Accepted Manuscript

‘It definitely made a difference’: a grounded theory study of yoga for

pregnancy and women’s self-efficacy for labour

Virginia Campbell , Mary Nolan

PII: S0266-6138(18)30305-X
DOI: https://doi.org/10.1016/j.midw.2018.10.005
Reference: YMIDW 2356

To appear in: Midwifery

Received date: 16 May 2018

Revised date: 7 October 2018
Accepted date: 16 October 2018

Please cite this article as: Virginia Campbell , Mary Nolan , ‘It definitely made a difference’: a grounded
theory study of yoga for pregnancy and women’s self-efficacy for labour, Midwifery (2018), doi:
https://doi.org/10.1016/j.midw.2018.10.005

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Title
‘It definitely made a difference’: a grounded theory study of yoga for pregnancy and

women’s self-efficacy for labour

Authors
1. Virginia Campbell (corresponding author)

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University of Worcester, St John's Campus, Henwick Grove, Worcester WR2 6AJ, UK1

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camv1_11@uni.worc.ac.uk2

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Present address: Yew Tree House, High St, East Meon, Hants, GU32 1QA

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Present email: vcampbell192@gmail.com
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2. Mary Nolan
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Professor of Perinatal Education, University of Worcester, St John's Campus, Henwick

Grove, Worcester WR2 6AJ, UK

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m.nolan@worc.ac.uk
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1. Conflict of interest
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The authors declare they have no conflict of interest.

2. Ethical approval and consent to participate

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Ethics approval for the study was gained from the University of Worcester Institute of

Health and Society Ethics Committee and NCT. The study adhered to the principles

outlined in the Charter for Ethical Research in Maternity Care. The women were provided

with a study information leaflet and written informed consent to participate was

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obtained. The women consented that their experiences could be used in publications

provided no details that could identify them were included.

3. Funding sources
The study was part of a PhD studentship supported by an HEI. Some expenses were paid

by the NCT.

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Availability of data and materials
Interview transcripts will not be made publicly available in line with participant consent.

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Keywords Yoga; pregnancy; self-efficacy; antenatal education; grounded theory;

coping

Introduction

In addition to lower healthcare costs, straightforward birth without interventions has

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physiological and psychological benefits for women and families (Kassebaum et al., 2014;

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O’Mahony et al., 2010; Smith et al., 2016). Most women would prefer to birth their babies

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without medical intervention (Care Quality Commission, 2015; Wharton et al., 2017) and

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the reduction of birth interventions has been identified as an urgent healthcare priority

(Amis, 2016). As pharmacological pain relief in labour results in more instrumental

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deliveries (Anim-Somuah et al., 2011), enabling women to use self-management

strategies to cope with the intensity of labour should result in more women birthing their
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babies physiologically.
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Antenatal education has the potential to teach women pain coping strategies which help

them in labour, but unanswered questions remain around which approaches are most
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effective (Gagnon and Sandall, 2007; McMillan et al., 2009). Yoga for pregnancy (YfP) is
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gaining attention as an intervention which may help both calm women and lower their

perceived pain in labour (Jones et al., 2012) thereby enabling them to birth their babies
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without pharmacological pain relief.

Systematic reviews give cautious support for the benefits of YfP in positively impacting

stress and anxiety during pregnancy and reducing labour duration (Curtis et al., 2012;

Jiang et al., 2015; Riley and Drake, 2013). However, the heterogeneity of dose and

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content of YfP interventions makes meta-analysis problematic. Many YfP studies

(Deshpande et al., 2013; Satyapriya et al., 2013; Sun et al., 2010) have been carried out in

developing countries where both the culture of childbirth and the practice of yoga are

very different from western countries, making transferability of findings questionable.

Most western yoga programmes comprise asanas (postures), Pranayama (breathing),

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Dhyana (meditation) and relaxation, but some authors (Maharana et al., 2013; Rakhshani

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et al., 2015) argue that YfP is an integrated therapy which should also encompass lifestyle

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and nutritional guidance. This raises questions about how YfP achieves its putative effects

and whether it is an holistic intervention, or whether individual elements can be isolated

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and utilised in other forms of antenatal education (Curtis et al., 2012; Field, 2016).
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Despite the synergy between yoga practice and the breathing and physical movements

which many women use to manage labour pain, the majority of recent YfP trials
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(Bershadsky et al., 2014; Davis et al., 2015; Mitchell et al., 2012; Muzik et al., 2012;
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Newnham et al., 2014) investigate its effect on the psychological health of women, rather

than on pain management. This has resulted in a lack of data on the effect of YfP on
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women’s ability to manage labour.

