Journal of Midwifery & Women’s Health
www.jmwh.org
Original Review
A Systematic Review of Maternal Confidence for Physiologic Birth: Characteristics of Prenatal Care and Confidence Measurement
CEU
Melissa D. Avery, CNM, PhD, Melissa A. Saftner, CNM, PhD, Bridget Larson, MPH, Elizabeth V. Weinfurter, MLIS
Introduction: Because a focus on physiologic labor and birth has reemerged in recent years, care providers have the opportunity in the prenatal period to help women increase confidence in their ability to give birth without unnecessary interventions. However, most research has only examined support for women during labor. The purpose of this systematic review was to examine the research literature for information about prenatal care approaches that increase women’s confidence for physiologic labor and birth and tools to measure that confidence. Methods: Studies were reviewed that explored any element of a pregnant woman’s interaction with her prenatal care provider that helped build confidence in her ability to labor and give birth. Timing of interaction with pregnant women included during pregnancy, labor and birth, and the postpartum period. In addition, we looked for studies that developed a measure of women’s confidence related to labor and birth. Outcome measures included confidence or similar concepts, descriptions of components of prenatal care contributing to maternal confidence for birth, and reliability and validity of tools measuring confidence. Results: The search of MEDLINE, CINAHL, PsycINFO, and Scopus databases provided a total of 893 citations. After removing duplicates and articles that did not meet inclusion criteria, 6 articles were included in the review. Three relate to women’s confidence for labor during the prenatal period, and 3 describe tools to measure women’s confidence for birth. Discussion: Research about enhancing women’s confidence for labor and birth was limited to qualitative studies. Results suggest that women desire information during pregnancy and want to use that information to participate in care decisions in a relationship with a trusted provider. Further research is needed to develop interventions to help midwives and physicians enhance women’s confidence in their ability to give birth and to develop a tool to measure confidence for use during prenatal care. c 2014 by the American College of Nurse-Midwives. J Midwifery Womens Health 2014;59:586–595 Keywords: confidence, physiologic birth, pregnancy, prenatal care, self-efficacy
INTRODUCTION
Returning to a normal or physiologic approach to labor and birth has reemerged in the literature and in clinical practice over the last 2 decades.1–6 In 1996, the World Health Organization recommended observation of a woman’s labor progress and not intervening in normal labor without a significant indication, personalized support to women by trusted individuals, encouraging freedom of movement and nonsupine positions, and immediate skin-to-skin contact and breastfeeding following birth.7 This focus on normal birth is the result of decades of increasing use of technology in childbirth worldwide. In the United States, this is evidenced by a 32.8% rate of cesarean,8 51.4% rate of induction of labor,9 and 61% rate of epidural use.10 Evidence supports a more physiologic approach to labor and birth, including a greater reliance on midwives and family physicians.4 The Maternity Care Working Party in the United Kingdom has defined a normal birth as one “without induction, without the use of instruments, not by caesarean section and without general, spinal or epidural anaesthetic before or during delivery.”11 In the United States, a task force of 3 midwifery organizations defined normal Address correspondence to Melissa Avery, CNM, PhD, University of Minnesota, School of Nursing, 5-140 Weaver Densford Hall, 308 Harvard St. SE, Minneapolis, MN 55455. E-mail: [email protected]
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physiologic labor and birth as “one that is powered by the innate human capacity of the woman and fetus.”12 The care processes and interventions that were recommended to support physiologic birth primarily relate to the support and management techniques that occur during labor and at the time of birth rather than the prenatal preparation for confident use of such techniques. Pregnancy is a time to promote health and well-being for the woman and fetus and to prepare for labor and birth. Most women receive some form of prenatal care from a licensed care provider, and care providers can partner with women to help increase their confidence in the ability to experience labor and give birth without the overuse of interventions.13 However, prenatal care is often based on a risk management approach to care that focuses on monitoring the status of the woman and fetus to identify and prevent problems.14 There is currently little guidance available for providers about specific care processes to support women during pregnancy to enhance their confidence and planning for a physiologic birth. The purpose of this systematic review was to examine the research literature for information about prenatal care approaches that increase women’s confidence or belief in their ability to accomplish a physiologic labor and birth, as well as tools to measure women’s confidence to give birth physiologically. The term confidence has been used in recent publications calling for a change in the approach to labor and
c 2014 by the American College of Nurse-Midwives
✦ Obtaining information, participation in decision making, and a respectful partnership with the prenatal care provider are key ingredients for women to build their confidence for labor and birth. ✦ Evidence for specific techniques for clinicians to use during prenatal care to help women enhance their confidence for labor and birth is limited. ✦ Existing tools for measuring women’s confidence for labor and birth have been used in a research context and have not been developed for use by clinicians. ✦ Research is needed to better understand how providers can help women increase confidence during pregnancy, develop and test specific interventions, and develop a valid tool for clinical use.
birth and in the way that care providers help women prepare for their birth15–17 ; however, we were unaware of specific research explaining how to help women gain confidence during pregnancy to promote the labor and birth process. In her concept analysis, Perry described confidence as the belief in one’s own abilities and the ability to succeed, a term that is contextually dependent.18 Thus, it may be possible to enhance and measure maternal confidence prenatally through provider practice. Specifically, we asked: 1) What characteristics of prenatal care help low-risk women attain confidence to give birth physiologically? and 2) What tools can be used to measure a woman’s confidence in her ability to labor and give birth physiologically? METHODS
The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist,19 a protocol for reporting on the completeness of a systematic review and meta-analysis, was used to guide this review. It may be used for research of any study design and is not an assessment of the quality of studies included in the review.19,20 We anticipated few studies addressing our questions; therefore, we examined published studies regardless of design or publication date. Studies exploring any element of a pregnant woman’s interaction with her prenatal care provider that helped her build confidence in her ability to labor and give birth, or that addressed a similar concept, were reviewed. In addition, we looked for studies that developed or utilized a measure of women’s confidence related to labor and birth, including previously validated tools that were examined in a new population. Presentation abstracts from selected conferences and dissertations, if they met our criteria and were available for review, were included. See Supporting Information: Appendix S1 for the search strategy. A single search strategy was used for both research questions. Studies were identified by searching electronic databases, reviewing reference lists, and hand-searching relevant conference proceedings with no limits for language or year. The librarian constructed search strategies optimized for Ovid MEDLINE, Ovid MEDLINE In-Process & Other Non-Indexed Citations, CINAHL, PsycINFO, and Scopus. Initial search terms included “self-concept,” “self-efficacy,” “internal-external control,” “self-control,” or “confidence.” Journal of Midwifery & Women’s Health r www.jmwh.org
These terms were combined with the terms “prenatal care,” “pregnancy,” or “obstetric labor or delivery.” The last search was run on July 11, 2013. In addition, presentation titles and abstracts from any of The Normal Labor and Birth Research Conferences, an international conference launched in England in 2002, were reviewed. Two authors (MA and MS) independently reviewed all titles and abstracts for all identified sources to determine articles for inclusion. Irrelevant items were excluded; publications noted as potentially relevant by any author were retrieved in full text. Data were abstracted from selected studies using a table that included the author, study design, research aim, participants, pregnancy status, age range, inclusion criteria, and outcomes. Articles identified for potential inclusion were carefully reviewed for consistency with inclusion criteria. Reviewers coded articles as yes, no, or possible. Any disagreements were discussed with a third author (BL) and resolved by discussion and consensus. Confidence is closely related to self-efficacy, as conceptualized by Bandura,21 and the 2 terms used interchangeably in many articles that we reviewed may be considered surrogates of each other in nursing literature.18 Confidence is defined as the belief in one’s own abilities and ability to succeed; self-efficacy is the belief in one’s ability to execute actions to reach a particular goal.18,21 Control has been used in research regarding women’s preparation for birth, but this concept may not be appropriate for the unpredictable experience of birth and for women across cultures22,23 ; thus, studies focusing on control and its measure were excluded. Research about prenatal classes has not been shown to be sufficient to answer questions about their effectiveness of prenatal classes,24 and the classes are typically not taught by prenatal care providers, so those studies were also excluded. Additional studies that validated original tools that measure maternal confidence in diverse populations were summarized but not included in this review. Information was abstracted from each selected study, including participants’ age and if data were collected during pregnancy, postpartum, or both. Descriptive data related to physiologic birth (if any) such as mode of birth, use of pharmacologic pain relief, and incidence of spontaneous labor were recorded. Any characteristics of prenatal care that 587
IdenƟficaƟon
Records idenƟfied through database searching n = 893
AddiƟonal records idenƟfied through other sources n=7
Eligibility
Screening
Records aŌer duplicates removed n = 737
Records screened n = 737
Records excluded n = 636
Full-text arƟcles assessed for eligibility n = 101
Full-text arƟcles excluded Not related to research quesƟon, n = 78 Not research, n = 15 Unable to obtain, n = 2
Included
Studies included in qualitaƟve synthesis n=6
Studies included in quanƟtaƟve synthesis (meta-analysis) N/A
Figure 1. Results of Search Strategy for Systematic Review of Maternal Confidence for Physiologic Birth
promoted maternal confidence were also collected. For studies examining tools to measure maternal confidence, age of participants and measures of reliability and validity of tools were abstracted. RESULTS
The search of MEDLINE, CINAHL, PsycINFO, and Scopus databases provided a total of 893 citations (Figure 1). After removing duplicates and articles that did not meet inclusion criteria, 6 articles were included in the review. Three relate to women’s confidence for labor during the prenatal period, and 3 describe tools to measure women’s confidence for birth. Question 1: What Characteristics of Prenatal Care Help Low-Risk Women Attain Confidence to Give Birth Physiologically?
