1. Introduction
Fear of childbirth has been found to be directly related to fear of pain, lowering mother’s confidence in her natural ability to give birth and leading to the use of painkillers and instrumental births [
1]. “Tocophobia” refers to anxiety about childbirth and seeking to give birth by caesarean section even though there is no medical reason for it [
2]. While most women are afraid of labor pain, they come to terms with it. They seek to give birth in a supportive, pleasant, respectful environment with staff that knows how to respond accordingly. They need reinforcement in their self-efficacy to give birth naturally, as their mothers and grandmothers did [
3]. Natural childbirth has physiological and psychological benefits for women and their families and for health care cost reduction [
1].
In the context of childbirth, women with high levels of anxiety tend to opt for an epidural injection as compared to women with low fear levels [
4,
5]. Self-efficacy was defined by Lowe (1993) as one’s belief of the ability to perform a behavior successfully in a particular context [
6]. A review has found that self-efficacy has a positive relationship with physiological and mental health outcomes. High self-efficacy at birth was associated with low-risk pregnancies, fewer caesarean sections, less labor pains and suffering, and low postpartum depression rates [
7]. Among 276 pregnant Spanish women, positive associations were found between self-efficacy in childbirth and the use of coping strategies, better positive assessment of the birth experience, and higher satisfaction with childbirth compared to women with lower self-efficacy [
8]. Women with low self-efficacy tended to choose a caesarean section instead of natural birth and continued to request a caesarean section in further pregnancies [
9]. Self-efficacy at birth was also associated with self-resilience and vigor [
4]. According to the theory of self-efficacy [
10,
11], experience serves as a means of strengthening self-efficacy. In the case of primigravid women, self-efficacy is not gained from previous experience
Childbirth preparation courses aim to help expectant mothers make decisions before and during childbirth, make use of skills they have learned in the course for self-control of labor pain, baby care, breastfeeding, and motherhood skills [
12]. Women should feel at the end of this course they have the skills and confidence to take actions that will contribute to successful pregnancy, childbirth, and early parenting [
13,
14]. On the other hand, childbirth preparation courses are artificial, with the aim of being a substitute for information received by women in the “female network”, and the question remains how effective they are. Courses vary in length depending on economic constraints and structural changes in the health system [
15]. In a review of 10 papers from Spain, Sweden, Canada, Australia, Iran, Thailand, and the US, findings regarding these courses’ effectiveness were not uniform [
16]. However, in general, childbirth preparation courses were found to have a positive effect on reducing mother’s anxiety and stress. In Israel, a study on primigravid women found that courses reduce stress but do not increase self-efficacy [
5].
The goal of the present study was to examine the effectiveness of birth preparation courses in affecting the self-efficacy of Israeli Jewish ultra-orthodox primigravid women. This population is grossly understudied, despite its high fertility rate. The study examined differences in self-efficacy between women who took a birth preparation course and women who did not take a course.
Ultra-orthodox Jews in Israel were about 8%–11% of the Israeli population in 2018, with a high fertility rate—around three times that of non-orthodox Jews. Having a baby is considered a fulfillment of a spiritual purpose. They live in closed neighborhoods with a lifestyle based on Jewish law—the Torah and subsequent writings. They avoid accessing the internet and wear modest clothes. While the men spend their days studying, the women take charge of the house, including income and children’s education [
17].
3. Results
The socio-demographic characteristics of the study participants by groups, as well as pregnancy and birth variables, are presented in
Table 1.
The total sample’s mean age was 24.0 years (SD = 4.9). Mean age was the only significant difference between the study and control groups (for the study group, M = 23.4, SD = 4.3; for the control group, M = 26.1, SD = 6.1). The vast majority of the participants were married (99.2%) and born in Israel (93.8%), and half of them had an academic or professional education (50.4%). The respondents answered the first questionnaire at a mean age of 33 weeks of gestation (SD = 4.4) and gave birth at week 39.6 (SD = 1.3); most had a natural birth (79.1%), 8.5% had a caesarean section, and 12.3% had an instrumental birth. Most participants stated that the pregnancy was normal (87.7%), chose to take a painkiller or an epidural (89.2%), and later reported that they were breastfeeding (93.8%). While not significantly different, the natural birth method was more frequent in the control group (86.7%) than in the study group (76.8%). Healthy pregnancy (89.0% vs. 83.3%) and usage of pain relief (91.0% vs. 83.3%) were more frequent in the study group than in the control group (NS).
