The Effect of Hospital-Based Childbirth Classes on Women's Birth Preferences and Fear of Childbirth: A Pre- and Post-Class Survey

Abstract

The purpose of this study was to examine the effect of a hospital-based childbirth class on fear of childbirth, anticipation regarding the birth experience, birth preferences and perception of the birth experience among first-time mothers. Expectant mothers (N = 207) completed an investigator-designed questionnaire before and after attending a prenatal hospital-based childbirth class held in the hospital where they intended to give birth. Statistically, significant changes postintervention included a decrease in fearfulness and an increase in birth anticipation. Shifts also occurred in birth preferences. Data collected from an open-ended question revealed the participants' increased excitement about birth. Findings provide evidence that attending hospital-based childbirth classes may influence women's perceptions and preferences regarding birth.

INTRODUCTION

Fear of Childbirth

Fear of childbirth (FOC) not only influences a woman's psychological well-being, but it is also associated with adverse outcomes including longer labors and increased risk for a cesarean surgery (CS; Adams, Eberhard-Gran, & Eskild, 2012; Roosevelt & Low, 2016). FOC can be related to the unknown and unpredictable nature of birth, fear of pain, lack of control and trust in one's ability, and concern over the well-being of mother and baby (Pallant et al., 2016; Roosevelt & Low, 2016). Nulliparous women report higher FOC than women who have previously given birth (Alehagan, Wijma, & Wijma, 2001). A culture of birth stories and images monopolized by fear and pain can overwhelm women, particularly those entering the hospital for the first time. Increased confidence from knowledge of childbirth is associated with decreased FOC and a strong preference for vaginal birth. Severe FOC is linked to a preference for elective CS (Stoll, Edmonds, & Hall, 2015). Women can make decisions based on fear and lack knowledge of key topics including the possible adverse effects of labor induction and CS (Declercq et al., 2013), as well as epidural anesthesia (Elvander et al., 2013).

Decision-Making

Preparing pregnant women for informed decision-making is a key factor in prenatal education and may reduce primary CS, a widely recognized public health initiative (Smith, Peterson, Lagrew, & Main, 2016). Previous research has focused on intrapartum events (American College of Obstetricians and Gynecologists, 2014; Smith et al., 2016) and largely overlooked and underutilized the role of childbirth education (Lamaze International, 2015). Physiologic birth, as defined by the American College of Nurse Midwives (ACNM), is “powered by the innate human capacity of the woman and fetus” (National Library of Medicine, 2013, p. 15). The increased medicalization of childbirth can undermine women's confidence in their ability to safely and independently give birth.

Empowerment

Empowering women through education to make informed birth choices can decrease fear of birth and can improve the overall birth experience. These are goals of many prenatal childbirth classes. There is evidence to suggest that women who attend classes have less fear (Karabulut et al., 2015) and greater satisfaction with their birth (Stoll & Hall, 2012). Research is limited, however, regarding which approaches to prenatal education best achieve these goals.

Hospital-based childbirth classes have been criticized for medicalizing birth and promoting organizational interests. However, hospital classes are in a unique position to build rapport with and support women as they enter into motherhood. This opportunity can develop trust and enhance communication between patients and providers before labor begins. Class content that includes not only the birth process but also the risks and benefits of medical intervention can change birth preferences (McCants & Greiner, 2016; Simpson, Newman, & Chirino, 2010). In an era when half of pregnant women do not attend prenatal classes (Declercq, Sakala, Corry, Applebaum, & Herrlich, 2013), it is important to study how class structure, content, and availability best meet the needs of women.

The goals of a hospital-based childbirth class entitled Great Expectations were designed to prepare women for childbirth by enhancing their confidence and diminishing their fear. The class was structured to include a welcoming environment, engaging and interactive activities, knowledge of choices, and promotion of birth as a normal, natural process. The purpose of this study was to examine the effect of a hospital-based childbirth class on FOC, anticipation regarding the birth experience, birth preferences and the perception of the birth experience among first-time mothers.

METHODS

Design

A quasi-experiment was conducted to evaluate the effect of a hospital-based prenatal class on four variables. Data were collected pre and postintervention on variables of interest using an investigator-designed questionnaire. The study was approved through the hospital Institutional Review Board. Participation in completing the survey implied consent.

