The Effect of Hospital-Based Childbirth Classes on Birth Outcomes

Abstract

The purpose of this study was to examine the effect of a hospital-based childbirth preparation class on birth outcomes in nulliparous women (N = 222). Outcomes of expectant mothers who attended the class were compared to a matched control cohort who did not attend preparation classes. Findings revealed women in the intervention group were more likely to give birth vaginally. While trends in a positive direction occurred, no significant difference was found in the frequency of elective induction, preterm birth, or length of stay. Data were also analyzed pre COVID-19 pandemic and 14 weeks after. A shorter time between hospital arrival and birth was significant for the intervention group. In addition, a significant change in elective induction (increase) occurred in the control group.

INTRODUCTION

Evidence-based prenatal education has been recognized as an important strategy for improving birth outcomes (Lamaze International, 2015; Smith et al., 2016). Previous research has been limited by inconsistent class content and inconclusive findings (Brixval et al., 2015; Ferguson et al., 2013). Outcomes such as reducing cesarean surgeries (CS), preterm births, elective inductions, and early labor hospital admissions can improve the well-being of women and newborns, therefore reducing the cost of care (Lamaze International, 2015). The previous study of these outcomes has focused on intrapartum care management and overlooked the impact of prenatal education. The importance of a standardized curriculum taught by certified childbirth educators (e.g., Lamaze Essential Content, Lamaze International, 2018) is a recommended strategy for increasing generalizability for future research. A careful examination of how childbirth class attendance affects birth outcomes may improve maternity care, decrease costs, and support the continued availability of prenatal classes.

Reducing Cesarean Birth

CS can be a life-saving operation with benefits to both mother and baby. However, because CS is a major abdominal surgery with the potential for serious complications, there is an increased risk of maternal and infant morbidity and mortality associated with overuse of the procedure (American College of Obstetricians and Gynecologists [ACOG], 2014). Because rising CS rates are not correlated with better patient outcomes, preventing primary CS has become a major focus for improving quality maternity care (ACOG, 2014).

Childbirth classes that prepare women for informed decision-making and include practices supportive of vaginal birth (spontaneous labor, staying home in early labor, comfort measures, position changes, and advocacy) are key strategies for reducing CS (Smith et al., 2016). Women who receive formal childbirth education have been shown to have higher rates of vaginal birth (Afshar et al., 2017; Cantone et al., 2017; Gluck et al., 2020; Kalayil Madhavanprabhakaran et al., 2017; Stoll & Hall, 2012) and decreased elective CS (Sanavi et al., 2014).

Surgical birth increases the risk of maternal pain, infection, hemorrhage, blood clots, hysterectomy, and death over vaginal birth (American College of Nurse-Midwives, 2012). Severe complications including cardiac arrest, shock, renal failure, and venous thromboembolism increase three-fold (ACOG, 2014). The psychological strain (on women as well as their families and caregivers) associated with CS exacerbates the typical exhaustion and stress associated with childbirth. Longer recovery times can strain family support systems, delay return to employment, and interfere with breastfeeding and bonding. Babies born by CS have a higher risk of severe respiratory complications, neonatal intensive care unit (NICU) admission, and childhood asthma (Smith et al., 2016).

Preventing CS in a first-time mother can potentially prevent multiple major abdominal surgeries over her lifetime. A primary CS increases the likelihood of a future CS, and risks to the mother increase with each surgery (Smith et al., 2016). Thus, prevention of the primary CS is of particular interest, mainly in the Nulliparous Term Singleton Vertex (NTSV) population. This group of first-time mothers, gravid with one, full-term (≥37 weeks) baby in the head-down position, represents the fastest-growing population of CS and is easily identifiable and reportable (Smith et al., 2016). The Joint Commission hospital accreditation organization identifies decreased NTSV CS rates as a Perinatal Core Measure (2016b).

