The Effect of a gamification-based educational intervention in childbirth preparation classes on maternal adaptation dimensions among pregnant women: a field randomized trial

Abstract

Background

Enhancing knowledge and skills during pregnancy improves psychological and physical preparedness for childbirth. This study examined the effect of a gamification-based educational intervention on maternal adaptation and its dimensions among pregnant women.

Methods

In this field randomized controlled trial with parallel groups and blinded data analysis, 80 pregnant women attending childbirth preparation classes in Gonabad were randomly assigned to intervention and control groups using permuted block randomization. The intervention group received eight weekly 90-minute gamification-based sessions integrated into standard classes, conducted from gestational weeks 20 to 28, including theoretical instruction, interactive question-and-answer sessions using a custom-designed game tool, physical exercises, and relaxation training. Topics covered anatomy and physiology of pregnancy, common complaints, labor stages, postpartum care, breastfeeding, and newborn care. The control group received routine prenatal education. Data were collected at three time points (baseline, immediately post-intervention, and four-week follow-up) using a demographic and obstetric questionnaire and the Prenatal Self-Evaluation Questionnaire. Effects were analyzed using generalized estimating equations.

Results

The mean (standard deviation) of the participants was 27.44 (6.64). The generalized estimating equations results indicated no significant baseline difference in maternal adaptation between groups (group effect: B = − 8.67; 95% Confidence interval: − 24.34 to 6.99; p = 0.278), but showed a significant overall improvement over time in the intervention group (time effect: B = − 13.53; 95% Confidence interval: − 16.09 to − 10.96; p < 0.001) and a slower improvement in the control group compared to the intervention group (group × time interaction effect: B = 7.78; 95% Confidence interval: 2.98 to 12.57; p = 0.001). Significant interaction effects were also found for self and child well-being (B = 1.75, 95% Confidence interval: 0.73 to 2.77, p < 0.001), preparedness for labor (B = 2.49, 95% Confidence interval: 1.48 to 3.50, p < 0.001), and control during labor (B = 2.56, 95% Confidence interval: 1.46 to 3.66, p < 0.001), indicating stronger positive changes in these specific domains over time in favor of the intervention group.

Conclusion

Gamification-based education can be used as an innovative approach in childbirth preparation classes to enhance maternal adaptation among pregnant women.

Trial registration

IRCT20230510058147N1(20230612).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-026-08982-w.

Background

Pregnancy is one of the most significant and influential periods in a woman’s life, often accompanied by mixed emotions such as joy, anticipation, and sometimes anxiety [1]. Beyond physical changes, this stage is characterized by profound psychological and emotional transformations that require adaptation and adjustment [2]. The process of adaptation begins in the early stages of pregnancy, as a woman gradually aligns herself with her new circumstances [3]. From a psychological perspective, adaptation refers to an individual’s ability to effectively manage life’s challenges and stressful situations by using personal and social coping skills [4]. During pregnancy, maternal adaptation refers to the degree of acceptance of physical and psychological changes as well as preparedness for embracing the maternal role [5]. Failure in this process may lead to adverse outcomes such as anxiety, depression, and stress [6]. Research shows that group education can play a significant role in improving maternal adaptation to pregnancy and childbirth. Such education not only reduces postpartum depression symptoms but also enhances overall maternal adjustment levels [7, 8]. However, prenatal education often faces several challenges. For instance, the American College of Obstetricians and Gynecologists emphasizes that education for mothers should be considered an integral part of prenatal care [9]. The primary goal of these educational programs is to establish sustainable health behaviors and correct misconceptions among mothers to foster positive changes in their attitudes and behaviors [10]. Statistics indicate that over half a million mothers die annually due to pregnancy-related complications [10], highlighting gaps in the implementation of effective and comprehensive prenatal education. In Iran, childbirth preparation classes have been identified as a key policy by the Ministry of Health and Medical Education [11]. These classes, aimed at providing essential information to pregnant women, serve as an effective solution to enhance their knowledge and preparedness [12]. However, some studies have reported that despite the implementation of childbirth preparation classes, their impact remains limited, indicating the need for innovative and effective educational models in this field [13–15]. One such innovative approach is gamification, which involves applying game elements in non-game contexts to make learning more engaging and effective [16]. Gamification is defined as the purposeful design and use of game mechanics in non-game contexts [17]. Research has shown that game-based education can lead to increased knowledge and improved learning outcomes compared to traditional methods such as pamphlets and educational media [18]. Another study has also introduced the use of innovative prenatal educational models as a creative approach to increase maternal engagement and awareness [15]. Given the critical importance of maternal adaptation in promoting psychological health for both mother and fetus, exploring effective educational strategies is essential.

Methods

Study objectives and hypotheses

Study objective

• The primary objective of this study was to evaluate the effectiveness of a gamification-based educational intervention delivered in childbirth preparation classes on maternal adaptation among pregnant women, compared to standard routine prenatal education.

Primary hypothesis

• There will be a significant difference between the gamification-based educational intervention and standard routine prenatal education in the overall pattern of change in maternal adaptation among pregnant women over time.

