“Psychometric validation of the Persian pregnancy coercion scale and its implications for reproductive autonomy in Iran”

Abstract

Objective

Pregnancy coercion is a public health issue that affects the mental, sexual, and reproductive health of women and one of the significant factors unintended pregnancies globally, remains understudied in Iran due to the lack of culturally validated assessment tools. This study aimed to psychometrically validate the Persian version of the Pregnancy Coercion Scale (PCS) to address this gap and enhance reproductive health equity in Persian-speaking populations.

Results

The Persian PCS demonstrated strong internal consistency (α = 0.85). EFA revealed a two-factor structure—pregnancy coercion and condom manipulation—explaining 57.53% of the variance and these two factors are aligned with the original scale. Content validity indices were robust (CVI: 0.80–1.00; CVR: 0.62–1.00), with no floor/ceiling effects. Significant associations were observed between coercion and lower education, unemployment, and having 1–3 children (p < 0.05), though no links emerged with age or income.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-025-07501-y.

Introduction

Pregnancy coercion, defined as behaviors intended to undermine reproductive autonomy through contraceptive sabotage or explicit pressure to become pregnant, is increasingly recognized as a critical contributor to unintended pregnancies globally [1]. In other words, reproductive coercion is a form of intimate partner violence (IPV) entailing the exertion of power and control over reproductive decisions, including contraception and pregnancy outcomes [2]. Unintended pregnancies continue to pose a substantial public health issue, with an estimated 44% of pregnancies globally categorized as unintended, frequently associated with detrimental maternal and neonatal health outcomes, including preterm birth, low birth weight, and maternal mental health disorders [3, 4]. In low- and middle-income nations, where access to reproductive health services is often constrained, the repercussions of unintended pregnancies are particularly pronounced, perpetuating cycles of poverty and exacerbating gender inequality [5].

In Iran, unintended pregnancy rates remain a pressing concern, with studies estimating that 22.4% of married women experience at least one unintended pregnancy, driven in part by sociocultural barriers to contraceptive access and gendered power dynamics within relationships [6]. Pregnancy coercion, however, remains understudied in this context, despite evidence suggesting that coercive reproductive behaviors are prevalent in settings where traditional gender norms limit women’s agency over their sexual and reproductive health [7]. For instance, a 2019 study in Tehran found that 18% of women reported experiencing contraceptive interference by a partner, highlighting the urgent need for culturally adapted tools to measure and address this phenomenon [8].

To assess this phenomenon, various validated instruments have been developed, including the Pregnancy Coercion Scale (PCS), which evaluates tactics such as contraceptive sabotage and pressure to conceive or terminate a pregnancy [1]. Similarly, the Reproductive Coercion Scale (RCS) provides a framework for measuring coercive behaviors related to pregnancy and contraception, demonstrating strong reliability (α = 0.86) and validity in diverse populations [9]. Additionally, the Coercive Abuse during Pregnancy Scale (CAPS) has been employed to assess threats or violence linked to reproductive control, further expanding methodological tools in this field [10].

Globally, adaptations of the Pregnancy Coercion Scale (PCS) have undergone rigorous psychometric evaluation to ensure cultural and linguistic relevance. For instance, the Spanish-language version of the PCS demonstrated high internal consistency (α = 0.89) and factorial validity, underscoring its utility in Hispanic populations [11]. In Brazil, the Brazilian-Portuguese adaptation of the PCS exhibited robust construct validity (CFI = 0.95) and test-retest reliability (r = 0.82), highlighting its cross-cultural applicability [12]. Similarly, the Turkish version of the PCS confirmed a unidimensional structure with strong discriminant validity, supporting its use in clinical and research settings [13].

