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Association between antenatal classes attendance and perceived fear and pain during labour
Taiwanese Journal of Obstetrics & Gynecology 58 (2019) 492e496
Contents lists available at ScienceDirect
Taiwanese Journal of Obstetrics & Gynecology journal homepage: www.tjog-online.com
Original Article
Association between antenatal classes attendance and perceived fear and pain during labour Joanna Kacperczyk-Bartnik a, Paweł Bartnik a, *, Aleksandra Symonides b, Natalia Sroka-Ostrowska a, Agnieszka Dobrowolska-Redo a, Ewa Romejko-Wolniewicz a a
2nd Department of Obstetrics and Gynaecology, Medical University of Warsaw, Karowa 2 Str, 00-315, Warsaw, Poland Students' Scientific Group Associated to 2nd Department of Obstetrics and Gynaecology, Medical University of Warsaw, Karowa 2 Str, 00-315, Warsaw, Poland
b
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 15 April 2019
Objectives: Antenatal classes are a common method of preparation for birth with proven efficiency in improving perinatal outcomes. Yet, their impact on fear perception during labour has not been identified. The aim of the study was to analyse whether preparation for labour by means of antenatal classes attendance could be associated with decrease in level of experienced fear and pain during birth. Materials and methods: It was a cross-sectional study of 147 women who had given vaginal births. Data was collected from mothers between 24 and 72 h postpartum. Patients answered self-reported questionnaires concerning subjective perception of birth including Delivery Fear Scale (DFS) and Numeric Rating Scale (NRS) for fear and pain assessment. The study group was divided into subgroups depending on parity and antenatal classes attendance. Results: Patients in the primiparas subgroup who attended antenatal classes scored lower in the DFS (48.7 ± 23.5 vs. 60.2 ± 16.5, p < .03). There was no difference in the DFS score in the multiparas subgroup (p < .90). No significant differences in the NRS score depending on antenatal classes attendance in any subgroup were observed. Conclusion: Participation in antenatal classes should be advised to every pregnant primiparous woman as this type of non-invasive preparation lowers level of fear experienced during childbirth. © 2019 Taiwan Association of Obstetrics & Gynecology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: Labour Labour pain Patient participation Pregnancy Prenatal education
Introduction Birth is a unique experience in a woman's life and preparation for it during prenatal period by attendance to antenatal classes seems to be helpful in achieving more optimal peri- and postnatal outcome [1e5]. Moreover, organised group activities facilitate experience exchange and provide emotional support from other women in similar life circumstances [6,7]. In industrialised countries there is a wide variety of available antenatal classes for couples who wish to be more adjusted to the transition to parenthood by participation in one of chosen activities [8]. Willingness to attend is an important factor as this form of prenatal counselling is not obligatory. Antenatal classes play an important educational role as information about pregnancy course during standard prenatal care
* Corresponding author. Karowa 2 Str, 00-315, Fax: þ48225966487. E-mail address: [email protected] (P. Bartnik).
Warsaw,
Poland.
may be deficient in case of even 75% of patients [9]. Apart from mothers' willingness to attend the classes, women must be aware of such opportunity, which usually requires obtaining information during prenatal consultations. According to Maternity Survey Report published in 2010, 69% of women in England were offered antenatal classes or workshops and this proportion differed depending on patient's age, parity and ethnicity [10]. Fear is not an asset in the delivery room. Affecting from 5 to even 26% of women at some stage of pregnancy, fear of childbirth (FOC) is associated with prolonged second stage of labour, difficulties in communication and collaboration with medical personnel as well as increased risk of emergency situations including emergency caesarean section [11e19]. Fear during birth is common among women fearful of childbirth earlier in pregnancy [16]. It is difficult to determine whether FOC is the fear of unknown, the fear of a difficult and meaningful event, or other. The aim of our study was to analyse, if preparation for birth by means of antenatal classes attendance could be associated with
https://doi.org/10.1016/j.tjog.2019.05.011 1028-4559/© 2019 Taiwan Association of Obstetrics & Gynecology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
J. Kacperczyk-Bartnik et al. / Taiwanese Journal of Obstetrics & Gynecology 58 (2019) 492e496
decrease in level of experienced fear and pain during vaginal delivery. Materials and methods It was a cross-sectional survey-based study of patients who gave birth at the tertiary referral centre between January and June 2016. The inclusion criteria for the purpose of this research were: providing informed oral consent for participation in the study and giving natural, live birth between 24 and 72 h before the survey completion. The exclusion criteria were: no consent, delivery by a caesarean section, multiple pregnancy, burdened obstetric history. Patients with a multiple-pregnancy, burdened obstetric history and who delivered by a caesarean-section were initially excluded before survey distribution. After initial answers analysis, 16 women who attended antenatal classes, but did not complete full course were excluded. There were 147 answers of women who gave natural birth selected for further investigation after the exclusion process, divided into two groups: primiparas (77 respondents) and multiparas (70 respondents). The structure of analysed population is presented in Fig. 1. All of the participants were asked to complete a self-reported survey, which consisted of two modules. The first one included demographic questions with a set about antenatal classes attendance during current and previous pregnancies. The second part consisted of Polish version of the Delivery Fear Scale (DFS) and 2 questions about the average and maximum pain felt by the patient during birth, which was assessed using the Numeric Rating Scale (NRS) [20,21]. The DFS was given in the past tense and patients