Elective Labor Induction

A medically managed childbirth (including induction of labor, continuous fetal monitoring, intravenous fluids, epidurals, artificial rupture of membranes, and supine birth positions) is often the standard picture of birth in the United States. As medical interventions rise, many women and care providers are not as familiar with physiologic birth as in previous generations. Women may choose elective labor induction (without a medical reason) because it offers the appearance of control and convenience but may lack knowledge about the risks (Declercq et al., 2013). Patient education that includes not only the physiologic birth process but also the risks and benefits of medical intervention (e.g., labor induction) can change birth preferences (McCants & Greiner, 2016; Simpson et al., 2010) and is an important part of the informed consent process (The Joint Commission, 2016a).

Preterm Birth

Preterm birth (before 37 weeks gestation) is a major factor in infant morbidity and mortality and can result in long-term health consequences for the neonate. Education may lead women to identify early signs of preterm labor and overcome reluctance to seek care (Coleman Smith, 2012). Recognizing and responding to symptoms may delay birth, providing more time for infant growth and development in utero. However, prenatal education has not been widely recognized as a significant intervention to prevent preterm birth (Barros et al., 2010; Hueston et al., 1995).

Length of Stay and Cost of Care

Implications of CS and preterm birth include increased costs for surgical expenses, NICU admissions, potential for complications, and longer length of stay (LOS). Reducing hospital CS rates can contribute to a shorter stay and ease already taxed resources related to staffing and bed availability. Prenatal education on the signs and stages of labor can also result in fewer early or false labor admissions (Ferguson et al., 2013), thus decreasing LOS.

Purpose

The childbirth class in this study is a hospital-based childbirth class entitled Great Expectations. It was designed in accordance with Lamaze International's (2018) guidelines for childbirth education: prepare women for childbirth through education of the birth process, and enhance confidence and empowerment through informed decision-making. The purpose of this study was to examine the effect of Great Expectations on birth outcomes — frequency of CS, elective labor induction, preterm birth, and length of hospital stay — in nulliparous women who attended this class compared to those who did not attend any formal childbirth education classes.

METHODS

Design

A quasi-experiment was conducted to evaluate the effect of participation in the childbirth education class, Great Expectations, on the four outcome variables. Data were collected through medical record review. Birth outcomes for nulliparous women who attended Great Expectations were compared to a matched cohort of women who did not attend any childbirth education. The study was approved through the hospital's Institutional Review Board.

Sample

Nulliparous pregnant women who attended Great Expectations were eligible to participate. Attendees who wished to participate signed a consent form at the conclusion of the class. They were matched to a control cohort based on maternal age range (low risk ≤34, and high risk ≥35) and birth month through retrospective medical record review by hospital decision support staff. All women gave birth at the same facility. To control for education received, the matched cohort was selected from those who self-reported on hospital admission they did not attend any prenatal childbirth education classes. Women who indicated they did receive childbirth education but were not in the experimental group were excluded. This eliminated women who may have attended alternate childbirth classes. Other exclusion criteria included women with multiple gestation, stillbirth, not fluent in English, and women who chose to give birth at another facility.

The Childbirth Class

A detailed description of the Great Expectations class is provided in a previous study article (Hands et al., 2020). Class content included all Lamaze Essential Content, including the Six Healthy Birth Practices: let labor begin on its own; walk, move around, and change positions throughout labor; bring a loved one, friend, or doula for continuous support; avoid interventions that are not medically necessary; avoid giving birth on your back and follow your body's urges to push; and keep your baby with you (Lamaze International, 2018). Great Expectations was held at a 391-bed Magnet^® re-designated community hospital averaging 3800 births per year, located in a mid-sized southeastern city. The class was offered as a three-part series, meeting one evening per week for three consecutive weeks, or one all-day Saturday class. Classes were free of charge, limited to 15 expectant mothers per class, and support persons were encouraged to attend. Great Expectations was structured to include interactive activities and a variety of teaching strategies. All classes in this study were taught by the same certified childbirth educator.

