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. 2026 Sep 30;13(10):e70893. doi: 10.1002/nop2.70893

Consensus on the Content of an Instrument to Assess Psychological Distress Following Multifetal Pregnancy Reduction: A Delphi Study

Jin Xu 1,✉, Qingge Li 1, Hong Wen 1, Cuiwei Ye 1, Ge Peng 1
PMCID: PMC13627879  PMID: 42817073

ABSTRACT

Aims

To reach expert consensus on the content of an instrument to assess psychological distress in women following multifetal pregnancy reduction (MFPR) and to provide a reference for frontline nurses in conducting psychosocial assessment and care planning.

Design

A two‐round Delphi expert consensus study.

Methods

The initial item pool was conceptualized based on an integrated framework combining the Dual‐Process Model and the Post‐Traumatic Stress Disorder model and generated through a literature review and semi‐structured interviews. The degree of consensus was assessed by measuring the concentration and coordination of expert opinions. Content validity of the preliminary instrument was evaluated using the scale‐level content validity index.

Results

Experts reached consensus on the preliminary Post‐Multifetal Pregnancy Reduction Maternal Psychological Distress Scale (PMRPDS), comprising 16 items across four dimensions: Post‐traumatic Stress Response (5 items), Depression and Guilt (4 items), Health Anxiety and Concerns (3 items) and Psychological Adjustment and Coping (4 items). The positive coefficients of the two Delphi rounds were 90.9% and 91.7%, respectively; the authority coefficients were 0.885 and 0.889, respectively; the Kendall's W values for the two rounds were 0.142 and 0.159, respectively, with statistical significance (p < 0.001). The content validity index scored 0.983.

Conclusion

Expert consensus was reached on the content of the preliminary PMRPDS, demonstrating established content validity for assessing MFPR‐related distress and guiding targeted psychosocial nursing interventions.

Implications for Nursing

The PMRPDS is helpful for nursing staff in systematically assessing psychological distress in women following MFPR. Nursing staff can use the instrument as an assessment and intervention tool to enhance patient‐centred perinatal psychosocial care.

Impact

  • What problem did the study address? The lack of a specialized assessment tool for psychological distress after MFPR.

  • What were the main findings? A 16‐item scale across four core dimensions was developed through a Delphi expert consensus study.

  • Where and on whom will the research have an impact? The research will impact perinatal mental health clinicians, researchers and ultimately, the care received by women undergoing MFPR.

Reporting Method

This study adhered to the Conducting and REporting of DElphi Studies (CREDES) reporting guidelines.

Patient or Public Contribution

No Patient or Public Contribution.

What Does This Paper Contribute to the Wider Global Clinical Community?

  • Provides the first structured instrument to assess complex psychological distress following MFPR.

  • Establishes a consensus‐based foundation for future cross‐cultural validation and research, facilitating improved perinatal mental health care protocols.

Keywords: content validity, Delphi study, instrument, multifetal pregnancy reduction, psychological distress

Abbreviations

CV

coefficient of variation

MFPR

multifetal pregnancy reduction

PMRPDS

Post‐Multifetal Pregnancy Reduction Maternal Psychological Distress Scale

PTSD

post‐traumatic stress disorder

1. Introduction

Multifetal Pregnancy Reduction (MFPR) is an important obstetric procedure developed to enhance outcomes in multifetal pregnancies. By selectively reducing one or more foetuses, MFPR seeks to lower high‐risk complications linked to excessive foetal numbers, such as extreme preterm birth, low birth weight and hypertensive disorders of pregnancy, thereby improving the survival and health of the remaining foetuses while protecting maternal well‐being (Cetin Arslan et al. 2025; Liu et al. 2022; van Baar et al. 2023). The growing use of Assisted Reproductive Technology has contributed to increased incidence of multifetal pregnancies, expanding the potential population considering MFPR. Although population‐based incidence data for MFPR remain limited, a Canadian study found that among 208,827 women who gave birth in British Columbia, 95 (0.04%) underwent foetal reduction (Razaz et al. 2017), and a 12‐year Chinese single‐centre cohort documented 1925 MFPR cases (Li et al. 2024). The decision to undergo MFPR is complex and multifaceted, shaped not only by medical indications (e.g., severe foetal congenital anomalies) but also by socioeconomic and psychological considerations (American College of Obstetricians and Gynecologists 2021; van Baar et al. 2025).

