Antenatal Education Systematic Overview

Antenatal Education Systematic Review

Antenatal education programms

In pregnant women, how does group antenatal education compare to no antenatal education or individual antenatal education for improving outcomes of childbirth and parenting?

In pregnant women, how does group antenatal education compare to no antenatal education or individual antenatal education for improving outcomes of childbirth and parenting?

Antenatal education programs are key in improving maternal health all over the world. They have been widely embraced in most developed countries where antenatal education programs are routinely provided as part of antenatal care. They are associated with benefit such as increased knowledge of labor and childbirth, parent-child attachment, reduced anxiety and depression, and increased knowledge of parenthood. They often involve several scheduled sessions with a facilitator or care provider (often a trained patient educator, midwife, or general practitioner) that last about 1 — 2 hours and focus on different aspects of labor, childbirth, and parenthood. These programs are often provided in groups meeting about seven (7) to ten (10) times for sessions running for 60 to 90 minutes on average over the course of the woman’s pregnancy. All antenatal care that is provided in group-based settings is integrated with other antenatal care assessments such as information, peer support, and education.


The current systematic review compares the effectiveness of group-based antenatal education and no antenatal education or individual antenatal education on labor, childbirth, and parenthood outcomes. A systematic search of electronic databases was conducted. The identified studies were used to understand the effectiveness and cost-effectiveness of group-based antenatal education programs.


The review identified five (5) randomized controlled trials conducted in different settings focusing on different aspects of antenatal care. The review highlights the paucity of research on effectiveness of antenatal education in developing countries. The identified studies provide low quality evidence that is at low risk of bias of the effectiveness of group-based antenatal education programs in promoting good labor, childbirth, and parenthood outcomes.

Discussion and conclusion

The limited evidence available suggests little to no difference in labor, birth, and parenthood outcomes though women in group-based antenatal education were more likely to initiate breastfeeding earlier than the comparator groups. There were no studies of the cost-effectiveness of group-based antenatal education programs. Therefore, the review could not highlight any significant differences in costs for the intervention and control.

Table of Contents

Abstract 4

Table of contents .. 5

Table of figures 10

Glossary of terms . 11

Chapter 1:


Rationale and justification of the review


Justification for antenatal education classes


Antenatal education in developing countries and emerging economies

Research questions

Objectives of the review

Summary of chapter 1

Chapter 2:



Literature Search Strategy

Searching other resources

Eligibility criteria

Types of studies and participants


Outcome measures

Data collection and analysis

Data extraction and management

Assessment of risk of bias

Data analysis

Summary of chapter 2

Chapter 3:



Effectiveness of antenatal education

Benediktsson 2013

Bergstrom 2009

Corwin 1999

Mehdizadeh 2005

Ickovics 2007


Summary of chapter 3

Chapter 4:



Impact on childbirth outcomes

Health behaviors during pregnancy

Psychological outcomes

Attachment with the newborn baby

Participative forms of learning

Preparing for parenthood before childbirth

Stakeholder involvement and perspectives


High-risk groups

Multicultural families

Agreement and disagreement with other reviews

Summary of chapter 4

Chapter 5:



Review of evidence

Implications for policy

Implications for practice

Direction of future research






Action plan

Summary of chapter 5

Table 1: Characteristics of included studies

Table 2: Risk of bias analysis of included studies

Table 3: Characteristics of excluded studies

Table 4: Eligibility form for judging inclusion and exclusion of studies

Table 5: Risk of bias assessment tool

Table of figures

Figure 1: Study flow diagram

Glossary of terms


Occurring or existing before childbirth; prenatal


State of nervousness or worry that occurs as a mental disorder


Difference between the expected value and the true value of an experiment


State of mother to produce breast milk for an infant to feed


Standard care against which a specific intervention is compared


State of mind characterized by pessimistic ideas and inactivity


Local anesthesia used during childbirth to reduce pain during labor


Quality of being different and not comparable to each other


Care provided to improve a specific situation


Final state of pregnancy from the onset of contractions to childbirth


Medicine concerned with treatment of tumors


Medical services concerned with the eye and its related diseases


State of becoming a parent


State of carrying developing offspring

Chapter 1: Introduction

1.1 Rationale and justification of the review

1.1.1 Introduction

Antenatal education is a key component in reducing and preventing pain and discomfort associated with pregnancy and childbirth. Recently, policy documents in various countries have been reviewed to pave way for antenatal education programs National Childbirth Trust, 2007.

These policy documents emphasize the fact that antenatal education programs play a key role in preparing the mother and the family generally for childbirth, improving the expectant mother’s confidence and self-esteem, and preparing them for care and feeding of the newborn. In addition to these, the antenatal education programs also help to increase the overall experience during pregnancy and childbirth Singh and Newburn, 2000(, Schneider, 2001)

These programs have become common in many developed countries but developing countries have lagged behind in their adoption of antenatal education programs. The major reason why developed countries have been faster in adopting education programs is because they recognize the importance of preparing expectant families for pregnancy, labor, childbirth, and care of the newborn baby. In particular, they recognize the significance of expectant women achieving the best physical and psychological health during the period of pregnancy Svensson et al., 2006.

They also see the importance of accessing good social support through attending the sessions with a member of family or a friend for support Robertson et al., 2009

( ADDIN EN.CITE, Lumbiganon et al., 2011)

1.1.2 Justification for antenatal education classes

I am currently working as a staff nurse in the Obstetrics and Gynecology ward at the Jeddah Branch of King Faisal Specialist Hospital and Research Centre in Saudi Arabia. The King Faisal Specialist Hospital in Saudi Arabia delivers the highest level of specialized healthcare within an integrated clinical practice and research setting. The hospital delivers 24-hour emergency care, dentistry services, medical oncology, cardiovascular, short-stay surgery services, as well as ophthalmology services. Despite the healthcare services delivered by the hospital, the King Faisal Specialist Hospital does not have antenatal education programs to educate pregnant women to prepare for childbirth and parenthood. Moreover, the hospital does not have a program to educate and equip clinical nurse specialists specializing in patient education to provide antenatal education to pregnant women.

Importantly, I have gained knowledge about the prenatal education in the UK and this has influenced my decision to choose antenatal education programs as the topic of my dissertation. Typically, there is a large difference between antenatal practice in the UK and Saudi Arabia. In the UK, antenatal education programs are offered free of charge to all pregnant women. These programs assist pregnant women to get a greater understanding of how they should prepare for childbirth and impart knowledge on the other aspects of parenthood such as breastfeeding. The antenatal education program that I attended in the UK assisted me to prepare for childbirth. The program also assisted me to manage my pregnancy effectively. While pregnant women with a supportive person are allowed to receive antenatal education in the UK, the issue is different in Saudi Arabia. Islam in Saudi Arabia forbids male and female individuals from being in the same location. Therefore, it is difficult for the mother to be accompanied by their spouse during antenatal education classes.

1.2 Background

Antenatal education is founded on the premise of using physical and psychological education methods to help mothers understand changes during pregnancy and understand how they can prevent and reduce pain and discomfort associated with pregnancy and childbirth Billingham, 2011

( ADDIN EN.CITE, Bergstrom et al., 2013, Artieta-Pinedo et al., 2010, Artieta-Pinedo et al., 2013)

. Recently, in developed countries, antenatal education classes have featured in policy documents. These emphasize their impact on preparing the mother for childbirth, improving behaviors of mothers and others such as the father and other family members during pregnancy, increasing self-esteem and confidence during pregnancy, and preparing the mother for feeding and providing care for the baby throughout infancy Ferguson et al., 2012

( ADDIN EN.CITE, Schachman et al., 2004)

Antenatal education, often referred to as childbirth education or prenatal education, offers a wide range of information for mothers to identify and prevent complications, ensure the well-being of the mother and their baby during the pregnancy period and after childbirth. As argued by Redman et al., 1991

(Brixval et al. (2014)

, antenatal education classes are mainly provided because scholars associate these with the importance of preparing mothers for labor, childbirth, and postnatal care. The authors posit that there is great significance of these classes in influencing health seeking behavior during pregnancy to reduce overuse of healthcare services and optimize health during pregnancy, and providing social support that improves the mother’s well-being and self-esteem )

Until recently, it was largely unknown whether antenatal education classes were effective in positively influencing the psychological and physical well-being of pregnant women and their families. However, recently, studies have shown an increase in knowledge as a result of these antenatal education classes. These studies have also highlighted the importance of using a wide range of techniques in the classes to improve the health and well-being of the pregnant mother Su et al., 2007a ()

The impact of antenatal education classes on maternal emotional states as one of the psychological well-being factors is an important consideration in understanding the effect of these classes Schachman et al., 2004.

Maternal emotions can influence the health and social well-being of the mother and the baby thus is important in both the behavioral and psychological well-being of the fetus and the mother as well Malata et al., 2007.

One important question to understand is the effect of antenatal education classes on the psychological well-being of the mother and the baby during fetal development and infancy since it is a psychologically stressful time Dennis, 2005()

It is also important to understand the influence of antenatal education classes on the information and preparation that pregnant mothers make for parenthood Schmied et al., 2002.

Though studies have shown that antenatal education classes are among the main sources of information for parents-to-be, it is important to understand the extent of this effect Ahlden et al., 2012.

Policy makers have often questioned the purpose and justification for antenatal education classes since they require significant infrastructural and other resource investment Jaddoe, 2009.

Therefore, it is important to understand the purpose of these classes with suggestions of how they can positively influence the knowledge that parents-to-be have about parenthood Al-Shammari et al., 1994()

A review conducted by Svensson et al., 2007(Gagnon and Sandall (2007)

identified studies that conducted antenatal education program on individuals and groups. The authors found that structured antenatal educational programs promote positive outcomes for both childbirth and parenthood though majority of the studies reviewed found little no difference in majority of the outcomes. Other literature available bears the same conclusion by showing that many health care professionals and researchers around the world recommend antenatal education for pregnant women )

. Other authors assessed the effect of antenatal educational program in helping to handle labor, pain, and anxiety prior to childbirth Svensson et al., 2008()

Their review search strategy technique was by searching different electronic databases such as the Cochrane database, CINAHL for studies published between 1982 and April 2006, ERIC between 1984 and April 2006, EMBASE between 1980 and April 2006 and PsycINFO between 1988 and April 2006 Gagnon and Sandall, 2007.