Despite these advancements, validated instruments like the Pregnancy Coercion Scale (PCS) are essential for quantifying the prevalence and impact of coercive behaviors. Research in Iran shows that 22.4% of married women have experienced at least one unintended pregnancy, including instances that may be forced. This underscores the importance of investigating the issue in our society. Furthermore, to our knowledge, this study represents the first evaluation of the PCQ’s psychometric properties conducted in Iran. The absence of such measures impedes both clinical screening and targeted interventions in Persian-speaking populations. This study aims to bridge this gap by assessing the psychometric properties of the Persian PCS, thereby contributing to global efforts to mitigate unintended pregnancies through enhanced understanding of coercive reproductive dynamics.

Methods

Study design and setting

This cross-sectional study was conducted in Tabriz, Iran, from September to December 2023. Ethical approval was obtained from the Tabriz University of Medical Sciences (IR.TBZMED.REC.1402.364). The study population comprised married women aged 18–49 years with a history of unintended pregnancy, recruited from comprehensive health service centers in Tabriz. Iran.

Participant recruitment and sampling strategy

Participants were selected using stratified cluster random sampling. Tabriz city comprises 10 municipal districts and 56 comprehensive health service centers. The districts (North, South, East, and West) served as clusters, with two health centers randomly selected from each. Subsequently, participants were randomly chosen from each selected center using a simple random number table, resulting in a final sample of 200 participants.

From the integrated healthcare system records at these centers, the researcher compiled a list of married women aged 18–49 years who had experienced unintended pregnancies. Eligible participants were contacted through telephone communication, during which they were apprised of the study’s objectives and methodological procedures. Willing participants were scheduled for an appointment at their respective health centers, where written informed consent was obtained before enrollment. Exclusion criteria included: women aged < 18 or > 49 years; those with a history of intentional pregnancy attempts; individuals unwilling to continue study participation; and those not in legally recognized marriages.

Sample size calculation

To determine the sample size, we followed the recommendation of Plichta et al. (2013) that 10–20 participants are needed per item, leading to an ideal range of 100–200 participants [14]. Therefore, a sample of 200 married women, aged 18–49 years with a history of unintended pregnancy, was recruited from a healthcare center registry in Tabriz, Iran, using stratified cluster random sampling.

Data collection

Data were collected using the Reproductive Coercion Scale (RCS). Trained personnel administered the questionnaire during participants’ scheduled visits to ensure standardized data collection.

Reproductive coercion scale (RCS)

The Reproductive Coercion Scale (RCS) was administered to evaluate participants’ exposure to behaviors aimed at undermining reproductive autonomy [9]. The RCS is a validated 9-item self-report instrument designed to measure two domains: pregnancy coercion (e.g., partner threats related to pregnancy outcomes) and contraceptive sabotage (e.g., tampering with birth control methods). Items were adapted from prior qualitative work on intimate partner violence and reproductive health (Example item: “My partner refused to use condoms despite my requests”). Responses were captured via a yes or no [9, 12, 13].

Design and item generation

The Persian version of the Pregnancy Coercion Scale (RCS) was developed through a multi-step translation and adaptation process. First, the original English-language PCS underwent forward translation by two bilingual experts, followed by back-translation into English by two independent translators including “a health education expert and reproductive health/gynecology” science to ensure conceptual equivalence. Discrepancies were resolved through consensus by a panel of “3 reproductive health specialists”, “3 psychologists”, and “a linguist”. The panel members were tasked with reviewing and evaluating the items, as well as assessing the relevance and suitability of the items concerning the research target demographic. A pilot test (n = 30) assessed preliminary comprehension and item clarity, And most participants criticized the similarity of the questions related to condom manipulation. But considering that each question of the questionnaire measures a different concept, we decided to retain the questions.

The Persian adaptation of the Pregnancy Coercion Scale (PCS) followed a rigorous translation and adaptation protocol. The original English PCS was forward-translated by two bilingual experts and then back-translated by two independent translators, including specialists in health education and reproductive health/gynecology. A panel comprising three reproductive health specialists, three psychologists, and a linguist resolved discrepancies to ensure conceptual equivalence. This panel also reviewed item relevance and suitability for the target population. A pilot test (n = 30) assessed comprehension and clarity. While participants noted similarity in questions about condom manipulation, these items were retained as each measures a distinct underlying concept.

