Investigating the influence of antenatal education on birth beliefs and delivery methods: a prospective cohort study from Turkey

Abstract

Background

Women’s prior knowledge about childbirth shapes their ideas about childbirth. The view that childbirth is a physiological process reflects the belief that it is a normal and safe event. Medical process believe that childbirth is dangerous and risky, that it should take place under the careful care of a trained obstetrician because it depends on anatomical conditions. The aim of this study is to identify women’s underlying prenatal and postnatal beliefs about childbirth and to examine the impact of childbirth preparation classes on their beliefs and the impact on the mode of delivery.

Materials and methods

Demographic and obstetric parameters were compared between August 2023 and August 2024, with the intervention group consisting of 75 patients who attended pregnancy school after the 14th week of pregnancy and the control group, which did not attend pregnancy school, consisting of 150 patients. The pregnant women in the intervention group were surveyed before and after the pregnancy school using the “Birth Belief Scale” questionnaire. It was investigated how the pregnancy school, in which the topics of antenatal care, childbirth, postpartum and newborn care were covered, affected the birth beliefs and what differences there were between the participants and those who did not take part. In this study, which had a twofold aim, firstly, the method of birth and birth characteristics were examined between those who attended pregnancy school and those who did not. Secondly, it investigated the impact of antenatal education on patients’ perceptions of childbirth and their decision as to whether childbirth was a medical process (which should take place under medical supervision) or a natural process.

Results

A total of 225 patients were included in the study. The primary outcome of the study was that the rate of patients requesting cesarean section during labor because they could not deliver vaginally or could not tolerate the pain during labor was higher in the control group (47.2% versus 73.4%; p = 0.009). There was a statistically significant difference in the indication for cesarean section in both groups and the rate of labor arrest was higher in the control group (8.3% versus 26.6%; p = 0.043). A secondary result of the study was a statistically significant change in the patients’ birth expectations after the training (p < 0.001). Through pregnancy education, the idea that childbirth is a medical intervention was replaced by the idea that it is a natural process.

Conclusion

This study shows that antenatal education has a positive impact on birth beliefs and birth preferences. It is recommended that educational programs such as childbirth preparation classes be expanded to influence pregnant women’s beliefs about birth and empower them to make informed decisions.

Introduction

Women’s prior knowledge about childbirth shapes their ideas about childbirth. The view that childbirth is a physiological process reflects the belief that it is a normal and safe event, that women’s bodies are naturally designed for it, and that women should trust their bodies to cope with the process. This view also states that pain is a natural part of childbirth and that medical interventions should only be used when absolutely necessary [1, 2]. Those who view childbirth as a medical process believe that childbirth is dangerous and risky, that it should take place under the careful care of a trained obstetrician because it depends on anatomical conditions, and that labor pain is an unnecessary sensation that should be treated with medication [2]. Although pregnancy and childbirth are usually defined as an exciting and joyful time in women’s lives because of these birth beliefs, the existing beliefs can lead them to experience fear and anxiety about childbirth. It is known that approximately 10% of pregnant women suffer from severe clinical anxiety related to childbirth [3, 4]. Fear of childbirth is increasingly recognized as a problem internationally, although there is no consensus on the optimal measure to define or assess it [5].

It is known that women who become pregnant for the first time suffer more frequently and more severely from anxiety. It has been observed that the birth wishes of pregnant women suffering from anxiety are also impaired [6,7,8]. With the increasing knowledge and experience in delivery techniques, it was possible in the past until today to deliver the fetus by cesarean section if vaginal delivery was not possible. Over time, however, the number of deliveries by cesarean section has increased considerably and has exceeded the number recommended by the World Health Organization (WHO). When the total number of births recorded in Turkey between 2018 and 2023 was analyzed, the overall cesarean section rate was 57.5% and the primary cesarean section rate was 28.83%. With these rates, Turkey has one of the highest rates of cesarean section births in the world [9, 10]. However, the WHO emphasizes that the ideal rate should be between 10 and 15% due to the risks of the procedure [11].

Although the first pregnancy schools in Turkey were established in the 1980s, they became widespread in the 2000s. There is no obligation to attend these schools. They are supposed to be standardized to cover all pregnant women and are free of charge. Education in pregnancy schools are usually taught by obstetricians and midwives. Unfortunately, attendance at pregnancy schools in Turkey has not reached the desired level. The education of pregnant women who do not attend pregnancy schools is only provided in the form of answering questions of pregnant women within a limited time in the polyclinics. The examination times in the obstetric clinics, which serve an average of 50 patients per day, are limited and it cannot be said that standardized information is provided under appropriate conditions. The World Health Organization (WHO) has emphasized the need for evidence-based care that includes nutrition, maternal and fetal examinations, preventive measures, interventions for common physiological symptoms, and the use of antenatal care models and health system interventions to ensure a positive pregnancy [12]. Similarly, the regulation on antenatal care prepared by the Turkish health authorities and implemented in our country underlines the importance of antenatal schools and the education offered there [13].

