Effectiveness of Childbirth Education on Labour Outcomes among Antenatal Mothers: Analytical Essay

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The birth of a baby is a powerful life event that has implications for a woman’s well-being and future health. But less attention is paid to interventions for the safety, and comfort of the antenatal mother and makes her feel positive about her experience during childbirth. A positive birth experience promotes a sense of achievement, enhances feeling of self-worth, and facilitates confidence—all of which are important for a healthy adaptation to motherhood and psychological growth. Childbirth classes help them to cope- not just with pain, but with the entire childbirth process.

Need for the study:

“Make every mother and child count” reflects the need for today. In India, as per 2016 statistics, the maternal mortality is 130 per 100000 live births1. At present around 5, 85,000 women die from complications due to pregnancy and childbirth globally each year2. Between 11% and 17% maternal death occurs during first 24 hrs and more than 2/3 during first weeks and average infant mortality rate is 49.4%. Female education is a strong predictor of the use of reproductive health care services but the extent and nature of relation between the two is not uniform across social settings. Every woman has the right to get best possible care during pregnancy, delivery, and postpartum periods without any distinction of race, religion and political belief, economic or social condition. The basic strategy of Birth Preparedness and Complication Readiness (BPACR) in Safe motherhood is the women’s empowerment, which facilitates her to take appropriate decisions on time3.

In India, practices relating to pregnancy and childbirth have been rooted in cultural beliefs and traditions that are based on knowledge contained in ancient Indian texts. Pondicherry is in the southernmost part of India, has female literacy rate of 71%, 99.9% institutional birth, 33.6% cesarean deliveries and ranks third in having lesser IMR 22.0 per 10000 live births. Childbirth is not a topic openly discussed in this region of India. No one talks about what will happen during childbirth other than it will be painful. The researcher, in her earlier survey, identified that 33% of the rural antenatal mothers attending antenatal clinics in a tertiary care hospital had inadequate level of knowledge regarding childbirth, 63% had moderate knowledge and only 3.3 % had adequate knowledge4.

If a mother is truly informed on childbirth, she is aware of the whole process of childbirth, and what is expected of her at each stage. She approaches labor with confidence, she is armed with coping strategies and therefore it gives her a satisfying approach, rather finding themselves going into it with full of anxiety, fear, and apprehensions. But that information needs to be complete and obtained from a reliable source. Midwives and doctors are in a unique position to develop a trusting insightful relationship with the women they encounter by providing clear, evidence-based information, reassurance, and one-to-one support.

Hence the investigator would like to evaluate the effects of a Child Birth Education programme on selected outcomes of labour.

Objectives:

To assess the level of Knowledge of childbirthrth among antenatal mothers in the experimental and control group
To compare the level of knowledge of antenatal mothers on Childbirth before and after childbirth education among antenatal mothers in the experimental group.
To determine the difference in the level of Anxiety on childbirth among antenatal mothers between the experimental group and control group
To compare the labor outcomes among antenatal mothers between the experimental and control group which includes, Duration of Labor, type of delivery, coping during labor, birth experience and Maternal-Infant Bonding.
To associate the labor outcomes with selected demographic and clinical variables in the experimental group and control group

Conceptual framework:

The researcher has adopted the model of “Modified version of the Negotiating the journey- preparing for childbirth through education by Mary Koehn”5. The concept of a journey to a destination is the culmination of the women’s phases of physical and emotional transition into a mother. Knowledge decreases the anxiety and fosters a sense of confidence. The tension and a sense of discomfort are associated with not knowing what was going to happen to them exist prior to the classes. At the end of the classes, a sense of serenity emerges in them which increases the confidence in them to face the labor, facilitates control, decision making, and thereby lesser interventions and a positive experience of childbirth. It also enhances the bonding between the mother and the unborn child. Thus this theory fits with the present study on preparation of women for childbirth

