Fetal Health Locus of Control Scale (FHLC)

1. Abstract

The Fetal Health Locus of Control Scale (FHLC) is a psychometric instrument developed by Shannon M. Labs and Suzanne K. Wurtele in 1986 to measure expectant mothers’ beliefs regarding the agents responsible for fetal health and pregnancy outcomes. Grounded in Julian Rotter’s social learning theory and adapted from the Multidimensional Health Locus of Control (MHLC) paradigm formulated by Wallston and colleagues, the FHLC evaluates specific control attributions related directly to the prenatal period. The instrument comprises 18 self-report items grouped into three distinct subscales: Internal Fetal Health Locus of Control (FHLC-I), Chance Fetal Health Locus of Control (FHLC-C), and Powerful Others Fetal Health Locus of Control (FHLC-P), with each domain assessed through six dedicated items. Respondents evaluate each statement using a 10-point Likert-type continuum ranging from 0 (“Strongly Disagree”) to 9 (“Strongly Agree”).

Psychometric evaluations demonstrate that the FHLC possesses robust reliability and validity across diverse clinical and non-clinical obstetrical cohorts. In the initial development samples, internal consistency coefficients (Cronbach’s alpha) were documented at α = 0.88 for the Internality dimension, α = 0.83 for the Chance dimension, and α = 0.76 for the Powerful Others dimension, with concurrent test-retest reliability indices demonstrating stability over time (r = 0.80, r = 0.86, and r = 0.67, respectively). Factor analyses have supported the hypothesized three-factor orthogonal or oblique structure, affirming the conceptual independence of personal agency, fatalistic beliefs, and medical reliance during gestation. The FHLC has been applied in clinical investigations examining maternal lifestyle behaviors, smoking cessation, high-risk obstetrical management (e.g., gestational diabetes), psychological adaptation to pregnancy complications, and prenatal health information-seeking behaviors. By identifying pregnant women’s health attributions, the FHLC serves as a critical predictive and diagnostic tool in perinatal psychology and maternal-fetal medicine.

2. Keywords

Fetal Health Locus of Control, FHLC, prenatal health beliefs, maternal psychology, health locus of control, internal health locus of control, powerful others, chance attributions, pregnancy health behaviors, perinatal assessment, psychometrics, obstetrical psychology

3. Authors

The Fetal Health Locus of Control Scale was created and psychometrically validated by:

• Shannon M. Labs, Ph.D. — Department of Psychology, Washington State University, Pullman, Washington, United States.
• Suzanne K. Wurtele, Ph.D. — Department of Psychology, Washington State University, Pullman, Washington (later Professor of Psychology at the University of Colorado Colorado Springs, specializing in child abuse prevention, maternal-child health psychology, and clinical behavioral assessment).

Correspondence regarding the foundational development of the scale was originally addressed through the Department of Psychology at Washington State University and documented in the Journal of Consulting and Clinical Psychology (1986). Subsequent distribution and clinical integration have appeared in compendiums authored by Joel Fischer and Kevin J. Corcoran.

4. Purpose

The perinatal transition represents a developmental period characterized by profound physiological transformation, heightened vulnerability to stress, and extensive behavioral restructuring. During this period, maternal adherence to clinical guidelines, dietary recommendations, substance abstinence, and regular prenatal care directly dictates fetal development and perinatal morbidity. While generalized health locus of control scales—such as the Wallston, Wallston, and DeVellis (1978) Multidimensional Health Locus of Control (MHLC) scale—demonstrated efficacy in predicting broad health attitudes, empirical research repeatedly illustrated that generalized expectancies display diminished predictive validity when applied to domain-specific health situations. The purpose of the Fetal Health Locus of Control Scale (FHLC) is to provide a domain-specific, psychometrically validated diagnostic instrument capable of capturing the nuanced attributional structures held by pregnant women concerning their unborn child’s well-being.

The clinical and behavioral rationale for developing the FHLC stems from the hypothesis that an expectant mother’s health practices (e.g., abstaining from tobacco, alcohol, and teratogens; seeking balanced nutrition; adhering to prenatal vitamins; attending scheduled clinic visits) are governed by her subjective expectancies regarding the direct efficacy of her actions. A woman who perceives that fetal outcome is an arbitrary consequence of fate or biological determinism (high Chance locus of control) may exhibit learned helplessness and disengage from recommended preventive behaviors. Conversely, a woman who perceives that fetal survival rests exclusively in the authority of medical staff (high Powerful Others locus of control) may defer personal responsibility, manifesting compliance only in the presence of external medical oversight while failing to regulate independent home health behaviors. Alternatively, mothers with a robust Internal fetal locus of control are anticipated to assume personal responsibility for fetal health, actively pursuing health education and engaging in self-regulatory wellness practices.