Secondary hypotheses

• The gamification-based educational intervention will lead to significant differences compared to standard routine prenatal education in each dimension of maternal adaptation (including acceptance of pregnancy, identification with the maternal role, relationship with the partner, preparation for labor, control during labor, well-being of self and baby, and relationship with one’s own mother) over time.

Study design, sample size, and sampling

This study was a parallel-group, field randomized controlled trial with blinding of the data analyst, conducted on 80 pregnant women participating in childbirth preparation classes. The study commenced in 2023 and continued through 2024. Ethical approval for the device construction was obtained from the Ethics Committee of the Research Deputy of Gonabad University of Medical Sciences under the code IR.GMU.REC.1401.193, and the proposal approval code was IR.GMU.REC.1402.027(2023-05-03). The committee supervised all aspects of the study. Additionally, the study protocol was registered in the Iranian Registry of Clinical Trials (IRCT) under the number IRCT20230510058147N1(2023-06-12), (https://irct.behdasht.gov.ir/trial/70147). The study adhered to the CONSORT 2017 guidelines for the design and reporting of randomized trials. The trial had two parallel arms with an allocation ratio of 1:1.

The sample size was calculated using G*Power software version 3.1.9.2, based on the primary outcome (overall maternal adaptation score). A two-tailed independent samples t-test was applied with a type I error (α) of 0.01 and a statistical power (1–β) of 0.99. The calculation used mean (µ₁=123.63, µ₂=118.89) and standard deviation (σ₁=3.84, σ₂=4.32) values from a similar study [19]. This resulted in a required sample size of 34 participants per group, which was increased to 40 per group to account for an anticipated 15% dropout rate.

Participant enrollment commenced after trial registration, in accordance with CONSORT guidelines. Sampling was performed randomly from pregnant women attending three Comprehensive Health Service Centers and one Midwifery Counseling and Services Center in Gonabad city. Pregnant women between 20 and 28 weeks of gestation were referred to the Health Deputy by these centers. After face-to-face consultation and provision of study protocol information by the study coordinator, eligible and consenting women were enrolled in the study.

All participants provided written informed consent prior to enrollment.

Eligibility criteria

Inclusion criteria were as follows: Iranian nationality, willingness to participate in the study, age between 18 and 45 years, literacy (ability to read and write), gestational age between 20 and 28 weeks, absence of medical conditions such as diabetes, hypertension, psychiatric disorders, multiple pregnancies, and cardiovascular or respiratory diseases. Additionally, participants must not have high-risk pregnancies requiring special care (e.g., history of bleeding during the current pregnancy, placenta previa, cervical cerclage, pregnancies achieved via assisted reproductive technologies), no history of substance abuse, no severe family conflicts, and the mother of the pregnant woman (i.e., the participant’s own mother) must be alive. Participants were required to have a living mother to consider the potential influence of intergenerational support on maternal adaptation.

Exclusion criteria included experiencing a stressful life event (e.g., divorce, death of close relatives), absence from more than one session, withdrawal from the study, or participation in similar educational programs (either in-person or virtual) during the study period.

Randomization and blinding

In this study, participants were randomly assigned to the intervention and control groups using permuted block randomization with block sizes of 2 and 4. The randomization list was generated by the data analyst through a web-based system using the website https://www.sealedenvelope.com/, and numbered, sealed opaque envelopes were prepared and provided to the researcher. The envelopes were opened sequentially as eligible pregnant women enrolled in the study, and participants were allocated to groups according to the randomization list.

Blinding was applied only to the data analyst, who was unaware of the nature of the interventions. The groups in the dataset were coded as “A” and “B” to maintain blinding during data analysis.

Participants and those delivering the intervention were not blinded due to the educational nature of the intervention.

Outcomes

Primary outcome

The primary outcome was the overall maternal adaptation score.

Secondary outcomes

Secondary outcomes included the seven subdimensions of maternal adaptation.

Instruments

Demographic and obstetric questionnaire

This questionnaire included questions about age, occupation, education, income level, number of pregnancies, number of children, gestational age, fetal sex, pregnancy status, history of nausea during early pregnancy, prior participation in childbirth classes, history of having a doula, history of postpartum depression, history of difficult labor, history of miscarriage, history of stillbirth, and history of congenital anomalies in previous newborns.

