CONCEPT ANALYSIS

Control in childbirth: a concept analysis and synthesis

Shaunette Meyer

Accepted for publication 28 April 2012

Correspondence to S. Meyer:

e-mail: shaunette.meyer@ucdenver.edu

Shaunette Meyer MA MS CNM RN

PhD Student

University of Colorado College of Nursing,

Denver, Colorado, USA

MEYER S. (2013)MEYER S. (2013) Control in childbirth: a concept analysis and synthesis. Journal

of Advanced Nursing 69(1), 218–228. doi: 10.1111/j.1365-2648.2012.06051.x

Abstract Aim. To report a concept analysis of control in childbirth.

Background. Control has a variety of definitions from a wide range of disciplines.

In childbirth, however, the concept is more tenuous and depends on the context. It

can be viewed in relationship to a woman’s body and labour progression, pain,

environment and the ability to request her method of birth.

Data sources. Medline, CINAHL and PsycINFO databases were searched between

1970–2011 using the keywords, ‘control’, ‘childbirth’, ‘labour’ and ‘delivery’.

Review methods. Walker and Avant’s method of concept analysis was used for this

review. In addition, cases were placed before defining attributes as recommended by

Risjord.

Results. Four attributes of control were identified: decision-making, access to

information, personal security and physical functioning. Antecedents include preg-

nancy and expectations of the birth. Consequences include childbirth satisfaction,

childbirth experience, emotional well-being, fulfilment and the transition into

motherhood. A model case, contrary case and borderline case are described.

Conclusion. Clarifying the definition of control in childbirth and defining its

attributes can help inform women and maternity providers throughout the world.

This analysis provides clarity to a previously tenuous concept and allows practi-

tioners to better understand the critical relationship between control in childbirth

and satisfaction with the childbirth experience. It also has the potential to affect

perinatal outcomes and subsequently healthcare costs.

Keywords: childbirth, choice, concept analysis, control, labour, midwifery, nursing,

pregnancy

Introduction

Across health conditions, control is an emerging topic of

concern. In health care, discussions about control centre on

control of healthcare costs, infection control, control of

disease progression and the desire of healthcare consumers to

be more involved in the decisions that are made about their

care and the care of their loved ones (Cole 2011, Hammouda

2011, Sheehan 2011, Vaknin & Zisk-Rony 2011). Control

has several definitions from a variety of other fields including

economics, engineering, research and psychology. In child-

birth, control has a more tenuous definition. Larkin et al.

(2009) recommended that control in childbirth be investi-

gated and analysed as a concept. The purpose of this concept

analysis is to help clarify the concept of control in the context

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J A N JOURNAL OF ADVANCED NURSING

of childbirth. For this concept analysis, the strategy outlined

by Walker and Avant (2011) is used to detail the meaning of

control in the context of childbirth.

Control in childbirth is an important concept for a variety of

reasons. First, the concept of control in childbirth is used

throughout the world and, therefore, has international impacts

(Viisainen 2001, Cheung et al. 2007, Oweis 2009, Hildings-

son et al. 2010). Second, women’s sense of control has been

linked with their satisfaction with the birth experience, which

can ultimately affect women’s future decisions about preg-

nancy and childbirth (Esposito 1999, Green & Baston 2003,

Cheung et al. 2007, Christiaens & Bracke 2007, Ford et al.

2009, Oweis 2009, Elmir et al. 2010, Hildingsson et al. 2010).

Third, control has been linked with the provider’s care, which

also has the potential for impacting women’s future childbirth

decisions (Green & Baston 2003, Tiedje & Price 2008, Ford

et al. 2009, Larkin et al. 2009, Elmir et al. 2010, Fenwick

et al. 2010). And finally, there is an implied relationship with

women’s sense of control and perinatal outcomes, which

ultimately can affect healthcare costs (Ayers & Pickering

2005, Cheung et al. 2007, Larkin et al. 2009).

