Assessment of self-management empowerment program on sense of coherence, self-‌efficacy and postpartum anxiety in cesarean mothers randomized trial

Abstract

Conflicting study outcomes on women undergoing cesarean sections underscore the complex relationship between repeated cesarean deliveries and factors such as sense of coherence, self-efficacy, and anxiety, highlighting the need for empowerment-based interventions to improve mothers’ mental health and parenting outcomes. This randomized controlled trial aimed to evaluate an educational program based on the self-management empowerment model on sense of coherence, self-efficacy, and postpartum anxiety in cesarean mothers. In 2024, 98 women scheduled for cesarean delivery at Shohada-ye-Khalij-e-Fars Hospital, Bushehr, Iran, were selected by convenience sampling and randomly assigned via block randomization to intervention (n = 49) or control (n = 49) groups. The intervention group received a five-step education program over two months. Antonovsky’s Sense of Coherence Questionnaire, Sherer’s Self-Efficacy Scale, and Spielberger Anxiety Questionnaire were administered pre- and post-intervention. Data were analyzed using SPSS version 27 with descriptive/inferential statistics (p < 0.05). Mean changes showed significant intervention effects: self-efficacy − 1.58 ± 7.31 (control) versus 2.79 ± 6.42 (intervention, ŋ² = 0.151, p < 0.001); sense of coherence 2.67 ± 8.36 (control) versus 4.81 ± 6.58 (intervention, ŋ² = 0.073, p = 0.018); anxiety 0.02 ± 15.99 (control) versus − 13.07 ± 13.7 (intervention, ŋ² = 0.224, p < 0.001). The self-management empowerment model significantly improved sense of coherence and self-efficacy while reducing postpartum anxiety, recommending its integration into postpartum care programs.

Trial Registration http://www.irct.ir/, IRCTID: IRCT20130422013092N12 registered July 11, 2024.

Introduction

Pregnancy is a potentially positive period of transformation for both mother and child, in terms of physiological, psychological, social, neurological, and emotional changes throughout life, while also causing significant challenges¹. The necessity of adapting to the parental role, along with competence and effectiveness in fulfilling this role, especially the maternal role, is of great importance². Studies demonstrate that women undergoing cesarean sections are at heightened risk of anxiety, postpartum depression, breastfeeding difficulties, feelings of inadequacy, loss of control, and dissatisfaction, often experiencing conflicting emotions or significant psychological distress³. The prevalence of postpartum anxiety varies widely (13–40%), with cesarean delivery identified as a key risk factor and rates reported between 20 and 30%^4–6. Janssen et al.⁷ reported persistent anxiety symptoms beyond one year postpartum, escalating from 27.3% pre-delivery to 35.1% at one year, particularly among cesarean mothers exhibiting elevated levels and doubled psychiatric risk following unplanned procedures⁸. Post-traumatic stress disorder (PTSD) rates post-cesarean ranges from 2.2 to 41.2%, with emergency procedures conferring significantly higher risk than elective ones^9,10. Cesarean mothers experience heightened anxiety alongside diminished breastfeeding self-efficacy, evidenced by reduced confidence in exclusive breastfeeding during the first postpartum month¹¹, adversely affecting maternal-infant bonding, lactation outcomes, and potentially breast milk composition¹². Kuo et al.¹³ identified distinct patterns of depression and anxiety symptoms among women undergoing elective cesarean sections, with mild symptoms being the most common. These findings underscore the urgent need for targeted psychological screening and support in this high-risk population. Given the substantial burden of post-cesarean anxiety, researchers have evaluated diverse interventions^14,15.

Moreover, pregnancy requires physical and emotional adaptability. Nowadays, the identification and early implementation of intervention programs with the purpose of preventing and reducing these conditions have become one of the priorities of global health services¹⁶. The results of studies demonstrated that a structured educational program regarding infant care affects maternal and infant health outcomes¹⁷; and postpartum care education increases mothers’ awareness of self-care during the postpartum period¹⁸. A particular set of parental beliefs shapes maternal self-efficacy, encompassing infant care, maternal role performance, and breastfeeding dimensions^18,19. Higher self-efficacy correlates with enhanced coping, positive birth experiences, and postpartum satisfaction²⁰. Additionally, providing education and counseling to mothers enhances their maternal self-efficacy and reduces stress related to infant care²¹, while also addressing many breastfeeding problems during the postpartum period²². However, women who have chosen repeated c-sections tend to have lower self-efficacy scores, indicating the need for targeted interventions²³. Similarly, Nigerian women who underwent cesarean delivery reported lower self-esteem and weaker parental self-efficacy compared to those who had vaginal births²⁴. Supliyani et al.²⁵ demonstrated that targeted education and mentoring could significantly enhance mothers’ confidence, increasing median self-efficacy scores from 64.50 to 81.

