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Medical Studies/Studia Medyczne
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Original paper

Effectiveness of childbirth classes in reducing anxiety before birth depending on age and education

Beata Bąk
1
,
Małgorzata Mastalerz
2

1.
Department of Perinatology and Gynecological-Obstetrical Nursing, Institute of Nursing and Obstetrics, Faculty of Medicine and Health Science, Jan Kochanowski University, Kielce, Poland
2.
Delivery Room, Swietokrzyskie Centre for Mothers and Newborns, Specialized Hospital, Kielce, Poland
Medical Studies/Studia Medyczne 2016; 32 (1): 10–17
Online publish date: 2016/04/05
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Introduction

Pregnancy and childbirth are critical moments in women’s lives [1]. Experiences of joyful anticipation can sometimes be accompanied by negative emotions, mainly in the form of fear of childbirth [2, 3]. These emotions may in some women cause in future mental disorders in the form of anxiety, lack of self-control and security, and be the cause of postpartum depression [4]. In addition, fear of childbirth during pregnancy may pose a risk of preterm delivery, low birth weight newborn, high blood pressure, and prolonged childbirth. It is mainly the reason women request a caesarean, and the cause of implementation of this emergency delivery [5–7]. Studies in the UK show that the number of women who fear childbirth is increasing in successive generations [8]. It has been proven that negative emotions associated with childbirth are present in 20–30% of women [2, 3]. Italians most often are afraid of not being in control of their own behavior in the delivery suite. The Swiss, Hungarian, Finns and Poles fear such a course of labor may endanger the health of their child as well as themselves [8]. Soet et al. argue that for 34% of women childbirth is a traumatic event and in 1.9% it leads to post-traumatic stress disorder [3].
Since the beginning of the twentieth century among some doctors and midwives caring for pregnant women and the women giving birth there has been a view that the contractions under physiological conditions are painless. The starting point is the fear of pain that increases tension and leads, by insufficient oxygenation of tissues, to pain. Anxiety can be removed by appropriate education and tension by relaxation. These beliefs led to psycho-obstetrics, on the basis of which today antenatal classes exist. They are supposed to prepare the pregnant woman and her partner to actively participate in the act of birth of their baby and allay the fear of impending birth. The birth of instrumental character is replaced with “the art of giving birth” [9]. Childbirth education equips participants with resources of resistance to stress, which according to Antonovsky include information resources and practical skills [10].

Aim of the research

The aim of the study was to evaluate subjective opinion on the perceived fear of childbirth by women giving birth, as well as to evaluate the effectiveness of participation in antenatal classes depending on the age and education of women surveyed.

Material and methods

The study using a proprietary survey included 125 women giving birth for the first time participating in VITA antenatal classes operating at the Swietokrzyskie Center for Mothers and Newborns in Kielce.

Statistical analysis

The results were analyzed statistically for measurable traits’ compliance with the 2 test. For statistical inference the level of significance was p < 0.05.

