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Effects of antenatal education on fear of childbirth, maternal self-efficacy and parental attachment
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Effects of antenatal education on fear of childbirth, maternal self-efficacy and parental attachment Pınar Serçekuş, PhD, RN (Assistant Professor), Hatice Başkale, PhD, RN (Assistant Professor)n Pamukkale University, Faculty of Health Sciences, Denizli, Turkey
art ic l e i nf o
a b s t r a c t
Article history: Received 27 January 2015 Received in revised form 29 May 2015 Accepted 19 November 2015
Objective: to examine the effects of antenatal education on fear of childbirth, maternal self-efficacy, and maternal and paternal attachment. Design: quasi-experimental study, comparing an antenatal education group and a control group. Participants: 63 pregnant women and their husbands. Measurements: demographic data forms, the Wijma Delivery Expectancy/Experience Questionnaire, the Childbirth Self-Efficacy Inventory, the Maternal Attachment Inventory and the Postnatal Paternal–Infant Attachment Questionnaire were used for data collection. Findings: antenatal education was found to reduce the fear of childbirth and to increase childbirthrelated maternal self-efficacy. However, antenatal education was found to have no effect on parental attachment. Key conclusions: it is recommended that widespread antenatal education programmes should be provided in developing countries, and the content of the education programme about parental attachment should be increased. Implications for practice: this study found that antenatal education has no influence on maternal and paternal attachment. As such, there is a need to increase the content of the education programme about parental attachment. & 2015 Elsevier Ltd. All rights reserved.
Keywords: Antenatal education Fear of childbirth Maternal attachment Paternal attachment Self-efficacy
Introduction Antenatal education is indispensable to the health of pregnant women and their infants in many parts of the world. Although numerous studies have been undertaken regarding the effects of antenatal education, evidence remains insufficient (Gagnon and Sandall, 2011). As such, a large number of interventional studies should be conducted on the effects of antenatal education on childbirth self-efficacy, fear of childbirth, and maternal and paternal attachment. Antenatal education Globally, antenatal education has an important place in couples' preparations for pregnancy, childbirth and parenting (Lowdermilk et al., 2012). Although antenatal education is provided as standard through training programmes in developed countries, there is no standard programme in developing countries. As such, n Corresponding author. Pamukkale University, Faculty of Health Sciences, Kınıklı Campus, Denizli, Turkey. E-mail addresses: [email protected] (P. Serçekuş), [email protected] (H. Başkale).
the quality and content of the education varies from one educator to another (Gagnon and Sandall, 2011). Studies have been conducted on the effects of antenatal education on childbirth and parenthood. Several studies have shown that education reduces anxiety suffered at birth (Ip et al., 2009; Miquelutti et al., 2013). In their pilot study, Byrne et al. (2014) showed that antenatal education reduced the fear of childbirth. Toohill et al. (2014) found that psycho-education by trained midwives was effective in reducing high levels of fear of childbirth. Three studies showed that education increases childbirth-related self-efficacy (Ip et al., 2009; Byrne et al., 2014; Toohill et al., 2014). However, Fabian et al. (2005) determined that education had no effect on the childbirth experience, and Schneider (2001) reported that women receiving antenatal education thought that the education provided was inadequate for childbirth preparation. It has been found that participation in antenatal classes does not affect parental attachment (Nichols, 1995), and Deave et al. (2008) reported that education in preparation for parenting is inadequate. Leigh et al. (2012) showed that education intended to promote parental attachment, given in the postpartum period, is ineffective. However, other studies have shown the benefits of education for parenting. Toosi et al. (2014) found that relaxation training during the antenatal period increased maternal
http://dx.doi.org/10.1016/j.midw.2015.11.016 0266-6138/& 2015 Elsevier Ltd. All rights reserved.
Please cite this article as: Serçekuş, P., Başkale, H., Effects of antenatal education on fear of childbirth, maternal self-efficacy and parental attachment. Midwifery (2015), http://dx.doi.org/10.1016/j.midw.2015.11.016i
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attachment, and Abası et al. (2013) found that education intended to promote maternal attachment was successful. As such, while some studies have indicated that education has a positive effect on the childbirth experience and parenthood, others have reported the opposite. In addition, one review study reported that there was insufficient evidence on this issue, and that the effects of general antenatal education for childbirth and parenthood remain largely unknown (Gagnon and Sandall, 2011). However, a limited number of interventional studies have been undertaken regarding the effects of antenatal education on fear of childbirth, maternal self-efficacy and parental attachment. As such, this study aimed to examine the effects of antenatal education on fear of childbirth, maternal self-efficacy, and maternal and paternal attachment. Fear of childbirth and maternal self-efficacy Fear of childbirth is a common problem, and has a negative impact on the childbirth experience (Saisto and Halmesmaki, 2003). This fear causes birth to take longer (Adams et al., 2012), and thus the prospective mother suffers labour pain more intensely (Saisto et al., 2001). Another major problem caused by fear of childbirth is that women ask to have a caesarean section, and the elective caesarean section rate is increasing (Sydsjö et al., 2012; Raisanen et al., 2014). Fear of childbirth may result in instrumental vaginal birth or emergency caesarean birth (Sydsjö et al., 2012). It is also known that fear of childbirth has a negative effect on the postpartum period (Saisto and Halmesmaki, 2003), and is associated with post-traumatic stress disorder (Andersen et al., 2012) and birth trauma (Nilsson et al., 2010). Self-efficacy is a person's belief in his/her own abilities to cope with a particular situation, and it has an important role in the fulfilment of a learned behaviour (Bandura, 2001). People with high self-efficacy are known to be more satisfied with childbirth (Berentson‐Shaw et al., 2009). Self-efficacy is also associated with levels of anxiety and fear of childbirth. A lower efficacy expectancy (i.e. lower confidence in one's own capability to perform helpful behaviours during labour) was associated with higher anxiety and fear of childbirth (Beebe et al., 2007; Salomonsson et al., 2013). Maternal and paternal attachment Maternal role attachment is the process by which a woman learns mothering behaviours and becomes comfortable with her identity as a mother (Davidson et al., 2012). It has been considered to be an indicator of adaptation to pregnancy, as well as being positively associated with antenatal health practices (Lindgren, 2001) and the child's growth and development (Pisoni et al., 2014). Studies have been undertaken regarding the factors affecting maternal–fetal attachment (Alhusen, 2008; Yarcheski et al., 2009). The factors associated with higher levels of maternal–fetal attachment included family support, greater psychological wellbeing, and having an ultrasound performed. Factors such as depression, substance abuse and higher anxiety levels have been found to be associated with lower levels of maternal–fetal attachment (Alhusen, 2008). Yarcheski et al. (2009) showed that gestational age, self-esteem, planned pregnancy, age, parity, ethnicity, marital status, income and education also affect maternal– fetal attachment. Becoming a father is a developmental event that marks a new transition for men. It is a period characterised by uncertainty, increased responsibility, disruption of sleep, and an inability to control the time needed to care for the infant and re-establish the couple's relationship (Lowdermilk et al., 2012). Yu et al. (2012) found that fathers who perceived more marital intimacy and support from their partners were more attached to their infants.