So as to reduce vulnerability in stressful situations, individuals must be able to understand circumstances and effectively use available resources in order to assist with resilience and coherence. A strong sense of coherence is a protective factor and a vital resource against stress²⁶. Sense of coherence refers to an individual’s capacity to navigate life and manage tension in ways that promote health, reflecting a stable yet dynamic general feeling of confidence in oneself²⁷. Studies indicate that people with a strong sense of coherence have access to coping resources and strategies, are sufficiently flexible, and are able to choose the most appropriate strategy for a given situation. In contrast, those with a weak sense of coherence may show more stress-related symptoms, experience greater social difficulties, employ fewer effective coping mechanisms, and are more prone to feelings of loneliness and social isolation²⁸. Studies have shown that a strong sense of coherence is associated with higher levels of well-being during pregnancy and with uncomplicated deliveries²⁹, as well as better emotional health, lower levels of anxiety, depression, and post-traumatic stress³⁰.

Enhancing population health is a key goal of the World Health Organization (WHO), which is shifting its focus from disease-centered approaches to health-centered ones³¹. In this approach, the “Salutogenic model” and its core component; that is, the Sense of Coherence (SOC), are used to better understand how people cope with life’s adversities while maintaining their health³². SOC, defined as a global orientation expressing confidence in the comprehensibility, manageability, and meaningfulness of life experiences²⁷; enables mothers to perceive stressors holistically, utilize internal/external resources effectively, and achieve self-management. The Salutogenic framework focuses on the discovery of the factors that promote health, instead of the causes of disease³³. Evidence indicates that sense of coherence (SOC) is influenced by multiple factors, including demographic variables (age, gender, income), health status, and psychological conditions (depression, anxiety, chronic grief). Additional determinants encompass family functioning, social support availability, and coping strategies such as self-management skills^34–36. Assessing the sense of coherence, that is, how individuals perceive their lives and use their resources and strategies to maintain and enhance their health, as well as self-efficacy, the extent to which individuals can influence their own motivation and performance, and understanding their impact on quality of life are necessary for identifying patients who require greater support in preserving and developing personal and interpersonal strengths³⁷.

Self-efficacy is also considered a resilience factor³⁸; however, debate continues as to whether sense of coherence and self-efficacy are truly protective factors or merely outcomes of being healthy. Most studies demonstrating cross-sectional correlations between health and various resilience factors have failed to adequately address this question³⁹. Additionally, self-efficacy is considered as a personal resource that is different from the sense of coherence, which reflects an individual’s overall perspective on life. Previous studies have shown a relationship between sense of coherence and self-efficacy in older adults, adolescents, and individuals with illnesses³⁹. Among these, self-efficacy is considered the strongest factor associated with sense of coherence⁴⁰.

Besides, a low Sense of Coherence has been linked to negative health outcomes during pregnancy, childbirth, and the postpartum period, and may expose parents to a several challenges. Maternity care should focus on a more comprehensive approach, one that not only emphasizes complications and risks, but also considers protective and stress-resilient factors that promote health, such as enhancing the Sense of Coherence in pregnant women⁴¹. Generally speaking, based on the challenges that mothers may face, using empowerment methods can be truly effective⁴².

Within the salutogenic framework, personal empowerment represents a dynamic process enabling individuals to assume greater control over their life circumstances, align personal aspirations with targeted efforts, and develop strategies for goal attainment and outcome realization⁴³. Originating from Paulo Freire’s seminal 1970 conceptualization, which frames empowerment as both a transformative process and measurable outcome, this approach has demonstrated capacity to enhance self-efficacy and sense of coherence (SOC)⁴⁴.

Despite established efficacy of Salutogenesis and self-management empowerment in chronic conditions^45–47, and elevated vulnerability among repeat cesarean mothers^13,23,24, our literature review identified no RCTs concurrently examining sense of coherence (SOC), self-efficacy, and postpartum anxiety in this population. Recent evidence indicates that cesarean delivery, particularly repeated procedures, negatively impacts maternal quality of life, emotional well-being, breastfeeding initiation, and neonatal outcomes relative to vaginal births^48–50. These insights highlight the necessity for scalable, nurse-led interventions. Accordingly, this study assesses an educational program based on the self-management empowerment model on sense of coherence, self-efficacy, and postpartum anxiety in cesarean mothers.

Materials and methods

Study design and participants

This study was a randomized controlled trial (RCT) with a parallel design. The CONSORT (Consolidated Standards of Reporting Trials) guidelines were used to design, conduct, and report this study. The study population included women admitted to the obstetrics and gynecology ward of Shohada-ye Khalij-e-Fars Hospital in Bushehr (the central hospital in Bushehr) in 2024, who were candidates for scheduled cesarean delivery and met the study inclusion criteria.

The inclusion criteria were: a history of one previous cesarean delivery; access to a smartphone; minimum literacy (ability to read and write); age between 18 and 45 years⁵¹; no self-reported history of psychiatric illness or use of psychotropic medications⁵¹; willingness to participate in the study; and residency in the city of Bushehr. The exclusion criteria were: high-risk pregnancy (e.g., multiple gestation or preeclampsia); experiencing a major stressful life event in the past six months⁵²; giving birth to an infant with congenital anomalies (based on self-report or physician diagnosis); withdrawal from the study; and undergoing an emergency cesarean section.