Prenatal self-evaluation questionnaire (PSEQ)

This questionnaire was developed by Lederman in 1996 [20]. The questionnaire assesses the mother’s psychological adaptation to pregnancy across seven dimensions: self and child well-being, acceptance of pregnancy, identification with the maternal role, preparedness for labor, control during labor, relationship with the mother, and relationship with the partner. It consists of 79 items with four response options (“very much,” “moderately,” “somewhat,” and “not at all”), and typically requires about 10–20 min to complete. In the scoring process, 48 items are reverse scored. Total scores range from 79 to 316; higher scores indicate poorer adaptation, whereas lower scores reflect higher levels of maternal adaptation to pregnancy [21]. The Cronbach’s alpha coefficients for its subscales ranged from 0.75 to 0.92 among a group of pregnant women, indicating good internal consistency. Correlation coefficients among the seven subscales ranged from 0.06 to 0.54, suggesting that the subscales are relatively independent and should be assessed separately [21]. In 2022, Zamani and Seyed-Mousavi conducted a psychometric evaluation of the questionnaire among pregnant women in Iran [22]. According to their findings, content validity was confirmed by a panel of five experts. Internal consistency testing revealed a Cronbach’s alpha of 0.935 for the total maternal adaptation score. Test-retest reliability demonstrated score stability over a three-month interval. Factor analysis indicated that all subscales (except for the preparedness for labor subscale) had significant factor loadings above 0.30 on pregnancy adaptation. Concurrent validity testing showed correlation coefficients between the PSEQ and the Experiences in Close Relationships Questionnaire ranging from 0.32 to 0.459. In addition to criterion validity, the strong correlations of subscales with the total score supported construct validity. The Cronbach’s alpha coefficients for all subscales were acceptable, ranging from 0.79 to 0.93, confirming good internal consistency. Overall, these results indicated that the Persian version of the PSEQ has favorable psychometric properties [22].

Intervention procedure

block randomization The study was conducted in childbirth preparation classes held at comprehensive health service centers. In the intervention group, in addition to the routine education provided in these classes, gamification techniques were used as an educational method. Each class included a maximum of 10 pregnant women along with their companions. The mothers were divided into two groups of five and, to reduce stress, they answered questions related to the presented educational content collaboratively using the gamification method. The aim of this game was not winning or losing; rather, it was to promote deeper and more effective learning in an enjoyable environment.

The gamification device (“MAMANO”) was a custom-designed mechanical tool developed by the research team to facilitate active and effective learning. The construction and use of the device were approved by the Ethics Committee of the Research Deputy of Gonabad University of Medical Sciences under the code IR.GMU.REC.1401.193. The device functioned like an interactive quiz board: mothers used a pointer pen to connect each question to its corresponding answer, and the device responded with light and sound feedback (a green light and positive sound for correct answers, and a red light otherwise). The tool was operated collectively in small groups to encourage collaboration and engagement. No devices were distributed for home use.

The educational program consisted of eight weekly sessions, each lasting 90 min, from gestational weeks 20 to 28. Each session included: 5 min of greetings and introductions, 30 min of theoretical instruction, 15 min of Q&A using the custom-made game tool, 30 min of physical exercises, and 10 min of relaxation training. From the second session onward, one-quarter of the Q&A questions were designed to review content from previous sessions. In each session, mothers answered 15 questions prepared within the game framework. Correct answers were rewarded with collectible cards representing fetuses and newborns (for every nine fetus cards collected, mothers received one newborn card as a bonus).

The content of the sessions was based on national guidelines for childbirth preparation, covering topics such as anatomy and physiology of pregnancy, common complaints, labor stages, postpartum care, breastfeeding, and newborn care (Table 1). No interim analyses were planned or conducted, and no stopping guidelines were applied due to the short duration and low risk of the trial. The trial was completed as planned without early stopping.

Table 1.

Educational content provided to pregnant women in the intervention group

Session	Week	Learning Objectives	Theoretical Content
1	Weeks 20–21	By the end of the session, participants are expected to: (1) Name the components of the reproductive system. (2) Describe each part of the reproductive system. (3) Understand anatomical and physiological changes during pregnancy. (4) Identify common pregnancy complaints. (5) Suggest solutions for each complaint. (6) Answer gamified quiz questions.	Introduction to class objectives and methods, class procedures, participant introductions, anatomical and physiological changes, common complaints, Q&A using gamification
2	Weeks 21–22	By the end of the session, participants are expected to: (1) List prenatal care practices. (2) Recognize warning signs during pregnancy. (3) Identify major food groups. (4) Modify their dietary habits. (5) Prepare a personal meal plan. (6) Answer gamified quiz questions.	Prenatal care, warning signs, nutrition during pregnancy, Q&A using gamification
3	Weeks 22–23	By the end of the session, participants are expected to: (1) Perform essential personal hygiene practices. (2) Understand fetal growth and development across pregnancy weeks. (3) Recognize psychological changes during pregnancy and coping strategies. (4) Answer gamified quiz questions.	Personal hygiene, fetal growth and development, mental health (partner education), Q&A using gamification
4	Weeks 23–24	By the end of the session, participants are expected to: (1) Identify birth-related hormones. (2) Learn pain relief methods during labor and name them. (3) Answer gamified quiz questions.	Labor pain and various pain relief methods, video on pain relief techniques, Q&A using gamification
5	Weeks 24–25	By the end of the session, participants are expected to: (1) Understand benefits of natural childbirth. (2) Recognize complications of cesarean Sect.  (3) Appreciate the role of an informed birth companion. (4) List and prepare essential items for mother and newborn. (5) Distinguish between false and true labor pains. (6) Answer gamified quiz questions.	Natural childbirth vs. cesarean section, role of the birth companion, birth planning, video on natural childbirth, Q&A using gamification
6	Weeks 25–26	By the end of the session, participants are expected to: (1) List the stages of labor. (2) Recognize various labor positions. (3) Identify essential interventions during labor. (4) Answer gamified quiz questions.	Stages and positions of labor, essential interventions during labor, Q&A using gamification
7	Weeks 26–27	By the end of the session, participants are expected to: (1) Describe postpartum body changes. (2) Name postpartum danger signs. (3) Explain benefits of breastfeeding. (4) Identify breastfeeding positions. (5) Answer gamified quiz questions.	Postpartum recovery and danger signs, breastfeeding education and video, Q&A using gamification
8	Week 28	By the end of the session, participants are expected to: (1) Describe characteristics of a healthy newborn. (2) Understand newborn screening tests. (3) Name neonatal danger signs. (4) Know vaccination schedule for infants. (5) Answer gamified quiz questions.	Newborn care and danger signs, newborn screening, vaccination, Q&A using gamification

