Original Article
Does antenatal education reduce fear of childbirth? Ö. Karabulut1 RM, D. Cos¸kuner Potur2 RN, PhD, Y. Dog˘an Merih3 S. Cebeci Mutlu4 RN & N. Demirci5 RN, PhD
RN, PhD,
1 Clinical Midwife Antenatal Educator, 3 Health Care Manager, 4 Policlinic Nurse, Zeynep Kamil Women and Child Disease Training and Research Hospital, ˙I stanbul, Turkey, 2 Assistant Professor, 5 Associate Professor, Faculty of Health Sciences, Department of Obstetrics and Gynecology Nursing, Division of Nursing, Marmara University, ˙I stanbul, Turkey
˘ AN MERIH Y., CEBECI MUTLU S. & DEMIRCI N. KARABULUT Ö., COS¸KUNER POTUR D. , DOG (2016) Does antenatal education reduce fear of childbirth? International Nursing Review 63, 60–67 Aim: The aim of this study was to determine the effect of antenatal education on fear of childbirth, acceptance of pregnancy and identification with motherhood role. Background: There is insufficient evidence pertaining to the effect of antenatal education on fear of childbirth, acceptance of pregnancy and identification with motherhood role. Introduction: The purpose of antenatal education is to help couples make the right decisions during delivery. Through antenatal education, couples prepare themselves for delivery. Methods: This is a quasi-experimental and prospective study that employs a pre- and post-education model. In total, 192 pregnant women (education group, n = 69 and control group, n = 123) participated in the study. Data were collected using the pregnancy identification form: the Prenatal Self-Evaluation Questionnaire and a version of the Wijma Delivery Expectancy/Experience Questionnaire. Results: Prior to participating in the study, the education group and control group had similar levels of acceptance of pregnancy and identification with motherhood role, whereas a significant difference was found in their fear of childbirth levels. When surveyed again after receiving education, the two groups’ levels of acceptance of pregnancy and fear of childbirth were found to be significantly different. However, they had similar levels of identification with the motherhood role. Conclusion: Antenatal education appears to increase the acceptance of pregnancy, does not affect the identification with motherhood role and reduces the fear of childbirth. Implications for nursing and health policy: A systematic antenatal education programme, as part of routine antenatal care services, would help reduce the rate of interventional labour and facilitate pregnant women’s conscious participation in the act of labour by reducing their fear of childbirth. Keywords: Antenatal Education, Fear of Childbirth, Midwife, Nurse, Pregnancy, Prenatal, Type of Birth
Correspondence address: Dilek Cos¸kuner Potur, Faculty of Health Sciences, Department of Obstetrics and Gynecology Nursing, Division of Nursing, Marmara University, Tıbbiye Cad No. 40 Haydarpas¸a, I˙stanbul, 34668, Turkey; Tel: +90-216-330-20-70-1141; Fax: +90-216-418-37-73; E-mail: [email protected]
Conflict of interest The authors declare no conflict of interest.
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Introduction Antenatal education is a service requested by the majority of pregnant women throughout the world; it appears under various names such as ‘childbirth education programmes’, ‘prenatal classes’ and ‘childbirth preparation classes’. In some parts of the world, even today, this education is provided by the
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Does antenatal education reduce fear of childbirth
transfer of information or experiences from mothers, sisters or traditional midwives (Cos¸ar & Demirci 2012; Gagnon & Sandall 2007; Ho & Holroyd 2002; Serçekus¸ & Mete 2010a). This informal sharing in a social environment may have negative effects on pregnant women’s thoughts about childbirth. In a qualitative study conducted in Turkey, it was found that incorrect information and insufficient knowledge of delivery leads to fear and requests for a caesarean section (Serçekus¸ & Okumus¸ 2009). Antenatal education provided by specialist health professionals (such as gynaecologists, midwives or nurses), working at state or private institutions, is important for preparing couples for pregnancy, delivery and parenthood. Numerous studies have researched the effects of antenatal education on pregnancy, delivery and post-partum period (Cos¸ar & Demirci 2012; Gagnon & Sandall 2007; Serçekus¸ & Mete 2010b). Previous research has demonstrated that pregnant women who participate in antenatal education show positive changes in health behaviours (Koehn 2002). Couples who are to become first-time parents, in particular, have fears and concerns about pregnancy and delivery. The purpose of antenatal education is to help couples make the right decisions during pregnancy, delivery and post-partum period (regarding the type of delivery, where the delivery will take place, etc.). Through antenatal education, couples prepare themselves for delivery and parenthood (Cos¸ar & Demirci 2012). Studies that examine the effects of antenatal education on delivery investigated the level of information on delivery (Lee & Holroyd 2009; Malata et al. 2007), satisfaction with delivery experience (Spinelli et al. 2003), anxiety during delivery (Lee & Holroyd 2009) and the benefits of education (Tighe 2010). To the authors’ knowledge, no studies have examined the effects of antenatal education on fear of childbirth (FOC), acceptance of pregnancy (AP) and identification with the motherhood role (IMR), which led us to conduct the present study. The purpose of the study was to determine the effect of antenatal education on FOC, AP and IMR. The following hypotheses were tested: H1: Pregnant women who receive antenatal education have higher levels of AP compared with pregnant women who do not receive antenatal education. H2: Pregnant women who receive antenatal education have higher levels of IMR compared with those who do not receive antenatal education. H3: Pregnant women who receive antenatal education have lower levels of FOC compared with those who do not receive antenatal education.
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Methods Study participant and procedure
This study, which uses a pre- and post-education model and is a quasi-experimental and prospective study, was conducted using a control group (CG) between December 2012 and December 2013. The participants consisted of pregnant women admitted to the Women’s and Children’s Disease Training and Research Hospital located on the Anatolian side of Istanbul. The free education programme was promoted using posters in the antenatal and gynaecology polyclinics and announcements on the hospital’s website. The education group (EG) was thus made up of pregnant women who voluntarily enrolled in the programme. Although a randomized sample would have been desirable, continuity was important in this case because the education programme consisted of five consecutive weekly sessions, with the participation of spouses. Assuming that an unwilling participant would not complete the course, it was decided to allow the EG to self-select. The CG consisted of pregnant women who did not choose to receive antenatal education, but who volunteered to participate in the study and who were receiving routine follow-ups (anamnesis, physical examination, ultrasound) at the study hospital’s antenatal polyclinic. Inclusion criteria
The sample included primipara women aged 18 years and older who could speak and understand Turkish, had a single foetus and were within weeks 24–28 of pregnancy. Exclusion criteria: In the EG, women were excluded if they were unable to participate in the programme with their spouses, did not attend the full 5-week course, did not attend regularly or if they developed any complications during the education period. In the CG, women were excluded if they failed to attend a follow-up appointment in the fifth week following the first interview, if they did not complete the questionnaires or if they developed complications during the 5-week study period. Sample size calculation
Assuming that the outcome variable levels pertaining to the EG and CG would differ by a standard error of at least 1.5 and that group variances would not be equal, it was determined that a minimum of 100 cases should be included in the CG and a minimum of 50 cases should be included in the EG, with a confidence interval of 95% and a minimum power of 95%. However, considering that some participants might withdraw from the study, a higher number of participants were recruited. Figure 1 summarizes the process of forming the sample group and the stages of the study.
