Randomised trial of structured antenatal training sessions to improve the birth process

Codesign and refinement of an optimised antenatal education session to better inform women and prepare them for labour and birth

OBJECTIVE

Our objective was to codesign, implement, evaluate acceptability and refine an optimised antenatal education session to improve birth preparedness.

DESIGN

There were four distinct phases: codesign (focus groups and codesign workshops with parents and staff); implementation of intervention; evaluation (interviews, questionnaires, structured feedback forms) and systematic refinement.

SETTING

The study was set in a single maternity unit with approximately 5500 births annually.

PARTICIPANTS

Postnatal and antenatal women/birthing people and birth partners were invited to participate in the intervention, and midwives were invited to deliver it. Both groups participated in feedback.

OUTCOME MEASURES

We report on whether the optimised session is deliverable, acceptable, meets the needs of women/birthing people and partners, and explain how the intervention was refined with input from parents, clinicians and researchers.

RESULTS

The codesign was undertaken by 35 women, partners and clinicians. Five midwives were trained and delivered 19 antenatal education (ACE) sessions to 142 women and 94 partners. 121 women and 33 birth partners completed the feedback questionnaire. Women/birthing people (79%) and birth partners (82%) felt more prepared after the class with most participants finding the content very helpful or helpful. Women/birthing people perceived classes were more useful and engaging than their partners. Interviews with 21 parents, a midwife focus group and a structured feedback form resulted in 38 recommended changes: 22 by parents, 5 by midwives and 11 by both. Suggested changes have been incorporated in the training resources to achieve an optimised intervention.

CONCLUSIONS

Engaging stakeholders (women and staff) in codesigning an evidence-informed curriculum resulted in an antenatal class designed to improve preparedness for birth, including assisted birth, that is acceptable to women and their birthing partners, and has been refined to address feedback and is deliverable within National Health Service resource constraints. A nationally mandated antenatal education curriculum is needed to ensure parents receive high-quality antenatal education that targets birth preparedness.

Cross Sectional Survey of Antenatal Educators' Views About Current Antenatal Education Provision

OBJECTIVES

Antenatal education (ANE) is part of National Health Service (NHS) care and is recommended by The National Institute for Health and Care Excellence (NICE) to increase birth preparedness and help pregnant women/birthing people develop coping strategies for labour and birth. We aimed to understand antenatal educator views about how current ANE supports preparedness for childbirth, including coping strategy development with the aim of identifying targets for improvement.

METHODS

A United Kingdom wide, cross-sectional online survey was conducted between October 2019 and May 2020. Antenatal educators including NHS midwives and private providers were purposively sampled. Counts and percentages were calculated for closed responses and thematic analysis used for open text responses.

RESULTS

Ninety-nine participants responded, 62% of these did not believe that ANE prepared women for labour and birth. They identified practical barriers to accessing ANE, particularly for marginalised groups, including financial and language barriers. Educators believe class content is medically focused, and teaching is of variable quality with some midwives being ill-prepared to deliver antenatal education. 55% of antenatal educators believe the opportunity to develop coping strategies varies between location and educators and only those women who can pay for non-NHS classes are able to access all the coping strategies that can support them with labour and birth.

CONCLUSIONS FOR PRACTICE

Antenatal educators believe current NHS ANE does not adequately prepare women for labour and birth, leading to disparities in birth preparedness for those who cannot access non-NHS classes. To reduce this healthcare inequality, NHS classes need to be standardised, with training for midwives in delivering ANE enhanced.

Application of Team-Based Flipped Classroom and Traditional Learning on the Antenatal Education Center Course

Background

The goal is to evaluate the effects of a flipped class strategy on knowledge, self-directed learning ability, learning satisfaction and pregnancy outcomes in primiparas undergoing antenatal education.

Methods

A random sampling method was adopted. A total of 600 primiparas who were diagnosed with early pregnancy in a first-class hospital in southeast China and received continuous prenatal health education from May to July 2020 were selected as the research subjects. In order to make the baseline of the two groups of primipara comparable, we divided the two groups in the antenatal education centre according to the odd-even number of the lesson card number. The odd-numbered group was the experimental group, who used the prenatal health education model based on blended learning; the even-numbered group was the control group, who used the traditional mode of prenatal health education. The two groups were compared on the following outcomes: knowledge, self-directed learning ability, learning satisfaction and pregnancy outcomes.

Results

Compared with traditional learning, the blended learning approach can effectively controlled the gestational weight gain (GWG), alleviated the anxiety and depression during pregnancy, improved the natural delivery rate of the primipara, shortened the delivery process and reduced the risk of gestational diabetes mellitus (GDM), the difference was statistically significant (all P<0.05).

Conclusion

Blended learning may be an effective strategy because of its validity and practicality in antenatal education.

The effect of prenatal education on fear of childbirth, pain intensity during labour and childbirth experience: a scoping review using systematic approach and meta-analysis

BACKGROUND

Antenatal education provides parents with strategies for pregnancy, childbirth, and parenthood. There is not enough evidence of the positive effect of prenatal education on childbirth and maternal outcomes. The present scoping review using a systematic approach, evaluates the effectiveness of prenatal education on fear of childbirth, pain intensity during labour, childbirth experience, and postpartum psychological health.

METHODS

We used Google Scholar and systematically reviewed databases such as PubMed, Web of Science, Cochrane, Scopus, and SID (Scientific Information Database). Randomized controlled and quasi-experimental trials examining the effect of structured antenatal education and routine prenatal care compared to routine prenatal care were reviewed. The participants included pregnant women preferring a normal vaginal delivery and had no history of maternal or foetal problems. The outcomes considered in this study included fear of childbirth, pain intensity during labour, childbirth experience (as primary outcomes) and postpartum psychological health (as secondary outcomes). The grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of evidence.

RESULTS

Overall, 3242 studies were examined, of which 18 were qualified for the final analysis. The meta-analysis showed that providing prenatal education and routine care compared to only routine care may decrease the fear of childbirth, postpartum depression, and pain intensity during labour. However, we found no study examining the outcome of the childbirth experience. In addition, the inconsistency of included studies prevented conducting a meta-analysis on the rest of the outcomes.

CONCLUSIONS

Our investigations showed that there are very few or no studies on the effect of prenatal education on outcomes such as childbirth experience, postpartum anxiety, and maternal attachment, and the existing studies on the effect of prenatal education on outcomes such as the fear of childbirth, postpartum depression, and pain intensity during labour lack sufficient quality to make definitive conclusions. Therefore, high-quality, randomized trials with a more extensive sample size are suggested to provide clear reports to make definitive decisions.

PROSPERO ID

CRD42022376895.

Cross-sectional survey of antenatal education attendance among nulliparous pregnant women in Sydney, Australia

BACKGROUND

Antenatal education aims to provide expectant parents with strategies for dealing with pregnancy, childbirth and parenthood and may have the potential to reduce obstetric intervention and fear of childbirth. We aimed to investigate antenatal education attendance, reasons for and barriers to attending, and techniques taught and used to manage labour.

METHODS

Antenatal and postnatal surveys were conducted among nulliparous women with a singleton pregnancy at two maternity hospitals in Sydney, Australia in 2018. Classes were classified into psychoprophylaxis, birth and parenting, other, or no classes. Reasons for and barriers to attendance, demographic characteristics, and techniques taught and used in labour were compared by class type, using Pearson's Chi Squared tests of independence.