Control group

The control group received only the standard routine prenatal education provided during pregnancy.

Data collection schedule

All participants completed the demographic and obstetric characteristics questionnaire as well as the Prenatal Self-Evaluation Questionnaire (PSEQ) before the first educational session (baseline). The same questionnaires were re-administered immediately after completion of the intervention and again four weeks after the last session (follow-up) to assess the sustainability of the effects over time.

Trained research staff administered the questionnaires face-to-face in both groups. Attendance was monitored in both groups, and participants were contacted if they missed a session to encourage continued participation. No important changes were made to the trial protocol after the commencement of the study.

Data analysis

After collection, the data were entered into SPSS software version 23 and underwent preprocessing before statistical analysis. The normality of continuous variables was assessed using the Kolmogorov–Smirnov test. For descriptive statistics, mean and standard deviation were used to describe normally distributed quantitative variables, whereas median and interquartile range (IQR) were used for non-normally distributed quantitative variables. Qualitative variables were summarized using frequencies and percentages.

Baseline demographic and obstetric characteristics of participants were compared between groups. Independent t-tests were applied for normally distributed quantitative variables, and the Mann–Whitney U test was used for non-normally distributed quantitative variables. The chi-square test was employed to compare qualitative variables between the groups when Cochran’s conditions were met; otherwise, Fisher’s exact test was used.

The effect of the gamification-based educational intervention on maternal adaptation was further assessed using Generalized Estimating Equations (GEE) regression models, accounting for repeated measurements over three time points (baseline, immediately post-intervention, and four-week follow-up). Baseline demographic and obstetric variables that showed significant differences between groups were included as covariates in the GEE models to adjust for potential confounding effects. An exchangeable working correlation structure was specified, assuming that correlations between repeated measurements within the same participant are constant regardless of the time interval. This structure was chosen based on the small number of repeated measurements and the similarity of time intervals. Model fit was evaluated using the Quasi-likelihood under the Independence model Criterion (QIC), and the exchangeable correlation structure provided the most parsimonious model. This approach ensured robust estimation of standard errors and valid statistical inference for the intervention effect [23].

All analyses were performed based on the per-protocol approach, and a significance level of p less than 0.05 was considered for all statistical tests.

Results

Flow of study

Figure 1 illustrates the flow of participants throughout the trial. A total of 80 pregnant women were screened for eligibility. All were eligible and provided written informed consent to participate. Participants were then randomized equally into two groups (intervention = 40, control = 40) using permuted block randomization.

Fig. 1.

Study design based on the CONSORT flow diagram

During the intervention period, one participant in the intervention group was excluded due to absence from more than one session. In addition, this participant had incomplete and invalid baseline questionnaire data, which could not be reasonably imputed.

No participants withdrew from the control group. Ultimately, data from 79 participants (39 in the intervention group and 40 in the control group) were included in the per-protocol analysis. No participants were lost to follow-up after the intervention or during the 4-week follow-up period, and no protocol deviations occurred.

Baseline demographic and obstetric characteristics

In the intervention group, the mean (Standard deviation (SD)) age was 26.77 (5.49) years, while in the control group it was 28.10 (6.7) years. The median (interquartile range) years of education was 14 (12–16). Most participants were housewives, comprising 84.6% in the intervention group and 75.5% in the control group. The majority of participants resided in urban areas, accounting for 64.1% in the intervention group and 65% in the control group. A higher percentage of participants in the intervention group (41%) reported income below the subsistence level, whereas most participants in the control group (92.5%) had income at or above the subsistence level. Other demographic and obstetric characteristics of the mothers are detailed in Table 2.

Table 2.