Figure 1 presents the means of self-efficacy at the three time points in the study and control groups. The subjects in both groups showed a high self-efficiency mean score at T
1 (3.40—study group, 3.53—control group), which decreased at T
2 (3.06—study group, 3.26—control group). At T
3, the mean score of the study group rose (M = 3.34), while the mean score of the control group dropped (M = 2.95).
Table 2 shows mean scores and standard deviations of childbirth self-efficacy at T
1–T
3 (weighted for age). In an independent t-test analysis, there were no significant main effects for the groups at T
1 and T
2. A significant main effect for the groups was found at T
3 (t(126) = 2.88,
p < 0.01).
Repeated-measures analysis within subjects showed a significant main effect for time (F(2,246) = 12.83, p < 0.001, Partial Eta Squared = 8.9%).
For the interaction effect between time and group, a repeated-measures analysis within and between subjects was performed. There was a significant interaction effect between time and groups (F(2,246) = 10.20, p < 0.01, Partial Eta Squared = 7.2%).
Further analysis found a significant difference within the study group between the second and the third measurements, with an upward trend (t(99) = 6.24, p < 0.01). On the other hand, in the control group, there were significant differences in all three measurements, in a downward trend (t(28) = 2.81, p < 0.05).
4. Discussion
The current study deals with a unique population of primigravid women in the ultra-orthodox religious Jewish community of Israel. The literature showed that fear of childbirth was associated with reduced maternal confidence [
1,
2,
3], increasing anxiety, and reduced self-efficacy [
5,
8]. The aim of the present study was to examine the contribution of childbirth preparation courses to a woman’s ability to cope successfully with childbirth by raising her self-efficacy.
The results in this study indicate that the preparatory course significantly contributed to self-efficacy for childbirth and allowed a higher score in the third measurement in the study group, as compared to the control group. Our findings show that regardless of the group, there were differences in the three measurements, with the first measurement results at time 1 being the highest. These results may mean that the self-efficacy of women before their first delivery was higher, corresponding to their level of expectation that they would cope with high success, than at later times. The control group had a higher self-efficacy than the intervention group. The self-efficacy of the intervention group at the end of the childbirth preparation course, and despite attending the course, was lower than that of women who did not attend the course. Another study [
5] also showed a reduction in stress levels but not an increase in self-efficacy. It is possible that for this reason, women in the control group chose not to attend a childbirth preparation course. A possible explanation could be that they valued their ability to cope with childbirth successfully due to their positive assessment of their self-efficacy to cope with childbirth. As a result, they did not feel the need to attend a childbirth preparation course. According to Bandura [
10,
11], the source of experience as a means of strengthening self-efficacy is not the cause of high self-efficacy in childbirth, because these women have never experienced childbirth before. Therefore, they drew their sense of self-efficacy from conversations with other women about childbirth through verbal persuasion [
19]. Women who attended a childbirth preparatory course may, similar to women who did not attend the course, have participated in conversations with other women who had already given birth and received support through their encouragement. Yet, they received formal and professional birth information that women who did not attend the course did not receive. Moreover, according to the theory of self-efficacy, high self-efficacy is very important because it is the one determinant that affects the motivation and the way an individual will approach and deal with a task, but knowledge and familiarity with the task is required to assess self-efficacy [
19].
In the second measurement, the self-efficacy of the two groups decreased, but the difference was noticeable in the third measurement after birth, when there was a significant change, with the readiness for childbirth of women who had taken a childbirth preparation course increasing again, while among women who had not taken the course, the decline continued. Hence the gap between women’s expectation of self-efficacy at birth and the result of postpartum self-efficacy was large and negative among women who did not take a course compared to women who did take a course. Despite the decrease in self-efficacy in both groups in the second measurement, the coping of women who participated in the course was higher than that of women who did not participate in it. High self-efficacy was associated with low-risk pregnancies, fewer caesarean sections, less labor pains and suffering, and low postpartum depression rates [
7], better positive assessment of the birth experience, and higher satisfaction with childbirth [
8]. In agreement with the literature, in our study, women who participated in the course learned about professional coping strategies in dealing with the birth itself, while women who did not attend the course did not receive, for example, breathing exercises. As a result, the assessment of retrospective coping was negative among women who did not attend the course.