FINDINGS

724 women were surveyed antenatally. The main reasons for attending classes were to better manage the birth (86 %), feel more secure in baby care (71 %) and as a parent (60 %); although this differed by class type. Reasons for not attending classes included being too busy (33 %) and cost (27 %). Epidural, breathing techniques, massage and nitrous oxide were the most common techniques taught. Women who attended psychoprophylaxis classes used a wider range of pain relief techniques in labour. Women found antenatal classes useful preparation for birth (94 %) and parenting (74 %). Women surveyed postnatally wanted more information on baby care/sleeping and breastfeeding.

CONCLUSION

The majority of women found antenatal education useful and utilised techniques taught. Education providers should ensure breastfeeding and infant care information is provided, and barriers to attendance such as times and cost should be addressed.

Early labour experience and labour characteristics after introduction of an electronic early labour educational intervention

OBJECTIVE

The study's aim was to compare first-time mothers' experience of early labour and subsequent labour characteristics before and after introducing an online early labour educational intervention. This article also reports on further testing of the underlying structure of the of the Early Labour Experience Questionnaire (ELEQ) in a Norwegian setting.

METHODS

Pre- and post-intervention cohorts were recruited. The ELEQ was translated into Norwegian, back-translated and distributed among primiparous mothers whilst in hospital. Confirmatory factor analyses were used to evaluate model fit, and the internal consistency of the scale was measured by Cronbach's α coefficient. The relationship between cohorts and demographic characteristics were analysed using chi-square statistics and t-tests.

RESULTS

Confirmatory factor analysis of the Swedish version of the ELEQ for primiparous women showed an acceptable fit. Neither the overall score nor the scores on the subscales for emotional well-being, emotional distress and perceptions of midwifery care differed significantly, but there was a significant difference between the groups on a few of the items. The cervix was significantly more dilated upon admission in the post-intervention group, and oxytocin use was significantly reduced. The number of telephone consultations increased significantly after the intervention was introduced.

CONCLUSION

The intervention did not improve women's experience with early labour. However, women who received the intervention were admitted in more advanced labour and required less oxytocin. The increased number of telephone consultations may indicate that an online early labour educational programme cannot replace women's need to communicate directly with staff.

Timing of hospital admission at first childbirth: A prospective cohort study

BACKGROUND AND AIMS

It is difficult for women in labor to determine when best to present for hospital admission, particularly at first childbirth. While it is often recommended that women labor at home until their contractions have become regular and ≤ 5-minutes apart, little research has investigated the utility of this recommendation. This study investigated the relationship between timing of hospital admission, in terms of whether women's labor contractions had become regular and ≤ 5-minutes apart before admission, and labor progress.

METHODS

This was a cohort study of 1,656 primiparous women aged 18-35 years with singleton pregnancies who began labor spontaneously at home and delivered at 52 hospitals in Pennsylvania, USA. Women who were admitted before their contractions had become regular and ≤ 5-minutes apart (early admits) were compared to those who were admitted after (later admits). Multivariable logistic regression models were used to assess associations between timing of hospital admission and active labor status on admission (cervical dilation 6-10 cm), oxytocin augmentation, epidural analgesia and cesarean birth.

RESULTS

Nearly two-thirds of the participants (65.3%) were later admits. These women had labored for a longer time period before admission (median, interquartile range [IQR] 5 hours (3-12 hours)) than the early admits (median, (IQR) 2 hours (1-8 hours), p < 0.001); were more likely to be in active labor on admission (adjusted OR [aOR] 3.78, 95% CI 2.47-5.81); and were less likely to experience labor augmentation with oxytocin (aOR 0.44, 95% CI 0.35-0.55); epidural analgesia (aOR 0.52, 95% CI 0.38-0.72); and cesarean birth (aOR 0.66, 95% CI 0.50-0.88).

CONCLUSIONS

Among primiparous women, those who labor at home until their contractions have become regular and ≤ 5-minutes apart are more likely to be in active labor on hospital admission and less likely to experience oxytocin augmentation, epidural analgesia and cesarean birth.

Vaginal Birth at Term - Part 2. Guideline of the DGGG, OEGGG and SGGG (S3-Level, AWMF Registry No. 015/083, December 2020)

Purpose This guideline aims to summarize the current state of knowledge about vaginal birth at term. The guideline focuses on definitions of the physiological stages of labor as well as differentiating between various pathological developments and conditions. It also assesses the need for intervention and the options to avoid interventions. The second part of this guideline presents recommendations and statements on care during the dilation and expulsion stages as well as during the placental/postnatal stage. Methods The German recommendations largely reproduce the recommendations of the National Institute for Health and Care Excellence (NICE) CG190 guideline "Intrapartum care for healthy women and babies". Other international guidelines were also consulted in individual cases when compiling this guideline. In addition, a systematic search and analysis of the literature was carried out using PICO questions where necessary, and other systematic reviews and individual studies were taken into account. For easier comprehension, the assessment tools of the Scottish Intercollegiate Guidelines Network (SIGN) were used to evaluate the quality of additionally consulted studies. Otherwise, the GRADE system was used for the NICE guideline, and the evidence reports of the IQWiG were used to evaluate the quality of the evidence. Recommendations Recommendations and statements were formulated based on identified evidence and/or a structured consensus.

Use of pain management in childbirth among migrant women in Iceland: A population-based cohort study

BACKGROUND

Immigration is rapidly increasing in Iceland with 13.6% of the population holding foreign citizenship in 2020. Earlier findings identified inequities in childbirth care for some women in Iceland. To gain insight into the quality of intrapartum midwifery care, migrant women's use of pain management methods during birth in Iceland was explored.

METHODS

A population-based cohort study including all women with a singleton birth in Iceland between 2007 and 2018, in total 48 173 births. Logistic regression analyses with odds ratios (ORs) and 95% confidence intervals (CIs) were used to investigate the relationship between migrant backgrounds defined as holding foreign citizenship and the use of pain management during birth. The main outcome measures were use of nonpharmacological and pharmacological pain management methods.

RESULTS

Data from 6097 migrant women were included. Migrant women had higher adjusted OR (aORs) for no use of pain management (aOR = 1.23 95% CI [1.12, 1.34]), when compared to Icelandic women. Migrant women also had lower aORs for the use of acupuncture (0.73 [0.64, 0.83]), transcutaneous electrical nerve stimulation (TENS) (0.92 [0.01, 0.67]), shower/bath (0.73 [0.66, 0.82]), aromatherapy (0.59 [0.44, 0.78]), and nitrous oxide inhalation (0.89 [0.83, 0.96]). Human Development Index (HDI) scores of countries of citizenship <0.900 were associated with lower aORs for the use of various pain management methods.

CONCLUSIONS

Our results suggest that being a migrant in Iceland is an important factor that limits the use of nonpharmacological pain management, especially for migrant women with citizenship from countries with HDI score <0.900.

Do women's perceptions of their childbirth experiences change over time? A six-week follow-up study in a Danish population

OBJECTIVE

To evaluate how women's perception of the childbirth experience developed during the postpartum period. The secondary aim was to explore how selected birth interventions were subjectively perceived as part of the birth experience.