493
were asked about the mean perception of particular feelings during the whole labour. In addition to this, data about specific labour parameters and past medical history were obtained from medical records. Patients were divided into subgroups and their answers were analysed on the basis of completed antenatal classes course or lack of any antenatal classes attendance during current or any previous pregnancy. Patients who attended antenatal classes, but did not complete them, were excluded from the study in order to avoid possible bias of wrong group placement. All patients gave informed oral consent for the participation in the study. The protocol of the study was approved by the Committee on Bioethics at the Medical University of Warsaw. Statistical analysis was performed using Statistica 12 (StatSoft. Inc.). U-ManneWhitney test and Student T-tests were used for quantitative data comparison between two groups as required. Two-sided Fisher's exact test was used for categorical and binary data comparison. P value < .05 was considered significant. Results Group characteristics presented in Table 1 and in Fig. 1 revealed that women who attended full-course of antenatal classes were more often primiparous. This observation led to separately performed analyses between primi- and multiparas subgroups. No differences regarding maternal age, gestational age, BMI, prevalence of premature births, comorbidities, nor assisted deliveries were observed between antenatal classes attendants and those who did not attend the classes. 52.4% (n ¼ 77) of respondents gave birth for the first time, while 47.6% (n ¼ 70) of surveyed women gave birth for the second or subsequent time. 53.1% (n ¼ 78) of patients attended antenatal classes during the current or any previous pregnancy. Women who gave birth for the first time and attended antenatal classes scored lower in the DFS questionnaire e their total score was 48.7 ± 23.5 in comparison to 60.2 ± 16.5 (p < .03). The results of the particular questions and total score comparison in this group are presented in Table 2. No significant differences in the DFS score were observed in case of patients giving birth for the second or subsequent time. Respondents who attended antenatal classes scored 58.9 ± 19.3 vs. 59.6 ± 23.3 in comparison to those who did not attend (p < .90). Table 3 presents detailed results of this group. Table 4 presents differences in other selected birth parameters in primiparous patients depending on antenatal classes attendance. No significant differences in case of perceived pain, use of epidural analgesia, prevalence of assisted births, nor neonatal condition were observed. The 1st stage of labour lasted on average 66 min shorter in patients who attended antenatal classes, however this observation was not statistically significant (p < .08). Table 5 presents similar comparison of labour parameters among multiparous patients. No statistically significant differences regarding perceived pain, use of epidural analgesia, labour duration, prevalence of assisted births, nor neonatal condition were observed. Discussion
Fig. 1. Study population selection.
Fear of childbirth (FOC) affects 5e26% of pregnant women and presents in its most severe form as tokophobia e the most common psychiatric indication for caesarean section [12e15,17e19]. In the times of raising caesarean section rate every woman giving physiological vaginal birth becomes a form of obstetric success. Report by Supreme Chamber of Control of the Republic of Poland states that caesarean section rate in Poland between 2010 and 2012 was
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Table 1 Group characteristics (n ¼ 147). Feature
Total
Antenatal classes attendance (n ¼ 78)
No antenatal classes attendance (n ¼ 69)
pb
Age [Mean (±SD)] BMI [At birth; Median (Quartiles)] Gravidity [Median (Quartiles)] Parity Mean [Median (Quartiles)] Week of gestation [at birth; Median (Quartiles)] Pre-term birthsa Gestational Diabetes Mellitusa Pregnancy-induced hypertensiona Pre-pregnancy hypertensiona Anaemiaa Intrahepatic cholestasis of pregnancya Hypothyroidisma Assisted deliveriesa
31.5 ± 4.8 26.8 (24.9e30.5) 2 (1e3) 1 (1e2) 39 (38e40) 11.5% (16) 19.0% (26) 10.9% (15) 0.7% (1) 3.6% (5) 3.6% (5) 16.5% (23) 3.4% (5)
31.5 ± 4.4 26.3 (24.9e28.7) 1 (1e2) 1 (1e2) 39 (38e40) 13.9% (10) 18.3% (13) 8.5% (6) 0 2.8% (2) 1.4% (1) 19.4% (14) 5.2% (4)
31.5 ± 5.3 27.5 (24.9e31.6) 2 (1e3) 2 (1e2) 39 (38e40) 9.0% (6) 19.7% (13) 13.4% (9) 1.5% (1) 4.5% (3) 5.9% (4) 13.4% (9) 1.5% (1)
<.98 <.08 <.001 <.002 <.80 <.43 <1.00 <.42 <1.00 <.68 <.20 <.37 <.37
Bold values represent P lower than 0.05 was considered significant. a In brackets e absolute number of cases. b Comparison between antenatal classes attendants and those who did not attend.