The authors also searched the Journal of Psychosomatic Research for studies published between 1956 and April 2006. The review included randomized-controlled trials and found that antenatal education programs for either parenthood or childbirth have effects on:


knowledge acquisition;

general social support;

obstetrical interventions;

infant care abilities;

breastfeeding success;

self-confidence; and maternal sense of control.

The review authors used quantitative techniques for data analysis using the Cochrane statistical package, RevMan The Nordic Cochrane Centre and The Cochrane Collaboration, 2013()

, with 95% confidence intervals. The results reveal that antenatal educational program generally enhance the outcomes of childbirth.

1.3 Antenatal education in developing countries and emerging economies

Unlike the UK where the main providers of antenatal care are the National Health Service (NHS) and the National Childbirth Trust (NCT), developing countries have a long list of antenatal care providers Vieira et al., 2008.

These range from large providers such as private and government hospitals to smaller providers such as clinics Su et al., 2007b ()

. As a result of the fragmentation in provision of antenatal care services, formal deployment of antenatal education classes remains a challenge with most developing countries relying on an inefficient information dissemination channel Renkert and Nutbeam, 2001.

This is where the pregnant mothers rely on their mothers to provide them with information regarding childbirth and parenthood Al-Nasser et al., 1994.

This inefficient channel has several hindrances such as distortion of information and lack of benefits such as increased confidence and self-esteem of the pregnant mothers.

As argued by Nolan, 2012(

Nylander and Adekunle (1990)

, the problem of antenatal education in developing countries is twofold. The first aspect is that there are insufficient or highly fragmented sources of antenatal care for pregnant women and the second is that in areas where antenatal care is provided, these services are often underutilized possibly due to lack of knowledge about existence of these services “Nylander, 1990 #2171”


. The authors propose solutions to these problems as follows. The first is for adequate facilities to be provided to ensure inclusiveness of antenatal education programs in the overall antenatal care landscape. This is an extremely difficult task especially where antenatal care centers are inadequate or highly fragmented Miquelutti et al., 2013


. The second solution proposed is for facilities that provide some form of antenatal care to be included in the list of facilities providing antenatal care Nigenda et al., 2003


. The challenge here will thus be to streamline the delivery of antenatal education services to ensure the classes are the same and make sure they are affordable May and Fletcher, 2013()

In Saudi Arabia, “at present, there is no established plan for antenatal education interventions in terms of content and delivery methods in Saudi Arabia,” Otaiby and Bawazir, 2013: 14.

This is despite the fact that previous systematic reviews conducted by McMillan et al. (2009)

investigating the effect of antenatal education classes on the health care system show that they have a positive effect on the knowledge of expecting mothers and fathers as well. However, the review also note that the effect of antenatal education classes on other aspects of pregnancy and motherhood particularly in developing countries remains unknown due to the paucity of studies in developing countries.

Gagnon and Sandall (2007)

and Rosenberg, 2002(Habib et al. (2011)

showed that in Saudi Arabia, pregnant women who are not formally educated are three times less likely to receive antenatal care compared to educated women and the result could consequently lead to increase in anxiety during pregnancy, childbirth, and parenthood. Another study also shows that pregnant women who do not receive antenatal care face increased risk of poor outcomes of childbirth Al-Ateeq et al. (2013)

also conducted a study to evaluate the level of knowledge of 300 women in Saudi Arabia and the results reveal that nearly all the subjects had not received important information about pregnancy, childbirth and motherhood pointing at the ineffectiveness of the current antenatal education classes. The authors further point out that there is clear need of antenatal education classes in order to achieve a better outcome of childbirth and motherhood in Saudi Arabia. Another study conducted by )

Despite the importance of antenatal education for pregnant women being demonstrated in these studies and in practices in developed countries such as the UK and the U.S., there is still a scarcity of research focusing on the antenatal education interventions in Saudi Arabia and other developing countries. This study attempts to review the evidence on the effectiveness of antenatal education classes systematically. Lack of comprehensive antenatal education intervention in Saudi Arabia and other developing countries is a challenge due to the paucity of research and the review will focus on studies conducted in both developing and developed countries.

1.4 Research questions

The aim of this systematic review is to assess the effect of antenatal education programs on various outcomes for pregnant women. The specific research questions are:

1. In expectant mothers in Saudi Arabia, what are the effects of antenatal education compared to no antenatal education, or individual antenatal education on psychological and social well-being?

2. In expectant mothers in Saudi Arabia, what is the effect of antenatal education compared to no antenatal education, or individual antenatal education on the knowledge and preparation for childbirth and parenthood?

1.5 Objectives of the review

Objective of this systematic review of secondary research is to evaluate the literature research to assist in answering the following questions:

What is the effectiveness of antenatal education programs in promoting positive labor, childbirth, and parenthood outcomes?

What are the contents of the antenatal education program that should be used to educate the target population?

1.6 Summary of chapter 1

This section was an introduction to antenatal education programs. It highlighted the background of antenatal education programs and why the topic is chosen as the review topic. Antenatal education programs have been implemented in developed countries with scholars positing it has positive effects. This review will help to investigate the effectiveness of group-based antenatal education programs at promoting positive outcomes of labor, childbirth, and parenthood. The review is divided into these sections: methodology, results, discussion, and conclusion. The methods section details the methods used in the study while the results section defines the results of the review. The discussion section provides a critical analysis of the findings and their implications while the conclusion provides a judgment of the implications of these findings.

Chapter 2: Methods

2.1 Introduction

This systematic review is conducted following the guidelines of the Cochrane Collaboration Higgins and Altman, 2008.

The review included peer-reviewed literature identified from searching electronic databases such as Medline, EMBASE, and CENTRAL (Cochrane Central Register of Controlled Trials).

The PICO (Population, Intervention, Control, and Outcomes) format for the research question is as follows:


Pregnant or expectant women and/or their partners or accompanying person


Antenatal education classes for expectant women


No intervention or antenatal care without antenatal education


Outcomes of labor and childbirth, and parenthood, psychological and social well-being, and cost-effectiveness of antenatal education

2.2 Literature Search Strategy

The search strategy involved the use of the standard keywords relevant to the study, and the search strategy included terms such as antenatal education, prenatal education, childbirth education, and education in pregnancy, pain management during labor, and breastfeeding classes to identify relevant studies. The study searched several electronic databases for the systematic identification of relevant studies on antenatal education programs. Further searches of relevant health journals and grey literatures were also conducted to ensure inclusiveness of the search.


Searching other resources

After identifying the initial search results, reference lists of these studies were read through to identify further studies. These reference lists help to identify other studies conducted on antenatal education programs to identify unpublished trials or those not included in the search results.

2.4 Eligibility criteria

2.4.1 Types of studies and participants

Eligible studies included randomized trials that use individual or cluster randomization techniques, published in English irrespective of publication year, publication type, or publication status dwelling on the implementation of antenatal education programs.

From literature, it is evident that how expectant mothers prepare for childbirth, parenthood greatly depends on their culture, and other contextual issues such as how the health system is organized. Therefore, the study attempted to include only studies that are conducted in developing countries. However, due to the paucity of research, Western studies may also be included depending on the number of studies from developing countries that are identified. Participants in the studies were pregnant or expectant mothers and their partners or other accompanying person and had provided informed consent of some form to participate in the trial. Table four (4) in Appendix two (2) shows the form used to judge the eligibility of studies.

2.4.2 Interventions

The experimental intervention in all included studies was antenatal education classes offered by a trained patient educator to groups of more than two individuals or couples addressing issues of childbirth and preparations for parenthood. The control intervention for the included studies was no antenatal education defined as standard antenatal care without antenatal education or individual antenatal education classes. If the study attempted to compare two antenatal education programs, these were excluded since this review only focused on antenatal education programs as the desired intervention.

2.4.3 Outcome measures

For the outcomes, quantitative measures were required in order to enable meta-analysis of the data. The review assessed the outcomes reported in the studies identified and clarifications were sought where needed. If the outcomes were measured more than once during the period of follow-up, the review used the first measure before or after the intervention started or ended and the last measure at the end of follow-up in defining the effect of the intervention. This was important to cater for inherent heterogeneity in the identified studies.

The primary outcomes for this systematic review were: proportion of patients who felt relieved of pain during labor, proportion of patients receiving interventions of an obstetric nature, mean of the measure of psychological or social well-being, and proportion of participants who felt they had increased their knowledge about childbirth and parenthood.

Secondary outcomes for the review include the involvement of partners during childbirth and parenthood, success rate of breastfeeding, ability to care for the infant, and the measure of active decision making by the expectant mother during labor and childbirth.

2.5 Data collection and analysis

After identifying the search results, screening of the initial search results was done. After initial screening, full-text copies of studies marked as potential for inclusion were retrieved. Each trial report was checked against the inclusion criteria and for evidence of multiple or duplicate publication from the same data set to ensure the studies included were individual studies. Any conflicts or disagreements in the screening and judging the studies for inclusion were resolved through discussion or consultation.

After completing the selection process, a PRISMA study flow diagram was generated to understand how the inclusion and exclusion criteria was applied to the final results of the review.

2.6 Data extraction and management

Data from the included studies was then extracted using summary tables to obtain information on the study characteristics such as the study methodology, participants included, interventions, comparison, outcomes, and types of effect analysis. This information was then used to present the review findings and assess the risk of bias for the included studies.