Another study showed that mental well-being is important for father–infant attachment (Condon et al., 2013).
Methods Study design A quasi-experimental study was conducted, comparing women who received antenatal education (experimental group), and women who received routine antenatal care (control group). The use of a quasi-experimental design offers many advantages for researchers, including: the provision of clear evidence of the effectiveness of interventions, the independent variable precedes the dependent variable, the influence of the independent variable can be measured, and a level of control can be introduced that reduces the effect of extraneous variables (Houser, 2015). The dependent variables in this study were fear of childbirth, selfefficacy and parental attachment, and the independent variable was antenatal education. Participants The study was undertaken in a province located in the Aegean region of Turkey. Before the study commenced, the fact that free antenatal education would be given was announced via the Internet. Women and their husbands who volunteered to participate in the study between March 2012 and January 2014, and who met the inclusion criteria, comprised the experimental group. The control group consisted of women and their husbands who received routine antenatal care at an outpatient maternity clinic in a university hospital. The inclusion criteria were as follows: gestation of 26–28 weeks, minimum education level of primary school graduation, nulliparous, not at high risk in pregnancy, and not attended any other antenatal programme in the antenatal period. Subsequently, inclusion also required giving birth at full term, having a healthy newborn (born at 38–42 weeks of gestation, not of low birth weight and with no disease) and having experienced no postnatal complications (haemorrhage, puerperal infection, mastitis, thromboembolic disease or postpartum psychiatric disorder). As no previous experimental studies had used the same surveys, the sample size could not be calculated prior to the start of the study. Thus, when the sample size reached eight participants in each group, the sample size was calculated based on the data collected at the time and by using Minitab 14. The total fear of childbirth score was considered to be the primary outcome. The numbers required for each group were calculated using power calculations based on a significance level of 0.05 and assumed mean differences (22.8) and standard deviations (20.73) within the proposed data collection tool. The number for each group was estimated as 15 to achieve a study power of 80%. However, a higher number of participants was included in case of missing participants. Thirty-five couples were enrolled in the experimental group, and 37 were enrolled in the control group. There were seven (antenatal four, post partum three) absences in the experimental group, and 10 (antenatal five, post partum five) absences in the control group. Among the reasons for absenteeism in the experimental group were refusal of permission to attend from their workplace, medical conditions, premature birth and postnatal complications. In the control group, reasons for being absent were the wish to withdraw from the study, medical conditions, difficulties in terms of access and postnatal complications. In the antenatal period, 31 couples in the experimental group and 32 couples in the control group completed the study. In the
Please cite this article as: Serçekuş, P., Başkale, H., Effects of antenatal education on fear of childbirth, maternal self-efficacy and parental attachment. Midwifery (2015), http://dx.doi.org/10.1016/j.midw.2015.11.016i
P. Serçekuş, H. Başkale / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Experimental group
Control group
n:35
n:37 Demographic data forms
Before education (26–28 weeks of
Wijma Delivery Expectancy/Experience Questionnaire Childbirth Self-Efficacy Inventory
gestation)
Routine prenatal care +
Routine prenatal care
antenatal education for 8 weeks
Excluded (n:4)
Excluded (n:5)
Refusal of permission request by workplace (2) Medical conditions (2)
Medical conditions (2) Wanted to withdraw from study (3)
Experimental group n:31
Control group n:32
After education (34–36 weeks of
Wijma Delivery Expectancy/Experience Questionnaire Childbirth Self-Efficacy Inventory
gestation)
Excluded (n:3)
Excluded (n:5)
Premature birth (1) Postnatal complications (2)
Failure to contact the couple (3) Postnatal complications (2)
Experimental group n:28
Control group n:27
n:28 (Mother)
n:27 (Mother)
Maternal Attachment
Maternal Attachment
Inventory
Inventory
4 months post partum
n:28 (Father)
n:27 (Father)
6 months
Postnatal Paternal–Infant
Postnatal Paternal–Infant
post partum
Attachment Questionnaire
Attachment Questionnaire
Fig. 1. Research schedule.
postpartum period, 28 couples in the experimental group and 27 couples in the control group completed the study (Fig. 1).
Data collection Five forms were used to collect data: demographic data forms, the Wijma Delivery Expectancy/Experience Questionnaire (WDEQ), the Childbirth Self-Efficacy Inventory (CBSEI), the Maternal Attachment Inventory (MAI) and the Postnatal Paternal–Infant Attachment Questionnaire (PPAQ). Demographic data forms Separate introductory information forms were used for the couples participating in the study. The form given to female participants consisted of questions on age, gestational age, educational level, employment status and family economic status. The form used for male participants consisted of questions on age, educational level, employment status and economic status.
Wijma Delivery Expectancy/Experience Questionnaire W-DEQ Version A was developed by Klaas and Barbro Wijma in order to measure fear of childbirth experienced by women during pregnancy. It is a six-point Likert-type scale and consists of 33 items. The responses given to the items on the scale are scored from 0 to 5, where 0 refers to ‘extremely’ and 5 refers to ‘not at all’. The minimum and maximum possible scores to be obtained from the scale are 0 and 165, respectively. As the score increases, so does the fear of childbirth experienced by women (Wijma et al., 1998). Körükcü and Kukulu (2012) examined validity and reliability of the Turkish version of W-DEQ with women in the last trimester of pregnancy, and found Cronbach's alpha of 0.89 and split-half reliability of 0.91. The internal consistency coefficient of W-DEQ in this study was 0.93. Childbirth Self-Efficacy Inventory CBSEI was developed by Lowe in 1993. The Likert-type scale assesses the effects of women's self-confidence and coping ability. The scale can be implemented during the antenatal and postnatal periods (Lowe, 1993). Ip et al. (2008) developed the Short Version
Please cite this article as: Serçekuş, P., Başkale, H., Effects of antenatal education on fear of childbirth, maternal self-efficacy and parental attachment. Midwifery (2015), http://dx.doi.org/10.1016/j.midw.2015.11.016i
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of the Childbirth Self-Efficacy Inventory (CBSEI-C32) to assess women's labour-related self-efficacy levels. The scale consists of two subscales: outcome expectancy (OE) and efficacy expectancy (EE). Each subscale contains 16 questions. High scores obtained from each subscale indicate that pregnant women have high levels of OA and EE related to labour. Turkish validity and reliability studies of the scale were performed during the antenatal period, and Cronbach's alpha was 0.90 (Ersoy, 2011). The internal consistency co-efficient of CBSEI in this study was 0.91. Maternal Attachment Inventory MAI, improved by Muller in 1994, is a one-dimensional scale showing affection after the birth period, used in measuring maternal emotions and behaviours. Each of the article values in the scale vary between ‘always’ and ‘never’. The scale is a fourpoint Likert scale, and includes 26 articles. The lowest score on the scale is 26, and the highest is 104. High scores on the scale indicate high maternal attachment. Validity and reliability studies of the scale have been performed in Turkey, and Cronbach's alpha of 0.77 in the first month and 0.82 in the fourth month have been reported (Kavlak and Şirin, 2009). Cronbach's alpha for MAI in this study was 0.87. Postnatal Paternal–Infant Attachment Questionnaire PPAQ was improved by Condon et al. in 2008 to evaluate father–infant attachment after birth. The scale consists of 19 articles and three subscales. Each article of the scale has values from 1 to 5. The lowest score achievable on the scale is 19, and the highest is 95. A high score shows that attachment is high. In the sixth month, Cronbach's alpha was found to be 0.81, and in the 12th month, it was 0.78 (Condon et al., 2008). A Turkish validity and reliability test has been developed, and its Cronbach alpha was found to be 0.76 (Güleç and Kavlak, 2013). For this study, Cronbach's alpha was found to be 0.76. The experimental group was administered the demographic data forms, W-DEQ and CBSEI before the training courses, and WDEQ and CBSEI after the training courses. The same scales administered to the experimental group were administered to the control group at the same gestation times. In addition to routine antenatal care, antenatal education was provided to the couples in the experimental group. Couples in the control group only received routine antenatal care. For both groups, women were given MAI in the fourth month post partum, and men were given PPAQ in the sixth month post partum (Fig. 1).