The 3 studies that contributed to answering question 1 are summarized in Table 1. They were qualitative in design, utilizing grounded theory, grounded theory plus interpretive phenomenology, and qualitative descriptive approaches M.25–27 The studies included 66 women aged 17 to 45 years (age pro588
vided in 2 of 3 studies) interviewed during the postpartum period in the first 5 weeks following birth. In 2 of 3 studies, women with an uncomplicated birth (not defined) or a spontaneous vaginal birth were recruited. Researchers interviewed women cared for by a particular midwifery practice29 or either physicians or midwives.27,28 Interviews were conducted face-to-face, audio-recorded, and lasted 45 minutes to 2 hours (duration provided in 2 studies). For 2 studies, the interview style was semistructured; in the third, it was open-ended and progressing to a more directive style. Study outcomes were themes that were related to women’s relationships with their prenatal care providers and the impact of the relationships on their development of confidence and the ability to make informed choices about care with their care providers and preferred sources of information. Additional outcomes included building confidence in women’s ability to labor and give birth without pharmacologic methods, learning from other women, and continuity of the care provider. No studies specifically defined or measured physiologic birth as an outcome. Brown25 used grounded theory to explore women’s search for knowledge, perception of self-efficacy, and patterns of involvement in childbirth. Interviews were conducted with Volume 59, No. 6, November/December 2014
Journal of Midwifery & Women’s Health r www.jmwh.org
589
Leap et al27
Coughlan & Jung26
Brown25
Author
Research Aim
Postpartum
Age Range
Inclusion Criteria
Outcomes
descriptive
other women’s stories in the
labor
after birth
myself; pride and elation
when I didn’t believe in
labor; she believed in me
coping with pain during
antenatal group; support for
birth at home; learning from
who would be there in labor; practice
building confidence to give
during pregnancy; knowing within single midwifery
support for pain in
(ࣙ4weeks)
Themes: building confidence
preparation and
of care model on
influence of continuity
Spontaneous vaginal birth
provider. 17-38
relationship Postpartum
choices respected by health
promoted by provider
theory 10
make informed choices, and midwife
agency can be
and grounded
Explore perceived
digest health information,
physician or licensed
Qualitative:
Agency is ability to access and
Birth with fee-for-service
19-45
of health care, how
Postpartum
midwife
involvement in care 40
relationship
setting with physician or
self-efficacy, and Explore agency in context
woman–provider
Themes: knowing all I could; confidence; nature of the
Insured women; first hospital or alternate birth
Not reported uncomplicated birth in
Postpartum
knowledge, perceived
16
Participants, N
for childbirth
Explore women’s search
Pregnant/
phenomenology
Qualitative:
grounded theory
Qualitative:
Study Design
Table 1. Summary of Included Studies Related to Women’s Confidence for Labor and Birth
16 insured postpartum women after a first uncomplicated birth. Participants had either given birth in one of several hospitals with physicians or in an alternative setting (not defined) with midwives. Themes identified included “knowing all I could,” “confidence,” and “nature of the woman/provider relationship.” Brown described the search for knowledge as the key concept that is essential to a woman’s developing confidence and influenced by her relationship with her prenatal care provider. Women searched for information during pregnancy using multiple sources. Experience and information “increased their childbearing confidence.” Knowledge gain was related to women’s relationship with their prenatal care provider and enhanced by a perceived close relationship and provider credibility. Brown concluded that prenatal care providers can increase women’s confidence for labor and birth and help women feel empowered to participate in their individual care. One participant remarked: “There was something about the way the midwives related to us that made me feel like, well, this is something all women can do, and I can do this.”25 Exploring agency (independence, ability to act in their own interest) in health care from the patient’s perspective, as well as understanding how the health care relationship impacts agency, were the focus of Coughlin and Jung’s study.26 Using grounded theory and interpretive phenomenology, 40 women from diverse socioeconomic backgrounds who received care from either male or female fee-for-service physicians or licensed midwives (gender not specified) were interviewed. Women were asked about their experience with the health care system; interactions with their male or female physicians or midwives; experiences during pregnancy, birth, and postpartum; and their overall satisfaction. Agency—or independence—was understood by participants as the ability to discuss health care information, make informed choices, and have those choices respected by their care provider. Researchers found no difference in descriptions of physician interaction by gender; satisfaction/dissatisfaction with physician care resulted from attitudes and behaviors perceived during care. Women were satisfied with care when physicians listened to their concerns and treated them respectfully and when they were able to obtain information and participate in care decisions. No participant stated that the physician was the top source of information. Women who received care from midwives reported the greatest satisfaction. Midwives were typically women’s top source of information, and women reported that their midwife helped them feel more confident in their ability to negotiate labor and birth. Women cared for by midwives were more mobile in labor and more often declined medications and were assertive about care choices. The following quote highlights their expressed confidence: “I felt that I was very self-confident about what I wanted and what I was doing during the labour—and felt that (the midwife) supported me in this. I was able to make choices for the most part.”26 Leap et al27 interviewed 10 racially diverse, low-income women from a specific midwifery practice with more home births and less medication use in labor compared to other local midwifery practices. The practice demonstrated 40% to 50% home births, 90% spontaneous labor, 15.5% cesareans, and high rates of breastfeeding. Women and their partners 590
could attend group sessions facilitated by the midwives with a focus on networking and sharing information among the women. Participants were asked to reflect on their support and preparation for labor and birth, specifically on support with labor pain. The practice utilized a midwifery continuity care model defined as care by 2 specific midwives throughout pregnancy, labor, birth, and the early weeks postpartum. Themes identified were “building confidence during pregnancy,” “continuity of carer: knowing who would be there in labor,” “building confidence to give birth at home,” “learning from other women’s stories in the antenatal groups,” “support for coping with pain during labor,” “she believed in me when I didn’t believe in myself,” and “pride and elation after birth.” The women described that the trusting relationship with their midwives helped them build confidence in their ability to labor and give birth without pharmacologic pain relief. Women linked their increased confidence to midwives providing information and discussing choices in a collaborative way. Continuity of care from a known midwife, learning from other women during optional antenatal group sessions, and support during the labor process were important to study participants. This quote highlights women’s confidence: The midwives encouraged me a lot, they talked to me a lot and made me feel that I was OK, and I’m strong, and the baby is a happy baby. Through the pregnancy they made me feel that pregnancy is a good thing and interesting to them, you know? So they made me feel . . . everything about me is something that I can do.27 Overall, the results of these 3 studies contribute to answering question 1 and suggest that women prefer a respectful and connected partnership with their pregnancy care provider through which they gain confidence as they increase their knowledge within that relationship. Gaining information during pregnancy and using that information to participate in care decisions with a trusted provider appears to further contribute to enhanced confidence. Provider confidence in the women helped women feel confident in themselves. These data resulted from analyses of individual interviews with women and not from quantitative measurement of confidence for physiologic birth. Bias
Although qualitative studies do not aim for generalizability, it is helpful to consider the samples included and how the authors address transferability (ie, the application of study results beyond individual studies).28 Brown25 recruited women with health insurance to reduce socioeconomic effects, resulting in a more homogenous sample. In addition, although participants were drawn from physician practices representing multiple hospitals, women recruited from midwifery practices gave birth in alternate settings, thus comparing subgroups of participants with perhaps differing views of pregnancy and birth. Coughlan and Jung26 recruited from fee-for-service physicians (including both male and female) and licensed midwives with a goal of a broad diversity of women. Leap et al27 selected women from a specific midwifery practice caring for a lower socioeconomic population and recruited across racial groups, with a goal to interview women from a practice with a high rate of home birth and low use of pharmacologic Volume 59, No. 6, November/December 2014
pain relief in labor compared to other local midwifery practices. No authors addressed efforts to assure transferability or trustworthiness of their studies, including researcher effects in the study.28,29 Question 2: What Tools Can Be Used to Measure a Woman’s Confidence in Her Ability to Labor and Give Birth Physiologically?
