The Association of Childbirth Preparation Classes with Labor Pain, Labor Duration, and Neonatal Outcomes in the Northeast of Iran During 2018–2019: A Retrospective Cohort Study

ABSTRACT

Background and Aims

Childbirth preparation classes aim to equip expectant parents with knowledge and skills for a smoother labor process. This study evaluated their effects on labor pain, duration, and neonatal outcomes.

Methods

This retrospective cohort study involved 240 primiparous women, with 120 attending at least four classes and 120 not participating. The classes comprised eight sessions conducted by certified midwives at Ayatollah Rouhani Hospital in Iran (2018–2019). Data were collected through questionnaires, clinical observations, and medical examinations. Pain severity was assessed using the Visual Analogue Scale (VAS).

Results

The intervention group reported significantly lower pain intensity during the late first stage of labor (mean ± SD: 8.21 ± 2.36 vs. 8.69 ± 1.75; p < 0.001) and the second stage (7.69 ± 3.08 vs. 8.37 ± 2.36; p < 0.05). No significant differences were observed in the durations of the first (219.09 ± 131.46 vs. 235.03 ± 138.73 min; p = 0.36), second (37.00 ± 26.10 vs. 42.77 ± 31.82 min; p = 0.12), or third stages (6.58 ± 4.49 vs. 7.07 ± 4.54 min; p = 0.40). Neonatal outcomes showed no significant differences. Women in the control group had nearly Seven times higher odds of experiencing pain scores above 5 during late first‐stage labor.

Conclusions

Childbirth preparation classes effectively reduce labor pain but do not significantly impact labor duration or neonatal health. Given the importance of promoting natural delivery, expanding such educational programs is recommended to enhance maternal adaptation and overall labor experience.

1. Introduction

Childbirth is a profound event in a woman's life, often creating memories that last a lifetime [1]. Prenatal childbirth preparation classes are designed to enhance health education and facilitate communication between pregnant women and healthcare professionals [2]. The World Health Organization (WHO) recommends incorporating birth plans into prenatal care, considering them a fundamental aspect of quality care for pregnant women [3]. Widespread adoption of birth planning has the potential to reduce unnecessary medical interventions during childbirth and empower women to participate actively in making decisions about their birthing experience [2]. Despite this, few studies worldwide have evaluated the direct impact of birth plans on maternal and neonatal outcomes [4, 5]. In the United States and Europe, only 12% to 39.8% of women are offered the option of a birth plan upon hospital admission [6]. Childbirth preparation classes—whether conducted in group or individual formats—aim to educate pregnant women and their partners about various aspects of pregnancy and delivery. These programs typically cover topics such as prenatal health, physiological changes, common complaints, high‐risk conditions, nutrition, the maternal role, mother‐fetus attachment, preparation for labor, pain management strategies, postpartum issues, breastfeeding, neonatal care, and exercise during pregnancy [7]. A significant factor influencing many women's preference to avoid natural childbirth is the fear of labor pain [8]. This fear often arises from insufficient knowledge or misconceptions about the childbirth process [9]. The experience of labor pain can lead to long‐term emotional distress and negatively impact maternal mental health and the mother‐infant bond [10]. Moreover, anxiety about pain may prolong labor stages [11, 12], increasing the risk of maternal and fetal injuries, as [13]. Recent research, such as a 2019 study on Asian primiparous women, reported that spontaneous labor lasted an average of 5.2 h during the first stage (4–10 cm cervical dilation) [14]. Evidence from Iran suggests that participation in prenatal education enhances women's empowerment [15] and reduces fear, anxiety, and depression among first‐time mothers [16], However, the impact of childbirth preparation classes on pregnancy outcomes remains uncertain. Some studies have found no evidence that attending such classes decreases the need for medical interventions during labor and delivery [17, 18], while others suggest potential benefits. For example, relaxation techniques introduced during pregnancy have been linked to improved maternal attachment [19] and increased mother‐infant bonding [20]. A 2024 meta‐analysis reported no significant differences in the duration of labor stages between women who received prenatal education and those who did not, with neonatal outcomes showing inconsistent results [5]. Similarly, a systematic review and meta‐analysis published in 2023 concluded that the effects of prenatal training on birth outcomes remain inconclusive. Although some findings indicate that childbirth preparation classes, when combined with routine prenatal care, can reduce fear of childbirth, postpartum depression, and pain during the first and second stages of labor, overall evidence remains mixed, underscoring the need for further research [21]. The present study simultaneously assesses the association of prenatal classes with three important outcomes—duration of labor, labor pain, and neonatal outcomes—a combination not previously examined in earlier research. As a result, it can yield direct empirical and context‐specific evidence from the findings. Moreover, by focusing on a population of Iranian primiparous women, the study provides data on the effectiveness of prenatal classes within the Iranian healthcare system. In summary, the innovation of this study lies not in introducing a completely novel intervention, but in offering systematic, context‐specific, and methodologically robust evidence regarding the impact of a recognized intervention (childbirth preparation classes) on specific and debated clinical outcomes. Given the limited and conflicting evidence regarding the influence of childbirth preparation classes on maternal and neonatal outcomes [5, 21], this study aims to further explore this relationship. Specifically, we will examine the association between attendance at these classes and outcomes such as labor pain, labor duration, and neonatal health. By comparing maternal and neonatal data between women who attended the classes and those who did not, we hope to generate insights that can inform and enhance clinical practices in maternal care. This study was conducted to answer two research questions. Does attending childbirth preparation classes affect the length of labor and labor pain? Are these classes associated with better neonatal outcomes?