and in writing by the researchers. All of the participants were informed that their participation in the study was voluntary, and that their names would remain confidential. Verbal and written informed consent was obtained from the participants. Data analysis Data were analysed using Statistical Package for the Social Sciences Version 20 (IBM Corp., Armonk, NY, USA). p o0.05 was considered to indicate statistical significance. Independent samples t-test and Χ2 test were used to determine differences in demographic features between the groups. Independent samples t-test was used to determine the differences in W-DEQ and CBSEI scores between the groups. Independent samples Mann–Whitney U-test was used to determine differences in MAI and PPAQ scores between the groups.
Findings Participants' characteristics Characteristics of the women in the two groups are given in Table 1. No significant differences were found between the demographic characteristics of the women in the two groups. The mean age of the women in the experimental group was 28.8 [standard deviation (SD) 2.2] years, and they were in the 27th week of gestation (SD 0.9). Most of these women (77.4%) perceived their income to be moderate. The majority of women in the experimental group were university graduates (83.9%) and employed (71%). The mean age of the women in the control group was 27.7 (SD 4.5) years, and they were in the 26.9th week of gestation (SD 0.8). Most of these women (84.4%) perceived their income to be moderate, 68.8% were university graduates and 81.2% were employed. The mean age of the men in the experimental group was 31.8 (SD 4.3) years, and the majority of them were university graduates (83.9%). The mean age of the men in the control group was 29.9 (SD 3.7) years, and the majority of them were university graduates (75.0%). All of the male participants in the control and experimental groups were employed. All Table 1 Demographic characteristics of the participants in the antenatal education and control groups.
Intervention Variable
Training was provided to groups of four to six couples, once a week (120 minutes) for eight weeks. The total training time was 16 hours. The content of the education was: nutrition during pregnancy and the postpartum period, physiological and psychological changes during pregnancy, and coping with these changes (two hours); introduction of mechanisms of labour and birth in adequate detail, discussion of feelings about childbirth, discussion of strategies to deal with fear of childbirth, coping techniques with labour pain (breathing and relaxation exercises, labour positions, massage, etc.) (6 hours); physical and emotional postpartum changes, being a parent, mother–infant interaction, father–infant interaction (2 hours); breast feeding (2 hours); and newborn care (4 hours). The education was provided using simulator mannequins, compact discs and slide presentations. Ethical considerations
Antenatal education group (n¼ 31)
Control group (n¼32)
28.8 72.2 27.0 70.9
27.7 7 4.5 26.9 7 0.8
0.224 0.414
5 (16.1)
10 (31.2)
0.237
26 (83.9)
22 (68.8)
χ2 ¼1.98
22 (71.0) 9 (29.0)
26 (81.2) 6 (18.8)
0.387 χ2 ¼0.91
24 (77.4) 7 (22.6) 31.8 (4.3)
27 (84.4) 5 (15.6) 29.9 (3.7)
0.536 χ2 ¼0.49 0.071
5 (16.1)
8 (25.0)
0.384
26 (83.9)
24 (75.0)
χ2 ¼0.75
Women's agen Gestational weekn Women's education† Primary or high school University Women's employment† Employed Unemployed Family income† Moderate High Men's agen Men's education† Primary or high school University
p-value
Values in parentheses are percentages.
Ethical approval was obtained from the university ethics committee. The participants were informed about the study verbally
n
†
Mean 7 standard deviation. Frequencies.
Please cite this article as: Serçekuş, P., Başkale, H., Effects of antenatal education on fear of childbirth, maternal self-efficacy and parental attachment. Midwifery (2015), http://dx.doi.org/10.1016/j.midw.2015.11.016i
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Table 2 Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) and Childbirth Self-Efficacy Inventory (CBSEI) scores before and after education. Pre-test (before education) Scales
Post-test (after education)
Antenatal education group (n¼ 31) Mean (SD)
Control group (n ¼32) Mean (SD)
p-value
Antenatal education group (n¼ 31) Mean (SD)
Control group (n ¼32) Mean (SD)
p-value
60.7 (25.1) 219.3 (37.7) 129.8 (18.2) 89.6 (27.8)
54.0 (18.9) 222.7 (37.4) 127.9 (21.2) 94.8 (23.0)
0.236 0.717 0.705 0.422
37.9 (23.4) 257.6 (44.9) 139.1 (21.6) 118.8 (27.6)
59.9 (19.1) 224.1 (37.8) 124.9 (23.9) 99.2 (24.5)
0.000 0.002 0.018 0.004
W-DEQ CBSEI-C32 OE-16 EE-16
OE, outcome expectancy; EE, efficacy expectancy; SD, standard deviation.
Table 3 Mean Maternal Attachment Inventory (MAI) and Postnatal Paternal–Infant Attachment Questionnaire (PPAQ) scores obtained by the two groups. Scales
Antenatal education group (n¼28) Mean (SD)
Control group (n¼ 27) Mean (SD)
p-value
MAI PPAQ
100.1 (4.9) 78.8 (6.5)
98.5 (5.3) 78.3 (5.2)
0.258 0.625
SD, standard deviation.
participants in both groups were married and attended with their husbands. Fear of childbirth and childbirth self-efficacy Differences between the two groups in terms of their mean pre-education scores for W-DEQ and CBSEI, and OE and EE subscales of CBSEI were not significant (Table 2). Mean post-education scores for the two groups for W-DEQ and CBSEI are given in Table 2. A significant difference was found between the groups (p o0.01). The mean W-DEQ score of the women in the experimental group was lower than that of the women in the control group, which indicates that their fear of childbirth was less than that of the women in the control group (p o0.01). The mean CBSEI score of the women in the experimental group was higher than that of the women in the control group, which indicates that their self-efficacy was higher than that of the women in the control group (p o0.01). The differences between the groups for OE and EE subscales were also significant (p o0.05 and o0.01, respectively). Maternal and paternal attachment Mean MAI and PPAQ scores of the couples in the experimental group and those in the control group are presented in Table 3, and no significant difference was found between the groups (p 40.05).