In clinical practice, the FHLC is utilized by obstetricians, clinical health psychologists, perinatal social workers, and nurse-midwives to:

• Identify pregnant women at risk of non-compliance with prenatal medical regimens and preventive health advisories.
• Tailor psychoeducational and behavioral interventions to align with or restructure maternal cognitive appraisals.
• Assess the psychological impact of obstetrical complications, such as gestational diabetes, preeclampsia, or a history of spontaneous abortion, on maternal perception of personal control.
• Evaluate the efficacy of prenatal education curricula in strengthening women’s perceived self-efficacy and active self-care orientations.

In research contexts, the FHLC serves as a foundational operationalization of prenatal attributional style, allowing investigators to elucidate the cognitive mechanisms mediating socio-demographic factors, maternal stress, health literacy, and obstetrical outcomes across diverse socioeconomic cohorts.

5. Psychological Construct

The construct assessed by the FHLC is locus of control of reinforcement, specifically contextualized within the psychological ecology of gestation and fetal health. Rather than conceptualizing health beliefs as a unidimensional continuum from internal to external orientation, the FHLC adopts a multidimensional model comprising three distinct, conceptually independent attributional axes: Internality, Chance, and Powerful Others.

Internal Fetal Health Locus of Control (FHLC-I)

The Internal Fetal Health Locus of Control subscale reflects the extent to which an expectant mother believes that fetal health, congenital well-being, and pregnancy outcomes are directly contingent upon her own behaviors, personal choices, and self-care efforts. Women exhibiting elevated scores on this dimension endorse the perspective that maternal diet, pre-pregnancy preparation, participation in prenatal instruction, self-monitoring, and day-to-day behavioral discipline exert a decisive influence on the physical status of the unborn infant. For example, item endorsements indicate a strong conviction that learning personal care regimens prior to pregnancy or actively attending health classes substantially mitigates fetal health hazards. High Internality is theoretically associated with proactive information seeking, lifestyle self-regulation, reduced consumption of harmful substances, and higher maternal self-efficacy.

Chance Fetal Health Locus of Control (FHLC-C)

The Chance Fetal Health Locus of Control subscale captures fatalistic, deterministic, or stochastic attributions regarding fetal outcomes. Individuals scoring high on this dimension view the physical condition of the baby, congenital abnormalities, or pregnancy loss as occurrences mediated by external random forces, natural laws, biological destiny, divine intervention, or inescapable luck. Such beliefs reflect an assumption of personal powerlessness, positing that rigorous maternal self-care cannot meaningfully alter the immutable courses dictated by nature, God, or fate. In clinical contexts, excessive Chance attributions have been observed to correlate with elevated prenatal anxiety, passive coping styles, delayed initiation of prenatal care, and fatalistic resignation when navigating obstetrical complications.

Powerful Others Fetal Health Locus of Control (FHLC-P)

The Powerful Others Fetal Health Locus of Control subscale measures the degree to which an expectant mother attributes fetal well-being to the authority, intervention, expertise, and oversight of healthcare professionals, such as obstetricians, perinatologists, midwives, and obstetrical nurses. This external dimension differs qualitatively from chance or fatalism; it conceptualizes control as external to the self yet highly predictable and vested within authoritative, competent human agents. High scores reflect beliefs that the unborn infant’s health is predominantly governed by the care delivered by medical personnel and that adherence to medical edicts is the solitary pathway toward a normal delivery. While high Powerful Others attributions ensure high compliance with medical appointments and prescription regimens, over-reliance on medical staff can occasionally foster maternal passivity, impeding the development of autonomous maternal confidence.

6. Theoretical Framework

The Fetal Health Locus of Control Scale is derived from Julian B. Rotter’s (1954, 1966) Social Learning Theory. Within Rotter’s theoretical paradigm, the potential for a specific behavior to occur in a designated psychological situation is a function of the individual’s expectancy that the behavior will lead to a particular reinforcement, coupled with the psychological value assigned to that reinforcement:

Behavior Potential (BP) = f(Expectancy [E] & Reinforcement Value [RV])

In Rotter’s conceptualization, “locus of control” refers to a generalized expectancy concerning whether reinforcements are contingent upon one’s own behavioral agency (internal locus of control) or are mediated by forces external to the individual, such as luck, fate, chance, or powerful others (external locus of control).

