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Development and Psychometric Properties of Prenatal Obsession
Pak Armed Forces Med J 2025; 75(SUPPL-2): S300
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Tayyeba Kiran, Sameera Shafiq
Department of Clinical Psychology, University of Gujrat, Pakistan
ABSTRACT
Objective: To develop an indigenous scale in Urdu language and determine psychometric properties to measure prenatal
obsessive compulsive symptoms in pregnant women.
Study Design: Cross sectional analytical study.
Place and Duration of Study: Department of Psychology, University of Gujrat, Pakistan, from Oct 2018 to Sep 2019.
Methodology: Diagnostic criteria of Obsessive Compulsive Disorder present in Diagnostic and Statistical Manual of Mental
Disorders-5 and Cognitive Behavior Model of Obsessive Compulsive Disorder were followed to develop the scale. An initial
item pool comprising 119 items was generated with the help of extensive literature review, Diagnostic and Statistical Manual-5
and focused group interviews. Expert evaluation limited the item pool to 100 questions. Tryout of scale retained 100 items.
Items were re-sequenced and rephrased for final administration. Moreover, data were collected by using self-reported
questionnaires from 300 pregnant women, selected by using purposive sampling technique from obstetric and psychiatric
wards of different private and government hospitals of district Gujrat. Reliability analysis, exploratory factor analysis and
confirmatory factor analysis were implied for data scrutiny.
Results: After final administration of 100 items, 69 items were retained after applying Exploratory Factor Analysis under three
sub factors; Obsessions, Compulsions and Impairment of Functioning whereas model fit (p=0.000, CMIN/DF =1.62,
CFI=0.934, RMSEA=0.046, SRMR=0.04, GFI=0.834 and TLI=0.93) of Confirmatory Factor Analysis confirmed 40 items for final
scale.
Conclusion: Prenatal Obsession Compulsion Scale with 40 items and three subscales is a reliable measure to assess obsessive
compulsive symptoms during prenatal period.
Keywords: Obsessive Compulsive Disorder, Pregnant Women, Scale Development.
How to Cite This Article: Kiran T, Shafiq S. Development and Psychometric Properties of Prenatal Obsession Compulsion Scale (POCS). Pak Armed
Forces Med J 2025; 75(Suppl-2): S300-S305 DOI: https://doi.org/10.51253/pafmj.v75iSUPPL-2.6582
INTRODUCTION
Pregnancy is a stage of life that is traditionally
affiliated with emotions for pregnant women and they
are naturally conscious for the safety of their fetus and
feel uniquely responsible for them. It is also a time of
growing stress and conversion to a new role, all of
which can enhance vulnerability to produce
problems.1 During the prenatal period several
psychological and hormonal changes take place but
usually physical changes are focused and psychiatric
changes are ignored unless a mental disorder
develops. Mental and physical health is influenced
negatively if the pregnant woman is unable to
accommodate these changes and become vulnerable to
suffer mild-to-severe mental disturbances.2 especially
psychosis, depression and the widely understudied
obsessive compulsive disorder (OCD).
Prenatal OCD is varied from OCD which is
exhibited in other times or situations. Normal
obsessional thoughts vary from clinical intrusive
thoughts by virtue of time they take and disability
they cause.3 The term prenatal OCD was chosen on the
basis of literature as several researchers have already
used this term in their research to refer OCD at the
prenatal stage. In Prenatal OCD, the compulsions and
obsessional thoughts are related to the health of the
fetus, environment and wellbeing. Intrusive thoughts
may be related to fetus getting hurt, lost or polluted,
germs or contamination regarding the fetus and
accidental/intentional injury to the fetus; and
compulsions may involve checking, avoidant
behaviors like avoid bathing or hang out, extravagant
cleaning/washing, seeking-reassurance and mental
rituals. Most common intrusive thoughts observed
during the prenatal period are: baby being taken away
after birth, being afraid of having an unhealthy baby at
birth, infant death and contamination. These signs of
prenatal OCD develop intense distress and disability
not only one’s personal, occupational and social life,
but may also impact the potential of the mother to take
care of her baby, disturbing the mother-infant bonding
process.4 The prenatal period has also been related to
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly ci ted.
