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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

BMC Pregnancy and Childbirth volume 23, Article number: 541 (2023) Cite this article

Abstract

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.

Peer Review reports

Introduction

Pregnancy and childbirth are among women’s most important experiences. Pregnancy leads to significant challenges, such as physical changes, psychological stress, and changing roles. In addition, childbirth has physical, psychological, emotional, social, and cultural dimensions [1]. Much evidence confirms the relationship between pregnancy and psychological problems such as fear, anxiety, and depression [2]. Fear of childbirth commonly leads to prolonged labour [3], more severe pain experience [4], a negative impact on the birth experience [5], and increasing requests for elective caesarean delivery [6, 7]. Anxiety and self-efficacy for childbirth are inversely related. The pregnant woman’s low self-efficacy increases their perception of childbirth pain and, in turn, increases their level of anxiety [8, 9].

There is a relationship between anxiety levels experienced during pregnancy and poor mother-infant bonding quality during pregnancy and after birth [10]. The World Health Organization (WHO) has requested preparation for birth as an essential component of prenatal care [11].

Prenatal education worldwide is essential in preparing couples for pregnancy, childbirth, and parenthood [12]. Prenatal education generally offers expectant parents strategies for coping with pregnancy, childbirth, and parenthood [13]. Its specific goals include increasing knowledge, growing mothers’ confidence in giving birth and parenthood, positively affecting childbirth experiences, promoting breastfeeding, and improving newborn care, postpartum care, and parenting skills in the postpartum period [14, 15].

Prenatal education classes in many countries are based on basic philosophies such as Dick-Read, Bradley, Lamaze, and Hypnosis. Pregnancy education classes discuss many topics, including health during pregnancy, physiological pregnancy changes, complaints and high-risk situations, nutrition during pregnancy, the mother’s role and relationship, childbirth preparation, pain control during childbirth, postpartum period and breastfeeding, newborn care, and pregnancy exercise [16]. American College of Obstetricians and Gynecologists (ACOG) suggests that exercise during pregnancy improves women’s health and prevents gestational diabetes and excessive weight gain [17].

Studies on the effect of prenatal education on childbirth and parenthood show that this education reduces the fear of childbirth [12, 18,19,20], anxiety at birth [17, 20, 21], depression [20], the perceived childbirth pain [22] and increases childbirth self-efficacy [12, 18, 19, 21, 22]. Although some studies do not confirm the effect of prenatal education on the childbirth experience [14] and parental attachment [12], Toosi et al. (2014) found that relaxation training during pregnancy increases maternal attachment [23], and Abbasi et al. (2013) found that maternal attachment promotion training was successful [24]. Gagnon and Sandall (2007) performed a meta-analysis on 2284 women participating in childbirth preparation courses. They concluded that the effect of prenatal education on women’s level of awareness and anxiety, sense of self-control, perceived labour pain, and social and emotional adjustment was not significant [15].

Due to limited healthcare resources, policymakers should make informed and scientific decisions about healthcare priorities [25]. A review is needed to evaluate the effectiveness of prenatal education compared to providing no education. Therefore, the present scoping review using a systematic approach evaluates the effects of antenatal education on fear of childbirth, pain intensity during labour, childbirth experience, and postpartum psychological health.

Methods

We used Cochrane Handbook for Systematic Reviews of Interventions [26] and the PRISMA statement and registered the study on the International Prospective Register of Systematic Reviews (PROSPERO) (Registration number: CRD42022376895).

Search strategy

Databases such as PubMed, Web of Science, Cochrane, Scopus, SID (Scientific Information Database) and search engine Google Scholar were explored. Search terms were adapted according to each database. The complete search strategy for each database is provided in Appendix 1, and only the clinical trials in English and Persian were searched. This study reviews the article cited in previous research and previous systematic reviews. No restrictions were applied to the publication date. The search was conducted two times: at the beginning of the study and just before the end of the study. No differences were found between the two-time points regarding the included studies.