Content validity

To evaluate the content validity of the PCS, two key metrics—the Content Validity Index (CVI) and the Content Validity Ratio (CVR)—were computed by an independent panel of 9 experts (4 health education expert, 2 psychologists, and 3 reproductive health specialists) who were not involved in the prior translation of the questionnaire. The CVI was used to measure the relevance, simplicity, and clarity of each item concerning the construct being assessed. Experts rated the relevance of each item on a 4-point scale: Not relevant, slightly relevant, relevant, and completely relevant. An item was deemed acceptable if it achieved a CVI score of ≥ 0.79 [15, 16]. The CVR, on the other hand, evaluated the necessity of each item in the questionnaire. Experts responded to a 3-point scale assessing whether each item was: Necessary, Useful but unnecessary, or Unnecessary. The Content Validity Ratio (CVR) was calculated using Lawshe’s criteria, retaining items with scores ≥ 0.78 (critical value for 9 experts) [17]. This structured approach ensured a rigorous assessment of both relevance and essentiality for each questionnaire item.

Face validity

The same panel of experts evaluated each questionnaire item for clarity, relevance, and difficulty. They examined face validity and rated the importance of each item using a 5-point scale. To determine face validity, an impact score (calculated as frequency × importance) was derived for each item. This score reflects the percentage of experts who deemed the item important or highly important. Items that achieved an impact score of ≥ 1.5, indicating a mean frequency of 50% coupled with an average importance score of 1.5 on a 5-point Likert scale, were deemed appropriate for inclusion in the study. In this section, we collected qualitative feedback from target users. Participants commonly noted that questions regarding condom manipulation felt repetitive. However, as each question measures a distinct concept, none were eliminated from the questionnaire.

Convergent and discriminant validity

To assess the convergent and divergent validity of the Reproductive Coercion construct, we employed Fornell and Larcker’s (1981) approach using Average Variance Extracted (AVE) and the Heterotrait-Monotrait Ratio (HTMT). Convergent validity requires an AVE > 0.5, while discriminant validity requires an HTMT < 0.8 [18].

Reliability

To evaluate reliability, internal consistency was measured using Cronbach’s alpha, while stability was assessed through test-retest analysis. Intraclass correlation coefficients (ICCs) were calculated after a two-week interval to determine questionnaire consistency over time.

Statistical analyses

All statistical analyses were performed using SPSS (version 26 for Windows) and AMOS (version 26; SPSS Inc., Chicago, IL, USA). Data distribution normality was assessed using one-sample Kolmogorov-Smirnov tests. We calculated the mean and standard deviation for PCS scores. Internal consistency reliability was evaluated using Cronbach’s Alpha, and stability over time was assessed with the intra-class correlation coefficient (ICC); values ≥ 0.7 were considered satisfactory [19].

The data analysis indicated a correlation between the two factors, prompting the use of Oblimin rotation. We then performed Exploratory Factor Analysis (EFA) using principal axis factoring. This method is less sensitive to deviations from normal distribution and permits the use of Pearson correlation matrices with binary data (coded 0/1). Subsequently, Confirmatory Factor Analysis (CFA) was conducted using the UnWeighted Least Squares (ULS) estimation method within Amos software. All items were specified as ordered categorical variables for this analysis. Goodness-of-fit indices—including RMR, GFI, AGFI, and PGFI—were obtained and interpreted. The proposed CFA model was developed based on the factor structure identified during the EFA stage and the theoretical framework underlying the original scale. While one item shifted to a different factor during EFA compared to the original scale, no items were ultimately removed.