Participants were recruited from August to November 2024. The intervention included a hospital-based postpartum educational program and home-based follow-up from August 2024 to January 2025.

Sample size and sampling methods

The sample size was calculated using G*Power software and an independent t-test, based on an effect size of 0.65, a Type I error rate (α) of 0.05, a power of 0.80, and an allocation ratio of 1:1. The required sample size was determined to be 39 participants per group. To account for a potential 20% dropout, 49 participants were allocated to each group, resulting in a total of 98 participants.

Participants were selected using a convenience sampling. A total of 106 women were screened for eligibility, of whom 100 met the inclusion criteria. Ninety-eight women consented to participate and were randomized into one of two study groups, each comprising 49 individuals.

Block randomization with varying block sizes (blocks of 4, 6, or 8) was used to allocate participants to the intervention and control groups. The allocation ratio was 1:1. Randomization sequences were generated by Random Allocation Software. The block sizes were concealed from the researchers enrolling participants to prevent foreknowledge of the next assignment and minimize the risk of selection bias. To maintain allocation concealment, assignments were placed in sealed opaque envelopes, which were prepared and numbered in advance by an independent individual not involved in the study. At the time of enrollment, envelopes were opened sequentially, and participants were assigned to the corresponding group, with 'A' representing the intervention group and 'B' the control group.

Data collection tools

The tools used for data collection included a demographic data form, the Sherer’s Self-Efficacy Scale, the Sense of Coherence Questionnaire, and an anxiety questionnaire. The Sense of Coherence scores were set as primary outcome.

Demographic data form

This form gathered demographic information such as age, education level, marital status, duration of marriage, number of children, type of previous deliveries, employment status, economic status, insurance coverage, tobacco use, and other relevant factors. These variables were compared between the intervention and control groups to minimize the influence of potential confounding variables.

Sherer’s self-efficacy scale

This questionnaire was developed by Sherer et al. in 1982 and consists of 23 items, 17 of which is related to general self-efficacy, while the remaining 6 items are linked to self-efficacy experiences in social situations. In the general self-efficacy scale, each item is rated on a 5-point Likert scale ranging from “strongly disagree” to “strongly agree.” The minimum possible score is 17, and the maximum is 85. Higher scores indicate a stronger sense of self-efficacy. In their study, Sherer et al.⁵³ reported a Cronbach’s alpha of 0.86 for the general scale, with an internal consistency coefficient of 0.76 specifically for the general self-efficacy subscale. The construct validity of the scale has been established through factor analysis. The reliability of the Iranian version of the questionnaire was confirmed in previous study⁵⁴.

Antonovsky’s sense of coherence questionnaire (1987)

In this study, the 13-item form of Antonovsky’s Sense of Coherence questionnaire (SOC-13) was used⁵⁵. Each item is rated on a 7-point scale, ranging from 1 to 7. Antonovsky⁵⁵ reported high levels of content, face, and consensual validity. Mohammadzadeh et al.⁵⁶ showed that the 13-item Iranian version of the questionnaire has adequate validity and reliability for use across cultures. They reported high correlations between domains and the total score⁵⁶.

Spielberger state-trait anxiety inventory (STAI)

The State-Trait Anxiety Inventory (STAI) developed by Spielberger in 1970 was used to assess anxiety levels. This instrument consists of 40 items, with items 1 through 20 measuring state anxiety. The questionnaire uses a 4-point Likert scale, including “Not at all,” “Sometimes,” “Often,” and “Very much so.” Each item is scored from 1 to 4. Previous research has reported satisfactory validity and reliability of the Iranian version for this questionnaire^57,58.

Procedure

Following approval of the research proposal, issuance of the university ethics code (IR.BPUMS.REC.1403.102), and registration of the trial in the Iranian Registry of Clinical Trials (IRCT20130422013092N12), the study was initiated. Permission to conduct the study was obtained from the Vice Chancellor for Research and the Vice Chancellor for Treatment at Bushehr University of Medical Sciences, as well as from the hospital director and the head of the obstetrics and gynecology department at Shohada-ye Khalij-e-Fars Hospital.

Women scheduled for cesarean delivery were approached and informed about the study objectives, procedures, voluntary nature of participation, data confidentiality, and their right to withdraw at any time without consequences. Written informed consent was obtained the night before the scheduled surgery. Eligible participants were then randomly assigned, using block randomization with block sizes of 4, 6, or 8, into one of two groups. Group A received a self-management empowerment training program, whereas Group B received routine postpartum education provided by the hospital.

Due to the nature of the educational intervention, no formal blinding was implemented in this study. Participants were aware of the study objectives, and questionnaires were distributed by the educator. However, all completed questionnaires were entered into the database and analyzed by personnel who were independent of the data collection process, which minimized the risk of detection bias.