Eligibility criteria

This scoping review using a systematic approach examined randomized controlled and quasi-experimental trials in which the intervention group received structured prenatal education and routine prenatal care, and the control group received only routine prenatal care. Structured prenatal education include training classes with various contents such as basic knowledge of pregnancy, care during pregnancy, the process of childbirth, care during the postpartum period and care of newborns, which were presented by trained midwives, nurses, or obstetricians and were held at least four sessions one hourly between 20 and 37 weeks of pregnancy [27]. Routine prenatal care included taking a complete history, performing physical and ultrasound examinations, and giving education. It last about 15–20 min, which is not sufficient time for antenatal education [28].

The participants were pregnant women desiring a normal vaginal delivery (a vaginal delivery, whether or not assisted or induced, usually used to contrast with the delivery by caesarean Sect. [29]) and having no maternal or foetal problems history. This study examined these outcomes: fear of childbirth, pain intensity in the first and second labour phases, and childbirth experience (as primary outcomes) and maternal attachment, postpartum depression, and postpartum anxiety (as secondary outcomes). Valid and reliable tools assessed all outcomes in all included studies. For example, a W-DEQ or other researcher-made questionnaires assessed the fear of childbirth. A numerical rating scale or visual analogue scale assessed pain intensity in the first and second labour phases. The Edinburgh Postnatal Depression Scale (EPDS) was used to assess postpartum depression, and Depression Anxiety and Stress Scale (DASS-21) was used to assess postpartum depression and anxiety.

Selection of studies

The reviewed articles were selected in two stages. First, two authors (Z.A-D & S.A) independently examined all the titles and abstracts to determine the studies’ eligibility in the systematic search. Second, the full text of the articles obtained in the first stage was evaluated based on the inclusion criteria. Possible disagreements were resolved through discussion or with the help of the third author (M.M).

Data extraction

A form based on the Cochrane manual for systematic review was designed to contain all the articles’ information [26]. Two researchers (Z.A-D & S.A) independently collected each article’s data, including authors’ names, year of publication, study place, intervention type, comparison group, final sample size, measurement tool, outcomes, and results.

Quality assessment

When assessing the risk of bias, the selected randomized controlled trials were investigated using the risk of bias-1 approach (ROB-1) [30] regarding random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessors, selective reporting, and incomplete outcome data. In addition, the selected semi-experimental trials were investigated using the ROBINS-1 approach [31].

Two authors (Z.A-D & S.A) used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to independently evaluate the quality or certainty of evidence in five dimensions: the risk of bias, inconsistency, indirectness, imprecision, and publication bias. Possible disagreements were resolved through discussion with the third author (M.M). All the trials were described and compared regarding demographic information and intervention type when investigating inconsistency. Statistical heterogeneity was checked using the I2 statistic and 95% confidence interval (with I2 ≥ 60% showing reduced certainty of the evidence due to inconsistency) [32]. In evaluating Indirectness, the study population, type of intervention, control group, and outcomes of included studies were examined to answer the question of the current review [33]. The sufficiency of the participants’ number in included trials for calculating the effect estimate and the confidence interval size around the effect estimate was examined when investigating imprecision [34]. Regarding publication bias, the study size of included trials was examined. Then, the outcomes with more than ten studies were plotted using a funnel plot, with asymmetric funnel plots indicating possible bias [35]. When calculating the evidence quality of the examined outcomes, potential severe concerns about any dimension were resolved by a one-degree reduction of the evidence quality. A two-degree decrease in the quality of evidence was used to determine very severe concerns.

Synthesis of results

Measures of treatment effect

Mean and standard deviation changes of baseline and post-intervention in both groups (intervention group received prenatal education and routine care and control group received only routine care) were calculated. Accordingly, the intervention effects on the continuous outcomes studied in the trials were calculated. Then, a mean difference (95% confidence interval) was used to report the mean change difference. In addition, a standardized mean difference (SMDs) (95% confidence interval) was used to report outcomes using different scales to examine continuous outcomes [36].

Data synthesis

Meta-analysis using Review Manager 5.3 was performed to compare the studied outcomes between the intervention and control groups in cases with at least two trials. Previous studies have used different tools to evaluate the outcomes. This study used the random effect method instead of the fixed effect method to calculate the intervention’s effect size on the desired outcome due to high heterogeneity.

