A Delphi Study of Self-Competence for Childbirth
Tanya Tanner, PhD, MBA, RN, CNMFaculty
Frontier Nursing University
Nancy K. Lowe, PhD, CNM, FACNM, FAANProfessor and Chair
University of Colorado College of Nursing
Background & Significance
• Increasing intervention and technology, even in “normal” situations.
• Maternal Child Health goals are not being met, maternal and neonatal morbidity and mortality are increasing.
• Women's desires and preferences are markedly different from even a generation ago.
Wondering
Why do women make the choices they do?– Primary elective cesarean section– Epidural use– Non-medicated birth
In spite of societal pressures to birth technologically, why do some women continue to birth with so much grace and skill?
Study Aims
• Overall aim: To better understand the defining attributes, attitudes, and beliefs of women who are self-competent for childbirth.
• Provide conceptual validation and a potential item pool for future instrument development
Research Questions
• How do expert maternity care providers describe their understanding of women who labor and birth self-competently?
• What are the defining attributes of the phenomenon of self-competence for childbirth in nulliparous women as identified by expert maternity care providers?
Conceptual Model
• A multi-round survey process designed to generate consensus among a panel of experts
• Effective in cases for which there may be no definitive answer
• Chosen for this study because:– Wide range of disciplines were involved– Geographic diversity was desired
Delphi Method
The Expert Panel
• Comprised of:– Doulas– Nurses– Midwives attending births in
homes– Midwives attending births in
birth centers– Midwives attending births in
hospitals– Family Practice Physicians
attending births– Obstetrician/Gynecologists– Maternal/Fetal Medicine
Specialists
• Inclusion Criteria:– Recommendation– Certification, licensure or
registration for last 5 years
– Hands- on clinical experience for last 5 years
– Consider self to be expert– Be willing to actively
participate in study process
Panelist Recruitment and EnrollmentRequest referrals from
boards of directors, other professional recommendations
Contact nominees to inquire about interest in
participation
Obtain consent
Send demographic and first round study surveys
335 Individuals contacted 398 Nominees identified
224 (56%) Did not reply43 (11%) Declined
131 (33%) Indicated Interest
11 (8%) Did not return consent form5 (4%) Didn’t meet inclusion criteria
1 (1%) Declined participation114 (87%) Consented to participate
5 (4%) Did not return surveys109 (96%) Returned surveys and were enrolled
Geographic Distribution of Panelists
Panel Demographics (N = 109)
Age
Gender
Ethnicity
Education
Years certified, licensed, or registered
M = 47.9, SD = 9.08
Female: 87%Male: 13%
Caucasian: 93%African American: 3%Asian: 2%Other: 2%
Some College: 6%Associates/Vocational: 8%Bachelors: 18%Masters: 34%Doctorate: 34%
M = 15.6, SD = 8.6
Panel Practice Characteristics (N = 109)
Births Attended per Month
Mode of Birth
Birth Location
Labor and Birth Interventions
Fetal Monitoring Use
M = 10.0, SD = 12.5, range = 1-100
Vaginal: M = 82.2%Operative Vaginal: M = 3.6%Cesarean Section: M = 14.2%
Home: M = 12.3%, SD = 27.0Birth Center: M = 14.4%, SD = 29.5Hospital: M = 73.3%, SD = 39.9
Induction of Labor: M = 21.4%, SD 20.8Pitocin Use: M = 32.1%, SD 26.4Elective Cesarean: M = 5.2%, SD 14.3Episiotomy: M = 5.9%, SD 11.3
None: M = .17%, SD .8Intermittent Auscultation: M = 27.3%, SD 23.3Intermittent EFM: M = 27.3%, SD 33.3Continuous EFM: M = 52.0%, SD 39.5
Round One Study Survey
• Contained five open-ended, qualitative questions– Characteristics – Outcomes– Rationale
• 97.2% Response rate • Content analysis of comments resulted in the
identification of:– 54 Outcomes Statements– 59 Rationale Statements– 72 Characteristics Statements– 185 Total Statements
Round Two Study Survey
• Contained 195 statements to be ranked on Likert scale of 1 - strongly disagree to 6 - strongly agree.
• 95.4% response rate• Consensus was reached for 49 (25%) of the items:– 21 Outcomes Statements (39%)– 14 Rationale Statements (21.5%)– 13 Characteristics Statements (10.7%)– 1 Miscellaneous Statement (10%)
Round Three Study Survey
• Contained 147 statements to be ranked on same Likert scale
• 88.9% Response rate• Consensus was reached for 13 (8.8%) of the
items:– 5 Rationale Statements (11.1%)– 4 Characteristics Statements (6.8%)– 3 Outcomes Statements (9.1%)– 1 Miscellaneous Statement (11.1%)
Round Four Study Survey
• Served as “member check” for final retained statements and to evaluate the experience of participating in the study.
• Contained the 62 consensus statements, 5 survey experience statements and 60 consensus statements to be applied to panelists’ nulliparous patients.
• 88.9% response rate• Mean agreement ranking: 5.07 • Mean disagreement ranking: 1.67
Results
• Internal Characteristics of women who are self-competent for childbirth– Personal Characteristics– Beliefs
• Supportive factors affecting self-competence for childbirth• Behaviors of women who are self-competent for childbirth• Outcomes associated with women who are self-
competent for childbirth– Positive Feelings and Emotions– Acceptance of Outcomes
Implications
• Practice– Panelists exposure to the concept influenced practice– “framing things in terms of self-competence is helpful in
how I tweak certain teaching points for different patients.” – Help women achieve their goals– Provide a supportive environment
• Policy– Support women’s self-competence and self-determination
Implications
• Research– Accomplished construct validation– Need to create instrument to measure self-
competence for childbirth– Intervention research to increase women’s self-
competence for childbirth– Investigate women’s experiences with self-
competence for childbirth– Investigate the role of birth team members on
women’s self-competence for childbirth
Strengths and Limitations
• Strengths– Strong theoretical foundation– Large, diverse panel– High response rate– “Member check” reflected agreement with results– Results reflected related extant literature
• Limitations– Delphi expert panel is inherently biased– Limited ethnic representation– Did not directly address women’s experiences
ReferencesBandura, A. (1997). Self-efficacy: The exercise of control. New York, NY: WH Freeman. Csikszentmihalyi, M. (1991). Flow: The psychology of optimal experience. New York, NY: HarperCollins. Csikszentmihalyi, M. Abuhamdeh, S., & Nakamura, J. (2005). Flow. In A. J. Elliot & C. S. Dweck, (Eds.), Handbook of competence and motivation (pp. 598- 608). New York, NY: Guilford Press. Dweck, C. S. (2006). Mindset: The New Psychology of Success. New York, NY: Random House. Foster, J. C. (1981). Utah test for the childbearing year: Beliefs and perceptions about childbearing. (Doctoral dissertation). Retrieved from ProQuest. (AAT 8121979).
ReferencesLowe, N. K. (2007). A review of factors associated with dystocia and cesarean section in nulliparous women. Journal of Midwifery and Women’s Health, 52(3), 216-228. Parratt, J. & Fahy, K. (2003). Trusting enough to be out of control: A pilot study of women’s sense of self during childbirth. Australian Midwifery Journal, 16(1), 15-23. Reed, P.G. (2008) The Theory of Self-Transcendence. In M.J. Smith & P.R. Liehr (Eds.), Middle Range Theory for Nursing (2nd ed.) (pp. 105-130). New York, NY: Springer Publishing.