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The Journal of Perinatal Education logoLink to The Journal of Perinatal Education
. 2023 May 1;32(2):94–103. doi: 10.1891/JPE-2022-0006

Outcomes of Childbirth Education for Women With Pregnancy Complications

Jennifer Vanderlaan ✉, Tricia Gatlin, Jay Shen
PMCID: PMC10321455  PMID: 37415933

Abstract

The purpose of this study was to examine associations between pregnancy outcomes and childbirth education, identifying any outcomes moderated by pregnancy complications. This was a secondary analysis of the Pregnancy Risk Assessment Monitoring System, Phase 8 data for four states. Logistic regression models compared outcomes with childbirth education for three subgroups: women with no pregnancy complications, women with gestational diabetes, and women with gestational hypertension. Women with pregnancy complications do not receive the same benefit from attending childbirth education as women with no pregnancy complications. Women with gestational diabetes who attended childbirth education were more likely to have a cesarean birth. The childbirth education curriculum may need to be altered to provide maximum benefits for women with pregnancy complications.

Keywords: perinatal education; diabetes, gestational; hypertension, pregnancy-Induced; cesarean surgery; breastfeeding

INTRODUCTION

The goal of childbirth education is to provide women and their families with knowledge and skills to deal with the challenges of labor and birth. This education reduces anxiety, increases confidence, and allows women to participate in informed decisions about their care (Edmonds et al., 2018; Mueller et al., 2020). Several studies suggest that childbirth education may have benefits at the population level in addition to the benefits for the individual. For example, childbirth education is associated with reduced rates of primary cesarean surgery, a national and state population health goal (Levett et al., 2018; Milcent & Zbiri, 2018; Mueller et al., 2020; Toohill et al., 2017). At this time there is limited population-level research examining the effects of childbirth education.

In the United States, national population health goals for maternity care are set by Healthy People 2030, by the Centers for Medicaid and Medicare Services (CMS), and by Title V Block Funding. States adopt goals based on the current health of their populations, and select population-level interventions to help meet the goals. Hospitals adopt these goals for quality improvement to meet the criteria for Joint Commission Accreditation and for CMS funding. Estimates of the effect of childbirth education on population health outcomes can help identify when childbirth education is a cost-effective intervention to improve population health.

Several topics covered in comprehensive childbirth education courses align with population health goals. For example, Lamaze Healthy Birth Practice 4, avoid interventions that are not necessary, aligns with national goals to reduce the primary cesarean birth rate (Centers for Medicare & Medicaid Services, n.d.; Health Resources and Services Administration, n.d.; Lothian, 2014; The Joint Commission, 2012; U.S. Department of Health and Human Services, n.d). Childbirth education includes information about postpartum care for the mother, including contraception and attending the postpartum visit. These topics align with the CMS goal to increase the quality of postpartum care and the HP2030 goal to reduce the rate of unintended pregnancies (Centers for Medicare & Medicaid Services, n.d.; U.S. Department of Health and Human Services, n.d). Comprehensive childbirth education includes breastfeeding and infant care information, which aligns with the objectives to increase breastfeeding and safe infant sleep practices for both Healthy People and Title V (Health Resources and Services Administration, n.d.; U.S. Department of Health and Human Services, n.d).

The generalized information shared in childbirth education courses may not benefit women with pregnancy complications in the same ways it benefits women without complications. For example, the risks and benefits of cesarean birth with gestational diabetes and gestational hypertension depend on specifics, such as the degree of severity and the gestational age (“ACOG Practice Bulletin No. 190: Gestational Diabetes Mellitus”, 2018; “ACOG Practice Bulletin No. 202: Gestational Hypertension and Preeclampsia”, 2019). When the effects of an intervention change under different circumstances, that intervention is said to be moderated by the circumstance. It is possible that pregnancy complications moderate the benefits of attending childbirth education.