Table 2 The impact of antenatal classes attendance on Delivery Fear Scale score e primiparas (n ¼ 77). Question
Antenatal classes attendance (n ¼ 51)
No antenatal classes attendance (n ¼ 26)
P
1. I can stand the pain 2. I feel very helpless 3. This feels positive 4. This feels as if I will never be able to get out of here 5. I can manage this 6. I do not want to go on any more 7. In the midst of all this I feel happy 8. I feel as if I will give up soon 9. This is taking forever 10. I feel calm Total score
6.4 ± 3.4 3.9 ± 3.5 6.6 ± 3.1 5.9 ± 3.6 6.4 ± 3.2 4.5 ± 3.5 4.83 ± 3.1 4.4 ± 3.5 4.8 ± 3.7 4.5 ± 3.3 48.7 ± 23.5
4.7 ± 3.1 4.8 ± 3.3 5.2 ± 3.4 6.3 ± 3.5 5.9 ± 3.1 5.4 ± 3.3 3.3 ± 2.3 5.6 ± 3.5 5.0 ± 3.2 2.6 ± 2.5 60.2 ± 16.5
.054 .19 .09 .84 .53 .28 .07 .17 .83 .02 .03
Bold values represent P lower than 0.05 was considered significant.
Table 3 The impact of antenatal classes attendance on Delivery Fear Scale score e multiparas (n ¼ 70). Question
Antenatal classes attendance (n ¼ 27)
No antenatal classes attendance (n ¼ 43)
P
1. I can stand the pain 2. I feel very helpless 3. This feels positive 4. This feels as if I will never be able to get out of here 5. I can manage this 6. I do not want to go on any more 7. In the midst of all this I feel happy 8. I feel as if I will give up soon 9. This is taking forever 10. I feel calm Total score
5.1 ± 3.4 4.7 ± 3.3 5.9 ± 3.0 7.0 ± 3.2 6.0 ± 3.0 5.0 ± 3.7 3.9 ± 3.2 5.3 ± 4.1 5.7 ± 3.7 3.3 ± 3.2 58.9 ± 19.3
5.1 ± 3.2 5.0 ± 3.3 4.6 ± 2.9 6.5 ± 3.8 5.4 ± 2.6 5.7 ± 3.4 3.8 ± 3.2 5.2 ± 3.7 5.0 ± 3.5 3.3 ± 3.0 59.6 ± 23.3
.92 .61 .09 .61 .63 .35 .92 .85 .67 .90 .90
Table 4 Antenatal Classes attendance and specific birth features e primiparas (n ¼ 77). Feature
Antenatal classes attendance (n ¼ 51)
No antenatal classes attendance (n ¼ 26)
P
Mean pain (NRS) Maximum pain (NRS) Epidural analgesia (%) Time of 1st stage of birth (min) Time of 2nd stage of birth (min) Assisted birth (%) Good neonate's condition based on Apgar 1st minute score (8 points; %) Good neonate's condition based on Apgar 5th minute score (8 points; %)
6.5 ± 2.2 9.2 ± 1.3 71.7% (33) 328 ± 142 49 ± 34 7.8% (4) 98.0% (50) 98.0% (50)
6.6 ± 2.3 9.2 ± 2.2 62.5% (15) 394 ± 158 41 ± 27 0 100% (26) 100% (26)
.43 .15 .43 .08 .40 .30 1.00 1.00
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Table 5 Antenatal Classes attendance and specific birth features e multiparas (n ¼ 70). Feature
Antenatal classes attendance (n ¼ 27)
No antenatal classes attendance (n ¼ 43)
P
Mean pain (NRS) Maximum pain (NRS) Epidural analgesia (%) Time of 1st stage of birth Time of 2nd stage of birth Assisted birth (%) Good neonate's condition based on Apgar 1st minute score (8 points; %) Good neonate's condition based on Apgar 5th minute score (8 points; %)
6.1 ± 1.9 9.7 ± 0.8 55.0% (11) 293 ± 103 18 ± 19 0 100% (27) 100% (27)
6.7 ± 2.1 9.3 ± 1.1 48.7% (19) 270 ± 151 26 ± 24 2.4% (1) 96.7% (42) 96.7% (42)
.29 .20 .78 .27 .24 1.00 1.00 1.00
as high as 42% of all deliveries [22]. According to the World Health Organization (WHO) recommendations, caesarean section rate should ideally reach no more than 15% of births [23]. Concerning all the possible complications following caesarean section and its impact on future obstetric outcomes as well as difficulties in abdominal access during future surgical interventions, every factor increasing the rate of vaginal births is anticipated [24,25]. However, caesarean section is not the only mode of delivery associated with FOC. Research proves that FOC may affect the course of natural births as well, for instance by prolonging its duration. Adams et al. identified FOC as an individual risk factor for longer lasting active part of labour [11]. The estimated difference in second stage of labour duration between women with and without FOC after excluding other factors was as long as 48 min. Our study results suggest an effective non-invasive intervention resulting in reducing the level of perinatal feeling of fear and psychological discomfort in women during labour. By means of antenatal education for future parents it is possible to prepare primiparas for the new circumstances and influence the way they experience birth. Due to feeling calmer and decreasing total level of fear, cooperation with obstetric team might be easier and more efficient. This is even more important for women who deliver for the first time as they need to learn the process by acquiring appropriate technique of pushing and breathing during labour, which is easier with help of professional midwife or obstetrician. Our findings should be considered by healthcare