By Mary Nolan, Professor of Perinatal Education, University of Worcester, UK
Self-efficacy refers to a person’s belief in their capacity to act in a way that will produce a desired outcome. So having low self-efficacy in relation to a particular challenge in your life – such as giving birth – means that you feel you will have no control over what happens to you and that you are likely to ‘fail’ the challenge – however it is that you define ‘failing’. Having high self-efficacy means that you approach a challenge with confidence that you have the inner strength and the external resources (such as a loving birth companion or a doula) to enable you to meet the challenge successfully.
Self-efficacy is a really important concept for all of us who aim to support women to make their own choices in pregnancy and achieve a satisfying birth. The concept helps us understand how people can move from a position of hopelessness where they feel that they simply can’t do something that they would dearly like to do – for example, have a vaginal birth rather than a caesarean – to one where they have confidence to say ‘I WILL do this’ and then do it!
The term ‘self-efficacy’ was coined by the Canadian psychologist Albert Bandura, now a very old gentleman in his mid-nineties. The main body of his work was published in three ground-breaking books over a 20-year period from 1977 to 1997123. In these, he explored ideas around self-confidence, motivation, learning and behaviour. His conclusion was that key factors (all at least partly modifiable) influence a person’s self-efficacy, that is their belief that they can take control of situations in which they find themselves.
So let’s take the example of a woman expecting her first baby who is thinking about her forthcoming labour and what she would like to happen. What factors will affect her confidence and ability to make her own choices about the care and interventions she receives?
According to Bandura, there are four factors that influence a person’s self-efficacy.
Our life experiences shape our sense of being in control of our circumstances and our confidence to make our own decisions. If all the decisions we have ever taken have turned out badly – for example, we chose to go to university and hated it; we chose a partner and the relationship failed; we chose a particular job and it led nowhere – we are likely to have low self-esteem and lack confidence in our capacity to ‘get it right’. I remember once discussing informed choice with a group of pregnant parents and one woman shared that everything she had ever tried to do in life had gone wrong so she was going to leave all the decisions during her labour to the staff at the hospital. On the other hand, if our life decisions have turned out well and we have aimed for certain things and achieved them, we’re likely to feel that our future decisions will work out well too.
Our self-efficacy in relation to a particular challenge will be affected by the experiences of other people close to us. This factor is highly influential when it comes to childbirth. First-time mothers may be exposed to so many horror stories – women sometimes seem to delight in telling each other how awful their labours were! If a woman has been told repeatedly by her friends and relatives that labour is unmanageable without an epidural, or that breastfeeding is extremely painful, her confidence in relation to labour and feeding will probably be eroded. The experiences of those who shape her view of the world will vicariously undermine her self-efficacy.
Nowadays, social persuasion operates in many forms – via the television, Facebook, Twitter, Instagram and less obviously, but equally powerfully, via what ‘experts’ tell us. We are all constantly being ‘persuaded’ of certain things by the way in which news is presented to us, by advertising and by the norms of the groups in which we move. If media and health professionals constantly present childbirth as a life-threatening experience requiring expert medical assistance, society’s view of childbirth will evolve to see the act of giving birth as intrinsically dangerous and best managed by professionals well versed in pathology and emergency care. Women’s trust in their own bodies and their self-efficacy for birth is diminished by this social persuasion.
Pregnancy is a profoundly emotional time when women and men start to redefine themselves as mothers and fathers. Growing understanding of the responsibility that they are taking on with a new baby heightens awareness of risk and also of opportunity – the opportunity to make a difference in the world by successfully nurturing a new human life. A woman’s naturally heightened emotions in pregnancy may be unreasonably exaggerated if she is in very difficult and frightening circumstances, such as living in poverty, or in a country whose language she doesn’t speak, or with an abusive partner. Being in a hyper-emotional state makes it difficult to make decisions and take control.
The four factors outlined above – mastery experiences, vicarious experiences, social persuasion and emotional state – will all affect whether a pregnant woman feels she is able to make her own choices about having a baby and carry them through. So what can we do as midwives, or doulas, or childbirth educators to enhance her self-efficacy?
In antenatal classes that I led, a popular discussion centered on how you might prepare for an important interview. Suggestions included: reading up on the company, business or institution you’re hoping to work with; talking to people doing the job you’re applying for; making sure you know how to get to the interview venue; choosing the right clothes; having a good night’s sleep, eating an energy-packed breakfast, practising relaxation and using positive affirmations (‘I can and I will give an excellent interview’). All of these enable mastery of the interview situation – and, I used to point out, are equally applicable to preparing for labour! By helping parents-to-be understand that the challenges they have already met in their lives would help them face the new challenges ahead, I aimed to illustrate that they have had MASTERY EXPERIENCES even if not yet of labour and birth.