Sample

Pregnant women who attended the prenatal class entitled Great Expectations were eligible to participate. The majority of participants in this study were aged 27 to 31 years (51.7%, n = 107), 32 – 36 weeks pregnant (41.5%, n = 86), and reported their primary support person was their spouse or partner (94.7%, n = 196). Further participant demographics are presented in Table 1.

TABLE 1. Participants Demographics.

Demographics N = 207		%	N
Age	21 and under	4.8	10
	22–26	22.7	47
	27–31	51.7	107
	32–36	16.4	34
	37 and up	4.3	9
Weeks ofpregnancy
	21 and under	0.5	1
	22–26 Weeks	15.0	31
	27–31 Weeks	40.1	83
	32–36 Weeks	41.5	86
	37 and up	2.4	5
Primary support person
	Spouse/partner	94.7	196
	Relative	2.9	6
	Friend/other	1.9	4

Setting

Classes are held at a 391-bed Magnet^® redesignated community hospital averaging 3,800 births per year, located in a mid-sized southeastern city. The class is offered as a three-part series, meeting one evening per week for three consecutive weeks, or one all-day Saturday class. Weeknight sessions meet for two and one-half hours. In total, seven and one-half hours of instruction are provided. There is no charge for participation. Class size is limited to 15 expectant mothers. Support persons are strongly encouraged to attend.

Measure

Given issues related to questionnaires addressing the variables of interest, a one page investigator-designed questionnaire, the Fear and Birth Preference Questionnaire (FBPQ), was developed following a comprehensive review of the literature (Elvander, Cnattingius, & Kjerulff, 2013; Nilsson et al., 2018; Pallant et al., 2016; Roosevelt & Low, 2016). For example, the Wijma Delivery Expectancy/Experience Questionnaire (WDEQ; Wijma, Wijma, & Zar, 1998) contains 33 items and was considered too lengthy for the purpose of this study. The visual analogue Fear of Birth Scale (FOBS; Haines, Pallant, Karlström, & Hildingsson, 2011) does not provide sufficient detail related to the variables of interest. The questionnaire used in this study (FBPQ) consists of 13 items as follows: demographics (five items), fear (one item), birth anticipation (one item) and birth preferences (six items). Fear and birth anticipation are assessed using a five-point Likert scale: not at all, a little, moderately, quite a bit, and extremely. The fear question asks, “At this time, I am fearful of giving birth.” The birth anticipation question asks, “At this time, I am looking forward to giving birth.” An open-ended statement “Childbirth is …” appears at the beginning of the questionnaire with the expectation that participants would describe their perception of childbirth in one word. At the conclusion of the questionnaire, a heading “optional comments” is provided for participants who want to write about their experience (see Appendix).

Items for the questionnaire were reviewed by three experts in the field and two psychometricians. Items were revised and edited for content and clarity. The time estimated to complete the questionnaire is approximately five minutes.

Great Expectations: A Detailed Description

A detailed description of the class is included in this article to demonstrate how we addressed fear, empowerment, and decision-making in the class content. At the beginning of the first class, each mother is given a reference text, The Gift of Motherhood book (Moran & Kallam, 2017). Additional handouts and reference articles are available on a table in the classroom. The class is structured to include interactive activities, lecture, instructor-designed PowerPoint presentations, videos, group discussion, demonstration/return demonstration, and practice stations. Based on the literature, classes are designed to be face-to-face and led by the same instructor (Kovala, Cramp, & Xia, 2016). Different learning styles (visual, auditory, psychomotor) are accommodated through a variety of teaching strategies. The overall environment, music, and seating arrangements are addressed in order to achieve a welcoming, comfortable atmosphere conducive to learning.

Part one (week 1) of Great Expectations begins with welcome and introductions, with class participants (including support persons) asked to verbalize their goals for the class. The instructor begins the class by defining childbirth as a normal, natural process. Content includes anatomy and physiology of birth, signs and stages of labor, warning signs, and natural labor comfort techniques. Visual aids such as diagrams, a cloth baby and pelvis model, and a ribbon to illustrate the average length of each stage are used. The fear/tension/pain cycle is discussed, and labor pain is presented using the P.A.I.N. acronym (Purposeful, Anticipated, Intermittent, and Normal; Amis & Green, 2018). Nonmedicinal pain relief measures are discussed using a grab bag of comfort items as visual aids.