Confidence for childbirth has been measured in various ways. Three studies were located describing the development of instruments to measure women’s confidence for labor and birth. These are summarized in Table 2. Two studies were conducted in the United States and one in Germany. They included a total of 711 women aged 18 to 45 years. Tools included the Childbirth Self-Efficacy Inventory (CBSEI), the Labor and Birth Self-Efficacy Questionnaire,30 and the Confidence and Trust in Delivery Questionnaire. The most widely used tool measuring self-efficacy for childbirth is Lowe’s CBSEI.30 The CBSEI is organized into 4 subscales with 15 to 16 questions in each subscale. The subscales include the self-efficacy expectancy for active labor, outcome expectancy for active labor, self-efficacy expectancy for the second stage of labor, and outcome expectancy for the second stage of labor. Subscales measure the behaviors that a woman believes will be most beneficial in labor, as well as the woman’s beliefs that she will perform those behaviors during labor. Respondents use a 10-point Likert scale that ranges from “not at all helpful” to “very helpful” for the outcome expectancy subscales and “not at all sure” to “very sure” for the self-efficacy expectancy subscales. Scores range from 0 to 150 on the active labor scales and 0 to 160 on the second stage of labor scales. Higher scores indicate higher self-efficacy or outcome efficacy for birth. Cronbach’s alpha for the subscales range from 0.86 to 0.95. One important finding from the tool’s validation is that multiparous women have higher self-efficacy for labor and the second stage, suggesting that experience with childbirth increases self-efficacy for childbirth. The CBSEI has been validated in English-speaking countries outside the Unites States including Australia and Ireland.31,32 Both Drummond and Rickwood31 and Sinclair and O’Boyle32 found high reliability on validation of the CBSEI (␣ ⬎ 0.90; ␣ = 0.91-0.94, respectively). Whereas Sinclair and O’Boyle concluded that the CBSEI was appropriate to use with Irish women, Drummond and Rickwood noted that Australian women did not differentiate the active phase and second stage of labor. Therefore, the CBSEI is a unidimensional tool for that population. Additionally, multiparous women with positive past labor and birth experiences had higher selfefficacy scores compared to those with negative experiences. The tool has also been translated and validated in Spanish, Swedish, Persian, Thai, and Chinese.33–38 High tool reliability was consistent across all translations and validation with non-American women. Similar to Australian women, Thai, Chinese, and Iranian women did not differentiate between the active phase of labor and the second stage.35,37,38 Culture can influence how a woman perceives labor, including viewing labor and birth as separate stages or seeing the process as fluid and not separated into phases. In the United States, labor and birth are typically described as 2 distinct phases. Journal of Midwifery & Women’s Health r www.jmwh.org
Two other tools were found in the search process. Bocchese39 developed the Labor and Birth Self-Efficacy Questionnaire (LBSEQ). This tool, based on Bandura’s concept of self-efficacy, measured a woman’s self-efficacy for labor and birth. Bocchese surveyed 140 women about their confidence that they could complete various tasks related to labor (eg, complete breathing exercises during labor, find ways to lessen the pain of labor). The LBSEQ’s content was validated by a panel of 4 doctorally prepared faculty members and a practicing nurse-midwife and had a reliability alpha coefficient of 0.77. Further factor analysis and validation were not conducted, and there is no evidence that further work has been done with this tool. This tool focused specifically on the beliefs and self-efficacy of women to cope with labor. There is no indication of how women gained the confidence or conversely lacked confidence to give birth. More recently, Jeschke, Ostermann, Dippong, Brauer, and Matthes40 developed the Confidence and Trust in Delivery Questionnaire (CTDQ). Two hundred twenty-one German women completed the CTDQ and a factor analysis was performed to determine validity. The tool aims to assess confidence and trust women have in birth prenatally. Factor analysis resulted in an 11-item scale with 4 distinct subscales: confidence (␣ = 0.82), partner support (␣ = 0.62), trust in medical competency (␣ = 0.68), and being informed (␣ = 0.60). The authors note that the scale may be limiting given the short nature of the survey. However, it could be a quick and efficient way for midwives and physicians to determine how a woman feels about her impending labor and birth. Similar to previously reviewed tools, there is no indication how women can gain confidence for birth in the prenatal period or how prenatal providers can support confidence-building. All 3 tools found in the review measure a woman’s perception of self-efficacy related to childbirth. Lowe’s tool30 is the most widely used and validated tool and offers a reliable and valid tool to assess self-efficacy before childbirth. Yet, the tool, like those developed by Bocchese39 and Jeschke et al40 only measures the woman’s inherent self-efficacy. Of the 3 tools, the CBSEI and the CTDQ are the most valid and reliable tools for clinicians to measure confidence, with the CBSEI tested across cultures. However, despite the efficacy of the tools, the process of developing confidence and trust in one’s ability to birth is not addressed, nor is possible tool use earlier in pregnancy in order to have an opportunity to intervene and make a difference. Although multiparous women may have higher self-efficacy than their nulliparous counterparts,30,31 none of the studies examined how health care providers can help a woman increase or enhance her confidence without a previous labor and birth. Therefore, clinicians can use the reviewed tools to assess their patient’s confidence for birth, but at this time there is no defined intervention for health care providers to increase a woman’s confidence for labor and birth if she has low confidence during pregnancy. Bias
Bias for these studies would include the degree of heterogeneity of participants and the level of evaluation of reliability and validity of the tools. Lowe’s30 sample included primarily middle-class white women; Bocchese’s39 sample included 591
592
Volume 59, No. 6, November/December 2014
Jeschke et al40
Bocchese39
Lowe
30
Lowe30
Lowe
30
Author
development
Tool
development
Tool
testing
psychometric
Phase 3:
testing
Phase 2: pilot
generation
Phase 1: item
Research Aim
221
140
Time 2 = 69
Time 1 = 351
76
48
Participants, N
gestation)
Pregnant (34-40 weeks’
gestation)
Pregnant (38-42 weeks’
gestation)
Pregnant (ࣙ 28 weeks’
gestation)
Pregnant (ࣙ 28 weeks’
Postpartum (⬍ 48 h)
Postpartum
Pregnant/
19-45
18-35
18-42
Not reported
18-39
Age Range
Table 2. Summary of Included Studies Related to Tools to Measure Women’s Confidence for Birth
Birth at study hospital
gestation
or after 38 weeks’
pregnancy, gave birth at
English literate, singleton
Efficacy: active labor =
childbirth classes
Content validity assessed
validities assessed
Construct, criterion-related
Validity Assessment
informed subscale = 0.60
subscale = 0.68; Being
medical competency
subscale = 0.62; Trust in
Partner’s support
in labor subscale = 0.82;
assessed
Overall = 0.79; Confidence Content and external validity
0.78
second stage = 0.95.
stage = 0.90; Efficacy:
expectancies: second
0.90; Outcome
active labor = 0.86;
Outcome expectancies:
community-based
Attendance at
Second-stage labor =
childbirth classes 0.81
Active labor = 0.67
Early labor = 0.68
N/A
Cronbach’s Alpha
community-based
Attendance at
newborn
birth of full-term, healthy
Uncomplicated vaginal
Inclusion Criteria
diverse women with the majority having at least a high school education; and Jeschke and colleagues’ tool40 was developed with German women who were well educated and primarily primiparous. All tools reported reliability coefficients, however, only Jeschke and Lowe report construct validity.