Results

Results of the search

The results of the study search strategy are summarized in the PRISMA diagram (Fig. 1). Overall, 3242 studies were examined, of which 3216 did not meet the inclusion criteria and were excluded. Finally, 26 studies were reviewed, of which 18 trials [12, 22, 27, 28, 37,38,39,40,41,42,43,44,45,46,47,48,49,50] were included in the final analysis, which one of them was PhD thesis [46], and the remaining eight trials [51,52,53,54,55,56,57,58] were excluded due to the lack of inclusion criteria.

Fig. 1
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Study flow diagram

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Characteristics of included studies

The characteristics of the trials included in the review are summarized in the characteristics table. This table contains information about the study design, the studied groups, intervention types, the blinding type, the follow-up period, the number of participants in each group, the inclusion and exclusion criteria, primary and secondary outcomes, and results (Table 1).

Table 1 Characteristics of included studies
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Included studies

This study systematically reviewed 12 randomized controlled trials [22, 28, 37,38,39,40, 44,45,46,47,48, 50] and six semi-experimental trials [12, 27, 41,42,43, 49] on 2056 pregnant women in Iran, Turkey, China, Egypt, and Kenya. The studies, including 17 articles and one PhD thesis, were published between 2014 and 2022. Two papers were in Persian, and the rest were in English. In all the trials, the control group only received routine prenatal care (taking a complete history, performing physical and ultrasound examinations, and giving education. It lasted about 15–20 min, which was not sufficient time for antenatal education), but the intervention group also received prenatal education. Pregnant women in the intervention group received structured training during pregnancy from trained midwives, nurses, or obstetricians. Different studies had different training classes: the training classes were held between 16 and 36 weeks of pregnancy, each class included 5 to 15 participants, each course included 3 to 8 sessions, each training session lasted 45 to 240 min, and the classes were held one to two times a week. The education included various contents such as physical, functional, and psychological changes during pregnancy, familiarity with the female reproductive system, warning signs during pregnancy, advantages and disadvantages of vaginal childbirth and caesarean section, nutrition and exercise during pregnancy, and stages of labour. Other contents included signs of false labour versus real labour, proper behaviours at the beginning of labour, labour breathing and pain-reducing techniques, natural, physical, and psychological changes after childbirth, after-labour dangerous signs, newborn care, and breastfeeding techniques. The training also included counselling through questions and answers, free discussion on intended topics, mental and muscle exercises, education on appropriate positions for labour and delivery, and appropriate breathing during labour and delivery.

Some specific studies were focused on more educational content. For example, the educational content of studies examining postpartum depression and anxiety was focused more on the self-image and emotional, mental, and psychological health of mothers in the postpartum period [27, 37, 39, 48]. Similarly, studies examining maternal attachment were focused on training mechanisms of mother-and-foetus communication or parents-foetus adaptation methods [12, 50]. Educational classes were held in person in health centres or hospitals, and the contents were presented through lectures, posters, PowerPoint slides, animation videos, and role plays. Uludag et al. in Turkey was the only study being held online due to the Covid-19 epidemic [28]. In addition to in-person training classes, a study examining postpartum depression and anxiety also provided the participants with an educational booklet for study at home, separate ten-minute telephone consultations for mother and father after the delivery, and answering the participants’ questions by phone [48]. The control group in the studied trials received routine care during pregnancy, including taking a complete history, physical examination, and sonography, with the trials lasting 10 to 20 min.

