Translation and Cross-Cultural Adaptation into French of the Mother-to-Infant Bonding Scale

Introduction

The perinatal period is emotionally challenging due to the development of the first bonds between the mother and her child. Bonding is defined as the “emotional tie from parent to infant”¹ and reflects the mother’s feeling towards her child.² Although bonding and attachment are often used interchangeably, we differentiate those two notions because attachment conveys a reciprocity that cannot be found in the pre-natal period.^2–4 Bonding begins during pregnancy and is of utmost importance since it impacts post-partum relationship.^5,6 Early bonding impairments affect the child’s development,⁷ with insecure or abusive parenting behaviour^7–9 such as child abuse,^10,11 associated with greater behavioral inhibition and anxiety in the adolescent period.¹²

Bonding disorders are also associated with parents’ issues and mental health problems such as child maltreatment, depression, anxiety and distress.^6,8,13,14 Given the prevalence of these issues and the above-mentioned short and long-term consequences, assessing the mother-infant bond is therefore critical.⁶ To evaluate various aspects of patient health status and the efficacy of interventions, patient-reported outcome measures (PROMs) have proven to be useful and are increasingly employed.¹⁵ Various authors have recommended assessing these measures before the mother leaves the hospital to ensure the appropriateness of mother-child bonding,^2,16–20 which is of great importance considering the general shortening of the postpartum length of stay.²¹ One of the most commonly used PROM is the Mother-to-Infant Bonding Scale (MIBS),² recently proposed by the International Consortium of Health Outcomes Measurement (ICHOM) to standardize outcomes in the prenatal care and childbirth area.²²

The MIBS is adapted from the Mother-to-Infant Bonding Questionnaire (MIBQ) proposed by Kumar & al.¹⁹ It is an 8-item questionnaire that evaluates the mother-to-infant bonding through one-word descriptors and a 4-point Likert scale. The instrument showed acceptable internal reliability² and a good correlation with longer questionnaires such as the Maternal Postpartum Attachment Scale (MPAS) and the Postpartum Bonding Questionnaire (PBQ). These findings suggest the MIBS is a practical and valid tool to be used as a screening tool for postpartum mental health issues, such as maternal depression and bonding disorders, allowing early intervention in vulnerable mother-infant dyads.^23–27 As a result, the MIBS has been adapted in other languages such as Japanese,²⁸ Indonesian²⁹ or Swedish.³⁰ However, translating PROMs involves challenges beyond direct linguistic equivalence, especially in emotionally sensitive constructs like maternal bonding. To date, no translation has yet been proposed with the developer’s involvement for French-speaking mothers. The objective of our study was therefore to develop a translation and cross-cultural adaptation into French of the MIBS (MIBS-Fr) to enable consistent assessment of mother-to-infant bonding in French-speaking populations and to support early screening and intervention in postpartum care.

Materials and Methods

MIBS Score

The MIBS is a self-administered questionnaire in which the mother expresses her agreement through a 4-point Likert scale (Not at all, A little, A lot, Very much) for the following 8 feelings: Loving, Resentful, Neutral or felt nothing, Joyful, Dislike, Protective, Disappointed, Aggressive. Scoring is reversed for items 1 (Loving), 4 (Joyful) and 6 (Protective). Total score ranges from 0 to 24 with a higher score indicating worse bonding. The questionnaire has demonstrated good reliability (Cronbach’s alpha = 0.71) and validity.²

Cultural Adaptation and Translation Process

The cross-cultural adaptation and translation process was carried out according to the recommendations of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR), also known as the Professional Society for Health Economics and Outcomes Research,³¹ comprising 10 steps (Figure 1): preparation, forward translation, reconciliation, back translation, back translation review, harmonization, cognitive debriefing, cognitive debriefing review, proofreading and final report. The research team followed the appropriate ethical procedures for this type of study. All patients who participated in this study provided a written informed consent for the use of their answers in research projects. Since this research was qualitative and only relied on non-medical data, an a priori approval from the local ethics (Cantonal Commission on Ethics in Human Research of Geneva) committee was not required. This study was conducted in accordance with the Declaration of Helsinki, and followed the COnsolidated criteria for REporting Qualitative research (COREQ) checklist.

