Labouring Under Misapprehensions: the Paradoxical Role of Self-Efficacy Beliefs in the Outcomes of a First Birth

Abstract

Self-efficacy beliefs are an individual's estimation of their ability to use cognitive resources and behaviours to implement personal control over specific events in their lives (Bandura, 1997a). The few studies examining self-efficacy's role in birth outcomes (e.g. Manning & Wright, 1983) contain many methodological problems. This thesis aims to rectify these problems by using a longitudinal, prospective design to examine the direct and indirect role of birth self-efficacy beliefs in the immediate physical and psychological outcomes of the primiparous (first-time) birth. This thesis asks four specific questions. Firstly, is there a direct relationship between birth self-efficacy beliefs and the immediate outcomes of birth? Secondly, do specific cognitive and social resources mediate the relationship between self-efficacy beliefs and birth outcomes? Thirdly, do birth expectations and birth experiences (events in labour and delivery) influence birth outcomes, both as individual constructs, and as a combined factor identified as 'congruency between expectations and experiences'? This thesis hypothesises that inaccurate or unrealistic expectations about birth could influence the likelihood of achieving congruency, which may alter the conventional or expected relationship between strong self-efficacy and positive birth outcomes. Fourthly, does a woman's perceived relationship with her maternity caregiver influence her birth outcomes, and does this construct have a relationship with birth self-efficacy beliefs? Primiparous women (N=230) completed the Childbirth Self-Efficacy Inventory (CBSEI) (Lowe, 1993) twice during their pregnancies, along with 16 other cognitive, social, behavioural, and physical measures. Following the delivery participants provided information on the following birth outcomes: pain tolerance, pain and distress experiences, clinical events of the labour and delivery, satisfaction with the birth, and adjustment after birth. Hierarchical Multiple Regression (HMR) indicated that stronger birth self-efficacy predicted decreased pain and distress in labour, and increased satisfaction with birth. The primary Structural Equation Model (SEM) revealed that specific cognitive and social resources mediated the relationship between self-efficacy beliefs and birth outcomes. Further HMR revealed that birth experiences made a significant contribution to satisfaction with birth, while birth expectations moderated this relationship and the relationship between birth experiences, pain and distress. The SEM indicated that expectations of low numbers of birth events are unlikely to be matched by birth experience, which in turn lead to poorer psychological outcomes. An indirect pathway between self-efficacy and satisfaction was discovered when strong self-efficacy beliefs lead to low or unrealistic expectations about birth incongruency resulted, and women experienced less satisfaction with birth. A second SEM found that a better relationship with a maternity caregiver lead to greater birth satisfaction, and was associated with stronger birth self-efficacy beliefs. The relationship between maternity caregiver factors and adjustment after birth was mediated by self-efficacy. In conclusion, these findings emphasise the utility of strong birth self-efficacy beliefs in achieving positive outcomes in the primiparous birth. However, they also emphasise the importance of accurate knowledge about birth. There is a paradoxical relationship between strong self-efficacy and positive outcomes when unrealistic or inaccurate birth expectations develop. The role of cognitive, social and maternity caregiver factors in the relationship between self-efficacy and postpartum well-being is discussed.