Demographic and obstetric characteristics of participants in the intervention and control groups

Variable	Control Group	Intervention Group	p
Age (years), Mean (SD)	28.10 (6.7)	26.77 (5.49)	0.375
Education (median, IQR)	14 (12–16)	14 (12–16)	0.616
Gestational age (median, IQR)	24 (22–26.75)	24 (22–26.75)	0.953
Occupation, n (%)			0.548
Employee	7 (17.5)	6 (15.4)
Housewife	31 (75.5)	33 (84.6)
Home-based jobs	2 (7.0)	0 (0.0)
Place of residence, n (%)			0.934
Urban	26 (65.0)	25 (64.1)
Rural	14 (35.0)	14 (35.9)
Income level, n (%)			< 0.001
At subsistence level	3 (7.5)	16 (41.0)
Below subsistence level	37 (92.5)	23 (59.0)
Number of pregnancies, n (%)			0.563
One	19 (47.5)	14 (35.8)
Two	9 (22.5)	15 (38.5)
Three	6 (15.0)	4 (10.3)
Four	5 (12.5)	4 (10.3)
Five	1 (2.5)	2 (5.1)
Number of children, n (%)			0.292
Zero	23 (57.5)	21 (53.8)
One	7 (17.5)	12 (30.8)
Two	9 (22.5)	5 (12.8)
Three	0 (0.0)	1 (2.6)
Four	1 (2.5)	0 (0.0)
Fetal sex, n (%)			0.338
Female	21 (52.5)	15 (38.5)
Male	19 (47.5)	24 (61.5)
Pregnancy intention, n (%)			0.168
Wanted	30 (75.0)	34 (81.0)
Unplanned	10 (25.0)	15 (19.0)
Nausea during pregnancy, n (%)			0.749
Yes	29 (72.5)	27 (69.2)
No	11 (27.5)	12 (30.8)
History of childbirth class attendance, n (%)			0.537
Yes	7 (17.5)	9 (23.1)
No	33 (82.5)	30 (76.9)
History of having a doula, n (%)			0.712
Yes	5 (12.5)	3 (7.7)
No	35 (87.5)	36 (92.3)
History of postpartum depression, n (%)			1.000
Yes	1 (2.5)	0 (0.0)
No	39 (97.5)	39 (100.0)
History of difficult labor, n (%)			0.974
Yes	3 (7.5)	3 (7.7)
No	37 (92.5)	36 (92.3)
History of miscarriage, n (%)			0.292
Yes	10 (25.0)	14 (35.9)
No	30 (75.0)	25 (64.1)
History of stillbirth, n (%)			1.000
Yes	1 (2.5)	0 (0.0)
No	39 (97.5)	39 (100.0)
History of neonatal anomalies, n (%)			1.000
Yes	1 (2.5)	0 (0.0)
No	39 (97.5)	39 (100.0)

SD Standard Deviation, IQR  Interquartile Range

Statistical analysis indicated no significant differences between the two groups regarding age, occupation, education, place of residence, gestational age, number of pregnancies, fetal sex, number of children, nausea during pregnancy, pregnancy status, history of attending childbirth preparation classes, history of having a doula, history of miscarriage, history of difficult labor, history of postpartum depression, history of stillbirth, and history of neonatal anomalies (All p > 0.05). However, the two groups differed significantly in terms of income level (p < 0.001) (Table 2).

Total maternal adaptation score

The overall maternal adaptation score is presented in Table 3. At baseline, both groups had comparable scores (Intervention: 159.3, SD = 21.28; Control: 158.2, SD = 34.35), indicating similar levels of maternal adaptation prior to the intervention. Immediately after the intervention, the intervention group improved to 124.25 (SD = 13.09), whereas the control group scored 135.55 (SD = 20.78). At the four-week follow-up, the intervention group maintained improvement (132.26, SD = 12.49), while the control group scored 146.7 (SD = 16.11). These findings suggest that the gamification-based educational program had a positive effect on overall maternal adaptation over time.

Table 3.

Comparison of mean maternal adaptation scores and its dimensions between intervention and control groups based on the GEE model *