Background

Control has a variety of uses and definitions across many

disciplines. Politically, it can be defined as having jurisdiction

over, having regulation of, or being the command central

(Free Dictionary 2011). From an engineering viewpoint,

control can be a device used to regulate or operate a machine

(Free Dictionary 2011). Economics uses the word to desig-

nate financial verification or regulation, whereas motor

racing uses it to define a checkpoint (Free Dictionary 2011).

A control in spiritual terms assists a medium during a séance

and a control mark indicates authenticity in philately (Free

Dictionary 2011). In research, a control group is a compar-

ison against experimental results (Free Dictionary 2011).

For women during the childbirth process, however, the

notion of control is more ambiguous. Control can be viewed

through the context of women’s bodies and the labour process,

pain and the environment where the birth takes place, or the

ability to elect the type of birth, i.e. a caesarean section (Cheung

et al.2007,Boucheret al.2009,Christianset al.2010,Fenwick

et al.2010).Control inchildbirthhas international relevanceas

it isused inavarietyof countries throughout theworld thathave

different cultures and customs related to childbirth and mater-

nity care. In all scenarios and contexts, women expressed a

desire for control over their childbirth experience. Clearly, the

issue of control in childbirth is unique for each woman.

Women’s sense of control in childbirth has been linked in

the literature with psychological attributes and satisfaction

with the birth experience. Two similar studies found a

correlation between women’s perceived control in childbirth,

decreased anxiety and increased emotional well-being (Green

& Baston 2003, Cheung et al. 2007). Women who developed

a written birth plan felt more in control and, therefore, more

satisfied with their birth experience, perhaps by reducing

their anxiety (Kuo et al. 2010). Despite the context of the

birth experience, several authors have found a link between

women’s perception of control during childbirth and feelings

of satisfaction with the experience (Esposito 1999, Green &

Baston 2003, Cheung et al. 2007, Christians & Bracke 2007,

Ford et al. 2009, Oweis 2009, Elmir et al. 2010, Hildingsson

et al. 2010).

Provider issues also surface in the literature when discuss-

ing control during childbirth. A Cochrane analysis revealed

that women feel more in control under the care of a midwife

(Hatem et al. 2009), whereas in a Swedish study, women

who planned a home birth felt more in control than women

who planned an elective caesarean (Hildingsson et al. 2010).

In contrast, Tiedje and Price (2008) found that women liked

providers who ‘take charge’ during childbirth and exerted

control in decision-making. What is missing in the literature

is any relationship between women’s sense of control in

childbirth and improved perinatal outcomes.

Due to the relationship between women’s sense of control,

satisfaction with the childbirth experience and the potential

for improved perinatal outcomes and subsequently decreased

healthcare costs, it is critical that healthcare professionals

understand the meaning behind a woman’s expectations of

control. Concepts, such as control represent phenomena that

are of interest to a discipline and are useful in classifying

experiences (Meleis 2007, Walker & Avant 2011). According

to Walker and Avant (2011), concept analysis is designed to

clarify and refine concepts that are currently embedded in the

literature by taking them apart, examining the pieces and

putting them back together. This process determines strengths

and limitations of the concept and is crucial in developing and

refining theory predictive of control in childbirth.

Several theoretical frameworks have already been identi-

fied in the literature when discussing control in childbirth.

Early work was rooted in Rotter’s social learning theory

when examining locus of control and the reinforcement or

outcomes of childbirth (O’Connell 1983). Lowe (2000)

identified Bandura’s self-efficacy theory when investigating

the relationship between women’s self-efficacy for labour and

childbirth fears. Two articles described the use of feminism

and Michel Foucault’s theoretical concepts concerning disci-

plinary power and knowledge to help understand women’s

sense of self and control during childbirth (Fahy 2002, Parratt

& Fahy 2003). Finally, a more recent study used Leininger’s

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cultural care diversity and universality theory in examining

the subculture of women who choose home birth in the US

(Boucher et al. 2009).

