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Childbirth Self-Efficacy Inventory and Childbirth Attitudes
Questionnaire: psychometric properties of Thai language versions
Kamonthip Tanglakmankhong, Nancy A. Perrin & Nancy K. Lowe

Accepted for publication 3 September 2010

Correspondence to K. Tanglakmankhong: T A N G L A K M A N K H O N G K . , P E R R I N N . A . & L O W E N . K . ( 2 0 1 1 ) Childbirth Self-
e-mail: tang_kamon@hotmail.com Efficacy Inventory and Childbirth Attitudes Questionnaire: psychometric properties
of Thai language versions. Journal of Advanced Nursing 67(1), 193–203.
Kamonthip Tanglakmankhong MSN PhD
doi: 10.1111/j.1365-2648.2010.05479.x
School of Nursing,
Oregon Health & Science University, Abstract
Portland, Oregon, USA Aim. This paper is a report of the psychometric properties of the Thai language
versions of the Childbirth Self-Efficacy Inventory and the Childbirth Attitudes
Nancy A. Perrin PhD Questionnaire, and the equivalence of the Thai and English versions of these
Senior Investigator instruments.
Center for Health Research, Background. The Childbirth Self-Efficacy Inventory and the Childbirth Attitudes
Kaiser Permanente Northwest, Portland,
Questionnaire were developed to measure women’s abilities to cope with labour and
Oregon, USA
fear of childbirth. Consistent with Bandura’s Self-Efficacy Theory, women who have
Nancy K. Lowe PhD RN CNM greater confidence in their ability to cope with labour have reported having less fear
Professor & Chair in childbirth. However, research is needed to validate the measures and this rela-
Division of Women, Children, & Family tionship in countries other than the United States of America, where the tools were
Health, College of Nursing, developed.
University of Colorado Denver, Aurora, Methods. Back-translation was used. Content validity was examined by experts.
Colorado, USA The psychometric properties were estimated with internal consistency reliability,
construct validity, contrasted groups and criterion-related validity with 148 preg-
nant women at a hospital in Thailand in 2008.
Results. Both measures were shown to have high internal consistency. Contrasting
group and criterion-related validity were consistent with self-efficacy theory and
findings in the United States. Differences between the stages of labour across
expectancies in the Childbirth Self-Efficacy inventory were found only for second
Conclusion. Support for good validity and reliability of the instruments when used
with Thai women was demonstrated. It may be appropriate for Thai women to use
The Childbirth Self-Efficacy Inventory only in relation to the second stage of labour.

Keywords: attitudes, childbirth, fear, midwifery, nursing, psychometric properties,
self-efficacy, Thai 

2010 The Authors
Journal of Advanced Nursing  2010 Blackwell Publishing Ltd 193

when a woman gives birth at home. 2001). ensure the content. therefore. Beebe et al. 2004). McCourt et al. 2000). 2007). hospital deliveries in Thailand during 1990–2001 showed p. A national survey examining to attain designated types of performance’ (Bandura 1986. 391). creates uncer. Waldenstrom et al. we should not Background assume that research from other countries applies in Thailand. Northern Thailand has been one of the most successful countries in Ireland (Sinclair & O’Boyle 1999) and Hong Kong (Ip et al.000 live births in 1962 to validity and reliability of the CBSEI (Dilks & Beal 1997. According to rate exceeds the World Health Organization recommended Bandura (2000). Following an economic recession in ous experience. Self-efficacy is based on four major sources of that caesarean section rates increased from 14Æ8% in 1990 to efficacy information: performance accomplishments. physicians or nurses (Sauvarin 2006) measure fear during childbirth and to explore the theoreti- to keep improving maternal and neonatal mortality rates. This performance accomplishment (Bandura 1977). developed the Childbirth Attitude Questionnaire (CAQ) to als. coupled are no published studies with Thai women that have with the fact that it is difficult to tell a woman exactly when measured self-efficacy and fear of childbirth. 1988) and to give evidence for the validity and birth process (Lowe 1993). 2005). raise doubts about her ability conceptual equivalence of the Thai and English versions to cope with labour and increase fear about the labour and (Flaherty et al. of studies based on Bandura’s self-efficacy theory (Lowe Black 2007).K. Kish 2003). South East Asia at reducing its maternal mortality rate. how long it will last. The CBSEI has been tested in other countries. given that birthing methods and experiences differ from country to country. home birth. it may be possible to improve cannot perform that behaviour such information may not childbirth experiences in Thailand by helping women to influence their behaviour. semantic. 2003). Efficacy expectation and outcome expectation are not the Research in the USA has shown that higher self-efficacy for same. Whether or do not allow family members to be present at birth not this knowledge can be applied to the care of childbearing (Chunuan et al.  2010 The Authors 194 Journal of Advanced Nursing  2010 Blackwell Publishing Ltd . Women must cope with their birth women in Thailand is unknown and requires validation using experiences alone in an unfamiliar environment in wards culturally and psychometrically sound instruments. Introduction such as Australia (Drummond & Rickwood 1997). this 2005). 2008). but if they think that they 2000. used as a framework to guide other studies in pregnancy sure that was originally developed in the USA through a series and childbirth (Sinclair & O’Boyle 1999. and on their beliefs about the higher than 15% have been shown to be associated with probable outcome of performance (outcome expectation). more harm than good (Althabe & Belizin 2006). Beebe et al. people act on their beliefs about what they rate of no more than 5–15% (Chalmers et al. Lowe (2000) women give birth in hospital with well-trained profession. giving birth in hospital is very different from efficacy and fear in nulliparous women. In almost exclusively derived from studies with women in contrast. Kish 9Æ8 in 2006 (Wibulpolprasert et al. applied in many areas of nursing research and has been The Childbirth Self-Efficacy Inventory (CBSEI) is a mea. criterion and tainty. Rates can do (efficacy expectation). Government 2003. Tanglakmankhong et al. or to conduct independent measurement validation studies to what she will experience during its course. because people can believe that a certain behaviour childbirth is associated with lower fear of childbirth (Lowe will produce a desired outcome. Self-efficacy theory has been increase their self-efficacy and reduce fears of childbirth. Multiple studies have provided evidence of good rate has fallen from 374Æ3 per 100. 1993. Thailand on self-efficacy. such as midwives. capacities to organize and execute courses of action required 2006. cally predicted inverse relationship between childbirth self- However. verbal persuasion and physiological Thailand. 2006. Self-efficacy theory Fear of childbirth has been recognized in several studies as a reason for increases in the number of women requesting Self-efficacy is a primary concept of social learning theory elective caesarean sections (Melender 2002. she has Knowledge about psychosocial aspects of childbirth is support from her family in a familiar environment. 2007. it is important spontaneous labour will occur. Saisto & that has been defined as ‘people’s judgments of their Halmesmaki 2003. may lower self-efficacy. The most influential source of information is approximately 20% (Teerawattananon et al. vicari- a peak of 22Æ1% in 1996. technical. staff in most delivery units in Thai public hospitals western countries in Europe and North America. This situation. the caesarean section rate remains stable at responses. As there with several other women in labour. Tsui et al. 2007) and the measure has been success- health authorities in Thailand recommend that all Thai fully translated into Chinese (Ip et al. There is a lack of research in reliability of the Thai version.