Discussion This study had some limitations. Firstly, the groups were not assigned at random because of concern that women might be unwilling to attend the training sessions they did not prefer, and would thus be likely to drop out. Instead, the couples who agreed to participate in the education sessions were included in the experimental group, and the couples who received the routine antenatal care at a university hospital, but who did not apply for the education programme, were included in the control group. Secondly, a self-report questionnaire was used to determine fear of childbirth, maternal self-efficacy, and maternal and paternal attachment. Self-perceived fear of childbirth, maternal self-efficacy, and maternal and paternal attachment may differ from the
fear of childbirth, maternal self-efficacy, and maternal and paternal attachment observed by professionals such as nurses. In this study, the women who received antenatal education had significantly lower W-DEQ scores than the women in the control group. Therefore, education was effective in reducing fear of childbirth. In other experimental studies on the same topic, women who attended educational courses were found to have less anxiety (Ip et al., 2009) and fear of childbirth (Byrne et al., 2014; Toohill et al., 2014). In a qualitative study, the majority of women who participated in a birth preparation programme reported that the information they received helped them to reduce their anxiety during pregnancy and labour (Miquelutti et al., 2013). It is known that a lack of knowledge about birth and negative perceptions of, and misinformation about, birth lead to fear (Melender, 2002; Serçekuş and Okumuş, 2009). Antenatal education may have been effective in reducing fears, as it provides information about birth and positively changes earlier misinformation acquired about birth. However, a qualitative study found that antenatal education had differing effects on women, reducing anxiety and fear related to childbirth in some women, and increasing anxiety and fear related to childbirth in other women (Serçekuş and Mete, 2010). Given that the provision of detailed information about birth might lead to fears (Lee and Holroyd, 2009; Serçekuş and Okumuş, 2009), the education programme in the present study was revised by eliminating the detailed content. The finding that the revised training was effective indicates that it is important to design and assess the content of the antenatal education carefully, taking the community's cultural characteristics into account. Thus, it is recommended that nurses and midwives responsible for antenatal education should take the results of pertinent studies into account, and should evaluate the effects of the education they provide on a regular basis. Self-efficacy is one's belief in one's own abilities to cope with a particular situation (Bandura, 2001), and is an important factor affecting satisfaction derived from the birth experience (Berentson‐Shaw et al., 2009). Byrne et al. (2014) demonstrated that antenatal education improved women's sense of control and confidence in giving birth. Their programme included eight weeks with an experienced yoga and meditation teacher and childbirth educator. Similarly, in a randomised controlled trial, Ip et al. (2009) determined that an efficacy-enhancing educational intervention raised women's confidence in their capabilities to cope with childbirth. These studies did not include women with fear of childbirth. Toohill et al. (2014) studied fearful women, and reported that a midwife telephone counselling intervention for women with high fear of childbirth could improve their confidence, and that childbirth self-efficacy was modifiable. In this study, the 8week antenatal education was also found to improve maternal self-efficacy. Two reasons were proposed. Firstly, during antenatal education, the woman learns how to develop labour-related selfreliance, how to cope with labour pain, and how to implement relaxation techniques together with her husband. Learning the techniques of coping with pain can lead to the development of
Please cite this article as: Serçekuş, P., Başkale, H., Effects of antenatal education on fear of childbirth, maternal self-efficacy and parental attachment. Midwifery (2015), http://dx.doi.org/10.1016/j.midw.2015.11.016i
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women's self-confidence and childbirth self-efficacy. Two experimental studies improved childbirth confidence through a birth ball exercise programme on pain (Gau et al., 2011) and a antenatal yoga programme (Sun et al., 2010). Secondly, childbirth-related self-efficacy is associated with fear of childbirth. Salomonsson et al. (2013) emphasised that emotional arousal was an important source of perceived self-efficacy, and that high emotional responses such as fear suppressed self-efficacy. The results of this study demonstrated that the women with fear of childbirth had lower levels of perceived self-efficacy. Similarly, Schwartz et al. (2015) showed that a high level of fear was correlated with low self-efficacy. Women with fear of childbirth do not concentrate on the tasks but on their perceived inability to cope with those tasks (Salomonsson et al., 2013). Similarly, in their longitudinal descriptive study, Beebe et al. (2007) reported that the higher the anxiety score, the lower the woman's confidence in her ability to perform relaxation and coping techniques during labour and birth. In this sense, reduction of the fear of childbirth acquired during antenatal education may be a factor that increases childbirthrelated self-efficacy. This study found that antenatal education has no influence on post partum maternal and paternal attachment. However, other studies have shown that education is influential. Toosi et al. (2014) found that relaxation education in the antenatal period increased maternal attachment. Another study found that maternal attachment education in the antenatal period increased maternal attachment (Abası et al., 2013). Özlüses and Çelebioğlu (2014) found that breast-feeding education for couples in the postpartum period had a positive effect on father–infant attachment. The reason for the difference in this study could be that the content of antenatal education is more focused on birth, and it may therefore be inefficient for increasing parent–infant attachment. In a qualitative study, Persson et al. (2012) performed interviews after the birth and found that fathers reported that parenthood classes had not included information about the time after birth, and that there had been too much focus on the birth itself. It has been shown, however, that, compared with standard programmes, the new, improved and detailed antenatal education programmes have a positive effect on maternal postpartum adaptation (Schachman et al., 2004). In a quasi-experimental study, Bryan (2000) showed that by including the first three months of life, the detailed education programme is more effective in increasing parent–child interaction than standard antenatal classes. For this reason, it would be useful to revise the antenatal education programme by adding new interventions to increase parent–infant attachment.
Conclusion This study investigated the effects of eight weeks of antenatal education on self-efficacy and fear of childbirth, and found that antenatal education reduced the fear of childbirth and increased labour-related maternal self-efficacy. Given the positive results of antenatal education programmes, it is recommended that widespread antenatal education programmes should be provided as standard in developing countries. When the content of the education programme is determined, the cultural characteristics of the community should be taken into account, and the programme should be updated constantly by obtaining participants' feedback at the end of each education programme. Further experimental studies on the topic should be conducted in different cultures. This study also found that antenatal education has no influence on maternal and paternal attachment. It is suggested that the content of education programmes about parental attachment should be increased.
Conflict of interest The authors declare that there is no conflict of interest.
Funding None declared.
Acknowledgement Authors had no financial support for this study.