These findings have implications for women who did not attend the course. These women who approached childbirth with high self-efficacy, but apparently without sufficiently good and accurate knowledge and without birth skills or effective coping strategies acquired in the course, were left with a feeling that they did not succeed as expected. The gap between their expected and real self-efficacy before and after birth led to a negative experience. These findings raise concerns about subsequent births among these women, especially since this is a population of ultra-orthodox women, whose fertility rate is high. These women may face psychological and physical difficulties in future births. Psychologically, after the initial experience, they have a self-measure of their self-efficacy to give birth, and this may cause them fears and disappointment. As a result of this experience, according to the theories of social learning and of self-efficacy at birth [
10,
11], in the next birth, their self-efficacy before birth will likely be low. Low self-efficacy in childbirth correlates with fear and apprehension of childbirth leading to tocophobia, stress, difficulty in coping with labor pains, demand for cesarean section [
2,
5,
9]. Although in the current study. the rate of caesarean sections was low (8.5%), the rate of caesarean sections is high worldwide. In Israel the proportion of caesarean section among Jewish women is 47.5% [
20].
Our study has a number of strengths. First, the study group was similar to the control group, lending further validity to the findings and strengthening the importance of the course. Second, the sample size was sufficiently large for the type of analysis required. Third, the study focused on a culturally unique group, for whom the importance of childbirth is significant and which, therefore, deserves to be addressed separately from the general population. Compared to secular women, ultra-orthodox religious women have fewer options for self-learning such as the internet that provides childbirth preparation courses, social networks, and/or counseling fora, CDs, or books. Ultra-orthodox religious women’s learning opportunities about childbirth are more limited for reasons of modesty and due to limitations in the sources of learning that must be approved by religious authorities.
This study has a few limitations that should be acknowledged. First, compared with secular women, religious women have fewer options for self-learning because of their modesty and of lack of access to resources of learning, which limits the generalizability of these results to the entire population of Israeli women. In addition, it does not represent women who decided to give birth outside a hospital. Second, the only significant difference between the study and the control groups was the age of the participants (3 years older in the control group than in the study group). The participants were not randomly selected into the groups for ethical reasons, and it might be that the younger felt less prepared, while the older believed to a lesser extent they needed this course, as they felt more mature and had had more chances to listen to friends’ experiences or read and have advice compared to the youngest. These factors might have affected the results of the study. Third, the results of this study show that the control group had a higher frequency of ‘natural’ births and a lower frequency of obstetric procedures than the intervention group, though not significantly so. These differences, if were significant, would be opposed to the suggested hypothesis and raise the question of whether self-efficacy scores decreased immediately after birth because these women felt they had failed to implement the self-help strategies they had been taught. This point should be addressed in a future study.
5. Conclusions
In contrast to some literature on childbirth preparation courses, this study presents evidence that these courses benefit primigravid women in the religious sector. The popularity of these courses has declined because of the possibility of learning through the internet and the rise in caesarean sections. However, participation in them can be recommended, at least in the population of religious women. In this population, participating in a course raised women’s self-efficacy to cope successfully in childbirth.
The practical recommendation following our findings is to continue to hold childbirth preparation courses and to encourage women who are undecided whether to attend the course to make a positive decision. It is desirable that future research includes groups of secular Jewish and Arab women, as well as other ethnic groups, in order to allow a more sweeping generalization for primigravid women in the Israeli society. For some ethnic groups, in which the pregnancy age of the majority is low compared to that of the average population, it is especially advisable to offer these courses in native languages and in a culturally adapted way. Alternatively, it will be important to compare birth preparation courses according to different teaching methods, such as online learning.