DISCUSSION
We performed an extensive search of published literature for information related to helping women build confidence with their prenatal care provider for a physiologic labor and birth, as well as for tools to measure that confidence. Evidence for specific techniques for clinicians to use during prenatal care to help women enhance their confidence for labor and birth is limited. Qualitative evidence suggests that obtaining information, participation in decision making, and a respectful partnership with the prenatal care provider are key ingredients for women to build their confidence. No research was found that has examined specific interventions to guide clinicians in helping women increase their confidence for labor and birth or variations to individualize approaches for women. The tools included in this review offer opportunities for confidence assessment. Yet, the current utility of the tools is untested for use by clinicians. The evidence currently available has all been collected in the context of research. The CBSEI30 evaluates women in the first and second stage of labor and consists of a 62-item scale. Lowe’s CBSEI is valid and reliable across different languages and cultures.31–38 However, the tool would likely be cumbersome for clinicians to quickly identify levels of confidence for birth prenatally. The CBSEI provides no direction for how to proceed if a woman has low self-efficacy for labor and birth. Conversely, the LBSEQ39 and CTDQ40 are simpler tools that could be completed by women in a single antenatal visit. The LBSEQ includes 14 questions and the CTDQ has 11. However, the LBSEQ was developed for one specific research project in 1992 and has not been used since. Further testing and validation would be necessary in order to ensure its efficacy in the clinical context. The CTDQ reliability was similar to the LBSEQ and has construct validity. However, the tool was developed in Germany with German women. Therefore, its applicability to women in the United States or other countries would need to be examined prior to implementation. Finally, similar to the CBSEI,30 there is no evidence to guide a clinician’s care if a woman has low confidence for labor and birth. Clinicians may hesitate to use a tool to examine confidence without an effective intervention to follow up with women with low scores. While the conversation in recent years has shifted to supporting physiologic birth, researchers have primarily examined how to best support women during labor and birth to achieve a physiologic birth. However, according to the evidence we reviewed, planning for birth and the opportunity to affect confidence starts well before a woman’s labor begins. Self-efficacy and a woman’s prenatal perception of what she is capable of can influence decisions made during labor and birth. Thus, it is critical that providers appreciate the opportunity to increase confidence prenatally to enhance physiologic birth outcomes. While tools are available to measure women’s Journal of Midwifery & Women’s Health r www.jmwh.org
self-efficacy or confidence for childbirth, the tools have limitations and have not been studied for clinical application. Limitations
Our search was limited by the paucity of research in this area, and inconsistent use of terms such as confidence, self-efficacy, self-competence for childbirth,41 and control to describe how women at low risk of complications prepare for and approach labor and birth. Our search strategy was wide; however, additional search terms may have resulted in additional related research. Studies were excluded that had components of prenatal education and confidence-building if the intervention was outside the context of the formal prenatal care setting. This is important because there may be existing interventions used in antenatal education that build confidence for labor and birth that are not regularly employed by prenatal care providers. However, a systematic review of antenatal education programs did not find sufficient evidence of such effects.24 Implications for Practice and Research
It is important that providers are able to assess a woman’s selfefficacy or confidence for childbirth well before birth takes place. This critical assessment could pinpoint areas where a woman lacks confidence and provide direction for prenatal care discussions. Providers can devote time during prenatal visits to discuss fear and anxiety about birth with women as well as emphasizing the normality of labor and birth. The qualitative literature supports open discussions between the provider and woman about labor and birth. The evidence also emphasizes the need to provide truthful information in the context of prenatal care. If women hear the message that they are able to cope with labor, give birth physiologically, and are provided with information that they need to prepare for labor and birth with realistic expectations, they may increase confidence in their ability to accomplish their goals. Research is needed to understand exactly how prenatal care providers enhance women’s confidence for birth by conducting and analyzing individual interviews and group discussions with a broad diversity of women. The information can then be used to develop specific prenatal interventions to support women, including both general guidance and specific techniques based on individual situations, and to support tool development. Theoretical models for this work might include salutogenesis (moving toward optimal health)16,42 and liberating intrinsic power,43 for which women and caregivers can use empowering practices to enhance a woman’s sense of self. Further information from women can guide research building on existing tools to develop and refine an assessment tool to measure maternal confidence for physiologic labor and birth for use in a clinical setting. Clinicians may appreciate a reliable and valid tool, similar to depression-screening tools, to help identify women with low confidence for labor and birth and then follow up with interventions shown to make a difference. Provider identification may lead to additional follow-up, including education, motivational interviewing, or other evidence-based interventions to help women to achieve a physiologic birth. 593
CONCLUSION
Information sharing in a respectful partnership between a pregnant woman and her prenatal care provider are the ingredients known at the present time to help women build confidence for a physiologic labor and birth. Further research is needed to help midwives and physicians more fully understand how to help women feel confident in their ability to give birth. Development of a clinically useful tool to assess a woman’s confidence for labor and birth and to guide care in support of a physiologic labor and birth is essential to enhance prenatal care. AUTHORS
Melissa D. Avery, CNM, PhD, FACNM, FAAN, is Professor and Chair, Child and Family Health Co-operative Unit, and Director of the University of Minnesota School of Nursing midwifery program. Melissa A. Saftner, CNM, PhD, is Clinical Associate Professor at the University of Minnesota School of Nursing and currently practices in an outpatient obstetrics and gynecology clinic. Bridget Larson, MPH, is a student in the Master of Nursing program at the University of Minnesota and will begin the DNP program, midwifery specialty, upon completion. Elizabeth V. Weinfurter, MLIS, is Associate Librarian in the Health Sciences Libraries at the University of Minnesota and librarian liaison to the School of Nursing. CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose. SUPPORTING INFORMATION
Additional Supporting Information may be found in the online version of this article at the publisher’s Web site: Appendix S1: Literature search strategies. REFERENCES 1.Curl M, Davies R, Lothian S, Pascali-Bonaro D, Scaer RM, Walsh A. Childbirth educators, doulas, nurses, and women respond to the six care practices for normal birth. J Perinat Educ. 2004;13(2):42-50. 2.International confederation of midwives. Keeping Birth Normal. The Hague, Netherlands: International Confederation of Midwives; 2008. 3.Romano AM, Lothian JA. Promoting, protecting, and supporting normal birth: A look at the evidence. J Obstet Gynecol Neonatal Nurs. 2008;37(1):94-105. 4.Sakala C, Corry MP. Evidence Based Maternity Care: What It Is and What It Can Achieve. New York, NY: Milbank Memorial Fund; 2008. 5.Amelink-Verburg MP, Buitendijk SE. Pregnancy and labour in the Dutch maternity care system: what is normal? The role division between midwives and obstetricians. J Midwifery Womens Health. 2010;55:216-225. 6.Kennedy HP, Grant J, Walton C, Shaw-Battista J, Sandall J. Normalizing birth in England: A qualitative study. J Midwifery Womens Health. 2010;55(3):262-269. 7.World Health Organization. Care in Normal Birth: A Practical Guide. Geneva, Switzerland: World Health Organization; 1996.
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8.Martin JA, Hamilton BE, Osterman JK, et al. Births: Final data for 2012. National vital statistics reports; vol 62 no 9. Hyattsville, MD: National Center for Health Statistics. 2013. 9.Russo CA, Wier L, Steiner C. Hospitalizations Related to Childbirth, 2006: Statistical Brief #71. Rockville, MD: Agency for Healthcare Research and Quality; 2009. 10.Osterman MJK, Martin JA. Epidural and spinal anesthesia use during labor: 27-state reporting area, 2008. Natl Vital Stat Rep. 2011;59(5):113. 11.Maternity Care Working Party. Making Normal Birth a Reality: A Consensus Statement From the Maternity Care Working Party. Maternity Care Working Party; 2007. 12.American College of Nurse-Midwives, Midwives Alliance of North America, National Association of Certified Professional Midwives. Supporting healthy and normal physiologic childbirth: A consensus statement by the American College of Nurse-Midwives, Midwives Alliance of North America, and the National Association of Certified Professional Midwives. J Midwifery Womens Health. 2012;57(5):529532. 13.Neerland CE. A supportive approach to prenatal care. In: Avery MD, ed. Supporting a Physiological Approach to Pregnancy and Birth. West Sussex, UK: John Wiley & Sons, Inc.; 2013:29-48. 14.Jordan RG, Murphy PA. Risk assessment and risk distortion: finding the balance. J Midwifery Womens Health. 2009;53(3):191-200. 15.Lothian JA. Back to the future: Trusting birth. J Perinat Neonat Nurs. 2001;15(3):13-22. 16.Sinclair M, Stockdale J. Achieving optimal birth using salutogenesis in routine antenatal education. Evidence Based Midwifery. 2011;9(3):75. 17.Talbot R. Self-efficacy: Women’s experience of pain in labour. Br J Midwifery. 2012;20(5):317-321. 18.Perry P. Concept analysis: Confidence/self-confidence. Nursing Forum. 2011;46(4):218-230. 19.Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med. 2009;6(6):e1000097. 20.Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: Explanation and elaboration. Ann Intern Med. 2009;151:W65-W94. 21.Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice-Hall; 1986. 22.Namey EE, Lyerly AD. The meaning of “control” for childbearing women in the US. Soc Sci Med. 2010;71(4):769-776. 23.Carter SK. Beyond control: Body and self in women’s childbearing narratives. Sociol Health Illn. 2010;32(7):993-1009. 24.Gagnon AJ, Sandall J. Individual or group antenatal education for childbirth or parenthood, or both. Cochrane Database Syst Rev. 2007;18(3):CD002869. 25.Brown CE. Women and their care providers: An exploration of knowledge, confidence and relationships in the context of childbearing and childbirth. Birth Issues. 1998;7(3):95-100. 26.Coughlan R, Jung KE. New mothers’ experiences of agency during prenatal and delivery care: Clinical practice, communication and embodiment. J Prenat Perinat Psychol Health. 2005;20(2):99-119. 27.Leap N, Sandall J, Buckland S, Huber U. Journey to confidence: Women’s experiences of pain in labour and relational continuity of care. J Midwifery Womens Health. 2010;55(3):234-242. 28.Malterud K. Qualitative research: Standards, challenges, and guidelines. Lancet. 2001;358:483-488. 29.Morrow SL. Quality and trustworthiness in qualitative research in counseling psychology. J Couns Psychol. 2005;52(2):250-260. 30.Lowe NK. Maternal confidence for labor: Development of the Childbirth Self-Efficacy Inventory. Res Nurs Health. 1993;16(2):141-149. 31.Drummond J, Rickwood D. Childbirth confidence: Validating the Childbirth Self-Efficacy Inventory (CBSEI) in an Australian sample. J Adv Nurs. 1997;26(3):613-622. 32.Sinclair M, O’Boyle C. The Childbirth Self-Efficacy Inventory: A replication study. J Adv Nurs. 1999;30(6):1416-1423.