Although these theories are each relevant to the concept of

control in childbirth, the prevailing theoretical framework

that guided this concept analysis was the Theory of Birth

Territory (Fahy & Parratt 2006). As a mid-range theory that

takes a critical poststructural feminist perspective, issues of

power and control are examined through their relationship

with the birthing room environment and the way a woman

experiences her birth.

Walker and Avant (2011) have a well-developed strategy

for concept analyses. Although Walker and Avant’s method

has been criticized by members of the nursing community, it

still remains the most used method of concept analysis

(Duncan et al.2007). It is for this reason that the method was

chosen. Walker and Avant (2011) outline eight steps in the

process: select a concept; determine the aims or purposes of

analysis; identify all uses of the concept; determine the

defining attributes; identify a model case; identify additional

contrary cases; identify antecedents and consequences and

define empirical referents. However, Risjord (2009, p. 686)

recommends putting defining attributes after identifying

cases, as the ‘cases form the evidence for a concept analysis’.

The cases are the means by which a concept can truly be

differentiated from another concept. It is through this

differentiation among all the cases that one can form an

amalgamation of attributes. This concept analysis uses the

modified Walker and Avant’s (2011) method as suggested by

Risjord (2009).

Data sources

A comprehensive search of the literature was completed using

the databases CINAHL, Medline and PsycINFO. Keywords

used in the search were ‘control’ in conjunction with

‘childbirth’ and ‘birth.’ The timeframe was limited to the

years 1970–2011, as this was the timeframe where control in

childbirth made an appearance in the literature. In addition,

the search was restricted to English language articles. The

search identified 20,017 citations; however, the majority used

the word control in reference to randomized controlled trials

or case–control studies. After removing the unrelated articles,

citations were reduced to 97 studies. Each article’s abstract

was read and the citations were further reduced to include

only women’s perceptions of control during the timeframe of

labour and birth. Perceptions of control by the healthcare

practitioner were excluded. Both qualitative and quantitative

articles were included. The final total number of studies

which met the inclusion criteria was 34. Studies included

women who planned home births, women who accessed

inner-city birth centres, women who desired epidurals and

women who elected a primary caesarean section. It includes

studies from China, Taiwan, Australia, Sweden, Finland,

Jordan, England, Canada and the USA.

Results

In this section, cases are presented to help define the concept

of control in childbirth. A model, contrary and borderline

case are presented. Together these cases help to identify the

differences in the use of the word and to refine the attributes.

Four attributes of control in childbirth are presented,

followed by antecedents, consequences and empirical

referents.

Model case

According to Walker and Avant (2011, p. 163), a model case

should be a pure exemplar, one ‘that we are absolutely sure is

an instance of the concept’. In the literature, several studies

describe how women desire to be in control throughout their

prenatal care and birth. Women desire information, choice,

freedom and the ability of their bodies to birth without

interference from medical technology (Green et al. 1990,

Hundley et al. 1997, Lavender et al. 1999). In addition,

many women choose to deliver in an out-of-hospital setting

(home or freestanding birth centre) as a way to exert more

control over their birth (Morison et al. 1998, Esposito 1999,

Viisainen 2001, Boucher et al. 2009, Lindgren & Erlandsson

2010).

A first-time mother decides to have her birth at a

freestanding birth centre. During her prenatal care, she

actively researches and reads about the birth process and asks

questions of her nurse-midwife when she needs clarification

or verification. The nurse-midwife in return discusses her

scope of practice and expectations of what the woman can

expect from her throughout her care. When labour begins

and the woman comes to the birth centre, the nurse-midwife

discusses the plan of care with the woman and her family.