Figure 1 Process for the cross-cultural adaptation and translation into French of the MIBS.

Preparation

Four professional translators and the source developer were contacted. Two translators (T1 and T2) who performed forward translations were native French speakers and fluent in English, living in Switzerland and having experience in PROMs translation. The two other translators (T3 and T4) who performed back translations were native English speakers and fluent in French.

Forward Translation

Two independent translations from English to French were developed (V1 and V2) by two translators (T1 and T2) who were contacted in step i.

Reconciliation

A selection of the most appropriate translations of V1 and V2 was made between T1, T2 and the project manager (PM) to preserve semantic, idiomatic, experiential and conceptual equivalence. The PM is a Clinical Project Manager experienced in PROMs use for both research and clinical purposes. This step resulted in the development of a third version (V3).

Back Translation

Two independent translators (T3 and T4) performed a back translation of V3, producing two versions (V4 and V5). They had no prior knowledge of the MIBS and had not seen the source language or any other versions before or during the back translation.

Back Translation Review

The translators, the original developer and the PM reviewed the two back translations (V4 and V5) against the original to avoid mistranslation or omission, and to make sure semantic, idiomatic, experiential, and conceptual equivalence were preserved. Any discrepancies identified between the back translations and the original questionnaire would lead to a review of the reconciled version (V3) and potential revisions.

Harmonization

The PM compared V3 with other existing translations to ensure inter-translation validity.

Cognitive Debriefing

Cognitive debriefing is designed to test the instrument on a small group of relevant patients in order to test alternative wording and to check understandability, interpretation, and cultural relevance of the translation.³¹ During this stage, a small, relevant sample of patients was included to test the French version. Inclusion criteria were a consecutive series of mothers with a current maternity stay at La Tour Hospital who could read and understand French. Mothers whose first language was not French or who withdrew their consent to participate in the study were excluded. The purpose was to assess the comprehensibility, interpretation and cultural relevance of V3, as well as to explore potential alternative wordings. Participants were given a paper-based version of the questionnaire during their stay and used a 10-point Likert scale to assess the level of comprehension for each item, ranging from 1 (not understood at all) to 10 (fully understood). Before completing the form, the PM (AP, male gender, MSc) met with each mother individually to explain the aim of the study and how to fill out the scale. The PM had no established relationship prior to study commencement. Mothers were encouraged to ask questions if anything was unclear, ensuring accurate interpretation of the items. Respondents who rated their comprehension level as ≤ 6 for a specific item were asked for a suggestion to improve comprehension. A translation was validated if the mean score of the item was ≥ 7. Suggestions were reviewed by clinicians, researcher expert in the use of PROMs and the PM. Analyses were performed using R version 4.3.2 (R Foundation for Statistical Computing, Vienna, Austria).

Review of Cognitive Debriefing Results and Finalization

Suggestions were reviewed by clinicians, researcher expert in the use of PROMs, translators and the PM to address problematic items and eventually modify V3. This resulted in a final version (VF).

Proofreading

The PM proofread the final version to check for grammatical and spelling errors.

Final Report

A report on the development of the MIBS-Fr was written to detail the concept and wording choices to harmonize subsequent translations.

Results

Forward Translation

The two forward translations were different as one respected the original format, using a one-word descriptor, while the other one used sentences to convey the feeling. The version with sentences was retained.

Backward Translation

As the reconciled version was composed of sentences, the two back-translations also used phrases. However, both back-translations were extremely similar, and both accurately conveyed the meaning of the original instrument. Examination of these two back-translations led to the modification of two items in V3. The developer considered that the 1^st item (Loving) sounded more like “affection” and therefore did not reflect a sufficiently strong feeling. The developer also pointed out that the back-translation of the 5^th item (Dislike) expressed the absence of love rather than the active negative emotion.