2.7 Assessment of risk of bias

The risk of bias of each of the included studies was assessed according to a predefined risk of bias tool. This tool was aimed at helping to determine the likelihood of biases that may have adversely affected the internal validity of the trials. Any discrepancies that existed between the review authors were once again solved through discussion and consultation. The risk of bias assessment tool (appendix 3 — table 5) included the following aspects of the studies:

1. Selection bias — this is statistical bias that exists when there is an error in choosing the participants for the trial Higgins and Altman, 2008.

It was judged on the basis of generation of the randomization sequence and adequacy of concealment of allocation.

2. Performance bias — this difference exists between the intervention and control groups for the trials Higgins and Altman, 2008.

It was judged by assessing blinding of the study participants, study personnel, and those assessing the outcome.

3. Attrition bias — this is bias that exists when there are systematic differences in the withdrawals from the study in both the intervention and control groups Higgins and Altman, 2008.

It was assessed by comparing the difference in loss to follow-up in the intervention and control groups for each study.

4. Reporting bias — this is bias that arises from differences between the reported and unreported findings of the study Higgins and Altman, 2008.

It was assessed based on the existence of a trail protocol and the extent to which outcomes are reported.

5. Other sources of bias — this is bias that arises from other sources such as source of funding, adequacy of the sample size, power calculations, and other potential sources of bias for each study Higgins and Altman, 2008()

For each trial, it was assumed to be at low risk of bias before assessment. For each of the above criteria, the study was judged as having high risk of bias, low risk of bias, or unclear risk of bias. This judgment was then used to identify the overall risk of bias judgment for each study. Studies rated as low risk of bias in all domains had overall low risk of bias while those having high risk of bias in more than one domain had overall high risk of bias.

2.8 Data analysis

Data extracted from the included studies was presented as structured summaries. These were structured around the type of intervention, the components of the intervention, the study population, and outcomes reported. From the included trails, intervention effects for dichotomous outcomes were calculated and reported in the form of risk ratios and for continuous outcomes were in the form of standardized mean difference. For both dichotomous and continuous outcomes, 95% confidence intervals and two-sided P. values were reported.

Due to the heterogeneity of the study, it was expected that there might be limited capability of conducting meta-analyses. However, the review tried to pool results from similar studies with similar outcomes using a random-effects model to account for inherent differences in the studies. Outcomes that were reported on ordinal scales were analyzed using the same method reported in the trial itself.

Studies that did not take into account the effect of clustering were adjusted accordingly. The review adjusted the standard deviations to allow for this design effect. Heterogeneity of the included studies was assessed using both the I-squared statistics, and chi-square test. For I-square values that were greater than 50% showed that the studies reporting that particular outcome had substantial heterogeneity and this was explored by conducting sensitivity analyses to investigate the sources of heterogeneity, data permitting.

Where possible, relevant subgroup analysis were conducted separately for each outcome to identify the specific type of content such as childbirth, parenthood, or labor topics, size of classes used in the intervention, timing of the classes, teaching approaches such as didactic or practical, and number of antenatal education classes. Subgroup analysis based on risk of bias analysis were also conducted as part of the subgroup analysis to compare studies judged as high risk of bias with those that have low risk of bias.

The systematic review also used quantitative techniques for data analysis. While quantitative meta-analysis of the included studies is most appropriate for this review, it might not be possible due to heterogeneity in the studies. Quantitative meta-analysis might also exclude data from the natural phenomenon. Nevertheless, the implication of the review findings of this study would assist in understanding the effectiveness of antenatal education programs in decreasing anxiety, expanding knowledge, and preparing women for childbirth and parenthood Ferguson et al., 2013

( ADDIN EN.CITE, Escott et al., 2009, Brixval et al., 2014)

. It would also help to understand the effectiveness of antenatal education programs in achieving breastfeeding success in Saudi Arabia.

2.9 Summary of chapter 2

The systematic review aims at identifying and assessing literature on the effectiveness of antenatal education programs in developing countries compared with no antenatal education or individual antenatal education packages. The aim of the review is to evaluate this effect on a wide range to capture all relevant effects using a wide range of outcomes for analysis. The review uses systematic methods to search for the studies comparing group-based antenatal education programs with individual antenatal education programs or no antenatal education programs.

Chapter 3: Results

3.1 Introduction

The results section of this systematic review presents the findings of the search based on the methods described in the methods section above. After conducting a systematic search of literature, the review found sixty-nine (69) publications of interest. Six (6) were systematic reviews while two (2) were overviews of reviews. After applying this review’s inclusion and exclusion criteria, six (6) papers were excluded for various reasons provided in appendix 1 – table 3 and finally, five (5) randomized controlled trials (RCTs) are included in the current review (see table 1). See figure 1 for the prisma-flow diagram providing the study flow. The studies were very heterogeneous because of how the intervention was delivered, the intervention setting, and measurement of outcomes. This made meta-analysis impossible and therefore, the findings are reported based on each study rather than by trying to organize them into different headings. Since meta-analysis was not possible, it was also not possible to conduct a quality assessment of the evidence for each outcome. However, the results section provides an assessment of the risk of bias for each study included in this review (see table 2).

Table 1: Characteristics of included studies




Outcomes measured

Key findings

Benediktsson 2013

Group-based antenatal education based on Centering Pregnancy model. Sessions were delivered by trained instructor

Individual antenatal education delivered by a health professional who is untrained in delivery of antenatal education

Psychosocial outcomes

Health behaviors during pregnancy

Postpartum outcomes

Women in intervention group were more likely to adopt healthy behaviors during pregnancy

The intervention group was also associated with decreased anxiety and depression

Women in intervention group were more likely to access other resources such as community resources to gain more knowledge

Bergstrom 2009

Group-based antenatal education that focused on preparation for natural childbirth with psycho-prophylaxis (training in breathing and relaxation techniques)

Standard antenatal care delivered individually focusing on childbirth and parenthood but without training on psycho-prophylaxis

Use of epidural analgesia (epidural rate)

Experience of childbirth

Stress during parenthood

No key difference in experience of childbirth and stress during parenthood

Rate of epidural was same in both groups

Use of psycho-prophylaxis greatly improved by intervention

Corwin 1999

Expanded or integrated antenatal education classes delivered in groups and concentrating on labor, childbirth, and parenthood coping skills

Traditional or conventional antenatal education delivered individually.

Parenting knowledge

Weighted mean group difference of 1.62 (95% CI 0.48 — 2.75, n=48) suggesting increased knowledge in expanded or integrated antenatal classed group

Mehdizadeh 2005

Group-based antenatal education classes focusing on baby care, labor, and diet during pregnancy

Sessions also included counselling and neuromuscular exercises

Individual antenatal education classes without components such as counseling, neuromuscular exercise, and baby care

Pain during pregnancy and labor

Duration of labor

Rates of vaginal delivery

Birth weight

Psychosocial outcomes

Length of labor was shorted in intervention group (weighted mean difference -1.10 hours, 95% CI -1.64 to -0.56 hours)

Women in intervention group were 50% more likely to have increased knowledge of labor and childbirth issues

Ickovics 2007

Group-based antenatal care based on the model of Centering Pregnancy

Standard individual antenatal care

Outcomes of pregnancy (low birth weight and preterm)

Psychosocial development and functions

Satisfaction with antenatal education

Potential costs

Group antenatal education was associated with increased knowledge of parents about prenatal issues, preparation for labor and childbirth, increased satisfaction with antenatal education and increased breastfeeding initiation rates.

The intervention group also had reduced risk of low birth weight or preterm births

Table 2: Risk of bias analysis of included studies


Selection bias

Performance bias

Attrition bias

Reporting bias

Other sources of bias

Benediktsson 2013






Bergstrom 2009






Corwin 1999






Mehdizadeh 2005






Ickovics 2007






Figure 1: Study flow diagram

3.2 Effectiveness of antenatal education

3.2.1 Benediktsson 2013

The first study was a multisite RCT conducted in the U.S. This study assessed the effect of antenatal education programs on 1047 women. The study compared Centering Pregnancy, which is a system of prenatal education classes conducted with the intention to improve prenatal knowledge of the mothers, improve satisfaction with antenatal care, increase attendance of antenatal clinics, and improve outcomes of pregnancy such as birth weight and overall care of the mother and baby Benediktsson et al., 2013


. This standard of care was compared to the ordinary standard of care whereby women individually attend their normal prenatal visits and individually receive small education sessions on a need basis.

This program of Centering Pregnancy was facilitated by physicians from a low-risk clinic and supported by antenatal educators. Women attended the classes in groups of 8 to 12 women and attended ten sessions lasting roughly two hours each. The women were allowed to come with their spouse or another family member or friend for support during the antenatal education sessions. Each session consisted of two parts, the first of which the health status of the expecting women was assessed. This includes an individualized physical assessment by a physician and recording vital aspects such as weight, blood pressure, complaints, etc. The second part was then the discussion of general pregnancy topics such as safety and care during pregnancy, labor and childbirth, and parenting. This content was standardized for all sessions to ensure women in different groups received the same standard of education. The expectant mothers also had the chance to interact socially between themselves during the sessions Benediktsson et al., 2013


The program was run in a region where majority of the women had low social economic status and therefore, there was no fee for the prenatal education program. It was also offered within the context of routine care meaning it was as close as possible to the natural environment for the mothers Mehdizadeh et al., 2005()

The study found that most women attended six (6) of the 10 sessions planned within the Centering Pregnancy program. There were no significant differences between the cohort of women attending the Centering Pregnancy education classes and the individual classes although women in the centering Pregnancy program had lower levels of education, lower household income and English was not their primary language. This was possibly because the study was conducted in a region with a high population of immigrants and they had lower socio-economic status Benediktsson et al., 2013


There were significant differences between the Centering Pregnancy cohort and the prenatal care cohort. Women in the Centering Pregnancy group had lower levels of depressive symptoms, anxiety, and stress. At the same time, they felt they received higher levels of social support as a result of attending the sessions in groups though this was not significantly different Mehdizadeh et al., 2005()