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Self-efficacy beliefs affect women’s ability to succeed in the tasks they set themselves,
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and may influence both labour pain perception and perinatal outcomes (Tilden et al.,

2016). Self-efficacy is defined as a person’s belief in their ability to succeed in specific

tasks and can be divided into self-efficacy expectancy and outcome expectancy. Self-

efficacy expectancy is the belief that one will be able to perform certain behaviours

successfully, for example, relax during labour. Outcome expectancy is the belief that

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performing the behaviour will result in the required outcome, i.e. that relaxing during

labour will result in less pain (Lowe, 1991). Women with higher self-efficacy expectations

are more likely to initiate and persist with pain management strategies (Bandura, 1977).

Bandura (1977) hypothesised that self-efficacy beliefs were enhanced through four

mechanisms. Lowe (1991) later related these to birth:

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 Performance accomplishments (Successful previous experience with childbirth or
other pain)

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 Vicarious experience (Observing successful coping by others)


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Verbal persuasion (Being encouraged by influential others)
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Physiological states (Learning to recognise and reduce reactions such as panic)

Although it has been shown that self-efficacy is a modifiable construct and that higher
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self-efficacy is associated with diminished fear of birth, decreased labour pain, increased

birth satisfaction and better perinatal outcomes (Tilden et al., 2016), little effort has been
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made to integrate it as a psychological theory into the design or evaluation of antenatal

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education programmes (Escott et al., 2009; Ip et al., 2009).

This paper arises from a study which explored women’s experiences of YfP before
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analysing them through a self-efficacy lens. The aim was to generate a theory, grounded
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in women’s voices, about which aspects of YfP are effective in enhancing women’s ability

to manage labour. Previous papers, (Campbell, 2018; Campbell and Nolan, 2016) have

reported on aspects of YfP teachers’ language and actions in classes which appear to

impact on women’s self-efficacy behaviour.

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Methods

Study design

This longitudinal, grounded theory study employed semi-structured interviews with

women attending YfP classes. Interviews were conducted at three time points. The first

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interviews were undertaken before the women started YfP, the second near their babies’

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due date, and the third postnatally. To ensure the women had enough experience of YfP

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for it to have the potential to effect change, a minimum attendance at six classes was

required for continued inclusion in the study at the second interview point. Grounded

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theory was used to generate a theory which would be relevant in implementing changes

to antenatal educators’ training and practice (Birks and Mills, 2011; Hall et al., 2012). A
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constructivist approach placed the women at the heart of the research, acknowledged
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multiple versions of ‘the truth’, and that the researcher and participants had a mutual

influence on each other (Charmaz, 2003; Lincoln and Denzin, 2003).

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Setting
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In order to ensure a degree of homogeneity in the women’s YfP experience, the research
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was restricted to classes run by YfP teachers trained by NCT (formerly known as the

National Childbirth Trust). NCT YfP classes are run by teachers working on a self-employed
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basis but within NCT operational and curriculum guidelines. NCT is the largest provider of

antenatal teacher training and private antenatal education for parents in the UK.

Annually, over 100,000 parents attend NCT courses for couples and an additional 2,000

women attend NCT YfP classes which are for women only. Women can attend YfP from

the twelfth week of pregnancy until they have their baby. NCT YfP classes are unique in

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being run by teachers who not only have an accredited NCT yoga qualification, but also

have a university degree in facilitating antenatal classes. The aims of NCT YfP classes

explicitly include enhancing women’s self-efficacy for labour in order to increase the

number of positive births (NCT and The University of Worcester, 2016). In addition to the

traditional aspects of yoga (breathing, positions, relaxation), NCT YfP classes aim to

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facilitate group bonding and increase knowledge of birth processes, aspects which are not

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necessarily part of non-NCT YfP classes.

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Recruitment

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Participants for the study were recruited via three NCT YfP teachers who were themselves

participants in the first part of the study (Campbell and Nolan, 2016). The teachers
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emailed a study information sheet to women who booked to join their YfP classes
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between August 2014 and January 2015. Women willing to take part returned the

consent form directly to the researcher. After this initial contact, all further
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communication about the study was between the researcher (VC) and the pregnant
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women.

Participants
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Twenty-two women gave an interview before their first YfP class. The women were
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between 15 and 34 weeks pregnant (median 23 weeks) and ranged in age from 29 to 48

years (median 33 years). Fourteen of the women were expecting their first baby and eight

were pregnant with their second or third child. The range of planned places of birth

included three hospitals, two alongside birth centres and home. Two women had not

decided where to have their baby at this stage.

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At the second interview, when the women were between 35 and 41 weeks pregnant

(median 37 weeks), seven women were excluded from the study on the basis of having

had too little exposure to YfP. Two of these women did not attend any classes due to

difficulties with the pregnancy or the advice of their GP. Five only attended one or two

classes due to travelling distance or preference for a more vigorous class. Three women

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did not respond to requests for a second interview. One woman missed her second

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interview as she had her baby earlier than expected. In total, eleven of the women who

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participated in a first interview gave second interviews. Third interviews were held when

the women’s babies were between 9 days and 10 weeks old (median 5 weeks),

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determined by when it was possible to arrange a time to talk with the new mothers. All
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eleven women who had a second interview, and the woman who had her baby early,

participated in a third interview.