DESIGN

A prospective cohort study comparing childbirth experience, assessed at one and six weeks postpartum, using the Childbirth Experience Questionnaire (CEQ).

SETTING

A regional hospital in the northern part of Denmark, with 1,400 childbirths annually.

PARTICIPANTS

A total of 201 women with low-risk births who gave birth at North Denmark Regional Hospital were included in this study. We included both nulliparous and multiparous women.

MEASUREMENTS AND FINDINGS

More than 50% of the women changed their perceptions about their childbirth experience after six weeks. After six weeks the overall CEQ score and the domains 'Participation' and 'Professional support' had a lower CEQ score compared to scores obtained one week postpartum, although differences were small. Induction of labor, augmentation of labor, emergency caesarean section, epidural analgesia, and use of nitrous oxide were associated with a lower CEQ score.

KEY CONCLUSIONS

Women assessed their overall birth experience more negatively at six weeks postpartum compared to one week postpartum. Some interventions in the labor process influenced the women's assessment of their experiences negatively.

IMPLICATIONS FOR PRACTICE

Paying attention to preventive initiatives to ensure the women a spontaneous birth, if possible, may be essential to create positive perceptions of the childbirth experience.

Childbirth experience, risk of PTSD and obstetric and neonatal outcomes according to antenatal classes attendance

Antenatal classes have evolved considerably and include now a discussion of the parents' birth plan. Respecting this plan normally results in a better childbirth experience, an important protective factor of post-traumatic stress disorder following childbirth (PTSD-FC). Antenatal class attendance may thus be associated with lower PTSD-FC rates. This cross-sectional study took place at a Swiss university hospital. All primiparous women who gave birth to singletons from 2018 to 2020 were invited to answer self-reported questionnaires. Data for childbirth experience, symptoms of PTSD-FC, neonatal, and obstetrical outcomes were compared between women who attended (AC) or not (NAC) antenatal classes. A total of 794/2876 (27.6%) women completed the online questionnaire. Antenatal class attendance was associated with a poorer childbirth experience (p = 0.03). When taking into account other significant predictors of childbirth experience, only induction of labor, use of forceps, emergency caesarean, and civil status remained in the final model of regression. Intrusion symptoms were more frequent in NAC group (M = 1.63 versus M = 1.11, p = 0.02). Antenatal class attendance, forceps, emergency caesarean, and hospitalisation in NICU remained significant predictors of intrusions for PTSD-FC. Use of epidural, obstetrical, and neonatal outcomes were similar for AC and NAC.

Evaluation of Pregnancy, Delivery, and Postpartum Effectiveness of Maternity School Trainings Organized Based on the Guideline of Ministry of Health in Turkey: A Comparative Study

Background

There are uncertainties and contradictions in the literature about the effectiveness of maternity schools. The purpose of this study is to determine the effectiveness of prenatal trainings performed in an institutional and disciplined manner.

Methods

This study was prospectively conducted between 2018 and 2019, and 245 primiparous pregnant women who gave birth in our hospital were examined. On a volunteer basis, a study group (n = 108) was created including patients who attended the maternity school trainings and a control group was created including patients who did not attend these trainings (n = 137). Both groups were compared in terms of caesarean section rates, active phase periods of birth, visual analogue scale (VAS) during active labor, Edinburgh Postnatal Depression Scale (EPDS) score, time from birth to first skin contact, newborn Apgar scores, and admission rates to the neonatal intensive care unit.

Results

Cesarean section rates were significantly lower in the maternity school group (21.1% versus 29.19%). In the maternity school group, the active phase period of delivery was shorter (p < 0.001), VAS was lower during active labor (p < 0.001), and EDPS score was lower (p < 0.001). Education level was higher in the maternity school group than in the control group (p < 0.001).

Conclusions

Institutional and disciplined antenatal pregnancy trainings provide significant benefits during pregnancy, delivery, and postpartum period depression by especially reducing the rates of cesarean section and postpartum depression.

Assessment of the level of anxiety and pain in women who do and do not attend childbirth classes during the SARS-CoV-2 pandemic

INTRODUCTION

Participation in childbirth classes is aimed at learning to cope with the anxiety that accompanies a woman during her pregnancy and childbirth. The aim of the study was to answer the question whether the lack of access to childbirth classes affected anxiety and perinatal pain in pregnant women who gave birth during the pandemic period.

MATERIALS AND METHODS

This cross-sectional survey-based study involved women who were pregnant during the lockdown period. The respondents were asked to fill in the following questionnaires: a personal questionnaire, the Polish version of the Delivery Fear Scale and the Numeric Rating Scale for the assessment of average and maximum pain experienced during the labour. The survey was completed within 24-72 hours after the birth of the child. The obtained questionnaires were divided into 2 groups based on the information concerning attending or not attending childbirth classes (divided into subgroups): group A - patients participated in childbirth classes, and group B - patients did not participate in childbirth classes.

RESULTS

Groups were homogeneous in terms of age, weight, height, body mass index and week of gestation. Perception of anxiety did not differ between groups. There was a correlation between particular formulation of the Delivery Fear Scale and "week of gestation" variable. In the group of women who gave birth naturally without anesthesia, there were no significant differences between groups in terms of mean and maximum pain during labour.

CONCLUSION

The level of anxiety and pain associated with childbirth is not modulated by childbirth classes during the pandemic period. There is s a correlation between particular formulation of the Delivery Fear Scale and "week of gestation" variable. In the group of women who gave birth naturally without anesthesia, there are no significant differences between groups in terms of mean and maximum pain during labour.

Development of and Experiences With an Informational Website on Early Labor: Qualitative User Involvement Study

Background

The period of regular contractions before 4 cm of cervical dilatation is often referred to as the latent phase or early labor. Women find it challenging to prepare for and cope with this phase of labor, and easily accessed web-based information from reliable sources may be useful in this preparation.

Objective

The aim of this study is to describe the development of a Norwegian website, Latens.no, for people seeking information on early labor and to explore users’ experiences with the website to increase its user-friendliness.

Methods

We developed a website using an iterative process involving a multidisciplinary research team, health personnel, users, a graphic designer, and an expert in software development. We explored the website’s user-friendliness using semistructured individual interviews and the think-aloud method. All interviews were audio recorded and transcribed. We then analyzed the participants’ feedback on the website.

Results

Participants included women who had recently given birth to their first baby (n=2), women who were pregnant with their first baby (n=4), and their partners (n=2). Results from participants’ experiences completing tasks included positive feedback related to the content of Latens.no, positive feedback related to the website’s design, and suggestions for improvement. Participants wanted to find information on early labor on the internet. Moreover, they found the information on the website relevant, trustworthy, and easy to read, and the design was attractive and easy to use. Overall, the participants performed the tasks easily, with few clicks and minimal effort.

Conclusions

The think-aloud method, while performing tasks, allowed for detailed feedback. The participants confirmed the user-friendliness of the website but at the same time provided information enabling improvement. We expect that changes made based on this user-centered design study will further increase the usability and acceptability of Latens.no.

Disruption of physiological labour; - A population register-based study among nulliparous women at term

OBJECTIVES

Current labour practices have seen an acceleration in interventions to either initiate, monitor, accelerate, or terminate the physiological process of pregnancy and childbirth. This study aimed to describe and analyse the use of interventions in childbirth in Denmark over almost two decades (2000-2017). We also examined the extent to which contemporary care adheres to current international recommendations towards restricted use of interventions.