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EG
CG
n = 100
n = 200
Before education 24th–28th weeks of gestation
Demographic data form Prenatal Self-Evaluation Questionnaire (PSEQ) (acceptance of pregnancy and identification with motherhood role)
First Evaluation
Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ A)
Routine Prenatal Care
Routine Prenatal Care
Group education for 5 weeks Lost n = 31 Withdrawal n = 9 Education attendance not regularly n = 15
Lost n = 77 Withdrawal n = 19 Prenatal control attendance regularly n = 32
Pregnancy and pregnancy-
Pregnancy and pregnancy-
related complications (Early
related complications (Early
birth, preterm labor, preeclampsia etc) n = 7
birth, preterm labor, preeclampsia etc) n = 18 Continued to receive prenatal care at another health institution n=8
End of education (30th–34th weeks of gestation) Second Evaluation
Prenatal Self-Evaluation Questionnaire (PSEQ) (acceptance of pregnancy and identification with motherhood role) Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ A)
EG
CG
n = 69
n = 123
Fig. 1 Flow chart of participant progress.
Data collection
All data collection instruments were administered via face-toface interviews; the first author (ÖK) interviewed the EG and the CG was interviewed by the fourth author (SCM), who is an antenatal polyclinic nurse.
demographic characteristics included age, length of marriage, education and employment status. Obstetric characteristics included the week of pregnancy, status of planned pregnancy and preferred type of delivery. Prenatal Self-Evaluation Questionnaire (PSEQ)
Descriptive information form
The form, prepared by the authors in accordance with the literature, consisted of 10 questions including two sections on socio-demographic and obstetric characteristics. Socio-
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The PSEQ is a measurement tool, developed by Lederman in 1979, used for evaluating pregnant women’s adaptation to pregnancy and motherhood. Beydag˘ & Mete (2008) have confirmed the validity and reliability of the scale in a Turkish population.
Does antenatal education reduce fear of childbirth
The scale has seven sub-dimensions and 79 items. The internal consistency coefficient of the Turkish translation of the scale was high (Cronbach’s alpha: 0.81), and internal consistency coefficients of the subgroups ranged from 0.72 to 0.85. This study used the 14-item ‘AP’ and 15-item ‘IMR’ subdimensions of the PSEQ. The items in the ‘AP’ sub-dimension were numbered 1, 3, 5, 7, 9, 17, 18, 19, 20, 22, 24, 26, 27 and 29. Those in the ‘IMR’ sub-dimension were numbered 2, 4, 6, 8, 10, 11, 12, 13, 14, 15, 16, 21, 23, 25 and 28. The scale items 1, 2, 3, 4, 6, 7, 9, 10, 15, 18, 23, 24, 25, 28 and 29 were reverse scored. Each item in the scale was measured in four response categories. Participants score each question from 1 to 4 (1: not at all, 2: somewhat, 3: moderately so and 4: very much so). The minimum and maximum scores that can be obtained in the ‘AP’ subdimension are 14 and 56, respectively, whereas the minimum and maximum scores in the ‘IMR’ sub-dimension are 15 and 60, respectively. Lower scores indicate higher levels of ‘AP’ and ‘IMR’. In this study, Cronbach’s alpha coefficient was 0.73 for the ‘AP’ sub-dimension and 0.85 for the ‘IMR’ sub-dimension (Beydag˘ & Mete 2008). Wijma Delivery Expectancy/Experience Questionnaire-A (W-DEQ version A)
Wijma, Wijma and Zar developed the W-DEQ in response to the absence of an appropriate psychological instrument for measuring women’s clinical experience of FOC. The W-DEQ
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measures fear by asking women about their expectations before delivery (version A) and about their experiences after delivery (version B) (Wijma et al. 1998). Körükçü et al. (2012) confirmed the validity and reliability of the questionnaire in a Turkish population. The internal consistency and split half method reliability of the W-DEQ-A was more than 0.87, indicating that the instrument is appropriate for measurement. In this study, the W-DEQ-A’s Cronbach’s alpha value was 0.92. The response categories in the questionnaire were numbered from 0 to 5 along a 6-point Likert-type scale, with 0 corresponding to ‘extremely’ and 5 corresponding to ‘not at all’. The 6-point Likert-type format was selected because the increase in questionnaire scores leads to an increase in reliability. The increase in reliability ceases after 7 points or more and remains stable. The minimum and maximum scores that can be obtained from the questionnaire are 0 and 165, respectively. Higher scores indicate greater levels of FOC. Implementation of education provided to the EG
Table 1 summarizes the education topics and contents according to weeks. The education sessions were carried out using relevant appropriate models and figurines, visual instruments and videos. Motion, demonstration and interactive education methods were used. The education sessions were conducted in a special room designed for pregnancy education within the study hospital.