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Pseudonyms are used in the paper to protect the women’s anonymity.

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Data collection
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In total, 45 interviews were conducted by telephone between August 2014 and August

2015. The interviewer aimed to adopt an informal tone and to be supportive in order to
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capture the women’s perceptions and feelings in as relaxed a manner as possible (Taylor,
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2005). Telephone-based active listening techniques were used to overcome the lack of

more nuanced communication which can take place face-to-face (Creswell, 2012; King

and Horrocks, 2010). Women were repeatedly reassured that there were no ‘right’

answers. Theoretical sensitivity led to questions which explored emerging themes being

added to the interview topics as interviews progressed.

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First interview topics included why the women were choosing to attend YfP, their

approach to labour and feelings about the birth. Second interview topics included the

women’s thoughts about the YfP classes, how they were feeling about labour, how they

thought they might manage contractions and their confidence in doing so. Third interview

topics included the women telling their birth story, how they managed contractions, and

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what, if anything, made a difference to their ability to manage their labour.

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Interviews lasted between 17 and 35 minutes (median 20). Consent for continued

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participation and permission to audio record interviews was renewed via email/phone

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with each woman before every interview. Interviews were professionally transcribed.
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Data analysis

The interviews at each of the three time points were treated as separate datasets to
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allow for thematic variability to be identified. Data generation and analysis proceeded
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concurrently.

Each transcript was anonymised and read through several times to enable content
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familiarisation. Approximately 500 pages of text were coded line-by-line using NVivo
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software. Codes and emerging themes were written in the women’s words wherever

possible. This ensured that they were transparently grounded in the data, with an
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avoidance of over-abstraction (Bryant, 2002; Mills et al., 2006; Thomas and James, 2006).

Field notes and memos were used to provide an audit trail, aid focus and theoretical

sensitivity (Hall et al., 2012; Holton, 2007). Emerging concepts were continually tested

using constant comparison techniques (Glaser and Strauss, 1967). Data sufficiency was

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achieved with no new themes emerging by the final interviews. Trustworthiness and

rigour were enhanced by co-author discussion of themes and by a combination of manual

and software analysis (Welsh, 2002).

The themes which emerged from the women’s third interviews where they spoke about

what had helped them in labour were explored through a self-efficacy framework

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(Bandura, 1977). This aided the emergence of a grounded theory which could be applied

to YfP teacher training and practice.

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Reflexivity

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One of the researchers (VC) was an NCT YfP tutor and one (MN) has no yoga training. The
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concept of researchers being either an insider or outsider has been challenged as

restrictive and too simplistic (Mercer, 2007; Shope, 2006). VC undertook the data
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collection and was an insider with the women by virtue of being a mother and YfP
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teacher. She was also an outsider as she was not ‘their’ teacher, placing her in the fluid

and multi-layered position Dwyer and Buckle (2009) represent as the hyphen between
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insider-outsider. In order to minimise potential bias, reflexive memos drawing on the

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researcher’s beliefs and sense of ‘place’ within the study were created before and during

observations, interviews and analytic work. Potential biases were discussed with MN who
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also reviewed the interview scripts to ensure they reflected emerging themes.

Findings

First interviews

Looking after myself and the baby

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The pregnant women had broad aims for attending YfP, seeing it as a holistic therapy

which could help with various physical and emotional aspects of the antenatal,

intrapartum and postnatal period.

The breathing, positions… Friends and fitness, and pick up some tips on the

way for the big day. (Wendy)

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Many of the women’s anxiety levels had increased during pregnancy. Others recognised

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that their habitual worrying or stress was not good for them and could impact upon their

baby’s health. The women said they hoped the classes would help reduce anxiety.

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To switch off and relax… The more you are stressed, the more you put your
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body under stress, and the more the baby will pick up on it. (Elizabeth)

A few women mentioned anxiety resulting from the loss of previous babies.
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It’s taken all the naivety away… makes you worry about every little aspect.
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So I’m trying… to be more in a positive frame of mind. (Rebecca)

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For some women, YfP was a way of avoiding excess weight gain. Many of them had
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reached a high level of physical fitness pre-pregnancy and wanted to engage in activity

which they felt was safe and would help them retain strength and flexibility.
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I’ve just started to feel that I’m putting on too much weight, so I wanted to

make sure that I am staying fit; there are not many exercises that you can do

during pregnancy. (Chloe)

Four subthemes emerged from the first interviews (figure 1):

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 Hoping for a natural or easier labour

 Preparing for something I can’t prepare for

 Being calm and in control

 Making friends

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Hoping for a natural or easier labour

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Only one aim was common to all twenty-two women: to learn techniques such as

breathing and relaxation to help them during the birth.