One of the main benefits of childbirth education is the ability to reinforce multiple health messages such as the importance of postpartum visit attendance, why to use safe sleep positions, or strategies to overcome breastfeeding challenges. Women with gestational diabetes and gestational hypertension have many opportunities for exposure to these health messages during antenatal health education and frequent antenatal visits with their healthcare provider. For example, health education about the conditions targets lifestyle interventions that have demonstrated benefits in pregnancy including improved glucose control and weight gain within recommended limits (Carolan-Olah & Sayakhot, 2019; Farpour-Lambert et al., 2018; Goldschmidt & Colletta, 2016). However, these lifestyle interventions are not associated with a reduction in cesarean birth for women with gestational hypertension or gestational diabetes (Goveia et al., 2018; Peaceman et al., 2018). Prior evidence has found the increased receipt of postpartum glucose testing and increased breastfeeding initiation when women with gestational diabetes receive targeted antenatal education. It is not known if the health education provided in childbirth education has similar benefits. The frequent educational opportunities may result in message fatigue, reducing the benefit of childbirth education for women with pregnancy complications (So et al., 2017). In contrast, the increased anxiety due to frequent visits and health concerns may reduce the benefit of individual general health messages (Kataja et al., 2017; Plamondon et al., 2015). If this is true, the additional messaging received during childbirth education may be associated with health behaviors for women with pregnancy complications.

The aim of this study was to examine associations between attending childbirth education and Title V maternal and newborn health objectives, accounting for the moderation that may occur for women with pregnancy complications gestational diabetes and gestational hypertension. The significance of this study is twofold. First, the evidence can be used by childbirth educators to ensure that the curriculum is available to meet the needs of all clients. Second, the evidence can inform state and hospital policy decisions to use childbirth education as a tool to achieve maternal and newborn outcomes.

STUDY DESIGN AND METHODS

The University of Nevada, Las Vegas Institutional Review Board determined this study was exempt from review because it did not meet the definition of human subjects’ research. Three samples were created from the Pregnancy Risk Assessment Monitoring Survey (PRAMS), Phase 8 for four states: Nebraska, New Jersey, Montana, and Pennsylvania. These states were selected because they include participation in childbirth education in the PRAMS survey. The PRAMS is a national survey, coordinated by the Centers for Disease Control and Prevention that allows states to measure Title V objectives. States identify potential participants through a random selection of birth certificates. Selected women are contacted by mail; if there is no response the women are interviewed by telephone. Data collection procedures are standardized to ensure comparable data across states.

Eligibility criteria for this study included reporting on the first live birth and answering (yes or no) the question about participating in childbirth education. Exclusion criteria included less than 37 completed weeks of pregnancy prior to birth because unanticipated early labor may have interfered with childbirth education participation.

The eligible respondents were stratified into three subgroups to identify the moderation of benefits of childbirth education. This is an appropriate method to detect moderation between two categorical (yes/no) variables. The first subgroup included respondents whose birth certificates indicated there were no pregnancy complications. The second subgroup included respondents whose birth certificates indicated the pregnancy was complicated by gestational diabetes. The final subgroup included respondents whose birth certificates indicated the pregnancy was complicated by gestational hypertension. Post hoc power calculations were conducted for each subgroup for each outcome and are available in the supplement.

Variables

The independent variable for this analysis was participation in childbirth education, which was included as a dichotomous (yes/no) variable in the PRAMS survey. The dependent variables included the induction of labor, cesarean birth, attendance at a postpartum visit, postpartum diabetes testing, postpartum use of birth control, use of safe infant sleep practices, and breastfeeding.

Cesarean birth was identified by mode of birth on the linked birth certificate and was limited to those with singleton fetus. No variable was available to restrict the sample to those with a vertex fetus. Induction of labor was a dichotomous variable based on a PRAMS survey question indicating the health care provider tried to start labor.

Attendance at a postpartum visit was a dichotomous variable indicating the participant had attended a postpartum visit or checkup for themselves after birth. Postpartum diabetes testing was included as a dichotomous variable indicating a postpartum diabetes test occurred during the postpartum visit. Postpartum use of birth control included sterilization, long-acting reversible contraceptives, or use of oral contraceptives and was limited to respondents who were not currently pregnant or planning to become pregnant. Safe infant sleep was coded as a dichotomous variable indicating the respondent put the infant to sleep on their back and in their own bed. Breastfeeding was measured as any breastfeeding, regardless of duration.