Table 1 Antenatal educational programme Weeks
Subject
Educational content
1
Health in pregnancy
2
Birth and breathing exercises
3
Breastfeeding
4
Baby care
5
Post-partum period and family planning
Introduction of anatomy and physiology in males and females and how pregnancy occurs, physiological and psychological changes during pregnancy, introduction of prenatal care and tests, nutrition during pregnancy, exercise during pregnancy, sexuality during pregnancy, danger and signs in pregnancy Make a birth plan, symptoms of impending birth, symptoms indicating the initiation of labour, mechanisms of labour and birth in adequate detail, prepare pregnant woman and partner for labour and delivery, teach pregnant woman breathing and relaxation techniques to be used during labour and delivery, techniques, operative delivery Breastfeeding, discuss advantages and disadvantages of breastfeeding and bottle feeding, instruct pregnant woman to prepare nipples for breastfeeding, positioning the baby, proper latch-on, preventing problems and returning to work The interventions newborn immediately after delivery (apgar scores, height, weight, head circumference measurement, etc), newborn reflexes, belly care, baby bath, baby’s clothing, newborn screening tests, communicating with the baby, baby massage, baby’s room, newborn baby’s safety, healthy child controls and vaccines Physical and emotional post-partum changes and coping and taking care of oneself, discussion, nutrition during post-partum, childbirth and post-partum changes, exercise during post-partum, post-partum sexuality, post-partum family planning, post-partum controls, determine pregnant woman’s knowledge and attitudes about parenting, promote pregnant woman’s self-esteem in taking on parental role, provide anticipatory guidance for parenthood
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Equipped with lighting, pillows and exercise cushions, the special room provided an environment in which the participants could feel comfortable. The course was conducted once a day for 180 min between the hours of 01:00–04:00 pm. Pregnant women and their spouses, or a relative, attended predetermined sessions for 5 weeks, totalling 15 h. The mean number of participants in each group was 6–10 couples. The first author (ÖK) delivered the programme and attended the Antenatal Preparation Class Instructor Training course twice. The author (ÖK) also had 6 years of experience as a pregnancy instructor at the study hospital and served as an instructor for the Childbirth Educator Courses numerous times. The CG
The CG consisted of pregnant women who attended the pregnancy follow-up polyclinic, met the inclusion criteria and did not attend the antenatal classes. The CG received only routine pregnancy care and information. Ethical considerations
Prior to the study, permission was obtained from the ethics board (ethics board approval date, protocol and decision number: 7 December 2012/21581/48). The participants received written and oral information about the study provided by the authors. The participants were assured that participation in the study was voluntary, that they could withdraw from the study at any time and that their identities would remain confidential. Their written consent was obtained. Data analysis
Statistical Package for the Social Sciences (SPSS) 15.0 (SPSS Inc., Chicago, IL, USA) was used for data analysis. Alpha score
of 0.05 was accepted for statistical significance. The t-test and chi-square test were used for determining between-group differences. The Kolmogorov–Smirnov test was used for testing whether the data were normally distributed. Because the scores were not in a normal distribution, the Mann–Whitney U-test was used to compare the EG and CG’s FOC, AP and IMR levels. The Wilcoxon test was used to compare the levels of AP and IMR as the scores were not normally distributed. Because the scores for FOC did exhibit a normal distribution, the mean scores were compared using the paired sample t-test.
Results The demographic characteristics of pregnant women in EG and CG were compared. The mean age of pregnant women in the EG and CG (28.87 ± 4.54; 25.73 ± 5.35, respectively), their mean length of marriage (3.01 ± 2.25; 2.32 ± 1.93, respectively) and their employment status showed no statistically significant differences (P > 0.05). However, significant differences were found between the educational level of women in the EG and CG (P < 0.002). More than half of the participants in the EG (60.9%) and 20.3% of participants in the CG were university graduates. Comparing the obstetric characteristics of pregnant women in EG and CG, they were similar (P > 0.05) in terms of week of pregnancy (26.10 ± 2.37; 25.88 ± 2.12, respectively), status of planned pregnancy and preferred type of delivery. As shown in Table 2, the EG’s pre- and post-education levels of AP, IMR and FOC were compared with the first and second measurements for CG. No significant difference was found between EG and CG’s baseline levels of AP (P > 0.05). However, there was a significant difference in the levels of AP between the EG’s post-education measurement and the CG’s second measurement (P < 0.001). According to this finding, the H1
Table 2 Between-group comparisons of pre- and post-education acceptance of pregnancy and identification with the motherhood role and fear of childbirth scores Scales
PSEQ First evaluation – acceptance of pregnancy Second evaluation – acceptance of pregnancy First evaluation – identification with a motherhood role Second evaluation – identification with a motherhood role W-DEQ A First evaluation W-DEQ A score Second evaluation W-DEQ A score
Education group (n = 69) Median (quartiles)*
Control group (n = 123) Median (quartiles)*
P†
18 (16–21) 14 (15–20.50) 23 (20–27) 21 (18.50–23)
19 (17–23) 18 (17–22) 21 (18–25) 21 (18–24)
0.475 0.002* 0.101 0.851
54 (35–70) 27 (14–49.50)
43 (24–63) 41 (22–62)
0.014* 0.022*
*25th and 75th percentile. †Mann–Whitney U-test. PSEQ, Prenatal Self-Evaluation Questionnaire; W-DEQ A, Wijma Delivery Expectancy/Experience Questionnaire version A.
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Table 3 Within-group comparisons of pre- and post-education acceptance of the pregnancy–motherhood role and fear of childbirth scores Scales
PSEQ Acceptance of pregnancy Identification with a motherhood role W-DEQ A score
Education group (n = 69)
Control group (n = 123)
Before education Median (quartiles)*
After education Median (quartiles)*
P†
First evaluation Median (quartiles)*
Second evaluation Median (quartiles)*
P†
18 (16–21) 23 (20–27) Mean ± SD 53.25 ± 25.75
17 (15–20.50) 21 (18.50–23) Mean ± SD 33.72 ± 24.33
0.000* 0.005* P‡ 0.000*
19 (17–23) 21 (18–25) Mean ± SD 44.32 ± 5.00
18 (17–22) 21 (18–24) Mean ± SD 41.97 ± 24.64
0.253 0.133 P‡ 0.200
*25th and 75th percentile. †Wilcoxon signed-rank test. ‡Paired sample’s t-test. PSEQ, Prenatal Self-Evaluation Questionnaire; SD, standard deviation; W-DEQ A, Wijma Delivery Expectancy/Experience Questionnaire version A.
hypothesis was accepted. The EG’s pre-education and CG’s first measurement level of IMR showed no significant differences (P > 0.05). Similarly, the EG’s post-education and CG’s second measurement levels of IMR showed no significant differences (P > 0.05). According to this finding, the H2 hypothesis was rejected. The EG’s pre-education and CG’s first measurement levels of FOC showed significant differences (P < 0.005). The EG’s post-education and CG’s second measurement levels of FOC also showed significant differences (P < 0.005). According to this finding, antenatal education was effective in reducing the FOC among primipara and hypothesis H3 was accepted. As shown in Table 3, the EG’s pre- and post-education scores and CG’s first and second scores for the AP, IMR and FOC were compared within groups. It was determined that the EG’s preeducation level of AP, IMR and FOC decreased compared with the post-education measurements, and significant differences were evident between the pre- and post-education levels (P < 0.001). The decrease in the scores indicates an increase in the AP and the IMR role. It was determined that the antenatal education improved AP, increased IMR and reduced FOC. In the CG, AP, IMR and the FOC decreased between the first and second measurements. However, these decreases were not statistically significant (P > 0.05).