From Generalized Expectancies to Domain-Specific Health Beliefs

In 1978, Kenneth A. Wallston, Barbara Strudler Wallston, and Robert DeVellis advanced social learning theory into medical behavioral science by demonstrating that generalized locus of control scales lacked sufficient sensitivity when predicting domain-specific health actions. They introduced the Multidimensional Health Locus of Control (MHLC) scale, decomposing generalized externality into two separate dimensions: Chance (MHLC-C) and Powerful Others (MHLC-P). Their research demonstrated that an individual might reject fatalism while concurrently placing immense trust in medical practitioners, establishing that externality is not a unitary psychometric entity.

Building on this theoretical framework, Shannon M. Labs and Suzanne K. Wurtele observed in the mid-1980s that generic health locus of control scales were insufficiently predictive when evaluated within pregnant cohorts. Pregnancy introduces a unique relational dynamic: maternal health behaviors are executed not only for the preservation of the self, but for the somatic protection of a biologically distinct yet physically contained fetus. Consequently, health beliefs during gestation diverge markedly from general health beliefs. A woman may consider her own personal adult health as contingent on chance, yet view the health of her unborn baby as strictly manageable through disciplined prenatal habits or competent medical monitoring.

The FHLC was constructed to ground Rotter’s expectancy construct directly within the situational parameters of gestation. In this specialized theoretical framework, the reinforcement value (RV) of giving birth to a healthy, normal infant is presumed to be universally high among expectant mothers. Therefore, variance in maternal health protective behaviors (e.g., attending prenatal checkups, smoking cessation, maintaining adequate prenatal nutrition) is primarily driven by variance in maternal expectancy (E)—the degree to which the mother believes that her actions (Internal), medical experts (Powerful Others), or uncontrollable deterministic forces (Chance) dictate the biological viability and physical integrity of the fetus.

7. Validity

The validation of the FHLC has been confirmed through extensive empirical testing across clinical obstetrics, reproductive psychology, and health psychology settings.

Construct and Convergent Validity

In their foundational validation investigations, Labs and Wurtele (1986) evaluated construct validity by correlating the subscales of the FHLC with the generalized Multidimensional Health Locus of Control (MHLC) scales and Rotter’s original I-E scale. As hypothesized, the FHLC subscales demonstrated moderate, statistically significant correlations with their corresponding generic counterparts:

• FHLC-I exhibited significant positive convergent correlations with the MHLC Internal scale (r ≈ 0.45 to 0.55).
• FHLC-C correlated significantly with the MHLC Chance scale (r ≈ 0.50 to 0.62).
• FHLC-P correlated significantly with the MHLC Powerful Others scale (r ≈ 0.48 to 0.58).

The moderate magnitude of these correlation coefficients confirmed convergent validity while demonstrating that the FHLC accounted for considerable unique, pregnancy-specific variance that generic health scales failed to capture.

Predictive and Behavioral Validity

Predictive validity has been substantiated across diverse behavioral domains:

• Substance Use and Smoking Cessation: In an empirical investigation by Stewart and Streiner (1995) examining cigarette smoking during pregnancy, women who successfully quit or maintained smoking cessation during gestation exhibited significantly higher FHLC Internality scores compared to persistent smokers, who displayed elevated Chance and Powerful Others scores. These findings demonstrated that belief in personal agency directly predicts maternal harm-reduction behaviors.
• Health Information-Seeking: Shieh, Broome, and Stump (2010) examined factors influencing prenatal health information-seeking among low-income pregnant women. Their findings confirmed that maternal Internality positively predicted active health information acquisition, with higher FHLC-I scores correlating with elevated maternal engagement with prenatal literature and clinical consultations.
• High-Risk Obstetrical Adaptation: Spirito, Ruggiero, McGarvey, and Coustan (1990) utilized the FHLC to evaluate women diagnosed with gestational diabetes alongside non-diabetic controls. Women with gestational diabetes demonstrated significantly higher scores on the Powerful Others subscale, reflecting an adaptive cognitive adjustment to the rigorous medical surveillance, daily glucose tracking, and exogenous insulin regimens mandated by clinical obstetrical protocols.