Variable	Group	Before Intervention	Immediately After Intervention	Follow-up	GEE Test Results
		Mean (SD)	Mean (SD)	Mean (SD)	Effect	B	95% CI	p
Maternal Adaptation (Total score)	Intervention	159.31 (21.29)	124.26 (13.09)	132.26 (12.49)	Group	0.88	-2.20 to 3.96	0.576
	Control	158.20 (34.36)	135.55 (20.79)	146.70 (16.11)	Time	-1.28	-1.72 to -0.84	< 0.001
					Time*Group	-0.04	-0.88 to 0.79	0.920
						-2.66	-5.74 to 0.42	0.070
Pregnancy acceptance	Intervention	24.37 (3.93)	21.32 (2.25)	21.82 (2.4)	Group	-1.63	-2.35 to -0.90	< 0.001
	Control	25.37 (7.13)	22.8 (4.8)	22.7 (4.8)	Time	1.75	0.73 to 2.77	< 0.001
					Time*Group	-0.27	-3.67 to 3.13	0.875
Self and child well-being	Intervention	22.71 (4.68)	16.53 (2.21)	19.46 (2.46)	Group	-2.06	-2.63 to -1.50	< 0.001
	Control	22.05 (5.28)	17.72 (3.14)	22.3 (1.91)	Time	0.33	-0.69 to 1.35	0.516
					Time*Group	-2.65	-5.73 to 0.43	0.070
Identification with maternal role	Intervention	25.48 (4.7)	21.15 (3.04)	21.35 (2.89)	Group	-3.17	-3.77 to -2.57	< 0.001
	Control	25.47 (6.66)	21.67 (4.62)	22.02 (3.81)	Time	2.49	1.48 to 3.50	< 0.001
					Time*Group	-3.66	-6.64 to -0.67	0.016
Preparedness for labor	Intervention	22.64 (4.34)	13.58 (2.38)	16.30 (2.52)	Group	-1.44	-2.17 to -0.71	< 0.001
	Control	22.35 (5.22)	17.35 (3.4)	21.00 (2.66)	Time	2.56	1.46 to 3.66	< 0.001
					Time*Group	-0.81	-3.25 to 1.63	0.510
Control during labor	Intervention	24.58 (4.60)	18.20 (2.30)	21.71 (2.84)	Group	-2.02	-2.57 to -1.48	< 0.001
	Control	23.95 (5.29)	20.07 (2.84)	26.20 (3.28)	Time	0.65	-0.08 to 1.38	0.080
					Time*Group	0.49	-2.72 to 3.70	0.764
Relationship with mother	Intervention	39.48 (7.28)	33.5 (4.77)	31.58 (3.43)	Group	-1.92	-2.59 to -1.26	< 0.001
	Control	39.00 (9.30)	35.92 (6.99)	32.45 (5.60)	Time	0.02	-0.94 to 0.99	0.962
					Time*Group	0.88	-2.20 to 3.96	0.576
Relationship with partner	Intervention	20.38 (4.57)	16.87 (3.09)	16.53 (2.20)	Group	-1.28	-1.72 to -0.84	< 0.001
	Control	20.57 (5.93)	18.30 (4.04)	16.77 (3.50)	Time	-0.04	-0.88 to 0.79	0.920
					Time*Group	-2.66	-5.74 to 0.42	0.070

SD Standard Deviation, B Regression coefficient, CI Confidence Interval

* GEE models were adjusted for baseline income level to control for potential confounding effects

Based on the results of GEE regression model, adjusted for baseline income level, the effect of group was negative and non-significant (B = -8.67, 95% CI: -24.34 to 6.99, p = 0.278), indicating that the intervention and control groups were comparable before the intervention. The effect of time was negative and significant (B = -13.53, 95% CI: -16.09 to -10.96, p < 0.001), indicating an improvement in maternal adaptation in the intervention group over time. The time × group interaction for the control group was positive and significant (B = 7.78, 95% CI: 2.98 to 12.57, p = 0.001), indicating a slower improvement in the control group compared to the intervention group. Based on model-estimated values, immediately post-intervention, the maternal adaptation score in the intervention group was approximately 0.9 points lower than in the control group, and at follow-up, this difference increased to 6.88 points, demonstrating a positive effect of the intervention on maternal adaptation improvement (Table 3) (Figure 2).

Fig. 2.

Mamanoʼs Game

Subdimensions of maternal adaptation

The mean (SD) scores of maternal adaptation dimensions are presented in Table 3. At baseline, the groups were comparable in most maternal bonding dimensions; an exception was observed for control during labor (B = -3.66, 95% CI: -6.64 to -0.670, p = 0.016), where the intervention group had slightly lower baseline scores.

Based on the results of GEE regression model, adjusted for baseline income level, the effect of time in the intervention group was significant for all dimensions, reflecting an improvement over time: pregnancy acceptance (B = -1.28, 95% CI: -1.72 to -0.84, p < 0.001), self and child well-being (B = -1.63, 95% CI: -2.35 to -0.90, p < 0.001), identification with maternal role (B = -2.06, 95% CI: -2.63 to -1.50, p < 0.001), preparedness for labor (B = -3.17, 95% CI: -3.77 to -2.57, p < 0.001), control during labor (B = -1.44, 95% CI: -2.17 to -0.71, p < 0.001), relationship with mother (B = -2.02, 95% CI: -2.57 to -1.48, p < 0.001), and relationship with partner (B = -1.92, 95% CI: -2.59 to -1.26, p < 0.001).

The time × group interaction was significant for self and child well-being (B = 1.75, 95% CI: 0.73 to 2.77, p < 0.001), preparedness for labor (B = 2.49, 95% CI: 1.48 to 3.50, p < 0.001), and control during labor (B = 2.56, 95% CI: 1.46 to 3.66, p < 0.001). Based on model-estimated values, immediately post-intervention, the intervention group scored 0.91 points lower than the control group for self and child well-being, 0.16 points lower for preparedness for labor, and 1.10 points lower for control during labor. At follow-up, these differences increased to 0.85, 2.33, and 1.47 points lower, respectively, demonstrating a positive effect of the intervention.

For the other dimensions—including pregnancy acceptance, identification with maternal role, relationship with mother, and relationship with partner—the time × group interaction was not significant, indicating similar trends over time in both groups.