Extensive evidence demonstrates that MFPR significantly improves perinatal outcomes by extending gestational age, increasing neonatal birth weight and reducing maternal complication rates (Leithner et al. 2021). However, despite these physiological benefits, the procedure often poses a profound psychological burden on women. The MFPR decision is inherently fraught with ethical and emotional conflict. For many women and their families, it is not a simple solution but a profoundly difficult choice, often accompanied by feelings of guilt, sorrow, loss and moral dilemma after considering all alternatives (Huang et al. 2021; McKinney and Leary 1999; Pasteau et al. 2025; Patuzzo Manzati et al. 2025). The psychological experience of MFPR for women cannot be summarized as ‘relief’. Instead, it involves a unique grieving process in which mourning the reduced foetus coexists with anxiety for the well‐being of the surviving one(s) (Schreiner‐Engel et al. 1995; van Baar et al. 2025; Wang and Yu Chao 2006). This emotional complexity places women at high risk for psychological conditions such as postpartum depression, anxiety and post‐traumatic stress disorder (PTSD) (Cuenca 2023).

Unfortunately, compared with substantial research on the physiological outcomes of MFPR, its psychosocial consequences have long been understudied. Academic inquiry into the psychological impact of MFPR emerged relatively late and remains fragmented, leaving this important topic as an ‘area of academic silence’ (Meng et al. 2021; Pike 2022). It is therefore imperative to foster open discourse and strengthen support throughout the entire process—from decision‐making to postoperative care—to establish a comprehensive and continuous framework for women undergoing MFPR (van Baar et al. 2025). In clinical practice, nurses serve as the frontline providers who accompany women through this entire trajectory, performing preoperative psychological screening, intraprocedural emotional support, postoperative grief counselling and follow‐up coordination (Little 2010; Wakui et al. 2025). Yet this nursing‐specific advantage is currently undermined by the absence of a standardized assessment tool. Nurses rely on fragmented clinical intuition to identify high‐risk women, leading to inconsistent referral decisions and delayed psychosocial support. Currently, there is no standardized instrument designed specifically to capture the unique psychological experiences of women following MFPR. General psychological scales, such as the Edinburgh Postnatal Depression Scale and the Generalized Anxiety Disorder scale, cannot adequately assess MFPR‐specific distress, including heightened anxiety regarding the surviving foetus, conflicted grief related to the reduction, or feelings of self‐blame (Fallon et al. 2016). This limitation not only increases the risk that clinicians may overlook the full scope of psychological distress but also creates a critical gap in nursing practice.

Against this backdrop, there is an urgent need to conceptualize a content‐validated and MFPR‐specific instrument to evaluate psychological distress among women after the procedure. Grounded in nursing practice, this tool enables bedside nurses to systematically identify at‐risk women, deliver targeted psychosocial support, and, through quantifiable indicators, evaluate intervention effectiveness, refine care pathways and advocate for resources. To bridge current research gaps and address pressing clinical needs, this study employs the Delphi method to reach expert consensus on the content of the Post‐Multifetal Pregnancy Reduction Maternal Psychological Distress Scale (PMRPDS), providing a preliminary foundation for frontline nurses to formulate evidence‐based care plans.

2. Methods

2.1. Establishment of a Research Group

The principal investigator of this study is affiliated with a nationally renowned Class A tertiary obstetrics and gynaecology specialty hospital. This institution maintains a dedicated multifetal pregnancy unit that manages patients undergoing MFPR (approximately 90 per year), concentrating relevant medical and nursing expertise. Leveraging these resources, the research team was established under the leadership of the head nurse, comprising a multidisciplinary team of three registered nurses (including one head nurse and two advanced nurses), one physician and one psychiatrist. The main tasks of the research group were to draft the preliminary items, review the expert inquiry letter and organise and analyse expert feedback.

2.2. Design

The conceptualisation and content consensus of the PMRPDS was conducted through a two‐round Delphi study from August to October 2025. The initial item pool was conceptualized based on an integrated theoretical framework combining Stroebe and Schut's Dual‐Process Model (Stroebe and Schut 1999; Stroebe et al. 2005) with the PTSD model (Ehlers and Clark 2000; Foa and Kozak 1986), supported by a systematic literature review, semi‐structured interviews with post‐MFPR women and multiple research team discussions. This methodology, incorporating deductive and inductive approaches, ensured the theoretical foundation and systematic conceptualisation of the preliminary instrument. The Delphi study aimed to establish expert consensus on the predetermined dimensions and corresponding psychological distress criteria (Powell 2003). As a well‐established methodology in instrument content validation, the Delphi method employs an anonymous group communication process in which expert panellists reach consensus through iterative rounds of evaluation and feedback on proposed items (Furtado et al. 2024; Shang 2023). To ensure methodological rigour, the study adhered to the Conducting and REporting DElphi Studies guidelines (Jünger et al. 2017) throughout the implementation process.

