Psychological Science and Education
2023. Vol. 28, no. 2, 70–82
doi:10.17759/pse.2023280206
ISSN: 1814-2052 / 2311-7273 (online)
Childbirth Education and Support During Labour: Association with Birth Satisfaction
Abstract
The purpose of this study was to compare the effectiveness of antenatal education and individual labour support in the context of the actual experience of childbirth and its psychological perception. Types of antenatal education and individual labour support were analysed in relation to the childbirth experience (mode of delivery, number of medical interventions, obstetric violence, satisfaction with childbirth, physical well-being of women after childbirth). In February-March 2021, we conducted an online survey of 1645 mothers of infants aged 0-13 months. As a result, it was found that preparation for childbirth has no direct relationship with the mode of delivery, the woman's well-being after childbirth and the birth satisfaction. However, preparation for childbirth is associated with fewer medical interventions. Women who gave birth without individual support were less satisfied with their births, more likely to experience obstetric violence, more likely to give birth via caesarean section, with more medical interventions. Thus, support during labour is a safe way to improve the experience of childbirth and the quality of life for mothers in general.
General Information
Keywords: labor and birth, childbirth education, labour support, doula, emotional support, obstetric violence, birth satisfaction
Journal rubric: Developmental Psychology
Article type: scientific article
DOI: https://doi.org/10.17759/pse.2023280206
Funding. The reported study was funded by Russian Science Foundation (RSF), project number 22-18-00356 (“PTSD and postpartum depression in mothers as a risk factor for the emotional and cognitive development of the child”).
Acknowledgements. The authors are grateful to Anna A. Kharchenko for assistance in data collection and to all participants of this study.
Received: 02.12.2022
Accepted:
For citation: Suarez A.D., Shraibman L.A., Yakupova V.A. Childbirth Education and Support During Labour: Association with Birth Satisfaction. Psikhologicheskaya nauka i obrazovanie = Psychological Science and Education, 2023. Vol. 28, no. 2, pp. 70–82. DOI: 10.17759/pse.2023280206.
Full text
Introduction
Antenatal education is a common practice, however, its effects on childbirth outcomes remain disputable due to a great variety of educational programs and heterogeneity of their content, as well as researchers’ confirmation bias [18].For example, two studies published in 2021 show contradictory results: in one of them women who had attended antenatal education had statistically higher rates of vaginal births [17], while the other study did not find any correlation between antenatal education and the mode of birth [33].Moreover, antenatal education can decrease the risk of obstetric violence, i.e.physical, sexualized and/or verbal abuse, intimidation, coercion, humiliation, and/or assault committed by medical staff during childbirth [35].However, studies report mixed results: for example, in Italy not having attended an antenatal education class was one of the factors most associated with obstetric violence [31], while women who attended such classes in Spain experienced obstetric violence more frequently [28].
Nevertheless, some studies report that antenatal education can improve long-term psychosocial outcomes due to lower rates of birth dissatisfaction that, in turn, often leads to postpartum depression and posttraumatic stress disorder [19; 14; 20].Another way of how antenatal education may impact birth satisfaction is by reducing discrepancies between birth expectations during pregnancy and actual birth experience [22; 23].
Childbirth education courses started to emerge in Russia and post-Soviet countries in 1980-s and represented closed communities of parents with shared values where one or several experienced mothers (often without any medical/obstetrical background) assumed a role of a childbirth educator to prepare other members to childbirth [6].As time passed by and in response to changing demands of pregnant women, these courses transformed into qualified antenatal schools and centers that follow Code of Ethics for Childbirth Educators [6].
Meanwhile, there are few studies in Russia that would explore the impact of antenatal education on birth outcomes.K.A.Silayev in his dissertation showed that antenatal education can reduces rates of cesarean births (CBs) and obstetric complications (such as hypotonic labor) and improve maternal and perinatal outcomes [4].Similar results were reported in a study on antenatal preparation of pregnant woman to VBAC: such comprehensive antenatal education helped more mothers decide to try VBAC and increased the success rate of VBACs [11].