STUDY DESIGN

A national retrospective Danish register-based cohort study including all nulliparous women with term births with singleton pregnancy and a foetus in cephalic between the years 2000 and 2017 (n = 380,326 births). Multivariate regression analyses with adjustment for change in population were performed.

MAIN OUTCOME MEASURES

Induction of labour, epidural analgesia, and augmentation of labour.

RESULTS

Between 2000/2001 and 2016/2017, the prevalence increased for induction of labour from 5.1% to 22.8%, AOR 4.84, 95% CI [4.61-5.10], epidural analgesia from 10.5% to 34.3% (AOR 4.10, 95% CI [3.95-4.26]), and augmentation of labour decreased slightly from 40.1% to 39.3% (AOR 0.84, 95% CI [0.81-0.86]). Having more than one of the three mentioned interventions increased from 12.8% in to 30.9%.

CONCLUSIONS

The number of interventions increased during the study period as well as the number of interventions in each woman. As interventions may interfere in physiological labour and carry the risk of potential short- and long-term consequences, the findings call for a careful re-evaluation of contemporary maternity care with a "first, do no harm" perspective.

Evidence-based labor management: before labor (Part 1)

In preparation for labor and delivery, there is high-quality evidence for providers to recommend perineal massage with oil for 5-10 minutes daily starting at 34 weeks until labor; ≥1 daily sets of repeated voluntary contractions of the pelvic floor muscles, performed at least several days of the week starting at approximately 30-32 weeks gestation; no x-ray pelvimetry; sweeping of membranes weekly starting at 37-38 weeks gestation; for women with a risk factor for abnormal outcome plans should be made to deliver in a hospital setting; for low-risk women, alongside birth center birth is associated with maternal benefits and higher satisfaction, compared with hospital birth; midwife-led care for low-risk women; continuous support by a professional such as doula, midwife, or nurse during labor; and training of birth attendants in low- and middle-income countries.

The prevalence of intimate partner violence among couples signing up for universally offered parent preparation

BACKGROUND

Intimate partner violence (IPV) during pregnancy can have serious health consequences for mothers and the unborn child. Nevertheless, IPV is seldom addressed in the context of parent preparation.

AIM

This study aimed to map the prevalence, direction, and severity of IPV in a sample of expectant couples signing up for universally-offered parent preparation.

METHOD

A total of 1726 Danish couples expecting their first child provided data on physical and psychological IPV by completing the Family Maltreatment measure during the second trimester of pregnancy.

RESULTS

In 18.5% of the couples, at least one partner reported psychological or physical IPV acts during the past year. In more than 8% of couples, one or both partners reported acts and impacts above the ICD-11 threshold for clinically-significant IPV (CS-IPV) during the past year (3.6% physical CS-IPV, 5.3% psychological CS-IPV, and 0.8% both physical and psychological CS-IPV). Among couples with physical IPV below the clinical threshold, pregnant-woman-to-partner (50%) and bidirectional (38.2%) IPV were more common than partner-to-pregnant-woman IPV (11.8%). Among couples with physical CS-IPV, pregnant-woman-to-partner (36.1%), partner-to-pregnant-women (29.1%) and bidirectional (34.4%) forms were equally common. Among couples with psychological IPV, pregnant-woman-to-partner (54.9%) and partner-to-pregnant-woman (39.6%) IPV were more common than bidirectional IPV (5.5%).

DISCUSSION

The prevalence of violence was markedly higher in this study compared with previous reports from the Nordic region and highlights a previous oversight of a substantial and clinically significant level of pregnant-woman-to-partner IPV-as well as the reverse. Data from this study call for IPV to be addressed in universally offered parent preparation programs.

Association between antenatal classes attendance and perceived fear and pain during labour

OBJECTIVES

Antenatal classes are a common method of preparation for birth with proven efficiency in improving perinatal outcomes. Yet, their impact on fear perception during labour has not been identified. The aim of the study was to analyse whether preparation for labour by means of antenatal classes attendance could be associated with decrease in level of experienced fear and pain during birth.

MATERIALS AND METHODS

It was a cross-sectional study of 147 women who had given vaginal births. Data was collected from mothers between 24 and 72 h postpartum. Patients answered self-reported questionnaires concerning subjective perception of birth including Delivery Fear Scale (DFS) and Numeric Rating Scale (NRS) for fear and pain assessment. The study group was divided into subgroups depending on parity and antenatal classes attendance.

RESULTS

Patients in the primiparas subgroup who attended antenatal classes scored lower in the DFS (48.7 ± 23.5 vs. 60.2 ± 16.5, p < .03). There was no difference in the DFS score in the multiparas subgroup (p < .90). No significant differences in the NRS score depending on antenatal classes attendance in any subgroup were observed.

CONCLUSION

Participation in antenatal classes should be advised to every pregnant primiparous woman as this type of non-invasive preparation lowers level of fear experienced during childbirth.

The effects of a childbirth preparation course on birth outcomes among nulliparous Jordanian women

OBJECTIVE

This study aimed to examine the effectiveness of a childbirth preparation course on birth outcomes among nulliparous Jordanian women.

DESIGN

A randomized control trial pre-test/post-test design was used to assess the effects of a childbirth preparation course conducted in a military hospital in Amman, Jordan from 1 July to 15 September 2016. A total of 133 low-risk nulliparous women were recruited and randomly assigned to either (1) a control group who received standard care in antenatal clinics or (2) an intervention group who received standard care in antenatal clinics as well as a childbirth preparation course specifically designed for the purpose of this study. Data were collected at two different time points: at recruitment and within 24 to 48 h after giving birth. The chi-square test and independent sample t-test were used to compare birth outcomes.

PARTICIPANTS

Low-risk nulliparous women in their third trimester of pregnancy attending antenatal clinics at King Hussein Medical Centre in Amman, the capital of Jordan.

MEASUREMENTS AND FINDINGS

The childbirth preparation course had a positive effect on three birth outcomes. Specifically, more women in the intervention group than in the control group had spontaneous onset of labour (89.0% vs 70.3%, p = .02), the average of cervical dilation was greater in the intervention group than in the control group [(mean = 3.8, SD = 1.55) vs (mean = 3.2, SD = 1.61); t = 2.24, p = .03] and there was earlier initiation of breastfeeding in the intervention group than in the control group [(mean = 6.2, SD = 0.4.43) vs (mean = 17.8, SD = 18.08); t = 4.90, p ≤ 01].

KEY CONCLUSIONS

The findings suggest that the childbirth preparation course increased the likelihood of pregnant women having spontaneous onset of labour and arriving at the maternity ward in active labour. Moreover, it helped them to initiate breastfeeding earlier after birth. No effect was found for other birth outcomes or neonatal outcomes. Further studies with a larger sample are needed to obtain more definitive conclusions.

IMPLICATION FOR PRACTICE

It is recommended that policymakers and administrators facilitate the embedding of this childbirth preparation course into antenatal care to improve maternal and neonatal health.

The role of intention and self-efficacy on the association between breastfeeding of first and second child, a Danish cohort study

BACKGROUND

The impact of parity on breastfeeding duration may be explained by physiological as well as psychosocial factors. The aim in the present study was to investigate the mediating influence of intention and self-efficacy on the association between the breastfeeding duration of the first and the following child.