RESULTS

Sample

One hundred sixty-one women attended Great Expectations during the study time period (see Figure 1). Fifty women were excluded for the following reasons: previous childbirth (n = 7), multiple gestation (n = 2), not fluent in English (n = 1), medical record not located (n = 1), did not complete class or opted out (n = 39). A total of 222 women were included in this study, 111 from the intervention group and 111 from the control group. Women ranged in age from 16 to 44 years in the intervention group (mean = 28.5) and 17 to 42 in the control group (mean = 26). Overall, 90% of participants were in the low risk ≤34 age group (n = 200) and 10% in the ≥35 high risk age group (n = 22).

Figure 1. Flow chart of study participants.

Data Analysis

Data were analyzed using SPSS (Statistical Package for Social Sciences version 25, Armonk, NY; IBM Corp). For comparison of group differences in categorical variables, chi-square analysis was calculated. For comparison of group differences in continuous variables, independent t-test analysis was calculated. An a priori significance was determined as p <.05.

Results

Women who attended childbirth class were more likely to give birth vaginally than women who did not attend class (χ² = 5.221, p = .022). The CS rate in the intervention group was 24% compared to 39% in the control group. Breech presentation (n = 12) was excluded in this analysis due to the practice of scheduling CS for this presentation. The NTSV CS rate (also excluding preterm births) for the intervention group was 23.0% compared to 33.6% in the control group.

In comparing elective inductions (n = 72), that is excluding women who experienced either medically indicated induction of labor or planned CS (n = 59), chi–square analysis did not demonstrate a significant group difference. In examining preterm birth, no significant group difference was found between the intervention and control groups (see Table 1).

TABLE 1. Comparison of Birth Outcomes.

		Intervention	Control
Outcome	N (%)	N	N	χ2 p-value
Cesarean Birtha	66 (31.4)	25	41
Vaginal Birth	144 (68.6)	79	65	.022
Elective Inductionb	72 (44.2)	31	41
Not Induced	91 (55.8)	46	45	.341
Preterm Birth	15 (6.8)	7	8
Term Birth	207 (93.2)	104	103	.789

^aExcluding breech presentation.

^bExcluding medically indicated induction and planned cesarean.

Independent t-test analysis examining group mean difference in total LOS found no significant difference between the groups. Hours from hospital arrival to time of birth also demonstrated no significant difference between those who attended childbirth class and those who did not (see Table 2).

TABLE 2. Comparison of Means: Length of Hospital Stay.

Outcome	N	Mean	Standard Deviation	t-value	p-value
Hours from arrival to give birth
Intervention	110	19.5	12.5
Control	110	22.9	37.9	–.898	.37
Missing	2
Total length of stay in hours
Intervention	110	71.1	19.7
Control	111	78	44.5	–1.479	.14
Missing	1

This study time period was November 2019 to June 2020. In March, study recruitment ended due to the cancellation of in-person classes due to the COVID-19 outbreak. At this time, women were restricted to one adult support person to accompany them throughout the duration of their hospital stay. All participants in the experimental group attended the in-person class before restrictions began. Some study participants gave birth before pandemic restrictions (n = 103, 46.4%) and some gave birth after (n = 119, 53.6%).

Intervention and control groups were analyzed separately to examine differences within the groups based on birth date, that is before or after COVID-19 restrictions went into effect. Within the control group, participants (excluding women who required a medically indicated induction or planned CS) who gave birth after COVID-19 restrictions demonstrated a higher likelihood of having an elective induction (χ² = 8.2, p = .004). No significant difference was noted within the intervention group before and after restrictions in choosing elective induction. Within the intervention group, women who gave birth after restrictions demonstrated a significantly lower time of arrival to birth when compared to women in the intervention group who gave birth before restrictions (t = 2.8, df = 108, p = .007). A significant difference in time to birth was not noted in the control group before and after COVID-19 restrictions.

DISCUSSION

The results of this study add to a growing body of research that women who attend childbirth preparation classes have a decreased rate of CS. Classes that promote birth as a normal, natural event can build confidence, manage expectations, and inform women of the benefits and risks of medical intervention. Education, however, is one of many factors that influence mode of birth. In addition to obstetric diagnoses, physician and hospital practices also influence likelihood of CS (Joint Commission, 2016b). Social norms are also a factor. The CS rate in the state where this study was conducted is the 9th highest in the nation (Martin et al., 2019). Given the high CS rates in the region, childbirth education may be more effective when part of a wider, multidisciplinary effort to reduce surgical birth.