2.3. Theoretical Framework

To define the conceptual structure and core dimensions of the instrument, this study adopted an integrated theoretical framework combining Stroebe and Schut's Dual‐Process Model and the PTSD model. The Dual‐Process Model (Stroebe et al. 2005) conceptualizes grief adaptation as an oscillatory process between two types of stressors: loss‐oriented coping (e.g., grief intrusion, yearning and confronting the reality of loss) and restoration‐oriented coping (e.g., adapting to life changes, mastering new roles and finding meaning). Complementarily, the PTSD model (Ehlers and Clark 2000) captures trauma‐specific responses, including re‐experiencing, avoidance, negative alterations in cognition and mood and hyperarousal. These interrelated psychological processes collectively formed the dimensional framework of the instrument: Post‐traumatic stress response, Loss‐oriented and Restoration‐oriented. Corresponding symptomatic manifestations and coping behaviours derived from both theories were used to generate the initial item pool.

2.4. Recruitment

A purposive sampling approach was adopted to assemble a Delphi expert panel. The panel comprised key healthcare professionals involved in the care of women undergoing MFPR during hospitalization, including nursing specialists from emergency, outpatient, obstetric ward, reproductive medicine ward and operating room settings; obstetricians performing the procedure; mental health specialists; and obstetric administrators. This multidisciplinary composition was essential for enhancing the instrument's clinical relevance, comprehensiveness and practical applicability. The criteria for expert inclusion were: (a) at least 5 years of professional or research experience in multifetal pregnancy reduction, or a minimum of 10 years in mental health‐related practice or research; (b) possession of an intermediate or higher professional title; (c) a bachelor's degree or higher; and (d) willingness to participate.

2.5. Data Collection

2.5.1. Generation of the Initial Item Pool for Delphi Consultations

This study employed a three‐phase approach to systematically conceptualize and generate an initial item pool for psychological assessment of pregnant women after MFPR.

First, a systematic literature review was conducted to identify psychological dimensions and assessment tools relevant to women following MFPR. We searched PubMed, Ovid, CINAHL, China National Knowledge Infrastructure and Wanfang databases, from database inception to February 2025. The search strategy used the following combination of subject terms: ((multiple pregnanc*) or (multiple gestation) or (multifetal) and (reduction or feticide)) and (psycholog* or mental or emotion* or posttraumatic or stress or anxiety or depressive). Through screening and synthesis, 23 descriptive items reflecting psychological issues in post‐MFPR pregnant women were extracted.

Second, existing assessment tools were integrated by referencing seven perinatal grief‐related scales (Hutti et al. 2013; Lijuan et al. 2016; Ritsher and Neugebauer 2002; Setubal et al. 2021; Toedter et al. 1988) (e.g., Perinatal Grief Scale, Perinatal Grief Intensity Scale) and three PTSD measures (Impact of Event Scale‐Revised (Motlagh 2010), Posttraumatic Stress Disorder Checklist‐5 (Blevins et al. 2015) and Post‐traumatic Stress Disorder Checklist‐C (Blanchard et al. 1996)). A total of 70 items were extracted from these instruments.

Third, to capture the authentic experiences of patients, semi‐structured interviews were conducted with 11 women who underwent MFPR between October 2024 and March 2025. The interview transcripts were analysed using thematic analysis to identify core psychological themes (including psychological collapse, anguish during waiting, intraoperative loss, concealed grief, vigilance for the surviving foetus and loneliness). Based on these themes, 31 additional items were generated.

Finally, by removing duplicate entries and merging semantically similar items, an initial item pool of 35 entries was constructed. These items were categorized into three core dimensions as defined by the theoretical framework. These 35 items were then subjected to the two‐round Delphi consensus process.

2.5.2. Delphi Survey

Based on comprehensive literature analysis and preliminary research, the Delphi questionnaire for the PMRPDS was developed. The questionnaire comprised four sections: (1) Introduction: outlines the purpose and significance of the study, provides instructions, explains the theoretical basis and relevant concepts of the instrument, and specifies the deadline and method for questionnaire return; (2) Basic expert information: includes age, educational background, professional title, field of work, years of experience, and other relevant details; (3) Expert evaluation: a 5‐point Likert scale was used to evaluate the importance of each dimension and item, ranging from ‘very important’ (5 points) to ‘not important at all’ (1 point). Experts were also invited to assess the suitability of each item and could suggest additions, deletions, mergers, or splits; (4) Expert authority self‐evaluation: experts were asked to indicate the basis of their judgements across four dimensions—theoretical analysis, clinical experience, reference to literature and intuitive selection—each rated at three levels: High, Medium and Low. Assigned values were clinical experience (0.5, 0.4, 0.3), theoretical analysis (0.3, 0.2, 0.1), reference to literature (0.1, 0.1, 0.1) and intuitive selection (0.1, 0.1, 0.1). Familiarity with questionnaire content was rated on five levels: very familiar, familiar, moderately familiar, unfamiliar and very unfamiliar, corresponding to values of 1.0, 0.8, 0.6, 0.4 and 0.2.