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33.Carlsson IM, Ziegert K, Nissen E. Psychometric properties of the Swedish Childbirth Self-Efficacy Inventory (Swe-CBSEI). BMC Pregnancy Childbirth. 2014;14:1. 34.Cunqueiro MJ, Comeche MI, Docampo D. Childbirth Self-Efficacy Inventory: psychometric testing of the Spanish version. J Adv Nurs. 2009;65(12):2710-2718. 35.Ip WY, Chan D, Chien WT. Chinese version of the Childbirth SelfEfficacy Inventory. J Adv Nurs. 2005;51(6):625-633. 36.Sieber S, Germann N, Barbir A, Ehlert U. Emotional well-being and predictors of birth-anxiety, self-efficacy, and psychosocial adaptation in healthy pregnant women. Acta Obstet Gynecol Scand. 2006;85(10):1200-1207. 37.Khorsandi M, Ghofranipour F, Faghihzadeh S, Hidarnia A, Bagheban AA, AguilarVafaie ME. Iranian version of Childbirth Self-Efficacy Inventory. J Clin Nurs. 2008;17(21):2846-2855. 38.Tanglakmankhong K, Perrin NA, Lowe NK. Childbirth Self-Efficacy Inventory and Childbirth Attitudes Questionnaire: Psychometric properties of Thai language versions. J Adv Nurs. 2011;67(1):193-203. 39.Bocchese JD. The relationship between self-efficacy, satisfaction with birth experience, postnatal stress response, and childbirth education
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attendance in an obstetrical clinic population [dissertation]. Chester, PA: Widener University; 1993. 40.Jeschke E, Ostermann T, Dippong N, Brauer D, Matthes H. Psychometric properties of the Confidence and Trust in Delivery Questionnaire (CTDQ): A pilot study. BMC Womens Health. 2012;12:26. 41.Tanner T. Self-competence for childbirth: A concept analysis. [dissertation]. Denver, CO: University of Colorado;2010. 42.Downe S, McCourte C. From being to becoming: Reconstructing childbirth knowledges. In: Downe S, ed. Normal Childbirth: Evidence and Debate. 2nd ed. London. Churchill Livingstone; 2008:3-28. 43.Parratt, JA. Feeling like a genius: Enhancing women’s changing embodied sense of self during first childbearing. [dissertation]. NSW, Australia: The University of Newcastle. 2010.
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Original Review
A Systematic Review of Maternal Confidence for Physiologic Birth: Characteristics of Prenatal Care and Confidence Measurement
CEU
Melissa D. Avery, CNM, PhD, Melissa A. Saftner, CNM, PhD, Bridget Larson, MPH, Elizabeth V. Weinfurter, MLIS
Introduction: Because a focus on physiologic labor and birth has reemerged in recent years, care providers have the opportunity in the prenatal period to help women increase confidence in their ability to give birth without unnecessary interventions. However, most research has only examined support for women during labor. The purpose of this systematic review was to examine the research literature for information about prenatal care approaches that increase women’s confidence for physiologic labor and birth and tools to measure that confidence. Methods: Studies were reviewed that explored any element of a pregnant woman’s interaction with her prenatal care provider that helped build confidence in her ability to labor and give birth. Timing of interaction with pregnant women included during pregnancy, labor and birth, and the postpartum period. In addition, we looked for studies that developed a measure of women’s confidence related to labor and birth. Outcome measures included confidence or similar concepts, descriptions of components of prenatal care contributing to maternal confidence for birth, and reliability and validity of tools measuring confidence. Results: The search of MEDLINE, CINAHL, PsycINFO, and Scopus databases provided a total of 893 citations. After removing duplicates and articles that did not meet inclusion criteria, 6 articles were included in the review. Three relate to women’s confidence for labor during the prenatal period, and 3 describe tools to measure women’s confidence for birth. Discussion: Research about enhancing women’s confidence for labor and birth was limited to qualitative studies. Results suggest that women desire information during pregnancy and want to use that information to participate in care decisions in a relationship with a trusted provider. Further research is needed to develop interventions to help midwives and physicians enhance women’s confidence in their ability to give birth and to develop a tool to measure confidence for use during prenatal care. c 2014 by the American College of Nurse-Midwives. J Midwifery Womens Health 2014;59:586–595 Keywords: confidence, physiologic birth, pregnancy, prenatal care, self-efficacy
INTRODUCTION
Returning to a normal or physiologic approach to labor and birth has reemerged in the literature and in clinical practice over the last 2 decades.1–6 In 1996, the World Health Organization recommended observation of a woman’s labor progress and not intervening in normal labor without a significant indication, personalized support to women by trusted individuals, encouraging freedom of movement and nonsupine positions, and immediate skin-to-skin contact and breastfeeding following birth.7 This focus on normal birth is the result of decades of increasing use of technology in childbirth worldwide. In the United States, this is evidenced by a 32.8% rate of cesarean,8 51.4% rate of induction of labor,9 and 61% rate of epidural use.10 Evidence supports a more physiologic approach to labor and birth, including a greater reliance on midwives and family physicians.4 The Maternity Care Working Party in the United Kingdom has defined a normal birth as one “without induction, without the use of instruments, not by caesarean section and without general, spinal or epidural anaesthetic before or during delivery.”11 In the United States, a task force of 3 midwifery organizations defined normal Address correspondence to Melissa Avery, CNM, PhD, University of Minnesota, School of Nursing, 5-140 Weaver Densford Hall, 308 Harvard St. SE, Minneapolis, MN 55455. E-mail: [email protected]
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physiologic labor and birth as “one that is powered by the innate human capacity of the woman and fetus.”12 The care processes and interventions that were recommended to support physiologic birth primarily relate to the support and management techniques that occur during labor and at the time of birth rather than the prenatal preparation for confident use of such techniques. Pregnancy is a time to promote health and well-being for the woman and fetus and to prepare for labor and birth. Most women receive some form of prenatal care from a licensed care provider, and care providers can partner with women to help increase their confidence in the ability to experience labor and give birth without the overuse of interventions.13 However, prenatal care is often based on a risk management approach to care that focuses on monitoring the status of the woman and fetus to identify and prevent problems.14 There is currently little guidance available for providers about specific care processes to support women during pregnancy to enhance their confidence and planning for a physiologic birth. The purpose of this systematic review was to examine the research literature for information about prenatal care approaches that increase women’s confidence or belief in their ability to accomplish a physiologic labor and birth, as well as tools to measure women’s confidence to give birth physiologically. The term confidence has been used in recent publications calling for a change in the approach to labor and
c 2014 by the American College of Nurse-Midwives
✦ Obtaining information, participation in decision making, and a respectful partnership with the prenatal care provider are key ingredients for women to build their confidence for labor and birth. ✦ Evidence for specific techniques for clinicians to use during prenatal care to help women enhance their confidence for labor and birth is limited. ✦ Existing tools for measuring women’s confidence for labor and birth have been used in a research context and have not been developed for use by clinicians. ✦ Research is needed to better understand how providers can help women increase confidence during pregnancy, develop and test specific interventions, and develop a valid tool for clinical use.