The participants were pregnant women aged 18 to 35 years, with a singleton pregnancy, a gestational age of 14 to 36 weeks, and a desire to have a normal vaginal delivery which in 13 reviewed studies were nulliparous [12, 22, 27, 28, 38,39,40, 42, 43, 45,46,47, 50] and in the rest of reviewed studies were multiparous [37, 41, 44, 48, 49]. The participants had consented to participate in the trials. Being nulliparous was not an inclusion criterion in some studies [37, 41, 44, 49], and women with one or two pregnancy histories were also included [48]. Some exclusion criteria in these trials were being unmarried, having a history of psychiatric diseases, drug addiction, and other medical diseases such as gestational hypertension, gestational diabetes, preeclampsia/eclampsia, placenta previa, preterm delivery, and diagnosis of congenital foetal abnormalities or foetal disease. The pregnant mothers and their partners participated in training classes in two studies. In the first one, the mothers and their partners were compared to those in the control group [12]. In the second one, the partners without mothers participated in a training session of 15–25 partners. It compared three groups (e.g., mothers with their trained partners, mothers with their untrained partners, and the control group mothers) regarding the intended outcome [48]. We found no study examining the effect of prenatal education on mothers’ childbirth experience. Two studies examined the effect of prenatal education classes on mothers’ attachment behaviour; one studied the effect of maternal-foetal attachment during pregnancy [50], and the other investigated parental-infant attachment and maternal bonding after delivery [12].

Excluded studies

The reasons for excluding seven studies from the review were as follows: three studies had provided the same prenatal education to the intervention and the control groups [51, 52, 58], one study was designed as a single-group study before and after the intervention [54], one paper’s full text was out of our reach [53], two paper had used interventions different from those intended in the present study [55, 56], and one paper was in the Indonesian language [57] (Table 2).

Table 2 Characteristics of excluded trials and main reasons for exclusion
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Risk of bias in included studies

The risk of bias was addressed in randomized controlled trials using the ROB-1 approach and in semi-experimental trials using the ROBINS-1 approach [30, 31]. Except for one case rated as unclear risk [22], all the randomized controlled trials were rated low risk in random sequence generation. Only six trials were rated as low risk in allocation concealment [28, 39, 40, 44, 47, 48], and the rest were rated as high or unclear risk. The nature of the studies made the blindness of the personnel providing the interventions impossible. Nevertheless, participants in only two studies were blinded regarding placement in the study groups and the type of intervention received in the other group [28, 47], and the rest were at high risk. In addition, only the outcome assessors in four studies were blinded [39, 46,47,48], and the rest were at high risk in this respect. Three studies were rated as high risk regarding incomplete outcome data or attrition bias [37, 40, 45], and the rest were low risk. Finally, all the studies were rated as low risk regarding selective reporting bias, and only two were rated as unclear risk [40, 50] (Table 3; Figs. 2 and 3).

Table 3 Risk of bias of included studies (RCTs)
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Fig. 2
figure 2

Risk of bias graph. Review authors’ judgments about each risk of bias item presented as percentages across all included studies

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Fig. 3
figure 3

Risk of bias summary: Review authors’ judgments about each risk of bias item for each included study

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The overall risk of bias for the semi-experimental trials was considered serious because there was at least one serious bias in the investigated subdomains. Thus, all studies were at moderate to severe risk of bias due to confounders. One study was at a low risk of bias caused by the participants’ selection [49], and the rest were at a high risk. All the studies were low risk regarding biases caused by the classification of interventions and deviations from intended interventions. Only one study was at low risk regarding biases due to missing data [42], and the rest were at moderate to severe risk. All the studies were at high risk of bias due to the measurement of outcomes. Only one study was at low risk regarding biases caused by the selection of reported results [27], and the rest were at moderate to severe risk. In summary, all semi-experimental trials examined in this study were at high risk of bias (Table 4).

Table 4 Risk of bias of included studies (Semiexperimental study)
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Outcome measurement