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To try and have some techniques or positions that… might calm me… To take

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your mind off the pain... keep your mind focused on that, rather than on the

fact that it really hurts. (Lisa)

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Many women articulated a strong desire to avoid medical intervention.

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I’m aiming to have as natural a birth as possible. It’s always been my goal.

(Josie)
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Most of the mothers expecting their second child were unhappy with how they had
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managed their previous labour. They hoped that attending YfP would give them practice

in breathing and pain management strategies which would enable them to cope better.
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I did NCT classes before, and they do teach you the breathing thing, but you
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kind of do it for 10 minutes as part of the class, whereas I think this will be

better doing it once a week… In [my last] labour I held my breath, I was

absolutely rubbish. I don’t know why I couldn’t apply everything I’d been

shown, or what I was told to do, but I think doing something weekly it will

mean hopefully, it will stick. (Rebecca)

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Preparing for something I can’t prepare for

Despite a desire to manage labour using their own resources, the women spoke of not

feeling confident that they would be able to do so. They said they would accept or ask for

pharmacological help if necessary as they did not know whether self-management

strategies would work.

I want to have a natural birth. I know everybody says it and it never works, so

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if I have to have anything I will. But I want it to be as natural as possible… I’m

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realistic at the end of the day. All the people I have known lately it hasn’t

gone the way they wanted. (Chloe)

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The first-time mothers spoke of not feeling confident in managing the unknown
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experience of labour pain.

I don’t know exactly what’s going to happen or how I will react. (Tessa)
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The women’s sense of lack of control had been fuelled by stories they had heard. They
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said that few women got the birth they wanted, so it was sensible to protect themselves

by not raising their hopes too high. In some cases, the stories they had heard had
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convinced them that birth could not be other than awful.

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Everyone tells you horror stories. (Wendy)

I know it’s going to be absolutely horrendous. (Elizabeth)

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Even the second-time mothers lacked confidence that they could have the birth they

hoped for, either because they had not had a good experience first time around, or

because they did not trust a second birth to go as well as the first.

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I’m actually probably a little more nervous this time round… because I kind of

know now what it’s all about… I had such a good birth that I am worried

that… I am kind of out of my luck. (Inge)

Being calm and in control

A complex subtheme emerged expressing how the women were grappling with a

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cognitive dissonance around control in labour. They wanted an easy, and for most, as

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natural a labour as possible and were trying to plan for that by attending yoga. But at the

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same time, they said that it was impossible to prepare for a natural labour and also that it

was unlikely to happen. Whilst accepting a lack of control over some events of their

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labour and that the safety of their baby must always be the priority, they wanted to be in
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control of their mental and emotional state, however the birth progressed.

My hope for the birth is… that we end up with a healthy baby… I understand
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that my wishes would always be secondary… But in an ideal world, my

hope… is that I’ll stay in control, that there won’t be any intervention, that I
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won’t need to have any drugs… and it’s all as natural and calm as possible.
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(Tessa)
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In addition to saying how yoga might help them stay in control by enabling them to cope

with contractions, the women described how practising techniques to ‘turn inwards’
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might help them to not panic, no matter what course their labour took.

Being able to sort of channel the breathing… I can try and relax and take

myself to a more positive place. Because I think even if all is going crazy … if

you’re in a calm place it’s much easier to deal with those things. (Josie)

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Making friends
Although not directly related to labour self-efficacy at this stage, the fourth subtheme to

emerge when the women were asked why they were choosing to attend YfP was a desire

to make friends.

Since I’ve become pregnant… there’s a need to sort of surround yourself with

people… going through exactly the same. Those things that you sit and worry

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about, they are worrying about as well. (Ailsa)

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Second interviews with the pregnant women - after attending YfP classes

Gaining confidence in managing labour

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The second interviews offered the opportunity to explore both whether the women felt
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their ability to manage labour had changed and also how they perceived any change

might have been effected. An overall theme of gaining confidence emerged with the
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women saying that YfP had helped them feel more positive about their ability to have the

labour they hoped for. Their hopes for a birth without medical intervention appeared to
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have strengthened: at this point, all the women stated a preference for a physiological
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labour, even those who had not mentioned it in their initial interview.

I’ve got loads of people around me that keep telling me… it’s not going to
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work… But I know that it is a natural process and if you do keep calm it will
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make it a lot easier… I’ve kind of educated myself and my body to think that I

can do it. (Chloe)

Four subthemes emerged from the second interviews. These were related to the

subthemes which emerged from the earlier interviews but had a different strength or

focus (figure 2):

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 Practising techniques for labour

 Learning from each other

 Being in control

 Preparing for something I can’t prepare for

Practising techniques for labour

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All the women said that learning different breathing techniques in combination with

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repeated practice of labour positions and relaxation had led them to feel more confident

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and prepared for birth.