The woman chooses her own room, eats and drinks as she

pleases and is mobile throughout the centre. As the labour

progresses, the nurse-midwife performs massage with essen-

tial oils and the woman moans and chooses a variety of

positions to help her manage the contractions. The woman’s

partner is an active participant, providing pressure on the

mother’s back and helping her stay hydrated. The woman

asks and is helped to get in the birthing tub. Vaginal exams

are minimal with discussion about them ahead of time. The

woman begins to push spontaneously in the water and the

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220 � 2012 Blackwell Publishing Ltd

nurse-midwife encourages her to push when her body tells

her to do so. A mirror is placed in the bottom of the tub for

the mother and her partner to see the progression during

second stage. As the baby is born, the nurse-midwife gently

passes the baby through the woman’s legs and into her arms.

The new mother brings the baby up to the surface who is

calm. With help, the duo moves to the bed where the placenta

is easily delivered and the baby stays on the mother and

spontaneously crawls to the breast for the first feeding. The

baby stays in its mother’s arms for 2 hours, while vital signs

of both are monitored unobtrusively. The newborn exami-

nation is performed on the bed while the parents watch and

ask questions. The mother takes a herbal bath and at

4 hours after birth, the family leaves the birth centre to return

home.

The model case described here comes from an amalgam-

ation of examples from the literature and my personal

experiences as a certified nurse-midwife in the USA. In this

scenario, the woman has a trusting relationship with her

provider and feels safe in asking questions about her care. She

is given information about the plan of care and has a choice

in the level of intervention. She is allowed freedom of

mobility and in choosing where to have her birth. She is given

tools to help her cope with labour pain and is encouraged to

let her body birth naturally.

Contrary case

Several articles in the literature describe a lack of control or

feeling out of control. Researchers who studied women’s

experiences of traumatic birth describe how women felt

invisible and disconnected from knowledge about proce-

dures that were performed on them (Sjogren 1997, Elmir

et al. 2010). Jordanian women perceived a lack of control

during their birth due to intense pain, fear, inductions,

episiotomies and a lack of quality care from their provider

(Oweis 2009).

A first-time mother comes to the hospital because she is

experiencing contractions and believes she is in labour. On

arrival, she is taken into a triage room where her cervical

dilation is checked by a labour and delivery nurse she has

never met. The nurse calls the obstetrician on call and gives

report, saying the woman is 5 cm. The nurse leaves the room

without speaking to the mother or her partner. A second

nurse comes in and tells the woman she needs to be admitted

to labour and delivery. When in the delivery room, she is told

she needs to lie on her back in the bed, is hooked up to an

electric foetal monitor and an intravenous catheter is started

during a contraction. The nurse tells her she can only have ice

chips because eating or drinking could cause her to aspirate if

she has to have a caesarean section and tells the woman to let

her know when she wants an epidural. The woman and her

partner are left alone. Two hours later, a nurse checks her

cervical dilation again. She calls the obstetrician and reports

that she is ‘only 6 cm’. The obstetrician comes in and

ruptures the woman’s membranes without asking permission

or discussing risks and benefits, only stating the woman is not

dilating as fast as she needs to. The obstetrician tells her she

should get an epidural and the woman agrees. Two hours

later, when the woman is 7 cm, the obstetrician orders

Pitocin augmentation. When the woman is completely dilated

and has been pushing on her back for 2 hours, the foetal

heart rate declines. The obstetrician comes in with three

resident obstetricians, cuts an episiotomy and uses forceps to

deliver the baby. The cord is cut immediately by the

obstetrician and a paediatric team takes the baby to the

warmer where she is intubated and sent to the NICU for

meconium aspiration. The woman’s episiotomy is repaired by

a resident obstetrician under bright lights and her legs in

stirrups, with four people watching.

In this contrary case, the woman has never met the variety

of healthcare providers responsible for her care and does not

feel supported or respected by them. She is not informed by

the providers nor feels able to ask questions of them. The

providers do not give her an opportunity to be part of the

decision-making of her care and instead, send the message

that the woman’s body is not capable of giving birth without

medical intervention.