2. Methods

2.1. Study Design and Participants

This observational study adhered to the STROBE guidelines. The study population comprised women admitted for childbirth at Ayatollah Rouhani Hospital in northern Iran between September 2018 and August 2020. Prior to participation, all women provided written informed consent. This study was designed as a retrospective cohort study comparing two groups based on their real‐world exposure to a standard care intervention. The research team did not design or implement a new intervention. The “intervention” was the standard, guideline‐based antenatal education program routinely implemented by the healthcare system.

2.2. Inclusion and Exclusion Criteria

Inclusion criteria were: primiparous women with singleton, term pregnancies (37 to 41 weeks and 6 days), cephalic presentation, in the active phase of labor (cervical dilation of 3–4 cm), aged 18–40 years, undergoing vaginal delivery, with no prior medical conditions or pregnancy complications, and who had not received medications, analgesics, anesthesia, induction, or augmentation agents. Exclusion criteria included refusal to participate, history of chronic physical or mental illness, substance abuse, or labor complications such as umbilical cord prolapse, meconium‐stained amniotic fluid, placental abruption, or cesarean section.

2.3. Sampling

Consecutive sampling was employed, with recruitment continuing until the target sample size was met, after providing detailed explanations and obtaining written consent.

2.4. Sample Size Calculation

Using G*Power, with a significance level (α) of 0.05 and power (1–β) of 0.90, effect sizes drawn from prior studies by Firouzbakht [22] and Makvandi et al. [23], an initial sample size of 100 women per group was determined. To account for an estimated 20% attrition rate, the final sample size was increased to 120 women per group, totaling 240 participants. Participants were classified as members of the case group if they attended at least four classes (≥ 4 sessions), and controls if they did not attend any classes, and subsequently comparing their obstetrical and neonatal outcomes at a uniform delivery setting.