The yoga has definitely given me way more practical things I’ll actually use

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when it comes to the labour and birth, like the breathing and positions…
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We’ve done it every single week… it’s given it much more of a kind of

embedded feel. (Faye)

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The women described a variety of coping strategies they had practised, differentiating
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them and showing an awareness of which ones might work for them.

I’ve got a little arsenal of tricks and things that I can try and pull together…
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So I feel confident I’ve got enough that I can sort of try and keep me
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occupied. (Wendy)
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There are certain techniques that I prefer to others… The counting one… I feel

personally for me will work better than others. (Tessa)

Learning from each other

The women’s confidence had increased after ‘show and tell’ visits by previous class

members who had returned with their babies. Hearing mothers who had recently given

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birth describe how yoga techniques had helped them in labour was influential in enabling

the pregnant women to believe the techniques could work for them too.

All of them [are] very, very positive about the benefits of what the yoga

brought to them… It puts faith in the fact that what you’re doing in the

sessions… are going to be beneficial. (Tessa)

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The women enjoyed the positive class ethos where both the teacher and second-time

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mothers spoke of straightforward birth as achievable. These stories helped counteract

negative input from other sources.

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We had one lady come back… with her baby, and she’d had like a really

straightforward birth… That really helped me to hear a positive story as

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opposed to people’s horror stories. (Kirsten)

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Being in control
At this stage, ‘Being in control’ continued to develop as a subtheme. Firstly, the women
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said yoga was helping them to approach labour in ‘the right frame of mind’ (Cassie).
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Yoga maybe puts you more in tune with your body… I feel quite empowered

in a way that birth isn’t something that is going to happen to me: I can kind
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of be active in it. (Terri)

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Secondly, they were making decisions about their birth environment which had the

potential to make it more straightforward.

One of the girls that brought their babies in, they’d had a water birth and

said how much it helped… I’m hoping for a water birth as well now. (Chloe)

Preparing for something I can’t prepare for

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Although the women felt more confident, none felt fully confident or in control. There

was less mention about fearing labour pain, but the first time mothers particularly still

spoke of not knowing what to expect. All the mothers recognised the possibility of

unforeseen medical complications. The women described their fear of losing control once

they arrived in hospital or if medical intervention was necessary.

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I feel more confident. Whether I feel 100% prepared? Probably not because I

have no idea what I really will go through. (Adali)

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The time spent at yoga classes had helped the women to reconcile the opposing

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paradigms of both retaining control and giving it to medical professionals. They described

how they might be able to retain control mentally even if their hopes for a natural labour
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did not happen.

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One half of me is consciously aware that [labour] might not go exactly to

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plan; but the other part of me is sort of aware that if I can think about my

breathing and… how I want to approach it from a kind of a mental

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perspective… that will help with the whole process. Yoga has helped me
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focus all those ideas. (Terri)

Postnatal interviews
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Having a positive labour experience

Postnatally, the women spoke about how they had used the skills they had learned in YfP.

Their descriptions of remaining calm, confident and in control during their labours were

consistent and powerful, as were their stories of managing their labours without medical

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intervention. The women attributed their positive labour experiences to what they had

learned in YfP.

I’m really pleased that the actual birth happened the way I wanted it… I

generally think of the whole experience with a real sense of calmness… and I

definitely think that’s from yoga. (Terri)

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All twelve women realised their hope of giving birth vaginally. Eleven of the twelve

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women used only natural pain relief methods or combined these with Entonox. One

woman accepted a syntocinon drip to speed up her labour. Another had an epidural once

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she was in second stage of labour and her baby’s birth was assisted with forceps.
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The three subthemes which emerged postnatally were closely related to those which had

emerged at the second interview stage (figure 3):

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 Using techniques to manage labour

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 Being calm, confident and in control

 Being positive and telling stories

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Using techniques to manage labour

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All the women spoke compellingly of the benefits they gained from using breathing

techniques, labour positions and movements they had practised in YfP.

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It was really just the breathing; that was really what got me through the

entire labour. (Chloe)

I used some of the positions we were taught - different labouring positions

like being on all fours and rocking backwards and forwards. (Cassie)

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The women emphasised how repeated practice of pain management strategies in YfP

classes had made the techniques feel comfortable and familiar. They said that because

they had been taught a variety of coping strategies, they were able to find the right ones

for them.

It was the teaching it every week… The calm… repeating… definitely

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increased my confidence. (Kirsten)

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What was really helpful was… she always encouraged us to try different

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kinds of positions… to see which position is the most comfortable for me… It

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was easier to try different things [in labour] because I had tried them already

during the course. (Adali)

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Being calm, confident and in control
Many of the women spoke about how they remained calm during the birth of their
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babies.
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I did stay so calm during the labour… I literally spent the whole time with my

eyes closed just in my own dream world… I didn’t scream, didn’t swear, just
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got on and did it. (Chloe)

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I was ridiculously calm during the labour. (Tessa)

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I was completely at peace and I think being relaxed then allowed it to all

progress really nicely. (Paula)

The women said this sense of calm was due to effective use of the pain management

strategies they had practised in YfP sessions.