Since women’s beliefs and preferences about childbirth are usually formed in the prenatal period, it is important to support these preferences through prenatal education. Pregnant women need education to manage the labor process before birth and to improve their skills related to baby care, postpartum and parenting after birth. Prenatal classes for pregnant women, such as childbirth preparation classes and childbirth information classes, help to empower pregnant women, prepare them for childbirth and improve their coping skills, pain management and positive birth memories. Childbirth preparation classes also have the effect of rationalizing pregnant women’s expectations of birth. It have been shown in the literature that antenatal classes reduce fear of childbirth [14,15,16]. It have also been reported that antenatal care measures reduce the cesarean section rates [17].

The primary aim of this study is to show the differences in obstetric characteristics between pregnant women who have attended pregnancy education and those who did not. The secondary aim is to identify women’s underlying antenatal and postnatal beliefs about childbirth and to examine the impact of pregnancy education on their beliefs and mode of delivery.

Materials and methods

In this prospective cohort study, the Birth Belief Scale questionnaire was completed before and after training for pregnant women over 14 weeks gestation who attended pregnancy school education between August 2023 and August 2024 in Ankara, the capital city of Turkey. This group of seventy-five people who met the inclusion and exclusion criteria was formed as an intervention group.

Inclusion criteria

• Pregnancy over 14 weeks (primiparous).

• No additional diseases that may affect maternal and neonatal outcomes.

• Attending and completing the pregnancy school.

Exclusion criteria

• Patients with high-risk pregnancies.

• Patients with maternal comorbidities [gestational hypertension, preeclampsia, uncontrolled diabetes or gestational diabetes, malignancy, vascular diseases, degenerative joint and connective tissue diseases, mental illness].

• Mothers of fetuses with known congenital / genetic abnormalities.

• Have a medical condition that makes a cesarean section necessary [history of cesarean delivery, history of myomectomy, malpresentation, placenta previa etc.]

Pregnancy school education

In the Pregnancy School, lessons are given in 4 sessions. The training covers the anatomy of pregnancy, prenatal care, high-risk pregnancies and screening, physiological changes during pregnancy, daily life during pregnancy, nutrition during pregnancy and the puerperium, exercises during pregnancy and childbirth, the psychology of pregnancy and the puerperium, the mechanism of birth, non-drug methods of coping with labor pain, A team of obstetricians, nutritionists, physiotherapists and prenatal educators provide training on emergency symptoms requiring hospitalization, newborn care, the importance of breast milk and breastfeeding support, and prenatal and postpartum care. (Supplementary data 1)

A control group of one hundred and fifty people with inclusion and exclusion criteria was formed according to the randomization rules and demographic and birth characteristics were compared between the intervention group and the control group.

Randomization

Seventy-five pregnant women who were selected according to the inclusion and exclusion criteria and who had completed pregnancy school education formed the intervention group. Then, the patients who registered at the hospital before and after each patient in the intervention group (who were the first to meet the inclusion and exclusion criteria) were enrolled in the control group, with an allocation ratio of 1:2.

In addition, the intervention group was given the birth belief scale questionnaire before and after the pregnancy school training. The effects of education on birth beliefs were investigated by analyzing the survey results before and after education of the pregnant women in this group. (Fig. 1)

Fig. 1

Flow chart

Blinding

The doctors who provide pregnancy school education and the doctors who evaluate the results of the Birth Belief Scale, as well as the persons who carry out statistical analyzes, have no influence on the time and method of birth. The doctors who decide on the timing and method of birth and the people who carry out the statistical analyzes are blind to which group of patients attended the pregnancy school and which did not.

Birth belief scale (Supplementary data 2)

The belief that childbirth is a medical procedure means that childbirth is risky, should be done under medical supervision and that the pain of childbirth is unnecessary. The belief that birth is a natural process means that birth is safe, that the woman’s body knows how to give birth, and that birth should not be interfered with [18]. Medical beliefs, on the other hand, mean that birth is dangerous and risky and should be done under the careful care of a trained doctor because it depends on anatomical conditions [18].

The Birth Beliefs Scale consists of two sub-dimensions: One evaluates childbirth as a natural process, while the other views it as a medical intervention. The scale is a five-point Likert scale consisting of a total of 11 items, including 5 items for belief in natural processes and 6 items for belief in medical processes in mixed order. The original text of the scale is in English and was developed by Preis and Benyamini in 2016 and validated in Turkish by Paker et al. in 2022 [18, 19].