Discussion Our study, which aimed to determine the effect of education on AP, IMR and FOC, found that antenatal education increases the AP, does not affect IMR and reduces FOC. There was a significant difference between women in EG and CG in terms of their level of education. More than half of women in the EG and only 20.3% of women in the CG had bac-
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helor’s degrees. In similar studies, most of the women in the EG were found to have graduated from college (Bergström et al. 2010; Cos¸ar & Demirci 2012; Fabian et al. 2005; Serçekus¸ & Mete 2010b). Because the EG was allowed to self-select, this significant difference can be explained by more highly educated women feeling the need for such education or being willing to undertake it because of their awareness of their lack of experience and knowledge and their desire to benefit from such a service. In Serçekus¸ & Mete (2010b), the prenatal coping of women in CG was better than that of women who took antenatal education, both individually and as a group. Similarly, in our study, the scores for AP were lower for women who received antenatal education, which corresponded to better coping, with a very significant difference. Accordingly, hypothesis H1 (pregnant women who receive antenatal education have better levels of AP compared with pregnant women who do not receive antenatal education) was verified. However, Hamilton-Dood et al. (1989) found that a 6-h prenatal class delivered a month before delivery had no effect on prenatal coping. This difference can be explained by the fact that in both Serçekus¸ & Mete (2010b) and our study, the education programmes started in weeks 24–28 of pregnancy, lasted longer and were completed before the final month of pregnancy, when women were focused solely on delivery. Additionally, increased coping could be explained as all women in our study were primipara and almost all had planned pregnancies. Based on these findings, future studies could compare AP between primipara and multipara who received antenatal education may be conducted. In our study, the IMR scores did not change significantly between the first and second measurements. Accordingly,
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hypothesis H2 (women who received antenatal education would have better IMR than those in the CG) was rejected. The identification with the role of motherhood begins before conception and completes within the year following delivery (Alligood 2013). This case may be explained by all women in the study being primipara, within their last trimester and lacking any experience of motherhood. Additionally, the lack of difference between groups in both measurements might suggest that neither education nor advancement of pregnancy had any effect on IMR. In light of this finding, studies may be planned in order to evaluate the effect of antenatal education on motherhood role during the post-partum period. Gagnon & Sandall (2007) stated that the reason pregnant women take antenatal education is to reduce anxiety regarding delivery. This study supports Gagnon and Sandall’s findings as a significant difference was found between the levels of FOC in EG and CG in the first measurements. Women in EG scored higher on FOC, which may explain why these women selfselected into the EG – women who experience FOC seek a way to cope. In similar studies, 20–25% of pregnant women were found to fear childbirth (Toohill et al. 2014; Zar et al. 2001), whereas 5–10% of pregnant women were found to experience serious anxiety and fear regarding childbirth (Ryding et al. 2007). The most prominent reasons for pregnant women’s childbirth-related fears were related to being primipara (Melender 2002; Wiklund et al. 2008), lacking knowledge regarding pregnancy and misinformation (Serçekus¸ & Okumus¸ 2009). The second measurements of levels of FOC also showed a significant difference between the two groups (P < 0.005). Accordingly, hypothesis H3 was verified. Ryding et al. (2003) found that pregnant women liked the services of midwives with special counselling training, although they did not find them very effective in reducing the FOC. Serçekus¸ & Mete (2010b) found that antenatal education reduced the FOC. According to these results, a professional and systematic education programme can reduce the FOC. For this reason, it can be recommended that similar studies test the effectiveness of education with multipara women who experience FOC and who had previous negative birth experiences. Implications for nursing and health policy
Formal provision of antenatal education by nurses/midwives, which is not currently included in routine antenatal care services, will facilitate pregnant women’s conscious participation in the act of labour by reducing their FOC. It will help reduce the rate of interventional labour and related complications in mothers and infants, thereby promoting the healthy development of mother–infant interaction. In Turkey, it is necessary to standardize and extend antenatal education programmes so as
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to provide them on a routine basis, and to consider relevant international health policies in order to increase the number of nurses/midwives qualified to provide such education. Limitations of the study
The main limitation of the study is the lack of randomization in the groups, which was not possible owing to the attendance risks related to women who were unwilling to receive the education. Although all EG participants voluntarily self-selected, there was a dropout rate of approximately 31% (due to wanting to quit the study, irregular participation in the course or complications related to pregnancy). As the institution determined the course schedule, not everyone could be accommodated, resulting in participant attrition. Moreover, the study was limited by sample losses in the CG because of non-attendance of appointments or transferring to other institutions.
Conclusion A systematic antenatal education programme provided by healthcare professionals (nurses/midwives) was found to increase pregnant women’s AP, reduce their FOC and have no effect on their IMR.
Acknowledgements The authors thank the pregnant women who participated in the study. They also wish to acknowledge their statistics expert, Associate Professor, Ays¸e Ergün and Associate Professor Nilüfer Özaydın.
Author contributions ÖK, DCP, YDM, SMC and ND: Study conception/design. ÖK, DCP and SMC: Data collection/analysis. ÖK, DCP, YDM and ND: Drafting of manuscript. DCP, YDM and ND: Critical revision for intellectual content. DCP and ND: Study supervision.
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Serçekus¸, P. & Mete, S. (2010a) Turkish women’s perceptions of antenatal education. International Nursing Review, 57 (3), 395–401. Serçekus¸, P. & Mete, S. (2010b) Effects of antenatal education on maternal prenatal and postpartum adaptation. Journal of Advanced Nursing, 66 (5), 999–1010. Serçekus¸, P. & Okumus¸, H. (2009) Fears associated with childbirth among nulliparous women in Turkey. Midwifery, 25 (2), 155–162. Spinelli, A., et al. (2003) Do antenatal classes benefit the mother and her baby? The Journal of Maternal-Fetal and Neonatal Medicine, 13 (2), 94–101. Tighe, S.M. (2010) Midwifery article an exploration of the attitudes of attenders and non attenders towards antenatal education. Midwifery, 26 (3), 294–303. Toohill, J., et al. (2014) Psychosocial predictors of childbirth fear in pregnant women: an Australian study. Open Journal of Obstetrics and Gynecology, 4 (9), 531–543. Wijma, K., Wijma, B. & Zar, M. (1998) Psychosomatic aspects of W-DEQ: a new questionnaire for measurement of fear of childbirth. Journal of Psychosomatic Obstetrics and Gynaecology, 19 (2), 84–97. Wiklund, I., Edman, G., Ryding, E. & Andolf, E. (2008) Expectation and experiences of childbirth in primiparae with caesarean section. BJOG: An International Journal of Obstetrics and Gynaecology, 115 (3), 324–331. Zar, M., Wijma, K. & Wijma, B. (2001) Pre- and postpartum fear of childbirth in nulliparous and parous women. Scandinavian Journal of Behaviour Therapy, 30 (2), 75–84.