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The midwife kept saying to me, “Oh you’re being so instinctive, everything

you are doing is so instinctive” and I didn’t correct her, but I just thought: if I

hadn’t been taught any of this, I wouldn’t have been able to do it… It kept me

calmer for longer, definitely. (Kirsten)

The confidence resulting from practice in pregnancy had enhanced the women’s feelings

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of trust in their body.

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I had been practising yoga and so therefore had built a relationship up with

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my body… Having confidence in your body, because that’s the most

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important thing: knowing that you can do it, believing that you can. (Paula)

I was just completely in trust of my body… It was just as though my body

AN
knew exactly what to do. (Inge)
M

The women’s birth stories showed that they had felt empowered to make decisions and

act in ways which felt right for them during labour.

ED

The midwife and other people were telling me to get into certain positions
PT

and I did try… but… it was… more painful… So I chose the positions….Even

down to the end she told me I had to lay down to give birth; and I wanted to
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be in the position that I was comfortable with, and I think that was listening
AC

to my body. (Chloe)

Although using breathing techniques and labour positions had helped them manage

contractions, two of the women were not calm throughout their labours. One had a very

fast labour and gave birth in the triage room. Ironically, another was disappointed that

she appeared so calm that she was unable to convince her caregivers that her labour had

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stalled despite her instincts telling her that she would need medical assistance. She asked

for an epidural a number of times before becoming distressed.

I wish I’d been a bit more forceful, because they said that I didn’t need [an

epidural, that+… I’d be fine and it would all be over soon… By the end I

definitely wasn’t in control, I was begging for help and absolutely shattered,

T
and just desperate for somebody to do something. (Kirsten)

IP
Being positive and telling stories

CR
The second strongest theme to emerge postnatally captured the benefits of hearing

positive stories in the YfP classes, which the women had also referred to in their second

interviews. US
AN
Hearing birth stories from other mums that came back to yoga class just sort

of put you in the right frame of mind, and sort of focused me on the things I
M

did want and the things I didn’t. (Cassie)

ED

The women remembered specific positive affirmations the teachers had used in YfP

classes that had helped them in labour. They appreciated how the teachers had
PT

encouraged them to believe in their ability to have control over their birth experience.
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*The affirmation+ kept going through my mind... “We’ve done that push;

that’s over and done with and we don’t have to do that push again; it’s one
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step closer to meeting your baby”… That’s just what I was thinking ‘Yes, done

that, just waiting for the next one’; and I was actually willing the next one

along - I wasn’t dreading the next one actually, I was willing it along because

he would be here sooner. (Chloe)

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A dissonant voice was heard from a woman who had expressed more anxiety than the

others at the second interview stage. Despite giving birth without medical intervention as

she had hoped, she remained anxious throughout her labour.

Sadly, the whole labour… I felt really quite anxious and frightened… even

though I gave birth naturally… I kept thinking all the worst case kind of…

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Unfortunately, it was quite detrimental I think to the actual labour… it was

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all I could focus on. (Grace)

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Discussion

US
The women’s hopes for straightforward birth, coupled with uncertainty around their

ability to achieve it, resonate with existing literature, as does their sense of confidence
AN
and control after attending YfP (Doran and Hornibrook, 2013; Eri et al., 2015; Mitchell,

2013). All the women said YfP enhanced their ability to manage their labour.
M

Definitely, it definitely made a difference. (Kirsten)

ED

Analysing the findings within a self-efficacy framework shows how the YfP elements

which the women said helped them most (skills practice, positive stories, affirmations and
PT

learning to relax) map closely to Bandura’s (1977) and Lowe’s (1991) work on efficacy-
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enhancing processes (Table 1, Figure 4).

Table 1: Mapping YfP content against Bandura’s (1977) categories and Lowe's (1991) processes
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Bandura (1977) Lowe (1991) Yoga for pregnancy classes

Performance Successful coping experiences Secondary performance

accomplishments such as past childbirth or accomplishments: practising breathing,
previous experience with pain labour positions, visualisations and other
coping strategies

Vicarious Observing successful coping Stories told by the teacher, other class
participants and women returning to

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experience by others ‘show and tell’

Verbal persuasion Being encouraged by Positive statements and affirmations

influential others spoken throughout the classes by the
teachers and pregnant women

Physiological Learning to recognise and Relaxation, meditation and practical

states (somatic reduce reactions, such as work including modelling breathing
awareness and panic, in response to the through contractions whilst noticing and
response) anticipation or experience of mitigating tension responses

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a stressful event.