JAN: RESEARCH METHODOLOGY Psychometric properties of Thai language versions being measured. The Thai CBSEI and CAQ were developed in two phases. Seven experts were asked to judge the content validity of Researchers must ensure that cross-cultural results are not the translated CBSEI – four Thai nurse–midwife instructors due to error in translation or differences in the construct and three Thai nurse researchers specializing in self-efficacy. Childbirth self-efficacy they should have similar internal consistency. 2005).  2010 The Authors Journal of Advanced Nursing  2010 Blackwell Publishing Ltd 195 .or anxiety-associated autonomic with those found in the USA (Lowe 1993) and China (Ip responses that some women may experience when thinking et al. the instrument has not been translated Skrutkowski 2002). The CBSEI and English versions of the instruments. crite- through labour and birth because childbirth is a difficult rion and conceptual equivalences between instruments must experience requiring a variety of coping behaviours. instructions from others (Lowe 1991). into other languages. with lower fears (Lowe 2000) and anxiety in childbirth (Beebe et al. technical. researchers found related validity with Thai pregnant women. the psychometric properties the CBSEI in English (estimates range from 0Æ86 to 0Æ95. criterion-related validity would be supported if birth self-efficacy. women develop their child. Lowe (1993) developed the CBSEI based on Bandura’s self. breathe through contractions and listen to English and Thai versions of an instrument are equivalent. the items has been defined as ‘a woman’s confidence in her ability to should be relevant in the Thai culture. the translated the CAQ. Therefore. Fear is one of the major emotions that can affect Thai. p. In the second phase. with an alpha equal to 0Æ83 (Lowe 2000) and 0Æ87 version is likely to be equivalent in meaning (Hilton & (Kish 2003). technical. that women could not differentiate between active and second stage labour (Ip et al. vicarious expe. content. 2005) and higher scores were found for women who about their approaching labour and birth. Con- rience of other women during childbirth. from the Thai versions of the instruments were consistent and friends. 1988). but rather are due to real differences Childbirth self-efficacy between cultures (Maneesriwongul & Dixon 2004). In plating their forthcoming birth experience. Lowe 2000. were tested by estimating internal consistency reliability. Analyses have supported the reliability of and back-translated versions are the same. if the the ability to relax. Using the Chinese version. through higher self-efficacy were associated with lower fear of personal experiences with labour and birth. (2008) Phase 1: Instrument translation and content validity developed a short form of the Chinese CBSEI by deleting the testing with experts two repetitive expectancy subscales of the original version. Ip et al. when women are actively contem. and the meaning of cope with labour’ (Lowe 1991. Previous experience with childbirth The study appears to improve self-efficacy. other professionals. It is intended for use during the third trimester of pregnancy. Internal consis. the first phase. semantic. However. example. Consistent with the items should be the same in the two cultures. 2005). For example. Lowe 1993) and Chinese (estimates range from 0Æ92 to 0Æ96. criterion and conceptual equivalence of the Thai efficacy theory and measurement principles. The aim of the study was to test the psychometric properties of the Thai language versions of the CBSEI and the CAQ. If the original version (Bandura 1977). construct validity. contrasted groups validity and criterion- Ip et al. either positively or negatively. Kish 2003). such as be established (Flaherty et al. the instrument translation and content validity tency estimates have provided evidence for the reliability of were tested. Research indicates had given birth previously in comparison to new mothers that higher self-efficacy for labour is significantly correlated (Lowe 1993). as multiparous women have higher self-efficacy than those who are pregnant for the first Aim time (Lowe 1993). Back-translation was used to determine the equivalence perceived self-efficacy in coping with threatening situations of the original and translated versions. and fear. discussions with struct validity would be evidenced if the factor structure childbirth educators. 2007). 457). In the Bandura’s self-efficacy theory. measures both outcome expectancies and self-efficacy expec- tancies for coping with childbirth during the first and second Methodology stages of labour. and Measuring childbirth self-efficacy and fear to examine the cultural equivalence including content. To Many women may feel uncertain about their ability to get answer these questions. Two bilingual experienced midwives did the forward-trans- Lowe (2000) developed the CAQ to measure fear in lation of the original English versions of the instruments into childbirth. family members. childbirth (Bandura 1977.