Primary outcomes

Fear of childbirth

Eight randomized controlled [28, 38,39,40, 44,45,46,47] and four semi-experimental [12, 42, 43, 49] trials compared the fear of childbirth in pregnant women receiving prenatal education and routine care with women receiving only routine care. All studies have used the W-DEQ questionnaire to measure fear of childbirth, except four studies that had used a researcher-made questionnaire [44], The Fear of Birth Scale (FOBS) [28], Delivery Fear questionnaire [49], and the Fear of Childbirth questionnaire [47]. Calpbinici and Özçirpan [38] (MD -34.58, 95% CI -42.57 to -26.59, p < 0.001), Çankaya and Şimşek [39] (MD -40.00, 95% CI -47.26 to -32.74, p < 0.001), Dai et al. [40] (MD -11.31, 95% CI -17.92 to -4.70, p = 0.001), İsbir et al. [42] (MD -29.80, 95% CI -39.55 to -20.05, p < 0.01), Karabulut et al. [43] (MD -17.18, 95% CI -24.31 to -10.05, p = 0.022), Masoumi et al. [44] (MD -10.90, 95% CI -17.68 to -4.12, p = 0.007), Ondieki [46] (p < 0.001), Ozcoban et al. [47] (MD -1.36, 95% CI -2.00 to -0.72, p = 0.036), Serçekuş and Başkale [12] (MD -28.70, 95% CI -39.49 to -17.91, p < 0.001), and Taheri et al. [49] (MD -30.50, 95% CI -33.85 to -27.15, p < 0.001) indicated that prenatal education significantly decrease the fear of childbirth. However, Mehrabadi et al. concluded that prenatal education significantly increases the fear of childbirth (MD 19.30, 95% CI 9.51 to 29.09, p < 0.001) [45]. Researchers had access to data on changes in the average scores of fear of childbirth before and after the intervention in control and intervention groups in all studies except for Ondieki’s study. All the data were entered into the meta-analysis. The data from 11 studies conducted on 1138 pregnant women showed that prenatal education and routine care might essentially decrease fear of childbirth among pregnant mothers compared to those receiving only routine care (SMD − 16.7, 95% CI -23.5 to -9.9, p < 0.00001, 11 trials, 1138 women, Low certainty) (Fig. 4).

Fig. 4
figure 4

Antenatal education versus routine prenatal care, Outcome 1: Fear of childbirth

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Pain intensity in the first labour phase

A randomized controlled trial [22] and a semi-experimental trial [41] have compared the pain intensity in the first labour phase in women receiving prenatal education and routine care with women receiving only routine care. El-Kurdy et al. [22] used Numerical Rating Scale to measure pain intensity in the first labour stage, and Firouzbakht et al. [41] used Visual Analog Scale. El-Kurdy et al. and Firouzbakht et al. showed that prenatal education and routine care decrease the pain intensity in the first labour phase in pregnant women compared to women receiving only routine care. However, although the results of the former were significant (MD -2.32, 95% CI -2.55 to -2.09, p < 0.001), the latter was insignificant (MD -2.48, 95% CI -11.03 to 6.07, p = 0.58). The meta-analysis applied to the data from two studies conducted on 299 pregnant women showed that prenatal education and routine care compared to routine care alone decrease the pain intensity in the first labour phase (SMD − 2.3, 95% CI -2.5 to -2.1; p < 0.00001, 2 trials, 299 women, Moderate certainty) (Fig. 5).

Fig. 5
figure 5

Antenatal education versus routine prenatal care, Outcome 2: Pain intensity in the first labour phase

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Pain intensity in the second labour phase

A randomized controlled trial [22] and a semi-experimental trial [41] have compared the pain intensity in the second labour phase in women receiving prenatal education and routine care with women receiving only routine care. El-Kurdy et al. [23] used Numerical Rating Scale to measure pain intensity in the second labour phase[22], and Firouzbakht et al. [41] used Visual Analog Scale. El-Kurdy et al. and Firouzbakht et al. showed that providing prenatal education along with routine care decreased the pain intensity in the second labour phase in pregnant women, with the difference that the former decrease was significant (MD -2.04, 95% CI -2.27 to -1.81, p < 0.001). Still, the latter was insignificant (MD -4.36, 95% CI -9.71 to 0.99, p = 0.58). The meta-analysis applied to data from two studies conducted on 299 pregnant women showed that providing prenatal education and routine care compared to providing only routine care decreased pain intensity in the second labour phase (SMD − 2.0, 95% CI -2.3 to -1.8, p < 0.00001, 2 trials, 299 women, Moderate certainty) (Fig. 6).

