Abstract
BACKGROUND:
Attention to the quantitative and qualitative aspects of midwifery education is of great importance. The virtual space can enhance the capabilities of midwifery students during the learning process of labor. The present study aims to design, implement, and evaluate the effectiveness of a labor process application to enhance the confidence and self-efficacy of midwifery students.
MATERIALS AND METHODS:
This study is of a semi-experimental type with a pre-test and post-test design conducted in two phases: In the first phase, the content of the program will be designed and implemented based on the midwifery curriculum (labor process by the Ministry of Health in Iran). In the second phase, the evaluation of the application’s effectiveness will be conducted based on the Kirkpatrick model. Students will complete demographic characteristics form before the intervention. The Cooper-Smith Self-Esteem Inventory, Sherer’s Self-Efficacy Questionnaire, and Visual Analog Scale Questionnaire will be completed before, immediately after, and 4 weeks after the intervention, along with the teaching satisfaction questionnaire, which will be completed immediately, and 4 weeks after the intervention. To analyze the data, version 26 of SPSS software (IBM Corp, Armonk, NY, USA) will be used, employing descriptive statistics, including minimum, maximum, mean, and standard deviation for quantitative variables, as well as frequency and percentage for qualitative variables. Additionally, paired t-tests and one-way analysis of variance will be used. The criterion for significance will be based on P < 0.05.
CONCLUSION:
The study is expected to provide evidence on the effectiveness of digital interventions in midwifery education. If successful, the application could complement traditional training, enhance clinical competence, standardize education, and inform national health policy by supporting integration of innovative digital tools into curricula. Ultimately, this intervention aims to strengthen students’ practical skills, improve maternal and neonatal care, and contribute to a competent and responsive maternal health workforce.
Keywords: Midwifery, mobile application, natural childbirth, self-concept, self-efficacy
Introduction
Midwifery is one of the academic fields that deals with human life, and attention to both the quantitative and qualitative aspects of its education is of great importance.[1] Enhancing the level of midwifery education ensures the provision of better care services. This profession is complex and challenging, and with the use of its specific sciences and skills, it can advance health in physical, psychological, and social dimensions. In this regard, clinical education in midwifery plays a major role and is considered an integral part of theoretical education, with the two being complementary.[2] The quality of midwifery education has a deep impact on the provision of clinical midwifery skills; graduates of this field must acquire at least the clinical and professional skills necessary to perform midwifery duties.[3] Internship programs play a crucial role in developing the foundational skills and professional competencies of midwifery students. The fifth development plan is a special emphasis on ensuring the reproductive health of individuals in the community, in which the role of midwifery students is undoubtedly notable. One of the key missions of medical universities is to train students and to contribute socially in line with national policies, particularly in the fields of health and healthcare. One of the ongoing programs in the health transformation plan is to encourage natural childbirth.[4] The goal of effective clinical education is to enhance critical thinking and analytical skills, gain competence in communication, timely management skills, and increase students’ confidence in their abilities to fulfil their professional clinical responsibilities.[5]
Self-confidence is considered one of the key elements of clinical skill, accompanied by continuous self-assessment and self-judgment, which reflects an individual’s belief in themselves and their competence, and notably impacts the quality of their actions and behaviors.[6] To build confidence, a safe and encouraging learning environment is important, and for students to take risks and try original content, they must feel comfortable and supported. The use of virtual space and applications in education help the transformation of thought patterns, enriches existing educational models, and presents new technology-based educational models, offering innovative learning methods in that the learner plays an active role and emphasizes self-direction, independence, flexibility, and interactivity.[7] The Sustainable Development Goals also emphasize virtual education as a means of empowering individuals in society. Virtual education currently encompasses educational environments and serves as the foundation of success in 21st-century education. Virtual education is a driving force in development and innovation in both developed and developing countries, and is considered a mainstream transformation in higher education.[8]