Approximately eight hours after surgery, once women in the intervention group were fully conscious, able to eat⁵⁹, and had completed their first breastfeeding session, their readiness to receive training was confirmed. At this point, both groups completed baseline assessments of anxiety, self-efficacy, and sense of coherence. The intervention group then received two face-to-face training sessions during hospitalization, followed by a structured home-based follow-up period grounded in the self-management empowerment program, whereas the control group received routine care only. After two months, post-intervention assessments were administered electronically to both groups, and the collected data were analyzed.

To standardize intervention delivery, an empowerment-based algorithm targeting anxiety, self-efficacy, and sense of coherence was developed with input from experts in nursing, midwifery, and public health. This algorithm defined key objectives and minimum required actions to ensure intervention fidelity.

Intervention

The self-management empowerment program’s content, developed from official postpartum care textbooks, Ministry of Health guidelines, and peer-reviewed studies, targeted postpartum anxiety management, holistic self-efficacy enhancement, meaning-making, and coping strategies. Content was validated by an expert panel (pediatricians, nurses, midwives, health educators). The intervention group followed a structured five-step self-management model over two months (Table 1):

• Steps 1–3 (self-awareness of changes/functioning, goal-setting, planning) were delivered via two flexible in-person sessions during hospitalization, based on participant preference.

• Step 4 (structuring the physical, psychological, and social environment) involved home implementation over eight weeks, supported by an educational booklet and biweekly researcher telephone follow-ups for guidance and monitoring.

• Step 5 (evaluation) assessed fidelity and progress through issue reviews, goal-aligned actions, and form completion.

Table 1.

The empowerment intervention Steps for cesarean mothers.

Step	Location	Content of the interview	Assigned tasks and activities	Evaluation methods
Step 1: Self-awareness of changes & personal performance/expectations	Hospital (in-person, Session1)	Conduct an in-depth interview using structured assessment forms to evaluate mothers’ awareness of physical (e.g., pain, mobility limitations), psychological (e.g., worry about the future), and social changes (e.g., shifts in family roles). Awareness is assessed in relation to usual lifestyle and living environment, functional status with the newborn and other family members, independence in self-care and infant care, adaptation to current conditions, available support resources, and expectations. Current and expected performance levels are then classified within predefined limits (appropriate vs. inappropriate; excessive vs. insufficient), using examples such as post-cesarean fatigue, breastfeeding challenges, anxiety triggers, and balancing newborn care with household duties. In addition, the mother’s perceived control over family matters as a mother and spouse, and her sense of empowerment to initiate change, are explored	Reflect on daily changes through guided questions and complete forms comparing current abilities with pre-birth expectations (e.g., “How has cesarean recovery altered your household tasks or interactions with your newborn?”)	Assess participants’ clarity regarding their expectations, understanding of family roles and decision-making processes, existing knowledge gaps, and readiness to assume parenting and spousal responsibilities. Use structured forms to identify awareness gaps and rate lifestyle and performance, with sample questions such as “On a scale of 1–10, how aware are you of your physical limitations in relation to family roles?”, “Which support resources feel insufficient for your independence and adaptation?”, and “Is your expected level of performance appropriate or excessive given your current limitations?”, with baseline status categorized as suitable or unsuitable
Step 2: Optimal goal-setting	Hospital (in-person, Session 1–2)	Collaboratively define realistic health goals based on step-1 findings, addressing postpartum concerns such as infant-care anxiety and sleep disruption. Identify and modify support resources to build strategies for self-efficacy, preventive behaviors, self-care adherence, and understanding of physical, emotional, and social changes; for example, setting goals such as initiating light physical activity a few days after cesarean section to rebuild strength or practicing deep breathing during anxiety episodes	Set 3–5 personalized SMART goals in collaboration with the researcher and brainstorm necessary resource adjustments (e.g., involving the spouse in newborn care duties). As a sample activity, participants list their top three challenges and identify corresponding sources of support	Align proposed goals with step-1 findings using questions such as “Does this goal match your current capacity (yes/no, why)?” and “What barriers might arise?”, and review goals for feasibility. Assess mothers’ understanding and agreement with the counseling goals and structure, and obtain their feedback on the process. In addition, identify problems and evaluate mothers’ ability to prioritize decisions regarding their recovery needs, infant-care responsibilities, and postpartum tasks
Step 3: Planning	Hospital (in-person, Session 2)	Develop tailored plans to achieve predefined goals, such as reducing anxiety and enhancing self-efficacy and sense of coherence, using participant input, available resources, and a fixed model framework, while individualizing content (e.g., schedules for wound care, relaxation techniques, and social reconnection). For example, a participant may integrate rest, nutrition, and family communication	Co-create an action plan with clear timelines and steps, and practice at least one element (e.g., rehearsing how to ask the doctor for advice)	End each session with a brief feasibility check, including questions such as “How confident are you in this plan (1–10)?” and “What adjustments are needed?”, followed by interim verbal feedback
Step 4: Adjusting physical, psychological, & social structures	Home (post-discharge, 8 weeks)	Implement self-management using an educational booklet derived from evidence-based postpartum care sources, focusing on timely information seeking (e.g., contacting a nurse or doctor for fever), skill acquisition (e.g., infant wrapping), resource management for health and family roles, and effective communication; family members or friends assist mothers with low literacy by reading the material aloud. Practical examples include maintaining a simple mood journal to monitor emotional changes over time	Implement the planned strategies over eight weeks, using the booklet daily, logging progress, and contacting the team as needed (e.g., “How should I handle night wakings?”). Biweekly telephone calls are used to reinforce adherence and provide additional support	Provide 14 telephone follow-ups (twice weekly, scheduled at participants’ preferred times) for guidance and questions, using prompts such as “Which strategy worked best?” and “How would you rate your anxiety this week on a scale from 1 to 10?”, with progress forms used to track adherence
Step 5: Evaluation	Evaluation was integrated across all steps via weekly telephone follow-ups