birth and in the way that care providers help women prepare for their birth15–17 ; however, we were unaware of specific research explaining how to help women gain confidence during pregnancy to promote the labor and birth process. In her concept analysis, Perry described confidence as the belief in one’s own abilities and the ability to succeed, a term that is contextually dependent.18 Thus, it may be possible to enhance and measure maternal confidence prenatally through provider practice. Specifically, we asked: 1) What characteristics of prenatal care help low-risk women attain confidence to give birth physiologically? and 2) What tools can be used to measure a woman’s confidence in her ability to labor and give birth physiologically? METHODS
The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist,19 a protocol for reporting on the completeness of a systematic review and meta-analysis, was used to guide this review. It may be used for research of any study design and is not an assessment of the quality of studies included in the review.19,20 We anticipated few studies addressing our questions; therefore, we examined published studies regardless of design or publication date. Studies exploring any element of a pregnant woman’s interaction with her prenatal care provider that helped her build confidence in her ability to labor and give birth, or that addressed a similar concept, were reviewed. In addition, we looked for studies that developed or utilized a measure of women’s confidence related to labor and birth, including previously validated tools that were examined in a new population. Presentation abstracts from selected conferences and dissertations, if they met our criteria and were available for review, were included. See Supporting Information: Appendix S1 for the search strategy. A single search strategy was used for both research questions. Studies were identified by searching electronic databases, reviewing reference lists, and hand-searching relevant conference proceedings with no limits for language or year. The librarian constructed search strategies optimized for Ovid MEDLINE, Ovid MEDLINE In-Process & Other Non-Indexed Citations, CINAHL, PsycINFO, and Scopus. Initial search terms included “self-concept,” “self-efficacy,” “internal-external control,” “self-control,” or “confidence.” Journal of Midwifery & Women’s Health r www.jmwh.org
These terms were combined with the terms “prenatal care,” “pregnancy,” or “obstetric labor or delivery.” The last search was run on July 11, 2013. In addition, presentation titles and abstracts from any of The Normal Labor and Birth Research Conferences, an international conference launched in England in 2002, were reviewed. Two authors (MA and MS) independently reviewed all titles and abstracts for all identified sources to determine articles for inclusion. Irrelevant items were excluded; publications noted as potentially relevant by any author were retrieved in full text. Data were abstracted from selected studies using a table that included the author, study design, research aim, participants, pregnancy status, age range, inclusion criteria, and outcomes. Articles identified for potential inclusion were carefully reviewed for consistency with inclusion criteria. Reviewers coded articles as yes, no, or possible. Any disagreements were discussed with a third author (BL) and resolved by discussion and consensus. Confidence is closely related to self-efficacy, as conceptualized by Bandura,21 and the 2 terms used interchangeably in many articles that we reviewed may be considered surrogates of each other in nursing literature.18 Confidence is defined as the belief in one’s own abilities and ability to succeed; self-efficacy is the belief in one’s ability to execute actions to reach a particular goal.18,21 Control has been used in research regarding women’s preparation for birth, but this concept may not be appropriate for the unpredictable experience of birth and for women across cultures22,23 ; thus, studies focusing on control and its measure were excluded. Research about prenatal classes has not been shown to be sufficient to answer questions about their effectiveness of prenatal classes,24 and the classes are typically not taught by prenatal care providers, so those studies were also excluded. Additional studies that validated original tools that measure maternal confidence in diverse populations were summarized but not included in this review. Information was abstracted from each selected study, including participants’ age and if data were collected during pregnancy, postpartum, or both. Descriptive data related to physiologic birth (if any) such as mode of birth, use of pharmacologic pain relief, and incidence of spontaneous labor were recorded. Any characteristics of prenatal care that 587
IdenƟficaƟon
Records idenƟfied through database searching n = 893
AddiƟonal records idenƟfied through other sources n=7
Eligibility
Screening
Records aŌer duplicates removed n = 737
Records screened n = 737
Records excluded n = 636
Full-text arƟcles assessed for eligibility n = 101
Full-text arƟcles excluded Not related to research quesƟon, n = 78 Not research, n = 15 Unable to obtain, n = 2
Included
Studies included in qualitaƟve synthesis n=6
Studies included in quanƟtaƟve synthesis (meta-analysis) N/A
Figure 1. Results of Search Strategy for Systematic Review of Maternal Confidence for Physiologic Birth
promoted maternal confidence were also collected. For studies examining tools to measure maternal confidence, age of participants and measures of reliability and validity of tools were abstracted. RESULTS
The search of MEDLINE, CINAHL, PsycINFO, and Scopus databases provided a total of 893 citations (Figure 1). After removing duplicates and articles that did not meet inclusion criteria, 6 articles were included in the review. Three relate to women’s confidence for labor during the prenatal period, and 3 describe tools to measure women’s confidence for birth. Question 1: What Characteristics of Prenatal Care Help Low-Risk Women Attain Confidence to Give Birth Physiologically?
The 3 studies that contributed to answering question 1 are summarized in Table 1. They were qualitative in design, utilizing grounded theory, grounded theory plus interpretive phenomenology, and qualitative descriptive approaches M.25–27 The studies included 66 women aged 17 to 45 years (age pro588
vided in 2 of 3 studies) interviewed during the postpartum period in the first 5 weeks following birth. In 2 of 3 studies, women with an uncomplicated birth (not defined) or a spontaneous vaginal birth were recruited. Researchers interviewed women cared for by a particular midwifery practice29 or either physicians or midwives.27,28 Interviews were conducted face-to-face, audio-recorded, and lasted 45 minutes to 2 hours (duration provided in 2 studies). For 2 studies, the interview style was semistructured; in the third, it was open-ended and progressing to a more directive style. Study outcomes were themes that were related to women’s relationships with their prenatal care providers and the impact of the relationships on their development of confidence and the ability to make informed choices about care with their care providers and preferred sources of information. Additional outcomes included building confidence in women’s ability to labor and give birth without pharmacologic methods, learning from other women, and continuity of the care provider. No studies specifically defined or measured physiologic birth as an outcome. Brown25 used grounded theory to explore women’s search for knowledge, perception of self-efficacy, and patterns of involvement in childbirth. Interviews were conducted with Volume 59, No. 6, November/December 2014
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589
Leap et al27
Coughlan & Jung26
Brown25
Author
Research Aim
Postpartum
Age Range
Inclusion Criteria
Outcomes
descriptive
other women’s stories in the
labor
after birth
myself; pride and elation
when I didn’t believe in
labor; she believed in me
coping with pain during
antenatal group; support for
birth at home; learning from
who would be there in labor; practice
building confidence to give
during pregnancy; knowing within single midwifery
support for pain in
(ࣙ4weeks)
Themes: building confidence
preparation and
of care model on
influence of continuity
Spontaneous vaginal birth
provider. 17-38
relationship Postpartum
choices respected by health
promoted by provider
theory 10
make informed choices, and midwife
agency can be
and grounded
Explore perceived
digest health information,
physician or licensed
Qualitative:
Agency is ability to access and
Birth with fee-for-service
19-45
of health care, how
Postpartum
midwife
involvement in care 40
relationship
setting with physician or
self-efficacy, and Explore agency in context
woman–provider
Themes: knowing all I could; confidence; nature of the
Insured women; first hospital or alternate birth
Not reported uncomplicated birth in
Postpartum
knowledge, perceived
16
Participants, N
for childbirth
Explore women’s search
Pregnant/
phenomenology
Qualitative:
grounded theory
Qualitative:
Study Design
Table 1. Summary of Included Studies Related to Women’s Confidence for Labor and Birth
16 insured postpartum women after a first uncomplicated birth. Participants had either given birth in one of several hospitals with physicians or in an alternative setting (not defined) with midwives. Themes identified included “knowing all I could,” “confidence,” and “nature of the woman/provider relationship.” Brown described the search for knowledge as the key concept that is essential to a woman’s developing confidence and influenced by her relationship with her prenatal care provider. Women searched for information during pregnancy using multiple sources. Experience and information “increased their childbearing confidence.” Knowledge gain was related to women’s relationship with their prenatal care provider and enhanced by a perceived close relationship and provider credibility. Brown concluded that prenatal care providers can increase women’s confidence for labor and birth and help women feel empowered to participate in their individual care. One participant remarked: “There was something about the way the midwives related to us that made me feel like, well, this is something all women can do, and I can do this.”25 Exploring agency (independence, ability to act in their own interest) in health care from the patient’s perspective, as well as understanding how the health care relationship impacts agency, were the focus of Coughlin and Jung’s study.26 Using grounded theory and interpretive phenomenology, 40 women from diverse socioeconomic backgrounds who received care from either male or female fee-for-service physicians or licensed midwives (gender not specified) were interviewed. Women were asked about their experience with the health care system; interactions with their male or female physicians or midwives; experiences during pregnancy, birth, and postpartum; and their overall satisfaction. Agency—or independence—was understood by participants as the ability to discuss health care information, make informed choices, and have those choices respected by their care provider. Researchers found no difference in descriptions of physician interaction by gender; satisfaction/dissatisfaction with physician care resulted from attitudes and behaviors perceived during care. Women were satisfied with care when physicians listened to their concerns and treated them respectfully and when they were able to obtain information and participate in care decisions. No participant stated that the physician was the top source of information. Women who received care from midwives reported the greatest satisfaction. Midwives were typically women’s top source of information, and women reported that their midwife helped them feel more confident in their ability to negotiate labor and birth. Women cared for by midwives were more mobile in labor and more often declined medications and were assertive about care choices. The following quote highlights their expressed confidence: “I felt that I was very self-confident about what I wanted and what I was doing during the labour—and felt that (the midwife) supported me in this. I was able to make choices for the most part.”26 Leap et al27 interviewed 10 racially diverse, low-income women from a specific midwifery practice with more home births and less medication use in labor compared to other local midwifery practices. The practice demonstrated 40% to 50% home births, 90% spontaneous labor, 15.5% cesareans, and high rates of breastfeeding. Women and their partners 590