Materials and methods

True Experimental- Post-test only- control group design was adopted. Ethical clearance from the Institutional Review Board was obtained. 248 primipara women attending antenatal clinic at PIMS Hospital with 32- 34 weeks of gestation who had planned to have delivery at PIMS and willing to participate in the study were registered as participants. Antenatal mothers who have absolute contraindication for vaginal delivery and who opted for epidural analgesia were excluded. After getting informed consent, the Antenatal mothers were assigned into either experimental (n=120) or control group (n=128) using double-blinded computer-assisted randomization. The experimental group had 3 sessions of video-assisted Childbirth education while the control group had followed routine care. Before shifting to labour room their level of anxiety on childbirth was assessed using a modified shortened anxiety questionnaire for both the groups. Throughout labour and delivery, they were observed by the Research Assistants(midwives) using a Structured Observation Checklist on level of coping. When the mother and the baby were shifted to the postnatal ward, the participants were assessed for their childbirth experience using a semi-structured interview Questionnaire within 24 hours of delivery. Maternal infant bonding was assessed using a likert scale on the 3rd postnatal day in both the groups. Data regarding Duration of labor, type of delivery, and complications arose during labour and delivery were gathered using a semi-structured observation checklist.

Statistical analysis

The data was analyzed using Descriptive Statistics: Frequency, Percentage, Mean, Standard error of mean and standard deviation to describe the socio demographic and clinical variables. The effect of child birth education on the labor outcomes was analyzed using t test, Fishers exact test, Mann Whitney U test. Chi-square test was used to determine the association between the demographic and clinical variables and the labour outcomes and Spearman correlation coefficient to determine the correlation between the labour outcomes.

The study findings revealed that the mean post test knowledge scoresof the antenatal mothers on childbirth education was significantly greater than the mean pretest knowledge score (t=70.63 p=0.000 ) This increase in knowledge is attributed to the child birth education. The child birth education was effective in increasing the level of knowledge of antenatal mothers.

Bendangaro (2016) in his study to evaluate the effectiveness of video assisted teaching on knowledge and attitude regarding childbirth preparation among 60primi mothers in selected hospitals at Dindigul district also got similar findings( t=19.023 at p < 0.01)6.

The present study findings showed that level of anxiety among the antenatal mothers in the experimental group was significantly lower than the level of anxiety among the antenatal mothers in the control group (Mann Whitney U= 13.65) at p=0.05. The findings of the present study can be compared with the quasi-experimental study conducted by Devilata and Swarna to assess the Effectiveness of pre-delivery preparation on anxiety among 60 Primigravida mothers at maternal child healthcentre, Tirupati, AP, India. The post-assessment mean anxiety value 46.233(SD=8.156) of the experimental group was lower than the pre-assessment mean anxiety value 71.767 (SD=10.782). The obtained “t” value was 19.023 which was significant at 0.01 level7.

The Study findings proved that the childbirth education improved the level of coping, reduced the duration of labor, improved the standard of experience, reduced the no. of cesarean section, and improved the level of coping. The findings can be compared with the following studies

Madhavan Prabhakaran, Girija& Dsouza, Melba &Nairy, Subrahmanya. (2016) did a randomized controlled trial with a two-group pretest/ posttest design was used among hundred nulliparous third-trimester pregnant women in major maternity hospital in Kerala, India. The experimental group (n = 50) received three sessions of childbirth education. The experimental group demonstrated a significantly high mean knowledge scores of (54.30 ± 3.86, P < 0.001) childbirth preparation than the control group (31.08 ± 1.96). Significant reductions of caesarean birth (50%) among nulliparous women along with a 12% increase in newborn’s birth weights were the main positive birth outcomes8.

Adams S, Eberhard‐Gran M, Eskild (2012), did a prospective study to assess the association between fear of childbirth and duration of labour among 2206 pregnant women with a singleton pregnancy and intended vaginal delivery during the period 2008–10at Akershus University Hospital, Norway also got similar findings. Labour duration was significantly longer in women with fear of childbirth compared with women with no such fear using a linear regression model (crude unstandardized coefficient 1.54; 95% confidence interval 0.87–2.22, corresponding to a difference of 1 hour and 32 minute, until delivery of the child9

A descriptive study was done to determine the effect of childbirth preparation classes on self-efficacy in coping with labor pain among sixty Thai primiparas selected by nonprobability convenience sampling assigned to either a control or an experimental group (thirty in each group). The control group participants received standard care and education. Self-efficacy expectancy in the experimental group was significantly different than that of the control group, F(1, 54) = 14.66, p < .001. Control group outcome expectancy decreased dramatically across three data points while the experimental group self-efficacy increased after the class and then decreased after the birth but was higher than baseline. The groups did not differ in duration of labor and type of delivery. These findings indicate partial effect of childbirth preparation classes on self-efficacy in coping with labor pain10.