Cognitive Debriefing and Final Version

The MIBS-Fr was given to 11 mothers who were during their maternity stay at the Maternity Unit of La Tour hospital from April to May 2023. The eleven mothers included in the cognitive debriefing had a mean age of 35.5 ± 5.4 years (range, 30–44), and none were excluded. The questionnaire’s average comprehension level was 9.7 ± 1.4, with a median understanding of 10 out of 10. The level of understanding for each item can be found in Table 1. Of the 88 scores collected (8 items for 11 participants), 3 had a level of comprehension lower than 7 (3.4%) and were distributed among items 3, 4 and 8 (Table 1).

Table 1 Level of Comprehension of the 8 Items

Final Version

The PM reviewed the final version (VF) and checked for spelling or grammar errors. The final version of the original MIBS (MIBS-Fr) can be found in Table 2.

Table 2 French Version of the Mother-to-Infant Bonding Scale (MIBS-Fr). The Italicised Text in Brackets Corresponds to the English Translation

Discussion

The bond between mother and child begins before birth and continues afterwards. It is an essential element, as it determines the future outcomes and behaviors of both child and parents, as well as the quality of the relationship.^6,7 PROMs are increasingly used as they are useful tools for assessing a patient’s health status, without any intermediaries likely to bias the assessment. The MIBS is a relevant instrument to assess the bond and has recently been recommended by an international consortium,²² however, no French version has been proposed to date with the involvement of the developer. This study is the first translation and cross-cultural adaptation of the MIBS into French conducted with direct involvement from the original developer, according to ISPOR recommendations, enhancing the relevance and usability of the MIBS-Fr in clinical and research settings involving French-speaking mothers.

Rigorous adherence to ISPOR recommendations not only guaranteed a high-quality translation, but more importantly allowed cultural adaptation. It is important to follow a strict methodology to preserve the characteristics of the original questionnaire (structure, psychometric properties, etc.) and to ensure uniformity across the different language versions of the MIBS for international data analysis.^31–33

The methodology facilitated the process and consequently, the MIBS-Fr was developed without major issues and resulted in a questionnaire that was highly comprehensiveto the 11 mothers, with a mean level of understanding of 9.7 ± 1.4 out of 10. A few discrepancies emerged during the forward translation as one version respected the original format and described the feelings with one word, and the second version expressed feelings through sentences. To better match the French language, the second version was preferred. A wide range of stakeholders was involved in the process, including patients, the original developer, clinicians, professional translators and researchers, to create the best possible adaptation and make the most appropriate decisions. The back translations were of high quality and deemed equivalent with very good consistency by the original developer, who requested two modifications: a strengthening of the emotion of the item 1 (“I feel affection” was then changed for “I feel love”) and a rewording of the item 5 (“I feel no affection” was changed for “I have a feeling of rejection”) to better express the active negative emotion. This step underlines the importance of involving the original developer in the questionnaire translation. None of the items had a mean score below 7. Three out of the 88 scores registered were below 7 (2 participants) and their comments were considered by the panel for an improvement of the French version. This detailed process aimed to ensure that future versions of MIBS would be consistent with existing versions.

A limitation to this study is that the panel involved in the cultural adaptation process (translators, clinicians, researchers and patients) are living in Switzerland or France. Therefore, this version may not be appropriate for French-speaking countries with different culture (eg Canada). Additionally, all mothers were recruited from a single healthcare setting, and the majority may not reflect the broader diversity of French-speaking populations in terms of ethnicity, educational background, or socioeconomic status. Moreover, although we thoroughly adapted the MIBS into French, we did not assess the psychometric aspects. Reevaluating psychometric properties of an already validated questionnaire is controversial, and the rigorous process should not have altered these properties.^28–30 Cognitive debriefing relies on self-reported comprehension, which may not always reflect true understanding or predictive validity. Further psychometric testing, including reliability and factor structure analysis, is warranted to fully validate the MIBS-Fr.

Conclusion

A French-version of the MIBS was developed according to international recommendations for translation and cultural adaptation. This version can now be used to assess mother-to-infant bonding among French-speaking mothers. Future psychometric validation will be essential to confirm its reliability and construct validity in this population, further supporting its clinical and research applications.