could attend group sessions facilitated by the midwives with a focus on networking and sharing information among the women. Participants were asked to reflect on their support and preparation for labor and birth, specifically on support with labor pain. The practice utilized a midwifery continuity care model defined as care by 2 specific midwives throughout pregnancy, labor, birth, and the early weeks postpartum. Themes identified were “building confidence during pregnancy,” “continuity of carer: knowing who would be there in labor,” “building confidence to give birth at home,” “learning from other women’s stories in the antenatal groups,” “support for coping with pain during labor,” “she believed in me when I didn’t believe in myself,” and “pride and elation after birth.” The women described that the trusting relationship with their midwives helped them build confidence in their ability to labor and give birth without pharmacologic pain relief. Women linked their increased confidence to midwives providing information and discussing choices in a collaborative way. Continuity of care from a known midwife, learning from other women during optional antenatal group sessions, and support during the labor process were important to study participants. This quote highlights women’s confidence: The midwives encouraged me a lot, they talked to me a lot and made me feel that I was OK, and I’m strong, and the baby is a happy baby. Through the pregnancy they made me feel that pregnancy is a good thing and interesting to them, you know? So they made me feel . . . everything about me is something that I can do.27 Overall, the results of these 3 studies contribute to answering question 1 and suggest that women prefer a respectful and connected partnership with their pregnancy care provider through which they gain confidence as they increase their knowledge within that relationship. Gaining information during pregnancy and using that information to participate in care decisions with a trusted provider appears to further contribute to enhanced confidence. Provider confidence in the women helped women feel confident in themselves. These data resulted from analyses of individual interviews with women and not from quantitative measurement of confidence for physiologic birth. Bias
Although qualitative studies do not aim for generalizability, it is helpful to consider the samples included and how the authors address transferability (ie, the application of study results beyond individual studies).28 Brown25 recruited women with health insurance to reduce socioeconomic effects, resulting in a more homogenous sample. In addition, although participants were drawn from physician practices representing multiple hospitals, women recruited from midwifery practices gave birth in alternate settings, thus comparing subgroups of participants with perhaps differing views of pregnancy and birth. Coughlan and Jung26 recruited from fee-for-service physicians (including both male and female) and licensed midwives with a goal of a broad diversity of women. Leap et al27 selected women from a specific midwifery practice caring for a lower socioeconomic population and recruited across racial groups, with a goal to interview women from a practice with a high rate of home birth and low use of pharmacologic Volume 59, No. 6, November/December 2014
pain relief in labor compared to other local midwifery practices. No authors addressed efforts to assure transferability or trustworthiness of their studies, including researcher effects in the study.28,29 Question 2: What Tools Can Be Used to Measure a Woman’s Confidence in Her Ability to Labor and Give Birth Physiologically?
Confidence for childbirth has been measured in various ways. Three studies were located describing the development of instruments to measure women’s confidence for labor and birth. These are summarized in Table 2. Two studies were conducted in the United States and one in Germany. They included a total of 711 women aged 18 to 45 years. Tools included the Childbirth Self-Efficacy Inventory (CBSEI), the Labor and Birth Self-Efficacy Questionnaire,30 and the Confidence and Trust in Delivery Questionnaire. The most widely used tool measuring self-efficacy for childbirth is Lowe’s CBSEI.30 The CBSEI is organized into 4 subscales with 15 to 16 questions in each subscale. The subscales include the self-efficacy expectancy for active labor, outcome expectancy for active labor, self-efficacy expectancy for the second stage of labor, and outcome expectancy for the second stage of labor. Subscales measure the behaviors that a woman believes will be most beneficial in labor, as well as the woman’s beliefs that she will perform those behaviors during labor. Respondents use a 10-point Likert scale that ranges from “not at all helpful” to “very helpful” for the outcome expectancy subscales and “not at all sure” to “very sure” for the self-efficacy expectancy subscales. Scores range from 0 to 150 on the active labor scales and 0 to 160 on the second stage of labor scales. Higher scores indicate higher self-efficacy or outcome efficacy for birth. Cronbach’s alpha for the subscales range from 0.86 to 0.95. One important finding from the tool’s validation is that multiparous women have higher self-efficacy for labor and the second stage, suggesting that experience with childbirth increases self-efficacy for childbirth. The CBSEI has been validated in English-speaking countries outside the Unites States including Australia and Ireland.31,32 Both Drummond and Rickwood31 and Sinclair and O’Boyle32 found high reliability on validation of the CBSEI (␣ ⬎ 0.90; ␣ = 0.91-0.94, respectively). Whereas Sinclair and O’Boyle concluded that the CBSEI was appropriate to use with Irish women, Drummond and Rickwood noted that Australian women did not differentiate the active phase and second stage of labor. Therefore, the CBSEI is a unidimensional tool for that population. Additionally, multiparous women with positive past labor and birth experiences had higher selfefficacy scores compared to those with negative experiences. The tool has also been translated and validated in Spanish, Swedish, Persian, Thai, and Chinese.33–38 High tool reliability was consistent across all translations and validation with non-American women. Similar to Australian women, Thai, Chinese, and Iranian women did not differentiate between the active phase of labor and the second stage.35,37,38 Culture can influence how a woman perceives labor, including viewing labor and birth as separate stages or seeing the process as fluid and not separated into phases. In the United States, labor and birth are typically described as 2 distinct phases. Journal of Midwifery & Women’s Health r www.jmwh.org
Two other tools were found in the search process. Bocchese39 developed the Labor and Birth Self-Efficacy Questionnaire (LBSEQ). This tool, based on Bandura’s concept of self-efficacy, measured a woman’s self-efficacy for labor and birth. Bocchese surveyed 140 women about their confidence that they could complete various tasks related to labor (eg, complete breathing exercises during labor, find ways to lessen the pain of labor). The LBSEQ’s content was validated by a panel of 4 doctorally prepared faculty members and a practicing nurse-midwife and had a reliability alpha coefficient of 0.77. Further factor analysis and validation were not conducted, and there is no evidence that further work has been done with this tool. This tool focused specifically on the beliefs and self-efficacy of women to cope with labor. There is no indication of how women gained the confidence or conversely lacked confidence to give birth. More recently, Jeschke, Ostermann, Dippong, Brauer, and Matthes40 developed the Confidence and Trust in Delivery Questionnaire (CTDQ). Two hundred twenty-one German women completed the CTDQ and a factor analysis was performed to determine validity. The tool aims to assess confidence and trust women have in birth prenatally. Factor analysis resulted in an 11-item scale with 4 distinct subscales: confidence (␣ = 0.82), partner support (␣ = 0.62), trust in medical competency (␣ = 0.68), and being informed (␣ = 0.60). The authors note that the scale may be limiting given the short nature of the survey. However, it could be a quick and efficient way for midwives and physicians to determine how a woman feels about her impending labor and birth. Similar to previously reviewed tools, there is no indication how women can gain confidence for birth in the prenatal period or how prenatal providers can support confidence-building. All 3 tools found in the review measure a woman’s perception of self-efficacy related to childbirth. Lowe’s tool30 is the most widely used and validated tool and offers a reliable and valid tool to assess self-efficacy before childbirth. Yet, the tool, like those developed by Bocchese39 and Jeschke et al40 only measures the woman’s inherent self-efficacy. Of the 3 tools, the CBSEI and the CTDQ are the most valid and reliable tools for clinicians to measure confidence, with the CBSEI tested across cultures. However, despite the efficacy of the tools, the process of developing confidence and trust in one’s ability to birth is not addressed, nor is possible tool use earlier in pregnancy in order to have an opportunity to intervene and make a difference. Although multiparous women may have higher self-efficacy than their nulliparous counterparts,30,31 none of the studies examined how health care providers can help a woman increase or enhance her confidence without a previous labor and birth. Therefore, clinicians can use the reviewed tools to assess their patient’s confidence for birth, but at this time there is no defined intervention for health care providers to increase a woman’s confidence for labor and birth if she has low confidence during pregnancy. Bias
Bias for these studies would include the degree of heterogeneity of participants and the level of evaluation of reliability and validity of the tools. Lowe’s30 sample included primarily middle-class white women; Bocchese’s39 sample included 591
592
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Jeschke et al40
Bocchese39
Lowe
30
Lowe30
Lowe
30
Author
development
Tool
development
Tool
testing
psychometric
Phase 3:
testing
Phase 2: pilot
generation
Phase 1: item
Research Aim
221
140
Time 2 = 69
Time 1 = 351
76
48
Participants, N
gestation)
Pregnant (34-40 weeks’
gestation)
Pregnant (38-42 weeks’
gestation)
Pregnant (ࣙ 28 weeks’
gestation)
Pregnant (ࣙ 28 weeks’
Postpartum (⬍ 48 h)
Postpartum
Pregnant/
19-45
18-35
18-42
Not reported
18-39
Age Range
Table 2. Summary of Included Studies Related to Tools to Measure Women’s Confidence for Birth
Birth at study hospital
gestation
or after 38 weeks’
pregnancy, gave birth at
English literate, singleton
Efficacy: active labor =
childbirth classes
Content validity assessed
validities assessed
Construct, criterion-related
Validity Assessment
informed subscale = 0.60
subscale = 0.68; Being
medical competency
subscale = 0.62; Trust in
Partner’s support
in labor subscale = 0.82;
assessed
Overall = 0.79; Confidence Content and external validity
0.78
second stage = 0.95.