An algorithm-based empowerment protocol was used to standardize the intervention, and participants who completed less than 40% of the prescribed tasks were excluded. No adverse events occurred during the intervention, and participants showed high engagement in face-to-face sessions and follow-up activities.

The control group received routine care only. Brief non-intervention follow-ups were conducted with this group to reduce the Hawthorne effect. Pre-intervention, both groups completed demographic forms and questionnaires (sense of coherence, anxiety, self-efficacy). Post-intervention (immediately after two months), questionnaires were readministered electronically, followed by data analysis and booklet provision to control group.

Data analysis

Data were analyzed using SPSS version 27. Quantitative variables were described using mean, standard deviation, minimum, and maximum values, while qualitative variables were presented as frequency and percentage. The Shapiro–Wilk test was applied to assess the normality of quantitative data distribution. To compare demographic qualitative and quantitative variables between the intervention and control groups, the Chi-square test, independent t-test, and Mann–Whitney U test were used as appropriate. For comparing the mean changes in sense of coherence and postpartum anxiety scores before and after the intervention between the two groups of cesarean mothers, the Mann–Whitney U test was employed. The independent t-test was used to compare the mean changes in self-efficacy scores before and after the intervention between the two groups. Subsequently, analysis of covariance (ANCOVA) was performed to examine the effect of the intervention on the outcome scores while controlling for confounding variables. Although anxiety may theoretically influence sense of coherence, these outcomes reflect distinct dimensions of postpartum psychological functioning. Given their conceptual independence and the primary aim of assessing intervention effects across multiple maternal well-being domains, each outcome was analyzed separately. Interrelationships are acknowledged, with future mediation analyses recommended. Partial eta-squared (ɳP²) values were reported as the effect size. P < 0.05 was considered as statistically significant.

Ethical considerations

This study was conducted in accordance with the principles outlined in the Declaration of Helsinki, which guided all ethical aspects of the research design. Ethical approval was obtained from the Ethics Committee of Bushehr University of Medical Sciences (approval code: 1403.102.IR.BPUMS.REC). The study protocol was registered at the Iranian Registry of Clinical Trials (registration number: IRCT20130422013092N12). To uphold research ethics, participants were informed that their participation was entirely voluntary. All mothers provided written informed consent before enrollment in the study. Questionnaires were anonymous, and all data were kept confidential. The results are reported in aggregate form without any identifying information. No costs were imposed on participants, and they were free to withdraw from the study at any time. Upon completion of the research, educational materials were provided to the control group in the form of a booklet.

Results

A total of 106 women undergoing cesarean section were assessed for eligibility, of whom 98 met the inclusion criteria and consented to participate. These participants were randomly allocated to the intervention (n = 49) or control (n = 49) group, with posttest data ultimately available for 47 and 43 women, respectively (Fig. 1).

Fig. 1.

Participant flow diagram according to CONSORT guidelines.

The mean age ± standard deviation of participants was 32.98 ± 5.72 years in the intervention group and 32.98 ± 6.05 years in the control group. The age of participants ranged from 22 to 45 years.

Tables 2 and 3 show a comparison of the frequency of qualitative and quantitative demographic variables between the intervention and control groups among mothers who underwent cesarean delivery. The most frequent numbers of cesarean deliveries and children were two deliveries and two children, respectively. According to the results represented in the tables, no significant differences were observed between the intervention and control groups in terms of baseline variables (p > 0.05).

Table 2.

Comparison of the baseline qualitative demographic characteristics of intervention and control groups.