providers and decision makers as antenatal classes do not require much additional organizational efforts and are already organized near numerous obstetric wards. Especially, that the size of group participating in the classes does not seem to affect the outcome [8]. Our study shows that attendance to antenatal classes should be advised to all primiparas as in multiparas results were not as much associated with participation in this type of activities as in women who gave birth for the first time. Similar findings were obtained in qualitative studies focussing on needs of future parents, in which over 90% of respondents - both men and women - claimed lack of preparation and need for additional support during becoming parents of the first child [26]. It is also worth mentioning that the feeling of calmness and being less fearful during labour was not a result of experiencing less severe pain. Differences between both maximum and mean levels of pain reported by respondents were not significant. Similarly, the percentage of women asking for and receiving epidural analgesia was comparable, no matter previous antenatal classes attendance or lack of it. These findings concerned both primiparas and multiparas. Therefore, it seems that feeling of control and being acquainted with possible situations that follow each step of labour are of higher impact on the level of fear than experienced pain, which was also reported in Hildingsson and Fabian studies [6,27]. Lack of visible effect of antenatal classes attendance in the multiparas group could be explained by stronger meaning of previous obstetric experience resulting in shaping expectations and
feelings associated with another birth [28]. It is also worth mentioning that results obtained in primiparas without preparation during antenatal classes and both subgroups of multiparas e with and without organized prenatal education e were comparable. This could suggest that antenatal classes might provide better preparation and labour perception in primiparas than in women who had experienced the birth before. The main limitation of presented study results from its type e a cross-sectional study. Due to this fact it cannot be determined whether lower levels of fear in primiparous women who have attended antenatal classes result from actual impact of these activities or if women with lower basal fear levels attend antenatal classes more eagerly. There is also a possibility of bias associated with data collection as study participants could presume there was a link between questions about antenatal classes and perception of experienced fear. To conclude, participation in antenatal classes should be advised to every pregnant primiparous woman as this type of preparation is associated with a decreased level of fear experienced during childbirth.
Conflict of interest All authors declare no conflict of interest.
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[11] Adams SS, Eberhard-Gran M, Eskild A. Fear of childbirth and duration of labour: a study of 2206 women with intended vaginal delivery. BJOG 2012; 119(10):1238e46. [12] Fenwick J, Gamble J, Nathan E, Bayes S, Hauck Y. Pre- and postpartum levels of childbirth fear and the relationship to birth outcomes in a cohort of Australian women. J Clin Nurs 2009;18:667e77. [13] Heimstad R, Dahloe R, Laache I, Skogvoll E, Schei B. Fear of childbirth and history of abuse: implications for pregnancy and delivery. Acta Obstet Gynecol Scand 2006;85:435e40. [14] Laursen M, Johansen C, Hedegaard M. Fear of childbirth and risk for birth complications in nulliparous women in the Danish National Birth Cohort. BJOG 2009;116:1350e5. [15] Rouhe H, Salmela-Aro K, Halmesmaki E, Saisto T. Fear of childbirth according to parity, gestational age, and obstetric history. BJOG 2009;116: 67e73. €m H. Fear of childbirth during preg[16] Ryding EL, Wijma B, Wijma K, Rydhstro nancy may increase the risk of emergency cesarean section. Acta Obstet Gynecol Scand 1998;77(5):542e7. [17] Saisto T, Halmesmaki E. Fear of childbirth: a neglected dilemma. Acta Obstet Gynecol Scand 2003;82:201e8. [18] Symonides A, Mogilnicka I, Krulak K, Kacperczyk J, Dobrowolska-Redo A, Romejko-Wolniewicz E. Understanding tokophobia phenomenon as a key to proper management. MEDtube Sci 2016;4(3):12e4. [19] Waldenstrom U, Hildingsson I, Ryding EL. Antenatal fear of childbirth and its association with subsequent caesarean section and experience of childbirth. BJOG 2006;113:638e46. [20] Wijma K, Alehagen S, Wijma B. Development of the delivery fear Scale. J Psychosom Obstet Gynaecol 2002;23(2):97e107.