stage = 0.90; Efficacy:
expectancies: second
0.90; Outcome
active labor = 0.86;
Outcome expectancies:
community-based
Attendance at
Second-stage labor =
childbirth classes 0.81
Active labor = 0.67
Early labor = 0.68
N/A
Cronbach’s Alpha
community-based
Attendance at
newborn
birth of full-term, healthy
Uncomplicated vaginal
Inclusion Criteria
diverse women with the majority having at least a high school education; and Jeschke and colleagues’ tool40 was developed with German women who were well educated and primarily primiparous. All tools reported reliability coefficients, however, only Jeschke and Lowe report construct validity.
DISCUSSION
We performed an extensive search of published literature for information related to helping women build confidence with their prenatal care provider for a physiologic labor and birth, as well as for tools to measure that confidence. Evidence for specific techniques for clinicians to use during prenatal care to help women enhance their confidence for labor and birth is limited. Qualitative evidence suggests that obtaining information, participation in decision making, and a respectful partnership with the prenatal care provider are key ingredients for women to build their confidence. No research was found that has examined specific interventions to guide clinicians in helping women increase their confidence for labor and birth or variations to individualize approaches for women. The tools included in this review offer opportunities for confidence assessment. Yet, the current utility of the tools is untested for use by clinicians. The evidence currently available has all been collected in the context of research. The CBSEI30 evaluates women in the first and second stage of labor and consists of a 62-item scale. Lowe’s CBSEI is valid and reliable across different languages and cultures.31–38 However, the tool would likely be cumbersome for clinicians to quickly identify levels of confidence for birth prenatally. The CBSEI provides no direction for how to proceed if a woman has low self-efficacy for labor and birth. Conversely, the LBSEQ39 and CTDQ40 are simpler tools that could be completed by women in a single antenatal visit. The LBSEQ includes 14 questions and the CTDQ has 11. However, the LBSEQ was developed for one specific research project in 1992 and has not been used since. Further testing and validation would be necessary in order to ensure its efficacy in the clinical context. The CTDQ reliability was similar to the LBSEQ and has construct validity. However, the tool was developed in Germany with German women. Therefore, its applicability to women in the United States or other countries would need to be examined prior to implementation. Finally, similar to the CBSEI,30 there is no evidence to guide a clinician’s care if a woman has low confidence for labor and birth. Clinicians may hesitate to use a tool to examine confidence without an effective intervention to follow up with women with low scores. While the conversation in recent years has shifted to supporting physiologic birth, researchers have primarily examined how to best support women during labor and birth to achieve a physiologic birth. However, according to the evidence we reviewed, planning for birth and the opportunity to affect confidence starts well before a woman’s labor begins. Self-efficacy and a woman’s prenatal perception of what she is capable of can influence decisions made during labor and birth. Thus, it is critical that providers appreciate the opportunity to increase confidence prenatally to enhance physiologic birth outcomes. While tools are available to measure women’s Journal of Midwifery & Women’s Health r www.jmwh.org
self-efficacy or confidence for childbirth, the tools have limitations and have not been studied for clinical application. Limitations
Our search was limited by the paucity of research in this area, and inconsistent use of terms such as confidence, self-efficacy, self-competence for childbirth,41 and control to describe how women at low risk of complications prepare for and approach labor and birth. Our search strategy was wide; however, additional search terms may have resulted in additional related research. Studies were excluded that had components of prenatal education and confidence-building if the intervention was outside the context of the formal prenatal care setting. This is important because there may be existing interventions used in antenatal education that build confidence for labor and birth that are not regularly employed by prenatal care providers. However, a systematic review of antenatal education programs did not find sufficient evidence of such effects.24 Implications for Practice and Research
It is important that providers are able to assess a woman’s selfefficacy or confidence for childbirth well before birth takes place. This critical assessment could pinpoint areas where a woman lacks confidence and provide direction for prenatal care discussions. Providers can devote time during prenatal visits to discuss fear and anxiety about birth with women as well as emphasizing the normality of labor and birth. The qualitative literature supports open discussions between the provider and woman about labor and birth. The evidence also emphasizes the need to provide truthful information in the context of prenatal care. If women hear the message that they are able to cope with labor, give birth physiologically, and are provided with information that they need to prepare for labor and birth with realistic expectations, they may increase confidence in their ability to accomplish their goals. Research is needed to understand exactly how prenatal care providers enhance women’s confidence for birth by conducting and analyzing individual interviews and group discussions with a broad diversity of women. The information can then be used to develop specific prenatal interventions to support women, including both general guidance and specific techniques based on individual situations, and to support tool development. Theoretical models for this work might include salutogenesis (moving toward optimal health)16,42 and liberating intrinsic power,43 for which women and caregivers can use empowering practices to enhance a woman’s sense of self. Further information from women can guide research building on existing tools to develop and refine an assessment tool to measure maternal confidence for physiologic labor and birth for use in a clinical setting. Clinicians may appreciate a reliable and valid tool, similar to depression-screening tools, to help identify women with low confidence for labor and birth and then follow up with interventions shown to make a difference. Provider identification may lead to additional follow-up, including education, motivational interviewing, or other evidence-based interventions to help women to achieve a physiologic birth. 593
CONCLUSION
Information sharing in a respectful partnership between a pregnant woman and her prenatal care provider are the ingredients known at the present time to help women build confidence for a physiologic labor and birth. Further research is needed to help midwives and physicians more fully understand how to help women feel confident in their ability to give birth. Development of a clinically useful tool to assess a woman’s confidence for labor and birth and to guide care in support of a physiologic labor and birth is essential to enhance prenatal care. AUTHORS
Melissa D. Avery, CNM, PhD, FACNM, FAAN, is Professor and Chair, Child and Family Health Co-operative Unit, and Director of the University of Minnesota School of Nursing midwifery program. Melissa A. Saftner, CNM, PhD, is Clinical Associate Professor at the University of Minnesota School of Nursing and currently practices in an outpatient obstetrics and gynecology clinic. Bridget Larson, MPH, is a student in the Master of Nursing program at the University of Minnesota and will begin the DNP program, midwifery specialty, upon completion. Elizabeth V. Weinfurter, MLIS, is Associate Librarian in the Health Sciences Libraries at the University of Minnesota and librarian liaison to the School of Nursing. CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose. SUPPORTING INFORMATION
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