Fig. 6
figure 6

Antenatal education versus routine prenatal care, Outcome 3: Pain intensity in second

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Childbirth experience

We found no randomized controlled or semi-experimental trials comparing the birth experience in women receiving prenatal education and routine care with women receiving only routine care.

Secondary outcomes

Maternal attachment

A randomized controlled trial [50] and a semi-experimental trial [12] have compared maternal attachment in women receiving prenatal education and routine care with those receiving only routine care. Toosi et al. [50] used Cranley’s Mother-Fetal Attachment Scale and showed that providing prenatal education and routine care significantly increases maternal-fetal attachment during pregnancy (MD 2.9, 95% CI 0.45 to 5.35, p = 0.023). Serçekuş and Başkale [12] used the Maternal Attachment Inventory four months after delivery and the Postnatal Paternal-Infant Attachment Questionnaire six months after delivery. They showed that the effect of prenatal education and routine care on maternal and parental-fetal attachments is not significant in the postpartum period (respectively MD 1.6, 95% CI -1.1 to 4.5, p = 0.258 and MD 0.5, 95% CI -2.61 to 3.61, p = 0.625). Since these two studies have evaluated different outcomes, no meta-analysis was performed on them.

Postpartum depression

Three randomized controlled trials [37, 39, 48] and one semi-experimental trial [27] have compared postpartum depression in women receiving prenatal education and routine care with those receiving only routine care. To evaluate postpartum depression, Beydokhti et al. [37] and Sanaati et al. [48] used the Edinburgh Postnatal Depression Scale (EPDS), and Çankaya and Şimşek used the Depression Anxiety and Stress Scale (DASS-21). The three mentioned studies measured the depression score of pregnant women before providing prenatal education in the intervention and control groups and also six weeks after delivery. Beydokhti et al. [37] (MD -3.67, 95% CI -5.33 to -2.01, p = 0.001), Sanaati et al. [48] (MD -3.20, 95% CI -4.74 to -1.66, p < 0.001), and Çankaya and Şimşek [39] (MD -6.70, 95% CI -9.34 to -4.06, p < 0.001) showed a significant decrease in the mean score of depression after providing prenatal education to the intervention groups compared to the control group. The meta-analysis applied to data from three studies conducted on 367 pregnant women showed that providing prenatal education and routine care compared to providing only routine care may decrease postpartum depression (SMD − 4.23, 95% CI -5.98 to -2.48; 3 trials, 367 women, Low certainty) (Fig. 7).

Fig. 7
figure 7

Antenatal education versus routine prenatal care, Outcome 4: Postpartum depression

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Gürkan et al. [27] performed a semi-experimental study without examining the depression scores of pregnant women before receiving prenatal education and measured their depression scores using the EPDS approach. They compared these scores with women receiving prenatal education and routine care six weeks after delivery and found no significant difference (MD -0.4, 95% CI -3.32 to 2.52, p > 0.05). Due to its different study design, this study was excluded from the meta-analysis.

Postpartum anxiety

Two randomized controlled trials [39, 48] compared postpartum anxiety in women receiving prenatal education and routine care with those receiving only routine care. Çankaya and Şimşek [39] used the DASS-21 approach to measure postpartum anxiety. They found a significant difference between the average anxiety score before providing prenatal education and six weeks after delivery (MD -04.6, 95% CI -7.12 to -2,08, p < 0.001). Sanaati et al. [48] evaluated postpartum anxiety using Spielberger State-Trait Anxiety Inventory based on two approaches (i.e., State anxiety and Trait anxiety) in women receiving prenatal education and routine care and those receiving only routine care. They found a significant decrease between the average state anxiety score before providing prenatal education and six weeks after delivery (MD -4.66, 95% CI -6.74 to -2.59, p = 0.001). In addition, they found a significant decrease in the average score of trait anxiety before providing prenatal education and six weeks after delivery (MD -5, 95% CI -8.4 to -1.6, p = 0.013). These two studies were excluded from the meta-analysis because they had different intended outcomes.

There were 11 studies on the fear of childbirth. Thus, publication bias only for this outcome was investigated using a funnel plot. Since the funnel plot was relatively symmetrical for this outcome, its publication bias was considered not serious (Fig. 8).