Original Article
Open Access
Correspondence: Dr Sameera Shafiq, Department of Clinical
Psychology, University of Gujrat, Pakistan
Received: 16 Apr 2021; revision received: 21 Mar 2023; accepted: 25 Mar 2023
mzahid689@gmail.com
Development and Psychometric Properties of Prenatal Obsession
Pak Armed Forces Med J 2025; 75(SUPPL-2): S301
aggravation of OCD signs; particularly in clients with
prior history of OCD.5
Prenatal OCD is influencing up to 9% of
pregnant women every year and onset of OCD signs
related to pregnancy ranges from 2-4%. Almost half of
all new mothers narrated intrusive, unwanted
thoughts of hurting their infant.6,7 and 81% of the
pregnant women could be classified as having
obsessive-compulsive disorder.8 However, in Pakistan
31.5% women showed severe symptoms of obsessions
and compulsions during the pregnancy.9
Currently only one scale has been developed in
2011 to assess pregnancy related OCD named as
Prenatal Obsessive Compulsive Scale by Lord et al.,4
Van Broekhoven, Hartman, Spek, Bergink, Van Son et
al., in 2016 developed the Pregnancy Obsession-
Compulsion-Personality Disorder Symptom
Checklist.10 These scales were developed in English
language which was not a suitable language for the
desired population of current study as well as cultural
biases could hamper investigation of OCD in Pakistan
so it was needed to construct a scale in Urdu language.
Hence, in present study, the first instrument in
Pakistan will be constructed to measure obsessive
compulsive symptoms during pregnancy and it would
be a primary research that will be carried out in
Pakistan to take into account the OCD during the
prenatal period. The findings of the study will provide
useful insights to increase the level of awareness
among pregnant women and their family members
and results will also be beneficial for the health
department. Prenatal OCD badly affects the
developing mother-infant bond so present study
suggests that the criteria of psychiatric assessment
should be added in antenatal care practice and
assessment of OCD should be a part of screening
procedure in obstetrical care.
METHODOLOGY
This was a cross sectional analytical study which
was conducted after getting approval of a proposal
from Advanced Studies and Research Board, no:
PSY/UOG/21/2679 under Psychology department of
University of Gujrat, Gujrat, Pakistan from February
to September 2019. Study was permitted and
approved by the ethical committee of the respective
department. Data were collected from obstetrics and
gynecology wards of the government and randomly
selected private hospitals/clinics of district Gujrat. A
demographic form and Prenatal Obsession
Compulsion Scale (POCS) were administered on a
sample of n=300 pregnant women that was selected by
using purposive sampling technique.
Inclsuion Criteria: Pregnant women who visited
hospital for their routine prenatal check up or
psychiatric consultation for OCD were included in the
study.
Exclusion Criteria: Patients who came for postnatal
checkup or had any other psychological disturbance
other than OCD/anxiety/depression were excluded
from the study.
Consent to participate in the study was taken from
respondents. It was assured to subjects that their
whole information will be kept confidential and will
only be used by the researcher for research purposes
and they have the right to withdraw from study
anytime. The purpose, whole procedure and
significance of current research were explained to
participants.
Current study was based on two phases of the
scale development process. In Phase-I Prenatal
Obsession Compulsion Scale (POCS) was constructed
by using a deductive approach. In current study, the
concept of prenatal OCD was derived from the
Diagnostic and Statistical Manual of Mental Disorders-
5 (DSM-5).11 model of psychopathology and
Salkovskis’s (1985) cognitive theory of OCD which
suggests that intrusive thoughts, ones practiced in the
normal population, convert into clinical obsessions
when the person translates the intrusions as
inculpating eminent personal responsibility.12
Phase-I was based upon four steps: At 1st step
item pool was generated in Urdu language through
three main sources: a) Literature review, b) In-depth
semi structured interviews with two psychiatrists and
five clinical psychologists c) In-depth semi structured
interviews from three OCD diagnosed pregnant
women. Total 119 items were generated by keeping in
mind the dimensions of OCD presented in DSM-5. At
2nd step content validity was done by nine experts
including six psychiatrists and three clinical
psychologists. After experts’ meetings, a draft of 100
items was finalized to proceed on. At 3rd step, five
point likert scale, ranging from 0 to 4 was selected to
try out 100 items of the newly developed instrument
for the psychometric cleansing of questions and to do
necessary modifications subsequently.
In pilot study, data were collected from 30
pregnant women. Reliability of scale was found to be
α= 0.97. All items were considered to be clear and
Development and Psychometric Properties of Prenatal Obsession
Pak Armed Forces Med J 2025; 75(SUPPL-2): S302
understandable for respondents. After the try out, the
final draft was consisted of 100 items with a changed
likert scale. Likert scale was changed just for the
convenience of respondents as the majority of
respondents stated that they don’t exactly know the
time duration of disturbance in a day. The changed
likert scale used the same ranges from 0 to 4 but the
intensity was measured from 0= never to 4= very
much instead of considering it in hours. These ranges
served the same purpose, meaning they measure
severity in total time duration of disturbance per day.