The total score of the questions in the two different categories (belief in natural processes, belief in medical processes) that make up the Birth Beliefs Scale is divided by the number of questions to determine the arithmetic mean for each section, and these mean scores are compared between categories. This makes it clear to which birth belief the pregnant woman is inclined.

Statistical analysis

The statistical analysis procedures were performed using Jamovi, an open statistical software, to analyze the data. The normal distribution of the variables was assessed using visual representations (histogram, probability plots) and analytical techniques (Kolmogrov-Simirnov/Shapiro-Wilk test). A Levene test was performed to assess the homogeneity of variance. In the statistical analysis between those who attended pregnancy school and those who did not, the statistical representation of the descriptive numerical data, which did not have a normal distribution, was performed as median and quartiles (Q1-Q3). Comparisons of these factors between groups were performed using Mann-Whitney U-tests. Descriptive analysis for the categorical variables was performed using frequencies and percentages. Statistical analysis of relationships between categorical variables was performed using either the chi-square test or Fisher’s exact test (in cases where the assumptions of the chi-square test are not applicable due to low expected cell counts). The descriptive statistics of the Birth Beliefs Scale scores before and after the training of the patients who had participated in the pregnancy school were presented with mean ± SD, median, quartiles, and minimum-maximum values. The analysis of numerical data with normal distribution was performed using the paired samples t-test. When comparing these data, the mean ± SD should be compared. Data without normal distribution was analyzed using the Wilcoxon test. The comparison of these data should be performed using the median values. A p-value below 0.05 was considered to indicate a statistically significant result.

When comparing the mean “early pregnancy natural birth belief score” and the “postpartum natural birth belief score” in the study [20] used as an example for the sample size calculation (group I: n: 750 mean ± SD 3.75 ± 0.56; group II: n: 1574 mean ± SD 4.01 ± 0.62; spooled: 0.601), the required number of patients was calculated as 70 patients with 0.05 alpha error and 95% power in the G-power analysis. In the post-hoc power analysis, which was carried out using the same criterion (Natural Birth Blief Score) to investigate the effect of pregnancy education on the group, a power of 99% was achieved.

Results

A total of 225 patients were included in the study. 75 of these patients took part in the pregnancy school (intervention group) and 150 patients were included in the study as a control group, who were not informed about any program apart from the routine education in the outpatient clinic.

Primary outcomes

When comparing the intervention group, which consisted of 75 people who received pregnancy school education, with the control group, which only received information under outpatient conditions and for a limited time, there was no difference between the groups in demographic and birth characteristics in terms of age, BMI, educational status and week of birth. In the intervention group, there was a higher rate of normal births (52.0% vs. 37.3; p: 0.036) and a lower rate of cesarean section requests (47.2% vs. 73.4%; p: 0.009). The cesarean section rates performed with the arrest of birth and unsuccessful induction indications were lower in the intervention group. (p: 0.032) (Table 1).

Table 1 Demographic characteristics of pregnant women and birth characteristics

Secondary outcomes

When the Birth Belief Scale questionnaire was evaluated before and after the pregnancy school education in the intervention group of 75 people, the total scores of the questionnaire did not change. (p:0.952) (Table 2) The total score for medical belief decreased and the total score for natural belief increased after the training compared to before the training. While the mean score for natural belief increased for each patient, the score for medical belief decreased. (p < 0.001) (Fig. 2).

Table 2 Birth belief scale scores of pregnant women before and after antenatal education

Fig. 2

Mean, median, minimum, maximum and quartile values of the birth belief scale before and after pregnancy school education for medical belief and natural belief

Discussion

In our study, we examined pregnant women’s beliefs about childbirth and the effects of childbirth preparation classes on their beliefs about childbirth. The results show that pregnant women’s beliefs about childbirth changed significantly after the education. There are several studies in the literature that overlap with our findings. These studies also show that childbirth preparation classes rationalize beliefs about childbirth and reduce fear of childbirth.

The mean age of the pregnant women in the study was 24.5 years. A review of similar studies in the literature found that pregnant women under the age of 30 were more likely to attend antenatal care. In the study by Dönmez et al., the mean age was 28.02 ± 5.38 years, in the study by Rashed et al. 25.8 ± 4.0 years and in the study by Çıtak et al. 59.4% of pregnant women were between 18 and 29 years old [21,22,23]. This could be related to inexperience and the greater need for social support during the first pregnancies. In the study by Stoll et al., the opposite was found: The higher the average age of the pregnant women, the more likely they were to attend a childbirth preparation class [24].