Fig. 8
figure 8

Funnel plot, Outcome 1: Fear of childbirth

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Examining the quality or certainty of the evidence using the GRADE approach showed that the quality of evidence for fear of childbirth and postpartum depression due to serious concerns in evaluating the risk of bias and inconsistency was reduced by two degrees and reached the level of low certainty. However, the quality of evidence for the pain intensity in the first and second labour phases due to serious concern only in assessing the risk of bias was reduced by one degree and reached the level of moderate certainty (Table 5).

Table 5 Certainty of the evidence using the GRADE approach by outcomes
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Discussion

This scoping review using a systematic approach included 12 randomized controlled trials and six semi-experimental trials investigating the effect of prenatal education on some maternal outcomes. We found no study investigating the outcomes of the childbirth experience. However, two studies investigating postpartum anxiety and maternal attachment were excluded from the meta-analysis due to their different approaches to examining the intended outcomes. We found two studies that have compared the labour pain intensity in women receiving prenatal education and routine care with women receiving only routine care. Considering that the studies evaluating pain intensity were consistent in terms of participants, interventions, and outcomes and also in the direction of effect size, they entered the meta-analysis [59, 60]. There was relatively good consistency in studies regarding outcomes of fear of childbirth and postpartum depression. Thus, a meta-analysis was performed on these outcomes. However, the low quality of the evidence on the desired outcomes in these studies was rated low to moderate, which prevents making definite conclusions regarding the effect of prenatal education on these outcomes. Nevertheless, it can be said that prenatal education may essentially decrease the fear of childbirth, postpartum depression, and pain intensity in the first and second stages of labour in pregnant mothers.

This review examined the risk of bias based on 18 trials and found that the overall risk of bias was high. Most randomized controlled trials included less than 200 participants in control and intervention groups, and their risk of bias was severe due to not blinding the participants and outcome assessors. Therefore, more extensive trials with fewer methodological limitations must report their results according to CONSORT principles [61] to provide more definitive conclusions in future systematic reviews.

Gagnon and Sandall [15] systematically reviewed the effect of individual and group training during pregnancy on information acquisition, anxiety, sense of control, labour pain, labour and delivery supports, breastfeeding, ability to newborn care, and psychological and social adaptation. They examined nine trials, including 2284 pregnant women. Studies reviewed by this paper needed more details regarding the randomization process, allocation concealment, and missing data, and the sample size was small to medium; thus, their internal validity was low. These studies lacked information regarding anxiety, social support, and breastfeeding and have examined outcomes such as information acquisition, the feeling of control, newborn care abilities, and some labour and delivery outcomes. Thus, the low quality of the included studies prevented us from drawing definitive conclusions. Brixval et al. [62] investigated the effect of prenatal education in small groups on midwifery and psychosocial outcomes of childbirth. It included seventeen trials that were different regarding the conditions of the intervention and control groups, reporting outcomes in a few trials, the heterogeneity of the studies in terms of interventions and outcomes, and the high risk of bias. Thus, it failed to draw definitive conclusions about the effect of prenatal education before the delivery.

Demirci et al. [63] reviewed the effect of prenatal education on the self-efficacy of childbirth in pregnant women. It included seven eligible articles, but the quality of evidence showed high heterogeneity between studies. The results of the meta-analysis showed that prenatal education had a positive and significant effect on outcome expectancy and efficacy expectancy.

Leutenegger et al. [64] investigated the effect of breathing and relaxation techniques taught in prenatal classes on maternal and neonatal outcomes such as mothers’ satisfaction with the labour and delivery, pain level, need for pharmacologic support for pain management, mobility in labour, delivery type, need to take blood from the baby to measure blood pH and 5-minute Apgar score. This study included nine randomized controlled trials and one semi-experimental study. The training provided in prenatal classes of these papers was very diverse and inconsistent, weakening the quality of this study’s evidence. The results showed that breathing and relaxation techniques might positively affect self-efficacy, and the need for medical support, especially epidural anaesthesia and labour pain, but no effect was seen on neonatal outcomes. Women who participated in the prenatal education class with breathing and relaxation techniques seemed to benefit from this intervention.

