STRENGTHENING WOMEN FOR THE FIRST BIRTH:
Identifying and enhancing self-efficacy for childbirth in primiparas
Background for the study:
Evidence demonstrates that management of early labour has an impact on maternal and
neonatal outcomes. Research findings show that women who are admitted in the active phase
of labour (4cms cervical dilatation and regular contractions), experience less interventions and
complications than those admitted in the latent phase of labour (3cms cervical dilatation or
less) [1, 2]. While the advantages of delayed-admission to hospital during the latent phase of
labour are documented, the efficacy of strategies designed to achieve the same remains at best
equivocal. For example assessment and midwife support at home versus support by telephone
reduced the amount of visits to hospital in latent labour but did not impact upon caesarean
section rates [3]. Likewise, there were no differences in time of admission or caesarean
section rates when comparing home visits with standard care in early labour [4]. Use of an
algorithm to assist midwives with the diagnosis of active labour showed no reduction in the
rate of intranatal interventions in relation to spontaneous labour [5]. Women who received an
intervention of structured care for minimum one hour on admission were no less likely to
have a spontaneous vaginal birth than those receiving standard care [6]. The efforts to keep
women home in early labour do not seem to have proved effective in reducing the numbers of
interventions women experience when they are admitted. In addition, care in early labour may
not meet women’s needs; many women want to be admitted during the early phase of labour
while the institutions may be want them to stay home longer [7, 8]. The results of these
studies indicate the importance of developing a women-centred approach to the management
of the early phase of labour.
Midwives’ overall priorities and strategies when communicating with first-time mothers in
early labour are to empower them to remain at home as long as possible [9]. In a Swedish
study, women who wanted to be admitted in the latent phase of labour mainly did so because
they sought reassurance or wished to hand over responsibility for the labour to care takers
[10]. Women who remained at home until the active phase of labour had an experience of
maintaining power [11]. The authors concluded that women’s power was constituted by a
driving force towards a particular goal; namely birth and motherhood. It is indicated that the
women’s level of self-efficacy was high in this specific situation. Self-efficacy involves an
individual’s evaluation of their capability to cope and perform required behaviour within a
specific situation [12]. Self-efficacy Theory differentiates between two components; self1
efficacy expectations and outcome expectations. They are differentiated because individuals
can believe that a certain behaviour will result in a specific outcome; however, they may not
believe that they are capable of performing the behaviour required for the outcome to occur.
The Childbirth Self-Efficacy Inventory (CBSEI) measures both outcome expectancies and
self-efficacy expectancies for coping with an approaching childbirth [13, 14], and can be used
to evaluate women’s level of confidence for labour prior to birth. The CBSEI is validated and
has shown internal consistency in different cultures [13, 15-17].
An important feature of the self-efficacy theory is the assumption that exposure to
different conditions can result in behavioural change by altering an individual’s level and
strength of self-efficacy. In the aforementioned Swedish study, the authors indicate that the
women who remained at home until the active phase of labour seem to have high levels of
self-efficacy [11]. Consequently, we may infer that the women who wanted to be admitted in
the latent phase had lower levels of self-efficacy in the specific situation [10]. However, we
do not know their levels of self-efficacy before the onset of labour (late pregnancy), or if it
changed due to the perception of the latent phase of labour. This indicates that one way for
women to have the confidence to stay home in the early phase of labour is by strengthening
self-efficacy for labour.
Defined as an expectancy-value theory of human motivation, Self-Efficacy Theory by
Bandura (1977) recognises that there are two significant determinants of motivated behaviour:
 the subjective value that the person places on the behaviour
 their perception concerning the probability they will succeed – referred to as
‘expectancy for success’ (Keller 1986)
If a “motivational balance” exists between the amount of value and expectancy for success
then behaviourally persistence and effort to perform will also be positively influenced [18].
This resonates with a study from New-Zealand, were stronger self-efficacy in primiparous
women did predict increased birth satisfaction, regardless of obstetric interventions during
labour and birth [19]. Strong self-efficacy beliefs prior to birth was furthermore found to
predict reduced pain experiences and distress in labour, but did not predict obstetric
interventions.