Borderline case

A woman plans to have a home birth. She trusts her nurse-

midwife and feels safe under her care. During labour, the

woman walks freely through her house, sits on a birth ball

during contractions and eats and drinks as she pleases. Her

partner is supportive and she feels informed about the

progression of her labour. Her membranes spontaneously

rupture and the midwife notices the umbilical cord hanging

out the woman’s vagina. She informs the mother of the

emergency and that she needs to be immediately transferred

to the hospital for a caesarean section. The woman agrees

and is transported via ambulance. On arrival to the hospital,

the woman’s anxiety surges as she remembers how her sister

died recently in a hospital due to a severe postpartum

haemorrhage. Despite the healthcare staff’s support and care

during the emergency, the woman remains in a highly

anxious state throughout her hospital stay.

Throughout her care, the woman is with supportive

providers who allow her to be part of the decision-making.

She is informed of the plan of care and procedures that are

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being performed and is able to ask questions. However, due

to the woman’s anxiety about her sister’s death, she is

fearful and unable to feel in control during her own

childbirth.

Attributes

Walker and Avant (2011, p. 162) state that the development

of attributes is ‘the heart of concept analysis’ and should

allow for the ‘broadest insight into the concept’. Four clusters

of attributes were identified through the literature review and

the creation of the cases in relationship to the concept of

control in childbirth. These attributes occurred repeatedly

and include consideration of the nurse-midwifery care con-

text where the concept of control is used: in childbirth. These

are decision-making, access to information, personal security

and physical functioning. Table 1 describes the articles

included in the literature review and the attributes each

contains.

Decision-making

Overwhelmingly, most examples of control had to do with

women’s sense of being an active member of the decision-

making process during their labour and birth. Christiaens

et al. (2010, p. 2) define personal control in labour pain as

‘about women’s active role in the decision to have or refrain

from having pain relief during labour’. In a study examining

women’s sense of control when choosing either home birth or

caesarean section, women who chose home birth were more

likely to feel in control by being able to choose their location

of birth and be a participant in the decisions about care

related to their progression of labour (Hildingsson et al.

2010). Similarly, Boucher et al. (2009) described that women

who chose home birth desired to be the primary person

making choices about their care. Kuo et al. (2010) found that

women who created birth plans felt more in control of their

childbirth because the process of writing the plan helped the

women think through scenarios ahead of time and anticipate

the choices they would make when faced with certain

decisions.

Other studies point to a woman’s sense of freedom. Ford

et al. (2009, p. 247) describe a woman’s ability to do what

she wanted that is dependent on her environment: ‘When I

was in the birth centre, I was very much in control of what

I wanted to do. I could pace around, I could sit in the pool, I

could shout, whereas the minute I got here [hospital], I knew

I would be stuck on the bed and I would be strapped to a

monitor and I wouldn’t be able to move around’. At planned

home births, women report feeling a sense of control over

who enters the birthing space and their ability to do and say

what they want (Lindgren & Erlandsson 2010).

Access to information

A second core attribute cluster revolved around women’s

access to information and knowledge around the events

related to their labour and birth. Namey and Lyerly (2010)

describe how women felt more in control when they had

received information about the normal process of labour and

what to expect. One woman stated ‘Yeah, I felt pretty much

in control, cause I mean the midwives were keeping me fully

informed and everything what was going on’ (Ford et al.

2009, p. 247). Women who experienced a traumatic birth

recall how they expected to be more informed by the staff

about their progression of labour and potential interventions

(Elmir et al. 2010). Tiedje and Price (2008) found that

information and having questions answered by the staff

allowed women to feel that they could make informed

choices.

Personal security

Personal security stems from women’s sense of trust, respect

and support from their provider. Namey and Lyerly (2010,

p. 773) define personal security as ‘order or management of

the birth experience and minimization of anxiety or fear’.