Supporting information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site Table S1 Distribution of women in education and control groups by demographic characteristics (n = 169)
Does antenatal education reduce fear of childbirth? Ö. Karabulut1 RM, D. Cos¸kuner Potur2 RN, PhD, Y. Dog˘an Merih3 S. Cebeci Mutlu4 RN & N. Demirci5 RN, PhD
RN, PhD,
1 Clinical Midwife Antenatal Educator, 3 Health Care Manager, 4 Policlinic Nurse, Zeynep Kamil Women and Child Disease Training and Research Hospital, ˙I stanbul, Turkey, 2 Assistant Professor, 5 Associate Professor, Faculty of Health Sciences, Department of Obstetrics and Gynecology Nursing, Division of Nursing, Marmara University, ˙I stanbul, Turkey
˘ AN MERIH Y., CEBECI MUTLU S. & DEMIRCI N. KARABULUT Ö., COS¸KUNER POTUR D. , DOG (2016) Does antenatal education reduce fear of childbirth? International Nursing Review 63, 60–67 Aim: The aim of this study was to determine the effect of antenatal education on fear of childbirth, acceptance of pregnancy and identification with motherhood role. Background: There is insufficient evidence pertaining to the effect of antenatal education on fear of childbirth, acceptance of pregnancy and identification with motherhood role. Introduction: The purpose of antenatal education is to help couples make the right decisions during delivery. Through antenatal education, couples prepare themselves for delivery. Methods: This is a quasi-experimental and prospective study that employs a pre- and post-education model. In total, 192 pregnant women (education group, n = 69 and control group, n = 123) participated in the study. Data were collected using the pregnancy identification form: the Prenatal Self-Evaluation Questionnaire and a version of the Wijma Delivery Expectancy/Experience Questionnaire. Results: Prior to participating in the study, the education group and control group had similar levels of acceptance of pregnancy and identification with motherhood role, whereas a significant difference was found in their fear of childbirth levels. When surveyed again after receiving education, the two groups’ levels of acceptance of pregnancy and fear of childbirth were found to be significantly different. However, they had similar levels of identification with the motherhood role. Conclusion: Antenatal education appears to increase the acceptance of pregnancy, does not affect the identification with motherhood role and reduces the fear of childbirth. Implications for nursing and health policy: A systematic antenatal education programme, as part of routine antenatal care services, would help reduce the rate of interventional labour and facilitate pregnant women’s conscious participation in the act of labour by reducing their fear of childbirth. Keywords: Antenatal Education, Fear of Childbirth, Midwife, Nurse, Pregnancy, Prenatal, Type of Birth
Correspondence address: Dilek Cos¸kuner Potur, Faculty of Health Sciences, Department of Obstetrics and Gynecology Nursing, Division of Nursing, Marmara University, Tıbbiye Cad No. 40 Haydarpas¸a, I˙stanbul, 34668, Turkey; Tel: +90-216-330-20-70-1141; Fax: +90-216-418-37-73; E-mail: [email protected]
Conflict of interest The authors declare no conflict of interest.
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Introduction Antenatal education is a service requested by the majority of pregnant women throughout the world; it appears under various names such as ‘childbirth education programmes’, ‘prenatal classes’ and ‘childbirth preparation classes’. In some parts of the world, even today, this education is provided by the
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Does antenatal education reduce fear of childbirth
transfer of information or experiences from mothers, sisters or traditional midwives (Cos¸ar & Demirci 2012; Gagnon & Sandall 2007; Ho & Holroyd 2002; Serçekus¸ & Mete 2010a). This informal sharing in a social environment may have negative effects on pregnant women’s thoughts about childbirth. In a qualitative study conducted in Turkey, it was found that incorrect information and insufficient knowledge of delivery leads to fear and requests for a caesarean section (Serçekus¸ & Okumus¸ 2009). Antenatal education provided by specialist health professionals (such as gynaecologists, midwives or nurses), working at state or private institutions, is important for preparing couples for pregnancy, delivery and parenthood. Numerous studies have researched the effects of antenatal education on pregnancy, delivery and post-partum period (Cos¸ar & Demirci 2012; Gagnon & Sandall 2007; Serçekus¸ & Mete 2010b). Previous research has demonstrated that pregnant women who participate in antenatal education show positive changes in health behaviours (Koehn 2002). Couples who are to become first-time parents, in particular, have fears and concerns about pregnancy and delivery. The purpose of antenatal education is to help couples make the right decisions during pregnancy, delivery and post-partum period (regarding the type of delivery, where the delivery will take place, etc.). Through antenatal education, couples prepare themselves for delivery and parenthood (Cos¸ar & Demirci 2012). Studies that examine the effects of antenatal education on delivery investigated the level of information on delivery (Lee & Holroyd 2009; Malata et al. 2007), satisfaction with delivery experience (Spinelli et al. 2003), anxiety during delivery (Lee & Holroyd 2009) and the benefits of education (Tighe 2010). To the authors’ knowledge, no studies have examined the effects of antenatal education on fear of childbirth (FOC), acceptance of pregnancy (AP) and identification with the motherhood role (IMR), which led us to conduct the present study. The purpose of the study was to determine the effect of antenatal education on FOC, AP and IMR. The following hypotheses were tested: H1: Pregnant women who receive antenatal education have higher levels of AP compared with pregnant women who do not receive antenatal education. H2: Pregnant women who receive antenatal education have higher levels of IMR compared with those who do not receive antenatal education. H3: Pregnant women who receive antenatal education have lower levels of FOC compared with those who do not receive antenatal education.
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Methods Study participant and procedure
This study, which uses a pre- and post-education model and is a quasi-experimental and prospective study, was conducted using a control group (CG) between December 2012 and December 2013. The participants consisted of pregnant women admitted to the Women’s and Children’s Disease Training and Research Hospital located on the Anatolian side of Istanbul. The free education programme was promoted using posters in the antenatal and gynaecology polyclinics and announcements on the hospital’s website. The education group (EG) was thus made up of pregnant women who voluntarily enrolled in the programme. Although a randomized sample would have been desirable, continuity was important in this case because the education programme consisted of five consecutive weekly sessions, with the participation of spouses. Assuming that an unwilling participant would not complete the course, it was decided to allow the EG to self-select. The CG consisted of pregnant women who did not choose to receive antenatal education, but who volunteered to participate in the study and who were receiving routine follow-ups (anamnesis, physical examination, ultrasound) at the study hospital’s antenatal polyclinic. Inclusion criteria
The sample included primipara women aged 18 years and older who could speak and understand Turkish, had a single foetus and were within weeks 24–28 of pregnancy. Exclusion criteria: In the EG, women were excluded if they were unable to participate in the programme with their spouses, did not attend the full 5-week course, did not attend regularly or if they developed any complications during the education period. In the CG, women were excluded if they failed to attend a follow-up appointment in the fifth week following the first interview, if they did not complete the questionnaires or if they developed complications during the 5-week study period. Sample size calculation
Assuming that the outcome variable levels pertaining to the EG and CG would differ by a standard error of at least 1.5 and that group variances would not be equal, it was determined that a minimum of 100 cases should be included in the CG and a minimum of 50 cases should be included in the EG, with a confidence interval of 95% and a minimum power of 95%. However, considering that some participants might withdraw from the study, a higher number of participants were recruited. Figure 1 summarizes the process of forming the sample group and the stages of the study.