Discriminant Validity

Discriminant validity has been demonstrated by evaluating the FHLC against measures of social desirability, generalized anxiety, and unrelated cognitive traits. Scores on the FHLC subscales exhibited non-significant correlations with the Marlowe-Crowne Social Desirability Scale, confirming that maternal responses on the FHLC are not merely artifacts of impression management or self-favoring response biases. Furthermore, cross-sectional studies on women with varying obstetric histories (Bielawska-Batorowicz, 1993) demonstrated that previous spontaneous abortion or complicated deliveries selectively modulated FHLC-C scores without skewing general personality metrics, corroborating the scale’s discriminant precision.

8. Reliability

The reliability of the FHLC has been examined through classical test theory across developmental and independent clinical replications, demonstrating robust internal consistency and temporal stability.

Internal Consistency

In the seminal psychometric investigation by Labs and Wurtele (1986), Cronbach’s alpha coefficients across the 18 items distributed across the three 6-item subscales demonstrated high internal consistency:

• FHLC-Internal: α = 0.88
• FHLC-Chance: α = 0.83
• FHLC-Powerful Others: α = 0.76

Subsequent investigations across clinical populations have produced comparable internal consistency metrics. For example, in studies evaluating maternal populations across diverse socioeconomic strata, alpha coefficients for FHLC-I and FHLC-C have routinely exceeded 0.80, while the FHLC-P subscale has demonstrated values ranging from 0.74 to 0.81, indicating that each subscale functions as a cohesive unidimensional measure.

Test-Retest Stability

Temporal stability of the FHLC was evaluated by Labs and Wurtele over a designated two-week interval among non-pregnant female cohorts evaluating hypothetical pregnancy scenarios, yielding high Pearson correlation coefficients:

• FHLC-Internal: r = 0.80
• FHLC-Chance: r = 0.86
• FHLC-Powerful Others: r = 0.67

In longitudinal assessments tracking pregnant women from the first trimester to the late third trimester (e.g., Spirito et al., 1990), test-retest coefficients demonstrated moderate stability (ranging from r = 0.55 to 0.72), reflecting both the structural consistency of the underlying belief constructs and their sensitivity to shifting obstetrical realities as delivery approaches.

9. Factor Analysis

The structural dimensionality of the FHLC was established via exploratory factor analysis (EFA) during its initial construction, with subsequent empirical inquiries utilizing confirmatory factor analysis (CFA) to verify the theoretical model.

Initial Exploratory Factor Analysis

Labs and Wurtele (1986) conducted a principal components analysis with varimax orthogonal rotation on the initial item pool administered to 345 female respondents. Inspection of the scree plot and eigenvalues greater than 1.0 supported a clean three-factor solution, accounting for a substantial proportion of the total item variance. The three identified factors mapped directly onto the theoretical constructs derived from the Wallston MHLC model:

• Factor 1 (Chance/Fate): Loaded heavily by items specifying biological determinism, natural destiny, acts of God, and the futility of maternal intervention in preventing congenital disorders (e.g., items 7, 8, 9, 10, 11, 12). Factor loadings for these items ranged from 0.52 to 0.81, with low cross-loadings on other factors.
• Factor 2 (Internal Control): Loaded prominently by items representing personal behavioral responsibility, dietary control, pre-pregnancy education, and maternal agency (e.g., items 1, 2, 4, 5, 6). Factor loadings ranged from 0.56 to 0.79.
• Factor 3 (Powerful Others): Loaded by items asserting that fetal survival and health are solely contingent upon medical professionals, compliance with doctors’ directives, and the unique competence of obstetrical staff (e.g., items 3, 13, 14, 15, 16, 17, 18). Factor loadings ranged from 0.48 to 0.74.

Confirmatory Structural Inquiries

Subsequent psychometric examinations using CFA across international and cross-cultural perinatal cohorts have generally supported the tripartite model, showing acceptable goodness-of-fit indices (Comparative Fit Index [CFI] > 0.90; Root Mean Square Error of Approximation [RMSEA] ≤ 0.06; Standardized Root Mean Square Residual [SRMR] ≤ 0.08) when minor inter-item error covariances are accommodated. While some psychometricians have explored oblique rotations allowing modest correlations between factors (most notably a low negative correlation between Internality and Chance, and a moderate positive correlation between Internality and Powerful Others), the orthogonal three-factor model remains the benchmark scoring structure.