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Please cite this article as: Serçekuş, P., Başkale, H., Effects of antenatal education on fear of childbirth, maternal self-efficacy and parental attachment. Midwifery (2015), http://dx.doi.org/10.1016/j.midw.2015.11.016i
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Effects of antenatal education on fear of childbirth, maternal self-efficacy and parental attachment Pınar Serçekuş, PhD, RN (Assistant Professor), Hatice Başkale, PhD, RN (Assistant Professor)n Pamukkale University, Faculty of Health Sciences, Denizli, Turkey
art ic l e i nf o
a b s t r a c t
Article history: Received 27 January 2015 Received in revised form 29 May 2015 Accepted 19 November 2015
Objective: to examine the effects of antenatal education on fear of childbirth, maternal self-efficacy, and maternal and paternal attachment. Design: quasi-experimental study, comparing an antenatal education group and a control group. Participants: 63 pregnant women and their husbands. Measurements: demographic data forms, the Wijma Delivery Expectancy/Experience Questionnaire, the Childbirth Self-Efficacy Inventory, the Maternal Attachment Inventory and the Postnatal Paternal–Infant Attachment Questionnaire were used for data collection. Findings: antenatal education was found to reduce the fear of childbirth and to increase childbirthrelated maternal self-efficacy. However, antenatal education was found to have no effect on parental attachment. Key conclusions: it is recommended that widespread antenatal education programmes should be provided in developing countries, and the content of the education programme about parental attachment should be increased. Implications for practice: this study found that antenatal education has no influence on maternal and paternal attachment. As such, there is a need to increase the content of the education programme about parental attachment. & 2015 Elsevier Ltd. All rights reserved.
Keywords: Antenatal education Fear of childbirth Maternal attachment Paternal attachment Self-efficacy
Introduction Antenatal education is indispensable to the health of pregnant women and their infants in many parts of the world. Although numerous studies have been undertaken regarding the effects of antenatal education, evidence remains insufficient (Gagnon and Sandall, 2011). As such, a large number of interventional studies should be conducted on the effects of antenatal education on childbirth self-efficacy, fear of childbirth, and maternal and paternal attachment. Antenatal education Globally, antenatal education has an important place in couples' preparations for pregnancy, childbirth and parenting (Lowdermilk et al., 2012). Although antenatal education is provided as standard through training programmes in developed countries, there is no standard programme in developing countries. As such, n Corresponding author. Pamukkale University, Faculty of Health Sciences, Kınıklı Campus, Denizli, Turkey. E-mail addresses: [email protected] (P. Serçekuş), [email protected] (H. Başkale).
the quality and content of the education varies from one educator to another (Gagnon and Sandall, 2011). Studies have been conducted on the effects of antenatal education on childbirth and parenthood. Several studies have shown that education reduces anxiety suffered at birth (Ip et al., 2009; Miquelutti et al., 2013). In their pilot study, Byrne et al. (2014) showed that antenatal education reduced the fear of childbirth. Toohill et al. (2014) found that psycho-education by trained midwives was effective in reducing high levels of fear of childbirth. Three studies showed that education increases childbirth-related self-efficacy (Ip et al., 2009; Byrne et al., 2014; Toohill et al., 2014). However, Fabian et al. (2005) determined that education had no effect on the childbirth experience, and Schneider (2001) reported that women receiving antenatal education thought that the education provided was inadequate for childbirth preparation. It has been found that participation in antenatal classes does not affect parental attachment (Nichols, 1995), and Deave et al. (2008) reported that education in preparation for parenting is inadequate. Leigh et al. (2012) showed that education intended to promote parental attachment, given in the postpartum period, is ineffective. However, other studies have shown the benefits of education for parenting. Toosi et al. (2014) found that relaxation training during the antenatal period increased maternal
http://dx.doi.org/10.1016/j.midw.2015.11.016 0266-6138/& 2015 Elsevier Ltd. All rights reserved.
Please cite this article as: Serçekuş, P., Başkale, H., Effects of antenatal education on fear of childbirth, maternal self-efficacy and parental attachment. Midwifery (2015), http://dx.doi.org/10.1016/j.midw.2015.11.016i
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attachment, and Abası et al. (2013) found that education intended to promote maternal attachment was successful. As such, while some studies have indicated that education has a positive effect on the childbirth experience and parenthood, others have reported the opposite. In addition, one review study reported that there was insufficient evidence on this issue, and that the effects of general antenatal education for childbirth and parenthood remain largely unknown (Gagnon and Sandall, 2011). However, a limited number of interventional studies have been undertaken regarding the effects of antenatal education on fear of childbirth, maternal self-efficacy and parental attachment. As such, this study aimed to examine the effects of antenatal education on fear of childbirth, maternal self-efficacy, and maternal and paternal attachment. Fear of childbirth and maternal self-efficacy Fear of childbirth is a common problem, and has a negative impact on the childbirth experience (Saisto and Halmesmaki, 2003). This fear causes birth to take longer (Adams et al., 2012), and thus the prospective mother suffers labour pain more intensely (Saisto et al., 2001). Another major problem caused by fear of childbirth is that women ask to have a caesarean section, and the elective caesarean section rate is increasing (Sydsjö et al., 2012; Raisanen et al., 2014). Fear of childbirth may result in instrumental vaginal birth or emergency caesarean birth (Sydsjö et al., 2012). It is also known that fear of childbirth has a negative effect on the postpartum period (Saisto and Halmesmaki, 2003), and is associated with post-traumatic stress disorder (Andersen et al., 2012) and birth trauma (Nilsson et al., 2010). Self-efficacy is a person's belief in his/her own abilities to cope with a particular situation, and it has an important role in the fulfilment of a learned behaviour (Bandura, 2001). People with high self-efficacy are known to be more satisfied with childbirth (Berentson‐Shaw et al., 2009). Self-efficacy is also associated with levels of anxiety and fear of childbirth. A lower efficacy expectancy (i.e. lower confidence in one's own capability to perform helpful behaviours during labour) was associated with higher anxiety and fear of childbirth (Beebe et al., 2007; Salomonsson et al., 2013). Maternal and paternal attachment Maternal role attachment is the process by which a woman learns mothering behaviours and becomes comfortable with her identity as a mother (Davidson et al., 2012). It has been considered to be an indicator of adaptation to pregnancy, as well as being positively associated with antenatal health practices (Lindgren, 2001) and the child's growth and development (Pisoni et al., 2014). Studies have been undertaken regarding the factors affecting maternal–fetal attachment (Alhusen, 2008; Yarcheski et al., 2009). The factors associated with higher levels of maternal–fetal attachment included family support, greater psychological wellbeing, and having an ultrasound performed. Factors such as depression, substance abuse and higher anxiety levels have been found to be associated with lower levels of maternal–fetal attachment (Alhusen, 2008). Yarcheski et al. (2009) showed that gestational age, self-esteem, planned pregnancy, age, parity, ethnicity, marital status, income and education also affect maternal– fetal attachment. Becoming a father is a developmental event that marks a new transition for men. It is a period characterised by uncertainty, increased responsibility, disruption of sleep, and an inability to control the time needed to care for the infant and re-establish the couple's relationship (Lowdermilk et al., 2012). Yu et al. (2012) found that fathers who perceived more marital intimacy and support from their partners were more attached to their infants.