[21] National Pharmaceutical Council. Pain: current understanding of assessment, management, and treatments. 2001. Available at, http://www.npcnow.org/ system/files/research/download/Pain-Current-Understanding-of-AssessmentManagement-and-Treatments.pdf. [Accessed 1 September 2018]. [22] Supreme chamber of control for the republic of Poland perinatal care in delivery wards. Registration number 203/2015/P/15/065/LBI. 2016. Available at, https://www.nik.gov.pl/kontrole/P/15/065/. [Accessed 1 September 2018]. [23] World Health Organization. World Health Organization WHO statement on caesarean section rates. Geneva, Switzerland: World Health Organization; 2015. [24] Chongsuvivatwong V, Bachtiar H, Chowdhury ME, Fernando S, Suwanrath C, Kor-Anantakul O, et al. Maternal and fetal mortality and complications associated with cesarean section deliveries in teaching hospitals in Asia. J Obstet Gynaecol Res 2010;36(1):45e51. [25] Loverro G1, Greco P, Vimercati A, Nicolardi V, Varcaccio-Garofalo G, Selvaggi L. Maternal complications associated with cesarean section. J Perinat Med 2001;29(4):322e6. €m IK. First-time parents' prenatal needs for early [26] Entsieh AA, Hallstro parenthood preparation-A systematic review and meta-synthesis of qualitative literature. Midwifery 2016;39:1e11. €m A, Lundgren I. A longitudinal survey of [27] Hildingsson I, Nilsson C, Karlstro childbirth-related fear and associated factors. J Obstet Gynecol Neonatal Nurs 2011;40(5):532e43. € m A, Nystedt A, Johansson M, Hildingsson I. Behind the myth-few [28] Karlstro women prefer caesarean section in the absence of medical or obstetrical factors. Midwifery 2011;27(5):620e7.
Contents lists available at ScienceDirect
Taiwanese Journal of Obstetrics & Gynecology journal homepage: www.tjog-online.com
Original Article
Association between antenatal classes attendance and perceived fear and pain during labour Joanna Kacperczyk-Bartnik a, Paweł Bartnik a, *, Aleksandra Symonides b, Natalia Sroka-Ostrowska a, Agnieszka Dobrowolska-Redo a, Ewa Romejko-Wolniewicz a a
2nd Department of Obstetrics and Gynaecology, Medical University of Warsaw, Karowa 2 Str, 00-315, Warsaw, Poland Students' Scientific Group Associated to 2nd Department of Obstetrics and Gynaecology, Medical University of Warsaw, Karowa 2 Str, 00-315, Warsaw, Poland
b
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 15 April 2019
Objectives: Antenatal classes are a common method of preparation for birth with proven efficiency in improving perinatal outcomes. Yet, their impact on fear perception during labour has not been identified. The aim of the study was to analyse whether preparation for labour by means of antenatal classes attendance could be associated with decrease in level of experienced fear and pain during birth. Materials and methods: It was a cross-sectional study of 147 women who had given vaginal births. Data was collected from mothers between 24 and 72 h postpartum. Patients answered self-reported questionnaires concerning subjective perception of birth including Delivery Fear Scale (DFS) and Numeric Rating Scale (NRS) for fear and pain assessment. The study group was divided into subgroups depending on parity and antenatal classes attendance. Results: Patients in the primiparas subgroup who attended antenatal classes scored lower in the DFS (48.7 ± 23.5 vs. 60.2 ± 16.5, p < .03). There was no difference in the DFS score in the multiparas subgroup (p < .90). No significant differences in the NRS score depending on antenatal classes attendance in any subgroup were observed. Conclusion: Participation in antenatal classes should be advised to every pregnant primiparous woman as this type of non-invasive preparation lowers level of fear experienced during childbirth. © 2019 Taiwan Association of Obstetrics & Gynecology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: Labour Labour pain Patient participation Pregnancy Prenatal education
Introduction Birth is a unique experience in a woman's life and preparation for it during prenatal period by attendance to antenatal classes seems to be helpful in achieving more optimal peri- and postnatal outcome [1e5]. Moreover, organised group activities facilitate experience exchange and provide emotional support from other women in similar life circumstances [6,7]. In industrialised countries there is a wide variety of available antenatal classes for couples who wish to be more adjusted to the transition to parenthood by participation in one of chosen activities [8]. Willingness to attend is an important factor as this form of prenatal counselling is not obligatory. Antenatal classes play an important educational role as information about pregnancy course during standard prenatal care
* Corresponding author. Karowa 2 Str, 00-315, Fax: þ48225966487. E-mail address: [email protected] (P. Bartnik).