Control variables were selected based on a preliminary analysis of variables associated with participation in childbirth education, the prevalence of pregnancy complications, or the outcomes of interest. Maternal age was included as a categorical variable using age less than 30, 30–34, or 35 and older (Janssen et al., 2017; Kozhimannil et al., 2014; Mylonas & Friese, 2015). Medicaid as the primary payer and college education were included as dichotomous variables. Recommended weight gain was included as a dichotomous variable indicating pregnancy weight gain was within our outside American College of Obstetricians and Gynecologists (ACOG) recommendations. Maternal race and ethnicity were included as a dichotomous variable indicating a person of color or White non-Hispanic person. Though race and ethnicity are associated with gestational diabetes and complications due to gestational diabetes, the small samples for those with pregnancy complications prevented full control for race and ethnicity.

Analysis

Analysis was conducted using SAS 9.0. Chi-square analysis was used to describe associations between attending childbirth education and sample characteristics for each subgroup. Univariate analysis of outcomes was conducted using chi-square analysis to (a) compare the prevalence of outcomes for those with pregnancy complications to those without and (b) identify associations between childbirth education and the outcomes among the subgroups.

The main analysis was conducted as logistic regression, using backward selection with a model exit set at 0.10. Models were created for each subgroup, which allowed the identification of moderation of effect. Observations with missing data were not included in the models. Because the odds ratios are likely to overestimate the effect size when the prevalence is higher than 10%, we converted the odds ratios to risk ratios (Zhang & Yu, 1998). Results were reported as approximated risk ratio (ARR) for attending childbirth education compared to not attending childbirth education within each subgroup.

RESULTS

A total of 2,238 respondents were eligible for this analysis. Of these, 1,888 were stratified as those with no pregnancy complications, 174 were stratified as those with gestational diabetes, and 176 were stratified as those with gestational hypertension.

There were multiple differences between participants who attended childbirth education and those who did not in each of the subgroups (see Table 1). Attendance at childbirth education was more common for participants aged 30 or older, those who did not use Medicaid, those who were college graduates, and those who identified as White non-Hispanic.

TABLE 1. Characteristics of Attendance at Childbirth Education for Women Preparing for First Live Birth, Stratified by Maternal Pregnancy Complication; PRAMS Phase 8.

No pregnancy complications N = 1,888 Gestational diabetes N = 174 Gestational hypertension N = 176
Childbirth education Childbirth education Childbirth education
No n = 1,098 (58.2%) Yes n = 790 (41.8%) p No n = 105 (60.3%) Yes n = 69 (39.7%) p No n = 100 (56.8%) Yes n = 75 (42.6%) p
Maternal age    
 <30 772 (66.5%) 389 (33.5%) <.001 48 (73.9%) 17 (26.2%) 0.005 68 (66.0%) 35 (34.0%) 0.015
 30–34 244 (45.3%) 295 (54.7%) 36 (59.0%) 25 (41.0%) 22 (46.8%) 25 (53.2%)
 >34 82 (43.6%) 106 (56.4%) 21 (43.8%) 27 (56.3%) 10 (40.0%) 15 (60.0%)
Insurance source                  
 Medicaid 457 (74.7%) 155 (25.3%) <.001 32 (76.2%) 10 (23.8%) 0.025 53 (82.8%) 11 (17.2%) <.001
 Other 625 (50.0%) 626 (50.0%) 72 (55.8%) 57 (44.2%) 47 (42.7%) 64 (57.3%)
Education completed                  
 College graduate 374 (41.3%) 531 (58.7%) <.001 49 (51.6%) 46 (48.4%) 0.007 26 (37.7%) 43 (62.3%) <.001
 Other 720 (73.7%) 257 (26.3%) 56 (71.8%) 22 (28.2%) 74 (69.8%) 32 (30.2%)
Gestational weight gain                  
 Recommended 863 (56.3%) 670 (43.7%) <.001 80 (62.5%) 48 (37.5%) 0.332 58 (52.3%) 53 (47.8%) 0.085
 Outside recommendations 235 (66.2%) 120 (33.8%) 25 (54.4%) 21 (45.7%) 42 (65.6%) 22 (34.4%)
Maternal race                  
 White non-Hispanic 550 (54.2%) 465 (45.8%) <.001 39 (51.3%) 37 (48.7%) 0.025 45 (46.9%) 51 (53.1%) 0.003
 Person of color 548 (62.8%) 325 (37.2%) 66 (68.0%) 31 (32.0%) 55 (69.6%) 24 (30.4%)
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In these data, several between-group differences in outcome prevalence were identified. Both the induction of labor and cesarean birth were more prevalent for both those with gestational diabetes (p = 0.024 and p < .001) or gestational hypertension (p = 0.046 and p < .001) compared to those without pregnancy complications. There was a higher prevalence of receiving a postpartum diabetes test among those with gestational diabetes than those without pregnancy complications (p < .001). There was no difference between the groups for the prevalence of postpartum visits, use of birth control, and breastfeeding.