Some authors found that women’s sense of control

increased when they felt supported by staff who were

considerate of their needs and desires (Green & Baston

2003, Ford et al. 2009). Esposito (1999) discussed how

marginalized women had positive experiences of a more

humanized birth process at an inner-city birth centre where

they felt listened to and respected by the midwives in

charge of their care and therefore safe. Other studies found

that women appreciated the provider who was in charge

and felt safer when that provider was responsible for

decision-making, particularly during a caesarean section

(Tiedje & Price 2008, Fenwick et al. 2010). This was made

possible through the development of a trusting relationship

prior to childbirth. In contrast, women who planned a

home birth felt empowered when their midwife put trust in

them to be able to make it through the birth (Lindgren &

Erlandsson 2010). This, in turn, allowed women to trust in

themselves.

Physical functioning

The final attribute relates to women’s sense of control over

their bodies, emotions and pain. Women who had warm

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222 � 2012 Blackwell Publishing Ltd

Table 1 Control in childbirth context and attributes.

Author/s; design; sample; country Control in childbirth context Attributes discussed

O’Connell (1983); prospective; n = 44; United States Locus of control in pregnancy Access to information

Personal security

Physical functioning

Green et al. (1990); prospective; n = 825; England Psychological outcomes of childbirth Decision-making

Access to information

Personal security

Physical functioning

Hundley et al. (1997); RCT; n = 2844; England Midwife-led care Decision-making

Physical functioning

Sjogren (1997); case-control; n = 100; Sweden Anxiety about childbirth Decision-making

Physical functioning

Morison et al. (1998); phenomenology; n = 10 couples;

Australia

Home birth Decision-making

Physical functioning

Esposito (1999); ethnography; n = 40; United States Marginalized women in hospital vs. birth

centre

Decision-making

Access to information

Personal security

Physical functioning

Lavender et al. (1999); prospective; n = 412; England Positive childbirth experience Decision-making

Access to information

Personal security

Physical functioning

Lowe (2000); secondary analysis; n = 280; United States Self-efficacy for childbirth fears Physical functioning

Viisainen (2001); qualitative; n = 31; Finland Home birth Decision-making

Green and Baston (2003); longitudinal; n = 1146; England Control during labour Decision-making

Personal security

Physical functioning

Parratt and Fahy (2003); feminist constructivist; n = 6;

Australia

Women’s sense of self during childbirth Personal security

Physical functioning

Ayers and Pickering (2005); prospective; n = 289; England Women’s expectations of childbirth Physical functioning

Cheung et al. (2007); prospective; n = 90; China First-time mothers Physical functioning

Christiaens and Bracke (2007); n = 605; cross-national; Belgium

and Netherlands

Satisfaction with childbirth Decision-making

Physical functioning

Nicholls and Ayers (2007); qualitative; n = 6 couples; England Childbirth-related post traumatic stress

disorder in couples

Decision-making

Access to information

Personal security

Physical functioning

Tiedje and Price (2008); qualitative; n = 12; United States Women’s attitudes about childbirth Decision-making

Access to information

Personal security

Boucher et al. (2009); qualitative descriptive; n = 160;

United States

Home birth Decision-making

Access to information

Dahlen et al. (2009); RCT; n = 599; Australia Perineal warm packs during birth Physical functioning

Ford et al. (2009); mixed-methods; n = 412; England Support and control in childbirth Decision-making

Access to information

Personal security

Physical functioning

Hatem et al. (2009); Cochrane meta-analysis; n = 11 trials,

12,276 women

Midwife-led care Access to information

Physical functioning

Larkin et al. (2009); concept analysis; n = 62 papers; Ireland Childbirth experience Decision-making

Personal security

Physical functioning

Oweis (2009); cross-sectional; n = 177; Jordan Childbirth experience Decision-making

Personal security

Physical functioning

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packs placed on their perinea during the second stage of

labour reported increased control over their bodies (Dahlen

et al. 2009). In addition, women discuss how bodily mobility

in relation to pain relief is a factor in their sense of control

(Oweis 2009, Angle et al. 2010, Cooper et al. 2010). Several

studies looked at control over women’s emotions during

childbirth. Green and Baston (2003) found that women who

had a greater expectation of being in control of their

behaviour and their contractions during labour felt more in

control during the actual birth. In addition, studies found a

negative correlation between women’s sense of control and

their level of anxiety (Ayers & Pickering 2005, Cheung et al.