2.5. Implementation and Data Collection

Data collection involved direct observation and structured questionnaires administered by two trained researchers. Upon hospital admission, participants' personal and reproductive histories were recorded. The number of childbirth preparation classes attended was verified via prenatal records and patient self‐report. Labor pain was assessed by dividing the first stage into two segments: from 4 to 7 cm dilation (first segment) and 8–10 cm dilation (second segment). The second stage was defined from full dilation (10 cm) until delivery. Gestational age was calculated based on the last menstrual period, confirmed by first‐trimester ultrasound if the date was unknown. According to the Ministry of Health Protocol, all pregnant women are recommended to attend eight biweekly sessions of 2 h pregnancy training classes from the 20th to the 37th week of gestation. These sessions, held in groups of up to 10 women and led by an experienced midwife trained in physiological childbirth (60 h), cover topics including physiological and psychological changes, high‐risk pregnancy signs, nutrition, exercise, neonatal care, labor stages, pain management, relaxation techniques, and proper postures and breathing methods [24]. Each 90 min session includes 15 min for greetings, 30 min of theoretical education, 15 min for questions and discussion, and 30 min of stretching, breathing exercises, relaxation, and demonstration videos. The prenatal classes constitute a multi‐component and structured program that simultaneously targets the cognitive, emotional, behavioral, and physical dimensions of the mother. These classes are purposively designed to influence the primary outcomes under investigation in this study (reducing labor pain, shortening labor duration, and improving neonatal outcomes). The comprehensive educational content covers three key domains: practical training on the stages of labor and facilitating techniques (such as optimal positions and stretching exercises) aimed at promoting effective labor progression and reducing its length; instruction on non‐pharmacological pain management strategies, including breathing techniques, muscular relaxation, and video demonstrations, to mitigate perceived pain through psychological and physiological pathways; and education on newborn care, breastfeeding, and the recognition of danger signs to enhance maternal preparedness and indirectly improve neonatal outcomes.

2.6. Outcomes Measures

The primary outcomes were labor pain intensity and duration of labor. Secondary outcomes included neonatal Apgar scores, birth weight, height, and head circumference. Additional variables recorded in both groups encompassed the mode of vaginal delivery, method of placental expulsion, time to first breastfeeding, skin‐to‐skin contact, acceptance of the infant's gender, and the need for NICU admission.

2.7. Study Instruments

Data were collected using a researcher‐developed questionnaire designed to capture demographic and reproductive characteristics, including age, education level, occupation, socioeconomic status, gestational age, and place of residence. The aim was to ensure homogeneity between the case and control groups. The questionnaire's content validity was evaluated and confirmed by six obstetrics and reproductive health experts, and subsequent revisions led to the final version used in the study.

The second section of the questionnaire addressed labor stages: the first stage (cervical dilation of 4–10 cm), the second stage (full dilation to delivery), and the third stage (placental delivery) It also collected data on neonatal Apgar scores at 1 and 5 min, birth weight, height, head circumference, delivery mode, method of placental expulsion, time to first breastfeeding, skin‐to skin contact, acceptance of the infant's gender, and NICU admission. The third section assessed maternal pain scores during the first and second stages of labor. Pain intensity was measured separately for the first stage—divided into two segments: cervical dilation of 4–7 cm and 8–10 cm—and the second stage (from full dilation until delivery). The Visual Analogue Scale (VAS), ranging from 0 (no pain) to 10 (worst pain imaginable), was used for pain assessment [25]. The scale employed one‐inch increments to enhance participant understanding. Based on verbal descriptions provided by patients, the VAS is considered a reliable measure of labor pain in both research and clinical settings, demonstrating strong reliability, sensitivity, and validity [26, 27, 28, 29, 30].

2.8. Statistical Analysis

Data were analyzed using SPSS version 24. Descriptive statistics, including frequencies, means, and standard deviations, summarized the sample characteristics. Independent t‐tests and chisquare tests were employed to compare baseline demographic and reproductive variables between groups. Additional analyses included Mann–Whitney U‐tests, Fisher's exact tests, and Tukey's post hoc tests where appropriate. Odds ratios (OR) were calculated to estimate the strength of associations. In this study, logistic regression was used to obtain a more precise estimate of the association between the main variables (length of labor and labor pain). In the first stage, potential demographic confounders (such as age, education, etc.) were evaluated for inclusion in the model. Since the initial analysis showed no statistically significant differences in these variables between the case and control groups (p > 0.05), this homogeneity indicates that these factors do not act as confounders. Accordingly, demographic variables were not entered into the final regression model. Therefore, the reported odds ratios (ORs) directly represent the association between the main independent variables and the outcomes. A significance level of p < 0.05 was considered statistically significant.

2.9. Ethical Considerations

This case‐control study was conducted in accordance with the Helsinki Declaration and received approval from the Ethical Committee of Research at Babol University of Medical Sciences (IR. MUBABOL. REC.1395.191).

3. Results

The study comprised 240 participants, with 120 women in the case group (attended childbirth preparation classes) and 120 in the control group (did not attend). There were no significant differences between the groups regarding demographic variables; most women reported planned pregnancies and received adequate prenatal care at gynecologist offices and health centers (see Table 1).