The role of the support person is discussed at length, including tips for success, self-care, advocacy, and communication strategies. The role of a birth doula is covered and a list of local doulas and resources for more information are available. Next, positions for labor progress and comfort are demonstrated by the instructor. The lights are then dimmed for a guided breathing and relaxation exercise. Women and their support partners rotate around the room through a succession of practice stations for return-demonstration. Stations include squat, lunge, slow dance, massage, guided imagery/visualization, bathroom break, upright/wall support, toileting, hands and knees, birth ball, breathing practice, matching game, stages of labor poster, discussion questions, and empathy belly pregnancy simulation exercise for the support person. Couples have one and one-half minutes at each station, demonstrating the approximate length of an advanced labor contraction. The class then discusses what stations worked best for them and why. A compilation birth video, Birth Becomes Her (Mamamia, 2018), is also shown.

Part two (or Week 2) begins with a review of the previous content and a short birth video depicting an unmedicated hospital vaginal birth Elana's Birth (InJoy Health Education, 2014). This class also includes an overview of the hospital stay from check-in through discharge and a maternity unit tour. Possible medical interventions including risks, benefits, and alternatives are presented and discussed. Students are instructed on the use of the BRAIN (benefits, risks alternatives, intuition, need time to decide) tool as a strategy for informed decision-making (Moran & Kallam, 2017).

The class then divides into small groups of two to four couples. Each group is given a common labor scenario and asked to discuss options from their perspective as a patient. Scenarios include: (a) unmanageable labor pain, (b) labor arrest, (c) suggested induction for postdate gestation, and (d) suggested CS for macrosomia. A participant from each group volunteers to share the scenario with the class. The class discusses each potential situation focusing on principles of informed consent and advocacy in order to empower women through shared decision-making. Procedures including induction, CS, medication options for pain relief and other medical interventions are discussed from a risk/benefit/alternative perspective. The role of individual values and preferences in decision-making are emphasized for empowerment.

To address fear, participants are given two sticky notes and asked to write a childbirth fear on one note and something they are looking forward to about birth on the other. This activity is based on research suggesting mothers want the opportunity to have their fears heard and acknowledged (Roosevelt & Low, 2016). The class then discusses strategies to manage fear and anxiety including physical and emotional techniques to decrease stress. Focusing on what participants are looking forward to regarding birth, including modifying thoughts regarding “what could go wrong” to “what could go right,” is a suggested strategy that may diminish their fears.

Another interactive activity involves a card game to illustrate birth plans and preferences. Each couple is given a pack of 10 cards with a choice on each side of the card (vaginal/CS, spontaneous/induced labor, my provider/provider on-call, epidural/no pain medication, etc.). Couples place the cards with their preference facing up, making a birth “plan.” The instructor then asks participants to prioritize the cards by flipping cards to the nonpreferred side. A discussion about the possibility of unexpected outcomes follows. Participants are asked to reflect on what “a good birth” means to them.

Part three (or Week 3) reviews postpartum and newborn care as well as adjustment strategies for life as a family. A grab bag containing postpartum personal care items is used to facilitate discussion of postpartum recovery that includes physical and emotional considerations and the need for support. Newborn care including swaddling, diapering, sponge bathing, safety, comforting techniques, and daily care are studied through discussion and demonstration/return demonstration. Breastfeeding is not covered in depth because the hospital offers a separate class on this topic. A pediatrician guest speaker concludes the class with a question and answer session.

RESULTS

Participants

Two hundred and fifty-nine women completed study questionnaires. Data could not be analyzed on 47 women because participants did not complete the entire class or the patient identifiers on pre- and post-class questionnaires could not be matched. Five participants' data were not analyzed because they had previously given birth. Some participants gave birth before the class series finished. Final data analysis included 207 matched pairs (see Figure 1 for participant flow).

Figure 1.

Flow chart of study participants.