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EG
CG
n = 100
n = 200
Before education 24th–28th weeks of gestation
Demographic data form Prenatal Self-Evaluation Questionnaire (PSEQ) (acceptance of pregnancy and identification with motherhood role)
First Evaluation
Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ A)
Routine Prenatal Care
Routine Prenatal Care
Group education for 5 weeks Lost n = 31 Withdrawal n = 9 Education attendance not regularly n = 15
Lost n = 77 Withdrawal n = 19 Prenatal control attendance regularly n = 32
Pregnancy and pregnancy-
Pregnancy and pregnancy-
related complications (Early
related complications (Early
birth, preterm labor, preeclampsia etc) n = 7
birth, preterm labor, preeclampsia etc) n = 18 Continued to receive prenatal care at another health institution n=8
End of education (30th–34th weeks of gestation) Second Evaluation
Prenatal Self-Evaluation Questionnaire (PSEQ) (acceptance of pregnancy and identification with motherhood role) Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ A)
EG
CG
n = 69
n = 123
Fig. 1 Flow chart of participant progress.
Data collection
All data collection instruments were administered via face-toface interviews; the first author (ÖK) interviewed the EG and the CG was interviewed by the fourth author (SCM), who is an antenatal polyclinic nurse.
demographic characteristics included age, length of marriage, education and employment status. Obstetric characteristics included the week of pregnancy, status of planned pregnancy and preferred type of delivery. Prenatal Self-Evaluation Questionnaire (PSEQ)
Descriptive information form
The form, prepared by the authors in accordance with the literature, consisted of 10 questions including two sections on socio-demographic and obstetric characteristics. Socio-
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The PSEQ is a measurement tool, developed by Lederman in 1979, used for evaluating pregnant women’s adaptation to pregnancy and motherhood. Beydag˘ & Mete (2008) have confirmed the validity and reliability of the scale in a Turkish population.
Does antenatal education reduce fear of childbirth
The scale has seven sub-dimensions and 79 items. The internal consistency coefficient of the Turkish translation of the scale was high (Cronbach’s alpha: 0.81), and internal consistency coefficients of the subgroups ranged from 0.72 to 0.85. This study used the 14-item ‘AP’ and 15-item ‘IMR’ subdimensions of the PSEQ. The items in the ‘AP’ sub-dimension were numbered 1, 3, 5, 7, 9, 17, 18, 19, 20, 22, 24, 26, 27 and 29. Those in the ‘IMR’ sub-dimension were numbered 2, 4, 6, 8, 10, 11, 12, 13, 14, 15, 16, 21, 23, 25 and 28. The scale items 1, 2, 3, 4, 6, 7, 9, 10, 15, 18, 23, 24, 25, 28 and 29 were reverse scored. Each item in the scale was measured in four response categories. Participants score each question from 1 to 4 (1: not at all, 2: somewhat, 3: moderately so and 4: very much so). The minimum and maximum scores that can be obtained in the ‘AP’ subdimension are 14 and 56, respectively, whereas the minimum and maximum scores in the ‘IMR’ sub-dimension are 15 and 60, respectively. Lower scores indicate higher levels of ‘AP’ and ‘IMR’. In this study, Cronbach’s alpha coefficient was 0.73 for the ‘AP’ sub-dimension and 0.85 for the ‘IMR’ sub-dimension (Beydag˘ & Mete 2008). Wijma Delivery Expectancy/Experience Questionnaire-A (W-DEQ version A)
Wijma, Wijma and Zar developed the W-DEQ in response to the absence of an appropriate psychological instrument for measuring women’s clinical experience of FOC. The W-DEQ
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measures fear by asking women about their expectations before delivery (version A) and about their experiences after delivery (version B) (Wijma et al. 1998). Körükçü et al. (2012) confirmed the validity and reliability of the questionnaire in a Turkish population. The internal consistency and split half method reliability of the W-DEQ-A was more than 0.87, indicating that the instrument is appropriate for measurement. In this study, the W-DEQ-A’s Cronbach’s alpha value was 0.92. The response categories in the questionnaire were numbered from 0 to 5 along a 6-point Likert-type scale, with 0 corresponding to ‘extremely’ and 5 corresponding to ‘not at all’. The 6-point Likert-type format was selected because the increase in questionnaire scores leads to an increase in reliability. The increase in reliability ceases after 7 points or more and remains stable. The minimum and maximum scores that can be obtained from the questionnaire are 0 and 165, respectively. Higher scores indicate greater levels of FOC. Implementation of education provided to the EG
Table 1 summarizes the education topics and contents according to weeks. The education sessions were carried out using relevant appropriate models and figurines, visual instruments and videos. Motion, demonstration and interactive education methods were used. The education sessions were conducted in a special room designed for pregnancy education within the study hospital.