It’s often revealing to ask parents-to-be what their friends’ experiences of labour have been. For example, to ask: ‘How did your friends’ labours start?’ ‘How long did friends’ labours last?’ Talking about other people’s experiences enables educators and midwives to understand how vicarious experiences might be affecting parents’ decision-making capacity. If a woman shares that her sister’s labour lasted three days and her best friend went into hospital four times before being finally admitted in labour, you have the chance to discuss how all women’s experiences of labour and birth are different and that a very long, slowly progressing labour isn’t necessarily going to be her experience. Unless you find out what are the vicarious experiences that are boosting or lowering a woman’s self-efficacy, you’re not in a position to help her develop a more rounded understanding of what labour and birth are like.
Sharing positive birth stories is very important in addressing the often negative influence of social persuasion. Positive stories shared by a childbirth educator in an antenatal class (‘Let’s read Maria’s story of her successful home birth’) or by a midwife at a clinic appointment (‘I’ve just been at the most beautiful birth…’) can counter-balance the many horror stories that women have been exposed to. Similarly, watching a video of a labour where the woman strongly and confidently births her baby without intervention can provide images of birth to compete with the medical dramas that are pervasive in our television viewing. It’s really important that we start to tackle social persuasion in relation to labour and birth by disseminating positive stories and images of powerful women who choose their own way to have a baby (whatever that way might be).
A woman’s emotional state in pregnancy is inevitably complex. Some people are living in circumstances that mean they are emotionally very fragile, with their confidence levels and their self-efficacy low. There may be very little, if anything, a childbirth educator or health professional can do to address such deeply entrenched problems as poverty, destructive relationships, lack of education or inter-generational disadvantage. However, the consistent, sensitive support of a known and trusted adult in the life of a pregnant woman who is struggling with adverse circumstances can make a huge difference. And this is why continuity of carer, which enables the development of a trusting relationship between the woman and someone who can walk alongside her on her pregnancy journey, is so very important (and sadly, so rarely available). Having such a caring consistent relationship can boost a woman’s self-efficacy in relation to labour and birth.
Finally, I want to say a little about information giving in pregnancy. This is also an important aspect of self-efficacy because it’s hard to feel powerful in a particular situation if you don’t understand what’s happening. Knowledge is Power. Information giving is a skilled undertaking; it’s not a question of simply dumping a whole load of facts on a bewildered parent-to-be. People need the information they want at a time that they want it. So in an antenatal appointment or antenatal class, if we’re discussing, for example, induction of labour, we can start by asking the woman or couple or group what they already know about induction. People – especially when they’re pregnant and are highly motivated to learn – often know far more about labour and birth than educators and health professionals give them credit for. I generally find that the information parents share with me is largely accurate and telling them that they already know a great deal boosts their self-efficacy wonderfully! Armed with the educator’s positive affirmation, they feel strong enough to correct any misinformation that they hold and to pay attention to essential new information.
However, facts aren’t enough to boost a woman’s self-efficacy to labour and give birth as she chooses. She also needs skills to work with her body. This is why it’s so important to offer women and their chosen birth companions the opportunity to learn and practise a variety of skills for labour - upright positions, calm breathing, massage, positive affirmations, visualisations and relaxation. If her choice is to aim for a straightforward vaginal delivery, she needs to acquire the skills to facilitate this.
This article has summarised the factors that influence an individual’s self-efficacy in relation to particular circumstances and has suggested ways in which childbirth educators, doulas and midwives can help pregnant women move up the self-efficacy scale and experience a birth which enables them to embark on motherhood with confidence and positive mental health.
(based on an idea from coachcampus.com/coach-portfolios/power-tools/robyn-goddard-self-efficacy-vs-self-doubt)
Author Bio: Mary Nolan worked as a birth and early parenting educator for 28 years before taking up her current post as Professor of Perinatal Education at the University of Worcester. She has published extensively in academic journals on birth-related issues and is the author of eight books. The most recent, 'Birth and Parent Education for the Critical 1000 Days', was published last year.
1 Bandura, A. (1977). Social Learning Theory. Englewood Cliffs, NJ: Prentice Hall
2 Bandura, A. (1986). Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, N.J.: Prentice-Hall
3 Bandura, A. (1997). Self-Efficacy: The Exercise of Control. New York: W.H. Freeman
AIMS supports all maternity service users to navigate the system as it exists, and campaigns for a system which truly meets the needs of all. AIMS does not give medical advice, but instead we focus on helping women to find the information that they need to make informed decisions about what is right for them, and support them to have their decisions respected by their health care providers. The AIMS Helpline volunteers will be happy to provide further information and support. Please email firstname.lastname@example.org or ring 0300 365 0663.
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