In univariate analysis, childbirth education was associated with several outcomes. For those with no pregnancy complications, attendance at childbirth education was associated with increased postpartum visit attendance (88.6%–95.9%; p < .001), decreased receipt of a postpartum diabetes test (22.3%–11.2%; p < .001), increased use of safe infant sleep positions (55.2%–66.8%; p = 0.028), and increased breastfeeding initiation (89.5%–97.6%; p < .001). For those with gestational diabetes, attendance at childbirth education was associated with increased use of cesarean birth (35.2%–50.7%; p = 0.043) and increased breastfeeding (87.6%–97.1%; p = 0.031). For those with gestational hypertension, childbirth education was associated with increased attendance at the postpartum visit (83.7%–98.7%; p = 0.001), increased use of safe infant sleep positions (56.0%–72.6%; p = 0.008), and increased breastfeeding initiation (79.0%–96.0%; p = 0.001). Results of univariate analysis are available in Table 2.

TABLE 2. Birth Outcomes by Attendance at Childbirth Education for Women at First Live Birth, Stratified by Maternal Pregnancy Complication; PRAMS Phase 8.

No pregnancy complications Gestational diabetes Gestational hypertension
N = 1,888 Childbirth education N = 174 Childbirth education N = 176 Childbirth education
No n = 1,098 Yes n = 790 p No n = 105 Yes n = 69 p No n = 100 Yes n = 75 p
Induction of labor 290 (26.4%) 211 (26.7%) 0.878 37 (35.2%) 23 (33.3%) 0.687 36 (36.0%) 23 (30.7%) 0.217
Cesarean birth 313 (28.5%) 210 (26.6%) 0.326 37 (35.2%) 35 (50.7%) 0.043 36 (36.0%) 34 (45.3%) 0.212
Postpartum visit 959 (88.6%) 748 (95.9%) <.001 92 (89.3%) 66 (97.1%) 0.062 82 (83.7%) 74 (98.7%) 0.001
Postpartum diabetes test 208 (22.3%) 81 (11.2%) <.001 57 (63.3%) 35 (53.0%) 0.196 28 (34.6%) 19 (26.0%) 0.251
Birth controla 763 (76.1%) 580 (80.3%) 0.097 64 (66.0%) 48 (76.2%) 0.275 67 (69.8%) 56 (82.4%) 0.195
Safe infant sleep 594 (55.2%) 514 (66.8%) 0.028 53 (50.5%) 35 (53.9%) 0.146 56 (56.0%) 53 (72.6%) 0.008
Breastfed 968 (89.5%) 760 (97.6%) <.001 92 (87.6%) 66 (97.1%) 0.031 79 (79.0%) 71 (96.0%) 0.001
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aSample limited to women not currently pregnant and not trying to become pregnant.

Main Results

In the multivariate analyses for those with no pregnancy complications, childbirth education was associated with increased attendance at a postpartum visit (ARR 1.04; 95% CI 1.01–1.06), increased use of birth control (ARR 1.04; 95% CI 1.01–1.06), increased use of safe infant sleep practices (ARR 1.11; 95% CI 1.03–1.19), and increased breastfeeding (ARR 1.06; 95% CI 1.04–1.07). In those with no pregnancy complications, childbirth education was associated with reduced use of cesarean birth (ARR 0.80; 95% CI 0.65–1.00), and reduced receipt of a postpartum diabetes test (ARR 0.68; 95% CI 0.51–0.73). There was no association between childbirth education and the induction of labor for those with no pregnancy complications. See Table 3 for full results.

TABLE 3. Estimate of the Effect of Childbirth Education on Birth Outcomes for Women at First Live Birth Using Approximated Risk Ratio, Stratified by Maternal Pregnancy Complication; PRAMS Phase 8.

