues reinforces Bandura’s self-efficacy theory, highlighting perceived competence as a protective factor during postpartum adjustment. Additionally, the multidimensional structure of the PBQ-32 reflects the biopsychosocial model, acknowledging the interplay of emotional, physical, and social factors in maternal mental health. These findings affirm the theoretical grounding of both instruments and support their relevance for clinical assessment and research in culturally specific contexts.

Ethical considerations

This study received ethical approval from the Health Research Ethics Committee of Universitas Batam, with approval number 045/LPPM-UNIBA/PI-EC/IV/2024, dated April 12, 2024, and valid through April 12, 2025. The ethical review was conducted under the seven ethical standards outlined by the World Health Organization (WHO, 2011)—including social value, scientific validity, favorable risk-benefit ratio, informed consent, respect for participants, privacy, and fairness—as well as the guidelines set forth by the Council for International Organizations of Medical Sciences (CIOMS, 2016). Before participation, all respondents were given detailed explanations about the study’s objectives, procedures, potential risks, and their right to withdraw at any time without consequence. Written informed consent was obtained from all participants. To protect confidentiality, all data were anonymised using coded identifiers and securely stored, with access limited to members of the research team.