One of the theories that can be used to evaluate the degree of confidence in the clinical performance of students is Bandura’s self-efficacy theory.[9] According to Bandura, self-efficacy is an individual’s belief in their ability to perform desired tasks.[10] The importance of self-efficacy in education relates to its impact on future performance.[11] High self-efficacy is associated with effective stress management, greater adaptability, higher self-confidence, improved physical health, and a more positive overall sense of well-being in students.[12] Given the importance of enhancing midwifery students’ confidence and practical skills in managing childbirth, this study was guided by Bandura’s Self-Efficacy theory. According to Bandura, individuals’ belief in their ability to perform specific tasks (self-efficacy) plays a critical role in determining their motivation and performance. Educational interventions that strengthen this belief can improve both confidence and competence. Therefore, the use of an interactive educational application, which enables repeated and experiential learning, is expected to enhance students’ self-efficacy, confidence, and clinical skills in the childbirth process.[13] Theories informing technology-enhanced learning demonstrate that interactive application-based exercises notably improve self-efficacy and confidence by providing immersive, hands-on experiences that bridge theoretical knowledge with practical skill development.[14] Training and clinical experiences should enhance the self-efficacy of the student and transform them into an individual who, by the end of their educational program, is capable of effectively and confidently applying the various skills they have learned to their competencies.[15]
A recent study has shown the impact of simulation-based animation training compared to traditional training in reducing anxiety and improving self-efficacy among students in the clinical obstetrics course,[16] which leads to student lethargy, learning disruptions, and increased absenteeism in class. It also boosts students’ motivation for learning and increases their confidence in performing various skills.[17] Today, given the increasing interest of individuals in the virtual space and the widespread adoption of smartphones in society, the use of applications as software for achieving specific goals on smartphones has gained notable attention. This space can be used for designing a childbirth application.[18] Several studies have demonstrated that the use of educational films in virtual spaces is effective in enhancing student learning outcomes compared to traditional teaching methods.[19,20]
The novelty of this study lies in the development of the first comprehensive childbirth process application specifically aligned with the Iranian midwifery curriculum. The effectiveness of this application will be evaluated using the Kirkpatrick model across multiple dimensions, including confidence, self-efficacy, and behavioral changes, providing a structured and evidence-based approach for midwifery education.
Based on the research team’s expertise and a review of reputable scientific sources, no previous study has investigated the design and evaluation of a childbirth education application aimed at improving midwifery students’ confidence. Therefore, this study will design, implement, and evaluate a mobile application intended to enhance the confidence and self-efficacy of midwifery students. The expected outcomes include measurable improvements in students’ confidence, self-efficacy, and practical skills, which may contribute to better maternal and neonatal health outcomes and overall indicators of community health.
Materials and Methods
Study design and setting
This study employs a semi-experimental design with a pre- and post-test approach, comprising two phases. The first phase aims to design and implement the childbirth application, and the second phase aims to evaluate the effectiveness of the intervention through the application. Sampling will be conducted by the researcher after the project is approved by the university’s research council, and approval has been obtained from the ethics committee, as well as after obtaining necessary letters from Mazandaran University of Medical Sciences. It will be conducted in the Nursing and Midwifery Faculty of Nasibeh in the year 2025 in two phases for midwifery students.
Study participants and sampling
The sample size will be equal to the population size and will be conducted via a census. Undergraduate students who have expressed their consent to participate in the study will be included. Midwifery students in the 6th and 8th semesters, who have completed the theoretical course on pregnancy and childbirth will be included in this study. In contrast, unwillingness to participate in the study, failure to attend training sessions, will be considered as exclusion criteria.
Data collection tool and technique
Initially, individuals who meet the inclusion criteria will complete a demographic information form. The research objectives will be explained to the participants, and they will be assured of the confidentiality of their information. This study will be conducted in two phases with a pre-and post-test design for midwifery students.
The first phase aims to design, implement, and validate the childbirth application, and the second phase aims to evaluate the effectiveness of the intervention through the childbirth application in the first phase of the study, according to the Ministry of Health curriculum, the necessary content related to the childbirth process will be provided to the technology expert, and the application will be designed in five stages for midwifery students in the year 2025. The method of implementation is briefly presented in Figure 1.
Figure 1.
Implementation, and evaluation phase of the effectiveness of the childbirth process application
Phase 1: Design, implementation, and evaluation of the effectiveness of the childbirth process application:
Conceptual modeling: The content of the program is defined, and how to use it presented to the audience.
Program design: Lists, images, videos, and access structures will be collected and specified by the research team mentioned in the study.