Results

The largest group participating in Lamaze classes (57.6%) consisted of women aged 31–40 years; there were slightly fewer (26.4%) women in the age group 20–30 years. The fewest were very young women under 20 years of age and older women above 40 years (respectively 7.2% and 8.8%). Higher education dominated (66.4%), while 20% of respondents had secondary education. The fewest (13.6%) were women with vocational education (Table 1).
Table 2 shows the results that have been confirmed statistically (p = 0.04). Only 11.2% of respondents under 20 years of age had reduced anxiety as they approach childbirth. Such a response was not observed in any other age groups. Replies from other respondents under 20 look the same: 22.2% of women claimed that fear grew the closer was the date of birth, the greatest fear was felt during the labor and felt no fear at all. The same number of respondents had no opinion. In the age group 20–30 years in more than 2/3 the greatest anxiety occurred during labor. In every fifth respondent anxiety grew the closer was the term. 27.3% of women felt no fear at all. About 12.1% of women had no opinion. Similar trends were observed in the age group 31–40 years. Almost half (48.6%) felt the greatest fear during labor. Twenty-five percent felt no fear at all, and in every fifth woman fear was greater as the final phase of labor was approaching. 5.6% of respondents had no opinion. Women over 40 years of age anxiety felt most strongly during the labor. In 36.4% anxiety increased as they become closer to childbirth, while for only 18.2% anxiety was a strange feeling.
Statistical analysis confirmed the relationship of education with the perceived fear of childbirth (p = 0.002). As many as 29.4% of women with vocational education felt the strongest anxiety during labor. In a slightly smaller group (23.5%), anxiety grew as it approached childbirth. Only 17.6% felt no fear at all and, in an even smaller percentage (5.9%), anxiety decreased as they approached childbirth. Almost one in four women had no opinion on the subject. Forty percent of respondents with secondary education declared that they felt no fear of childbirth at any stage of pregnancy and labor. In almost every fifth anxiety grew as it approached childbirth and one in four felt the strongest anxiety during labor. Among women with higher education no reduction of anxiety was observed as they approached the date of birth. The most common (54.2%) greatest fear was present during the birth, one in four did not feel fear at all, and in 16.9% anxiety increased as they approached the birth (Table 3).
Although the statistical results do not support dependence on age of the degree of use in practice the knowledge and skills acquired in Lamaze classes (p = 0.36), 44% of women under 20 years of age benefited fully from them. 22.2% of respondents were unable to take advantage of the acquired knowledge and skills during later labor. 11.1% partially made use of them in practice. More than every fifth respondent did not express any opinion. In the age group 20–30 years women, in whole or in part, benefited from the Lamaze course (respectively 36.3% and 30.4%). Every fifth negatively referred to the possible use of classes in practice. The same was true in the age group 31–40 years, where 41.7% fully used what they learned in antenatal classes, 33.3% fully and only 15.3% was not able to put the acquired knowledge into practice. Among women over 40 years of age, 36.4% of the respondents fully took advantage of the classes and only 9.1% did it partially. Quite a large percentage (27.3%) was unable to take advantage of the classes. The same percentage had no opinion on the subject (Table 4).
As shown in Table 5, the level of education statistically significantly (p = 0.0002) affects the use in practice of the knowledge and skills learned in Lamaze classes. 47.1% of women with vocational and 48.2% with higher education made use of them in full. In addition, 32.5% of those with higher education partially utilized during childbirth previously acquired information and skills. The worst knowledge was observed in the group of women with secondary education, where as many as 48% of respondents did not know how to use childbirth classes in practice, and about every fifth used them as a whole. Eight percent in this group benefited from the course in its entirety. What is worrying is the fact that 23.5% of respondents were unable to use information and skills gained during the course.