No pregnancy complications ARR (95% CI) Gestational diabetes ARR (95% CI) Gestational hypertension ARR (95% CI)
Induction of labor 1.08 (0.89–1.30) 0.78 (0.41–1.32) 0.58 (0.21–1.31)
Cesarean birth 0.80 (0.65–1.00) 1.43 (1.05–1.78) 1.31 (0.92–1.69)
Postpartum visit 1.04 (1.01–1.06) 1.07 (0.98–1.10) 1.11 (1.02–1.13)
Postpartum diabetes test 0.68 (0.51–0.73) 0.89 (0.59–1.21) 1.52 (0.80–2.38)
Birth controla 1.05 (0.98–1.11) 1.16 (0.91–1.33) 1.17 (0.94–1.31)
Safe infant sleep 1.11 (1.03–1.19) 1.04 (0.71–1.37) 1.18 (0.93–1.36)
Breastfeeding 1.06 (1.04–1.07) 1.07 (0.97–1.09) 1.14 (1.05–1.16)
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aSample limited to persons not currently pregnant or planning pregnancy.

For those with gestational diabetes, childbirth education was associated with increased use of cesarian birth (ARR 1.43; 95% CI 1.05–1.78). There was no association with childbirth education among those with gestational diabetes for induction of labor, postpartum visit attendance, postpartum diabetes testing, use of birth control, use of safe infant sleep practices, or breastfeeding.

For those with gestational hypertension, childbirth education was associated with increased attendance at a postpartum visit (ARR 1.11; 95% CI 1.02–1.13) and increased breastfeeding (ARR 1.14; 95% CI 1.05–1.16). There was no association with childbirth education among those with gestational hypertension for induction of labor, cesarean birth, postpartum diabetes testing, use of birth control, or use of safe infant sleep positions.

DISCUSSION

These data provide evidence that childbirth education is an intervention that helps meet population maternal health goals. In addition, this was the first study to examine the potential for pregnancy complications to moderate the effects of childbirth education in meeting these goals. These data demonstrate that the intended benefits of childbirth education are not experienced by women with pregnancy complications, including benefits from the general health information on safe infant sleep.

In these data, participation in childbirth education was not associated with induction of labor for any subgroup. To date, only one study has found a reduction in the induction of labor with childbirth education, but this study was able to distinguish between elective and nonelective inductions (Mueller et al., 2020). PRAMS data were unable to distinguish between medically necessary and non-medically necessary induction and did not provide the variables to stratify induction prior to 39 weeks and induction of labor after 39 weeks. The lack of association may reflect a current lack of consensus on best practices for the induction of labor for both women with and without risk factors as evidence evolves (Middleton et al., 2018). Both gestational diabetes and gestational hypertension increase the risk for medically indicated induction of labor, which is consistent with the increased prevalence of indication of labor among these subgroups (Feghali et al., 2016; Potti et al., 2012). Many obstetricians offer induction of labor at 39–40 weeks’ gestation for women with gestational diabetes (“ACOG Practice Bulletin No. 190: Gestational Diabetes Mellitus”, 2018). One reason may be the insufficient evidence to clearly identify if there are differences in health outcomes for women with gestational diabetes and their babies when elective birth is undertaken compared to waiting for labor to start spontaneously or until 41 weeks’ gestation if all is well (Biesty et al., 2018). In contrast, induction of labor is considered beneficial for women with gestational hypertension and is recommended after 37 completed weeks (Cífková et al., 2020). Given this, one may expect a positive association between childbirth education and induction. The lack of an association in these data may be due to the small sample size or may indicate that childbirth education did not contribute to shared decision-making about the induction of labor. This is consistent with prior evidence that provider, rather than patient, decision-making, predicts induction of labor (Jou et al., 2015).

Though childbirth education was associated with decreased use of cesarean for women with no pregnancy complications, it was associated with increased use of cesarean birth for women with gestational diabetes and had no association for women with gestational hypertension. Prior findings of reduced cesarean with childbirth education have been interpreted to mean that persons who attend childbirth education are better prepared to participate in shared decision-making for labor and birth (Mueller et al., 2020). The lack of association for persons with gestational hypertension may be due to the small sample size, or it may indicate that the curriculum in childbirth education is not addressing the information needs of women with this condition. The rate of cesarean was higher for women with pregnancy complications in these data than was reported in prior literature (Feghali et al., 2016).