Warsaw,
Poland.
may be deficient in case of even 75% of patients [9]. Apart from mothers' willingness to attend the classes, women must be aware of such opportunity, which usually requires obtaining information during prenatal consultations. According to Maternity Survey Report published in 2010, 69% of women in England were offered antenatal classes or workshops and this proportion differed depending on patient's age, parity and ethnicity [10]. Fear is not an asset in the delivery room. Affecting from 5 to even 26% of women at some stage of pregnancy, fear of childbirth (FOC) is associated with prolonged second stage of labour, difficulties in communication and collaboration with medical personnel as well as increased risk of emergency situations including emergency caesarean section [11e19]. Fear during birth is common among women fearful of childbirth earlier in pregnancy [16]. It is difficult to determine whether FOC is the fear of unknown, the fear of a difficult and meaningful event, or other. The aim of our study was to analyse, if preparation for birth by means of antenatal classes attendance could be associated with
https://doi.org/10.1016/j.tjog.2019.05.011 1028-4559/© 2019 Taiwan Association of Obstetrics & Gynecology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
J. Kacperczyk-Bartnik et al. / Taiwanese Journal of Obstetrics & Gynecology 58 (2019) 492e496
decrease in level of experienced fear and pain during vaginal delivery. Materials and methods It was a cross-sectional survey-based study of patients who gave birth at the tertiary referral centre between January and June 2016. The inclusion criteria for the purpose of this research were: providing informed oral consent for participation in the study and giving natural, live birth between 24 and 72 h before the survey completion. The exclusion criteria were: no consent, delivery by a caesarean section, multiple pregnancy, burdened obstetric history. Patients with a multiple-pregnancy, burdened obstetric history and who delivered by a caesarean-section were initially excluded before survey distribution. After initial answers analysis, 16 women who attended antenatal classes, but did not complete full course were excluded. There were 147 answers of women who gave natural birth selected for further investigation after the exclusion process, divided into two groups: primiparas (77 respondents) and multiparas (70 respondents). The structure of analysed population is presented in Fig. 1. All of the participants were asked to complete a self-reported survey, which consisted of two modules. The first one included demographic questions with a set about antenatal classes attendance during current and previous pregnancies. The second part consisted of Polish version of the Delivery Fear Scale (DFS) and 2 questions about the average and maximum pain felt by the patient during birth, which was assessed using the Numeric Rating Scale (NRS) [20,21]. The DFS was given in the past tense and patients
493
were asked about the mean perception of particular feelings during the whole labour. In addition to this, data about specific labour parameters and past medical history were obtained from medical records. Patients were divided into subgroups and their answers were analysed on the basis of completed antenatal classes course or lack of any antenatal classes attendance during current or any previous pregnancy. Patients who attended antenatal classes, but did not complete them, were excluded from the study in order to avoid possible bias of wrong group placement. All patients gave informed oral consent for the participation in the study. The protocol of the study was approved by the Committee on Bioethics at the Medical University of Warsaw. Statistical analysis was performed using Statistica 12 (StatSoft. Inc.). U-ManneWhitney test and Student T-tests were used for quantitative data comparison between two groups as required. Two-sided Fisher's exact test was used for categorical and binary data comparison. P value < .05 was considered significant. Results Group characteristics presented in Table 1 and in Fig. 1 revealed that women who attended full-course of antenatal classes were more often primiparous. This observation led to separately performed analyses between primi- and multiparas subgroups. No differences regarding maternal age, gestational age, BMI, prevalence of premature births, comorbidities, nor assisted deliveries were observed between antenatal classes attendants and those who did not attend the classes. 52.4% (n ¼ 77) of respondents gave birth for the first time, while 47.6% (n ¼ 70) of surveyed women gave birth for the second or subsequent time. 53.1% (n ¼ 78) of patients attended antenatal classes during the current or any previous pregnancy. Women who gave birth for the first time and attended antenatal classes scored lower in the DFS questionnaire e their total score was 48.7 ± 23.5 in comparison to 60.2 ± 16.5 (p < .03). The results of the particular questions and total score comparison in this group are presented in Table 2. No significant differences in the DFS score were observed in case of patients giving birth for the second or subsequent time. Respondents who attended antenatal classes scored 58.9 ± 19.3 vs. 59.6 ± 23.3 in comparison to those who did not attend (p < .90). Table 3 presents detailed results of this group. Table 4 presents differences in other selected birth parameters in primiparous patients depending on antenatal classes attendance. No significant differences in case of perceived pain, use of epidural analgesia, prevalence of assisted births, nor neonatal condition were observed. The 1st stage of labour lasted on average 66 min shorter in patients who attended antenatal classes, however this observation was not statistically significant (p < .08). Table 5 presents similar comparison of labour parameters among multiparous patients. No statistically significant differences regarding perceived pain, use of epidural analgesia, labour duration, prevalence of assisted births, nor neonatal condition were observed. Discussion
Fig. 1. Study population selection.