Designing connection lines: Defining and implementing how the various parts of the application interact, which directly impacts the application’s efficiency, security, and user experience.
Implementation: Using intelligent software, all the content from the previous stages is translated into computational language.
After design, the collected content of the application will undergo qualitative evaluation by a panel consisting of specialists in reproductive health, midwives, medical education experts, and software engineers. The qualitative evaluation process will be reviewed from various aspects, such as performance, security, user experience, and accessibility, for final review.
Phase 2: Evaluating the effectiveness of the intervention through the childbirth application. To evaluate the effectiveness of the training, the Kirkpatrick evaluation model can be used, which consists of four levels: reaction, learning, behavior, and results [Figure 2].
Figure 2.
Evaluation of the Kirkpatrick Model
In this study, evaluation will be conducted at three levels: reaction, learning, and behavior, according to the Kirkpatrick model.
Level One (Reaction): At this level, the participants’ reactions to the training or their feelings about the training are measured. In the present research, at this level, students’ satisfaction with the current intervention is evaluated using a satisfaction questionnaire regarding the teaching method.
Level Two (Learning): This level evaluates how much the participants have learned from the training. In the present research, self-assessment is measured using a visual analog questionnaire and the score that students give themselves.
Level Three (Behavior): This level refers to the transfer of training and the sustainability of changes in the performance or attitudes of the participants. Evaluation will also be conducted at appropriate times, one month (4 weeks) after implementation, to ensure the presence of behavioral changes. Additionally, at this level, self-confidence will be measured using the Cooper-Smith questionnaire, and self-efficacy will be evaluated using the Sherer self-efficacy questionnaire for students.
Level Four (Results): This level is for determining the effectiveness and final suitability of educational programs over time. At this stage, students need to be followed up after graduation to observe the effectiveness. Due to the limited opportunity, the students cannot conduct this type of evaluation.[21]
After the approval of the Ethics Committee of Mazandaran University of Medical Sciences and registration and confirmation in Iranian Registry of Clinical Trials (IRCT), the study will be conducted. The study ‘the researcher (a master’s student in midwifery counseling) will explain s objective. The classification of educational objectives will be based on Bloom’s learning domains.[22] The objectives of the present study will be outlined in two areas of behavior, including cognitive, and emotional goals. The content of the intervention will be based on the curriculum for natural childbirth training for midwifery students. The educational framework through this application will be implemented using the method of repeated learning, and students will learn a single content multiple times (for 1 month) using various methods such as educational videos, colored images, voice-over slides, and so on. A checklist will be designed to specify the frequency of practice. The educational content includes: monitoring fetal heart rate, non-stress test and its interpretation, Leopold’s maneuvers, venipuncture, stages of labor, interpretation of the partograph, vaginal examination, delivery, newborn evaluate, examination of the placenta, episiotomy repair, control of postpartum bleeding, and non-pharmacological methods for reducing labor pain, which will be presented to students for 4 weeks. Then, the students will complete questionnaires before, immediately after, and 4 weeks after the intervention [Table 1].
Table 1.
Topics and educational protocols for childbirth
| Topics | Educational content | |
|---|---|---|
| NST | Fetal heart rate monitoring and performing, and interpreting reactive and non-reactive NST strips | |
| Leopold’s maneuvers | Training and how to properly perform the Leopold | |
| Vein puncture | Familiarity with the necessary equipment and the correct method of venipuncture | |
| Stage of labor | Familiarity with the stages of labor and accurate identification of the stages | |
| Methods of pain reduction | Familiarity with non-pharmacological pain relief | |
| Partograph | Familiarity with the Pareto chart form and correctly completing the form in the active phase of labor | |
| Vaginal examination | Vaginal examination education of the patient and simultaneous use of a model through video | |
| Delivery | Observation of childbirth on the patient and management of the second and third stages of labor | |
| Newborn assessment | Initial assessment of the newborn immediately after delivery and scoring based on the Apgar score | |
| Placenta examination | Delivery of the placenta and examination of the placenta, membranes, and umbilical cord | |
| Episiotomy repair | Perineum Examination and repair of episiotomy incision | |
| Postpartum control | Estimation of postpartum hemorrhage and management of postpartum bleeding control |
Tools
The data collection tools in this study include: a demographic characteristics form, the Cooper-Smith Self-Esteem Inventory, the Sherer General Self-Efficacy Scale, the Visual Analog Self-Assessment Questionnaire, and the Teaching Method Satisfaction Questionnaire.
