Factors Associated With Low Vaginal Birth Self-Efficacy Among High-Risk Pregnant Women

To editor: Childbirth self-efficacy, defined as a woman’s confidence in managing labor and achieving vaginal birth, is a key determinant of childbirth outcomes.1 It influences coping, emotional responses, and decision-making, with higher self-efficacy associated with lower anxiety and more positive birth experiences, and lower self-efficacy linked to fear of childbirth and increased medical intervention.2 Although distinct from fear of childbirth, both constructs interact and influence decision-making. Instruments such as the Childbirth Self-Efficacy Inventory (CBSEI) assess perceived capability, while the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) measures fear.3,4 Maintaining self-efficacy is particularly challenging in high-risk pregnancies, defined by conditions such as hypertensive disorders, gestational diabetes, advanced maternal age, previous cesarean section, and assisted reproductive technology. These conditions increase perceived vulnerability and uncertainty.5 High-risk diagnoses often trigger anxiety, fear, and reduced confidence in vaginal birth. Social influences, including partner support and negative birth narratives, further shape perceptions. Healthcare communication also plays a critical role; risk-focused or non-empathetic approaches may undermine confidence, whereas supportive, woman-centered communication may enhance it.5 This review synthesizes factors associated with low vaginal birth self-efficacy among high-risk pregnant women. Materials and methods This systematic review followed Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020 guidelines6 and applied the population, exposure, outcome, and study design framework. The population included women with high-risk pregnancies. Exposure encompassed psychological, clinical, social, and healthcare-related factors influencing childbirth self-efficacy. The primary outcome was childbirth self-efficacy measured using validated instruments such as the CBSEI. Studies using related constructs, such as fear of childbirth measured by the W-DEQ, were included but interpreted cautiously. Inclusion criteria were: peer-reviewed articles published between 2019–2025, examining determinants or associated factors of childbirth self-efficacy, and published in English. Exclusion criteria included studies limited to low-risk populations, intervention-only studies without determinant analysis, non-original articles, and studies with insufficient data. A comprehensive search was conducted in PubMed, Scopus, ScienceDirect, and Google Scholar. Records were screened through title, abstract, and full-text review by two independent reviewers. Data on study characteristics, measurement tools, and key findings were extracted. Methodological quality was assessed using JBI tools and MMAT. Due to heterogeneity, findings were synthesized using thematic narrative analysis. The study selection process is presented in Fig. 1.Figure 1: PRISMA 2020 flow diagram of study selection. PRISMA: Preferred Reporting Items for Systematic reviews and Meta-AnalysesResults Study characteristics A total of 11 cross-sectional studies met the inclusion criteria, with sample sizes ranging from 57 to 603 participants across diverse settings. Childbirth self-efficacy was most commonly measured using the CBSEI, with some studies incorporating related constructs such as fear of childbirth assessed through the W-DEQ. Across studies, a high-risk pregnancy was consistently defined by medical or obstetric conditions associated with increased maternal or fetal risk. Factors associated with low vaginal birth self-efficacy Across the included evidence, factors associated with low vaginal birth self-efficacy clustered into four interconnected domains: psychological, clinical and obstetric, social, and healthcare-related determinants. Psychological factors emerged as the most consistent and dominant contributors. Antenatal anxiety and fear of childbirth were strongly associated with reduced confidence in managing labor and achieving vaginal birth.7–9 Women frequently reported concerns about labor pain, complications, and loss of control, particularly in the context of high-risk diagnoses. Fear of childbirth (tokophobia) showed a robust inverse relationship with self-efficacy, reinforcing avoidance tendencies and negative birth expectations.10 In addition, exaggerated risk perception and catastrophic thinking further diminished perceived capability, with women interpreting medical diagnoses as indicators of bodily inadequacy despite stable clinical conditions. These findings suggest that psychological distress plays a central role in shaping self-efficacy beliefs.7–10 Clinical and obstetric conditions were consistently associated with lower self-efficacy, primarily through their influence on perceived vulnerability. Conditions such as hypertensive disorders, gestational diabetes mellitus, advanced maternal age, previous cesarean section, and assisted reproductive technology were linked to increased fear of complications and reduced confidence in vaginal birth.7,8,10 Rather than acting as direct determinants, these conditions appeared to function as catalysts that intensified psychological distress and risk perception. Women with prior cesarean sections, in particular, demonstrated lower confidence in vaginal birth, often accompanied by persistent fear related to previous birth experiences.8,10 Social factors played a significant moderating role. Partner support consistently emerged as a strong protective factor, associated with higher confidence and improved coping capacity.7,9,10 Conversely, lack of social support contributed to increased anxiety and reduced self-efficacy. Negative birth narratives from family members or peers further reinforced fear and discouraged confidence in vaginal birth.9,10 These findings highlight the importance of social context in shaping women’s perceptions and emotional responses to childbirth. Healthcare-related factors were also identified as critical determinants. Non-empathetic communication, limited shared decision-making, and risk-focused counseling were consistently associated with lower self-efficacy.7 Women frequently reported that antenatal care emphasized potential complications without adequate reassurance or coping guidance, which intensified fear and uncertainty. In addition, perceived clinical bias toward cesarean delivery further undermined confidence in vaginal birth. Negative prior healthcare experiences, including inadequate communication or lack of emotional support, also contributed to reduced self-efficacy.7 Overall, the findings indicate that low vaginal birth self-efficacy among high-risk pregnant women is not solely determined by clinical risk, but rather emerges from the interaction between psychological distress, perceived vulnerability, social influence, and healthcare communication. Discussion Low vaginal birth self-efficacy among high-risk pregnant women arises from interconnected psychological, clinical, social, and healthcare factors. Psychological distress, particularly anxiety and fear of childbirth, was the strongest determinant. This aligns with social cognitive theory, where emotional distress reduces perceived capability. Catastrophic thinking and exaggerated risk perception further amplify this effect. Clinical conditions act as catalysts by increasing perceived vulnerability. Their impact depends on individual risk appraisal, consistent with the health belief model. Social support moderates these effects, with positive reinforcement enhancing confidence and negative narratives reinforcing fear.10 Healthcare communication is a critical and modifiable factor. Risk-focused, non-empathetic interactions reduce confidence, whereas supportive communication enhances self-efficacy. An integrated pathway emerges in which clinical risk triggers psychological distress, shaped by social and healthcare influences. The integrated pathway identified in this review indicates that clinical risk increases perceived vulnerability, triggering psychological distress that undermines childbirth self-efficacy, while social and healthcare factors modulate this process. This finding is consistent with Social Cognitive Theory, where emotional arousal reduces perceived capability, and with the Health Belief Model, where perceived risk drives cognitive and behavioral responses. Implications for practice Interventions to improve self-efficacy should adopt a multi-level approach that addresses psychological distress, enhances social support, and improves healthcare communication. Woman-centered antenatal care emphasizing empathy, balanced risk communication, and shared decision-making is essential. Conclusion Low vaginal birth self-efficacy among women with high-risk pregnancies is influenced by psychological, clinical, social, and healthcare-related factors. Addressing these factors through woman-centered, psychologically informed care may enhance self-efficacy and improve childbirth outcomes. Acknowledgments The authors acknowledge and appreciate the contributions of previous researchers and colleagues who supported this work. Funding The research was self-funded by all authors. Conflict of Interest None. Data Availability All data analyzed in this study are derived from previously published articles included in the review.