Another study showed that mental well-being is important for father–infant attachment (Condon et al., 2013).
Methods Study design A quasi-experimental study was conducted, comparing women who received antenatal education (experimental group), and women who received routine antenatal care (control group). The use of a quasi-experimental design offers many advantages for researchers, including: the provision of clear evidence of the effectiveness of interventions, the independent variable precedes the dependent variable, the influence of the independent variable can be measured, and a level of control can be introduced that reduces the effect of extraneous variables (Houser, 2015). The dependent variables in this study were fear of childbirth, selfefficacy and parental attachment, and the independent variable was antenatal education. Participants The study was undertaken in a province located in the Aegean region of Turkey. Before the study commenced, the fact that free antenatal education would be given was announced via the Internet. Women and their husbands who volunteered to participate in the study between March 2012 and January 2014, and who met the inclusion criteria, comprised the experimental group. The control group consisted of women and their husbands who received routine antenatal care at an outpatient maternity clinic in a university hospital. The inclusion criteria were as follows: gestation of 26–28 weeks, minimum education level of primary school graduation, nulliparous, not at high risk in pregnancy, and not attended any other antenatal programme in the antenatal period. Subsequently, inclusion also required giving birth at full term, having a healthy newborn (born at 38–42 weeks of gestation, not of low birth weight and with no disease) and having experienced no postnatal complications (haemorrhage, puerperal infection, mastitis, thromboembolic disease or postpartum psychiatric disorder). As no previous experimental studies had used the same surveys, the sample size could not be calculated prior to the start of the study. Thus, when the sample size reached eight participants in each group, the sample size was calculated based on the data collected at the time and by using Minitab 14. The total fear of childbirth score was considered to be the primary outcome. The numbers required for each group were calculated using power calculations based on a significance level of 0.05 and assumed mean differences (22.8) and standard deviations (20.73) within the proposed data collection tool. The number for each group was estimated as 15 to achieve a study power of 80%. However, a higher number of participants was included in case of missing participants. Thirty-five couples were enrolled in the experimental group, and 37 were enrolled in the control group. There were seven (antenatal four, post partum three) absences in the experimental group, and 10 (antenatal five, post partum five) absences in the control group. Among the reasons for absenteeism in the experimental group were refusal of permission to attend from their workplace, medical conditions, premature birth and postnatal complications. In the control group, reasons for being absent were the wish to withdraw from the study, medical conditions, difficulties in terms of access and postnatal complications. In the antenatal period, 31 couples in the experimental group and 32 couples in the control group completed the study. In the
Please cite this article as: Serçekuş, P., Başkale, H., Effects of antenatal education on fear of childbirth, maternal self-efficacy and parental attachment. Midwifery (2015), http://dx.doi.org/10.1016/j.midw.2015.11.016i
P. Serçekuş, H. Başkale / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Experimental group
Control group
n:35
n:37 Demographic data forms
Before education (26–28 weeks of
Wijma Delivery Expectancy/Experience Questionnaire Childbirth Self-Efficacy Inventory
gestation)
Routine prenatal care +
Routine prenatal care
antenatal education for 8 weeks
Excluded (n:4)
Excluded (n:5)
Refusal of permission request by workplace (2) Medical conditions (2)
Medical conditions (2) Wanted to withdraw from study (3)
Experimental group n:31
Control group n:32
After education (34–36 weeks of
Wijma Delivery Expectancy/Experience Questionnaire Childbirth Self-Efficacy Inventory
gestation)
Excluded (n:3)
Excluded (n:5)
Premature birth (1) Postnatal complications (2)
Failure to contact the couple (3) Postnatal complications (2)
Experimental group n:28
Control group n:27
n:28 (Mother)
n:27 (Mother)
Maternal Attachment
Maternal Attachment
Inventory
Inventory
4 months post partum
n:28 (Father)
n:27 (Father)
6 months
Postnatal Paternal–Infant
Postnatal Paternal–Infant
post partum
Attachment Questionnaire
Attachment Questionnaire
Fig. 1. Research schedule.
postpartum period, 28 couples in the experimental group and 27 couples in the control group completed the study (Fig. 1).
Data collection Five forms were used to collect data: demographic data forms, the Wijma Delivery Expectancy/Experience Questionnaire (WDEQ), the Childbirth Self-Efficacy Inventory (CBSEI), the Maternal Attachment Inventory (MAI) and the Postnatal Paternal–Infant Attachment Questionnaire (PPAQ). Demographic data forms Separate introductory information forms were used for the couples participating in the study. The form given to female participants consisted of questions on age, gestational age, educational level, employment status and family economic status. The form used for male participants consisted of questions on age, educational level, employment status and economic status.
Wijma Delivery Expectancy/Experience Questionnaire W-DEQ Version A was developed by Klaas and Barbro Wijma in order to measure fear of childbirth experienced by women during pregnancy. It is a six-point Likert-type scale and consists of 33 items. The responses given to the items on the scale are scored from 0 to 5, where 0 refers to ‘extremely’ and 5 refers to ‘not at all’. The minimum and maximum possible scores to be obtained from the scale are 0 and 165, respectively. As the score increases, so does the fear of childbirth experienced by women (Wijma et al., 1998). Körükcü and Kukulu (2012) examined validity and reliability of the Turkish version of W-DEQ with women in the last trimester of pregnancy, and found Cronbach's alpha of 0.89 and split-half reliability of 0.91. The internal consistency coefficient of W-DEQ in this study was 0.93. Childbirth Self-Efficacy Inventory CBSEI was developed by Lowe in 1993. The Likert-type scale assesses the effects of women's self-confidence and coping ability. The scale can be implemented during the antenatal and postnatal periods (Lowe, 1993). Ip et al. (2008) developed the Short Version
Please cite this article as: Serçekuş, P., Başkale, H., Effects of antenatal education on fear of childbirth, maternal self-efficacy and parental attachment. Midwifery (2015), http://dx.doi.org/10.1016/j.midw.2015.11.016i
P. Serçekuş, H. Başkale / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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of the Childbirth Self-Efficacy Inventory (CBSEI-C32) to assess women's labour-related self-efficacy levels. The scale consists of two subscales: outcome expectancy (OE) and efficacy expectancy (EE). Each subscale contains 16 questions. High scores obtained from each subscale indicate that pregnant women have high levels of OA and EE related to labour. Turkish validity and reliability studies of the scale were performed during the antenatal period, and Cronbach's alpha was 0.90 (Ersoy, 2011). The internal consistency co-efficient of CBSEI in this study was 0.91. Maternal Attachment Inventory MAI, improved by Muller in 1994, is a one-dimensional scale showing affection after the birth period, used in measuring maternal emotions and behaviours. Each of the article values in the scale vary between ‘always’ and ‘never’. The scale is a fourpoint Likert scale, and includes 26 articles. The lowest score on the scale is 26, and the highest is 104. High scores on the scale indicate high maternal attachment. Validity and reliability studies of the scale have been performed in Turkey, and Cronbach's alpha of 0.77 in the first month and 0.82 in the fourth month have been reported (Kavlak and Şirin, 2009). Cronbach's alpha for MAI in this study was 0.87. Postnatal Paternal–Infant Attachment Questionnaire PPAQ was improved by Condon et al. in 2008 to evaluate father–infant attachment after birth. The scale consists of 19 articles and three subscales. Each article of the scale has values from 1 to 5. The lowest score achievable on the scale is 19, and the highest is 95. A high score shows that attachment is high. In the sixth month, Cronbach's alpha was found to be 0.81, and in the 12th month, it was 0.78 (Condon et al., 2008). A Turkish validity and reliability test has been developed, and its Cronbach alpha was found to be 0.76 (Güleç and Kavlak, 2013). For this study, Cronbach's alpha was found to be 0.76. The experimental group was administered the demographic data forms, W-DEQ and CBSEI before the training courses, and WDEQ and CBSEI after the training courses. The same scales administered to the experimental group were administered to the control group at the same gestation times. In addition to routine antenatal care, antenatal education was provided to the couples in the experimental group. Couples in the control group only received routine antenatal care. For both groups, women were given MAI in the fourth month post partum, and men were given PPAQ in the sixth month post partum (Fig. 1).