Demographic characteristics form
This form includes questions such as age, marital status, academic term, experience using educational applications, experience attending natural, or simulated childbirth, type of device used for the application, level of familiarity with digital technologies, internet access, your willingness, and main reason for using the application, and any suggestions or comments for improving the application.
Cooper-Smith self-esteem inventory
Cooper-Smith (1995) designed this inventory to measure the self-esteem of different groups of individuals. The current version comprises 58 questions, each with five options based on a Likert scale, where a higher score indicates a higher level of self-esteem. According to the results of an Iranian study (1996) reported the reliability of this inventory using Cronbach’s alpha as 0. 89 and its validity as 0.91.[23]
Self-assessment questionnaire visual analog scale
This scale is also referred to as a continuous quantitative comparison and a graphical ranking scale. Self-assessment is measured using a visual analog scale, consisting of a graded statement with a minimum score of 0 and a maximum score of 100, representing poor self-assessment, and excellent self-assessment, respectively. The validity and reliability of the questionnaire have been confirmed in previous studies.[24]
Teaching method satisfaction questionnaire
The Teaching Method Satisfaction Questionnaire is a researcher-made instrument. This scale consists of 16 items, using a three-point Likert scale (completely, relatively, and not at all and measures satisfaction with the teaching method.[25] The results of an Iranian study obtained a validity and reliability of the questionnaire using Cronbach’s alpha above 0.70.
Self-efficacy questionnaire by sheerer
This questionnaire was designed by Sherer et al. as a tool to determine the various levels of general self-efficacy of individuals. It evaluates 17 general self-efficacy questions with a mean of 57.99 and a standard deviation of 12.08. For each question, a self-efficacy scale with five responses on a Likert scale is proposed, and each question is assigned 5 points. Questions number 1, 3, 8, 9, 13, and 15 increase from a score of 1 (deeply disagree), 2 (disagree), 3 (neutral), 4 (agree), to 5 (deeply agree) from right to left, while the remaining questions are scored in reverse, meaning their scores increase from the left to right. The scoring range is between 17 and 85.[26] Barati Bakhtiari reported the validity and reliability of this questionnaire using Cronbach’s alpha as 0.79 in 1997.
Primary outcome: The average scores that students will obtain from self-confidence and self-efficacy.
Secondary outcome: The average scores that students will obtain from self-assessment and satisfaction with the teaching method.
Ethical consideration
This study has been approved with the ethics code (IR.MAZUMS.REC.1403.460), and the IRCT code of this study is IRCT20110827007422N6 and accessible at https://irct.behdasht.gov.ir/user/trial/81422/view. The educational researchers of this project will avoid any situation that may lead to a conflict of interest and will conduct educational research only within their area of expertise and based on the training they have received, the skills they have acquired, or relevant professional experience. The information of the participants will also remain confidential. Ethical standards will be adhered to during the of publishing, reviewing, and editing scientific materials. Researchers acknowledge the right of each participant to withdraw from the study for any reason and at any time, and they will inform them of this right. All participants will be informed about the purpose of the study, and written consent will be obtained from each participant.
Statistical analysis method
Data entry will be performed in SPSS v. 26 software. Descriptive statistics, including minimum, maximum, mean, and standard deviation for quantitative variables, as well as frequency and percentage for qualitative variables, will be used for data analysis. In the analytical section, the normality assumption will first be examined using graphical methods and the Kolmogorov–Smirnov test. If the normality assumption is met, parametric tests such as the paired t-test and one-way analysis of variance (ANOVA) will be used; if the normality assumption is not met, non-parametric tests such as the Wilcoxon and Kruskal–Wallis tests will be used. Additionally, to examine each variable over time (before, immediately, and four weeks after using the application), a one-way ANOVA with repeated measures will be employed. The criterion for judging significance will be based on P < 0.05.
Discussion
This study aims to design, implement, and evaluate the effectiveness of a mobile application for the childbirth process to enhance confidence and self-efficacy among undergraduate midwifery students. The study hypothesis is that using an app-based learning program will increase students’ self-efficacy and confidence in clinical practice.
