Background: in Western countries, caesarean section rates are increasing at an alarming rate. This trend has implications for women's health and calls into question the use of pathogenesis to frame maternity services. The theory of salutogenesis offers an alternative as it focuses on health rather than illness. Sense of coherence (SOC), the cornerstone of salutogenesis, is a predictive indicator of health. This study aimed to explore associations between pregnant women's SOC, their birthing outcomes and factors associated with SOC changes. Methods: a longitudinal survey was conducted where women completed a questionnaire in the antenatal and postnatal period. Questionnaire one provided information on SOC scores, Edinburgh Postnatal Depression Scale (EPDS) scores, Support Behaviour Inventory (SBI) scores, pregnancy choices and demographics. Questionnaire two provided information on SOC scores, EPDS scores and birthing outcomes. Findings: 1074 women completed questionnaire one and 753 women completed questionnaire two. Compared to women with low antenatal SOC, women with high antenatal SOC were less likely to experience caesarean section (OR 0.437 95% CI 0.209-0.915) and more likely to experience assisted vaginal birth (AVB) (OR 3.108 95% CI 1.557-6.203). Higher birth satisfaction, higher antenatal EPDS scores and lower antenatal SOC were associated with an increase in SOC. Epidural, AVB and decreased birth satisfaction were associated with a decrease in SOC. Conclusion: high sense of coherence in pregnant women is associated with half the likelihood of caesarean section compared to women with low sense of coherence. Women's sense of coherence is raised and lowered by degree of satisfaction with their births and lowered by some labour interventions.