Discussion

Experiences of joy and happiness because of a newborn baby are emotions expected of young mothers. However, for some of them pregnancy and childbirth are a major disappointment and leave behind painful, traumatic memories. Precursors of research on emotional experiences accompanying pregnancy and childbirth are Dunbar and Squier [11]. In the following years it has been proven that psychological stress can cause premature childbirth and other obstetric complications [12]. One of the tasks of antenatal classes recommended by the Polish Gynecological Society is to prevent unpleasant emotions associated with pregnancy and childbirth through education and skills training to prepare for motherhood [13].
The results of this study show that most participants of antenatal classes were women aged 31–40 years with higher education. Slightly different results for age were obtained by Kwiatek et al., studying the demographic profile of women attending antenatal classes held at the Department of Obstetrics and Pathology of Pregnancy, Medical University of Lublin [14]. According to the authors, the majority were pregnant at the age of 25–30 years, while the smallest group – here no diference was observed – consisted of those pregnant under 25 years of age. As in our work, women with higher education prevailed among all respondents. Kołomyjec et al. found that the average age of primiparous subjects participating in antenatal classes was 27.7 years and 32.5 years for multiparous. More than half of all those surveyed had a higher education, and more than one third a secondary education. Basic education was only reported by 2.5% of pregnant women, and vocational 5.9% [15]. On the basis of these data, and on the basis of the presented results, a special emphasis on health promotion and promoting the idea of antenatal classes should apply among the youngest mothers and those above 40 years of age and among women with secondary and vocational education.
There is now a tendency to postpone motherhood to a later period of women’s life. In connection with the change of lifestyle, pregnancy after age 30 is very popular nowadays. It is believed that higher age (30–40 years) does not qualify the women to be in the group at high risk, because a lot depends on the mode of life, general health and individual predisposition [16]. Budrowska believes that the reduction of maternal mortality and neonatal modern methods of infertility treatment and dealing with health problems give women more and more certainty that in the later period of their life they will be able to become mothers of healthy children [17]. The results show a low percentage of participants of antenatal classes under the age of 21 years. Caus et al. believed that the lack of education of young people in the planning of pregnancy and delivery causes a low percentage or non-participation in antenatal class activities among women in this age. In these same studies, the authors emphasize that interest in the program which offers antenatal increases with the level of education [18]. A woman educated better understands the necessity of good preparation for motherhood.
Anxiety during pregnancy can lead to premature births and low birth weight. Lobel et al. studied women who gave birth before 37 weeks’ gestation and those with infant birth weight not exceeding 2500 g. They found that anxiety related to pregnancy and childbirth was correlated with smoking, drinking large amounts of coffee, irrational nutrition and lack of physical activity [19]. It has been shown that a sense of fear during pregnancy and childbirth is related to the behavior of infants who are more anxious compared with infants of mothers not experiencing negative emotions [20]. Taghizadeh et al. in research on the sources of anxiety before birth they gave a sense of helplessness when confronted with the new situation, a new environment, concern about the lack of control over an anticipated birth and loneliness. These feelings cause lack of confidence in women. Negative emotions according to the authors can occur at any stage of pregnancy and during childbirth, and their research has shown that the majority of mothers felt fear throughout pregnancy. The same authors, summarizing the results of their research, concluded that it concerned mostly experiencing the act of childbirth and the state of the child. It was so significant that it influenced the decision about the next pregnancy. The intensity of the fear felt meant that 10% of the women demanded a caesarean section. The decision about surgery was mainly driven by the fear of pain during labor [21]. Many authors in the study of anxiety related to pregnancy and childbirth found that 11% of Swedish, 5.3% of Swiss and 78% of Finnish women felt very strong fear for their child [22–24]. It has also been shown that fear of childbirth is conditioned by age, education, economic situation of women, culture and the state of medical care [25].
According to the presented results of the research into the interrelation between the fear of giving birth and the age of pregnant women participating in antenatal classes, older women often felt more fear during the course of labor and as they approached the birth than women under 20 years of age. Moreover, in the youngest age group for 11.2% anxiety decreased as they approached the date of birth. Almost every fourth respondent claimed that she felt no fear at all, which is not recorded in any other age groups. Studies assessing the level of antenatal anxiety in pregnant women physiological conducted by Bączyk et al. showed that older women (over 35 years old) show a higher level of anxiety than younger ones. They point out however that moderate fear of birth is beneficial for the course of childbirth, especially for co-operation for a woman who is giving birth [26]. Piela et al. have shown that elevated levels of anxiety before birth occur in women between 18 and 35 years of age, while in women below and above this age group they are low [27].
More than half of the surveyed women with higher education felt fear during active labour or just as labour was upcoming. Small differences in the assessment of anxiety were presented by a group of women with vocational education. Only a group of women with secondary education in the majority claimed that they felt no fear at all. Alipour et al. in research on anxiety during pregnancy and childbirth proved that women frequently experience anxiety as they approached the date of birth. In addition, those at 28 and 38 weeks of gestation identified anxiety as strong; more often than others they feared the impending birth. According to the authors, strong fear of childbirth is very often finished by emergency caesarean and the use of large quantities of painkillers [28]. Fenwick et al., investigating the source and modifying factors of anxiety experienced during childbirth, pointed to the low level of education on the subject, the negative experiences described by other women, negative experience in previous deliveries, lack of control over their own reactions and the inability to make decisions [29].
The English obstetrician GD Read, creator of the idea of antenatal classes, stated that during childbirth anxiety causes an increase in muscle tone, which enhances the perception of pain and leads to increased anxiety, medically known as a vicious circle of disease. To break this circle the pregnant woman must be informed about the course of childbirth and be told clearly what she can expect [30]. Women applying for an antenatal course are searching for knowledge of pregnancy, childbirth and the childbed period and expect education in the skills of taking care of a newborn. They want to consciously participate in the childbirth, and allay the concerns and fears of pain and what is unknown [31]. The presented results indicate that regardless of age, in the Kielce classes of the school of childbirth, most of the participants put the knowledge acquired during the course into practice fully or partially. However, in the oldest group of women (over 40 years old), a relatively large group did not benefit from the knowledge and skills offered by the classes, claiming that they could not use all the knowledge that had been taught in the delivery suite. The same trend has been noted in the group of younger women (under 20 years of age). These data suggest that the program of the courses should include the needs of the oldest and youngest women, and involve all the pregnant women much more during the courses.
Respondents with vocational and higher education in the majority in whole or in part made use of the knowledge and skills gained during birth classes. But for almost half of the women with secondary education there was characteristic inability to implement in life the educational resources gained during the course. In this group, only a few have used these resources as a whole. It should also be noted that difficulties in the use of knowledge and skills acquired in childbirth classes were experienced by nearly one quarter of women with vocational education. Fabian et al., in research on the effectiveness of antenatal classes, found that 74% of participants in practice applied knowledge and skills gained on the course, while 40% of women felt that the school had prepared them to give birth and for early parenthood [32].
The research results presented in this paper inefficiencies in antenatal classes in which pregnant women participated. It is therefore necessary to modify the course itself so as to contribute to the reduction of negative emotions, and also take into account the needs of all age groups of participants. Maybe you should take into account a greater role for the psychologist, who will be able to equip participants with techniques for coping with the stress of pregnancy and that accompanies the pregnancy childbirth. An interesting proposal, existing since 1994 in Canada, the US and Sweden, is group prenatal care (GPC), run by midwives on the basis of support groups connected with education about pregnancy and childbirth. Meetings with pregnant women in a similar gestational age and their partners are held at regular time intervals starting from the 28th week. The frequency of these meetings increases with the approaching date of birth. During the course participants, in addition to the principles of healthy behaviors during pregnancy, consciously participate in childbirth and newborn care, learn how to perform a blood pressure measurement, interpret results of measurement of body weight and the use of tests to detect the presence of protein in the urine, and the choice of topics is agreed with the interested parties. Psychoprophylaxis for pregnancy and delivery involves sharing your emotions, experiences and concerns. The atmosphere of classes is to help foster partnerships between two people expecting a child, between individual pairs and between the pairs and midwives. It also teaches the practical implementation of the acquired knowledge and skills, which, as the results show, the Kielce course lacked, perhaps for the reason of the large size of the group. In principle, the purpose of the GPC is to provide the leaders with health information for pregnant women, and persons accompanying them learn to look at the situation through the eyes of mothers and derive maximum satisfaction from their work [33, 34]. In Canada, a survey was conducted on GPC participants of the course. They were mostly positive. They pointed to the possibility of contact with other pregnant women (knowing that it continued after the end of the pregnancy), thereby reducing the sense of isolation, the atmosphere of mutual trust, the small group size, strengthening self-esteem and symptoms of treatment [35].
The benefits of completing the Lamaze course depend not only on the individual characteristics of the participants, but also on the knowledge, skills and commitment of people running the course. An interesting solution that supplements a childbirth school, is provided by a complementary helpline for pregnant women run by midwives. Such an institution was introduced in Australia. Women at any time can benefit from free advice on topics related to pregnancy, childbirth and future puerperium. They can also share their emotions. The effectiveness of psychoeducational intervention is expressed in the reduction of numbers of caesarean sections and emotional consequences that may be associated with a traumatic birth [36]. Fewer requests for a caesarean section, and the low level of anxiety associated with childbirth, were noted by Aksoy et al., proving that these phenomena are associated with obtaining reliable knowledge about natural childbirth methods of pain relief [37].
The Lamaze course should place more emphasis on the ability to use personal resources to protect against negative emotions. Taheri et al. conducted a study among pregnant women with weekly sessions conducted by midwives and doctors, in order to arouse faith in its effectiveness, ability to verbalize their feelings, acting out negative emotions and positive motivation. The results showed that high levels of self-efficacy achieved by actions of psychopreventions and education cause that women prefer vaginal birth and the forces of nature and are less likely to demand cesarean section [38]. In turn, Butler et al. are of the opinion that prenatal care involving education and psychological support contributes to more effective and longer breastfeeding [39]. A greater role is therefore justified for a psychologist in antenatal classes or equipping midwives with the skills for communication therapy and supportive psychotherapy.
The most important thing is the subjective opinion of the participants of Lamaze classes. The analysis of opinions should be conducted systematically, and all the conclusions should be used to modify curricula and adapt them to the current needs of the participants. Raising skills and updating knowledge of people running antenatal classes is essential for their effective functioning.