and in writing by the researchers. All of the participants were informed that their participation in the study was voluntary, and that their names would remain confidential. Verbal and written informed consent was obtained from the participants. Data analysis Data were analysed using Statistical Package for the Social Sciences Version 20 (IBM Corp., Armonk, NY, USA). p o0.05 was considered to indicate statistical significance. Independent samples t-test and Χ2 test were used to determine differences in demographic features between the groups. Independent samples t-test was used to determine the differences in W-DEQ and CBSEI scores between the groups. Independent samples Mann–Whitney U-test was used to determine differences in MAI and PPAQ scores between the groups.
Findings Participants' characteristics Characteristics of the women in the two groups are given in Table 1. No significant differences were found between the demographic characteristics of the women in the two groups. The mean age of the women in the experimental group was 28.8 [standard deviation (SD) 2.2] years, and they were in the 27th week of gestation (SD 0.9). Most of these women (77.4%) perceived their income to be moderate. The majority of women in the experimental group were university graduates (83.9%) and employed (71%). The mean age of the women in the control group was 27.7 (SD 4.5) years, and they were in the 26.9th week of gestation (SD 0.8). Most of these women (84.4%) perceived their income to be moderate, 68.8% were university graduates and 81.2% were employed. The mean age of the men in the experimental group was 31.8 (SD 4.3) years, and the majority of them were university graduates (83.9%). The mean age of the men in the control group was 29.9 (SD 3.7) years, and the majority of them were university graduates (75.0%). All of the male participants in the control and experimental groups were employed. All Table 1 Demographic characteristics of the participants in the antenatal education and control groups.
Intervention Variable
Training was provided to groups of four to six couples, once a week (120 minutes) for eight weeks. The total training time was 16 hours. The content of the education was: nutrition during pregnancy and the postpartum period, physiological and psychological changes during pregnancy, and coping with these changes (two hours); introduction of mechanisms of labour and birth in adequate detail, discussion of feelings about childbirth, discussion of strategies to deal with fear of childbirth, coping techniques with labour pain (breathing and relaxation exercises, labour positions, massage, etc.) (6 hours); physical and emotional postpartum changes, being a parent, mother–infant interaction, father–infant interaction (2 hours); breast feeding (2 hours); and newborn care (4 hours). The education was provided using simulator mannequins, compact discs and slide presentations. Ethical considerations
Antenatal education group (n¼ 31)
Control group (n¼32)
28.8 72.2 27.0 70.9
27.7 7 4.5 26.9 7 0.8
0.224 0.414
5 (16.1)
10 (31.2)
0.237
26 (83.9)
22 (68.8)
χ2 ¼1.98
22 (71.0) 9 (29.0)
26 (81.2) 6 (18.8)
0.387 χ2 ¼0.91
24 (77.4) 7 (22.6) 31.8 (4.3)
27 (84.4) 5 (15.6) 29.9 (3.7)
0.536 χ2 ¼0.49 0.071
5 (16.1)
8 (25.0)
0.384
26 (83.9)
24 (75.0)
χ2 ¼0.75
Women's agen Gestational weekn Women's education† Primary or high school University Women's employment† Employed Unemployed Family income† Moderate High Men's agen Men's education† Primary or high school University
p-value
Values in parentheses are percentages.
Ethical approval was obtained from the university ethics committee. The participants were informed about the study verbally
n
†
Mean 7 standard deviation. Frequencies.
Please cite this article as: Serçekuş, P., Başkale, H., Effects of antenatal education on fear of childbirth, maternal self-efficacy and parental attachment. Midwifery (2015), http://dx.doi.org/10.1016/j.midw.2015.11.016i
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Table 2 Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) and Childbirth Self-Efficacy Inventory (CBSEI) scores before and after education. Pre-test (before education) Scales
Post-test (after education)
Antenatal education group (n¼ 31) Mean (SD)
Control group (n ¼32) Mean (SD)
p-value
Antenatal education group (n¼ 31) Mean (SD)
Control group (n ¼32) Mean (SD)
p-value
60.7 (25.1) 219.3 (37.7) 129.8 (18.2) 89.6 (27.8)
54.0 (18.9) 222.7 (37.4) 127.9 (21.2) 94.8 (23.0)
0.236 0.717 0.705 0.422
37.9 (23.4) 257.6 (44.9) 139.1 (21.6) 118.8 (27.6)
59.9 (19.1) 224.1 (37.8) 124.9 (23.9) 99.2 (24.5)
0.000 0.002 0.018 0.004
W-DEQ CBSEI-C32 OE-16 EE-16
OE, outcome expectancy; EE, efficacy expectancy; SD, standard deviation.
Table 3 Mean Maternal Attachment Inventory (MAI) and Postnatal Paternal–Infant Attachment Questionnaire (PPAQ) scores obtained by the two groups. Scales
Antenatal education group (n¼28) Mean (SD)
Control group (n¼ 27) Mean (SD)
p-value
MAI PPAQ
100.1 (4.9) 78.8 (6.5)
98.5 (5.3) 78.3 (5.2)
0.258 0.625
SD, standard deviation.
participants in both groups were married and attended with their husbands. Fear of childbirth and childbirth self-efficacy Differences between the two groups in terms of their mean pre-education scores for W-DEQ and CBSEI, and OE and EE subscales of CBSEI were not significant (Table 2). Mean post-education scores for the two groups for W-DEQ and CBSEI are given in Table 2. A significant difference was found between the groups (p o0.01). The mean W-DEQ score of the women in the experimental group was lower than that of the women in the control group, which indicates that their fear of childbirth was less than that of the women in the control group (p o0.01). The mean CBSEI score of the women in the experimental group was higher than that of the women in the control group, which indicates that their self-efficacy was higher than that of the women in the control group (p o0.01). The differences between the groups for OE and EE subscales were also significant (p o0.05 and o0.01, respectively). Maternal and paternal attachment Mean MAI and PPAQ scores of the couples in the experimental group and those in the control group are presented in Table 3, and no significant difference was found between the groups (p 40.05).