literate and was interested and met the inclusion criteria. slightly below the recommended 10–1 ratio (Sapnas identity of any participants. Return of a completed question- & Zeller 2002). revisions were re-validated by the Thai content experts. (ii) were clear. For second stage of proportion of raters responding ‘yes’ to that item. Inclusion criteria were to give each pregnant woman an information sheet about the age 18–45 years. Partici. Lowe (2000) reported an internal consistency reli- ability estimate for the CAQ of 0Æ83 in her study with 280 Participants nulliparous women attending childbirth education classes The majority of prenatal care in Thailand is provided by a after 28 weeks of gestation. Kish 2003) is a measure adapted from women Harman (1988) and Areskog et al. she was referred fluent in Thai. Ethical considerations All pregnant women who accessed care through a prenatal clinic at one major hospital in Thailand during January Ethics approval was attained from the appropriate institu- 2008 were invited to complete the questionnaires. from 1 (not at all helpful or not at all sure) to 10 (very helpful was clear. along with the comments about the items total correlations >0Æ30 for all items on each scale (Lowe made by the content experts (Lynn 1986). Content validity indices were calculated as the contractions 5 minutes apart or less’. Nurses at the prenatal clinic were asked pation in the study was voluntary. tional review boards. Scale scores are computed by taking the mean of the 16 items. The raters me in labour’. women are asked to think about when they are judgment-quantification stage of content validity required six pushing their baby out to give birth. Important item 1993). Childbirth Attitudes Questionnaire Phase 2: Psychometric evaluation among Thai pregnant The CAQ (Lowe 2000. The labour. Five Thai nurse–midwife instructors were asked to judge the (Outcome AL and Efficacy AL) and have 15 items each. The raters read both other two subscales are Outcome and Self-efficacy Expec- the English and Thai versions of the questionnaire items and tancy for Second Stage of labor (Outcome SS and Efficacy determined. Tanglakmankhong et al. An delivery. and was appropriate for use with Thai pregnant or completely sure). 15 of which are identical to the AL the definitions of the concepts. correlations and t-tests. Instruments Data analysis Childbirth Self-Efficacy Inventory Psychometric testing of the CBSEI and CAQ included The CBSEI (Lowe 1993) has four subscales. where it had high internal consistency minimum agreement among the experts were considered for reliability with estimates ranging from 0Æ86 to 0Æ95 and item- potential revision. pregnant with a singleton foetus. The sample size was 150. Care is delivered in govern- ment hospitals and each major hospital has a prenatal clinic. One additional item. Translated items that did not achieve the required tested in the USA. of seven experts for the CBSEI and four of five experts for the Scale scores are the mean of the responses to each item CAQ to find that the item fitted the definition of the concept. It is a 16-item questionnaire with a Likert res- reliability of the Thai version of the CBSEI and CAQ among ponse scale of 1–4. The content validity of the translated CAQ. fear. To differentiate answered yes or no for each aspect and wrote any comments. The CBSEI has been psychometrically women. women are oriented to the A yes/no format was selected over 1–4 scale to avoid cultural experience of active labour by the statement. in the study when they arrived at the prenatal clinic. if the translated CBSEI and CAQ items: (i) fitted SS). ‘Think about differences in interpretation of the anchors for the numerical how you imagine labour will be and feel when you are having ratings. universal coverage programme. factor analyses. possible benefits and anonymity of the data. who informed her about the purposes of the pregnancy. naire was considered as consent to participate. is included in each SS subscale. ‘Focus on the person helping appropriate for use with Thai pregnant women. (1982) to measure fear of The purpose of this phase was to evaluate the validity and childbirth. If the woman third trimester of pregnancy (28–40 weeks). with 16 items each. and not having had a previous caesarean study. Five  2010 The Authors 196 Journal of Advanced Nursing  2010 Blackwell Publishing Ltd . and (iii) were subscales. between the stages of labour. giving a ratio of information sheet rather than an informed consent for was participants to number of items (for the longest scale) of used to ensure that the researcher would not know the 9Æ4–1.K. with higher scores representing higher Thai pregnant woman. not at high risk for complications of to the researcher. The first two are Cronbach’s alpha coefficients to estimate internal consistency Outcome and Self-efficacy Expectancy for Active Labor reliability.