The procedure of Delphi method was conducted mainly through WeChat and face‐to‐face distribution of questionnaires. Upon receipt, each questionnaire was reviewed for completeness. Any missing entries, illegible responses, or delayed submissions were promptly verified. After the first‐round questionnaires were collected, the data were collated and analysed. Based on predefined screening criteria and expert input, the research team revised, added, or removed items to form the second‐round questionnaire. In the second round, experts were provided with a summary of revisions and were asked to reassess the importance of the modified items. Following two rounds of consultation, the content validity of the PMRPDS was evaluated.

2.6. Statistical Analysis

Data analysis was conducted using SPSS 26.0 and Excel 2019. Descriptive statistics are presented as frequency, proportion, mean, standard deviation and coefficient of variation. The response rate was used to evaluate expert engagement, with a value ≥ 0.7 considered acceptable (Powell 2003). Expert authority was quantified using the authority coefficient (Cr), calculated from the familiarity coefficient (Cs) and the judgement coefficient (Ca) with Cr = (Ca + Cs)/2; Cr ≥ 0.7 was considered indicative of reliable expertise (Deng et al. 2025). Consensus was evaluated based on three dimensions: (1) concentration of opinions, assessed by mean score (> 3.5 on a 5‐point Likert scale) and full‐mark rate (> 20%); (2) coordination of opinions, assessed using the coefficient of variation (CV < 0.25) and Kendall's W, where higher values reflected stronger agreement (p < 0.05) (Gracht 2012); and (3) percentage of agreement, defined as ≥ 70% of experts rating an item as 4 or 5 on the Likert scale (Wang et al. 2025). Qualitative inputs from expert comments and research team discussions were incorporated into final decision‐making, complementing the formal data analysis. The content validity of the PMRPDS was evaluated using the content validity index (CVI). The scale‐level content validity index (S‐CVI) of ≥ 0.80 was considered indicative of excellent content validity (Polit and Beck 2006).

2.7. Ethics

Research Ethics Committee approval was obtained from Ethics Committee of Women's Hospital, School of Medicine, Zhejiang University (approval numbers IRB‐20240039‐R) prior to data collection.

3. Results

3.1. Characteristics of the Delphi Expert Panel

In the first round of the Delphi survey, questionnaires were distributed to 22 experts, with 20 valid responses received, yielding a response rate of 90.9%. In the second round, 24 questionnaires were distributed and 22 valid responses were collected, corresponding to a response rate of 91.7%. Both rounds involved a diverse panel of experts representing outpatient and emergency departments, obstetric wards, reproductive medicine units, operating rooms and management departments. All participants held at least a bachelor's degree and had a minimum of 7 years of work experience. More detailed characteristics of the experts are provided in Table 1. The authority coefficients for the two rounds were 0.885 and 0.889, respectively, reflecting a high degree of expert reliability.

TABLE 1.

Characteristics of experts in each round of Delphi process.

Characteristic Round 1 (n = 20) Round 2 (n = 22)
Gender
Male 5 (25) 4 (18.18)
Female 15 (75) 18 (81.82)
Age, years
30–39 12 (60) 14 (63.64)
40–49 6 (30) 6 (27.27)
≥ 50 2 (10) 2 (9.09)
Education level
Undergraduate 8 (40) 10 (45.45)
Master 10 (50) 10 (45.45)
Doctor 2 (10) 2 (9.09)
Professional title
Intermediate 13 (65) 14 (63.64)
Associate senior 5 (25) 6 (27.27)
Senior 2 (10) 2 (9.09)
Work role
Obstetric Nurse 7 (35) 8 (36.36)
Obstetrician 6 (30) 6 (27.27)
Emergency Nurse 1 (5) 2 (9.09)
Outpatient Nurse 1 (5) 1 (4.55)
Reproductive Medicine Nurse 1 (5) 1 (4.55)
Operating Room Nurse 1 (5) 1 (4.55)
Psychologist 2 (10) 2 (9.09)
Obstetric Nursing Manager 1 (5) 1 (4.55)
Years of work in this field (years)
5–9 2 (10) 2 (9.09)
10–14 8 (40) 8 (36.36)
15–19 4 (20) 6 (27.27)
20–24 3 (15) 3 (13.64)
≥ 25 3 (15) 3 (13.64)
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3.2. First‐Round Delphi Survey

Regarding the concentration of expert opinions, all 35 items received a mean importance score above 3.5. However, two items (A1 and A10) did not meet the required threshold of greater than 20% for full marks (with 15% and 20%, respectively). Furthermore, the percentage of agreement for both items was below 70%. As a result, these two items were removed from the instrument.