Table 1.

Demographic characteristics of primiparous pregnant women in childbirth classes and control groups.

Variable		Case		Control		p value
		Number	Percentage	Number	Percentage
Age (years)		24.70 (4.29)a		24.38 (5.25)a		0.60
Gestational age (days)		275.60 (7.38)a		276.18 (8.77)a		0/57
Education	Elementary	1	0.8	1	0.8	0.48
	Middle school	7	5.8	14	11.7
	High school	7	5.8	10	8.3
	Diploma	54	45.0	51	42.5
	University	51	42.5	44	36.7
Husband's education	Elementary	2	1.7	2	1.7	0.19
	Middle school	36	30.0	35	29.2
	High school	5	4.2	6	5.0
	Diploma	27	22.5	42	35.0
	University	50	41.7	35	29.2
Job	Housewife	107	89.2	101	84.2	0.25
	Employed	13	10.8	19	15.8
Husband's job	Self‐employment	84	70.0	86	71.1	0.17
	Worker	16	13.3	7	5.8
	Employee	13	10.8	15	12.5
	Otherb	7	5.8	12	10.0
Household income adequacy	Quite enough.	47	39.2	50	41.7	0.86
	Enough to some extent.	66	55.0	62	51.7
	Not enough at all.	7	5.8	8	6.7
Place of residence	City	68	56.7	61	50.8	0.36
	Village	52	43.3	59	49.2
Acceptance of pregnancy	Wanted	104	86.7	101	84.2	0.63
	Unwanted	8	6.7	12	10.0
	It doesn't matter	8	6.7	7	5.8
Prenatal care	Health center	19	15.8	19	15.8	0.26
	Specialist office	20	16.7	29	24.2
	Midwife's office	1	0.8	1	0.8
	Health center and specialist office	66	55.0	61	50.8
	Health center and midwife office	4	3.3	7	5.8
	Specialist and midwife office	10	8.3	3	2.5

^aMean (SD).

^bDoctor, Cleric, University professor.

3.1. Labor Pain and Duration

According to the Independent samples t‐test results, there was a significant difference in mean pain intensity scores during the late first stage of labor (cervical dilation 8–10 cm) and the second stage (cervical dilation of 10 cm until delivery) between the groups (p < 0.001 and p = 0.04, respectively). In contrast, no significant difference was observed during the early first stage (cervical dilation 4–7 cm) (p > 0.05). Furthermore, there were no significant differences in the durations of the first, second, and third stages of labor between the two groups (p > 0.05; see Table 2).

Table 2.

Comparison of pain intensity, labor length and neonatal outcome in childbirth classes and control groups.

Variable	Group	Case (N = 120)		Control (N = 120)		p value
		Mean	SD	Mean	SD
Pain intensity of labor	Early first stagea	7.01	2.19	7.43	2.11	0.13*
	Late first stageb	8.21	2.36	8.69	1.75	p < 0.001*
	Second stage	7.69	3.08	8.37	2.36	0.04*
Length of labor (minutes)	First stage	219.09	131.46	235.03	138.73	0.36*
	Second stage	37.00	26.10	42.77	31.82	0.12*
	Third stage	6.58	4.49	7.07	4.54	0.40*
Apgar	First minute	8.99	0.54	8.96	0.43	0.60*
	Fifth minute	9.98	0.20	9.99	0.09	0.41*
Newborn's weight (grams)		3290.33	391.80	3285.79	461.79	0.93*
Newborn's height (cm)		50.76	2.13	50.83	2.86	0.81*
Newborn's head circumference (cm)		34.31	1.61	34.07	1.65	0.25*
		Number (%)		Number (%)		p‐value
Vaginal delivery						0.62**
Spontaneous		5	4.2	5	4.2
With episiotomy		115	95.8	115	95.8
Placenta delivery						0.37**
Spontaneous		114	95	116	96.7
with manipulation		6	5	4	3.3
First Breastfeeding						0.71**
Immediately after delivery		10	8.3	7	5.8
30 min after delivery		33	27.5	36	30.0
1 h after delivery		77	64.2	77	64.2
Skin‐to‐Skin Contact						0.23**
Yes		104	86.7	99	82.5
No		16	13.3	21	17.5
Acceptance of Baby's Gender						0.50**
Yes		116	96.7	99	82.5
No		4	3.3	21	17.5
NICU Admission						0.25**
Yes		3	2.5	6	5.0
No		117	97.5	114	95.0

^a cervical dilation 4–7 cm.