Table 1 Antenatal educational programme Weeks
Subject
Educational content
1
Health in pregnancy
2
Birth and breathing exercises
3
Breastfeeding
4
Baby care
5
Post-partum period and family planning
Introduction of anatomy and physiology in males and females and how pregnancy occurs, physiological and psychological changes during pregnancy, introduction of prenatal care and tests, nutrition during pregnancy, exercise during pregnancy, sexuality during pregnancy, danger and signs in pregnancy Make a birth plan, symptoms of impending birth, symptoms indicating the initiation of labour, mechanisms of labour and birth in adequate detail, prepare pregnant woman and partner for labour and delivery, teach pregnant woman breathing and relaxation techniques to be used during labour and delivery, techniques, operative delivery Breastfeeding, discuss advantages and disadvantages of breastfeeding and bottle feeding, instruct pregnant woman to prepare nipples for breastfeeding, positioning the baby, proper latch-on, preventing problems and returning to work The interventions newborn immediately after delivery (apgar scores, height, weight, head circumference measurement, etc), newborn reflexes, belly care, baby bath, baby’s clothing, newborn screening tests, communicating with the baby, baby massage, baby’s room, newborn baby’s safety, healthy child controls and vaccines Physical and emotional post-partum changes and coping and taking care of oneself, discussion, nutrition during post-partum, childbirth and post-partum changes, exercise during post-partum, post-partum sexuality, post-partum family planning, post-partum controls, determine pregnant woman’s knowledge and attitudes about parenting, promote pregnant woman’s self-esteem in taking on parental role, provide anticipatory guidance for parenthood
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Equipped with lighting, pillows and exercise cushions, the special room provided an environment in which the participants could feel comfortable. The course was conducted once a day for 180 min between the hours of 01:00–04:00 pm. Pregnant women and their spouses, or a relative, attended predetermined sessions for 5 weeks, totalling 15 h. The mean number of participants in each group was 6–10 couples. The first author (ÖK) delivered the programme and attended the Antenatal Preparation Class Instructor Training course twice. The author (ÖK) also had 6 years of experience as a pregnancy instructor at the study hospital and served as an instructor for the Childbirth Educator Courses numerous times. The CG
The CG consisted of pregnant women who attended the pregnancy follow-up polyclinic, met the inclusion criteria and did not attend the antenatal classes. The CG received only routine pregnancy care and information. Ethical considerations
Prior to the study, permission was obtained from the ethics board (ethics board approval date, protocol and decision number: 7 December 2012/21581/48). The participants received written and oral information about the study provided by the authors. The participants were assured that participation in the study was voluntary, that they could withdraw from the study at any time and that their identities would remain confidential. Their written consent was obtained. Data analysis
Statistical Package for the Social Sciences (SPSS) 15.0 (SPSS Inc., Chicago, IL, USA) was used for data analysis. Alpha score
of 0.05 was accepted for statistical significance. The t-test and chi-square test were used for determining between-group differences. The Kolmogorov–Smirnov test was used for testing whether the data were normally distributed. Because the scores were not in a normal distribution, the Mann–Whitney U-test was used to compare the EG and CG’s FOC, AP and IMR levels. The Wilcoxon test was used to compare the levels of AP and IMR as the scores were not normally distributed. Because the scores for FOC did exhibit a normal distribution, the mean scores were compared using the paired sample t-test.
Results The demographic characteristics of pregnant women in EG and CG were compared. The mean age of pregnant women in the EG and CG (28.87 ± 4.54; 25.73 ± 5.35, respectively), their mean length of marriage (3.01 ± 2.25; 2.32 ± 1.93, respectively) and their employment status showed no statistically significant differences (P > 0.05). However, significant differences were found between the educational level of women in the EG and CG (P < 0.002). More than half of the participants in the EG (60.9%) and 20.3% of participants in the CG were university graduates. Comparing the obstetric characteristics of pregnant women in EG and CG, they were similar (P > 0.05) in terms of week of pregnancy (26.10 ± 2.37; 25.88 ± 2.12, respectively), status of planned pregnancy and preferred type of delivery. As shown in Table 2, the EG’s pre- and post-education levels of AP, IMR and FOC were compared with the first and second measurements for CG. No significant difference was found between EG and CG’s baseline levels of AP (P > 0.05). However, there was a significant difference in the levels of AP between the EG’s post-education measurement and the CG’s second measurement (P < 0.001). According to this finding, the H1
Table 2 Between-group comparisons of pre- and post-education acceptance of pregnancy and identification with the motherhood role and fear of childbirth scores Scales
PSEQ First evaluation – acceptance of pregnancy Second evaluation – acceptance of pregnancy First evaluation – identification with a motherhood role Second evaluation – identification with a motherhood role W-DEQ A First evaluation W-DEQ A score Second evaluation W-DEQ A score
Education group (n = 69) Median (quartiles)*
Control group (n = 123) Median (quartiles)*
P†
18 (16–21) 14 (15–20.50) 23 (20–27) 21 (18.50–23)
19 (17–23) 18 (17–22) 21 (18–25) 21 (18–24)
0.475 0.002* 0.101 0.851
54 (35–70) 27 (14–49.50)
43 (24–63) 41 (22–62)
0.014* 0.022*
*25th and 75th percentile. †Mann–Whitney U-test. PSEQ, Prenatal Self-Evaluation Questionnaire; W-DEQ A, Wijma Delivery Expectancy/Experience Questionnaire version A.
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Table 3 Within-group comparisons of pre- and post-education acceptance of the pregnancy–motherhood role and fear of childbirth scores Scales
PSEQ Acceptance of pregnancy Identification with a motherhood role W-DEQ A score
Education group (n = 69)
Control group (n = 123)
Before education Median (quartiles)*
After education Median (quartiles)*
P†
First evaluation Median (quartiles)*
Second evaluation Median (quartiles)*
P†
18 (16–21) 23 (20–27) Mean ± SD 53.25 ± 25.75
17 (15–20.50) 21 (18.50–23) Mean ± SD 33.72 ± 24.33
0.000* 0.005* P‡ 0.000*
19 (17–23) 21 (18–25) Mean ± SD 44.32 ± 5.00
18 (17–22) 21 (18–24) Mean ± SD 41.97 ± 24.64
0.253 0.133 P‡ 0.200
*25th and 75th percentile. †Wilcoxon signed-rank test. ‡Paired sample’s t-test. PSEQ, Prenatal Self-Evaluation Questionnaire; SD, standard deviation; W-DEQ A, Wijma Delivery Expectancy/Experience Questionnaire version A.
hypothesis was accepted. The EG’s pre-education and CG’s first measurement level of IMR showed no significant differences (P > 0.05). Similarly, the EG’s post-education and CG’s second measurement levels of IMR showed no significant differences (P > 0.05). According to this finding, the H2 hypothesis was rejected. The EG’s pre-education and CG’s first measurement levels of FOC showed significant differences (P < 0.005). The EG’s post-education and CG’s second measurement levels of FOC also showed significant differences (P < 0.005). According to this finding, antenatal education was effective in reducing the FOC among primipara and hypothesis H3 was accepted. As shown in Table 3, the EG’s pre- and post-education scores and CG’s first and second scores for the AP, IMR and FOC were compared within groups. It was determined that the EG’s preeducation level of AP, IMR and FOC decreased compared with the post-education measurements, and significant differences were evident between the pre- and post-education levels (P < 0.001). The decrease in the scores indicates an increase in the AP and the IMR role. It was determined that the antenatal education improved AP, increased IMR and reduced FOC. In the CG, AP, IMR and the FOC decreased between the first and second measurements. However, these decreases were not statistically significant (P > 0.05).