METHODS

A 5-year Danish cohort study with data from online questionnaires was used. Data came from 1162 women, who participated in the "Ready for child" trial in 2006-7 and gave birth to their second child within 5 years in 2011-3. Analysis included multiple regression models with exclusive/any breastfeeding duration of first child as the exposure variables, intention and self-efficacy measured as mediators, and exclusive/any breastfeeding duration of the second child as the outcome variables.

RESULTS

Duration of exclusive breastfeeding of the first child was significantly associated with exclusive breastfeeding duration of the second child (p <  0.001) and with the self-reported intention and self-efficacy in the ability to breastfeed the second child (p <  0.001). The exclusive breastfeeding period was slightly longer for the second child. Self-efficacy and intention mediated the association between breastfeeding duration in the first and second child. Together the two factors explained 48% of the association in exclusive breastfeeding and 27% of the association in any breastfeeding between the first and second child.

CONCLUSION

Due to a reinforcing effect of intention and self-efficacy, breastfeeding support should focus on helping the first time mothers to succeed as well as to identify the second time mother with low self-efficacy and additional need for support.

'It definitely made a difference': A grounded theory study of yoga for pregnancy and women's self-efficacy for labour

OBJECTIVE

To explore women's experience of attending yoga for pregnancy classes in order to generate a theory about which aspects, if any, are effective in enhancing self-efficacy for labour and birth.

DESIGN

A longitudinal grounded theory study.

METHODS

Semi-structured interviews were undertaken with women before they started yoga for pregnancy classes, after they had attended at least six classes, and finally, postnatally. Interview transcripts were analysed using constructive grounded theory and a self-efficacy framework.

SETTING

Three yoga for pregnancy teachers' classes in England.

PARTICIPANTS

Twenty two women attending yoga for pregnancy classes.

FINDINGS

Analysis of interviews with women at three time points led to a propositional theory that yoga for pregnancy enhances women's self-efficacy for labour by building their confidence and competence through a combination of techniques. These include repeated practice of a variety of pain management strategies, use of affirming language and the telling of positive labour stories, underpinned by yoga practice to lower somatic response to stress.

Creating a positive perception of childbirth experience: systematic review and meta-analysis of prenatal and intrapartum interventions

BACKGROUND

A negative experience in childbirth is associated with chronic maternal morbidities. The aim of this systematic review and meta-analysis was to identify currently available successful interventions to create a positive perception of childbirth experience which can prevent psychological birth trauma.

METHODS

Randomized controlled trials of interventions in pregnancy or labour which aimed to improve childbirth experience versus usual care were identified from 1994 to September 2016. Low risk pregnant or childbearing women were chosen as the study population. PEDRO scale and Cochrane risk of bias tool were used for quality assessment. Pooled effect estimates were calculated when more than two studies had similar intervention. If it was not possible to include a study in the meta-analysis, its data were summarized narratively.

RESULTS

After screening of 7832 titles/abstracts, 20 trials including 22,800 participants from 12 countries were included. Successful strategies to create a positive perception of childbirth experience were supporting women during birth (Risk Ratio = 1.35, 95% Confidence Interval: 1.07 to 1.71), intrapartum care with minimal intervention (Risk Ratio = 1.29, 95% Confidence Interval:1.15 to 1.45) and birth preparedness and readiness for complications (Mean Difference = 3.27, 95% Confidence Interval: 0.66 to 5.88). Most of the relaxation and pain relief strategies were not successful to create a positive birth experience (Mean Difference = - 2.64, 95% Confidence Intervention: - 6.80 to 1.52).

CONCLUSION

The most effective strategies to create a positive birth experience are supporting women during birth, intrapartum care with minimal intervention and birth preparedness. This study might be helpful in clinical approaches and designing future studies about prevention of the negative and traumatic birth experiences.

A standardized antenatal class reduces the rate of cesarean section in southern Italy: A retrospective cohort study

Italy, along with Poland and Hungary, has the highest cesarean section rate (35.7%) in Europe. Among Italian regions, Campania has the highest rate of cesarean section (58.4%).We developed a standardized antenatal class to evaluate whether women who attend this class during pregnancy have a lower cesarean section rate. This antenatal class was developed according to the indication of the Italian Ministry of Health and the World Health Organization. We selected a cohort of women who participated in this antenatal class and a cohort of women who did not participate. We collected information on the mode of delivery, and other characteristics, of these women from certificate of birth assistance form available in 2 hospitals where the women gave birth.Among women who participated in the antenatal class, there were more Italians, the women were more educated, more women were employed and there were more primiparas compared with those who did not participate. Non-participants of antenatal class showed a higher rate of cesarean section than those who participated (56.2% vs 23.1%; relative risk [RR] = 2.43; 95% confidence interval [CI] 1.95-3.03; P < .0001), as well as after adjustment for other variables. This difference was stronger in 1 hospital (RR = 2.88; 95% CI 2.13-3.89; P < .0001) than in the other hospital (RR = 1.86; 95% CI 1.36-2.55; P < .0001).Our standardized antenatal class, which was performed in an area with a high rate of cesarean section, significantly reduced this rate, and this was still significant after adjustment for potential confounders.

The effect of attending a prenatal childbirth preparedness course on labor duration and outcomes

OBJECTIVE

To evaluate the effect of attending a prenatal childbirth preparation course (CPC) on labor duration and outcomes.

METHODS

A cross sectional study of 53 primiparous women who attended and 54 women who did not attend a CPC was conducted. The state-trait anxiety inventory (STAI) score was used to diagnose anxiety. Clinical and obstetrical data were collected from the perinatal database of our center. Through post-partum interviews, coping strategies were assessed, patients graded their childbirth experience and breastfeeding was evaluated. Data were analyzed using description analyses and a P-value <0.05 was considered statistically significant.

RESULTS

The STAI score was significantly lower in the study group compared with controls (P=0.025). The first stage and the entire duration of labor were significantly shorter (P=0.036 and P=0.026, respectively) in women who attended the CPC. No significant differences were found with regard to the mode of delivery, rate of episiotomy, use of analgesics and neonatal outcomes between the groups. Women in the study group rated their labor experience significantly higher (P=0.016) and exhibited significantly higher rates of breastfeeding (P<0.001) than controls.

CONCLUSIONS

The knowledge acquired in the CPC has positive effects on the course of labor and delivery outcomes as well as higher rates of breastfeeding.

Can antenatal classes reduce the rate of cesarean section in southern Italy?

BACKGROUND

Among European Countries, Italy has the highest rate of cesarean section (36.8%), and in the Campania region this rate reaches 60.0%.

QUESTION

We conducted a retrospective cohort study to evaluate whether participation in antenatal classes during pregnancy reduces the rate of cesarean delivery in southern Italy.

METHODS

We selected three local health authorities, with the lowest, the highest, and an intermediate rate of cesarean delivery. The study included 1893 mothers who brought their children for vaccination and were interviewed about their participation in antenatal classes and their obstetric history.