The study showed that women who attended individual sessions and those who attended group education sessions did not have different levels of recall. They were able to recall most of the information they received though the study found that recall in the third trimester was much higher than the first and second trimesters. The study found that women in the group session had higher chances of recalling information on smoking and second hand smoke, consumption of alcohol, nutrition and various aspects of parenting than the women who attended the individual sessions Corwin, 1998()

There were no difference between the women in the group sessions and individual sessions when focusing on their nutrition and their ability to meet the daily recommended dietary intake. Women who attended the group sessions, however, consumed less alcohol during their pregnancy though the group sessions had not significant effect on the rates of smoking. In fact the study showed that women who attended the group antenatal education sessions were less likely to stop smoking during the period of pregnancy and even after childbirth Benediktsson et al., 2013


In terms of parenting behaviors, the study did not find any significant differences between the expecting parents who had attended the group sessions in the Centering Pregnancy program and those who had attending the individual education sessions. There was no difference in the attendance of antenatal and postnatal checkups and attendance for infant vaccinations between the two groups. There was also no difference in the time the women in both groups initiated breastfeeding, plans they made for breastfeeding, and postnatal care for the baby. Women in the group sessions provided in the Centering Pregnancy program were less likely to sustain breastfeeding past 4 months of the infant’s age. They had greater chances of introducing their infants to solid food at 4 months of age or slightly afterwards. This was possibly because they needed to go back to work as a result of their low socio-economic status Benediktsson et al., 2013


The study findings highlight the significance of educational status and socioeconomic status in the outcomes of expectant mothers. Women who attended the group sessions in the Centering Pregnancy program were less educated and at lower socio economic status. They also only spoke English as their second language. This many have greatly influenced the effectiveness of the group antenatal education classes and the decisions that the mothers made after the program. The study found that most expectant mothers in this group stopped breastfeeding early, which could be closely linked to these demographic characteristics Corwin, 1998()

The conclusion of this study, therefore, is that group-based antenatal education programs leads to improved or equal outcomes in terms of mental health, behaviors and knowledge during and after pregnancy for expectant women compared to the individualized standard antenatal care package that is provided. There is also no cost implication of the group-based antenatal education package when it is provided in routine care setting since it reduces the deviation from the norm and reduces costs significantly Benediktsson et al., 2013


This study provides low quality evidence of the effectiveness of antenatal education programs in improving labor, childbirth, and parenthood outcomes. The study is judged to be at high risk of bias because the risk of selection bias is high as a result of the study not in clearly stating the inclusion and randomization procedure. The participants were also not blinded suggesting high risk of performance bias. See table 2 for risk of bias judgment for this study.

3.2.2 Bergstrom 2009

A similar study was also undertaken in Sweden. The study focused on antenatal education classes in a similar way to the Centering Pregnancy program. Women were allowed to attend classes with their supporting partners and randomly assigned to a natural education package or the standard care package that mimicked the situation in Sweden. The natural education package focused on preparation for natural childbirth and also offered training on techniques that the women can use for breathing and relaxation during labor, commonly referred to as psycho-prophylaxis. The standard care package focused on both childbirth and parenting and did not provide training on psycho-prophylaxis. For the two groups that were being compared in the study, they received four sessions each two-hours in length. The sessions consisted of twelve (12) participants and were undertaken during the third trimester. The follow-up period for evaluation of effectiveness was up to one (1) month after delivery


(Bergstrom et al., 2009)

The study used trained midwives to deliver the education package and midwives were also randomly allocated to the two groups to improve validity of the study. The natural education package focused on alternative methods of pain relief during labor, majorly non-pharmacological methods for pain relief. In each of the sessions, the women spent about 30 minutes on practical training aimed at improve their breathing, relaxation, and other techniques such as massaging. This was the major component of the psycho-prophylaxis training that was supported by the use of booklets to facilitate women to read more at home together with their supporting partner, other relative and friends. The educator was trained to exhibit an attitude of bias towards natural birth and psycho-prophylaxis and did not focus on postnatal issues arising during the sessions. Where possible, the sessions also included a visit to the hospital maternity and delivery wards to improve the practicality of training Bergstrom et al., 2009


The standard care package allocated equal time in the four sessions to childbirth issues and parenting concerns in order to reflect the standard of care that was being offered in other antenatal clinics in the country. The educators spent time discussing childbirth including pharmacological ways of reducing pain and aspects of parenting. They did not focus on breathing, relaxation or any other psycho-prophylactic techniques that they could use to cope with pain during labor. External experts were also invited as co-educators as is the norm around the country and other visual aspects of teaching such as films were used. The educators also took the women on a visit of the maternity and delivery wards according to standard practice around the country Bergstrom et al., 2009


The women were then asked to fill versions A and B. Of the Wijma Delivery Expectancy/Experience Questionnaire in order to measure their expectations and experience of childbirth. The expectations questionnaire (version A) was a baseline questionnaire while the experience questionnaire (version B) was a follow-up questionnaire after childbirth. The questionnaire measure the antenatal and postnatal psychosocial aspects of the expecting mother such as fear of childbirth, father’s expectations, and outcomes (post-natal). Other outcomes such as pain was measured using a likert scale and the epidural rates in both groups was also recorded Bergstrom et al., 2009


The study did not find any difference in the baseline characteristics of the participants in both groups. In both groups (natural care model and standard care model), women attended four sessions of two hours each totaling to 8 hours of antenatal education. According to the prenatal and postnatal evaluation scores, the study found that the natural education model group spent just under 6 hours per group on issues relating to labor and birth, about half of which was dedicated to psycho-prophylaxis. In this group, postnatal issues were allocated about 1.7 hours on postnatal issues, majorly focusing on breastfeeding of the newborn baby. The remainder of half an hour was spent discussing various mixed topics relating to postnatal and prenatal issues as well as answering questions that the group members raised Bergstrom et al., 2009


As part of standard care, about 3.9 hours was allocated to preparation for childbirth while a slightly less amount of time, 3.5 hours, was allocated to issues of the newborn and other postnatal issues. The other half hour was spent discussing questions and topics that the group members raised. This session, however, did not cater for issues relating to psycho-prophylaxis. Films were used as an instruction method with 95% of women and 90% of men reporting having watched a minimum of one film relating to childbirth. Co-educators also featured in the education sessions Bergstrom et al., 2009


Psycho-prophylaxis was significantly highly practiced in the natural group with 85% of women practicing it compared to 45% of women in the standard care group. However, both groups had similar rates of epidurals at 52%. In both groups, 66% of women had a normal spontaneous vaginal delivery (SVD) with the mean duration of labor being eleven (11) hours. The rate of Caesarean section was also not significantly different between the two groups with the rate in the Natural care group being 20% and 21% in the standard care group. The rate of instrumental vaginal delivery was also the same at 14% for the natural group compared to 12% in the standard care group Bergstrom et al., 2009


There was no significant difference between the rating that women in the natural care group gave compared to the standard care group. Majority of women in both groups rated childbirth as a negative experience or a very negative one. Memory of labor pain was also similar in both care groups with a majority of women in both groups stating that they had a very positive experience about three (3) months after delivery of their baby. There was no statistically significant difference between the groups in these two outcomes Bergstrom et al., 2009


The study found two noticeable differences between the natural care model and standard care model. The first was the impact of psycho-prophylaxis on the behavior of women and men attending the sessions as many more in the natural care model group practiced psycho-prophylaxis while at home compared to the standard care group. However, the standard care group also used the method during labor having received information from other source and this may have negatively affected the results by introducing ‘contamination’ of participants. However, the study authors evaluated the effect of this cross-over and found that since educators adhered to the study protocol, the only point where ‘contamination’ was introduced was by the participants. Contamination may have also been increased since the study increased awareness in the participants community about the psycho-prophylaxis methods. Therefore, the study results remain valid for this particular situation. The second noticeable difference was that more women in the natural care group practiced psycho-prophylaxis during their labor period. This difference was also affected by the contamination Bergstrom et al., 2009


The study thus concludes that group antenatal education, where childbirth issues including training on psycho-prophylactic training improve the birth experience by training the mothers to deal with pain in non-pharmacological ways, can aid preparation for childbirth. This study highlights the importance of focusing on specific topics and the impact this has on the outcome of childbirth. It also highlights the importance of practical sessions in antenatal education, which are important in disseminating information effectively Bergstrom et al., 2009


This study is judged to be at overall high risk of bias because the authors do not specify how the participants were randomized suggesting high risk of selection bias and they did not also blind the participants suggesting high risk of performance bias. The study was judged to be at high risk of bias because the sample size was very small. This study thus provides low quality evidence of the effectiveness of antenatal education programs in promoting positive outcomes in labor, childbirth, and parenthood outcomes.

3.2.3 Corwin 1999

This was a randomized-controlled trial with two arms. The first arm was the intervention arm where women were required to attend group antenatal education classes. The groups were balanced based on their age in order to provide an integrated intervention based on learning theory and attachment theory Corwin, 1998.