Data Analysis

Using SPSS version 25.0, paired samples t tests were conducted to assess the influence of Great Expectations on expectant mothers' FOC as well as the extent to which they looked forward to giving birth. There was a statistically significant decrease in fearfulness scores from before the class (M = 2.13, SD = .979) compared to after the class (M = 1.59, SD = .833), t(204) = 9.07, p <.001 (two-tailed). The eta squared statistic (.29) indicated a large effect. There was also a statistically significant increase in the extent to which participants reported looking forward to giving birth after the class (M = 2.62, SD = .975) compared to before the class (M = 2.24, SD = 1.142), t(205) = -6.76, p < .001 (two-tailed). The eta squared statistic (.18) indicated a large effect size. Frequency statistics were conducted to assess the impact of the class on birthing preferences. The results are presented in Table 2.

TABLE 2. Percentages and Frequencies of Participants' Responses to Questions About Birth Preferences.

	Pre- Class		Post- Class
Item	Yes % (n)	Don't know % (n)	Yes % (n)	Don't know % (n)
Prefer to give birth vaginally	86.89 (179)	10.68 (22)	94.66 (195)	3.40 (7)
Chosen care provider is a doctor	87.92 (182)	0.48 (1)	87.92 (182)	0.48 (1)
Planned c-section	3.40 (7)	16.02 (33)	3.92 (8)	15.20 (31)
Prefer to give birth without pain medication	26.57 (55)	19.81 (41)	38.83 (80)	16.99 (35)
Prefer labor to start on its own (not induced)	80.98 (166)	15.61 (32)	94.66 (195)	4.85 (10)
Prefer a doula to attend birth	4.85 (10)	39.80 (82)	3.38 (7)	17.87 (37)

The majority of Great Expectations participants attended a one-day class (n = 125, 60.39%), while (n = 82, 39.61%) attended in a three-part series. A mixed between-within subjects analysis of variance was conducted to assess the impact of class format on fearfulness scores and the extent to which participants looked forward to giving birth. There was no significant interaction between class format and fearfulness scores, F(1, 203) = .478, p = .49, or birth anticipation scores, F(1, 204) = 1.56, p = .21.

Study participants were asked to complete the open-ended phrase, “Childbirth is ____.” Pre- and post-class responses were independently reviewed by the research team and the themes extracted. Four members of the team, including a labor and delivery nurse educator, completed thematic analysis and comparison of responses. An agreement was reached on the themes. In preclass responses, the overall theme was apprehension related to the unknown. There were 7 preclass subthemes. These were fear (i.e., scary, terrifying, nerve-wracking), excitement (exciting, fun, an adventure), pain (painful), beauty (beautiful, amazing, a miracle), hard work (difficult, hard, complicated), natural (normal, natural), and mystery (unknown, mysterious, strange, unpredictable).

The overall post-class theme identified was anticipation. A new subtheme of manageability (doable, manageable, attainable) was noted after class that did not appear before instruction. Words related to the mystery or unknown nature of childbirth were notably missing from the post-class data. Some women listed a fear-based word post-class, but often with a qualifier such as scary but doable, not as scary, overwhelming but exciting. The most frequent words used to describe childbirth pre- and post-class are shown in Figure 2.

Figure 2.

Frequency of themes pre and post-class.

Optional comments were rare but indicated appreciation for the class. Some comments included: “Thank you for making childbirth less scary for me”; “I felt like my spouse got a lot out of it. He was clueless before”; “You've made me feel more comfortable giving birth without pain medication”; “We feel equipped and prepared!”

DISCUSSION

FOC clearly influences the birth experience (Elvander et al., 2013; Waldenström, Hildingsson, & Ryding, 2006). Decreasing women's FOC can lead to shorter labors and decreased risk of CS birth. The impact of maternal stress in pregnancy can lead to physical and emotional sequelae that affect both mother and baby. Findings from this study support limited prior research on the effects of prenatal education on fear and birth preferences (Karabulut, Coşkuner Potur, Doğan Merih, Cebeci Mutlu, & Demirci, 2015; Waldenstrom, Hildingsson, & Ryding, 2006). Results also revealed an increase in women's anticipation of giving birth. They were more likely to “look forward to giving birth” following the class.