6Æ90. comprehensiveness. Independent t-tests of differences in Nulliparous 75 (50Æ7) outcome and self-efficacy expectancy between women with Multiparous 73 (49Æ3) and without prior childbirth experiences were conducted to examine contrasting group validity. who had a mean age of 25Æ47 years (range Because the CBSEI items were repetitive in each subscale. the factor  2010 The Authors Journal of Advanced Nursing  2010 Blackwell Publishing Ltd 197 . Paired t-tests were used to determine if women differentiated active labour from Phase 2 second stage. and needed to be modified. 0Æ58–0Æ73 for Outcome SS and 0Æ60– one CAQ item did not accurately reflect the English version 0Æ77 for Efficacy SS). Comparison with loadings >0Æ40 (range 0Æ43–0Æ77 for Outcome AL. (Appendix B). the first factor explained 39Æ58–50Æ49% of variance. Three 6Æ85–7Æ1%. factor analyses for the Education Outcome AL subscale and Efficacy AL subscale each had 15 Primary school 43 (29Æ1) items and factor analyses for Outcome SS subscale and Secondary school 81 (54Æ7) College 10 (6Æ8) Efficacy SS subscale each had 16 items. These translators had no prior knowledge of the original consistent with theory. due to the 31–35 31 (20Æ95) repetition of the items for active and second stage labour 36–40 5 (3Æ38) (Lowe 1993). SD = 5Æ63) 18–25 80 (54Æ05) subscales. providing evidence for semantic The first two eigenvalues for the CAQ were 6Æ41 and 1Æ47. solution for each of the subscales was interpretable and sors. and therefore selected for each scale. culture. 7Æ75. Level of significance was set at P = 0Æ05. The first three eigenvalues were 5Æ94. Table 1 shows the demographics of Phase 1 the 148 women. Efficacy AL. Participant demographics The sample comprised of 150 Thai pregnant women. respectively. All translated items of the CBSEI and CAQ met the 80% criteria for fitting the conceptual definitions Construct validity (Lynn 1986). Over half (54Æ7%) reported at least some high expert raters were asked to evaluate the 16 unique items of school education and half reported being pregnant for the the CBSEI (Appendix A) and the 16 items for the CAQ first time (50Æ4%). and outcome from self-efficacy expectancy. 42Æ27%. 0Æ51– the original version of CBSEI and CAQ indicated that only 0Æ77 for Efficacy AL. and were considered for revision. When examining the two-factor solution. English versions and were not clinical or theory experts. 46Æ02% compared and discussed for clarity. Therefore. Data from two of them were not used because they failed to Results complete more than 20% of the items on the CBSEI and did not complete the CAQ. Pearson’s correlation Bachelor’s degree 4 (9Æ5) coefficients for the CBSEI with the CAQ were used to assess Parity concurrent validity. All items had acceptable factor appropriateness and cultural relevance. and 8Æ08. 1Æ64 and 1Æ07 for Efficacy AL. Twelve of the 16 CAQ items were clear and 15 of the the second explained 9Æ22–11Æ39% and the third explained 16 items were evaluated as appropriate in Thai culture. 1Æ47 and 1Æ11 for Outcome SS. The women. The The variance explained for Outcome AL. these items were 1Æ10 for Efficacy SS. is likely. the 18–39 years). items that loaded on these factors did not have any clear The modified Thai instruments were back-translated to association and could not be named.JAN: RESEARCH METHODOLOGY Psychometric properties of Thai language versions exploratory factor analyses (one for each of the four subscales Table 1 Participant demographics (N = 148) of the CBSEI and one for the CAQ) with principal axes N (%) factoring and oblique rotation were used to assess the unidimensionality and construct validity of each of the Age in years (mean = 25Æ47. The single-factor English by two Thai English department university profes. Thirteen of the 16 CBSEI items were clear and In each of the four factor analyses for the subscales of the 15 of the 16 items were evaluated as appropriate in Thai CBSEI. equivalence of the English and Thai versions of both The first factor explained 40Æ09% of variance and the second instruments. The four subscales of the CBSEI were analysed 26–30 32 (21Æ62) separately because systematic error in responses. original versions and the back-translated versions were Outcome SS and Efficacy SS was 39Æ58%. 9Æ21%. Both the second and third factors were paraphrased to clarify the conceptual meaning for Thai not conceptually interpretable for any of the scales. 1Æ58 and Based on suggestions from the experts. and 48Æ43%. agreement of the experts. 1Æ71 and CBSEI items and four CAQ items did not meet the minimum 1Æ04 for Outcome AL.

the word ‘relax’ was expectancy scores had no relationship with childbirth fear. the two groups of women were not statistically Expectancy for Second Stage of labor.  2010 The Authors 198 Journal of Advanced Nursing  2010 Blackwell Publishing Ltd . to 0Æ13). was substi- (Table 3). tuted for ‘contraction’. Self-Efficacy Expectancy for Active Labor. In addition to the instructions. many did not understand the outcome expectancy was statistically significantly higher words ‘behaviour’ and ‘contraction’. with all Inventory (CBSEI) and Childbirth Attitudes Questionnaires (CAQ) items having factor loadings from 0Æ48 to 0Æ72. CAQ. feedback. Efficacy AL. the instructions were revised to say. They were also not than self-efficacy expectancy (mean difference = 0Æ14. questionnaire. Based on their t = 2Æ23. 3 and 14. please indicate how many points you feel the Concurrent validity was assessed in terms of the relation. Self-efficacy Expectancy for Active Labor. familiar with the 1–10 response format. Efficacy SS. P = 0Æ027. Independent t-tests Outcome SS 0Æ12 0Æ08 Total outcome 0Æ15 0Æ09 showed that the mean self-efficacy score for women with Efficacy AL 0Æ22** 0Æ37** childbirth experience was statistically significantly higher Efficacy SS 0Æ19* 0Æ33** than for those without prior childbirth experience for both Total efficacy 0Æ22** 0Æ36** active (mean difference = 0Æ57. scores in the present study and Lowe (2000) Table 2 summarizes the means and standard deviations Correlation with CAQ for each of the subscales by parity. Outcome AL. ence = 0Æ59. and second stage labour (mean differ- Outcome AL. Outcome Expectancy for Second Stage of labor. Table 2 Comparison mean and standard deviation of the Childbirth Self-Efficacy Inventory (CBSEI) and the Childbirth Attitudes Ques- tionnaires (CAQ) according to parity Sample (N = 148) Nulliparous (N = 75) Multiparous (N = 73) Scales Mean SD Mean SD Mean SD T P Outcome AL 7Æ29 1Æ22 7Æ27 1Æ22 7Æ31 1Æ22 0Æ18 0Æ854 Efficacy AL 7Æ19 1Æ39 6Æ91 1Æ42 7Æ48 1Æ29 2Æ56 0Æ012* Outcome SS 7Æ30 1Æ32 7Æ12 1Æ24 7Æ48 1Æ37 1Æ66 0Æ099 Efficacy SS 7Æ16 1Æ47 6Æ87 1Æ46 7Æ45 1Æ43 2Æ64 0Æ015* CAQ 2Æ39 0Æ56 2Æ53 0Æ53 2Æ24 0Æ58 3Æ04 0Æ003** *P < 0Æ05. 