The intervention was based on the fact that the expectant mothers should be able to adjust to their new situation in order to improve the outcome of pregnancy for both the mother and the newborn. The attachment theory is used to guide the integrated antenatal education classes by informing the authors of the importance of building trust between the mother and the baby during the first year of the infant. This trusting relationship is important in defining the predictability of the infant’s environment and other how signals of interaction affect this attachment. The authors point out that the expectant parents are often unaware of the importance of attachment to the newborn baby thus the need to integrate this into the antenatal education classes Corwin, 1998()

The whole antenatal education curriculum developed for this study focused on providing information on the mother-fetus interaction both before and after birth and how this improves the psychological, physical and emotional outcomes of pregnancy. It also focused on the importance of communicating a mutually reinforcing interaction between the mother and the baby. Other aspects that were covered in these antenatal education classes include the needs of the infant that are evident in crying, trust, and dependence, and coping with childbirth for the expectant mother Corwin, 1998()

The classes were targeted at expectant couples since the pregnant women were encouraged to come along with their spouse. The study included 48 parents who were randomly assigned to either the intervention group or the control group. The control group consisted of standard antenatal education classes that did only focused on aspects of childbirth and only the breastfeeding aspect of parenthood Corwin, 1999()

From the study, it was clear that couples in both the intervention and control groups were similar in most ways. They all had high level of education with 70% of the subjects in the intervention group being college graduates compared to 66% in the control group. They also had similar levels of income though more participants in the intervention group fell into the highest income category — 41% for the intervention group compared to 20% for the control group. The study failed to exclude subjects who had given birth earlier and this may have influenced the overall outcome of the study since these couples had experience of childbirth and parenting and may introduce ‘contamination’ in the study Corwin, 1999()

The study participants responded to a questionnaire dubbed the prenatal parenting scale that was used as a before and after questionnaires and found that post-interventions scores were relatively higher compared to pre-intervention scores pointing at the relative improvement in outcomes as a result of the study intervention Corwin, 1999()

The study conducted by Corwin (1999)

provides low quality evidence of the effectiveness of antenatal education programs in promoting positive outcomes in labor, childbirth, and parenthood. This study was at high risk of selection bias as a result of the randomization procedure in the study not being clearly stated. The study participants were also not blinded meaning the study was at high risk of performance bias. The sample size in the study was also too small for the study to be adequately powered to measure differences between the intervention and the control (table 1).

3.2.4 Mehdizadeh 2005

Participants in this study were randomized to seven (7) group antenatal education classes each about 90 minutes in length. However, this study had other interventions aimed at improving the outcome of expectant mothers. From the study, it was evidence that those mothers who received prenatal education alongside other interventions were about 50% more likely to understand the behavior change that they needed to make to improve their pregnancy outcomes. The expectant mothers who received prenatal education classes also experienced shorter labor because they understand the optimal behavior to improve pregnancy outcomes. They were in active labor with a weighted mean difference (WMD) of 1.10 hours less than the control group, 95% confidence interval (CI) -1.64 to — 0.56. The same reduction was also seen in duration of second stage labor (WMD -8.70, 95% CI -12.6 to — 4.8) Mehdizadeh et al., 2005()

This study like other studies included in this review provides low quality evidence of the effectiveness of antenatal education programs in promoting positive outcomes during labor, childbirth, and parenthood. The study was downgraded because it was found to be at high risk of selection and performance bias. The study participants were not blinded and the randomization procedure is not clearly stated (table two (2) details the risk of bias judgment for this study).

3.2.5 Ickovics 2007

The primary outcomes of the study were gestational age at delivery in order to identify preterm and low birth weight babies and satisfaction with the antenatal education classes. About half (50%) of the participants in the study were aged between 14 and 19 years. Results from the study pointed at significant improvements in rates of preterm and low birth weight babies associated with antenatal education classes. More women who attended group-based antenatal education classes were less likely to have preterm births or low birth weight babies (p = 0.048). The study, however, found no differences in percentage of low birth weight babies or preterm babies when using intention-to-treat analyses that included those patients that had been excluded for reasons such as multiple births (for example, twins).

The study also found that expectant women who attended group-based antenatal education classes had better psychosocial outcomes (p < 0.001). These women felt better prepared for labor and childbirth and also felt they had more knowledge on the various aspects of pregnancy, and childbirth. There were also significantly higher rates of satisfaction reported in the women who attended group-based antenatal education classes.

This last study also provides low quality evidence of the difference between group-based antenatal education classes and individual antenatal education classes. The study did not clearly define the randomization procedure for the study participants thus it is judged to be at high risk of selection bias. The study participants were also not blinded pointing at high risk of performance bias in the study (table 2).

3.3 Cost-effectiveness

None of the studies evaluated the cost-effectiveness of group antenatal education classes compared to no antenatal education classes or individual antenatal education classes effectively. This is because all studies provided antenatal education free of charge to participants and did not factor in the cost of training the educators, providing training material such as handouts, etc. Therefore, no cost effectiveness evaluation of antenatal education can be reported in this review.

3.4 Summary of chapter 3

The systematic review found five (5) randomized controlled trials that highlight the effectiveness of antenatal education classes in improving outcomes of labor, childbirth, and parenthood. The studies were different in most aspects including methods, intervention and controls used, and measurement of the outcomes. This made meta-analysis of the studies difficult and is the major reason for presenting the review findings in a descriptive/qualitative format. However, each study is analyzed critically to highlight its strength and weaknesses and to help in presenting the discussion in the next chapter.

Chapter 4: Discussion

4.1 Introduction

Structured antenatal education in preparing expectant couples for childbirth and parenting has received greater attention over the last two decades because of reduced impact of traditional methods of sharing information. Traditionally, expectant mothers would get information primarily from their mother, mother-in-law, or friends. Many maternity health providers, including but not limited to hospitals, clinics, charities, public health department and private practices of family physicians and obstetricians provide antenatal education classes today. Antenatal education is often delivered either individually or in groups. This discussion section of the review presents a critical analysis of the review findings by focusing on the completeness of the review findings and comparing the findings to the overall picture presented in other reviews and studies.

4.2 Impact on childbirth outcomes

The studies available that compare individual antenatal education classes to group antenatal education classes only provide limited evidence of the effectiveness of antenatal education on childbirth or obstetric outcomes. From the studies, it was evidence that women who took part in group antenatal education classes that were had extra components aimed at enhancing their labor coping strategies used the strategies they were taught compared to those who attended standard antenatal education classes without these additional components.

The evidence available also highlights the importance of antenatal education on childbirth preparation of the expectant parents. Antenatal education, which was majorly a participative process of childbirth preparation helped to influence the sense of control of women on the childbirth experience by enabling them to take action towards improving their outcomes. It also increased their knowledge about childbirth preparation and factors affecting outcomes. However, the studies do not show a significant difference between individual and group antenatal education classes for the outcome of increased knowledge.

The benefits of group-based antenatal education programs on expectant mothers and their newborns remain largely unclear. The studies point at intended and favorable effects of group-based antenatal education as well as other unintended favorable effects. Antenatal education did not have any impact on epidural rates as evaluated in one study. The other studies show that antenatal education aids in preparation for childbirth and has a role to play in the health of both the mother and the newborn during pregnancy, labor, and also in postpartum.

Though antenatal education classes may not decrease pain experienced by mothers in labor or the use of epidural anesthesia, the evidence suggests positive effects of antenatal education in other aspects such as mode of birth and clinical outcomes through improved breathing and relaxation.

4.3 Health behaviors during pregnancy

During pregnancy, the studies show strong association between engagement of expectant mothers in group-based antenatal education programs and improvement of maternal health behaviors. The studies show that after attendance of antenatal education classes, there was decreased risk of smoking cigarettes, reduced alcohol intake, and consumption, and increased likelihood of breastfeeding the baby. One study also showed that after attending group-based antenatal education classes, there was improved attendance of antenatal appointments including adherence to vaccination schedules for the baby.

Breastfeeding initiation was also a target for all antenatal education programs in the studies National Institute of Clinical Excellence, 2006.

The evidence available suggests that when antenatal education is provided in groups, there are higher chances of the mothers breastfeeding their children. Consequently, breastfeeding initiation rates among women, especially those of low-income families or low socioeconomic status also increased considerably. However, the evidence shows that though breastfeeding initiation rates are improved, the ability to sustain exclusive breastfeeding to six (6) months as recommended is hindered greatly by other factors relating to their low socioeconomic status such as the need to go back to work.

The evidence supports the use of antenatal education classes delivered in a group model to promote breastfeeding of the newborn baby and initiation of breastfeeding from birth. Peer support during these antenatal education programs was reported to highly influence the breastfeeding initiation rates, possibly because this interactive component of the antenatal education classes in combination with other strategies such as multimodal education campaigns that concentrate equal time to childbirth aspects and parenting aspects should be used.

Only one study that is included in this review focused on the effects of group-based antenatal education classes on rates of low birth weight babies. The Centering Pregnancy study showed a positive association between the intervention and reduced risk of giving birth prematurely or giving birth to a low birth weight baby. The study had an integrated antenatal education program where women were encouraged to improve their health behavior that may have consequently led to these reduced rates of premature birth and low birth weight


(Baldwin, 2006, Lu et al., 2003)

. The findings of this review suggest that when group-based antenatal education classes are targeted at health behaviors of the expecting couples by recommending reduced alcohol consumption, ceasing smoking, reducing second hand smoke, and other positive health behavior, the childbirth outcomes also improve considerably. The findings, however, also show that in order for rates of premature birth and low birth weight babies to decrease even more lower, there is need for long-term comprehensive antenatal education. This long-term strategy should focus on the nutritional and reproductive health of the expectant couple (not only the expectant mother) during teenage or adolescence, during pregnancy and over the course of their reproductive life Dennis et al., 2007()

4.4 Psychological outcomes

Antenatal education when delivered in group sessions does not appear to be any different from individual antenatal education programs in preventing the onset of maternal depression, anxiety, and other psychological problems. Although group-based antenatal education programs were associated with improved mood of the mother during pregnancy and postpartum, the evidence is limited in nature.

When a supporting person such as their spouse, friend, or other relative accompanies the expectant mothers, there is evidence that group-based antenatal education classes improve their psychological outcomes. This is associated with the support that they receive from the accompanying person for the antenatal education sessions. More women felt better psychological outcomes as a result of group-based antenatal education when they were accompanied by their spouse Dieter et al., 2008

( ADDIN EN.CITE, Kinsella and Monk, 2009)

Increased partner involvement also translated to decreased anxiety and depression during labor when the partner who attended the antenatal education classes participated in the classes and received training on how they can be supportive of the expectant mother at home. This finding is important since most antenatal education classes only focused on the expectant mother with aspects of childbirth and parenting Escott et al., 2005


. This highlights the relative importance of educating the accompanying person as well in order to improve the outcomes for the expectant mother.