Conclusions

There is a relationship between age and the subjective assessment of the fear of childbirth among participants of the childbirth classes. The older the woman is, the more likely she is to experience anxiety as she approaches the birth or during it. This means that, older women, younger women need more mental support and activity in order to increase their awareness and capabilities.
Fear of childbirth depends on the degree of education. Women with secondary education are least afraid of childbirth. The biggest fear is presented by women with vocational and higher education. It covers the period before birth and birth itself. Less fear is not associated with either a higher or lower level of education. Women with higher education as well as women with vocational education require greater attention in order to reduce their fear of childbirth.
Lamaze classes do not contribute to reducing anxiety as they approach childbirth regardless of age and education of the participants.
Most women, regardless of age, entirely or partly used the knowledge and skills learned in Lamaze classes. However, one should particularly pay attention to skill training implementation resources acquired during the course, because there is a large group of women, of all ages, who could not use the acquired knowledge and skills in the delivery suite.
The degree of education is significant in putting into practice the knowledge and skills acquired in childbirth classes. This course is best utilized by women with vocational and higher education. Antenatal classes should focus more on people with a secondary education.
The results presented in the work indicate inefficiencies in antenatal classes in which pregnant women participated. The program must be modified so that it contributes to the reduction of negative emotions, while taking into account the needs of all participants.

Conflict of interest

The authors declare no conflict of interest.

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Address for correspondence:

Beata Bąk MD
Department of Perinatology and Gynaecological-Obstetrical Nursing
Faculty of Health Science
Jan Kochanowski University
al. IX Wieków Kielc 19, 25-317 Kielce, Poland
Phone: +48 692 113 477
E-mail: beatab5@onet.eu
Copyright: © 2016 Jan Kochanowski University in Kielce This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) License (http://creativecommons.org/licenses/by-nc-sa/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.
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