^b cervical dilation 8–10 cm.

^*Independent t‐test.

^**Chi‐squared test or Fisher exact test.

3.2. Neonatal Outcomes

Analysis of neonatal outcomes revealed no significant differences in the first‐minute Apgar scores (t = 0.52, p > 0.05) or fifth‐minute Apgar scores (t = −0.81, p > 0.05). Additionally, mean birth weight (t = −0.08, p >0.05), height (t = −0.23, p > 0.05), and head circumference (t = 1.13, p > 0.05) did not differ significantly between groups (see Table 2).

3.3. Postpartum and Neonatal Care

Regarding postpartum practices, no significant difference was observed in the timing of the first reastfeeding postpartum; over 64% of women in both groups initiated breastfeeding within the first hour. Most participants in both groups underwent natural delivery with episiotomy and experienced spontaneous placental expulsion without intervention. Skin‐to‐skin contact after delivery was common, and most women expressed satisfaction with their infant's gender. NICU admissions were infrequent and did not significantly differ between groups (see Table 2).

3.4. Regression Analysis of Outcomes

Logistic regression analysis revealed a statistically significant association between attendance at childbirth preparation classes and pain intensity during the late first stage of labor. Women in the control group had 6.55 times higher odds (OR = 6.55; p = 0.01) of experiencing pain scores greater than 5 compared to the class‐attending group. Although higher odds ratios were observed for pain scores greater than 5 during the early first stage (OR = 1.19) and second stage (OR = 1.90), these differences were not statistically significant (p > 0.05). Additionally, the odds ratios for prolonged labor stages—first stage (> 360 min), second stage (> 50 min), and third stage (> 5 min)—were 1.84, 1.48, and 0.85, respectively, in the control group; none of these reached statistical significance (p > 0.05; see Table 3).

Table 3.

The relationship between childbirth preparation classes with pain intensity score, and labor length based on logistic regression test.

Group	Pain intensity of labor
	Early first stage			Late first stage			Second stage
Control	B	P	OR (95% CI)	B	P	OR (95% CI)	B	P	OR (95% CI)
	0.17	0.55	1.19 (0.66–2.12)	1.88	0.01	6.55 (1.43–29.95)	0.64	0.09	1.90 (0.89–4.08)
Childbirth classes	0

	Length of labor
	First stage			Second stage			Third stage
Control	B	P	OR (95% CI)	B	P	OR (95% CI)	B	P	OR (95% CI)
	0.61	0.08	1.84 (0.91–3.70)	0.39	0.18	1.48 (0.82–2.67)	−0.16	0.68	0.85 (0.38–1.87)
Childbirth classes	0

Note: The logistic regression models were adjusted for demographic characteristics.

A pain intensity score above 5, the duration of the first stage above 360 min, the second stage above 50 min, and the third stage above 5 min is the reference.

4. Discussion

The primary objective of this study was to investigate the association between attendance at childbirth preparation classes and labor pain intensity, labor duration, and neonatal outcomes in primiparous women. Our findings demonstrated a significant reduction in mean pain intensity scores during the advanced first stage (cervical dilation 8–10 cm) and the second stage of labor among women who attended preparation classes. Conversely, no significant difference was observed during the early first stage (cervical dilation 4–7 cm). This pattern of pain reduction aligns with several studies suggesting that prenatal education can alleviate labor pain [2, 31] and is supported by recent meta‐analyses [21, 32]. The specificity of the effect to later stages may be attributed to the nature of the pain and the skills taught. Early labor pain is primarily visceral, whereas advanced labor involves more somatic, pressure‐related pain, which may be more amenable to the conscious application of learned techniques such as focused breathing, relaxation, and positional changes [2, 33, 34]. Furthermore, by fostering an accurate understanding of the childbirth process, these classes dispel misconceptions and reduce anxiety—a known modulator of pain perception [35]. This combination of cognitive preparedness and practical skill‐building empowers women, transforming them into active participants and potentially making childbirth a more positive and controlled experience, thereby reducing perceived pain intensity.