4.5 Attachment with the newborn baby

Only one study evaluated the effect of group-based antenatal education classes on the attachment between the mother and the newborn baby. After delivery of the newborn baby, the mother needs to create a new attachment with her infant. This attachment is built over a process that begins from conception and continues for the whole period of infancy — one (1) year after birth. Group-based antenatal education focusing on improving the attachment between the mother and the baby improves this outcome considerably. When mothers are educated on how to appropriately interact and react to their baby both emotionally and physically, it improves the psychological outcomes of both the mother and the baby.

The mother feels less fear of inadequacy and less concern about the quality of care they are providing to their newborn baby because she is able to understand the feedback she is receiving from her baby in form of crying, smiling, etc. Bryan, 2000.

They can also differentiate cries for the baby such as feeding, wetness, need for attention, etc.

Mothers who receive education on this attachment aspect of parenting are better able to nurture their child and reduce their own exhaustion while providing the necessary care and attention to their newborn Feinberg et al., 2009


. Antenatal education classes help them prepare for the psychological demands of parenting early enough that the mother and spouse (where the spouse attended the antenatal education classes) experience lower levels of postpartum stress Koehn, 2002()

4.6 Participative forms of learning

Evidence from the studies in this review is limited. The evidence shows that when small groups are used for antenatal education, more concerns and needs of the expectant couples are addressed in detail. The expectant couples valued this greatly. The Centering Pregnancy study showed that when small participative groups are formed, there is associated increase in health outcomes and preparation for parenthood compared to individual antenatal education classes.

Evidence available also suggests that the overall experience of parenthood and childbirth can be improved if women attend classes that are led by qualified educators and co-educators who have been through raising their first child. This points to the need for mothers to connect with educators as mentors and they themselves being mentees in the antenatal classes Lumley and Brown, 1993.

The need for this mentor-mentee relationship emerged from one study that used co-educators from different backgrounds and women reported increased satisfaction with these sessions with the co-educators having given greater importance to the women’s needs and questions.

Men also feel that they are better prepared for parenthood in participatory learning sessions. One study had men-only sessions where they were taught about fatherhood and what they can do to improve the overall childbirth experience for their spouse. In this session, men were able to raise their questions and they reported having received detailed answers to their concerns and questions Fabian et al., 2005.

Overall, this participatory learning experience was valued since the men felt better prepared for childbirth and parenthood as well Koehn, 2008

( ADDIN EN.CITE, Hallgren et al., 1999)

Studies have shown that the number and size of the groups in the antenatal education program greatly affect the participant’s experience with the antenatal education program Hart, 1995.

Participants favor small groups of up to 10 people since it allows the perfect social mix to exchange ideas and support each other while not putting too much pressure on the facilitator or educator that it limits or reduces the quality of opportunities for interaction with the facilitator. From the studies included in this review, the involvement of the private stakeholders in providing antenatal education program as was seen in the Centering Pregnancy study is an exemplary model that facilitates interaction of participants and the facilitator and improves the participant experience considerably.

4.7 Preparing for parenthood before childbirth

In the recent years, antenatal education programs have begun to focus promoting healthy behavior in parenthood by focusing on issues such as attachment with the newborn and breastfeeding. These sessions have mainly focused on specific parenting issues such as emotional changes that the parents experience at this time, and how they can enhance their parenting skills through attachment and bonding with the newborn Ickovics et al., 2003


. Interventions that included parenthood education as part of the antenatal education classes overall improved the breastfeeding initiation rate and helped the expectant parents to transition into parenthood. The expecting couples also reported improvements in their relationship as a couple since each one understood their role and responsibility completely Dumas, 2002.

They also gained problem-solving and conflict-resolution skills that improved their reported outcomes.

There is increasing need to address parenting concerns in antenatal education programs and most antenatal classes have focused on beginning parenting education at the antenatal stage Klima et al., 2009


. From the studies in this review, there seems to be a benefit of sustaining parenting education in the postpartum period to enhance the exclusive breastfeeding practice, which from the studies is stopped at an early period of 4 months. Continuing parenting education after childbirth could also help to improve the psychological and physical well-being of the parents and the baby, instill greater confidence in the parents, improve the satisfaction of the couple with their relationship with the newborn, and improve their emotional connection with the newborn Deave et al., 2008


. Indirect evidence from different studies that allowed spouses to join in the antenatal education sessions as the pregnant woman’s supporting person suggests that by directly discussing the importance of co-parenting, the couple and child are able to adjust to postpartum issues with greater ease Fletcher et al., 2004.

It also promotes better individual health by reducing the stress on mother and father Korol and von Baeyer, 1992()

Surveys that have been previously conducted in the United Kingdom and the United States of America point at the need to establish these supportive relationships between the couple as part of the prenatal education program Cliff and Deery, 1997.

The surveys show that a gap in the family exists when one member of the couple bears too much of the burden during parenting Magill-Evans et al., 2006.

Participant’s expectations and the experiences that they face as parents-to-be present opportunities to leverage these supportive relationships towards improved well-being of the mother, father, and child as well Hallgren et al., 1995()

4.8 Stakeholder involvement and perspectives

4.8.1 Fathers

In most studies, fathers have been the most dominant stakeholder to feature in the antenatal education classes as the supporting person. The benefit that these new antenatal education classes is seen from these studies since they experience lower levels of dissatisfaction with the content and delivery if the program is tailored to recognize their presence by given them a role to play in the classes themselves. Evidence from other studies not included in this review suggests that by engaging men in the classes, there is improved attendance of classes by both the expectant mother and their spouse


(Chapman, 2000, Hallgren et al., 1999)

. This is possibly as a result of the value that they see in improving the emotional support they provide to their partner and this in turn enhances the overall quality and experience of their relationship with their partner and the newborn child as well Barclay et al., 1996()

Qualitative studies that have been conducted to evaluate the experience of fathers in antenatal education classes show that the classes need to be inclusive of the father to be successful. This is supported by the evidence from the studies in this review that show the importance of the classes being sensitive of the presence of the father-to-be. Men valued participative learning as much as women did with greater interest in the fatherhood role of parenting Deave and Johnson, 2008()

Consistent evidence from different studies shows that men value the opportunity that these antenatal education classes provide to share their experiences and concerns with other fathers-to-be since they feel only men understand fatherhood concerns and problems. Studies that have been conducted on a small-scale that involve low-income fathers and their experience in antenatal education classes show that they value the facilitation of these antenatal education sessions by experienced fathers, just as women value the facilitation by experienced mothers Diemer, 1997.

The reason for this is the potential promise that experienced fathers will impart knowledge and wisdom to demystify fatherhood.

Studies point at the potential value of including several separate sessions for men-only to discuss issues of fatherhood Fletcher et al., 2004.

These studies, conducted within the mainstream antenatal education classes though focused on men only and the transition into fatherhood would benefit men by focusing on their experiences to reduce depression and anxiety.

One study conducted showed that fathers-to-be also benefit from attendance at other antenatal education classes since they are able to support their wives in the pregnancy and childbirth process Friedewald et al., 2005.

This in turn improves their emotional and psychological well-being having the experience and knowledge to support their wives Greenhalgh et al., 2000()

In Saudi Arabia, Sharia law of Islam forbids the interaction of male and female individuals in one room (Islam in the World Today, 2010)

4.8.2 High-risk groups

This review did not identify any studies conducted in high-risk groups such as adolescent and teenagers. However, there is evidence from other studies conducted in the United Kingdom suggesting that adolescents and teenagers are unable to access antenatal education programs partly due to the stigma attached with teenage or underage pregnancy Covington et al., 1998.

These studies suggest that when antenatal education programs are tailored for this group and made to be participative in nature, they can improve health outcomes of the pregnant girl, improve breastfeeding, promote maternal mental health, and improve the child’s postnatal outcome


(Carrington et al., 1994, Emmons and Nystul, 1994)

Evidence from integrated programs targeted at pregnant adolescent girls benefit from support from a range of sources


(Howie and Carlisle, 2005, Perrow, 2004)

. These programs often combine home visits by the nurse or through enhanced Doula programs. Group support also comes from pregnant adolescents supporting each other through the program Carrington et al., 1994()

For women with drug addictions, there is no evidence for the effectiveness of antenatal education programs as the standalone support provided to them. The needs of drug-dependent women who are expectant often are high and therefore multimodal programs are the best fit for them. This is because these programs need to be individualized to the drug-dependency of the woman and other factors such as income or socio-economic status Carrington et al., 1994.

One such program is the Parenting Under Pressure program that is common in the Australia and is designed to help drug-dependent women in various aspects and not just antenatal education PuP Program, 2014()

Despite the limited research that has been conducted on antenatal preparation for women in prison as well, several studies have highlighted their increased risk of physical and mental health in this population. Women in prison are often also stigmatized and sidelined. They suffer from lack of programs to support them during the antenatal stage. One such program that was recently evaluation shows that women in prison, like other women, value participative learning methods greatly and would benefit from the possibility of receiving social support from the group Egeland and Sroufe, 1981.

They also learn about different aspects of childbirth, labor, and parenting while in the prison setup.

4.8.3 Multicultural families

Cultural sensitivity and awareness is important for successful delivery of antenatal education. A study that was conducted in Turkey found that since according to Islam Sharia law, women and men have to be in separate rooms, such cultural conflict has to be avoided in delivering antenatal education programs. Men cannot participate in what is traditionally viewed as the women’s space Matthey et al., 2004


. Therefore, educators in these settings need to be culturally aware and respect this aspect of culture Ickovics et al., 2007


. Women and men are thus provided with antenatal education classes separately.

Similarly, in Hong Kong, Chinese women highlighted the difficulty that they face when recording dietary instructions that they receive from didactic antenatal education classes Lee and Holroyd, 2009.

They were also faced with challenges in recording advice that they receive from their relatives Ho and Holroyd, 2002.