Variable	Subgroups	Control group		Intervention group		p-value
		Frequency	percentage	Frequency	percentage
Number of previous cesarean deliveries	1	13	30.2	21	44.7	0.202
	2	17	39.5	20	42.6
	3	10	23.3	5	10.6
	4	3	7	1	2.1
Number of children	1	12	27.9	15	31.9	0.676
	2	18	41.9	19	40.4
	3	8	18.6	11	23.4
	4	4	9.3	2	4.3
	5	1	2.3	0	0
History of miscarriage	Yes	10	23.3	16	34	0.259
	No	33	76.7	31	66
Number of abortions	0	33	76.7	31	66	0.354
	1	5	11.6	11	23.4
	2	4	9.3	5	10.6
	3	1	2.3	0	0
Employment status	Housewife	29	67.4	31	66	0.881
	Employed	14	32.6	16	34
Economic status	poor	2	4.7	3	6.4	0.850
	average	29	67.4	33	70.2
	good	12	27.9	11	23.4
Type of insurance coverage	Social Security	25	58.1	28	59.6	0.931
	Health Services	9	20.9	10	21.3
	Armed Forces	7	16.3	8	17
	other	2	4.7	1	2.1
Education level	Elementary School	1	2.3	0	0	0.360
	Junior High School	7	16.3	5	10.6
	High School Diploma	12	27.9	20	42.6
	Associate degree	7	16.3	3	6.4
	Bachelor’s Degree	12	27.9	16	34
	Master’s degree and above	4	9.3	3	6.4
Tobacco use	Yes	4	9.3	1	2.1	0.138
	No	39	90.7	46	97.9

Chi-Square test was used for comparison. P < 0.05 was considered statistically significant.

Table 3.

Comparison of the baseline quantitative demographic characteristics of intervention and control groups.

Variable	Control group		Intervention group		Total		p-value
	Mean	SD	Mean	SD	Mean	SD
Age (years)	32.98	6.05	32.66	5.72	32.81	5.85	0.935
Duration of marriage (in years)	8.60	3.61	7.89	3.27	8.23	3.44	0.328
Time since last delivery [previous delivery] (in years)	4.91	3.01	4.47	2.49	4.68	2.74	0.600
Time since last abortion (in years)	0.98	2.19	1.32	2.61	1.16	2.41	0.308

SD = Standard Deviation. Values are presented as Mean ± SD. Mann-Withney U test was used for comparison. P < 0.05 was considered statistically significant.

The results demonstrated that the mean difference in self-efficacy scores after the intervention compared to the time before the intervention was − 1.58 ± 7.31 in the control group and 2.79 ± 6.42 in the intervention group. The difference between the two groups was statistically significant (t  = − 3.02, p = 0.003).

The ANCOVA test indicated that the effect of the intervention on self-efficacy scores remained statistically significant after adjusting for potential confounding variables (F [1,89] = 13.5, P ≤ 0.001, ɳP² = 0.151).

Also, the mean difference in sense of coherence (SOC) scores after the intervention compared to the time before the intervention was 2.67 ± 8.36 in the control group and 4.81 ± 6.58 in the intervention group, and there was no statistically significant difference between the two groups (U = 801, Z = − 1.7, P = 0.09).

The ANCOVA test demonstrated that the effect of the intervention on SOC scores was significant after adjusting for potential confounding variables. (F [1,89] = 5.8, P = 0.018, ɳP² = 0.073).

The mean difference in anxiety scores after the intervention compared to the time before the intervention was 0.02 ± 16 in the control group and − 13.07 ± 13.7 in the intervention group. The difference between the two groups was statistically significant. (U = 440, Z = − 4.510, p < 0.001).

The ANCOVA test indicated that the effect of the intervention on anxiety scores remained statistically significant after adjusting for potential confounding factors. (F [1,89] = 21.1, P < 0.001, ɳP² = 0.224) (Table 4).

Table 4.

Comparison of pre–post mean changes in self-efficacy, sense of coherence, and anxiety scores between intervention and control groups.

Variable	Group	Mean	SD	Test	Z	t/U	P-value
Self-efficacy	Control	-1.58	7.31	t-test	–	− 3.02	0.003
	Intervention	2.79	6.42
Sense of coherence	Control	2.67	8.36	Mann–Whitney U	− 1.7	801	0.09
	Intervention	4.81	6.58
Anxiety	Control	0.02	15.99	Mann–Whitney U	− 4.51	440	< 0.001
	Intervention	-13.07	13.7

SD = Standard Deviation. Test statistics are reported as t-values or Mann–Whitney U Z-scores. P < 0.05 was considered statistically significant.

Discussion

The present randomized controlled trial evaluated the effect of an educational program based on the self-management empowerment model on sense of coherence, self-efficacy, and postpartum anxiety among cesarean mothers in Bushehr, Iran. The two groups were comparable in baseline demographic characteristics, confirming the homogeneity of the sample. The findings showed that the intervention led to a significant improvement in sense of coherence in the intervention group, whereas the observed increase in the control group was likely influenced by confounding factors. However, after adjusting for potential confounders using ANCOVA, the intervention effect became statistically significant. This shift indicates that unadjusted analyses were confounded by covariates, and removing their influence enhanced precision of the effect estimate, revealing a clearer independent treatment effect and supporting the study hypotheses.

The improvement in sense of coherence observed in the intervention group is broadly consistent with previous research reporting that targeted psychosocial or behavioral interventions can strengthen SOC in different populations^60–63. Pregnancy and the transition to parenthood involve major changes in roles and responsibilities, and prior work has shown that a strong family sense of coherence, supported by open communication and mutual adjustment, facilitates adaptation for new parents⁶³. In line with this, Granberg et al.⁶⁰ followed mothers over two years postpartum and found that higher SOC was positively associated with breastfeeding enjoyment and the perceived quality of the partner-child relationship, underscoring the role of coherent family dynamics in postpartum adjustment.