10. Instrument / Measurement Tool

• Instrument Name: Fetal Health Locus of Control Scale (FHLC)
• Alternative Titles: Labs-Wurtele Fetal Health Locus of Control Scale
• Target Population: Expectant pregnant women, postpartum mothers (retrospective), and women planning pregnancy
• Administration Format: Self-report paper-and-pencil or computer-assisted questionnaire
• Total Number of Items: 18 items
• Administration Time: Approximately 5 to 10 minutes
• Response Scale: 10-point Likert-type scale ranging from 0 (“Strongly Disagree”) to 9 (“Strongly Agree”)
• Scale Dimensionality: 3 subscales (6 items each):
  • Internal Fetal Health Locus of Control (FHLC-I): Items reflecting maternal personal agency and behavioral influence over fetal well-being.
  • Chance Fetal Health Locus of Control (FHLC-C): Items reflecting fatalism, divine intervention, luck, and biological determinism.
  • Powerful Others Fetal Health Locus of Control (FHLC-P): Items reflecting reliance on physicians, nurses, and formal obstetrical care.
• Scoring and Item Assignment:
  • Subscale scores are obtained by calculating the sum of the numerical ratings within each respective subscale.
  • Possible scores for each subscale range from 0 to 54, with higher scores reflecting stronger attributional adherence to that specific locus of control dimension.
  • There is no single “total” locus of control score; each of the three dimensions is analyzed independently as an autonomous continuous variable.
  • Item Subscale Distribution:
    • Internality (FHLC-I): Items 1, 2, 4, 5, 6, and item 3 in some clinical allocations (or items 1, 6, 8, 12, 15, and 17 based on altered numbering matrices; standard published mapping assigns: Internality to items 1, 2, 4, 5, 6; Chance to items 7, 8, 9, 10, 11, 12; Powerful Others to items 3, 13, 14, 15, 16, 17, 18).

11. Permissions & Fee and Test Year

The Fetal Health Locus of Control Scale (FHLC) was developed and published in 1986 by Shannon M. Labs and Suzanne K. Wurtele. The original scale was published in the American Psychological Association’s (APA) Journal of Consulting and Clinical Psychology. Under academic fair-use and conventional psychometric research practices, the instrument is generally accessible for non-commercial scientific research, academic dissertations, and clinical assessment without licensing fees.

Clinical practitioners and behavioral investigators intending to reproduce, digitize, or administer the FHLC in funded institutional research or commercial ventures should seek formal permission from the original authors or the copyright holder (American Psychological Association). The full instrument, scoring protocols, and psychometric documentation are also indexed in clinical reference sourcebooks, notably Measures for Clinical Practice and Research: A Sourcebook (Fischer & Corcoran, 2007, Oxford University Press).

12. References

• Bielawska-Batorowicz, E. (1993). The effect of previous obstetric history on women’s scores on the Fetal Health Locus of Control scale (FHLC). Journal of Reproductive and Infant Psychology, 11(2), 103–106. https://doi.org/10.1080/02646839308403204
• Fischer, J., & Corcoran, K. J. (2007). Measures for clinical practice and research: A sourcebook (4th ed., Vol. 1, pp. 341–343). Oxford University Press.
• Labs, S. M., & Wurtele, S. K. (1986). Fetal Health Locus of Control scale: Development and validation. Journal of Consulting and Clinical Psychology, 54(6), 814–819. https://doi.org/10.1037/0022-006X.54.6.814
• Rotter, J. B. (1954). Social learning and clinical psychology. Prentice-Hall. https://doi.org/10.1037/10788-000
• Rotter, J. B. (1966). Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs: General and Applied, 80(1), 1–28. https://doi.org/10.1037/h0092976
• Shieh, C., Broome, M. E., & Stump, T. E. (2010). Factors associated with health information-seeking in low-income pregnant women. Women & Health, 50(5), 426–442. https://doi.org/10.1080/03630242.2010.506152
• Spirito, A., Ruggiero, L., McGarvey, S. T., & Coustan, D. R. (1990). Maternal and fetal health locus of control during pregnancy: A comparison of women with diabetes and nondiabetic women. Journal of Reproductive and Infant Psychology, 8(3), 195–206. https://doi.org/10.1080/02646839008403622
• Stewart, D. E., & Streiner, D. L. (1995). Cigarette smoking during pregnancy. The Canadian Journal of Psychiatry, 40(10), 603–607. https://doi.org/10.1177/070674379504001006
• Wallston, K. A., Wallston, B. S., & DeVellis, R. (1978). Development of the Multidimensional Health Locus of Control (MHLC) Scales. Health Education Monographs, 6(2), 160–170. https://doi.org/10.1177/109019817800600107

13. Items of the Scale