Discussion Our study, which aimed to determine the effect of education on AP, IMR and FOC, found that antenatal education increases the AP, does not affect IMR and reduces FOC. There was a significant difference between women in EG and CG in terms of their level of education. More than half of women in the EG and only 20.3% of women in the CG had bac-
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helor’s degrees. In similar studies, most of the women in the EG were found to have graduated from college (Bergström et al. 2010; Cos¸ar & Demirci 2012; Fabian et al. 2005; Serçekus¸ & Mete 2010b). Because the EG was allowed to self-select, this significant difference can be explained by more highly educated women feeling the need for such education or being willing to undertake it because of their awareness of their lack of experience and knowledge and their desire to benefit from such a service. In Serçekus¸ & Mete (2010b), the prenatal coping of women in CG was better than that of women who took antenatal education, both individually and as a group. Similarly, in our study, the scores for AP were lower for women who received antenatal education, which corresponded to better coping, with a very significant difference. Accordingly, hypothesis H1 (pregnant women who receive antenatal education have better levels of AP compared with pregnant women who do not receive antenatal education) was verified. However, Hamilton-Dood et al. (1989) found that a 6-h prenatal class delivered a month before delivery had no effect on prenatal coping. This difference can be explained by the fact that in both Serçekus¸ & Mete (2010b) and our study, the education programmes started in weeks 24–28 of pregnancy, lasted longer and were completed before the final month of pregnancy, when women were focused solely on delivery. Additionally, increased coping could be explained as all women in our study were primipara and almost all had planned pregnancies. Based on these findings, future studies could compare AP between primipara and multipara who received antenatal education may be conducted. In our study, the IMR scores did not change significantly between the first and second measurements. Accordingly,
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hypothesis H2 (women who received antenatal education would have better IMR than those in the CG) was rejected. The identification with the role of motherhood begins before conception and completes within the year following delivery (Alligood 2013). This case may be explained by all women in the study being primipara, within their last trimester and lacking any experience of motherhood. Additionally, the lack of difference between groups in both measurements might suggest that neither education nor advancement of pregnancy had any effect on IMR. In light of this finding, studies may be planned in order to evaluate the effect of antenatal education on motherhood role during the post-partum period. Gagnon & Sandall (2007) stated that the reason pregnant women take antenatal education is to reduce anxiety regarding delivery. This study supports Gagnon and Sandall’s findings as a significant difference was found between the levels of FOC in EG and CG in the first measurements. Women in EG scored higher on FOC, which may explain why these women selfselected into the EG – women who experience FOC seek a way to cope. In similar studies, 20–25% of pregnant women were found to fear childbirth (Toohill et al. 2014; Zar et al. 2001), whereas 5–10% of pregnant women were found to experience serious anxiety and fear regarding childbirth (Ryding et al. 2007). The most prominent reasons for pregnant women’s childbirth-related fears were related to being primipara (Melender 2002; Wiklund et al. 2008), lacking knowledge regarding pregnancy and misinformation (Serçekus¸ & Okumus¸ 2009). The second measurements of levels of FOC also showed a significant difference between the two groups (P < 0.005). Accordingly, hypothesis H3 was verified. Ryding et al. (2003) found that pregnant women liked the services of midwives with special counselling training, although they did not find them very effective in reducing the FOC. Serçekus¸ & Mete (2010b) found that antenatal education reduced the FOC. According to these results, a professional and systematic education programme can reduce the FOC. For this reason, it can be recommended that similar studies test the effectiveness of education with multipara women who experience FOC and who had previous negative birth experiences. Implications for nursing and health policy
Formal provision of antenatal education by nurses/midwives, which is not currently included in routine antenatal care services, will facilitate pregnant women’s conscious participation in the act of labour by reducing their FOC. It will help reduce the rate of interventional labour and related complications in mothers and infants, thereby promoting the healthy development of mother–infant interaction. In Turkey, it is necessary to standardize and extend antenatal education programmes so as
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to provide them on a routine basis, and to consider relevant international health policies in order to increase the number of nurses/midwives qualified to provide such education. Limitations of the study
The main limitation of the study is the lack of randomization in the groups, which was not possible owing to the attendance risks related to women who were unwilling to receive the education. Although all EG participants voluntarily self-selected, there was a dropout rate of approximately 31% (due to wanting to quit the study, irregular participation in the course or complications related to pregnancy). As the institution determined the course schedule, not everyone could be accommodated, resulting in participant attrition. Moreover, the study was limited by sample losses in the CG because of non-attendance of appointments or transferring to other institutions.
Conclusion A systematic antenatal education programme provided by healthcare professionals (nurses/midwives) was found to increase pregnant women’s AP, reduce their FOC and have no effect on their IMR.
Acknowledgements The authors thank the pregnant women who participated in the study. They also wish to acknowledge their statistics expert, Associate Professor, Ays¸e Ergün and Associate Professor Nilüfer Özaydın.
Author contributions ÖK, DCP, YDM, SMC and ND: Study conception/design. ÖK, DCP and SMC: Data collection/analysis. ÖK, DCP, YDM and ND: Drafting of manuscript. DCP, YDM and ND: Critical revision for intellectual content. DCP and ND: Study supervision.
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Serçekus¸, P. & Mete, S. (2010a) Turkish women’s perceptions of antenatal education. International Nursing Review, 57 (3), 395–401. Serçekus¸, P. & Mete, S. (2010b) Effects of antenatal education on maternal prenatal and postpartum adaptation. Journal of Advanced Nursing, 66 (5), 999–1010. Serçekus¸, P. & Okumus¸, H. (2009) Fears associated with childbirth among nulliparous women in Turkey. Midwifery, 25 (2), 155–162. Spinelli, A., et al. (2003) Do antenatal classes benefit the mother and her baby? The Journal of Maternal-Fetal and Neonatal Medicine, 13 (2), 94–101. Tighe, S.M. (2010) Midwifery article an exploration of the attitudes of attenders and non attenders towards antenatal education. Midwifery, 26 (3), 294–303. Toohill, J., et al. (2014) Psychosocial predictors of childbirth fear in pregnant women: an Australian study. Open Journal of Obstetrics and Gynecology, 4 (9), 531–543. Wijma, K., Wijma, B. & Zar, M. (1998) Psychosomatic aspects of W-DEQ: a new questionnaire for measurement of fear of childbirth. Journal of Psychosomatic Obstetrics and Gynaecology, 19 (2), 84–97. Wiklund, I., Edman, G., Ryding, E. & Andolf, E. (2008) Expectation and experiences of childbirth in primiparae with caesarean section. BJOG: An International Journal of Obstetrics and Gynaecology, 115 (3), 324–331. Zar, M., Wijma, K. & Wijma, B. (2001) Pre- and postpartum fear of childbirth in nulliparous and parous women. Scandinavian Journal of Behaviour Therapy, 30 (2), 75–84.
Supporting information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site Table S1 Distribution of women in education and control groups by demographic characteristics (n = 169)