IP
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Performance accomplishments

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Performance accomplishment, for example perceived ‘success’ in managing a previous

labour, is the most influential source of efficacy beliefs (Bandura, 1977; Cunqueiro et al.,
AN
2009). In addition to the confidence gained from personal achievement, performance

mastery reduces somatic response by mediating anxiety. For women who have not had a
M

baby, or not had what they perceive as a successful experience of labour, practising
ED

through modelling behaviour (secondary performance accomplishment) has been

hypothesised as the most effective way to enhance self-efficacy perception (Bandura,

PT

1986). This resonates with the findings from the present study where all the women said
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the main factors enabling them to manage their labour were learning pain coping skills

and the confidence they gained from repeatedly practising them.

AC

The literature has found an uncertain relationship between antenatal skills education, use

of self-management strategies in labour and the effectiveness of such strategies in terms

of reduced use of pharmacological pain relief (Bergström et al., 2009; Escott et al., 2005).

In comparison, all the women in the present study spoke of how the breathing and

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positions they had learned in YfP helped in labour. Belief in one’s own ability to control

labour pain predicts both the intention to use and the actual use of coping strategies

(Escott et al., 2009; Ip et al., 2009; Lowe, 1989). Yet women’s outcome expectancies have

consistently been shown to be greater than self-efficacy expectancies: women believe

more in the efficacy of coping strategies than in their ability to use them successfully

T
(Beebe et al., 2007; Cunqueiro et al., 2009; Ip et al., 2005; Lowe, 1993; Salomonsson et

IP
al., 2013b). It has been suggested that this might be due to insufficient practice of pain

CR
management strategies in the antenatal period (Escott et al., 2009; Larsen and Plog, 2012;

Schwartz et al., 2015). The women in this study attended more sessions than participants

US
in other studies of antenatal education interventions aimed at increasing self-efficacy
AN
(Bergström et al., 2009; Escott et al., 2005; Larsen and Plog, 2012; Maimburg et al., 2010),

and attributed their confidence to repeated practice of coping techniques. It is possible

M

that their increased confidence in their ability to use strategies effectively was due to
ED

regular practice which, in turn, resulted in their trying more coping strategies and

persisting with them for longer, thus leading to increased success in pain management.
PT

It may also be surmised that the variety of coping strategies taught in YfP (Campbell,
CE

2018) helped the women to become more aware of their personal coping style, resulting

in their using the strategies which suited them best. This resonates with studies indicating
AC

that women might benefit from antenatal education which helps them to choose from

and incorporate a wide range of coping strategies covering all the different coping styles

(Carlsson et al., 2014; Escott et al., 2004; Escott et al., 2009; Karlsdottir et al., 2014; Levett

et al., 2016; Salomonsson et al., 2013a;).

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Vicarious experience
The significance of hearing positive birth stories was a recurring theme in the women’s

interviews, supporting Bandura’s (1977) hypothesis that vicarious experience is an

influential factor in self-efficacy beliefs. Before the women began YfP, ‘horror stories’ and

previous experience had convinced them that joyous, straightforward birth was not

T
usually possible. The positive stories they heard in YfP not only increased their confidence

IP
but also affected decisions they made before and during labour. This is in line with

CR
findings from several studies (Brand et al., 2014; Doran and Hornibrook, 2013; Savage,

2006). The effect of story-telling on self-efficacy is complex, as effect is linked with the

US
content and perspective of the story as well as the credibility of the story-teller (Carlsson

et al., 2015; Fenwick et al., 2005; Kay et al., 2017; Taheri et al., 2014; Thomson et al.,
AN
2017). Stories showing the courage and power of women, and infused with a belief in
M

normal birth, inspire confidence, whilst negative stories promote catastrophising and

reduce use of pain coping strategies (Bar-On et al., 2014; Fisher et al., 2006; Jackson et al.,
ED

2005; Taheri et al., 2014).

PT

Verbal persuasion
Self-efficacy can be strengthened through encouragement, particularly by people
CE

regarded as influential or peer group role models (Bandura, 1977; Cunqueiro et al., 2009;

Salomonsson et al., 2013a). Verbal persuasion in the YfP classes took many forms, for
AC

example linking coping strategies and breathing practice to positive words such as ‘calm’

and ‘easy’, and repeated positive statements about women’s ability to birth. The women

valued the positive ethos in the YfP classes and four of them used affirmations they had

practised in YfP to help them in labour. Verbal persuasion is most likely to succeed when,

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as in YfP, it is used in conjunction with other methods of increasing self-efficacy (Bandura,

1977): it is easier to convince a mother that she can succeed if she is confident in her

coping skills and has seen her peer group succeed before her. The benefits of mastering a

range of self-coping techniques are only realised in women who have a conviction that

coping is possible.