With respect to the coordination of expert opinions, 24 of the 35 items had a CV value below 0.25, indicating an acceptable level of consensus. Of the remaining 11 items, 8 received specific comments from experts. Based on the coordination analysis, expert suggestions and panel discussions, seven items were removed, two were merged with others and two were revised. For the instrument as a whole, the value of Kendall's W in the first round was 0.142 (p < 0.001).

Regarding the percentage of agreement, 12 items had a value below 70%. Among these, 10 also exhibited either poor coordination (CV ≥ 0.25) or a low full‐mark rate (≤ 20%). Following group discussions, a consensus was reached to remove 11 of these items and merge one with another.

Although 23 items showed favourable consensus, they still elicited comments from several experts. Based on this feedback, 7 items were revised and 10 were either merged with other items or consolidated with one another. Additionally, two new items were introduced based on expert recommendations.

For the three dimensions of the instrument, all demonstrated good consensus results. However, eight experts raised two critical issues: some items were found to potentially cross‐load on multiple dimensions, suggesting a need for refinement to ensure clearer discriminant validity; and the current dimension labels were considered overly broad and should be revised to more specific terms to better represent the core constructs being measured. Based on further analysis and group discussions, the research team revised the dimensional structure, resulting in four finalized dimensions for the 19 items: Post‐traumatic Stress Response, Depression and Guilt, Health Anxiety and Concerns and Psychological Adjustment and Coping. A second version of the instrument containing 19 items under these four dimensions was established. Detailed results of consensus analysis are shown in Table 2.

TABLE 2.

Revision of the preliminary instrument based on the first‐round Delphi (n = 20).

Mean score Full mark rate (%) Coefficient of variation Percentage of agreement (%) Original item Type Final item
Post‐traumatic stress response
3.55 15 0.26 55 A1 During the multifetal pregnancy reduction procedure, I felt a strong urge to flee. Remove
4.4 50 0.15 90 A2 Following the reduction, I experienced a momentary emotional collapse. Merge A2 and A3 merged into: I have difficulty controlling my emotions and am prone to sudden outbursts of crying or anger.
4.05 45 0.27 75 A3 Since the reduction, I have become easily irritated and often fly into a rage over minor issues. Merge A2 and A3 merged into: I have difficulty controlling my emotions and am prone to sudden outbursts of crying or anger.
4.3 55 0.23 85 A4 This experience has made it difficult for me to fall asleep, and my sleep has become very light. Revise My sleep has been affected (e.g., difficulty falling asleep, frequent awakenings, waking up too early).
4.05 50 0.27 65 A5 This event has led to a loss of appetite. Remove
3.75 35 0.31 55 A6 I find it hard to concentrate. Remove
4.45 55 0.17 95 A7 I involuntarily think about things related to the reduction. Revise I uncontrollably think about things related to the reduction.
4.15 45 0.22 75 A8 I often dream about the reduction. Revise I have distressing dreams about the reduction.
4.25 50 0.21 80 A9 Thinking about this event triggers physical reactions, such as sweating, palpitations and shortness of breath. Revise Whenever I recall the reduction, I experience physical discomfort such as palpitations, shortness of breath, or sweating.
3.7 20 0.23 55 A10 After the reduction, I do not want to acknowledge the existence of the reduced foetus(es). Remove
4.05 30 0.19 75 A11 After the reduction, I am afraid to face the fact that the report shows one less foetus. Merge A11 and A12 merged into: I make efforts to avoid anything that reminds me of the reduction.
4.45 60 0.17 85 A12 I try to avoid memories or feelings associated with the event. Merge A11 and A12 merged into: I make efforts to avoid anything that reminds me of the reduction.
3.8 25 0.24 60 A13 I often find myself reminiscing about the time before the reduction. Remove
4 45 0.27 65 A14 Thinking about this makes me cry uncontrollably. Remove
3.9 40 0.31 70 A15 I often imagine what the reduced foetus(es) would have been like. Revise I often involuntarily imagine what the reduced foetus(es) would have looked like
Add Recalling the reduction procedure still makes me feel nervous or fearful.
Loss‐oriented
3.8 30 0.25 55 B1 The decision to undergo reduction was difficult and painful. Remove
4.7 80 0.14 90 B2 I am tormented by doubts about whether the reduction decision was correct.
4.55 60 0.13 95 B3 I feel low‐spirited and depressed.
4.5 55 0.13 95 B4 I often feel guilty about the decision to undergo reduction.
4.1 30 0.18 80 B5 I constantly check for signs that the remaining foetus(es) are still alive. Merge B5, B6 and B8 merged into: I am constantly worried about the health and safety of the remaining foetus(es).
4.45 65 0.20 85 B6 I worry about the prognosis and quality of life of the surviving foetus(es). Merge B5, B6 and B8 merged into: I am constantly worried about the health and safety of the remaining foetus(es).
4 40 0.26 70 B7 After the reduction, I have become overly cautious in my actions, fearing that something might go wrong. Revise I have grown anxious in my conduct, constantly fearing a potential mishap.
4.55 65 0.15 90 B8 I worry that the reduction procedure itself may have harmed the remaining foetus(es). Merge B5, B6 and B8 merged into: I am constantly worried about the health and safety of the remaining foetus(es).
4.15 50 0.24 70 B9 I have lost interest in important activities, such as work, hobbies, sports, or socializing. Revise I have lost interest in activities I previously enjoyed (e.g., hobbies, socializing).
3.8 40 0.31 60 B10 I try to make myself happy but find myself unable to feel joy. Remove
3.9 30 0.23 65 B11 It is painful that no one can truly understand what I am going through. Remove
Add I often become extremely anxious due to minor physical sensations (e.g., changes in foetal movement) and repeatedly seek medical examinations.
Restoration‐oriented
4.75 75 0.09 100 C1 The surviving foetus(es) gives me great hope.
3.95 35 0.24 65 C2 I believe the reduction decision was necessary for my family. Remove
4.3 55 0.20 75 C3 Sometimes I feel I need professional psychological counselling to help me return to a normal life. Merge C3 and C4 merged into: I feel the need for professional psychological counselling to help me return to a normal life.
4 30 0.23 80 C4 After the reduction, I was able to quickly return to my normal life and work routine. Merge C3 and C4 merged into: I feel the need for professional psychological counselling to help me return to a normal life.
4.35 50 0.19 90 C5 I am satisfied with how I coped during and after the reduction, given what I had to go through. Merge C5 and C9 merged into: I am able to overcome the emotional impact of the reduction on me.
4.5 55 0.13 95 C6 I am satisfied with my interactions with my family members during and after the reduction. Merge C6 and C7 merged into: I am satisfied with the family and social support I received during and after the reduction.
3.75 25 0.27 60 C7 I am satisfied with my interactions with my friends during and after the reduction. Merge C6 and C7 merged into: I am satisfied with the family and social support I received during and after the reduction.
3.9 35 0.26 65 C8 I feel the need to talk to someone about my experience. Remove
4.45 50 0.14 95 C9 I am able to overcome the emotional impact of the reduction on me. Merge C5 and C9 merged into: I am able to overcome the emotional impact of the reduction on me.
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3.3. Second‐Round Delphi Survey