E-learning has become an essential component of contemporary education, providing immediate feedback, promoting critical thinking, and facilitating the exploration of complex clinical scenarios.[27,28,29,30] In midwifery education, the complexity of the healthcare environment may induce anxiety and stress in students, potentially affecting their clinical performance.[31] Therefore, ensuring that students acquire sufficient theoretical knowledge and practical skills before entering clinical practice is crucial for patient safety, confidence building, and effective student-patient interactions.[32]
Self-efficacy allows individuals to objectively assess their abilities, reduces the negative effects of anxiety and stress, and reflects self-confidence.[33] Enhancing self-efficacy during clinical training is critical, as it underpins independent practice and professional competence.[34] The mobile application developed in this study is designed to strengthen both theoretical knowledge and practical skills, directly addressing the study hypothesis.
Previous studies support the expected outcomes of this intervention. Esfandyari Nejad et al. reported that distance learning methods, when combined with face-to-face training, significantly improve clinical skills among nursing, midwifery, and operating room technology students.[35] Bokari et al. found that smartphone-based videos improved nursing students’ clinical performance and confidence.[36] O’Connor et al. (2023) showed that digital learning interventions increased student engagement and self-efficacy in nursing and midwifery education.[37] Yeh and Yang demonstrated that simulation-based animation training reduced anxiety and increased self-efficacy in clinical obstetrics courses.[16] These studies support the hypothesis that a mobile application can effectively enhance confidence and self-efficacy among midwifery students.
Potential limitations include students’ non-compliance in using the app, the absence of a traditional control group, and external variables such as prior clinical experience that may influence outcomes. These limitations will be addressed through clear communication of research objectives, follow-up with participants, and structured assessment points.
Strengths of the study include a comprehensive educational application aligned with the Iranian midwifery curriculum, the use of the Kirkpatrick evaluation model, repetitive learning opportunities, and multiple assessment time points.
Future research directions
Based on the limitations and anticipated outcomes of this study, future research may include the following:
Conducting randomized controlled trials with larger sample sizes to provide stronger evidence of the app’s effectiveness.
Implementing long-term follow-ups to evaluate the sustained impact of the application on students’ confidence, self-efficacy, and clinical performance.
Applying similar digital interventions in other medical and nursing education fields to examine generalizability.
Comparing app-based interventions with traditional teaching methods or control groups to isolate the effect of the intervention.
Conducting cost-effectiveness analyses to assess the economic feasibility of integrating mobile applications into standard curricula.
Exploring additional outcomes, such as students’ clinical decision-making skills, quality of patient interactions, and preparedness for independent practice.
These future research directions can help refine digital learning interventions, support evidence-based education policies, and strengthen the preparation of competent maternal health professionals.
Conclusion
This study protocol presents a structured plan to develop and evaluate a childbirth education mobile application aimed at enhancing midwifery students’ confidence and self-efficacy. Utilizing virtual learning tools—including educational videos, interactive simulations, and formal assessments—the intervention is designed to address gaps in clinical training and facilitate practical skill acquisition. The study will employ a quasi-experimental pre- and post-test design, assessing outcomes such as self-confidence, self-efficacy, and student satisfaction through validated instruments. While recognizing potential limitations, including participant adherence and the absence of a control group, this protocol establishes a robust framework for implementing and evaluating digital educational interventions in midwifery. If effective, the application could serve as a complementary tool to traditional education, aligning with contemporary pedagogical trends and fostering clinical competence and preparedness among students.
Moreover, the study aligns with national and international health policy priorities by providing evidence to support the integration of innovative digital tools into midwifery curricula. This approach has the potential to standardize training, ensure graduate competency, and ultimately improve maternal and neonatal outcomes. By empowering students during clinical internships, the intervention is expected to enhance motivation, engagement, and practical skill development, thereby contributing to higher-quality reproductive healthcare, and strengthening the foundation of primary care services.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
We sincerely thank the Research and Technology Deputy of Mazandaran University of Medical Sciences, and the midwifery professors and students of Mazandaran University of Medical Sciences who will assist in the implementation of this project. All methods will be conducted following the guidelines and regulations of the National Strategic Research Agency in medical education.
Funding Statement
Nil.
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