T
Physiological states: Somatic awareness and response

IP
The women in this study expressed a desire from their first interviews for YfP to help

CR
them get into the ‘right frame of mind’ for labour. Later, they attributed a sense of calm

and confidence to having attended YfP. A woman’s state of mind affects her labour pain

US
experience, birth choices and outcomes (Alder et al., 2007; Koelewijn et al., 2017;
AN
Whitburn et al., 2014). Anxiety is associated with low efficacy expectancy and reduced

use of coping strategies (Beebe et al., 2007; Lowe, 2000; Salomonsson et al., 2013b;
M

Schwartz et al., 2015; Sieber et al., 2006). Despite the abundant evidence that anxiety has

multiple negative effects on pregnancy and birth, there is a relative paucity of evidence
ED

on antenatal interventions to reduce it (Marc et al., 2011).

PT

Yoga, with its focus on breathing, meditation and relaxation is ideally placed to help
CE

women achieve the somatic awareness which Bandura (1977) hypothesised was the

fourth source of self-efficacy. The reduction in anxiety which the women in this study
AC

expressed is mirrored by findings in YfP literature (Newnham et al., 2014; Riley and Drake,

2013; Sheffield and Woods-Giscombé, 2015). Interventions aimed at increasing self-

efficacy work best when techniques for reducing somatic arousal are combined with

mastery techniques, vicarious experience and verbal persuasion (Bandura, 1982). Women

who believe themselves able to cope with labour have a reduced stress response

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(Carlsson et al., 2015) and the use of pain coping strategies itself reduces stress responses

and increases feelings of control (Slade et al., 1993; Spiby et al., 2003). The women in this

study benefited in labour from the effects of a combination of efficacy-enhancing

strategies.

Strengths and limitations

T
This is the first study where the development of women’s thoughts around their hopes

IP
for birth, ability to manage labour and which aspects of YfP they find most effective, have

CR
been explored over time, and analysed in relation to self-efficacy theory.

US
A strength of the study is the richness of the data which was generated from interviews

with women at different stages of their transition to parenthood. Limitations are that the
AN
participants were restricted to women who attended multiple sessions of self-funded YfP

classes. The YfP teachers did not record whether they sent invitations to participate in the
M

study to every woman who enquired about their classes, and it is unknown how many
ED

women did not respond to the invitation. The findings may therefore not apply to women

who were not invited to take part in the study, who chose not to participate, or who
PT

withdrew after the first interview.

CE

A strength of the study is the consistency of the intervention as the YfP classes shared a
AC

common ethos, structure and curriculum. A corresponding limitation is that the results

are not necessarily transferable to YfP classes which are facilitated by non-NCT YfP

teachers.

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Conclusion
The aim of this study, to generate a theory about which aspects of YfP are effective in

enhancing women’s ability to manage labour, was achieved. The evidence from this study

is that YfP enhances women’s self-efficacy for labour through a combination of efficacy-

enhancing strategies. Increased confidence and competence enable women to remain

T
calmer, to mobilise pain management skills and take greater control of their labour. The

IP
congruence between what the women said helped them and self-efficacy theory suggests

CR
that the elements in YfP classes which are most effective for enhancing women’s ability to

manage labour are:

 US
The inclusion of all four efficacy-enhancing strategies
AN
 Multiple opportunities for practice

 Being taught a variety of pain management strategies covering different coping

M

styles.
ED

The results from this study suggest that in order to increase positive, straightforward

birth, antenatal education programmes need to incorporate multi-focused interventions

PT

which recognise the complex interplay between these efficacy enhancing methods.
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Acknowledgements
We are grateful to both the women and teachers who participated in this study.
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 Looking after myself and my baby
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Hoping for a natural or easier labour

Preparing for something I can’t prepare for

Being calm and in control

Making friends

Figure 1: First interview themes

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First interview: Looking after myself and my Second interview: Gaining confidence in

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baby managing labour

Hoping for a natural or easier labour Practising techniques for labour

Preparing for something I can’t prepare for

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Learning from each other
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Being calm and in control Being in control
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Making friends Preparing for something I can’t prepare for

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Figure 2: First and second interview themes

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First interview: Looking after Second interview: Gaining Postnatal interview: Having a

myself and my baby confidence in managing labour positive labour experience

Hoping for a natural or easier Practising techniques for labour Using techniques to manage labour

Preparing for something I can’t Learning from each other Being positive and telling stories

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Being calm and in control Being in control Being calm, confident and in

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Making friends Preparing for something I can’t

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Figure 3: Progression of themes through all interviews
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Having a positive labour Self-efficacy increasing

experience processes

Using techniques to manage labour Performance accomplishments

Vicarious experience

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Being positive and telling stories

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Verbal persuasion

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Being calm, confident and in control Somatic awareness

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Figure 4: How the postnatal interview themes relate to efficacy-enhancing techniques
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