2007).

Finally, studies addressed issues of pain control. Namey

and Lyerly (2010) discuss how some women feel more in

control with an epidural as it allows them to focus on

something other than pain, whereas others feel in control if

they are not engaging in behaviour that would compromise

their dignity, such as screaming or swearing. Similarly, Ford

et al. (2009) found that some women felt in control when

they had pain relief from an epidural, whereas others felt less

in control when they experienced mental side effects from

opioids. Angle et al. (2010) found that women who had

received epidural pain relief valued its control of pain and its

ability to restore their focus, but appreciated when it

preserved their bodily sensations of labour progress, mobility

and strength.

Antecedents

The major antecedent for control over childbirth is the

pregnancy itself. Larkin et al. (2009) discuss the additional

antecedent of expectations of the birth experience. Women’s

expectations of what their labour will be like, how long their

labour will be, how much pain they will be in and how much

control they will have can greatly affect their sense of control

during the birth itself, with women expecting to be more in

control during childbirth reporting postnatally that their level

of control was higher than those who did not expect to be in

control (Green & Baston 2003).

Consequences

The literature supports the idea that women who experience

a sense of control during their labour and birth ulti-

mately have a more positive experience or higher level of

Table 1 (Continued)

Author/s; design; sample; country Control in childbirth context Attributes discussed

Angle et al. (2010); qualitative descriptive; n = 28; Canada Neuraxial labour analgesia Decision-making

Physical functioning

Christiaens et al. (2010); cross-national; n = 327; Belgium

and Netherlands

Pain relief Decision-making

Physical functioning

Cooper et al. (2010); RCT; n = 1054; England Low-dose and traditional epidurals vs.

non-epidural

Physical functioning

Elmir et al. (2010); meta-ethnographic; n = 10 papers;

Australia

Birth trauma Decision-making

Access to information

Personal security

Physical functioning

Fenwick et al. (2010); qualitative description; n = 14; Australia Elective caesareans in first- time mothers Decision-making

Access to information

Personal security

Physical functioning

Hildingsson et al. (2010); descriptive; n = 797; Sweden Planned home birth vs. planned caesarean Decision-making

Physical functioning

Kuo et al. (2010); RCT; n = 296; Taiwan Birth plans Decision-making

Lindgren and Erlandsson (2010); qualitative; n = 735; Sweden Home birth Decision-making

Personal security

Physical functioning

Namey and Lyerly (2010); qualitative; n = 101; United States Meaning of control Decision-making

Access to information

Personal security

Physical functioning

Structure based on Emmanuel & St. John (2010).

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224 � 2012 Blackwell Publishing Ltd

satisfaction. In addition, women have expressed a sense of

fulfilment and emotional well-being (Green & Baston

2003). Women also enter a new role of motherhood and

their sense of accomplishment and satisfaction during their

birth can greatly influence their level of self-confidence and

the outcome of future pregnancies, such as whether they

choose to have more children or whether they choose to

have elective caesareans for future births (Larkin et al.

2009).

Empirical referents

According to Walker and Avant (2011, p. 168), empirical

referents are ‘classes or categories of actual phenomena

that by their existence or presence demonstrate the occur-

rence of the concept itself’. They further state that referents

help you measure the defining attributes. With decision-

making, the referent is the woman’s ability to make her

own choice as to the care or interventions she receives,

which can be measured through observations or subjective

expressions of being able to make her own decision. Where

there is access to information, there is an exchange of

information between the healthcare provider and the

pregnant woman, where women would be able to ask

questions and clarify information as needed. Personal

security can be measured by the woman’s subjective

determination of the building of trust, respect and support

with those who care for her. More concrete measures could

include observations of eye contact, appropriate touch, the

vocalization of gentle and compassionate statements and

statements of encouragement and validation towards the

mother. Finally, physical functioning referents can include

women’s level of coping with pain, having low levels of

fear and anxiety and the freedom of mobility. Antecedents,

attributes, empirical referents and consequences are shown

in Table 2.