Other conflicts that are experienced when antenatal education is provided through traditional culture and knowledge also exist and were recorded in Ireland communities Midmer et al., 1995()

Little research has been conducted on other cultural aspects of antenatal education. Few empirical studies provided emerging evidence of the differential needs of antenatal education by refugees and persons seeking asylum. Research from these studies highlights the obstacles that women refugees face when accessing antenatal education. These include the language barriers that they experience, cultural differences that exist between them and the refugee community and other authors have pointed at stigmatization as a result of their refugee or asylum status. Researchers and policy makers as well have pointed at the need to provide information during antenatal education in as many languages as possible and in a culturally sensitive way in order to integrate minority groups and communities into the complete prenatal education system or program.

4.9 Agreement and disagreement with other reviews

The Cochrane review conducted by Corwin, 1999(Gagnon and Sandall (2007)

that found nine trials involving close to 2,300 women found that three of the included studies showed benefit of antenatal education on knowledge gained by the mother. The weighted mean group difference in one study was 1.62 on a scale of 20 )

. The second study focused on expectant fathers and found that antenatal education also improved their level of knowledge on specific antenatal issues. The review also included the Hamilton-Dodd et al., 1989

(Mehdizadeh et al. (2005)

study that found that those parents who received antenatal education had mastery of behavior change requirements during pregnancy and parenthood. The review also found that maternal role preparation increased significantly after attending antenatal education classes )

, as well as improvement in behavior that promote attachment with the mother


(Carter-Jessop, 1981, Davis and Akridge, 1987)

. Other smaller studies included in the review that may be subject to bias, especially methodological bias, report no differences in the outcomes they measured Gagnon and Sandall, 2007()

This Cochrane review had similar findings to the current review by finding that there was significant improvement in knowledge of expectant mothers after attending antenatal education classes. The review also found that antenatal education had a significant impact on preparation for childbirth and parenthood. The review also reports that the effect of antenatal education programs to participants and the newborn remain largely unclear since majority of the evidence is from small trials with methodological limitations that limit their generalizability into other settings other than that which they were conducted. The review also found that outcomes in the studies were reported differently which made it difficult to conduct a meta-analysis on the review findings because of how the findings were measured and reported. This variation in outcomes did not also allow subgroup analyses to be conducted to explore the various approaches to teaching such as didactic and participatory learning, and other specific content and theoretical concepts such as the effect in different populations Gagnon and Sandall, 2007()

The review authors concluded that the evidence available was not sufficient enough to present recommendations for change in practice. However, the studies identified in the review should be used to guide future antenatal education research to determine the effects on childbirth and parenting outcomes. Programmatic experience from implementations in the United Kingdom and the United States of America should also be considered as future evidence to guide implementation of similar programs, specifically in developing countries. However, this should be done with a caveat that the settings are different thus, the implementation itself should be tailored and the intervention effect may differ Gagnon and Sandall, 2007()

A second systematic review of all literature on antenatal education found evidence that prevention of low birth weight requires a different strategy that is longitudinal and integrated in nature in order to promote proper health behavior and nutrition during pregnancy and over the course of life as well. The review authors discuss the evidence of benefits of antenatal education on behaviors related to health promotions such as proper nutrition, exercise, and health responsibility in general McMillan et al., 2009()

The review also found no evidence of the effect of antenatal education on the onset of depression or effectiveness of treatment of depression. However, they found studies that supported the use of group-based antenatal education classes to reduce certain symptoms of depression and anxiety. The review also studied other interventions in antenatal education classes such as music therapy and massage that were provided as extras in antenatal education programs McMillan et al., 2009()

The review also focused on the importance of antenatal education classes in supporting fathers-to-be and preparations to transition to parenthood. It found evidence that men valued guidance from other experienced fathers and participation in men-only groups where they have an opportunity to focus on their psychosocial, physical, and emotional needs and experiences to help them cope with depression and anxiety McMillan et al., 2009()

4.10 Summary of chapter 4

This discussion section provides a critical discourse of the review findings into the overall picture of antenatal education. Antenatal education classes are of extreme importance in preparing women for labor, childbirth, and parenthood as supported by the studies included in the review. However, there are several areas where further research is needed. These include the areas of women in high-risk groups such as teenagers, women in prison, and drug users. Other studies should also focus on the effect of antenatal education classes on fathers. The chapter that follows is the conclusion that highlights how the review findings fit into policy and practice and the suggested direction for future research.

Chapter 5: Conclusion

5.1 Introduction

The review was intended at evaluating the effectiveness of implementing antenatal education programs in Saudi Arabia. It identified literature from different sources that focused on implementation of antenatal education programs in developing countries using a systematic search strategy.

Antenatal education traditionally was aimed at preparing expectant parents for the events of pregnancy, labor and childbirth, and parenthood. The current systematic review identified and assessed literature on the effectiveness of antenatal education programs in developing countries compared with no antenatal education. The aim of the review was to evaluate this effect on a wide range to capture all relevant effects and analyze a wide range of outcomes. The review found focused on two aspects of antenatal education, the effectiveness of these programs and the costs associated with these programs.

The review is very important because it enhances a greater understanding about the antenatal education support programs that scholars argue help to decrease anxiety, expand knowledge, prepare women for labor and parenthood, and help achieve breastfeeding success Jennifer et al., 2013


. Antenatal education is still in its micro level in Saudi Arabia, this is why it was chosen as the area of study in the review. A simple comparative analysis of the antenatal education programs in the UK and Saudi Arabia reveals that the level of antenatal education in the UK is advanced because the program is delivered free of charge for all pregnant women in the country.

5.2 Review of evidence

The review found limited evidence of the effectiveness of antenatal education classes in preparing women for childbirth and reducing pain during labor. The evidence available showed no difference between the use of epidurals to reduce pain though there was higher incidence of spontaneous vaginal birth (normal child birth). Based on the limited studies identified in this review, it emerged that antenatal education classes increase relaxation in labor and reduce anxiety and depression related to labor, childbirth, and parenthood.

The review also found limited evidence that parent’s participation in antenatal education classes with satisfaction with the birth experience. This points at the ineffectiveness of antenatal education classes in influencing the labor experience though there was significant dedication to promoting an improved birth experience in antenatal education classes. These classes also promoted breastfeeding of the newborn baby. Limited evidence shows that peer support during these antenatal education programs greatly helps to improve breastfeeding initiation and when participatory learning is used in the classes, there is higher breastfeeding initiation rates. More, however, needs to be done in order to improve the sustenance of breastfeeding to 6 months in order to improve the nutritional outcomes of the newborns.

Limited evidence from the studies included in this review shows that the effect of antenatal education programs on incidence of low birth weight babies is mixed. One study found no difference in the rates of low birth weight babies as a result of the psychosocial support provided in these antenatal education classes. However, another study, the Centering Pregnancy Study, found a reduction in rates of low birth weight babies as a result of the antenatal education classes. Overall, evidence from the studies is mixed but it is important to conduct further studies to understand the effectiveness of prevention of low birth weights through these antenatal education classes.

There is also evidence of benefits of antenatal education classes on health behaviors of pregnant mothers. There were improvements of health behavior seen in the health responsibility of expectant women who reduced their smoking rates and were involved in exercise and better nutrition.

The review found no evidence that participation in antenatal education classes prevents expectant parents from becoming depressed or its effectiveness in relieving the effects of depression. Group-based antenatal education classes that encouraged women to come with a supporting person such as their spouse, other relative or friend helped to relieve depression and anxiety. On a small scale, there was also evidence that antenatal education programs and support can reduce depression and anxiety in expectant women.

In high-risk groups, there is some evidence of the value of antenatal education programs. However, these studies were not identified in this review. Antenatal education interventions should be targeted at expectant women in these groups. They should be tailored to meet individual needs of parents depending on their stage of development, exposure to certain stressful conditions or situation, and the available coping strategies.

Fathers also benefit greatly from antenatal education interventions. There is evidence from the studies included in this review and other studies as well of the effectiveness of men-only preparation of fathers for childbirth and parenthood in improving their reported outcomes. Fathers enjoyed sharing their experience with other experienced fathers facilitating the experience and this was associated with reduced anxiety and depression.

In drug-dependent women, there is no evidence of the effectiveness of antenatal education classes for drug-dependent women when used as a standalone intervention. There is need for integrated programs that include a parent-education component to improve the health and outcomes of expectant mothers in this group. Expectant women need programs targeted at remission from drugs that tie in the potential effect of drugs on their pregnancy. These hybrid programs may be effective in drug-dependent women.

Although there are studies conducted in expectant women in prisons that highlight their physical and psychological health needs, there is limited evidence of the effectiveness on antenatal education on this population. The evaluation of one such antenatal program for women in prison showed that like women in other places, they value participatory learning methods since they allow them to support each other socially and acquire knowledge on labor, childbirth, and parenthood.

In the systematic review conducted by Homer et al. (2012)

also conducted a review on group-based antenatal education programs compared to individual antenatal education and found two trials providing limited evidence of the effectiveness of antenatal education on expectant women’s outcomes. The review points at few clinical implications of group-based antenatal education and less severe or adverse outcomes for expectant women and their babies. This review, however, also concludes that there is limited evidence of the effectiveness of antenatal education programs.Gagnon and Sandall (2007)

, the review authors evaluated the effect of antenatal education conducted in groups and on individuals for parenthood and childbirth. The review concludes that there was insufficient high-quality evidence for the effect of antenatal education. Therefore, the effects of antenatal education programs remain largely unknown.

5.3 Implications for policy

Antenatal care and antenatal education is greatly dependent on the culture and contextual issues such as the organization of the health system Moran et al., 2006

( ADDIN EN.CITE, Lumbiganon et al., 2012, Lumbiganon et al., 2011)

. Since this review is majorly aimed at Saudi Arabia, the review aimed at including only studies conducted in developing countries since comparing the effects of antenatal education programs across two very different economies may be misleading and difficult as well Matsuyama et al., 2013.

However, due to the expected paucity of research, studies from Western setting were included. These studies provided limited evidence of effectiveness of antenatal education programs and did not inform the future design of antenatal education programs especially in Saudi Arabia. More research is required in order to inform future aspects of antenatal education programs.