A randomized controlled trial to test the effectiveness of an efficacy‐enhancing educational intervention to promote women’s self‐efficacy for childbirth and coping ability in reducing anxiety and pain during labour. The experimental group received two 90‐minute sessions of the educational programme in between the 33rd–35th weeks of pregnancy. The experimental group was significantly more likely than the control group to demonstrate higher levels of self‐efficacy for childbirth (p NazikEvsen (2016) did a descriptive casecontrol study to determine the effect of childbirth education classes on prenatal attachment among 246 pregnant women, The mean Prenatal Attachment score of the case group was 38.30 ± 9.64 and the control group was 34.10 ± 10.52, and the difference was statistically significant (p = 0.001). It was determined that the prenatal attachment levels of the mothers participating in the childbirth education class were higher12.

The above study findings correlate with the present study findings and the hypothesis that there is a significant difference in the labour outcomes among women in the experimental group and control group was supported.

Chi-square analysis was done to determine the association between the labor outcomes and gestational age of the mothers in the experimental and control group. It was found that gestational age has a significant association with Level of coping( X²=0.781 at p=0.05) and Standard of Experience (X²=1.053 at p=0.05).

A similar kind of study was done by Maryam et al.,(2014) among 100 primiparous women, referring to the selected heath care centers of Mashhad. Pregnant women with a gestational age of 35-41 weeks, who met the inclusion criteria, completed Cranley’s questionnaire, as well as the demographic/obstetric questionnaire. There was a direct positive relationship between maternal-fetal attachment and mothers’ emotional behaviors toward infants four and eight weeks after delivery. The gestational age of the mother had positive correlation with the Maternal infant bonding.( R = -170.0 p= 0.211)13

Paridhi Et.al,.did a survey to assess the woman’s satisfaction with childbirth services and its significant impact on her mental health and ability to bond with her neonate in Chattisgarh, India. In logistic regression analysis, Period of gestation in current pregnancy is associated with the childbirth satisfaction at p= 0.00014

Chi-square analysis was done to determine the association between the Weight of the mothers and the Mode of Delivery of the mothers in the experimental and control group.

Similar study findings were identified with Ingegerd and Ian in their survey among 919 pregnant women to identify the propotion of pregnant women with high BMI(>30) and compare the pregnancy outcomes. Prevalence of obesity was 15.2%. High BMI was associated with labor induction and operative delivery. No difference in Birth complications, birth experience or satisfaction with the care during labor and delivery 15

The infant’s sex and mother-infant bonding was analyzed to determine any association between them using Chi-square analysis. It was identified that there was highly significant association between the infant’s sex and the maternal-infant bonding (X2=3.283, p 0.070). Even in this 21st century, where men and women are equally educated and enjoy equal status in the society, male children are looked upon than the female children by the mothers themselves. This brings about the deep-rooted cultural influence inspite of all the education, status, and the advancement of the society prevailing in the region.Rizk (2012 ) and Abbas (2018 ) concluded from their study thatthe positive attachment between mother and child was more inclined toward boys and girls respectively, that might be attributed to the effect of social and cultural differences16.

Limitations

The data was collected by the research assistants.
The effect of all potential sources of information on childbirth, such as family and friends, books, and the Internet, was not assessed.

Implications for nursing practice:

The findings of the present study are an important contribution to the evidence-based strategies in making child birth a positive experience through childbirth preparation courses.

It is recommended to extend childbirth preparation classes as in developed countries and support the participation of both antenatal mothers and the spouse to provide a more positive experience of pregnancy and childbirth.
An assessment of maternal confidence and fear of childbirth be incorporated into existing pregnancy care guidelines for third trimester.
Training and education to antenatal care providers in the hospital and community on childbirth education based on adult learning principles can be included as a project in the curriculum for post graduate midwifery program.
Encourage the students for effective utilization of research-based practices in antenatal, intranatal, and post-natal care.
Nurse administrators can develop strategies to move from medicalization of childbirth to a more humanistic and low-intervention midwife-led care that empowers women.
Collaborate with the obstetric team to formulate standard policies and protocols to emphasize evidence-based intranatal care with minimum interventions to bring about a positive childbirth experience for all women

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