Results

Participants

The study included 200 married women with a mean age of 34.27 ± 7.12 years. 45% of the participants were aged between 25 and 34 years [20]. The majority of women (81.5%) were housewives, and 42.5% had less than a diploma-level education. Regarding economic status, 65% rated their family income as somewhat sufficient. These results are based on participant self-reports [21]. Most participants (87.5%) had 1 to 3 children, and nearly all (99%) were of Turkic ethnicity. As shown in Table 1, demographic characteristics such as occupation, education level, and number of children had a statistically significant relationship with pregnancy coercion (p < 0.05). However, no significant association was found between age, ethnicity, or income and pregnancy coercion (p > 0.05).

Table 1.

Associations of demographic characteristics with pregnancy coercion (n = 200)

Variable		Frequency n (%)	Mean ± SD	p value*
Age(years)	18–24	18 (9)	0.27 ± 0.66	0.10
	25–34	87 (43.5)	0.32 ± 0.90
	35–44	80 (40)	0.53 ± 1.13
	45–49	15 (7.5)	1.00 ± 1.77
	Total	200 (100)	0.45 ± 1.07
Education	Less than a diploma	85 (42.5)	0.69 ± 1.36	0.01
	Diploma	58 (29)	0.37 ± 0.89
	Academic degree	57 (28.5)	0.17 ± 0.60
	Total	200 (100)	0.45 ± 1.07
Job	Housewife	163 (81.5)	0.53 ± 1.17	0.01*
	Employed	37 (18.5)	0.08 ± 0.27
	Total	200 (100)	0.45 ± 0.19
Family income	Completely adequate	33 (16.5)	0.15 ± 0.44	0.19
	Somewhat adequate	130 (65)	0.53 ± 1.13
	Not at all adequate	36 (18)	0.44 ± 1.22
	Total	200 (100)	0.45 ± 1.07
Ethnicity	Turk	198 (99)	0.45 ± 1.08	0.955*
	Kurd	2 (1)	0.50 ± 0.70
	Total	200 (100)
Number of children	Childless	5 (2.5)	1.60 ± 2.50	0.02
	1 to 3 children	175 (87.5)	0.38 ± 0.93
	More than 3 children	20 (10)	0.75 ± 1.51
	Total	200 (100)	0.45 ± 1.07

One-Way ANOVA *Independent Samples t-Test

Feasibility

Because these questionnaires use dichotomous (yes/no) items scored as 0 or 1, ceiling and floor effects were not calculated.

Content validity

The impact score for face validity exceeded 1.5 for all items, indicating strong relevance and clarity. Both CVI and CVR scores ranged between 0.78 and 1.00, confirming high content validity. As a result, no items were deleted from the scale (Table 2). Additionally, the expert panel verified the clarity, appropriateness, and relevance of the translated RCS items, further supporting their validity.

Table 2.

The scores of IS, CVI and CVR

Questions on partner pregnancy-promoting behavior	CVI	CVR	IS
Told you not to use any birth control	0.93	1	4/56
Said he would leave you if you didn’t get pregnant	1	1	4/67
Threatened to have a baby with someone else	0.81	1	4/44
Taken/hidden birth control	0.81	1	4/67
Forced unprotected sex for pregnancy	1	1	4/78
Physically harmed for refusing pregnancy	0.93	1	4/67
Removed condom during sex	0.89	1	4/78
Put holes in the condom	0.81	0.78	4/11
Broke condom intentionally	0.85	0.78	4/00

Content Validity Index Content Validity Ratio Impact Score

Factor structure

Two tests assessed the suitability of the data for exploratory factor analysis. The first was the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy. KMO values range from 0 to 1, with values of 0.5–0.7 indicating adequacy, 0.7–0.8 indicating goodness, 0.8–0.9 indicating desirability, and values > 0.9 indicating excellence [22]. The second test was Bartlett’s test of sphericity, which evaluates the null hypothesis that the correlation matrix is an identity matrix (i.e., all correlation coefficients are zero) [23]. A significant result for Bartlett’s test is necessary to proceed with factor analysis.