Discussion

The present study aimed to determine the effect of a gamification-based educational intervention in childbirth preparation classes on the dimensions of maternal adaptation during pregnancy among women covered by comprehensive health service centers. The results indicated that in both groups receiving one of the two educational methods, maternal adaptation increased after the intervention compared to before it. However, no statistically significant difference was observed between the two groups in some dimensions of maternal adaptation. Overall, the findings suggest a greater impact of the gamification-based educational method compared to the routine educational method commonly used.

Maternal psychological well-being is vital for the optimal health of the newborn and extends beyond the direct mother-infant relationship, playing a key role in early postpartum development [24]. Childbirth also impacts maternal well-being. A significant correlation has been found between depression and the psychological well-being dimension, and primiparous women demonstrated better environmental mastery and self-acceptance compared to multiparous women [25]. Furthermore, education and acquisition of necessary knowledge and skills during pregnancy facilitate this transitional period and better prepare the mother for fulfilling the maternal role and child-rearing. Mothers who maintain greater psychological balance and mental calmness after childbirth can establish deeper emotional bonds and more secure attachments with their infants [26]. Educational interventions can improve maternal adaptation scores during pregnancy [7]. A quasi-experimental study conducted on 60 pregnant women with a history of infant loss in Mashhad aimed to evaluate the effect of pregnancy adaptation training on maternal-fetal attachment and maternal adaptation. The results showed that receiving pregnancy adaptation education, in addition to routine prenatal care, led to a significant increase in the mean scores of maternal attachments to the fetus and pregnancy adaptation [19].

A quasi-experimental study conducted in Turkey investigated the effect of prenatal education on prenatal and postnatal adaptation among 120 primiparous women divided into group education, individual education, and control groups. The intervention consisted of adaptation training lasting 120 min, once a week, for 5 weeks in the individual education group and 7 weeks in the group education group. The study results showed that the mean adaptation scores increased in both the group and individual education groups compared to the control group [27].

A quasi-experimental pilot study examined the relationship between a maternal preparation program and women’s competence in maternal caregiving behaviors, perceived adaptation to the maternal role, and satisfaction with the education received alongside maternity care. Sixteen participants took part in the study, and four educational sessions lasting six hours, beginning one month before delivery, were conducted for the intervention group. The results showed that the only statistically significant difference was related to mothers’ satisfaction with maternity care and readiness for the maternal role, which were higher in the intervention group compared to the control group, while no effect was observed on prenatal adaptation [28].

A quasi-experimental study was conducted in Turkey to determine the effect of childbirth preparation education on maternal adaptation during pregnancy. Forty-two pregnant women participated in four educational sessions. The study results showed a significant difference between adaptation scores before and after the intervention, with increases observed in various dimensions of adaptation except for the preparedness for labor dimension [29].

An experimental study was conducted in Turkey to examine the effect of antenatal education on pregnancy and postpartum adaptation and infant perception among pregnant adolescents. Seventy pregnant women were assigned to intervention and control groups and received individual, face-to-face education supported by an educational guide, brochures, and other visual materials (slides, models, and CDs). The educational sessions lasted between 25 and 35 min, starting from the 12th week of pregnancy and conducted at five-week intervals. The results of this study regarding increased adaptation to pregnancy are consistent with the findings of the present research [7].

A randomized controlled trial entitled “The effect of gamification-based antenatal education on knowledge and attitudes of pregnant women participating in antenatal classes in Indonesia” was conducted. The study sample consisted of pregnant women attending childbirth preparation classes in Indonesia. The intervention group received educational content using the Snakes and Ladders game, while the control group received education through pregnancy booklets every three days over a period of ten days. The results of this study showed that gamification-based antenatal education helped improve the knowledge and attitudes of pregnant women [15].

Another randomized controlled trial entitled “The preeclampsia tree educational model for pregnant women as an effort to change preventive behavior against preeclampsia was conducted” in Indonesia. A total of 64 pregnant women were enrolled in the study. The preeclampsia tree educational model was designed as a learning concept to prevent preeclampsia in pregnant women and was developed using a gamification-based learning approach. The results showed that the preeclampsia tree educational model was feasible to implement and was ten times more effective in improving pregnant women’s knowledge, attitudes, and preventive behaviors regarding preeclampsia compared to the control group [30].

Another study aimed at developing programs for antenatal classes and assessing the increase in maternal knowledge was conducted in Indonesia. Participants included five media experts, five content experts, and ten mothers who were selected through purposive sampling. After the Android application was developed by media experts and approved by content experts, the mothers watched three 10-minute videos and participated in an in-app quiz game. The results showed that using this software was able to enhance the knowledge level of mothers attending virtual classes [31].

Another study aimed to develop and evaluate the effectiveness of a decision-support game to improve pregnant women’s knowledge about prenatal screening and assess their satisfaction with this type of decision-making tool. A total of 73 pregnant women participated in the study, divided into intervention and control groups, and engaged in the game. The average playing time was 6 min and 43 s. The results indicated that using such a game-based tool can help promote more informed decision-making among pregnant women [18].