Fear of childbirth (FOC) affects 5e26% of pregnant women and presents in its most severe form as tokophobia e the most common psychiatric indication for caesarean section [12e15,17e19]. In the times of raising caesarean section rate every woman giving physiological vaginal birth becomes a form of obstetric success. Report by Supreme Chamber of Control of the Republic of Poland states that caesarean section rate in Poland between 2010 and 2012 was
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Table 1 Group characteristics (n ¼ 147). Feature
Total
Antenatal classes attendance (n ¼ 78)
No antenatal classes attendance (n ¼ 69)
pb
Age [Mean (±SD)] BMI [At birth; Median (Quartiles)] Gravidity [Median (Quartiles)] Parity Mean [Median (Quartiles)] Week of gestation [at birth; Median (Quartiles)] Pre-term birthsa Gestational Diabetes Mellitusa Pregnancy-induced hypertensiona Pre-pregnancy hypertensiona Anaemiaa Intrahepatic cholestasis of pregnancya Hypothyroidisma Assisted deliveriesa
31.5 ± 4.8 26.8 (24.9e30.5) 2 (1e3) 1 (1e2) 39 (38e40) 11.5% (16) 19.0% (26) 10.9% (15) 0.7% (1) 3.6% (5) 3.6% (5) 16.5% (23) 3.4% (5)
31.5 ± 4.4 26.3 (24.9e28.7) 1 (1e2) 1 (1e2) 39 (38e40) 13.9% (10) 18.3% (13) 8.5% (6) 0 2.8% (2) 1.4% (1) 19.4% (14) 5.2% (4)
31.5 ± 5.3 27.5 (24.9e31.6) 2 (1e3) 2 (1e2) 39 (38e40) 9.0% (6) 19.7% (13) 13.4% (9) 1.5% (1) 4.5% (3) 5.9% (4) 13.4% (9) 1.5% (1)
<.98 <.08 <.001 <.002 <.80 <.43 <1.00 <.42 <1.00 <.68 <.20 <.37 <.37
Bold values represent P lower than 0.05 was considered significant. a In brackets e absolute number of cases. b Comparison between antenatal classes attendants and those who did not attend.
Table 2 The impact of antenatal classes attendance on Delivery Fear Scale score e primiparas (n ¼ 77). Question
Antenatal classes attendance (n ¼ 51)
No antenatal classes attendance (n ¼ 26)
P
1. I can stand the pain 2. I feel very helpless 3. This feels positive 4. This feels as if I will never be able to get out of here 5. I can manage this 6. I do not want to go on any more 7. In the midst of all this I feel happy 8. I feel as if I will give up soon 9. This is taking forever 10. I feel calm Total score
6.4 ± 3.4 3.9 ± 3.5 6.6 ± 3.1 5.9 ± 3.6 6.4 ± 3.2 4.5 ± 3.5 4.83 ± 3.1 4.4 ± 3.5 4.8 ± 3.7 4.5 ± 3.3 48.7 ± 23.5
4.7 ± 3.1 4.8 ± 3.3 5.2 ± 3.4 6.3 ± 3.5 5.9 ± 3.1 5.4 ± 3.3 3.3 ± 2.3 5.6 ± 3.5 5.0 ± 3.2 2.6 ± 2.5 60.2 ± 16.5
.054 .19 .09 .84 .53 .28 .07 .17 .83 .02 .03
Bold values represent P lower than 0.05 was considered significant.