FINDINGS

The main causes of cesarean section given in the interview were clinical indications (61.0%), previous cesarean section (31.0%) and woman's request (8.0%). When we excluded emergency cesarean delivery, we found a moderate association between participation in antenatal classes and cesarean section reduction (relative risk=1.27; 95% CI=1.08-1.49; in percentage values from 49.3% to 38.8%). Private hospitals and the two local health authorities with higher baseline rates of cesarean section showed an enhanced reduction of these rates.

CONCLUSION

Our paper shows moderate efficacy of antenatal classes, which reduced the occurrence of cesarean section by about 10%. However, the cesarean section rate remained high. As it is possible that different classes have a different level of efficacy, a further study on a standardized model of an antenatal classes is in progress, to assess its efficacy in term of cesarean section reduction, with the purpose of its widespread implementation to the whole region.

Effect of antenatal education in small classes versus standard auditorium-based lectures on use of pain relief during labour and of obstetric interventions: results from the randomised NEWBORN trial

OBJECTIVE

To examine the effect of an antenatal education programme in small classes versus standard auditorium-based lectures.

DESIGN

Randomised trial using random-generated web-based 1:1 allocation.

SETTING

The largest birth site in the Capital Region of Denmark, from August 2012 to May 2014.

PARTICIPANTS

1766 pregnant women. Inclusion criteria ≥18 years, pregnant with a single child, and able to speak and understand Danish. Women were enrolled in the trial from 10+0 to 20+0 weeks of gestation.

INTERVENTIONS

The intervention programme consisted of three times 2.5 hours of antenatal education in small classes (n=6-8 women), and focused on improving information and problem-solving skills for expectant parents in order to ease birth and the transition to parenthood. The control group received standard auditorium-based lectures consisting of two times 2 hours in an auditorium with participation of ∼250 people.

MAIN OUTCOME MEASURES

The primary trial outcome was use of epidural analgesia. Other types of pain relief and obstetric interventions were analysed as explorative outcomes.

RESULTS

There was no statistically significant difference in use of epidural analgesia between participants in the intervention group (30.9%) versus the control group (29.1%), adjusted OR 1.10 (95% CI 0.87 to 1.34). Also, the two groups did not differ regarding other types of pain relief or obstetric interventions. Concomitant birth preparation was common in both groups and highest in the control group, but did not seem to influence our results noticeably.

CONCLUSIONS

Antenatal education in small groups versus standard auditorium-based lectures did not differ regarding use of epidural analgesia, other pain relief, or obstetric interventions.

TRIAL REGISTRATION NUMBER

NCT01672437; Results.

Content of antenatal care: Does it prepare women for birth?

OBJECTIVE

clinical guidelines for antenatal care recommend informing women about birth. The aim of this study was to explore the content of antenatal care from women's perspective and to establish whether they consider information on birth to be sufficient.

METHOD

the data was gathered in a longitudinal, cross-sectional cohort study known as The Childbirth and Health Study in Iceland. The study group consisted of 765 women attending antenatal care at 26 urban and rural health care centres in Iceland, during the year 2009-2010. They participated by replying to two questionnaires, at 16 gestational weeks and six months after birth. The questions covered objective and subjective aspects of antenatal care, pregnancy, birth, and the postpartum period.

RESULTS

the majority (87%) of the women want to be informed about birth in the antenatal phase of care, and 41% reported 5-6 months post partum that too little time had been spent on this issue, by health care professionals. Post partum, mode of delivery affected women's estimated time spent on information in pregnancy, with women who had planned caesarean section being most satisfied with the time spent on antenatal information about birth. Women who experienced their birth as difficult or very difficult were more likely to report that insufficient time had been spent on information than women who had experienced their birth as easy or very easy.

CONCLUSIONS

antenatal care can play an important role in preparing women for birth. This study shows that information about birth provided during pregnancy is insufficient from women's perspective, although some groups of women do report being more satisfied with this information. The way that this segment of antenatal care is provided leaves room for improvement.

Cost-Effectiveness Analysis of Latent versus Active Labor Hospital Admission for Medically Low-Risk, Term Women

OBJECTIVE

To assess the outcomes and costs of hospital admission during the latent versus active phase of labor. Latent labor hospital admission has been consistently associated with elevated maternal risk for increased interventions, including epidural anesthesia and cesarean delivery, longer hospital stay, and higher utilization of hospital resources.

METHODS

A cost-effectiveness model was built to simulate a theoretic cohort of 3.2 million term, medically low-risk women either being admitted in latent labor (< 4 cm dilation) or delaying admission until active labor (≥ 4 cm dilation). Outcomes included epidural use, mode of delivery, stillbirth, maternal death, and costs of care. All probability, cost, and utility estimates were derived from the literature, and total quality-adjusted life years were calculated. Sensitivity analyses and a Monte Carlo simulation were used to investigate the robustness of model assumptions.

RESULTS

Delaying admission until active labor would result in 672,000 fewer epidurals, 67,232 fewer cesarean deliveries, and 9.6 fewer maternal deaths in our theoretic cohort as compared to admission during latent labor. Additionally, delaying admission results in a cost savings of $694 million annually in the United States. Sensitivity analyses indicated the model was robust within a wide range of probabilities and costs. Monte Carlo simulation found that delayed admission was the optimal strategy in 76.79 percent of trials.

CONCLUSION

Delaying admission until active labor is a dominant strategy, resulting in both better outcomes and lower costs. Issues related to clinical translation of these findings are explored.

The Family Startup Program: study protocol for a randomized controlled trial of a universal group-based parenting support program

Background

Inadequate parenting is an important public health problem with possible severe and long-term consequences related to child development. We have solid theoretical and political arguments in favor of efforts enhancing the quality of the early family environment in the population at large. However, little is known about effect of universal approaches to parenting support during the transition to parenthood. This protocol describes an experimental evaluation of group based parenting support, the Family Startup Program (FSP), currently implemented large scale in Denmark.

Methods/design

Participants will be approximately 2500 pregnant women and partners. Inclusion criteria are parental age above 18 and the mother expecting first child. Families are recruited when attending routine pregnancy scans provided as a part of the publicly available prenatal care program at Aarhus University Hospital, Skejby. Families are randomized within four geographically defined strata to one of two conditions a) participation in FSP or b) Treatment As Usual (TAU). FSP aims to prepare new families for their roles as parents and enhance parental access to informal sources of support, i.e. social network and community resources. The program consists of twelve group sessions, with nine families in each group, continuing from pregnancy until the child is 15 months old. TAU is the publicly available pre- and postnatal care available to families in both conditions. Analyses will employ survey data, administrative data from health visitors, and administrative register based data from Statistics Denmark. All data sources will be linked via the unique Danish Civil Registration Register (CPR) identifier. Data will be obtained at four time points, during pregnancy, when the child is nine months, 18 months and seven years. The primary study outcome is measured by the Parenting Sense of Competence scale (PSOC) J Clin Child Psychol 18:167-75, 1989. Other outcomes include parenting and couple relationship quality, utility of primary sector service and child physical health, socio-emotional and cognitive development.

Discussion

The protocol describes an ambitious experimental evaluation of a universal group-based parenting support program; an evaluation that has not yet been made either in Denmark or internationally.

Trial registration

ClinicalTrials.gov ID: NCT02294968. Registered November 14 2014.

Women-centred interventions to increase vaginal birth after caesarean section (VBAC): A systematic review

OBJECTIVE

to evaluate the effectiveness of women-centred interventions during pregnancy and birth to increase rates of vaginal birth after caesarean.