In a randomized controlled clinical trial conducted in the United States on 30 pregnant women, the benefits of mindfulness education for childbirth preparation were evaluated. The results showed that 18 h of mindfulness training delivered over 2.5 days in the intervention group led to an increase in childbirth self-efficacy scores and a reduction in postpartum depressive symptoms, as well as a relative decrease in the use of narcotic analgesics during labor [32].

In a quasi-experimental case–control study conducted in Turkey on 132 pregnant women in two groups, the effect of prenatal education on gestational blood pressure, adaptation to pregnancy, and maternal and neonatal outcomes was investigated. The results indicated that education based on the Roy adaptation model was effective in controlling hypertension among pregnant women [33].

A controlled clinical trial aimed at improving maternal adaptation and childbirth experience through group-based psychoprophylaxis and relaxation for severe fear of childbirth was conducted on 371 pregnant women. The results indicated that six group psychoprophylaxis sessions during pregnancy and one postpartum session increased the mean adaptation score in the intervention group [34]. The findings of the present study are consistent with these previous studies, indicating that education positively affects maternal adaptation. Moreover, it shows that gamification-based education can enhance adaptation in some dimensions. Given that gamification-based education is increasingly being used for various types of training, it seems that this educational approach could be employed in childbirth preparation classes instead of routine educational methods.

Strengths, limitations, and suggestions

One of the main strengths of this study was the development of a custom-designed physical game tool based on the official childbirth preparation class handbook. This approach enabled the delivery of standardized content in an interactive and engaging format, facilitating hands-on participation among pregnant women. Unlike most previous studies that relied solely on printed materials or manuals, this study incorporated a tangible game to enhance motivation and learning. Another strength was the multidimensional assessment of maternal adaptation, providing a more comprehensive understanding of the intervention’s potential effects compared with studies evaluating only one or two variables.

However, several limitations should be acknowledged. First, data were collected using self-report questionnaires, which may have introduced response bias, as some participants might have provided socially desirable rather than fully accurate answers. Second, this study evaluated only the short-term effects of the intervention; thus, the sustainability of the observed improvements over time remains unclear. Additionally, the study was conducted among pregnant women attending childbirth classes in a single city, which may limit the generalizability of the findings.

Future research is recommended to explore the long-term impact of gamification-based education and to assess additional outcomes such as maternal self-efficacy, knowledge, attitudes, childbirth fear, stress, and anxiety during pregnancy and labor, as well as natural birth outcomes. It would also be valuable to conduct similar studies among women in earlier stages of pregnancy, non-pregnant women, or even family members involved in maternal care, to better understand the broader applicability of this educational approach.

Conclusion

The findings of this study suggest that the use of gamification-based educational interventions may enhance maternal adaptation among pregnant women. Incorporating motivational and interactive elements into childbirth education appears to create a more engaging learning environment that can improve mothers’ knowledge and attitudes, potentially reduce anxiety and fear of childbirth, and promote greater participation in prenatal care. This educational approach, through experiential learning, positive feedback, and intrinsic rewards, may serve as a useful model for improving the quality of prenatal education.

In the long term, gamification-based strategies could contribute to optimizing maternal and fetal health outcomes by supporting stress reduction and enhancing maternal satisfaction with health services. However, further studies with larger and more diverse populations are recommended to confirm these findings and evaluate their generalizability.

Authors’ contributions

T.T.Z., F.A., and F.M. contributed to the conception and design of the study. T.T.Z. collected the data. F.M. performed the data analysis and interpretation. T.T.Z., F.A., F.M., and G.H. drafted the manuscript. F.A., F.M., and G.H. critically revised the manuscript for important intellectual content. All authors read and approved the final version of the manuscript.

Funding

This study was financially supported by the Vice Chancellor for Research and Technology, Gonabad University of Medical Sciences, Iran.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to privacy concerns and ethical restrictions but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted after obtaining ethical approval from the Ethics Committee of Gonabad University of Medical Sciences with the code IR.GMU.REC.1402.027, adhering fully to the ethical principles outlined in the Declaration of Helsinki. Participation of all pregnant women in this study was based on informed and voluntary consent, and they were allowed to withdraw from the study at any stage.

Before commencing the research, briefing sessions were held for participants, during which the study objectives, the voluntary nature of participation, confidentiality assurance, and participants’ rights were explained in detail. They were also assured that this study posed no physical or psychological risks. All research-related education was provided free of charge.

Throughout the study period, a direct communication line was maintained between the researchers and participants. Contact numbers of the research team were provided to all participants to address any questions or concerns. In the dissemination of the study results, the rights of authors and participants were fully respected. Furthermore, final study outcomes were made available to participants upon request. In addition, after the completion of the study, a gamification-based educational session was also provided to the control group to ensure fairness.

Throughout the study period, a direct communication line was maintained between the researchers and participants. Contact numbers of the research team were provided to all participants to address any questions or concerns. In the dissemination of the study results, the rights of authors and participants were fully respected. Furthermore, final study outcomes were made available to participants upon request. In addition, after the completion of the study, a gamification-based educational session was also provided to the control group to ensure fairness.

Consent for publication

Not applicable. No identifying personal data of participants are included in this publication.

Competing interests

The authors declare no competing interests.