Table 3 The impact of antenatal classes attendance on Delivery Fear Scale score e multiparas (n ¼ 70). Question
Antenatal classes attendance (n ¼ 27)
No antenatal classes attendance (n ¼ 43)
P
1. I can stand the pain 2. I feel very helpless 3. This feels positive 4. This feels as if I will never be able to get out of here 5. I can manage this 6. I do not want to go on any more 7. In the midst of all this I feel happy 8. I feel as if I will give up soon 9. This is taking forever 10. I feel calm Total score
5.1 ± 3.4 4.7 ± 3.3 5.9 ± 3.0 7.0 ± 3.2 6.0 ± 3.0 5.0 ± 3.7 3.9 ± 3.2 5.3 ± 4.1 5.7 ± 3.7 3.3 ± 3.2 58.9 ± 19.3
5.1 ± 3.2 5.0 ± 3.3 4.6 ± 2.9 6.5 ± 3.8 5.4 ± 2.6 5.7 ± 3.4 3.8 ± 3.2 5.2 ± 3.7 5.0 ± 3.5 3.3 ± 3.0 59.6 ± 23.3
.92 .61 .09 .61 .63 .35 .92 .85 .67 .90 .90
Table 4 Antenatal Classes attendance and specific birth features e primiparas (n ¼ 77). Feature
Antenatal classes attendance (n ¼ 51)
No antenatal classes attendance (n ¼ 26)
P
Mean pain (NRS) Maximum pain (NRS) Epidural analgesia (%) Time of 1st stage of birth (min) Time of 2nd stage of birth (min) Assisted birth (%) Good neonate's condition based on Apgar 1st minute score (8 points; %) Good neonate's condition based on Apgar 5th minute score (8 points; %)
6.5 ± 2.2 9.2 ± 1.3 71.7% (33) 328 ± 142 49 ± 34 7.8% (4) 98.0% (50) 98.0% (50)
6.6 ± 2.3 9.2 ± 2.2 62.5% (15) 394 ± 158 41 ± 27 0 100% (26) 100% (26)
.43 .15 .43 .08 .40 .30 1.00 1.00
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Table 5 Antenatal Classes attendance and specific birth features e multiparas (n ¼ 70). Feature
Antenatal classes attendance (n ¼ 27)
No antenatal classes attendance (n ¼ 43)
P
Mean pain (NRS) Maximum pain (NRS) Epidural analgesia (%) Time of 1st stage of birth Time of 2nd stage of birth Assisted birth (%) Good neonate's condition based on Apgar 1st minute score (8 points; %) Good neonate's condition based on Apgar 5th minute score (8 points; %)
6.1 ± 1.9 9.7 ± 0.8 55.0% (11) 293 ± 103 18 ± 19 0 100% (27) 100% (27)
6.7 ± 2.1 9.3 ± 1.1 48.7% (19) 270 ± 151 26 ± 24 2.4% (1) 96.7% (42) 96.7% (42)
.29 .20 .78 .27 .24 1.00 1.00 1.00
as high as 42% of all deliveries [22]. According to the World Health Organization (WHO) recommendations, caesarean section rate should ideally reach no more than 15% of births [23]. Concerning all the possible complications following caesarean section and its impact on future obstetric outcomes as well as difficulties in abdominal access during future surgical interventions, every factor increasing the rate of vaginal births is anticipated [24,25]. However, caesarean section is not the only mode of delivery associated with FOC. Research proves that FOC may affect the course of natural births as well, for instance by prolonging its duration. Adams et al. identified FOC as an individual risk factor for longer lasting active part of labour [11]. The estimated difference in second stage of labour duration between women with and without FOC after excluding other factors was as long as 48 min. Our study results suggest an effective non-invasive intervention resulting in reducing the level of perinatal feeling of fear and psychological discomfort in women during labour. By means of antenatal education for future parents it is possible to prepare primiparas for the new circumstances and influence the way they experience birth. Due to feeling calmer and decreasing total level of fear, cooperation with obstetric team might be easier and more efficient. This is even more important for women who deliver for the first time as they need to learn the process by acquiring appropriate technique of pushing and breathing during labour, which is easier with help of professional midwife or obstetrician. Our findings should be considered by healthcare providers and decision makers as antenatal classes do not require much additional organizational efforts and are already organized near numerous obstetric wards. Especially, that the size of group participating in the classes does not seem to affect the outcome [8]. Our study shows that attendance to antenatal classes should be advised to all primiparas as in multiparas results were not as much associated with participation in this type of activities as in women who gave birth for the first time. Similar findings were obtained in qualitative studies focussing on needs of future parents, in which over 90% of respondents - both men and women - claimed lack of preparation and need for additional support during becoming parents of the first child [26]. It is also worth mentioning that the feeling of calmness and being less fearful during labour was not a result of experiencing less severe pain. Differences between both maximum and mean levels of pain reported by respondents were not significant. Similarly, the percentage of women asking for and receiving epidural analgesia was comparable, no matter previous antenatal classes attendance or lack of it. These findings concerned both primiparas and multiparas. Therefore, it seems that feeling of control and being acquainted with possible situations that follow each step of labour are of higher impact on the level of fear than experienced pain, which was also reported in Hildingsson and Fabian studies [6,27]. Lack of visible effect of antenatal classes attendance in the multiparas group could be explained by stronger meaning of previous obstetric experience resulting in shaping expectations and
feelings associated with another birth [28]. It is also worth mentioning that results obtained in primiparas without preparation during antenatal classes and both subgroups of multiparas e with and without organized prenatal education e were comparable. This could suggest that antenatal classes might provide better preparation and labour perception in primiparas than in women who had experienced the birth before. The main limitation of presented study results from its type e a cross-sectional study. Due to this fact it cannot be determined whether lower levels of fear in primiparous women who have attended antenatal classes result from actual impact of these activities or if women with lower basal fear levels attend antenatal classes more eagerly. There is also a possibility of bias associated with data collection as study participants could presume there was a link between questions about antenatal classes and perception of experienced fear. To conclude, participation in antenatal classes should be advised to every pregnant primiparous woman as this type of preparation is associated with a decreased level of fear experienced during childbirth.
Conflict of interest All authors declare no conflict of interest.
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