Assignment: Concept Analysis
C O N C E P T A N A L Y S I S
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
M E Y E R S . ( 2 0 1 3 )M E Y E R S . ( 2 0 1 3 ) 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
218 � 2012 Blackwell Publishing Ltd
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, Boucher et al. 2009, Christians et al. 2010, Fenwick
et al. 2010). Control in childbirth has international relevance as
it is used in a variety of countries throughout the world that have
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).
S. Meyer
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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