In this study, the KMO value of 0.63 indicated adequate sampling adequacy for factor analysis. Bartlett’s test of sphericity was significant (χ² = 703.974, df = 36, p < 0.001), further confirming the data’s suitability. Principal-axis factoring with Oblimin rotation was performed, extracting two factors with eigenvalues exceeding 1. These factors collectively explained 57.63% of the total variance. Factor loadings for each item are presented in Table 3.

Table 3.

Rotated oblimin with Kaiser normalization for variable solutions (9 items) of the factors

Items	Factor 1	Factor 2
Forced unprotected sex for pregnancy	0.726	0.346
Said he would leave you if you didn’t get pregnant	0.668	− 0.107
Threatened to have a baby with someone else	0.601	− 0.076
Taken/hidden birth control	0.555	0.012
Removed condom during sex	0.518	0.382
Told you not to use any birth control	0.510	− 0.070
Physically harmed for refusing pregnancy	− 0.137	0.873
Put holes in condom	− 0.082	0.669
Broke condom intentionally	0.154	0.644

Rotation Method: Oblimin with Kaiser Normalization

Convergent validity

To assess the convergent validity of the intimate partner violence scales with the PCS, the questionnaires were randomly completed by 50 married women with a history of unwanted pregnancy. The results revealed a weak positive correlation (r = 0.15) between the scales.

Internal consistency, reliability and convergent and discriminant validity

As shown in Table 4, the internal consistency and reliability indices for the PCS approached acceptable levels (Cronbach’s α = 0.73 [0.69–0.73]; ICC = 0.84 [0.68–0.93]). However, the Average Variance Extracted (AVE) was 0.4 for the first factor and 0.7 for the second factor. As acceptable AVE values are typically above 0.5, the first factor falls below this threshold. Furthermore, the Heterotrait-Monotrait ratio (HTMT) value was 0.95. Values less than 0.85 (or 0.90 in some sources) are desirable, indicating that this high HTMT value suggests potential issues with discriminant validity between the constructs.

Table 4.

Item cronbach’s Alpha, convergent and divergent validity for PCS

Index Factor	Cronbach’s Alpha	AVE	HTMT
Factor 1	0.73	0.4
Factor 2	0.69	0.7
Total	0.73		0.95

The acceptable level of the index α > 0.7, AVE > 0.5, HTMT < 0.8

Quantitative construct validity appraisal

The two-factor solution obtained in exploratory factor analysis (9 items) was assessed using confirmatory factor analysis (CFA). Results indicated acceptable model fit based on standard indices: RMR = 0.004, GFI = 0.955, AGFI = 0.943, PGFI = 0.764. While the chi-square statistic was significant (χ²(36) = 703.974, p < 0.001)—often sensitive to sample size—the overall fit supports the confirmed factorial structure.

Discussion

The present study sought to validate the Persian version of the Pregnancy Coercion Scale (RCS), addressing a critical gap in tools for assessing reproductive coercion in Persian-speaking populations. The results exhibited acceptable psychometric characteristics, with a Cronbach’s alpha coefficient of 0.73 and notable test-retest reliability (ICC: 0.84), consistent with previous adaptations of the PCS in various languages, such as the Spanish version (α = 0.89) [11] and the Brazilian-Portuguese variant (r = 0.82) [12]. Exploratory factor analysis (EFA) revealed a two-factor structure comprising Factor 1 (pregnancy coercion) and Factor 2 (condom manipulation). Six items loaded primarily on Factor 1, while three items loaded primarily on Factor 2. This structure aligns with the original scale, with one key difference: in our analysis, the item “I hurt you physically because you did not agree to get pregnant” shifted from Factor 1 to Factor 2, whereas “Taken off the condom while you were having sex, so you would get pregnant” moved from Factor 2 to Factor 1 [9].