DESIGN

we searched bibliographic databases for randomised trials or cluster randomised trials on women-centred interventions during pregnancy and birth designed to increase VBAC rates in women with at least one previous caesarean section. Comparator groups included standard or usual care or an alternative treatment aimed at increasing VBAC rates. The methodological quality of included studies was assessed independently by two authors using the Effective Public Health Practice Project quality assessment tool. Outcome data were extracted independently from each included study by two review authors.

FINDINGS

in total, 821 citations were identified and screened by title and abstract; 806 were excluded and full text of 15 assessed. Of these, 12 were excluded leaving three papers included in the review. Two studies evaluated the effectiveness of decision aids for mode of birth and one evaluated the effectiveness of an antenatal education programme. The findings demonstrate that neither the use of decision aids nor information/education of women have a significant effect on VBAC rates. Nevertheless, decision-aids significantly decrease women's decisional conflict about mode of birth, and information programmes significantly increase their knowledge about the risks and benefits of possible modes of birth.

KEY CONCLUSIONS

few studies evaluated women-centred interventions designed to improve VBAC rates, and all interventions were applied in pregnancy only, none during the birth. There is an urgent need to develop and evaluate the effectiveness of all types of women-centred interventions during pregnancy and birth, designed to improve VBAC rates.

IMPLICATIONS FOR PRACTICE

decision-aids and information programmes during pregnancy should be provided for women as, even though they do not affect the rate of VBAC, they decrease women's decisional conflict and increase their knowledge about possible modes of birth.

The effect of antenatal education in small classes on obstetric and psycho-social outcomes - a systematic review

BACKGROUND

The aims of antenatal education are broad and encompass outcomes related to pregnancy, birth, and parenthood. Both form and content of antenatal education have changed over time without evidence of effects on relevant outcomes. The effect of antenatal education in groups, with participation of a small number of participants, may differ from the effect of other forms of antenatal education due to, for example, group dynamic. The objective of this systematic review is to assess the effects of antenatal education in small groups on obstetric as well as psycho-social outcomes.

METHODS

Bibliographic databases (Medline, EMBASE, CENTRAL, CINAHL, Web of Science, and PsycINFO) were searched. We included randomized and quasi-randomized trials irrespective of language, publication year, publication type, and publication status. Only trials carried out in the Western world were considered in this review. Studies were assessed for bias using the Cochrane risk of bias tool. Results are presented as structured summaries of the included trials and as forest plots.

RESULTS

We identified 5,708 records. Of these, 17 studies met inclusion criteria. Studies varied greatly in content of the experimental and control condition. All outcomes were only reported in a single or a few trials, leading to limited or uncertain confidence in effect estimates. Given the heterogeneity in interventions and outcomes and also the high risk of bias of studies, we are unable to draw definitive conclusions as to the impact of small group antenatal education on obstetric and psycho-social outcomes.

CONCLUSIONS

Insufficient evidence exists as to whether antenatal education in small classes is effective in regard to obstetric and psycho-social outcomes. We recommend updating this review following the emergence of well-conducted randomized controlled trials with a low risk of bias.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42013004319.

Comparing the postpartum quality of life between six to eight weeks and twelve to fourteen weeks after delivery in iran

Background:

Women during the postpartum period experience many physiological, psychological, and social changes. Quality of life (QOL) is a sense of well-being and arises from satisfaction or dissatisfaction with various aspects of life including health, employment, socioeconomic state, psychological-emotional state, and family. Moreover, QOL is an important criteria for assessing healthcare system.

Objectives:

The purpose of this study was to compare the postpartum QOL between six to eight and 12 to 14 weeks after delivery in women referred to public health centers in Dezful City, Iran, in 2011.

Materials and Methods:

This study was a longitudinal study. The study participants were 150 postpartum women referred to public health centers. Quota method was used for sampling. Data collection tools in this study were demographic questionnaire, Edinburgh Postnatal Depression Scale (EPDS), short form health survey questionnaire (SF-36), and Specific Quality of Life after Delivery Questionnaire. Data were analyzed using SPSS.

Results:

The results showed that the mean scores of various dimensions of the SF-36 were significantly higher at 12 to 14 weeks than at six to eight weeks (P < 0.001). The postpartum mean depression score was significantly higher at six to eight weeks than at 12 to 14 weeks (P < 0.001). The mean score of QOL questionnaires at 12 to 14 weeks were increased in all dimensions in comparison with six to eight weeks; however, this increase was significant only in dimension of the mother's feelings toward herself, her husband, and others (P < 0.001).

Conclusions:

Because enormous changes develop in postpartum women, we suggest supportive measures for mother by her mother-in-law, family, and caregivers to improve the QOL and health status of the mother and her child.

Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis

OBJECTIVES

To assess the effects of nonpharmacologic approaches to pain relief during labor, according to their endogenous mechanism of action, on obstetric interventions, maternal, and neonatal outcomes.

DATA SOURCE

Cochrane library, Medline, Embase, CINAHL and the MRCT databases were used to screen studies from January 1990 to December 2012.

STUDY SELECTION

According to Cochrane criteria, we selected randomized controlled trials that compared nonpharmacologic approaches for pain relief during labor to usual care, using intention-to-treat method.

RESULTS

Nonpharmacologic approaches, based on Gate Control (water immersion, massage, ambulation, positions) and Diffuse Noxious Inhibitory Control (acupressure, acupuncture, electrical stimulation, water injections), are associated with a reduction in epidural analgesia and a higher maternal satisfaction with childbirth. When compared with nonpharmacologic approaches based on Central Nervous System Control (education, attention deviation, support), usual care is associated with increased odds of epidural OR 1.13 (95% CI 1.05-1.23), cesarean delivery OR 1.60 (95% CI 1.18-2.18), instrumental delivery OR 1.21 (95% CI 1.03-1.44), use of oxytocin OR 1.20 (95% CI 1.01-1.43), labor duration (29.7 min, 95% CI 4.5-54.8), and a lesser satisfaction with childbirth. Tailored nonpharmacologic approaches, based on continuous support, were the most effective for reducing obstetric interventions.

CONCLUSION

Nonpharmacologic approaches to relieve pain during labor, when used as a part of hospital pain relief strategies, provide significant benefits to women and their infants without causing additional harm.

Evaluation of the Bonapace Method: a specific educational intervention to reduce pain during childbirth

OBJECTIVE

As pain during childbirth is very intense, several educational programs exist to help women prepare for the event. This study evaluates the efficacy of a specific pain management program, the Bonapace Method (BM), to reduce the perception of pain during childbirth. The BM involves the father, or a significant partner, in the use of several pain control techniques based on three neurophysiological pain modulation models: (1) controlling the central nervous system through breathing, relaxation, and cognitive structuring; (2) using non-painful stimuli as described in the Gate Control Theory; and (3) recruiting descending inhibition by hyperstimulation of acupressure trigger points.

METHODS

A multicenter case control study in Quebec on pain perception during labor and delivery compared traditional childbirth training programs (TCTPs) and the BM. Visual analog scales were used to measure pain perception during labor. In all, 25 women (TCTP: n = 12; BM: n = 13) successfully reported their perceptions of pain intensity and unpleasantness every 15 minutes.