In the second round, all 19 items demonstrated satisfactory concentration of expert opinions, with mean importance scores above 3.5 and a full‐mark rate exceeding 20%. However, coordination analysis revealed that three items (A5, A6 and B5) had a CV ≥ 0.30, indicating poor consensus. Among these, item A6 also showed a percentage of agreement below 70% and attracted comments from several experts recommending its removal. Following panel discussions, items A6 and B5 were removed, while A5 was revised. For the instrument as a whole, Kendall's W in this round was 0.159 (p < 0.001).

The remaining 16 items exhibited favourable consensus but still received expert feedback. Based on these comments, four items were revised and two were merged. The final version of the instrument thus consists of 16 items across four dimensions: Post‐traumatic Stress Response (5 items), Depression and Guilt (4 items), Health Anxiety and Concerns (3 items) and Psychological Adjustment and Coping (4 items). All the results of the second‐round analysis are shown in Table 3.

TABLE 3.

Revision of the second version of the instrument based on the second‐round Delphi (n = 22).

Mean score Full mark rate (%) Coefficient of variation Percentage of agreement (%) Original item Type Final item
Post‐traumatic stress response
4.45 64. 0.18 82. A1 I uncontrollably think about things related to the reduction.
4.50 59. 0.15 91. A2 Recalling the reduction procedure still makes me feel nervous or fearful. Merge A2 and A7 merge into: Recalling the experience of foetal reduction causes me psychological and physiological discomfort (e.g., fear, palpitations, shortness of breath).
4.09 41. 0.24 77. A3I have distressing dreams about the reduction.
4.14 50. 0.24 68. A4 I make efforts to avoid anything that reminds me of the reduction.
3.91 41. 0.32 73. A5 I often involuntarily imagine what the reduced foetus(es) would have looked like. Revise I often have intrusive mental images of what the reduced foetus would have been like had it survived.
3.91 32. 0.25 68. A6 My sleep has been affected (e.g., difficulty falling asleep, frequent awakenings, waking up too early). Remove
4.00 36. 0.23 68. A7 Whenever I recall the reduction, I experience physical discomfort such as palpitations, shortness of breath, or sweating. Merge A2 and A7 merge into: Recalling the experience of foetal reduction causes me psychological and physiological discomfort (e.g., fear, palpitations, shortness of breath).
Depression and guilt
4.77 86. 0.13 91. B1 I am tormented by doubts about whether the reduction decision was correct.
4.64 64. 0.11 100. B2 I feel low‐spirited and depressed. Revise Since the foetal reduction, I have felt depressed and lacking in energy.
4.32 55. 0.23 86. B3 I often feel guilty about the decision to undergo reduction. Revise I feel guilty and blame myself for the reduction decision.
4.45 59. 0.17 86. B4 I have difficulty controlling my emotions and am prone to sudden outbursts of crying or anger. Revise I have become prone to crying spells or outbursts of anger, and find it difficult to control my emotions.
4.00 41. 0.28 73. B5 I have lost interest in activities I previously enjoyed (e.g., hobbies, socializing). Remove
Health anxiety and concerns
4.77 77. 0.09 100. C1 I often become extremely anxious due to minor physical sensations (e.g., changes in foetal movement) and repeatedly seek medical examinations. Revise Minor bodily sensations make me intensely anxious, triggering an urge to repeatedly seek reassurance from healthcare providers.
4.77 86. 0.13 91. C2 I am constantly worried about the health and safety of the remaining foetus(es).
4.59 73. 0.17 91. C3 I have grown anxious in my conduct, constantly fearing a potential mishap.
Psychological adjustment and coping
4.36 64. 0.24 82. D1 The surviving foetus(es) gives me great hope.
4.23 50. 0.22 77. D2 I feel the need for professional psychological counselling to help me return to a normal life.
4.59 68. 0.15 91. D3 I am satisfied with the family and social support I received during and after the reduction.
4.41 59. 0.19 86. D4I am able to overcome the emotional impact of the reduction on me.
