Italian Translation and Cultural Validation of the Physiological Practices Observation Tool: A Tool for Midwifery Practice

OBJECTIVES: This study aimed to translate and culturally validate the Physiological Practices Observation (PPO) tool into Italian version (PPO-ITA) to enable systematic observation of midwifery care practices that support physiological labor and birth in Italy. Given the high medicalization of childbirth in Italy, the availability of a culturally adapted tool is essential for evaluating and improving midwifery-led care. METHODS: The translation and adaptation process followed the five-step methodology proposed by Sousa and Rojjanasrirat: forward translation, synthesis, back translation, second synthesis, and cognitive debriefing. Two bilingual translators conducted independent forward and backward translations. A multidisciplinary expert panel reviewed discrepancies and ensured conceptual equivalence. Twelve Italian-speaking midwives participated in cognitive debriefing to assess clarity and content validity. Feedback informed revisions to produce the final PPO-ITA version. RESULTS: The translation process revealed challenges in conveying midwifery-specific concepts such as “advocates” and “praising,” which lack direct Italian equivalents. Inclusive language (donna/persona assistita) was adopted to reflect evolving gender awareness. Cognitive debriefing led to the revision of Domain 6, aligning it with Italian national guidelines on postpartum care. One item was removed and another revised, resulting in a final tool comprising 7 domains and 30 items. CONCLUSIONS: The PPO-ITA tool is a culturally adapted, linguistically validated instrument suitable for observing midwifery practices in Italy. It preserves the conceptual integrity of the original PPO while reflecting local clinical and cultural contexts. Its implementation may enhance research on physiological childbirth and support evidence-based midwifery care in diverse Italian settings.