The finding of increased risk of cesarean birth with childbirth education for women with gestational diabetes needs further investigation. The ACOG suggests that expectant management be practiced in women with gestational diabetes, and recommends against elective birth before 39 weeks’ gestation (“ACOG Practice Bulletin No. 190: Gestational Diabetes Mellitus”, 2018). However, ACOG guidelines recommend that if the mother is deemed high risk, as evidenced by poor glycemic control or fetal complications, early elective birth should be considered before the end of the 40th week of gestation. One potential interpretation of this finding is that women who participate in childbirth education are better educated about the risks of their condition and are therefore more likely to agree to a medically indicated elective cesarean birth. However, these data do not include an associated reduction in the use of induction of labor, which might be expected with an increase in planned cesareans. Another potential interpretation is that women who are planning a medically indicated elective cesarean are more likely to attend a hospital information class to prepare for the planned surgical experience (Declercq et al., 2013). These data did not provide information about the content of childbirth education courses.

Childbirth education was associated with increased postpartum visit attendance for women with no pregnancy complications and women with gestational hypertension, but not women with gestational diabetes. In these data, women with both gestational diabetes and gestational hypertension were more likely to report attending a postpartum visit than in prior studies (Fabiyi et al., 2019; Rosenbloom & Blanchard, 2018). The high prevalence of attendance at a postpartum visit for those with gestational diabetes is likely due to repeated health messaging during antenatal care. In contrast, childbirth education was not associated with the use of birth control for any group studied. The lack of association for women both with and without pregnancy complications may mean that postpartum birth control is not included in childbirth education courses. Childbirth education is an opportunity to increase awareness and knowledge of the immediate post-partum placement of long-acting reversible contraception (LARC). A recent systematic review found that immediate postpartum LARC placement is rated favorably among women who receive it, and up to 62% of women who did not receive immediate postpartum LARC placement would have liked the option (Thompson et al., 2019).

Childbirth education was not associated with an increase in postpartum diabetes testing for women with gestational diabetes. The Women’s Preventive Services Initiative recommends a glucose test be completed between 1 and 6 months postpartum (Women’s Preventive Services Initiative, 2018). The low rate of postpartum glucose testing among those with gestational diabetes in these data is consistent with prior findings (Rosenbloom & Blanchard, 2018). Prior research found increased rates of postpartum glucose testing when women received care in a gestational diabetes clinic, but this intervention included both provider adherence to guidelines and patient education (Huynh et al., 2017). Childbirth education includes information about postpartum health and self-care, so the lack of association with receiving appropriate postpartum care for women with gestational diabetes may indicate the need for curriculum adjustments.

Though childbirth education was associated with the use of safe infant sleep positions for women with no pregnancy complications, there was no association for either pregnancy complication group. One potential explanation for this is that women with pregnancy complications are more likely to receive closer neonatal surveillance during postpartum hospitalization. This increased care may provide more opportunities for education about safe sleep positions and may negate any effect of attending childbirth education classes (Kellams et al., 2017; Walcott et al., 2018). However, those with gestational diabetes had a lower prevalence of the use of safe infant sleep than those without complications, suggesting this message is not being received by persons with gestational diabetes.

Women with no pregnancy complications and those with gestational hypertension are more likely to breastfeed if they attend childbirth education, but there was no association between childbirth education and breastfeeding for those with gestational diabetes. Though the prevalence of breastfeeding was higher with childbirth education for participants with gestational diabetes, the lack of statistical significance is concerning because targeted educational interventions for people with gestational diabetes have been successful at improving breastfeeding (Stuebe et al., 2016; You et al., 2020). Breastfeeding can help improve postpartum glucose control, making this newborn feeding practice particularly valuable for women with gestational diabetes (Gunderson, 2007; Tarrant et al., 2020).

The lack of association between childbirth education and improved health outcomes for women with gestational diabetes indicates a need for an improved curriculum targeting specific learning needs. An alternative interpretation of the increased use of cesarean birth and lack of association with other outcomes in these data is that persons with gestational diabetes may be more likely to take childbirth education courses that are focused on the experience of a planned birth instead of comprehensive evidence-based childbirth education.

