Individual studies were initially selected for scrutiny in this chapter if they investigated antenatal education interventions specifically aimed at increasing women’s self-efficacy. However, as the study progressed, the women’s emphasis on taught coping strategies became increasingly important and so antenatal education trials which focus on taught strategies which aim to enable women to manage labour without medical intervention are also included here. Trials which explore complex systems, for example Pilates, Tai Chi and hypnotherapy where the components cannot be dismantled and transported into YfP classes are excluded, as are those exploring the effects of educational software on self-efficacy, and studies exploring antenatal education with narrow demographic groups, for example those with severe fear of childbirth.
2005 - England
Escott et al. (2005) compared the outcomes for 41 women receiving a coping strategy enhancement (CSE) intervention with outcomes for those attending standard antenatal education. This study was included in Birth and Beyond, McMillan et al.’s (2009) review of the evidence around antenatal education, but excluded from Gagnon and Sandall's (2007) Cochrane review as it was a comparison study with no control group. The intervention consisted of five two-hour midwife-led sessions. The women
receiving standard antenatal education were taught three coping mechanisms: ‘sigh out slowly’ breathing, positions for labour and the Laura Mitchell method of relaxation (Payne, 1995). Those receiving CSE were taught strategies based on their previously identified coping mechanisms. Although it was found that women receiving CSE were more likely to use pain coping strategies during labour, no significant differences were found in use of pain medication or mode of delivery.
2006 - Switzerland
Sieber et al. (2006) studied 61 low-risk primiparous Swiss women in a prospective longitudinal study of aspects of emotional well-being such as birth-anxiety, self-efficacy and psychosocial adaptation to pregnancy. Self-self-efficacy scores were calculated at three time points: 29-33 weeks gestation, 4-5 weeks later after attending childbirth classes, and 2-5 days postpartum. Sieber et al. (2006) found self-efficacy scores increased after attendance at classes. However, as there was no control group it is impossible to attribute this to attendance at childbirth classes. At the first time point, self-efficacy was negatively correlated with birth anxiety.
2009 - Hong Kong and Sweden
Building on their earlier work (2008, 2005) which is described in the self-efficacy literature review in chapter four, Ip et al., (2009) designed a randomised controlled trial drawing many theoretical elements of self-efficacy together. Ip et al.’s study was included in Marc et al.’s (2011) Cochrane review and is not only one of the strongest in methodological design, but also one of very few which have designed an antenatal education programme around Bandura’s 1977 principles. It is therefore particularly relevant to the present study. Ip et al. (2009) evaluated the effect of a self-efficacy
enhancing educational programme (SEEEP) on self-efficacy, pain, anxiety and performance behaviours in low risk Chinese primiparous women. The SEEEP sessions embraced the four components of self-efficacy enhancement as described by Bandura (1977):
Performance accomplishments
o Demonstrating and actively encouraging the women to practise coping skills and pain management strategies, including breathing, relaxation, distraction and cognitive restructuring of pain
o Making a verbal contract with the women to increase mastery by practising the coping techniques at home
o Giving the women written guidelines summarising the self-coping strategies
Vicarious experience
o Showing a video where women successfully persevered with coping behaviours to regain control over their birth
Verbal encouragement o Positive comments
o Aiming to give the women a sense of confidence in their ability to cope with childbirth by reviewing their practice of coping strategies
Somatic awareness
o Giving the women psychological and physical information about childbirth o Asking the women to complete a daily log with the aim of building a sense
of personal control and confidence through awareness of successful practice in challenging conditions.
The control group received the usual care provided in Hong Kong maternity services where there is no standard antenatal education programme. One hundred and ninety-two (52%) of the 366 eligible women recruited from one Hong Kong hospital agreed to participate in the trial. The attrition rate was relatively high, although not unusual for a longitudinal study in this field: 36/96 and 23/96 women withdrew from the experimental and control groups respectively. Reasons for withdrawing included medical (breech), personal (tiredness) and convenience (difficulty getting to the sessions). The group who received the SEEEP intervention demonstrated higher levels of self-efficacy for childbirth, lower perceived anxiety, lower perceived pain and greater performance of coping behaviours during labour than the control group. An increased level of confidence in the ability to manage labour was a predictor for use of labour-coping behaviours.
The same year, in a randomised controlled, multicentre trial to examine the effects of psychoprophylactic training versus standard antenatal education, Bergström et al.