Discussion

Birth territory

The concept of control in childbirth fits well in Fahy and

Parratt’s (2006) Theory of Birth Territory. Key concepts in

the theory are terrain and jurisdiction. Terrain encompasses

the physical space of the birth and is categorized as being

either a sanctum or a surveillance room. In jurisdiction, a

woman can possess either integrative power or disintegrative

power and the provider can promote either midwifery

guardianship or midwifery domination. Midwifery guardian-

ship supports the woman’s ability to access her inner self and

power by controlling who enters the birth space and

nurturing her sense of safety, whereas midwifery domination

is a form of disintegrative power that manipulates women

into being docile and subverts their ability to exercise power

over their birth. Control in childbirth is not explicitly

addressed, but integrative power implies the importance.

Addition of the concept of control in childbirth to the Theory

of Birth Territory would add an important dimension, which

might better describe this important concept.

Limitations

There are some limitations to this analysis. The search terms

and databases used may have limited the breadth of discovery

of studies about the concept. In addition, expanding the

timeframe may have uncovered additional information

important in understanding control in childbirth. In addition,

the conceptual investigation of control is limited to the

context of childbirth. By limiting the discussion to one

health condition, a more detailed and focused analysis is

possible that expands academic and practitioner leverage on

the subject. However, it also limits generalizability across

healthcare conditions. Additional conditions that may benefit

Table 2 Antecedents, attribute, empirical referents and consequences of control in childbirth.

Antecedents Attributes Empirical referents Consequences

Pregnancy Decision-making Observations/subjective report of maternal decision-making Motherhood

Expectation of

the childbirth

experience

Access to information Observations of maternal questioning of provider Satisfaction with childbirth

experience

Personal security Subjective report of trust, respect and support from provider Fulfilment

Physical functioning Observations of eye contact, appropriate touch,

compassionate statements and validation

Future pregnancy outcomes

Measurement of maternal coping

Measurement of maternal fear and anxiety

Observation of maternal mobility

JAN: CONCEPT ANALYSIS Control in childbirth

� 2012 Blackwell Publishing Ltd 225

from exploration into how control is used and defined are

glycaemic control, asthma control, infection control and

involving children in decisions about their care.

Conclusion

Childbirth is a complex phenomenon, which engenders a

multitude of feelings for the woman, and diverse perinatal

outcomes. Conceptually, control in childbirth can be viewed

as a means by which a woman experiences her birth as a

positive experience or a negative one. Women who demon-

strate the four attributes described have an increased chance

of being satisfied with her birth (Esposito 1999, Green &

Baston 2003, Cheung et al. 2007, Christians & Bracke 2007,

Ford et al. 2009, Oweis 2009, Elmir et al. 2010, Hildingsson

et al. 2010, Kuo et al. 2010).

In conclusion, description of the attributes and clarification

of the definition of control in childbirth can help inform

women and maternity providers throughout the world.

Addition of the concept to an existing theory (Theory of

Birth Territory) provides clarity to a previously tenuous

concept and offers a structure for both research and clinical

practice activities. Testing the concept of control through the

Theory of Birth Territory also would expand disciplinary

knowledge. Future research has the potential to expand this

work on control by examining related concepts of coping,

choice, power and autonomy. Such work by nurse-midwife

scientists has the ability to promote improved understanding

of not only the birth experience but also of the impact of

control in childbirth and improved perinatal outcomes.

Acknowledgements

The author wishes to thank Dr Marie Hastings-Tolsma and

Dr Nancy Lowe.

Funding

This research received no specific grant from any funding

agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

No conflict of interest has been declared by the author.

Author contributions

All authors meet at least one of the following criteria

(recommended by the ICMJE: http://www.icmje.org/ethi-

cal_1author.html) and have agreed on the final version:

• Substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data;

• drafting the article or revising it critically for important intellectual content.

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