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

Introduction

In the Bible, Eve was punished for her sin, “…in sorrow thou shalt bring forth children” (Genesis 3:6). Sorrow is defined as the distress, grief, sadness, or regret caused by loss, affliction, or disappointment [1]. Today, more than 5000 years later, women still have an array of negative feelings and emotions that accompany pregnancy and delivery. These may have detrimental effects on both maternal and neonatal pregnancy outcomes such as preterm delivery, cesarean section (CS) and maternal depression after birth, among others [2], [3], [4], [5], [6], [7].

Fear of childbirth has gained growing attention. One out of every five pregnant women fear childbirth [3], [4]. Several factors have been associated with increased prevalence of fear of childbirth, including young maternal age, nulliparity, pre-existing psychological problems, lack of social support and a history of abuse or adverse obstetric events [8], [9], [10]. Anxiety and fear of childbirth is reported as being severe and symptomatic in many women. Symptoms may manifest as nightmares, physical complaints and difficulties in concentrating on work or on family activities [4], [6]. A possible explanation for these observations can lie in increased plasma concentrations of catecholamines often seen in states of anxiety and fear [3], [11], [12], [13].

It has been postulated that antenatal preparation could play a major role in the health of the mother and newborn during labor and postpartum. Studies on the treatment for fear of childbirth are few, and no consensus exists on how, where and by whom the possible treatment should be given [14]. Childbirth preparation and support during pregnancy and delivery are principal elements in such care. Education and information reduce concerns on the infant’s health, but relaxation training and methods of coping with pain are needed to alleviate general anxiety [4].

Studies evaluating birth preparation courses and interventions have shown conflicting results. Following birth preparation courses and interventions, favorable effects such as reduction in dystocic deliveries, decreased duration of vaginal labor and CSs were noted. Moreover, reducing high childbirth fear levels and increasing childbirth confidence in pregnant women promotes antenatal emotional well-being and may have wider positive social and maternity care implications for optimal childbirth experiences [15], [16], [17], [18]. Others have shown no reduction in the request for cesarean delivery or use of overall pain relief medication [19], [20].

Every year about 135,000 pregnant women receive prenatal services in Israel. This care is provided mainly in mother and child health clinics. The purpose of these clinics is to monitor the health of pregnant women and their fetuses, diagnose and detect high risk pregnancies, advice, educate, support and provide preventive and therapeutic treatment where appropriate [21]. Prenatal care is an integral part of health services provided to all women in Israel, whether as part of preventive medicine or therapeutic health care. Lately, care is increasingly being delivered by other providers including private doctors, primary care clinics and women’s health clinics. Women are also increasingly using this array of services in conjunction with the traditional mother and child health clinics or instead of them [22].

We undertook this study in order to evaluate the effect of childbirth preparedness courses on labor duration and perinatal outcomes.

Methods

Discussion

In the current study, we aimed to evaluate the effect of attending a prenatal childbirth preparedness course on labor duration and outcomes. The main findings of our study are that attending a prenatal childbirth preparedness course was associated with a significantly shorter first stage and total duration of labor and with an improved labor experience and significantly higher rates of breastfeeding.

Clinical fear of childbirth complicates approximately 20% of pregnancies in developed countries where it is mostly evaluated. Severe clinical fear affects some 6%–10% of parturients [4], [6]. Fear of childbirth can be attributed to biological (fear of pain), psychological (related to personality, previous traumatic events, or fear of future parenthood), social (lack of support, economic uncertainty), or secondary (originating from previous childbirth experiences) reasons and factors [4].

In the current study, a difference of borderline significance was demonstrated between groups in rates of labor induction that were lower among patients that attended a childbirth preparedness course. Nevertheless, no significant difference was noted between the groups with regard to the mode of delivery, use of epidural analgesia and neonatal outcomes. These results are similar to previous studies [16], [18], [23] that found no differences between groups for use of pharmacological analgesia, induction of labor or neonatal outcomes.