Although many practitioners recognise the advantages of strong maternal confidence (selfefficacy) achieving the same through routine antenatal education is not straightforward.
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The ARCS Model of Motivational Instructional Design is a widely applied model that is both
simple and powerful in its approach [20]. The conceptual foundation for the model is based
primarily on an expectancy-value approach to motivation. Because an individual’s level of
self-efficacy for a specific situation can be subject to change, an intervention in pregnancy
based on the ARCS model could be a way to intervene prior to the onset of labour. A
structured antenatal training program has been tested in a trial in Denmark [21]. The
primiparous women who attended ‘The Ready for Child’ program arrived more often at the
labour ward in active labour compared with those in the reference group. There were no
differences in in the women’s ability to cope with fear on arrival, and this may indicate that
the women who attended the structured antenatal training program were better able to cope in
early labour at home. The women in the intervention group used less epidural analgesia
during labour, but not less pain relief overall. Medical interventions and the women’s selfreported birth experiences were similar in the two groups. This study did not focus explicitly
on self-efficacy though, the described intervention provided information on pregnancy, the
birth process, infant care and early parenthood. The program was given by midwives who
were specifically instructed for this purpose. An educational intervention to improve firsttome mother’s ability to cope with childbirth was performed in China [22]. The intervention
was based on Bandura’s self-efficacy theory and comprised two 90-minute interactive
educational sessions between the 33rd and 35th pregnancy weeks, although not based on the
ARCS model. The experimental group was significantly more likely than the control group to
demonstrate higher levels of self-efficacy for childbirth after the intervention. Twenty-four to
48 hours postnatally the experimental group reported lower perceived anxiety and pain in the
early and middle stages of labour than the control group. Secondary outcome measures such
as rates of interventions or mode of labour are unfortunately not reported from this study.
Objectives of the study:
 To describe levels of self-efficacy in primiparous women in late pregnancy and in the
latent phase of labour.
 To identify relationships among levels of self-efficacy in late pregnancy and in the
latent phase, cervical dilatation on arrival, interventions, mode of labour, women’s
satisfaction with childbirth and postnatal well-being.
 To develop and test a structured antenatal training program specifically aimed at
strengthening self-efficacy for childbirth.
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Research questions:
 Are levels of self-efficacy for childbirth in primiparous women persistent from late
pregnancy to the latent phase of labour?
 Do levels of self-efficacy for childbirth in primiparous women in late pregnancy (SE 1)
predict hospital admission status, interventions, mode of labour, satisfaction with
childbirth and post-natal well-being?
 Do levels of self-efficacy for childbirth in primiparous women in the latent phase of
labour (SE 2) predict hospital admission status, interventions, mode of labour,
satisfaction with childbirth and post-natal well-being?
 Do possible relations between SE 1 and SE 2 in primiparous women predict hospital
admission status, interventions, mode of labour, satisfaction with childbirth and postnatal well-being?
 Can an intervention in pregnancy based on the ARCS model enhance self-efficacy for
childbirth in primiparous women?
 Can an intervention in pregnancy based on the ARCS model have impact on cervical
dilatation on arrival at the maternity ward, medical interventions, mode of labour,
satisfaction with childbirth and postnatal well-being in primiparous women?
Design:
The study will have two phases: the first will be observational and the second phase will be
experimental.
In phase one, women who are expecting a first child will be asked to complete the CBSEI in
34th to 36th week of pregnancy and 2 to 4 hours after subjective onset of labour. Postpartum
measures of satisfaction will include the Maternal perceptions of Support and Control in
Birth questionnaire (SCIB) [23] and the Women’s Views of Birth Labour Satisfaction
Questionnaire (WOMBLSQ) [24]. Maternal well-being will be measured by the MotherGenerated Index (MGI) [25, 26]. Information about cervical dilatation on arrival,
interventions and mode of labour will be collected from the women’s hospital records.
Based on the results form phase one, a structured antenatal training program will be
developed in line with the ARCS model of motivational instructional design [20]. In phase
two, the program will be tested through a randomised controlled trial with levels of selfefficacy for childbirth as the main outcome. Secondary outcomes will be cervical dilatation
on arrival at the maternity ward, medical interventions, mode of labour, satisfaction with
childbirth and postnatal well-being.
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