Regarding labor duration, the mean lengths of all stages were shorter in the intervention group, though these differences did not reach statistical significance. This finding is consistent with some reports indicating a modest or non‐significant impact of prenatal education on labor duration [36], while contrasting with others reporting a shortening effect [37]. The observed trend towards shorter duration may be explained by the psychological and physiological mechanisms targeted by childbirth education. Anxiety and fear during labor can activate the stress response, elevating catecholamines and epinephrine, which are known to inhibit uterine contractility and cervical dilation [38, 39]. By reducing anxiety and promoting relaxation, preparation classes may help mitigate this inhibitory hormonal response, facilitating more efficient labor progression. The lack of statistical significance in our study could be due to sample size, the specific content of the classes, or the influence of other unmeasured factors affecting labor dynamics.

Analysis of neonatal outcomes revealed no significant differences in Apgar scores between groups, a result consistent with the heterogeneous literature on this topic [2, 40, 41, 42]. While some studies report benefits such as improved Apgar scores or earlier breastfeeding initiation, others, like ours, find no significant direct impact. The absence of a difference may reflect the high baseline standard of intrapartum care received by all participants, which could minimize detectable disparities in immediate neonatal outcomes measured by the Apgar score. Nonetheless, prenatal education confers benefits that may indirectly support neonatal well‐being. Programs typically emphasize vital health behaviors—including balanced nutrition, physical activity, and avoidance of harmful substances—that positively influence fetal development [43]. Moreover, by equipping women with knowledge and coping strategies for labor, these classes promote a calmer birthing environment, which may reduce the likelihood of obstetric interventions and associated neonatal stress [44].

4.1. Limitations and Strengths

A key strength of this study is the homogeneity of baseline characteristics between groups, which reduces the potential for confounding. Several limitations warrant consideration. First, the exclusive focus on primiparous women limits the generalizability of findings to multiparous populations. Future research should include multiparous women to determine if the benefits of preparation classes are parity‐dependent. Second, the retrospective cohort design introduces the potential for recall bias, particularly for subjective outcomes like pain, and could lead to an overestimation of the intervention's effect. Third, our assessment was limited to immediate intrapartum and neonatal outcomes; the potential long‐term benefits of prenatal education on postpartum recovery, mental health, breastfeeding duration, and mother‐infant bonding remain important avenues for future investigation.

5. Conclusion

In conclusion, this study adds to the evidence that childbirth preparation classes are associated with a significant reduction in labor pain intensity during the active and second stages of labor among primiparous women. While the effect on labor duration was not statistically significant, a positive trend was observed. Given the challenges faced by first‐time mothers and the central role of education in empowerment, integrating structured, skills‐based prenatal education into routine maternity care represents a valuable, low‐risk strategy to improve the childbirth experience. We recommend the widespread implementation and accessibility of such programs to support maternal adaptation and promote positive birth outcomes.

Author Contributions

Fatemeh Yahyavi Koochaksaraei, Masoumeh Alijanpour, and Fatemeh Nasiri‐Amiri contributed to the study conception and design. Fatemeh Yahyavi Koochaksaraei, Shanaz Barat, Shabnam Omidvar, and Masoumeh Alijanpour conducted the study and contributed to data acquisition. Hemmat gholinia‐ahangar analyzed the data. Masoumeh Alijanpour, Shabnam Omidvar, Fatemeh Nasiri‐Amiri, Fatemeh Yahyavi Koochaksaraei, and Shanaz Barat interpreted and wrote the manuscript. All authors read and approved the final manuscript.

Consent

Written informed consent was obtained from all subjects before the study.

Conflicts of Interest

The authors declare no conflict of interest.

Transparency Statement

The lead author Fatemeh Nasiri‐Amiri affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Data Availability Statement

The datasets generated and/or analyzed during the current study are not publicly available due [to individual privacy could be compromised] but are available from the corresponding author on reasonable request.