5.4 Implications for practice

The fact that the review only found limited evidence limits the ability to make recommendations for practice. However, from the limited evidence, there is evidence of satisfaction with antenatal education programs by both the mothers and fathers and a need to include antenatal education programs in antenatal care programs. At the same time, further research should be conducted to further evaluate the effectiveness of antenatal education programs as an intervention in antenatal care.

5.5 Direction of future research

In developing countries, there is a dearth of research on the nature, effectiveness, and cost-evaluation of antenatal education evaluations that were delivered during the prenatal period to support parents to improve outcomes of childbirth and parenting. There is urgent need for future research on antenatal education interventions to be conducted in developing countries and to focus on the best method for providing antenatal education in developing countries in order to help expectant parents to transition to parenting. Research should also focus on finding the best and most effective methods of allowing expectant women to receive support from their husband and support husbands as well, especially in Islam where women and men are not allowed to be in the same room. This research should also focus on minority and highly at-risk groups such as teenagers, drug users, and women in prison and focus on issues such as best implementation strategies for multicultural families and settings.

There is limited research on the effectiveness of antenatal education programs. Furthermore, no research has been conducted in group-based antenatal education programs in developing countries. More research is needed to understand the potential effect of these programs in developing countries. This research should focus on finding statistically significant differences through adequately powering the studies. Further research will provide increased knowledge on the inherent factors in this model to promote behavior of participants and lead to better childbirth and parenthood outcomes. Studies should also be conducted in Islam countries where it is more difficult to get fathers to be involved in antenatal education programs due to laws the prevent women and men from being in the same room. These studies should focus on ways to maximize the effectiveness of these antenatal education programs despite the inhibiting factors inherent in Islam.

Further research should also be conducted in women in special groups. These include teenagers, women in prison, and drug users. This research should focus on identifying integrated programs for antenatal education that focus on self-help or group-based support and thus allow the women to evaluate the model and identify and utilize strategies to improve their pregnancy and parenthood outcomes.

Future studies should focus on the costs of antenatal education programs. There is fundamental need to understand the cost implications of these programs to the overall economic landscape, specifically in developing countries, which are resource poor. In these countries, these programs may also face challenges as a result of poor attendance due to pressure on the women to work to raise money for their family. Therefore, these studies should focus on cost implication of these programs for the health system and the participants as well to measure the cost-effectiveness of these programs.

5.6 Reflection

Reflection is an important process that enables me to systematically review the information gained through the review process and the experience in conducting the review. It is useful for me to think about the importance of advanced nursing skills such as being a patient educator throughout all phases of learning. The reflection section shows how the review process has helped me to appreciate the aspects of advanced nursing that I learnt in class while allowing me to add some thoughts about the overall review process.

5.6.1 Description

From the literature, it is evident that antenatal education is important for improving the outcomes of labor, childbirth, and parenthood. Antenatal education programs have not been introduced in Saudi Arabia and the rationale for this review was to determine the effectiveness of antenatal education classes to guide the introduction of group-based antenatal education programs in King Faisal Specialist Hospital in Saudi Arabia. Introduction of antenatal education programs into Saudi Arabia presents various opportunities and challenges as well.

The evidence reviewed in this review is from developed countries and thus presents a challenge since implementation of antenatal education classes in Saudi Arabia, which is a developing country, may require different strategies for success. The evidence reviewed has helped in creating an understanding of the importance of antenatal education classes in influencing healthy behavior of the mother during pregnancy and after childbirth, as well as demonstrating the perceived benefits including parent-child attachment, reduced anxiety and depression, and increased knowledge of labor, childbirth, and parenthood.

5.6.2 Feeling

During the review process, I was ecstatic to learn the importance of being detail oriented and searching various electronic databases to find studies that compare group-based antenatal education with individual antenatal education classes or no antenatal education classes. The process also made me enthusiastic about applying critical analysis to review the studies included in this review and the interact with the data from the included studies to present a thorough review of the findings and discussion of their fit into the larger picture of antenatal education and special groups.

5.6.3 Evaluation

From the review process and the review findings, it emerges that antenatal education leads to positive outcomes of labor, childbirth, and parenthood. The review highlights the importance of interaction during group-based antenatal education classes. The review also helps to highlight how group-based antenatal education improves the overall outcomes of labor, childbirth, and parenthood by reducing anxiety and depression. Though the review findings do not present the aspect of Sharia law and prohibiting men and women from being in the same room together, this will need to be looked into when considering implementing antenatal education classes in Saudi Arabia. One way to do this is to allow the women to bring other relatives such as sister, aunt, etc. during the antenatal classes while having separate sessions for the fathers and that the fathers would appreciated.

5.6.4 Analysis

Overall, the review process and the findings of this review highlight the opportunities and difficulties present in implementing antenatal education classes in Saudi Arabia. To successfully implement antenatal education classes in Saudi Arabia, there are several considerations that need to be made. There is need to identify the specific persons to conduct the classes as patient educators such as nurses or other cadres at a similar level as nurse aides or midwives. It will also be important to manage change since the overall process of implementing antenatal education classes presents a shift in practice and requires change management for successful implementation.

5.6.5 Action plan

Having conducted a comprehensive review of the literature on antenatal education, the plan is to identify and discuss with the hospital management ways to implement the antenatal education program in King Faisal Specialist Hospital. This will require several meetings with relevant stakeholders in the hospital management to enable us to provide them with as much information as possible about the effectiveness of antenatal education, cost implications and benefits for the hospital and expectant couples as well. It will also be important to identify colleagues to help in crafting the learning material and other relevant material for the classes and to help run the program.

5.7 Summary of chapter 5

This last chapter of the thesis is a summary of the review process, review findings, and their implication to practice, policy, and future research. The review concludes that further evidence is required to be able to make a conclusive judgment regarding the effectiveness of antenatal education classes but King Faisal Specialist Hospital could benefit from a pilot implementation of the antenatal education program.


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Appendix 1: Excluded studies

Table 3: Characteristics of excluded studies

Study name

Study title

Reason for exclusion

Bjornson 1997

Assessment of parent education methods for infant immunization

Study evaluated an intervention of a video and presentation on infant immunization without a control.

De Nuncio 2000

A prospective randomized study to determine the effects of a prenatal immunization intervention on timeliness of immunization initiation in Latino infants in two San Diego county community clinics

Intervention was immunization education and the control was education to prevent sudden infant death syndrome. The intervention and control combination was not of relevance to this review.

Escott 2005

Preliminary evaluation of a coping strategy enhancement method of preparation for labour

The study intervention was the use of antenatal education programs compared to the control, which was the use of pre-existing coping strategies. This intervention and comparator were not the focus of this review.

Ford 2002

Effects of prenatal care intervention for adolescent others on birth weight, repeat pregnancy, and educational outcomes at one year postpartum

The study compared group-based antenatal education to group-based antenatal education of a different nature and scope. This combination was not important in this review.

Linares 2006

A randomized trial of personalized prenatal education

Intervention group was educational sheet with age-specific information about medical and pregnancy complications while the control was a standard educational sheet on other pregnancy-related topic. This was not of importance to this review.

Schonenberger 2004

Compliance of asthmatic families with a primary prevention programme of asthma and effectiveness of measures to reduce inhalant allergens – a randomized trial

The study intervention was focused on reducing exposure of newborns to allergens without a control of interest to this review.

Appendix 2: Assessment of inclusion and exclusion of studies

Table 4: Eligibility form for judging inclusion and exclusion of studies

Study name:

Study title:


(1) Design

(a) Described as randomized?

If ‘No’, exclude. If ‘Yes’, go to question (2)

Yes No Unclear


(2) Participants

(a) Were the participants pregnant women in their first to third trimester?

Yes No Unclear


If answer ‘No’, exclude. If ‘Yes’ go to question (3)

(3) Interventions

(a) Did the participants attend group-based antenatal education classes?

Yes No Unclear (Circle)

(b) Did the other group of participants receive individual antenatal education or no antenatal education?

Yes No Unclear (Circle)

If (a) or (b) answer ‘No’, exclude. If ‘Yes’ go to question (4)

(4) Outcomes

Did the study report any of the following outcomes?

(a) Knowledge of labor

Yes No Unclear (Circle)

(b) Knowledge of childbirth

Yes No Unclear (Circle)

(c) Knowledge of parenthood

Yes No Unclear (Circle)

(d) Anxiety and/or depression

Yes No Unclear (Circle)

(e) Parent-child attachment

Yes No Unclear (Circle)

If all (a) to (e) answer ‘No’, exclude.

Final Decision


Yes No (Circle)


Yes No (Circle)


Yes No (Circle)

Excluded or unclear because:

If ‘Unclear’, action taken:

Appendix 3: Risk of bias assessment tool

Table 5: Risk of bias assessment tool

Study name

Risk of bias item

Risk of bias judgment

Rationale for judgment

Selection bias

High Low Unclear

Performance bias

High Low Unclear

Attrition bias

High Low Unclear

Reporting bias

High Low Unclear

Other bias

High Low Unclear

Overall risk of bias

Assessment instructions

1. Each trial is assumed to be at low risk of bias before assessment.

2. For each of the above criteria, the study is judged as having high risk of bias, low risk of bias, or unclear risk of bias based on the study report.

3. This judgment is then used to identify the overall risk of bias judgment for each study.

4. Studies rated as low risk of bias in all domains have overall low risk of bias while those having high risk of bias in more than one domain have overall high risk of bias.

Studies included in quantitative synthesis = 0 (meta-analysis)?(n = )

Studies included in qualitative synthesis = 5?(n = )

Full-text articles excluded, with reasons = 6?(n = )

Full-text articles assessed for eligibility = 11?(n = )

Records excluded = 50?(n = )

Records screened = 69?(n = )

Records after duplicates removed = 69?(n = )

Additional records identified through other sources = 0?(n = )

Records identified through database searching = 69?(n = )

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