In a study of 2206 women with intended vaginal delivery, women with fear of childbirth spent 1.54 h (1 h and 32 min) longer in labor than women with no such fear. This was reduced to 0.78 h (47 min) after adjustment for other factors associated with labor duration. However, the duration of labor remained significantly longer in these women [3]. In our study we found that, patients who attended a childbirth preparedness course had a significantly shorter mean first stage of labor as well as significantly shorter mean total labor duration. The second and third stages of labor were not significantly different between the groups; however these are less likely to change regardless of prenatal interventions. Although no correlation was found between the STAI scores and labor duration, attending a prenatal childbirth preparedness course may have wider positive social and obstetrical care implications other than alleviating anxiety.

Breastfeeding for all infants is strongly supported by both governmental and medical professional organizations because of its acknowledged benefits to the infant with respect to nutrition, gastrointestinal function, host defense and psychological well-being. In addition to these direct short-term benefits, breastfeeding is associated with long-term benefits to the infant. As with infants, breastfeeding provides direct clinical benefits to mothers during lactation and long-term benefits beyond the breastfeeding period. Moreover, there are also significant economic benefits for the family and society [24], [25], [26]. In this study, we have demonstrated that the rate of breastfeeding was significantly higher among patients who attended the childbirth preparedness course. Likewise, Imdad et al. [27] reported that prenatal counseling had a significant impact on breastfeeding outcomes at 4–6 weeks [27].

In our study, feelings of anxiety, depression and fear of childbirth were evaluated using the STAI score. The STAI is a validated instrument that quantifies adult anxiety. The univariate analysis revealed that women who attended a prenatal childbirth preparedness course had significantly lower STAI scores and that the rate of women with a high STAI score (indicating severe anxiety) was also lower. Previous studies have demonstrated that prenatal psycho-educational interventions provided by trained midwives or other obstetrical staff, are effective in reducing high childbirth fear levels. Moreover, improving antenatal emotional well-being has beneficial effects on perinatal outcomes such as a reduction in overall CS rates and may also have wider positive, social and maternity care implications for optimal childbirth experiences [17], [18]. In contrast to the favorable impact of prenatal interventions aimed at alleviating anxiety and fear of childbirth, in our study, the multivariate analysis revealed that anxiety levels were not independently associated with attending the childbirth preparedness course. In addition, no correlation was demonstrated between the STAI score and other outcome variables such as labor duration and neonatal birth weight. These findings may indicate that the favorable outcomes of attending the childbirth preparedness course as were demonstrated in our study can be attributed to other effects rather than alleviating anxiety.

Our study might have some limitations. We evaluated several outcomes in association with attending a prenatal preparedness course in nulliparous women. It is possible that for at least some of these outcomes our sample size was underpowered to detect significant differences between groups. In addition, as we included only nulliparous women, our results may not be generalized to the entire parturient population. It is possible that other factors including previous childbirth experience and previous labor trauma may influence the results. This point may be perceived by some as a merit of this study, as it isolates previous experiences and focuses on pure perceptions of labor that are possible only in nulliparous women. It would be interesting in the future to investigate differences between primiparous and multiparous women. However, there are several strengths to our study including the prospective nature of data collection, using a validated tool to evaluate anxiety and fear of labor and the use of the perinatal database in our medical center for retrieving data. It should be noted that the clinical and obstetrical data are routinely reported by an obstetrician directly after delivery. Skilled medical secretaries routinely review the information prior to entering it into the database. Coding is done after assessing the medical prenatal care records together with the routine hospital documents. This makes missing data less likely.

In conclusion, the knowledge acquired in the prenatal childbirth preparation course may have a role in reducing anxiety of labor and is associated with a significantly shorter first stage and total duration of labor and with an improved labor experience. Moreover, attending the prenatal course, increases women’s awareness to the importance of breastfeeding and results in significantly higher rates of breastfeeding.