(2009) found no statistical differences in the experience of childbirth between the groups. In this methodologically strong trial which was included in Birth and Beyond (McMillan et al., 2009) and Smith et al.’s (2011) Cochrane review, both groups took part in antenatal programmes consisting of four two-hour sessions. The ‘natural’
model included 30 minutes practice per session of relaxation and breathing techniques plus partner coaching and the educator was encouraged to be in favour of natural childbirth. The ‘standard’ model included information and discussion on childbirth and parenting but no practical training or information on non-pharmacological methods of coping with labour pain. The epidural rate across the sample was high (52%) implying
an acceptance of epidural anaesthesia within the Swedish maternity culture or a lack of support during labour. Whilst 70% of the ‘natural’ group practised psychoprophylaxis during labour, 45% of the standard group also did so, implying influence from outside the trial, either from previous experience of coping with pain or attendance at other education classes.
2010 - Denmark
Maimburg et al. (2010) trialled an intervention consisting of three three-hour sessions:
Birth, Parenting and The Newborn, with the Birth module consisting of ‘lectures and discussion of labour onset, birth process, the attending father, pain relief, birth interventions, fear of childbirth and a film on giving birth’. One of the aims of the trial was that women would use less pain relief and receive less medical intervention during labour. Although there is no standard antenatal education programme in Denmark, the control group receiving standard care could choose to attend classes provided by other stakeholders, which were mainly relaxation classes. In the trial group, 72% of women received the intervention, often attending sessions with their partner, whilst 45% of the women in the control group attended sessions provided by external stakeholders.
In contrast with earlier researchers (Bergström et al., 2009; Fabian et al., 2005), Maimburg et al. (2010) found that women receiving the antenatal training used less epidural analgesia during labour but not less pain relief overall. A five-year follow-up of this trial (Maimburg et al., 2016) showed that women who received the antenatal education programme reported a more positive birth experience compared with those in the control group. A strength of Maimburg et al.’s research was the relatively low
withdrawal rate: the participant response rates were 97% in the initial trial (2010) and 82% at 5 years (2016).
2011 - Taiwan
Gau et al. (2011) examined the effectiveness of a birth ball exercise programme on self-efficacy with a randomised group of 188 Taiwanese mothers. The programme consisted of a booklet and videotape, with follow-ups during antenatal appointments.
The experimental group were asked to practise at home for at least 20 minutes three times a week. They were given a birth ball and encouraged to choose comfortable positions every hour in labour. Women in the experimental group had significant improvements in childbirth self-efficacy, shorter first-stage labour, less epidural analgesia, and fewer caesarean deliveries than the control group. However, fewer than half the women who started the trial completed it, making the results less reliable. In addition, women in the experimental group were encouraged to use the birth ball hourly throughout labour and their partners recorded the length of time they stood up during labour. As upright positions have been associated with shorter labour and a greater ability to manage labour without pharmacological pain relief (Lawrence et al., 2013), interpretation of the results may have been confounded.
2013 - Brazil
Miquelutti et al. (2013) conducted a phenomenological study of 21 Brazilian first time mothers, interviewing them 24-48 hours after delivery. The intervention group attended a women-only antenatal programme covering breathing, relaxation, stretching exercises and pharmacological pain relief. Non-pharmacological pain techniques were practised and doubts discussed. The control group had usual care
including information on breastfeeding, signs and symptoms of labour and the opportunity to attend a meeting which included physical exercise and coping techniques for labour. The women in the intervention group reported that they maintained self-control during labour, using breathing exercises, upright positions and other self-help strategies to control pain. They also reported satisfaction with their birthing experience. Women in the control group referred to difficulties in maintaining control with almost half reporting a lack of control. They were also more likely to be dissatisfied with labour. A limitation of this trial noted by Miquelutti et al. (2013) was that in the hospital where the women birthed their babies, the decision whether to give spinal anaesthesia is made by the medical staff rather than the women and so it was not possible to evaluate the effect of the antenatal programme on pain relief in labour.
2016 - Australia
A recent randomised controlled trial with 176 primiparous Australian women (Levett et al., 2016) evaluated a novel approach towards antenatal preparation by investigating the effect on epidural use of a two-day antenatal education programme based on six complementary medicine techniques. Relevant to the present study, three of the components taught on the two-day courses were relaxation, breathing and yoga techniques. Women who received the intervention showed a reduction of 63% in epidural use compared with the control group. They were also more likely to birth vaginally without surgical or mechanical assistance, had reduced rates of augmentation, shorter second stage of labour, less perineal trauma and reduced need for newborn resuscitation. In common with other antenatal education research, a
limitation of this trial was that the women who participated tended to be wealthy, well-educated and from higher socio-economic groups than the general population.