Notably, the Turkish version of this tool yielded a single-factor structure [13]. The model fit indices met acceptable standards across all indicators, confirming appropriate factor loadings. Confirmatory factor analysis (CFA) further validated the observed factor structure, with all fit indices reaching suitable thresholds. It is worth mentioning that neither the original version nor the Turkish adaptation employed CFA to verify the underlying factor structure [9, 13].

Although the explained variance (57.63%) was slightly lower than in some cross-cultural validations [24], this difference may reflect sociocultural nuances in how coercive behaviors manifest within Iranian marital dynamics. Traditional gender norms in this context often amplify power imbalances, suggesting that coercive behaviors may be influenced by cultural factors that differ from—or manifest differently than—those in other societies.

Regarding factor loadings, values of 0.71 and above are considered excellent, 0.63 as very good, 0.55 as good, 0.45 as acceptable, and 0.32 as weak [25]. This aligns with both the original scale and its Turkish adaptation [9, 13].

In this study, KMO values below 0.7 indicate limited sampling adequacy. Thus, future research with larger or more diverse samples is needed to strengthen the finding.

Notably, the study revealed significant associations between pregnancy coercion and demographic factors such as education level, occupation, and number of children, consistent with global literature linking lower education and economic dependency to heightened vulnerability to reproductive control (p < 0.05) [6]. However, the lack of association with age or income contrasts with findings from studies in other Low-or Middle-Income Countris (p > 0.05) [9], possibly due to the homogeneity of the sample (e.g., 99% Turkic ethnicity, 81.5% housewives). These sociodemographic limitations may restrict the generalizability of the results to more diverse Iranian subpopulations, such as urban employed women or ethnic minorities.

This validated Persian Pregnancy Coercion Scale provides clinicians with a culturally relevant tool for early identification of at-risk women in Iran. Addressing this understudied driver of unintended pregnancy it enables targeted interventions to uphold reproductive autonomy and reduce maternal health disparities.

Future research should use longitudinal designs to assess the Persian PCS’s predictive validity and establish causality with pregnancy outcomes. Its design must align with local cultural norms for community acceptance. Incorporating qualitative interviews, especially among rural or minority groups, can reveal unmeasured coercion mechanisms. Expanding recruitment to diverse populations and using mixed methods will further refine the tool’s cultural applicability.

Limitations

In this study, due to the dichotomous (yes/no) nature of the items and their binary scoring (0/1), calculating ceiling and floor effects was not meaningful. The binary data structure of this study may not be ideal for exploratory factor analysis (EFA) based on correlation. Consequently, KMO values below 0.7 are not unexpected for this type of data and should be considered a limitation. Naming the factors was not feasible due to the misalignment of one question with its intended factor. Additionally, the second factor had a Cronbach’s alpha below 0.7. While the translation and psychometric analysis were conducted rigorously, the resulting psychometric properties remain a limitation of this research.

Conclusion

This study validated the Persian version of the Pregnancy Coercion Scale, confirming its reliability and validity in an Iranian context. This instrument addresses a critical gap by enabling the measurement of pregnancy coercion, thereby supporting efforts to safeguard reproductive autonomy and mitigate unintended pregnancies. It provides a vital tool for research and intervention in Iran and other similar low- and middle-income settings.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

Mahin Alinejad: First authorDepartment of Health Education & Promotion Zeinab Javadivala*(Co-Corresponding author)Hamid Allahverdipour: Second authorResearch Center of Psychiatry and Behavioral SciencesParvin Sarbakhsh: (fourth author)Ahmad Kousha(Corresponding author) *.

Funding

Not funding.

Declarations.

Data availability

“The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.”

Declarations

Ethics approval and consent to participate

The study protocol was approved by the Ethics Committee of Tabriz University of Medical Sciences (Approval Code: IR.TBZMED.REC.1402.364), and written informed consent was obtained from all women before their inclusion in the study. They were given full details about the aims, methods, potential risks, and benefits of the research. They were assured that all data collected was kept confidential and anonymous to protect their privacy. The study was conducted in accordance with Helsinki Declaration as revised in 2013.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.