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3.4. Content Validity

The 15 experts rated the relevance of the 16 items on a four‐point Likert scale. Of these, 13 items received unanimous ratings of 3 (‘quite relevant’) or 4 (‘highly relevant’) from all 15 experts, while the remaining 3 items received ratings of 1 (‘not relevant’) or 2 (‘somewhat relevant’) from some experts. The S‐CVI was 0.983, exceeding the recommended threshold of 0.80, indicating excellent content validity of the PMRPDS.

4. Discussion

Women following MFPR experience a distinct pattern of psychological distress involving both trauma‐related stress responses and complex grieving processes. This study conceptualized the PMRPDS using the Delphi method, integrating findings from a comprehensive literature review and qualitative interviews, yielding a preliminary tool with established content validity for frontline nursing assessment and individualized care planning.

The Delphi method successfully obtained expert input and achieved consensus on the instrument's dimensions and measurement criteria, drawing upon experts' extensive clinical experience with psychological disorders following MFPR. The expert panel was composed to include multidisciplinary backgrounds, encompassing all key specialties involved in the care of pregnant women undergoing foetal reduction, ensuring that the conceptualisation of the instrument incorporated comprehensive clinical perspectives. The two Delphi rounds achieved high response rates of 90.9% and 91.7% respectively, demonstrating strong expert engagement. The experts' Cr for the two rounds were 0.885 and 0.889, respectively, reflecting a high level of reliability of the findings. The Kendall coefficients of 0.142 and 0.159 suggested increasing alignment of expert opinions across rounds, ultimately leading to stable consensus on all 16 preliminary items. Content validity was supported by an S‐CVI of 0.983, confirming that the PMRPDS items are highly relevant for assessing psychological distress in women following MFPR.

The dimensional structure of this instrument is theoretically grounded in Stroebe and Schut's Dual‐Process Model and the PTSD model. The Dual‐Process Model, originally developed to explain psychological adjustment following bereavement (Larsen et al. 2025; Stroebe and Schut 1999; Yu et al. 2024), has been widely applied to reproductive health contexts such as miscarriage and stillbirth (Black 2020). Building on this expanded usage, our study preliminarily explores its utility in understanding the psychological experience following MFPR, thereby contributing to the further broadening of its theoretical scope. Theoretical analysis indicates that women need to maintain a healthy oscillation between loss orientation, which involves grieving the reduced foetus and restoration orientation, which entails preparing for the surviving foetus and future maternal identity. However, the traumatic nature of foetal reduction surgery, as described by the PTSD framework through symptoms such as intrusive memories, avoidance and hyperarousal, may severely disrupt this process (Williamson et al. 2021). Such disruption can trap individuals in a predominantly loss‐oriented state, while rendering the restoration‐oriented process filled with fear and anxiety. Guided by this theoretical framework, the initial structure of three dimensions was later refined through expert consultation into four domains. Dimension 1 (Post‐traumatic Stress Response) and Dimension 2 (Depression and Guilt) capture pathological manifestations of being stuck in loss orientation; Dimension 3 (Health Anxiety and Concerns) reflects obstacles in restoration orientation due to trauma‐driven fear; Dimension 4 (Psychological Adjustment and Coping) assesses key psychological adaptation processes and social support that facilitate healthy oscillation. Unlike previous instruments that focused solely on trauma or grief (Dryer et al. 2022), this preliminary instrument is the first to systematically assess both processes simultaneously in this population.