At 4th step the structure of the instrument was
decided through factorial validity. For this purpose,
EFA and CFA were applied.13 Data Analysis to
analyze the data reliability analysis, exploratory factor
analysis (EFA) and confirmatory factor analysis (CFA)
were implied by using Statistical Package for Social
Sciences (SPSS-21) and Analysis of a Moment
Structures (AMOS-21) for windows. Reliability of
POCS was found to be α= 0.97, KMO value was 0.95
and the value of CFI was 0.93 that was in the
acceptable range with the p-value of ≤0.05. The results
confirmed the model fit of the POCS.
RESULTS
After conducting a pilot study, 100 items were
further administered on 300 pregnant women.
Suitability of data for factor analysis was verified by
analyzing the normality, adequacy of sample size and
by checking if any outlier present in data. It was found
that data had symmetrical distribution and no outlier
was present in data as well as sample size was
adequate and suitable for factor analysis. The
skewness value was found to be 0.01 and the value of
z-test was 0.07. KMO value was 0.95 with significant
value of Bartlett’s test of Sphericity (p<0.01) which
showed that data is suitable for further exploratory
factor analysis.
By applying EFA on 100 items, principal
component analysis extracted three factors that
collectively accounted for 51.2% of variance.
Theoretical framework and scree plot of POCS both
supported to extract three factors of scale. From 100
items, 69 were retained after EFA while deleting the
irrelevant questions. Factor-I named as Obsessions
detained 38 items, Factor II-Compulsions kept 25
items and Factor III-Impairment in Functioning
reserved 7 items.
All items had high loading in their defined factor
which revealed that all items of a factor were
conceptually/theoretically relevant to each other.
Confirmatory Factor Analysis was performed on
69 items to confirm the factorial structure of the scale.
The three factor model of POCS was evaluated and
data were modeled by using continuous and
maximum likelihood estimation. Finally, CFA
extracted 3 factors having a total no. of 40 items in
POCS with 22 items in Factor-Obsessions, 13 in Factor-
Compulsions and 5 items left in Factor-Impairment in
Functioning. The values of model fit indicated a
perfect model fit for POCS.
Once EFA and CFA were completed; at phase-II
psychometric properties of POCS were established.
The assessment for reliability, validity and
unidimensionality for the measurement model was
needed before modeling the structural model.
Unidimensionality was achieved through discarding
the items that had low factor loading. The new model
was run and the item deletion process was performed
repeatedly until the fitness indices attained the
required level and all items had positive factor
loading.
There are two requirements of reliability in the
measurement model: Average Variance Extracted
(AVE) and Composite Reliability (CR). These both are
always computed to guarantee the validity of the
structural model.
Figure-1: Prenatal Obsessive Compulsive Model for Pregnant
Women
Table-I: Kaiser-Meyer-Olkin and Bartlett’s Test for Sampling
Adequacy of 69 items (n=300)
Scale
KMO
Chi-
Square
Bartlett’s Test
df
p-value
Prenatal Obsession
Compulsion Scale
0.95
15213.004
2346
<.001
Composite reliability of three factors of POCS
was above 0.7 which was good and acceptable and
values indicated that these were highly reliable
Development and Psychometric Properties of Prenatal Obsession
Pak Armed Forces Med J 2025; 75(SUPPL-2): S303
constructs. In terms of AVE, factors had acceptable
levels of average variances. Cronbach’s alpha
reliability of total scale was 0.96 which was
significantly high and above from acceptable
reliability value 0.70. Validity was examined through
convergent and construct validity. Convergent
validity: The value of AVE of all factors was in
acceptable range except obsessions which was near to
acceptability range. Construct validity: Construct
validity for model was obtained by fitting the model to
the required level of fitness indices. Values showed
that POCS was a valid and highly reliable instrument
having a total of 40 items. The minimum score which
can be obtained on POCS is ‘0’ and the maximum
score can be ‘160’. Total scores obtained on scale
represent the severity of OCD during prenatal period.
High score represents higher/extreme level of
prenatal OCD.
Table-III: Model Fit Indices of Confirmatory Factor Analysis
for Prenatal Obsession Compulsion Scale (n=300)
Indices
CMIN/DF
RMSEA
SRMR
GFI
CFI
TLI
Model
1.628
.046
.042
.834
.934
.930
CMIN/DF= Minimum Discrepancy per Degree of Freedom, RMSEA= Root Mean
Squared Error Approximation, SRMR= Standardized Root Mean Square Residual,
GFI= Goodness of Fit Index, CFI= Comparative Fit Index, TLI= Tucker Lewis index
Figure-2: Factor Structure of the Prenatal Obsession
Compulsion Scale Obtained from Confirmatory Factor
Analysis
Table-IV: Alignment on Strategic Orientation; Composite
Reliability (CR) Coefficients, Average Variance Extracted
(AVE) and Cronbach’s Alpha Reliability (α) Coefficients (n=
300)
Construct
Composite
Reliability
Average
Variance
Extracted
Cronbach’s
Alpha
Reliability (α)
Obsessions
0.92
0.36
0.94
Compulsions
0.90
0.43
0.92
Impairment in
Functioning
0.92
0.72
0.90
Prenatal Obsession
Compulsion Scale
0.96
DISCUSSION
The principal objective of present study was to
construct and validate an indigenous Prenatal
Obsession Compulsion Scale in native language Urdu.