RESULTS

A POSITIVE CORRELATION BETWEEN THE PROGRESSION OF LABOR AND PAIN WAS FOUND (PAIN INTENSITY: P < 0.01; pain unpleasantness: P < 0.01). When compared to TCTP, the BM showed an overall significant lower pain perception for both intensity (45%; P < 0.01) and unpleasantness (46%; P < 0.01).

CONCLUSION

These significant differences in pain perception between TCTP and the BM suggest that the emphasis on pain modulation models and techniques during labor combined with the active participation of a partner in BM are important variables to be added to the traditional childbirth training programs for childbirth pain management.

Group-based antenatal birth and parent preparation for improving birth outcomes and parenting resources: study protocol for a randomised trial

OBJECTIVES

To examine the efficacy and cost-effectiveness of group based antenatal education for improving childbirth and parenting resources compared to auditorium based education.

METHODS

PARTICIPANTS

2350 Danish pregnant women and their partners ≥18 years old, recruited before 20+0 gestational weeks. Population-based individually randomised superiority trial with two parallel arms: Four sessions of birth and parent preparation in small groups (experimental group); two lectures in an auditorium (control group). Data is collected by (1) questionnaires at baseline (≈18 weeks of gestation), 37 weeks of gestation, 9 weeks-, 6 months-, and 1 year post-partum, (2) the hospital obstetric database, (3) national registers.

PRIMARY OUTCOME

use of epidural analgesia.

SECONDARY OUTCOMES

stress, parenting alliance; explorative outcomes: depressive symptoms, use of health care services, self-efficacy, well-being, family break-ups. Analyses will be intention-to-treat as well as per protocol. Process evaluation will be conducted using questionnaires and qualitative interviews. The incremental societal cost of the intervention will be computed and compared to the measured outcomes in a cost-effectiveness analysis.

CONCLUSION

To the best of our knowledge this is the largest well-designed randomised trial of its kind to date. The trial will bring much-needed evidence for decision makers of the content and form of antenatal education.

Does antenatal education affect labour and birth? A structured review of the literature

OBJECTIVE

To undertake a structured review of the literature to determine the effect of antenatal education on labour and birth, particularly normal birth.

METHOD

Ovid Medline, CINAHL, Cochrane and Web of Knowledge databases were searched to identify research articles published in English from 2000 to 2012, using specified search terms in a variety of combinations. All articles included in this structured review were assessed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

FINDINGS

The labour and birthing effects on women attending antenatal education may include less false labour admissions, more partner involvement, less anxiety but more labour interventions.

CONCLUSION

This literature review has identified that antenatal education may have some positive effects on women's labour and birth including less false labour admissions, less anxiety and more partner involvement. There may also be some negative effects. Several studies found increased labour and birth interventions such as induction of labour and epidural use. There is contradictory evidence on the effect of antenatal education on mode of birth. More research is required to explore the impact of antenatal education on women's birthing outcomes.

Women's perception of the onset of labour and epidural analgesia: a prospective study

OBJECTIVE

childbearing women and their midwives differ in their diagnoses of the onset of labour. The symptoms women use to describe the onset of labour are associated with the process of labour. Perinatal factors and women's attitudes may be associated with the administration of epidural analgesia. Our study aimed to assess the correlation between women's perception of the onset of labour and the frequency and timing of epidural analgesia during labour.

DESIGN

prospective cohort study.

SETTING

41 maternity units in Lower Saxony, Germany.

PARTICIPANTS

549 nulliparae (as defined in the "Methods" section) and 490 multiparae giving birth between April and October 2005. Women were included after 34 completed weeks of gestation with a singleton in vertex presentation and planned vaginal birth.

MEASUREMENTS

the association between women's symptoms at the onset of labour and the administration of epidural analgesia - frequency, timing in relation to onset of labour and cervical dilatation - was assessed. The analysis was performed by Kaplan-Meiers estimation, logistic regression and Cox regression.

FINDINGS

a total of 174 nulliparae and 49 multiparae received epidural analgesia during labour. Nulliparae received it at a median time of 5.47hrs (range: 0.25-51.17hrs) after onset of labour, at a median cervical dilatation of 3.3cm (range: 1.0-10.0cm). In multiparae, epidural analgesia was applied at a median time of 3.79hrs (range: 0.42-28.55hrs) after onset of labour; the median cervical dilatation was 3.0cm (range: 1.0-8.0cm). Women who were admitted with advanced cervical dilatation received epidural analgesia less often. Women who defined their onset of labour earlier than it was diagnosed by their midwives received epidural analgesia earlier. Gastrointestinal symptoms and irregular pain at the onset of labour were associated with later administration of epidural analgesia. Induction of labour was associated with a reduced interval from the onset of labour to epidural analgesia.

KEY CONCLUSIONS

women's self-diagnosis of the onset of labour and their perception of their labour duration when meeting their midwives has some impact on their admission to the labour ward and the timing of epidural analgesia.

IMPLICATIONS FOR PRACTICE

consideration of women's own perceptions and expectations regarding the onset and process of labour is necessary for individual care during labour.

Individual or group antenatal education for childbirth or parenthood, or both

BACKGROUND

Structured antenatal education programs for childbirth or parenthood, or both, are commonly recommended for pregnant women and their partners by healthcare professionals in many parts of the world. Such programs are usually offered to groups but may be offered to individuals.

OBJECTIVES

To assess the effects of this education on knowledge acquisition, anxiety, sense of control, pain, labour and birth support, breastfeeding, infant-care abilities, and psychological and social adjustment.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2006), CINAHL (1982 to April 2006), ERIC (1984 to April 2006), EMBASE (1980 to April 2006) and PsycINFO (1988 to April 2006). We handsearched the Journal of Psychosomatic Research from 1956 to April 2006 and reviewed the reference lists of retrieved studies.

SELECTION CRITERIA

Randomized controlled trials of any structured educational program provided during pregnancy by an educator to either parent that included information related to pregnancy, birth or parenthood. The educational interventions could have been provided on an individual or group basis. Educational interventions directed exclusively to either increasing breastfeeding success, knowledge of and coping skills concerning postpartum depression, improving maternal psycho-social health including anxiety, depression and self-esteem or reducing smoking were excluded.

DATA COLLECTION AND ANALYSIS

Both authors assessed trial quality and extracted data from published reports.

MAIN RESULTS

Nine trials, involving 2284 women, were included. Thirty-seven studies were excluded. Educational interventions were the focus of eight of the studies (combined n = 1009). Details of the randomization procedure, allocation concealment, and/or participant accrual or loss for these trials were not reported. No consistent results were found. Sample sizes were very small to moderate, ranging from 10 to 318. No data were reported concerning anxiety, breastfeeding success, or general social support. Knowledge acquisition, sense of control, factors related to infant-care competencies, and some labour and birth outcomes were measured. The largest of the included studies (n = 1275) examined an educational and social support intervention to increase vaginal birth after caesarean section. This high-quality study showed similar rates of vaginal birth after caesarean section in 'verbal' and 'document' groups (relative risk 1.08, 95% confidence interval 0.97 to 1.21).

AUTHORS' CONCLUSIONS

The effects of general antenatal education for childbirth or parenthood, or both, remain largely unknown. Individualized prenatal education directed toward avoidance of a repeat caesarean birth does not increase the rate of vaginal birth after caesarean section.