This study underwent a scientific process from comprehensiveness to refinement. An initial pool of 35 items was generated from literature review, existing scales and individual interviews to ensure broad content coverage, which was then optimized through quantitative analysis and qualitative expert feedback. The revision process, guided by expert recommendations, merged overlapping items, clarified ambiguous phrasing and removed theoretically misaligned content. The resulting consensus‐based 16‐item preliminary instrument succinctly captures core psychological vulnerabilities after MFPR while minimizing respondent burden.

This study has limitations. The expert panel was predominantly composed of healthcare professionals from tertiary hospitals in a single region, which may affect the instrument's applicability across diverse healthcare settings. Due to notable variations in medical systems and cultural backgrounds across regions, future research should focus on conducting multicentre validation studies that include experts from various geographical locations and different levels of healthcare institutions to further examine the scale's generalizability. Additionally, cross‐cultural adaptation studies should be advanced to investigate the scale's performance across different cultural contexts, thereby progressively enhancing its international applicability.

5. Implications for Nursing Application

In routine clinical practice, the preliminary PMRPDS is intended to offer frontline nurses a specialized tool for assessing psychological distress after MFPR. Through its four‐dimensional framework, the instrument enables nurses to precisely identify patient needs and translate assessment findings into targeted nursing actions: the Post‐traumatic Stress Response dimension facilitates timely referral to trauma‐focused mental health support; the Depression and Guilt dimension aids in prioritizing emotional support and grief counselling during daily nursing rounds; the Health Anxiety dimension highlights areas for targeted obstetric psychoeducation; and the Psychological Adjustment dimension helps uncover personal resilience resources, offering an entry point for strengths‐based care planning. The instrument can be seamlessly integrated into nursing practice at three key post‐procedure time points: at 1 day, as an initial screening tool to capture acute psychological responses and identify high‐risk women; at 1 week, to monitor early responses, evaluate initial intervention effectiveness and dynamically adjust care; and at 1 month, to assess recovery trajectories and inform continuity‐of‐care planning. For example, in future applications, a total score above a predefined threshold at 1 day post‐procedure can trigger a standardized referral pathway to perinatal mental health specialists, accompanied by a nursing care plan that includes daily emotional check‐ins during hospitalization, family involvement and post‐discharge telephone follow‐up at 1 week and 1 month. This approach is supported by evidence that maternal anxiety influences foetal development and long‐term child outcomes, underscoring the importance of timely referral and ongoing evaluation (Wakui et al. 2025).

6. Conclusions

The two‐round Delphi consultation successfully established expert consensus on the content of PMRPDS, a 16‐item instrument structured across four dimensions. This scientifically grounded tool enables frontline nurses and healthcare providers to systematically assess psychological distress in women following MFPR, helping identify specific challenges and protective factors in their adaptation process. By integrating this scale into routine nursing practice, nurses can move beyond subjective judgement to deliver structured, evidence‐based psychosocial support, thereby strengthening holistic nursing assessment and advancing patient‐centred perinatal mental health services. Although the instrument shows significant promise for clinical use, further psychometric validation is required.

Author Contributions

Jin Xu: conceptualization, data curation, formal analysis, methodology, investigation, supervision, project administration, writing – review and editing, writing – original draft, validation, software. Qingge Li: writing – original draft, writing – review and editing, investigation, data curation, formal analysis, project administration, funding acquisition, conceptualization, methodology, software. Hong Wen: writing – original draft, formal analysis, conceptualization, methodology, supervision. Cuiwei Ye: formal analysis, writing – original draft. Ge Peng: data curation, investigation, formal analysis.

Funding

This work was supported by the 2024 Medical Science and Technology Project of Zhejiang Province (No. 2024KY1156) and the 2023 Medical Science and Technology Project of Zhejiang Province (No. 2023KY126).

Ethics Statement

Research Ethics Committee approval was obtained from the Ethics Committee of Women's Hospital, School of Medicine, Zhejiang University (approval numbers IRB‐20240039‐R) prior to data collection.

Consent

Written informed consent was obtained from all participants.

Conflicts of Interest

The authors declare no conflicts of interest.

Acknowledgements

We sincerely thank all the experts who participated in this study for their valuable contributions and support, especially those involved in the Delphi consultation. We also thank Charlesworth Author Services (https://www.cwauthors.com) for English language editing and review services.

Data Availability Statement

The datasets generated and/or analysed during the current study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets generated and/or analysed during the current study are available from the corresponding author upon reasonable request.

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