95% CI 0Æ02–0Æ26). Self-efficacy significantly different on outcome expectancy at either stage Expectancy for Second Stage of labor. Total childbirth outcome required rephrasing. which fear had a statistically significant inverse relationship is better known among Thai pregnant women. of labour. reworded as ‘making your body become less stiff or less while total childbirth self-efficacy expectancy scores and rigid’. 95% CI 1Æ01 *P < 0Æ05. the phrase ‘labour pain’. Efficacy AL. 95% CI 1Æ05 to 0Æ12). P = 0Æ015. certain items also with Lowe’s (2000) findings. Outcome Expectancy for Active Labor. For the CAQ. For the CBSEI. **P < 0Æ01.K. Outcome Expectancy for Active Labor. Paired t-tests showed that the mean scores for outcome and Twenty participants were asked to paraphrase their under- self-efficacy expectancy did not differ between active and standing of the instructions and items after completing the second stage labour. Outcome SS. a situation when you are in labour pain every five minutes or less. Efficacy SS. Childbirth Attitudes Questionnaire. However. If the Criterion-related validity full score is 10. Additional feedback from participants 95% CI 0Æ10–0Æ45). Tanglakmankhong et al. Outcome ever. For items 2. suggestion could be in helping you deal with this part of ship between the CBSEI and CAQ and was consistent labour’. Differences in outcome CBSEI Present study Lowe (2000) and self-efficacy expectancy between women with and without prior childbirth experience were used to give Outcome AL 0Æ13 0Æ10 evidence for contrasting group validity. **P < 0Æ01. P = 0Æ012. loadings were not clearly interpretable. Self-efficacy Expectancy for Second Stage of labor. ‘Please imagine outcome and self-efficacy expectancy did not differ. The single-factor Table 3 Comparison correlations of Childbirth Self-Efficacy solution was appropriate and consistent with theory. For item 1. P = 0Æ003. the mean childbirth fear score for multiparous women was statistically significantly lower than for nulliparous women (mean difference = 0Æ27. and the nurse suggests you do the following item. How. Outcome SS. in second stage labour. In active labour.

2005). Efficacy SS. Self-Efficacy Expectancy for Active Labor. CBSEI subscales. providing additional is needed to strengthen the findings of this study. The content equivalence of the Thai and English versions Although the study provides support for the content. Australia Our study provided evidence of reliability for the (Drummond & Rickwood 1997). lending support to the Discussion equivalence of the CBSEI across cultures (Lowe 1993. Outcome SS. The self-efficacy expectancies in the first stage. Ireland. Lowe 2000. Australia and the USA. Ip ison of the reliability estimates for the Thai CBSEI and those et al. seman- of the CBSEI and CAQ was supported by high agreement tic. Both the expert raters’ review and the use of the full range of the scale support the technical equivalence of the Self-efficacy theory. Childbirth Attitudes Questionnaire. 2005). The estimated internal consistency reliabil- including Hong Kong. from five studies conducted in USA (Lowe 1993). providing support for good reliability of the four framework seems to be applicable to a variety of cultures. measured by Cron- evidence for consistent reliability of the instruments across bach’s coefficient alpha. A study conducted with a new sample of women were comparable to the English version. for the CBSEI were similar to those found in Hong Kong. paper format in both cultures and the expert raters found the because women could not differentiate between outcome and response scale to be appropriate for the Thai culture. Semantic equivalence was supported by without limitations. birth choice (Dilks & Beal 1997) and the progression of preeclampsia (Black 2007). Self-efficacy Expectancy for Second Stage of labor. Outcome Expectancy for Active Labor. 2005).JAN: RESEARCH METHODOLOGY Psychometric properties of Thai language versions Table 4 Comparison of reliability estimates in present study and five previous studies Thailand United States Northern Ireland Australia United States of (Present HongKong of America (Sinclair & (Drummond & America Scales study) (Ip et al. For the CAQ. Additional evidence for semantic equivalence of the Thai and English research is also needed to determine whether the Thai CBSEI versions. 2005) (Lowe 2000) O’Boyle 1999) Rickwood 1997) (Lowe 1993) Pregnant women Pregnant women Nulliparous women Pregnant women Pregnant women Pregnant women 28–41 weeks 36–41 weeks 28–41 weeks 36–41 weeks 7–41 weeks 36–41 weeks Sample N = 148 N = 148 N = 280 N = 126 N = 100 N = 351 Outcome AL 0Æ89 0Æ93 0Æ88 0Æ91 >0Æ90 0Æ86 Efficacy AL 0Æ92 0Æ92 0Æ90 0Æ93 >0Æ90 0Æ93 Outcome SS 0Æ93 0Æ95 0Æ93 0Æ95 >0Æ90 0Æ90 Efficacy SS 0Æ93 0Æ96 0Æ94 0Æ94 >0Æ90 0Æ95 CAQ 0Æ90 N/A 0Æ83 N/A N/A N/A Outcome AL. they used the full 1–4 range of the scale Psychometric properties of the instruments for all items. 2007). including its role in prehospitalization  2010 The Authors Journal of Advanced Nursing  2010 Blackwell Publishing Ltd 199 . Outcome Expec- tancy for Second Stage of labor. criterion and conceptual equivalence of the among the expert raters on the appropriateness of each item English and Thai versions of the CBSEI and CAQ. Northern Ireland (Sinclair subscales of the Thai CBSEI and the CAQ as evidenced by & O’Boyle 1999) and Hong Kong (Ip et al. The instruments are administered in a pencil and should be shortened to only address second stage labour. The 0Æ89 to 0Æ93. Ireland and Australia (Drummond & ity was 0Æ90 for the Thai CAQ. A convenience sample of pregnant the fact that raters considered that the items met the women at one prenatal clinic in one major hospital in conceptual definitions as specified in English. 2000. has Cronbach’s alpha coefficients of the Thai CBSEI ranged from conceptual meaning in Thai in the context of childbirth. A revised short Thai participants used the full 1–10 range of the response form of the Thai CBSEI is currently being evaluated. where the range was 2–10. Drummond & Rickwood 1997. The internal consistency estimates cultures. technical. Sinclair & O’Boyle 1999. it is not to the Thai culture. Efficacy AL. Table 4 presents a compar- Rickwood 1997. When the Thailand may not be representative of all women in instruments were back-translated. Sinclair & O’Boyle 1999. CAQ. Reliability labour (Beebe et al. scale for all but one item of the CBSEI. Study limitations Ip et al. which has been applied in many areas Thai and English versions of the CBSEI and CAQ. of nursing research. all items except for one Thailand. providing good internal consistency reliability.

