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.