In relation to birth preferences, descriptive analyses examining percentage response before and after the showed that participants had an increased preference for spontaneous labor, vaginal birth, and no pain medication after class. Fewer individuals wanted a doula present during birth following the class. No change was observed in the choice of provider and little change occurred regarding planned CS. In some instances, participants were uncertain regarding their preferences and responded: “don't know.”

Participants' comments revealed changes regarding fear of the birth experience. Their excitement related to having a baby and their perceived ability to manage labor and birth increased. Comments suggested that these women remained somewhat concerned about the birthing experience but following the class felt it was doable.

Overall, participants who attended Great Expectations experienced less fear at the conclusion of classes, were more excited about childbirth, and had an increased preference for vaginal birth, spontaneous labor, and no pain medication. While some of these findings are descriptive in nature, they provide a foundation for further study. Research on the efficacy of prenatal education may be important to achieve optimal maternity outcomes. Areas for future study include how childbirth classes affect maternal and neonatal outcomes, patient satisfaction, and the overall birth experience. Other areas of interest include how web-based or in-person/online hybrid classes impact learning, and how class incentives affect attendance. A careful examination of outcome variables of prenatal classes can not only promote the well-being of women but also ensure the continued availability of childbirth classes in the hospital setting.

Study Limitations

This study was conducted in one hospital within one healthcare system in the southeastern United States. Hospital data suggest that participants were probably White, well-educated and from a middle class or higher socioeconomic status. Findings may not, therefore, apply to women from differing backgrounds. In addition, due to the questionnaire being designed specifically for this study, it has not been pilot tested for reliability or validity. The findings are therefore limited by the lack of reliability and validity and cannot be generalized. The questionnaire used was designed for one-time use for this study and was not intended to be used as an instrument. The items on this questionnaire were not designed to inter-relate to one another and were not all measuring the same attribute or dimension as in a composite scale (Polit & Beck, 2017).

Implications for Practice

The results of this study can be used to guide future hospital-based prenatal education classes. Strategies used in teaching Great Expectations can be readily translated to other healthcare environments. Childbirth educators can develop interventions that encourage women to seek information and support prior to their birth experience. While developing prenatal classes in a hospital setting may be difficult, women want to increase their knowledge regarding pregnancy and birth (Stoll & Hall, 2012). Findings from the present study provide information that may facilitate the development of hospital-based interventions.

Biographies

KRISTEN K. HANDS is a registered nurse and certified childbirth educator.

ALYSSA CLEMENTS-HICKMAN is a research fellow in the Nursing and Allied Health Office.

CLAIRE C. DAVIES is a research consultant in the Nursing and Allied Health Office.

DOROTHY BROCKOPP is the coordinator of the Nursing and Allied Health Office.

Appendix. Birth Questionnaire

This is a confidential survey to compare your views of birth before and after class. Please answer the following questions and place this form in the secure box in the back of the room.

Childbirth is ____________________________________________________ (fill in any word you wish).

My mother's birthday (month and day) is _______________________________ (If unsure, choose another person but remember what you wrote. This will be used to link your responses before and after class.)

This will be my first childbirth	☐ Yes	☐ No
My current age is	☐ 21 and under	☐ 22–26	☐ 27–31	☐ 32–36	☐ 37–40+
My current week of pregnancy is	☐ 21 and under	☐ 22–26	☐ 27–31	☐ 32–36	☐ 37–40+
My primary labor support person is	☐ Spouse/Partner	☐ Relative	☐ Friend/Other	☐ None

At this time…

I am fearful about giving birth.

☐ Not at all ☐ A little ☐ Moderately ☐ Quite a bit ☐ Extremely

I am looking forward to giving birth.

☐ Not at all ☐ A little ☐ Moderately ☐ Quite a bit ☐ Extremely

I prefer to give birth	☐ Vaginally	☐ C-section	☐ Don't know
My chosen care provider is a	☐ Doctor	☐ Midwife	☐ Don't know
I already know I will have a planned c-section	☐ Yes	☐ No	☐ Don't know
I prefer to give birth without pain medication	☐ Yes	☐ No	☐ Don't know
I prefer my labor to start on its own (not induced).	☐ Yes	☐ No	☐ Don't know
I prefer a doula to attend my birth.	☐ Yes	☐ No	☐ Don't know

Optional Comments:

DISCLOSURE

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

FUNDING

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