other hand. Ip et al. the single-factor solution was books or other women’s experiences. Bandura’s (1977) theory of self-efficacy. self. the Childbirth Self-Efficacy Inventory and Childbirth When assessing the sensitivity of the CBSEI in differenti- Attitudes Questionnaire. The differences between outcome expectancy and self- • The standard for using an instrument in another efficacy were statistically significant only for second stage language should include content validity with experts. Ip et al. Sinclair & O’Boyle 1999). 2005) reported sample and back-translation for conceptual. understand women’s self-efficacy and fear of childbirth. as did the Chinese version (Ip et al. However. 2005) that raised second stage of labour cannot be easily distinguished concerns about the use of two repetitive and parallel sets of among Thai Pregnant women. Ip et al. and in differ- groups and criterion-related validity. Consistent with significant correlated with childbirth fears. 1988). This is studies in the United States of America (USA) and other consistent with self-efficacy theory and the previous finding countries that have provided strong evidence that the of Lowe (1993). & Rickwood 1997. This ability of Thai clearly interpretable in all three cultures. while previous researchers (Lowe monolingual testing with a culturally appropriate 1993. Thai women may be able to differentiate the expectancies in the second stage labour because it is more The CBSEI was found to have a single factor for each intense than active labour. thinking about having labour pain every 5 minutes because the second and third factors were theoretically and empirically they had impressions of second stage labour from films. Sinclair & O’Boyle 1999. showed that a prior good experience had statistically signif- efficacy expectancies in childbirth are statistically icant effects on childbirth self-efficacy. Australia did not demonstrate this difference (Drummond & • The Childbirth Attitudes Questionnaires were Rickwood 1997. This is Inventory and Childbirth Attitudes Questionnaire. Tanglakmankhong et al. entiating between the stages of labour. Women who have good childbirth experi- What this paper adds ences are more likely to have more self-efficacy expectancies if • Evidence for the validity of Thai language versions of they judge themselves capable of handling that situation. This • Consistent with Bandura’s self-efficacy theory. supported by contrasting ating outcome from self-efficacy expectancies. expectancy in women who had prior childbirth experience was What is already known about this topic statistically significant higher than for those having their first • The Childbirth Self-Efficacy Inventory was developed child further supported the conceptual equivalence of the through a well-planned and conceptualized series of CBSEI between the Thai and English versions. cultural outcome expectancy to be greater than self-efficacy scores for and linguistic appropriateness. 2005). previous experiences (Drummond & Rickwood 1997). 2005) and the explained. (2008) Efficacy Inventory and Childbirth Attitudes have developed a short form of the Chinese CBSEI by using Questionnaire can be used in a Thai population to only the two subscales of Outcome SS and Efficacy SS. labour in the present study.K. Perhaps Thai women cannot differen- • Increasing a woman’s self-efficacy of childbirth can tiate outcome and self-efficacy expectancies well.  2010 The Authors 200 Journal of Advanced Nursing  2010 Blackwell Publishing Ltd . These researchers claimed that women’s confidence in their coping and their repertoire of coping Implications for practice and/or policy behaviours did not vary across the birth process (Drummond • The Thai language versions of the Childbirth Self. supporting the women to imagine the second stage labour might help them conceptual equivalence of the CBSEI across Thai. consistent with previous findings in Australia (Drummond & • Childbirth self-efficacy scores for active labour and Rickwood 1997) and Hong Kong (Ip et al. further differences in outcome expectancy and self- the theoretically predicted relationship between efficacy were by comparing women with good and bad childbirth self-efficacy and fear in nulliparous women. Consistent with Lowe’s findings. pushing the baby out was easier to imagine than English version (Lowe 1993). However. expectancy scales to differentiate between the first and second stages of labour. expectation of personal mastery affects both initiation and persistence of coping behaviour. Chinese and differentiate between outcome and self-efficacy expectancies English (Flaherty et al. Recently. uninterpretable. As some participants in this study subscale. The finding that self-efficacy during childbirth. On the reduce her fear of labour and childbirth. both stages of labour. In the study in developed to measure fear of childbirth and to explore Australia. the studies in North Ireland and measure has good psychometric properties. the non-significant • Evidence of strong internal consistency reliability for the findings indicate that the stages of labour cannot be easily Thai language versions of the Childbirth Self-Efficacy distinguished from each other by Thai women.