Evidence from non-obstetric populations also supports the modifiability of SOC through structured interventions. In elderly patients with cardiovascular disease, a self-management empowerment program led to improvements in SOC and its components, comprehensibility, manageability, and meaningfulness, suggesting that empowering individuals to understand and actively manage their condition may enhance their global orientation to life⁶². Similarly, Kekäläinen et al.⁶¹ reported that a nine-month resistance training program gradually improved SOC, indicating that sustained, lifestyle-oriented interventions may be required to produce meaningful changes. However, Pakkala et al.⁶⁴ did not find a significant effect of intensive strength training on SOC in patients with hip fractures. This discrepancy may be related to methodological and contextual factors such as small sample size, limited physical tolerance, higher levels of uncertainty about future mobility, and substantial concerns regarding daily functioning, all of which may constrain participation, undermine perceived control, and hinder the development of meaningfulness and coherence.

In the present trial, the increase in SOC in the control group may partly reflect natural adaptive processes and satisfaction with the birth experience, as prior evidence suggests that women with higher childbirth satisfaction tend to report higher postpartum SOC compared with the prenatal period³⁰. Furthermore, the participants had a history of at least one previous cesarean delivery, which may have reduced uncertainty and enhanced predictability, thereby supporting SOC. Nonetheless, the adjusted analyses indicate that the self-management empowerment program had an independent effect beyond these background factors. The five-step intervention, explicitly designed to enhance self-efficacy and SOC across physical, psychological, social, cultural, and spiritual domains, likely helped mothers to interpret their postpartum experiences as more understandable, manageable, and meaningful^31,65.

Taken together, these converging and diverging findings suggest that SOC is a dynamic construct that can be strengthened when interventions are sufficiently tailored to the individual’s context, sustained over time, and delivered in a way that supports autonomy and active engagement. At the same time, the pattern of change in the control group and the influence of satisfaction with childbirth highlight the potential impact of unmeasured or residual confounders, such as prior birth experiences or informal support, which may represent sources of bias in estimating the true effect of the intervention in this study.

The self-management empowerment intervention significantly enhanced self-efficacy in the intervention group, with no significant change observed in the control group, likely reflecting the targeted educational components that fostered skill acquisition and confidence in postpartum self-management. These findings align with prior research demonstrating the efficacy of structured, home-based or prenatal education programs in boosting maternal self-efficacy among cesarean mothers^66–68. For instance, Farasti et al.⁶⁷ reported improvements in maternal functioning and breastfeeding self-efficacy following home-based counseling for first-time cesarean mothers, with effects emerging at 2 and 4 months postpartum. Similarly, Mohseni et al.⁶⁸ found that multi-session home-based prenatal and early postpartum education on breastfeeding enhanced self-efficacy in Iranian first-time mothers, while El-Kader et al.⁶⁶ showed that prenatal classes equipped Egyptian primiparas with practical labor skills, increasing childbirth self-efficacy and reducing fear.

Supporting evidence extends to technology-assisted and booklet-based approaches. Chuektong et al.¹¹ demonstrated that a mobile app-based breastfeeding self-efficacy program improved exclusive breastfeeding rates in Thai cesarean mothers, though they noted limitations in trial design and long-term follow-up. Azizah et al.⁶⁹ observed gains in parental self-efficacy via post-cesarean counseling and booklets, albeit constrained by short follow-up (1 day postpartum), small sample, non-randomization, and single-site recruitment, factors that may overestimate early effects but limit generalizability. In non-maternal contexts, Moattari et al.⁷⁰ reported empowerment interventions improved decision-making and stress reduction (self-efficacy components) in hemodialysis patients through family-involved problem-solving, aligning with Bandura’s reciprocal model where self-efficacy reinforces behavioral self-management^71,72.

In contrast, Kellams et al.⁷³ found no effect of video-based prenatal education on breastfeeding self-efficacy, suggesting that passive formats may insufficiently engage cognitive or skill-based mastery experiences central to self-efficacy development. Farasti et al.⁶⁷ also noted delayed group differences (not immediate post-birth), potentially due to initial recovery barriers or unmeasured moderators like parity, social support, or breastfeeding success⁷⁴. These discrepancies highlight contextual influences: our intervention’s five-step, multi-domain focus (physical, psychological, social) likely accelerated gains by addressing cesarean-specific needs, unlike shorter or less tailored programs.

The absence of control group change underscores the intervention’s specific impact, though unmeasured factors, such as participants’ prior cesarean experience (mostly multiparous), informal support, or natural adaptation, may introduce residual confounding, akin to patterns seen in SOC analyses. Self-efficacy’s multifaceted role (outcome, mediator, or enabler of empowerment)⁷⁵ suggests our program’s emphasis on skill-building created a virtuous cycle, but potential biases like self-selection or attrition warrant caution in causal attribution. Collectively, these insights affirm self-efficacy’s modifiability via sustained, context-tailored interventions, with optimal effects requiring ≥ 2 months follow-up to capture lagged adaptations.