Discussion This study had some limitations. Firstly, the groups were not assigned at random because of concern that women might be unwilling to attend the training sessions they did not prefer, and would thus be likely to drop out. Instead, the couples who agreed to participate in the education sessions were included in the experimental group, and the couples who received the routine antenatal care at a university hospital, but who did not apply for the education programme, were included in the control group. Secondly, a self-report questionnaire was used to determine fear of childbirth, maternal self-efficacy, and maternal and paternal attachment. Self-perceived fear of childbirth, maternal self-efficacy, and maternal and paternal attachment may differ from the
fear of childbirth, maternal self-efficacy, and maternal and paternal attachment observed by professionals such as nurses. In this study, the women who received antenatal education had significantly lower W-DEQ scores than the women in the control group. Therefore, education was effective in reducing fear of childbirth. In other experimental studies on the same topic, women who attended educational courses were found to have less anxiety (Ip et al., 2009) and fear of childbirth (Byrne et al., 2014; Toohill et al., 2014). In a qualitative study, the majority of women who participated in a birth preparation programme reported that the information they received helped them to reduce their anxiety during pregnancy and labour (Miquelutti et al., 2013). It is known that a lack of knowledge about birth and negative perceptions of, and misinformation about, birth lead to fear (Melender, 2002; Serçekuş and Okumuş, 2009). Antenatal education may have been effective in reducing fears, as it provides information about birth and positively changes earlier misinformation acquired about birth. However, a qualitative study found that antenatal education had differing effects on women, reducing anxiety and fear related to childbirth in some women, and increasing anxiety and fear related to childbirth in other women (Serçekuş and Mete, 2010). Given that the provision of detailed information about birth might lead to fears (Lee and Holroyd, 2009; Serçekuş and Okumuş, 2009), the education programme in the present study was revised by eliminating the detailed content. The finding that the revised training was effective indicates that it is important to design and assess the content of the antenatal education carefully, taking the community's cultural characteristics into account. Thus, it is recommended that nurses and midwives responsible for antenatal education should take the results of pertinent studies into account, and should evaluate the effects of the education they provide on a regular basis. Self-efficacy is one's belief in one's own abilities to cope with a particular situation (Bandura, 2001), and is an important factor affecting satisfaction derived from the birth experience (Berentson‐Shaw et al., 2009). Byrne et al. (2014) demonstrated that antenatal education improved women's sense of control and confidence in giving birth. Their programme included eight weeks with an experienced yoga and meditation teacher and childbirth educator. Similarly, in a randomised controlled trial, Ip et al. (2009) determined that an efficacy-enhancing educational intervention raised women's confidence in their capabilities to cope with childbirth. These studies did not include women with fear of childbirth. Toohill et al. (2014) studied fearful women, and reported that a midwife telephone counselling intervention for women with high fear of childbirth could improve their confidence, and that childbirth self-efficacy was modifiable. In this study, the 8week antenatal education was also found to improve maternal self-efficacy. Two reasons were proposed. Firstly, during antenatal education, the woman learns how to develop labour-related selfreliance, how to cope with labour pain, and how to implement relaxation techniques together with her husband. Learning the techniques of coping with pain can lead to the development of
Please cite this article as: Serçekuş, P., Başkale, H., Effects of antenatal education on fear of childbirth, maternal self-efficacy and parental attachment. Midwifery (2015), http://dx.doi.org/10.1016/j.midw.2015.11.016i
P. Serçekuş, H. Başkale / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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women's self-confidence and childbirth self-efficacy. Two experimental studies improved childbirth confidence through a birth ball exercise programme on pain (Gau et al., 2011) and a antenatal yoga programme (Sun et al., 2010). Secondly, childbirth-related self-efficacy is associated with fear of childbirth. Salomonsson et al. (2013) emphasised that emotional arousal was an important source of perceived self-efficacy, and that high emotional responses such as fear suppressed self-efficacy. The results of this study demonstrated that the women with fear of childbirth had lower levels of perceived self-efficacy. Similarly, Schwartz et al. (2015) showed that a high level of fear was correlated with low self-efficacy. Women with fear of childbirth do not concentrate on the tasks but on their perceived inability to cope with those tasks (Salomonsson et al., 2013). Similarly, in their longitudinal descriptive study, Beebe et al. (2007) reported that the higher the anxiety score, the lower the woman's confidence in her ability to perform relaxation and coping techniques during labour and birth. In this sense, reduction of the fear of childbirth acquired during antenatal education may be a factor that increases childbirthrelated self-efficacy. This study found that antenatal education has no influence on post partum maternal and paternal attachment. However, other studies have shown that education is influential. Toosi et al. (2014) found that relaxation education in the antenatal period increased maternal attachment. Another study found that maternal attachment education in the antenatal period increased maternal attachment (Abası et al., 2013). Özlüses and Çelebioğlu (2014) found that breast-feeding education for couples in the postpartum period had a positive effect on father–infant attachment. The reason for the difference in this study could be that the content of antenatal education is more focused on birth, and it may therefore be inefficient for increasing parent–infant attachment. In a qualitative study, Persson et al. (2012) performed interviews after the birth and found that fathers reported that parenthood classes had not included information about the time after birth, and that there had been too much focus on the birth itself. It has been shown, however, that, compared with standard programmes, the new, improved and detailed antenatal education programmes have a positive effect on maternal postpartum adaptation (Schachman et al., 2004). In a quasi-experimental study, Bryan (2000) showed that by including the first three months of life, the detailed education programme is more effective in increasing parent–child interaction than standard antenatal classes. For this reason, it would be useful to revise the antenatal education programme by adding new interventions to increase parent–infant attachment.
Conclusion This study investigated the effects of eight weeks of antenatal education on self-efficacy and fear of childbirth, and found that antenatal education reduced the fear of childbirth and increased labour-related maternal self-efficacy. Given the positive results of antenatal education programmes, it is recommended that widespread antenatal education programmes should be provided as standard in developing countries. When the content of the education programme is determined, the cultural characteristics of the community should be taken into account, and the programme should be updated constantly by obtaining participants' feedback at the end of each education programme. Further experimental studies on the topic should be conducted in different cultures. This study also found that antenatal education has no influence on maternal and paternal attachment. It is suggested that the content of education programmes about parental attachment should be increased.
Conflict of interest The authors declare that there is no conflict of interest.
Funding None declared.
Acknowledgement Authors had no financial support for this study.
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Please cite this article as: Serçekuş, P., Başkale, H., Effects of antenatal education on fear of childbirth, maternal self-efficacy and parental attachment. Midwifery (2015), http://dx.doi.org/10.1016/j.midw.2015.11.016i