Limitations

This study had several analytic limitations that should be considered when interpreting the data. First, diagnosis of gestational diabetes or gestational hypertension was available as a dichotomous variable, which did not allow for more precise control based on the severity of the condition. However, since severity would be expected to be distributed evenly between those who attended and did not attend childbirth education, this limitation is unlikely to result in bias. Second, participation in childbirth education was available as a dichotomous variable, which did not allow for analysis based on the content or the dose of the educational intervention (Vanderlaan et al., 2021). Some childbirth education is conducted as single-session hospital introduction classes, while others are conducted over a series of weeks (Declercq et al., 2013). The differences in content and structure of these classes likely result in different effects on the outcomes studied and the inability to differentiate in this analysis would bias the result toward finding no difference. The variables for induction of labor and testing for diabetes during the postpartum were taken from the PRAMS survey and therefore may suffer from misclassification bias if the participant was not fully informed about the care received. This analysis was limited to population health outcomes of interest to policy makers. Other outcomes associated with childbirth education, such as reduced maternal anxiety, may occur similarly for women with and without pregnancy complications.

Finally, this analysis was limited to the sample available in the states that included a question about childbirth education in the PRAMS Phase 8 questionnaire. The small sample size for the participants with gestational diabetes and participants with gestational hypertension subgroups meant our analysis was underpowered to identify some moderate associations. However, each sample did have sufficient power to identify at least one small association. The power to achieve statistical significance is dependent on the size of the sample but the magnitude of the effect is stable with a larger sample increasing the precision and reducing the size of the confidence interval (Sullivan & Feinn, 2012). Additional studies with larger sample sizes may achieve a statistically significant result; however, the potential magnitude of an association may be too small to be clinically relevant.

Implications for Practice

These results suggest states can use childbirth education as a tool to improve pregnancy outcomes. Childbirth educators should be aware that women with gestational diabetes or gestational hypertension do not experience the same benefits from the general educational content. Curricula should be adapted to address condition-specific needs for women with gestational diabetes, such as the benefits of breastfeeding on glucose metabolism and the need for postpartum glucose screening. Educators should be aware that the stress of the pregnancy complication may hinder learning; providing additional learning resources on postpartum and infant care may be required.

Conclusion

Women with gestational diabetes or gestational hypertension do not experience the same benefits from childbirth education as women with no pregnancy complications. The lack of an association between childbirth education and health behaviors such as the use of contraception, the use of safe infant sleep positions, and breastfeeding initiation suggests that childbirth education courses may need to be specialized for women with pregnancy complications. Specifically, women with gestational diabetes and gestational hypertension need information on the risks and benefits of elective induction of labor and cesarean birth. More information on standard care for gestational diabetes, infant care and screening, breastfeeding, and postpartum glucose control is needed for women with gestational diabetes. Additional research is needed to understand the reasons for the reduced benefit and the best methods for providing childbirth education to populations with pregnancy complications.

Supplement: Results of post-hoc power calculations for each outcome.

Supplement: Results of post-hoc power calculations for each outcome.
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Biographies

Jennifer Vanderlaan, JENNIFER VANDERLAAN began work as a childbirth educator in 2000 and is currently an assistant professor at the University of Nevada, Las Vegas School of Nursing. Her research examines how the organization of health services affect health outcomes.

Tricia Gatlin, TRICIA GATLIN began conducting research on self-care and diabetes in 2012. Over the years she has expanded this research to include healthy eating and exercise during pregnancy to reduce the risk of gestational diabetes. She is currently the Dean and Professor at Wegmans School of Nursing at St. John Fisher University.

Jay Shen, JAY SHEN began conducting research on maternal and child health in a national project supported by UNICEF in China in the mid-1990s and continued his research on disparities in maternal outcomes since the 2000s. He is currently a professor at UNLV School of Public Health.

DISCLOSURE

The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.

ACKNOWLEDGMENTS

This work uses data collected by the PRAMS Working Group at the United States Centers for Disease Control and Prevention.

FUNDING

The author(s) received no specific grant or financial support for the research, authorship, and/or publication of this article

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