In this study, the NTSV CS rate for the intervention group (23.0%) meets the National Institute of (Health's Healthy People 2020) target goal of 24.7% for this population (U.S. Department of Health and Human Services, 2014). For context, the NTSV rate for the facility in this study was reported as 32.6% in 2019 to the Leapfrog Group, a national, nonprofit organization that reports hospital quality and safety data.

No significant difference in elective labor induction was found in this study, which may indicate other factors have a stronger influence on decision-making. There were ten fewer elective inductions in the intervention group, which can be clinically meaningful to those women despite the lack of statistical significance. A future research focus could be a qualitative exploration of why women in this class choose elective induction.

For the preterm birth variable, the results of this study support previous research that education about the signs of preterm labor does not significantly affect preterm births. However, prenatal education on the signs and stages of labor can result in fewer early or false labor admissions (Ferguson et al., 2013), decreasing LOS. In this study, there was no significant difference in LOS with the exception of pre/post-COVID-19 differences within the intervention group. Given that participants in the control group had more CS births (which result in a longer stay), this lack of difference could be attributed to prenatal complications, which were beyond the scope of this study.

Women who are pregnant during a time of disaster can experience increased stress and trauma as well as reduced access to prenatal care, support, and medication, therefore affecting maternity outcomes (King et al., 2012; Saulnier & Brolin, 2015). Disaster is defined by the United Nations as “a serious disruption of the functioning of a community or a society at any scale due to hazardous events interacting with conditions of exposure, vulnerability and capacity, leading to one or more of the following: human, material, economic and environmental losses and impacts” (United Nations Office for Disaster Risk Reduction, n.d., para. 1). During the pandemic, the community experienced physical, emotional, and financial strains unique to times of global crisis. Social isolation, fear of illness, job insecurity, and economic depression were widespread. When pregnant women are exposed to excessive stressors, neuroendocrine changes may result in a higher risk for preterm birth and low birth weight infants (Hobel et al., 2008). There is also evidence to support that increased anxiety and depression in pregnancy may increase preterm birth and CS rates (Alder et al., 2007; Andersson et al., 2004).

During the COVID-19 pandemic, hospital visitation policies limited the number of labor support persons allowed at the bedside and often excluded doulas. Evidence indicates that women with continuous labor support are more likely to have spontaneous vaginal births, shorter labor, and decreased CS. There is a greater effect size with a professional support person such as a doula (National Partnership for Women & Families, 2018). The post-outbreak decreased rate of elective induction and shorter LOS from arrival to birth in the intervention group could indicate that in times of disaster, education may prepare women to labor at home longer and delay hospital admission. An examination of overall birth trends pre and post-COVID-19 is an area for future study.

Limitations of this study included: an evaluation of one childbirth class in one hospital and a homogenous sample of participants consisting of predominantly white, well-educated women from a middle class or higher socioeconomic background. Findings may not, therefore, apply to women of different backgrounds. Also, women who choose to attend prenatal classes may be more interested in a vaginal birth, creating a potential self-selection bias.

Implications for Practice

Quality childbirth education is a low-cost intervention to improve maternity outcomes and decrease the cost of care. Hospitals that support prenatal education programs as part of a system of evidence-based care contribute to the improved well-being of women and newborns. The results of this study support the continued availability of prenatal childbirth education in the hospital setting.

Biographies

KRISTEN K. HANDS is a nurse and childbirth educator.

CLAIRE DAVIES are research consultants in the Nursing and Allied Health Research Office. All are employees of Baptist Health Lexington in Lexington, KY.

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

MARTHA MONROE are research consultants in the Nursing and Allied Health Research Office. All are employees of Baptist Health Lexington in Lexington, KY.

DISCLOSURE

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

FUNDING

This study was funded by Lamaze International. The author (Kristen Hands) received funding for this research study from Lamaze International. The co-authors received no specific grant or financial support for the research, authorship, and/or publication of this article.