The self-management empowerment intervention significantly reduced postpartum anxiety in the intervention group, with minimal change in the control group, attributable to its targeted training on self-awareness, goal-setting, and adaptation to postpartum changes. These results align with studies demonstrating that self-efficacy-based or mindfulness-oriented education can mitigate anxiety in pregnant or cesarean mothers^76–79. Arfaei et al.⁷⁶ showed that family counseling addressing maternal role concerns reduced anxiety in Tehran-based pregnant women, while Gandomi et al.⁷⁷ reported that self-efficacy education lowered pregnancy anxiety and cesarean rates (though not preterm labor) in Birjand primiparas after one month. Kharazi et al.⁷⁸ found self-efficacy training improved maternal health literacy and newborn outcomes in Mashhad, and Kuo et al.⁷⁹ demonstrated mindfulness sessions decreased childbirth fear, anxiety, and depression while boosting mindfulness in high-risk pregnant women and partners.

In contrast, Mohammadi et al.⁸⁰ observed non-significant anxiety reductions post-delivery despite self-efficacy classes, likely due to postpartum stressors like infant care and breastfeeding overwhelming prenatal gains^81,82. Missler et al.⁸³ also failed to replicate these effects, which may be partly explained by differences in participant characteristics: our sample, composed mainly of diploma-educated cesarean multiparas with moderate socioeconomic status (SES), may benefit more from concise booklets that address information gaps, whereas the higher-SES, better-educated participants in their study were more likely to access such resources independently; though Henshaw et al.⁸⁴ note that greater information access does not uniformly reduce stress across backgrounds. These discrepancies underscore contextual moderators: our multi-domain intervention (emphasizing awareness of cesarean-specific physiological/psychological shifts) likely enhanced manageability, unlike shorter prenatal-focused programs.

The control group’s stability highlights the intervention’s specificity, though natural adaptation or unmeasured factors (e.g., prior cesarean experience reducing uncertainty) may contribute, mirroring patterns in SOC and self-efficacy analyses. Self-awareness components directly tackled key anxiety drivers like poor understanding of childbirth events^85,86, fostering perceived control. Potential biases, such as selection into a hospital-based trial or residual confounding from parity/SES, temper causal claims, yet the pattern supports tailored education as a scalable strategy. Overall, converging evidence affirms anxiety’s responsiveness to empowerment models in lower-resource cesarean contexts, with optimal designs prioritizing postpartum follow-up and holistic needs.

This RCT adapted a structured self-management empowerment model, algorithm-informed by multidisciplinary expert input (nurses, midwives, public health specialists), targeting maternal roles in newborn care, spousal dynamics, and family boundaries. The randomized design with baseline homogeneity enhances internal validity. Although randomization occurred post-recruitment, initial convenience sampling introduces selection bias, potentially limiting sample representativeness. Single-site recruitment from a single public hospital, constrains generalizability to other settings or regions; results should be cautiously applied to similar populations. Lack of blinding, participants aware of objectives, questionnaires distributed by the educator, may induce performance bias in self-reported outcomes (sense of coherence, self-efficacy, postpartum anxiety); independent data entry/analysis reduced detection bias. Online self-reports risk social desirability overestimation. Uncontrolled variables (social support, SES, pre-pregnancy mental health) and short-term follow-up limit causal inference; long-term effects unexplored. In conclusion, the self-management empowerment intervention improved sense of coherence and self-efficacy while reducing postpartum anxiety in cesarean mothers. This model is recommended for postpartum support programs, with nurses prioritizing such structured education. Future multi-site RCTs using probability-based sampling, combined subjective/objective measures, long-term follow-up (≥ 6 months), and control for confounders (social support, SES, pre-pregnancy mental health) are needed to enhance internal/external validity and confirm sustained effects.

Abbreviations

CS

Cesarean section

CONSORT

Consolidated standards of reporting trials

PTSD

Post-traumatic stress disorder

RCT

Randomized controlled trial

SOC

Sense of coherence

SES

Socioeconomic status

WHO

World Health Organization

Author contributions

The contribution of the authors to the research was as follows: Research design by MR, FK, SM, FN; data collection by FN; research execution by MR, FK, SM, FN; data analysis by SM; documentation by MR, FK, SM, FN; and primary responsibility for the final content by MR, FK, SM, FN. All authors were major contributions in writing the manuscript and approved the final version.

Funding

This work was supported by the Research Council of Bushehr University of Medical Sciences (Grant Number: IR.BPUMS.REC.1403.102). The Research Council of Bushehr University of Medical Sciences had no role in conducting the study, data analysis or interpretation, writing the manuscript, or decisions about submitting the script for publication.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Declarations

Competing interests

The authors declare no competing interests.