410–418. While in western cultures. New Jersey.. 1–9. Journal of Perinatal & Neonatal Nursing 11(1). Journal of Advanced Nursing 26(3). the data suggest Gynecologic. ing Thai women’s self-efficacy during childbirth may be one Drummond J. the CBSEI only for second stage labour where differentiation Chalmers B. and design. However. (2007) versions of the CBSEI and CAQ. (2007) Stress. NP fear of childbirth with a single total score. & Therefore. However. included both nulliparous and multiparous women. tested with Thai pregnant women.JAN: RESEARCH METHODOLOGY Psychometric properties of Thai language versions The pattern of findings with respect to differentiation developing and testing interventions to improve women’s between outcome and self-efficacy expectancies and differ.D. NP and NL made critical loadings for all items. This study and 22(4). increas. entiation between active and second stage labour did not support criterion equivalence between the Thai and English Funding versions of the CBSEI. Prentice-Hall. & Beal J. consistent with the previous study by Lowe (2000). KT performed the data collection. KT provided administrative.M. Evidence was found to The effects of childbirth self-efficacy and anxiety during pregnancy support the validity and reliability of both instruments when on prehospitalization labor. it is appropriate to measure revisions to the paper for important intellectual content. providing support for the criterion equiva- lence of the Thai and English versions of both instruments. Kala S. Mangiaterra V. self-monitoring confidence. it may be appropriate for Thai women to use Neonatal Nursing 36(5). Bandura A. Birth: Issues in Perinatal Care 28(3). therefore. symptoms. Journal of Obstetric. 191–215. The Australian sample. UK. Our findings support the equivalence of the Thai and English Beebe K. Gynecologic. pp. Although KT. KT.. In Handbook of Principles of Organization Behavior (Lock E. 263–272. (1982) Identification of women with fear of childbirth during late pregnancy. However. & Rickwood D.. and postpartum care course. self-efficacy expectancy for active labour and the second stage Lancet 368. higher Althabe F. 613–622.R.A.). Correlations provided statistical expertise. English version. Kjessler B.M. (1977) Self-efficacy: toward a unifying theory of behav- study only included nulliparous women. birth experiences in Thailand. while our study ioral change. the Areskog B. (2000). (2004) Childbirth policy in and determine whether the Thai CBSEI should be shortened Thailand: is it a time to change? Songklanagarind Medical Journal to only address the second stage of labour. perinatal care: the essential antenatal. KT and NP atory factor analysis was conducted to test the construct performed the data analysis. others have shown that lower self-efficacy for childbirth is Dilks F. between the CAQ and CBSEI mirrored those found with the technical or material support. Black K. The Thai CAQ demonstrated good internal consistency Author contributions reliability as measured by Cronbach’s coefficient alpha. distinct concepts. Thai women appeared to see them as the same concept. & Belizin J. ed. & Kochapakdee W. & Uddenberg N. NP and NL were responsible for the study conception factor analysis of CAQ was not previously reported. 120–136.. Psychological Review 84(2). 1472–1473. This could possibly be due to the fact that Lowe’s Bandura A. & Humphreys J. perinatal. Lee K.A. and Neonatal Nursing 36(5). The single-factor solution had good the drafting of the manuscript. Therefore. JOGNN: Journal of Obstetric. Gynecologic correlations were weaker than those reported by Lowe & Obstetric Investigation 13. labour were associated with lower fear. Bandura A. gestational hypertension. KT and NP were responsible for validity of CAQ. 98–107. explor. associated with greater fear of childbirth. evidence for criterion equivalence. References Although there were no relationships between outcome expectancy for either the stage of labour or fear. & Porter R. (1997) Role of self-efficacy in birth choice. (2000) Cultivate self-efficacy for personal and organi- Conclusion zational effectiveness. (1997) Childbirth confidence: validating the Childbirth Self-Efficacy Inventory (CBSEI) in an approach to improve childbirth experiences in Thailand. Carrieri-Kohlman V. Additional research is needed to cross-validate these findings Chunuan S. Thai versions of the CBSEI and CAQ will be useful in  2010 The Authors Journal of Advanced Nursing  2010 Blackwell Publishing Ltd 201 . (2006) Caesarean section: the paradox. (1986) Social Foundations of Thought and Action: A Social Cognitive Theory. the pattern of correlations between Conflicts of interest the CBSEI subscales and the CAQ was similar for the English and Thai versions of the instruments. 419–429. 202–207.A. and social support in the progression of preeclampsia/ same manner for active and second stages of labour. providing supporting None. that women responded to the items in the Thai CBSEI in the well-being.. (2001) WHO principles of of outcome and self-efficacy expectancies was demonstrated. Oxford. self-efficacy in active and second stage labour tend to be seen as two The Royal Thai Government Scholarship. Blackwell..