Hong et al. [65] investigated the effect of various prenatal education programs on maternal and neonatal physical and psychological outcomes to help the development of future guidelines for maternal and neonatal health. It included 14 controlled trials and nine observational studies. Except for the rate of cesarean delivery and the use of epidural anaesthesia, which were lower in prenatal education, the mothers’ physical outcomes were not significantly different. Stress and self-efficacy in the group receiving prenatal education (as outcomes of the mother’s mental health) were significantly improved, but no significant difference was observed in anxiety and depression. Neonatal outcomes such as weight at birth or gestational age at birth were the same between groups.

Pregnancy and puerperium are known as periods along with physical, personal, emotional, and social changes for women. Mood disorders related to these periods have been widely described, so women may represent a vulnerable population who might be severely psychologically affected. Recently published studies confirmed a significantly increased rate of depressive symptoms, anxiety, and thoughts of self-harm in the obstetric population after the declaration of the COVID-19 pandemic, even in subgroups generally at low risk [66]. So the importance of providing interventions to prevent psychological disorders is even more obvious.

Strengths and limitations

Considering that the trials were inconsistent regarding interventions, contents, the studied populations, and the results evaluation method. Thus, comparing them was difficult and did not lead to definitive conclusions.

We found very few or no studies that have compared the labour pain intensity, childbirth experience, postpartum anxiety, and maternal attachment in women receiving prenatal education and routine care with women receiving only routine care.

Implications for research

This scoping review using a systematic approach showed that there are very few or no studies on the effect of prenatal education on outcomes such as labour pain intensity, childbirth experience, postpartum anxiety, and maternal attachment. Therefore, high-quality trials with a more extensive sample size are suggested to clarify the effect of prenatal education on these outcomes. Our investigations showed that these studies lack sufficient quality to make definitive conclusions regarding the effect of prenatal education on other outcomes. Therefore, high-quality, randomized trials with a more extensive sample size are suggested to provide clear reports to make definitive decisions. In addition, future trials should consider the feasibility of prenatal education to make educational program development and evaluation possible.

Conclusion

Our scoping review using a systematic approach and meta-analysis showed that providing prenatal education and routine care compared to providing only routine care may essentially decrease the fear of childbirth, postpartum depression, and pain intensity in the first and second stages of childbirth in pregnant mothers. However, our results do not provide definitive conclusions regarding the outcome of the childbirth experience, maternal-fetal attachment, and postpartum anxiety.

Data Availability

All data are included in the tables.

Abbreviations

WHO:

World Health Organization

ACOG:

American College of Obstetricians and Gynecologists

PROSPERO:

International Prospective Register of Systematic Reviews

ROB-1:

the risk of bias-1 approach

GRADE:

Grading of Recommendations Assessment, Development and Evaluation

SMDs:

standardized mean differences

FOBS:

Fear of Birth Scale

EPDS:

Edinburgh Postnatal Depression Scale

DASS-21:

Depression Anxiety and Stress Scale

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Acknowledgements

We would like to thank the Clinical Research Development Unit of Taleghani Hospital, Tabriz University of Medical Sciences, Tabriz, Iran.

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Authors and Affiliations

  1. Midwifery Department, Faculty of Nursing and Midwifery, Students’ Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran

    Zohreh Alizadeh-Dibazari & Somayeh Abdolalipour

  2. Social Determinants of Health Research Center, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran

    Mojgan Mirghafourvand

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This study was designed by all of the authors. MM will provide supervision throughout the study as a principal investigator. ZA-D drafted the manuscript under direct supervision of MM (Corresponding author). All authors read and approved the final manuscript. Z. A-D and S.A are contributed to literature search, data extraction and analysis.

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Alizadeh-Dibazari, Z., Abdolalipour, S. & Mirghafourvand, M. 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. BMC Pregnancy Childbirth 23, 541 (2023). https://doi.org/10.1186/s12884-023-05867-0

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