In the questionnaire that was carried out in the study before the training, it was found that the pregnant women’s ideas about childbirth were more in the medical direction. After the training, the scores for natural beliefs increased significantly, showing that the training had increased the women’s confidence in the birth process. Knowledge of the physiology of pregnancy through the training enabled the pregnant women to view the birth process as safe and natural. In addition, the decrease in medical belief scores suggests that the training reduced the perception that unnecessary medical interventions and surgical methods such as a cesarean section are inevitable during childbirth. Cesuroğlu et al. found that the pregnant women who participated in the study had a significantly higher belief in natural childbirth than in medical childbirth [25] In a study conducted in the Netherlands, the mean score for belief in natural childbirth ranged from 3.73 to 4.01 points, while the mean score for belief in medical childbirth ranged from 2.92 to 3.12 points [20]. The study found that women’s belief that childbirth is a natural process was higher than their belief that childbirth is a medical process. This is attributed to the fact that the perinatal providers in the Netherlands made the women aware of their birth beliefs and explained to them that they should accept their influence on their birth beliefs. In the study conducted by Preis et al., scores for women’s beliefs that childbirth is a natural process were high and it was found that fear of childbirth was related to beliefs about childbirth [26].

Our study found that prenatal education affects beliefs about childbirth and that the rate of normal deliveries was higher in the group that received education. A study by Stoll et al. reported that beliefs about childbirth are one of the factors influencing women’s preferred method of delivery [27]. Coates et al. found that continuous care from a midwife or doctor influenced women’s beliefs about normal birth [28]. In the study by Unver et al. 62.3% of pregnant women had a modarate level of Belief Scale for Normal Delivery (BSND). They emphasized that providing healthy information to pregnant women would prevent factors such as the transmission of negative birth experiences that pregnant women are exposed to [29].

Significant differences were found in the mode of delivery between those who attended a childbirth preparation education program and those who did not. The rate of vaginal deliveries was higher in those who had attended a childbirth preparation course than in those who had not. This suggests that the education conveyed a positive attitude towards a normal birth and reduced the tendency to have a cesarean section. Buran et al. reported in their systematic review that antenatal classes increased the rate of normal deliveries [7].

When evaluating the cesarean sections requested by the mothers, it was found that the pregnant women who did not receive prenatal education requested a cesarean section more frequently, while fewer cesarean sections were requested in the group that received education. This result suggests that the women have a better understand of the birth process as a result of prenatal education and are more cautious about surgical interventions such as a cesarean section. Similar studies in the literature also show that prenatal education helps to reduce the demand for cesarean sections. Eser et al. found that prenatal education increased the demand for normal birth after cesarean Sect. [30]. Karimi et al. reported that childbirth preparation classes significantly reduced the demand for cesarean section and that participants in the study preferred natural childbirth after education [31].

Another point that can be derived from this study could be that antetanal education reduces the fear of childbirth. We can draw this conclusion from the fact that birth beliefs changed and preferences for normal birth were higher. In particular, rates of labor arrest and unsuccessful labor induction were lower in the educated group. This finding suggests that education can help prevent complications during labor by increasing confidence in the birth process. In the study by Buran et al., childbirth preparation was shown to reduce fear of childbirth, increase vaginal delivery rates and facilitate positive birth experiences [7]. In her study, Dönmez came to the conclusion that childbirth preparation training promotes adaptation to pregnancy, a positive birth experience and adaptation to the role of motherhood [14].

Limitations of the study

The study has important limitations. The study was conducted in a single center and long-term effects, such as the effects of training on birth anxiety after training or in the postpartum period, were not measured. Socio-cultural factors affecting participants’ prenatal beliefs were not analyzed in detail. Therefore, further studies are needed to investigate the long-term consequences of changes in beliefs and preferences after training.

Conclusion

This study shows that prenatal education has a positive effect on birth beliefs and birth preferences. In order to influence pregnant women’s beliefs about childbirth and enable them to make informed decisions, it should be recommended that educational programs such as childbirth preparation classes should be made widespread and classes for childbirth preparation should be offered in pregnancy care centers to better adapt mothers to the different steps of childbirth, to reduce mothers’ tendency towards elective cesarean section, and to encourage mothers to prefer natural and/or physiological birth. Furthermore, in addition to midwife and physician support from the beginning of pregnancy to pregnant women who adopt natural childbirth to reduce cesarean section rates, educational schools policies developed in addition to midwife and physician support should be supported and internet-based distance education programs should be planned to increase visibility and awareness. In order to check the functionality of the prenatal education, getting feedback from patients both after the course and after delivery can lead to a redesign of the content of the education.