257–263. other languages: development and testing processes.. 141–149.H.. Tsui M. 1–7. Nursing Research 35(6). Wibulpolprasert S. UNFPA County Technical Services team for East and Self-Efficacy Inventory: the development of a short form. Wintrob R. Weaver J. Appendix A* Childbirth Self-Efficacy Inventory Items (Lowe 1993) 1. & Ryding E. (2007) Elective cesarean section and decision making: a cultural psychiatric research... & Chien W. and 1990-2001 a national survey. (1988) Developing instruments for cross. Cancer 201–208.R. yasoti P. Diseases 176.H. Concentrate on an object in the room to distract myself 7. Journal of Health Science 12(1). Gynecologic. Tell myself that I can do it 13.S. Not think about the pain 12. (1993) Maternal confidence for labor: development of the T. Keep myself calm 8. Xu L. Meeting of the American College Nurse-Midwives. Beake S.. Srirattana S. Policy and Strategy.K. & Zeller R. Pang M.K. validity. & Skrutkowski M. Acta Obstetricia et Gynecologica Scandinavica 82(3). (2006) Maternal and Neonatal Health in East and South- Ip W. Think about relaxing 6. 638–646.. Statham H. Journal of Advanced Nursing 30(6). Use breathing during labour contractions (use breathing during labour pain)** 4.L. Concentrate on getting through one contraction at a time 15. & O’Boyle C. (2003) Twelve years pattern of hospital delivery in Thailand efficacy concept. Sinclair M. Pathak D. Nonthaburi. & Leung Lowe N. Focus on the person helping me in labour 16. Lau T. MI.A. McCourt C. Chan D. Neonatal Nursing 20(6). Journal of Advanced Nursing 48(2). Women and Health 44(4). 175–186. Thailand. 79–92.. Melender H. (1999) The Childbirth Self-Efficacy Kish J. Among Nulliparous Pregnant Women. (2002) Fears and coping strategies associated with Harman P. (2006) Maternal fear associated with pregnancy and child- Childbirth Self-Efficacy Inventory. & Halmesmaki E.. & Maneesriwongul W. (2005) Chinese version of the Childbirth using exploratory factor analysis for measurement.. JOGNN: Journal of Obstetric.A. Journal South-East Asia.M. Relax my body (making your body becomes less stiff or rigid)** 2..A.. & Birz S. & Tipa- Lowe N. Journal of Advanced Nursing 51(6). University of Maryland. 1416–1423. Mitchell T. 65–79.. Flaherty J. Gamble J. 135–154. Stay on top of each contraction (try to control each pain that happens)*** 10.K. Sauvarin J. Think positively 11. pregnancy and childbirth in finland. Journal of Self-efficacy Inventory.K. Journal of Psychosomatic Obstetrics of childbirth and its association with subsequent caesarean section & Gynecology 21. Watanamano N.. Research in Nursing & Health birth in Hong Kong Chinese women. An International Journal of Obstet- Lynn M.N.  2010 The Authors 202 Journal of Advanced Nursing  2010 Blackwell Publishing Ltd .A.K.K.K. ***The revised items in Thai version based on the experts’ suggestions. 1–18. Gaviria F. (2004) Instrument translation Taverat R. D. 219–224. Journal of Nervous and Mental critical review of the literature. Think about others in my family 14. Thailand. 382–385. Sapnas K. 16(2). Nursing 25(1). (2000) Self-efficacy for labor and childbirth fears in Waldenstrom U. (1986) Determination and quantification of content rics and Gynaecology 113. & Creedy Richman J. (2003) Fear of childbirth: a neglected Hilton A. College Park. Concentrate on thinking about the baby 9. Presented at the 33rd Annual Women’s Health 47(4). (2008) The Chinese Childbirth East Asia.. Sirilak S. & Tang C. (2002) Minimizing sample size when Ip W.. Bureau of process: a methods review.G. (2003) The Development of Maternal Confidence for Labor Inventory: a replication study. Ministry of Public Health.K.K. Fear of Childbirth and Related Incidence of Com. Get ready for each contraction (get ready for each labour pain)** 3..L. & Dixon J..W.. Hildingsson I. Teerawattananon Y. Journal of Midwifery & plications in Labor and Delivery. Ekachampaka P.. (2002) Translating instruments into dilemma. (1991) Maternal confidence in coping with labor: a self. 625– Nursing Measurement 10(2). Tangcharoensathein V. of Clinical Nursing 17(3). 633. Detroit. 256–263. Lowe N. Listen to encouragement from the person helping me *Reproduced with the permission of Lowe. 457–463. (1988). (2006) Antenatal fear nulliparous pregnant women. Bangkok. Chung T. Tanglakmankhong et al. Birth 34(1). and experience of childbirth.. **The revised items in Thai version based on Thai pregnant women’s suggestions. Saisto T.. 333–340. Keep myself in control 5. Melender H. (2008) Thailand Health Profile 2005-2007.

000 in developing countries with free or low cost access). rarely longer than seven months. I have fear of something being wrong with the baby 7. I have nightmares about the delivery (considered for deletion in Thai CAQ) 4. and fully citable. I have fear of the hospital environment*** (I have fear of the environment in labour and birth room) 15.manuscriptcentral. I am really afraid of giving birth 3. I have fear of painful labour contractions 13. **The revised items in Thai version based on Thai pregnant women’s suggestions. JAN publishes research reviews. I have fear I will not be able to help during the delivery 6. original research reports and methodological and theoretical papers. For further information. midwifery and health care by disseminating high quality research and scholarship of contemporary relevance and with potential to advance knowledge for practice. • Early View: rapid online publication (with doi for referencing) for accepted articles in final form. I have fear of painful injections 8. scientific journal.wiley. I have fear of not getting the kind of care that I want 16. JAN has been in the top ten every year for a decade. JAN contributes to the advancement of evidence-based nursing. The Journal of Advanced Nursing (JAN) is an international.g. PubMed). as well as the option to deposit the article in your own or your funding agency’s preferred archive (e. I have fear of the baby being injured during the delivery 12. • Positive publishing experience: rapid double-blind peer review with constructive feedback.000 libraries worldwide (including over 4.  2010 The Authors Journal of Advanced Nursing  2010 Blackwell Publishing Ltd 203 . peer-reviewed. please visit JAN on the Wiley Online Library website: http://onlinelibrary. I would rate my anxiety about childbirth as *Reproduced with the permission of Lowe. I have fear of being left alone during labour 9. • Fast and easy online submission: online submission at http://mc.com/jan. I have fear of losing control of myself at the delivery 2. I have fear of being torn with the birth of the baby*** (I have fear of vaginal tear when giving birth) 11. Overall. • Online Open: the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley Online Library. management or policy.com Reasons to publish your work in JAN: • High-impact forum: the world’s most cited nursing journal and with an Impact Factor of 1Æ518 – ranked 9th of 70 in the 2010 Thomson Reuters Journal Citation Report (Social Science – Nursing). I have fear of bleeding too much during the delivery 5. • Faster print publication than most competitor journals: as quickly as four months after acceptance. education. I have fear of having to have a Caesarean section 10.JAN: RESEARCH METHODOLOGY Psychometric properties of Thai language versions Appendix B* Childbirth Attitudes Questionnaires Items (Lowe 2000) 1. • Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 7. ***The revised items in Thai version based on the experts’ suggestions. I have difficulty relaxing when thinking of the coming birth*** (I feel uneasy when thinking about the upcoming birth-giving) 14.