For this purpose, factor analysis was conducted after
collecting data from 300 pregnant women by
administering an item pool composed of 100 items.
Present study reported 0.95 KMO value with
significant value of Bartlett’s test of Sphericity and
51.2% of explained variance. These values indicated
that data were normal, multivariate and suitable for
Table-II: Exploratory Factor Analysis Item Loading of
Prenatal Obsession Compulsion Scale on Three Factors
Using Rotated Component Matrix (n=300)
Item
No.
Obsessions
Item
No.
Compulsions
Item
No.
Impairment in
Functioning
03
.672
88
.725
97
.872
25
.667
87
.721
98
.866
43
.665
85
.689
99
.861
17
.648
76
.685
96
.853
02
.646
93
.677
95
.847
14
.638
57
.671
94
.807
31
.635
69
.667
100
.797
42
.633
68
.666
30
.622
64
.661
44
.615
92
.656
01
.613
63
.646
04
.607
58
.641
05
.595
77
.632
15
.592
81
.628
28
.591
82
.622
13
.584
86
.616
24
.584
61
.613
29
.580
62
.590
12
.578
60
.583
20
.573
89
.578
21
.572
71
.575
10
.571
78
.532
53
.571
90
.522
11
.566
80
.521
32
.565
33
.562
36
.559
45
.553
23
.549
26
.545
22
.539
09
.536
06
.533
47
.526
39
.520
50
.515
52
.510
51
.505
Development and Psychometric Properties of Prenatal Obsession
Pak Armed Forces Med J 2025; 75(SUPPL-2): S304
further exploratory factor analysis and the sample was
adequate.14 Pett, Lackey, and Sullivan found that as a
general rule variance should be at least 50%.15 and
confirmed that KMO value equals to 0.5 is acceptable
and between 0.8-0.9 is considered excellent.16
EFA extracted three factors and 69-item POCS;
having 38 items in factor Obsessions, 24 in factor
Compulsions and 7 in factor Impairment in
Functioning. All items on EFA had high loading in
their defined factor which depicted that all items of a
factor were theoretically relevant to each other.
Literature explored that generally 0.32 is considered as
a good rule of thumb for minimum loading of any
item in a scale.16
CFA was applied on the remaining 69 items and
it extracted a 40-item POCS. POCS retained good CFA
model fit as: CMIN/DF= 1.62, CFI= 0.93, RMSEA=
0.04, SRMR= 0.04, GFI= 0.83 and TLI= 0.93. Marsh and
Hocevar demonstrated that for acceptable model fit,
the minimum discrepancy per degree of freedom
should be <3.0 with p-value >0.05.17 Bentler supported
the above results by stating that good model fit is
supposed with a CFI >0.90.18 combined with RMSEA
≤0.05 as closer the value of RMSEA is to zero, the
better the fit indices.19 SRMR ≤0.08.20 GFI >0.90.21 and
TLI >0.90.22 Factor loadings greater than 0.50 reflect
that items are good indicators of associated latent
factor.23
POCS also retained good psychometric
properties. The reliability value of the final 40 items
was α= 0.96 which demonstrated a desirable value of
internal consistency of the scale. Previous study is in
line to support the reliability findings of the current
study that argued: an alpha value ranging from 0.93-
0.94 is regarded as excellent, and it is considered
statistically good if it ranges from 0.91-0.93.24 The
Composite Reliability of three factors of POCS was
above 0.7 that depicts that these were highly reliable
constructs as confirmed by previous findings23; and in
terms of AVE, factors had acceptable level (AVE ≥0.50
but 0.40 can also be accepted) of average variance
except obsessions.25
Final scale consists of 3 factors having a total no.
of 40 items. The values of the newly developed scale of
POCS were highly in acceptable ranges as these are
according to the statistically adequate range.
CON CLUSION
An indigenous Prenatal Obsession Compulsion Scale
(POCS) consists of 40 items and three subscales, has been
developed in Urdu language by following standardized
steps of scale development. Scale has good psychometric
properties and can be used in further research.
Conflict of Interest: None.
Funding Source: None.
Authors’ Contribution
Following authors have made substantial contributions to
the manuscript as under:
TK & SS: Data acquisition, data analysis, critical review,
approval of the final version to be published.
Authors agree to be accountable for all aspects of the work
in ensuring that questions related to the accuracy or integrity
of any part of the work are appropriately investigated and
resolved.
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