By contrast, there are hundreds of studies that confirmed benefits of continuous support during labor for tens of thousands of women.In 2003 Hodnett et al.published the first Cochrane review1 on continuous support for women during childbirth, with the latest revision published by Bohren et al.in 2017 [15].The authors reviewed data of 26 studies and came to a conclusion that continuous support during labor had numerous benefits, including higher rates of spontaneous vaginal births, lower rates of instrumental vaginal births and CBs and
1 Cochrane Reviews are systematic reviews of research in health care and health policy published in the Cochrane Database of Systematic Reviews https://russia.cochrane.org/ru
less need in pharmacologic management of pain [15].Mothers who had a support person who only focused on providing their comfort were more satisfied with their childbirth experience and more rarely suffered from symptoms of postpartum depression.Labour support was most effective when provided by a companion who was neither part of the hospital staff nor the woman’s social network prior to her pregnancy and labor [24].Based on all these benefits from a presence of a support person during labour and the lack of any side effects, the American College of Obstetricians and Gynecologists (ACOG) and World Health Organization (WHO) recommend that all women are provided with continuous labour support by a companion of choice [12; 36].The emotional component of doula support during labour includes non-judgmental reflection of a labouring woman’s emotions, reassurance, encouragement, breathing techniques for alleviating anxiety, and providing information on the process of childbirth [21; 29].
The presence of a birth partner in Russia has only become a legal right in 2012 [16].However, small maternity care hospitals can still restrict a birth partner’s presence during labor due to absence of individual wards.It is even more difficult for any other person, such as doula or private midwife, to get access to a maternity care hospital and provide support during labour.Most maternity care hospitals allow individual support by a doula/midwife only under a paid contract but not during labour under state compulsory health insurance.Moreover, maternity care hospitals may restrict doula access to the unit as there is no law in Russia that would ensure a woman’s right to have a doula during labour [5].Therefore, women in Russia face an acute problem of inaccessibility of continuous labour support, despite the fact that there are studies on Russian samples that already confirmed positive effects of labour support such as lower rates of CBs, medical interventions, and obstetric violence [37].
Thus, the aim of this study is to examine the associations between antenatal education and individual labour support with the following factors of childbirth: the mode of birth, obstetric violence, birth satisfaction, and women’s physical wellbeing after childbirth in Russia.
Methods
2.1 Procedure and participants
In February — March 2021 women were invited to take part in the study via specialized online and offline communities and antenatal education classes.The survey was conducted online using ‘Testograph’ platform.The inclusion criteria were respondent’s age of 18 years and over, ability to read and write in Russian, and having given birth no longer than 14 months prior to the study.A total of 1,645 mothers of infants aged 0—13 months (M = 6.93) met these criteria and completed the online survey.
The study was approved by the Ethical Committee of the Russian Psychological Society, Lomonosov Moscow State University.All participants were offered to sign an informed consent via the online ‘Testograph’ platform.The study was conducted in accordance with the WMA Declaration of Helsinki.
2.2 Demographic, pregnancy
and childbirth experience
questionnaire
2.2.1 Demographic characteristics
The participants specified their age at the time of childbirth, education (basic school education/vocational education/ higher education), marital status (married/ cohabiting with a partner/single), and the place of childbirth (Moscow and capital region/Other city in Russia with population >1 million/Other city in Russia with population <1 million/Post-Soviet States/Other). 2.2.2 Obstetric and medical characteristics
The survey included questions regarding childbirth experience: the respondents provided information regarding gestational age at the time of birth (in weeks), time since birth (in months), parity, and mode of birth (vaginal/CB).We also collected information about the type of the childbirth healthcare plan (childbirth in a maternity care hospital under state compulsory health insurance/ childbirth in a maternity care hospital with a paid contract/home birth).
In addition, the participants reported whether they had experienced obstetric violence during childbirth.If they had faced any, we asked the women to specify the type of obstetric violence (medical interventions without patient’s consent and approval/verbal aggression /physical aggression (such as immobilization, forbiddance to drink)/threats and accusations/Kristeller maneuver/pain relief denial/ignoring the needs of the birthing woman).
The participants also rated how they felt physically after childbirth on a scale from 1 to 10, where 1 is very bad and 10 is excellent.
2.2.3 Individual labour support and antenatal education
Further we collected information about the sources of support during labour (none/ partner/doula or private midwife/partner + doula or private midwife) and antenatal education type (none/self-education/ educational courses/mixed educational strategies, where participants chose several sources for childbirth preparation).We also asked the participants whether their labour support plan prepared during pregnancy was actually fulfilled during birth.
2.3 Birth Satisfaction Scale
Revised Indicator
We used the Russian version of the Birth Satisfaction Scale Revised Indicator (BSS-RI) [27] to assess the levels of birth satisfaction.It is a short 6-item self-report questionnaire to assess birth satisfaction where the subscales represent the level of stress and anxiety, feeling of control, and caregivers’ support.A 3-point Likert scale is used for each question (range 0—2, where 0 means “no”, 1 means “partly” and 2 means “yes”).Minimum score is 0, maximum score is 12.The Cronbach’s α in this study was 0.805.
2.4 Statistical analysis
We explored the association between the type of support during labour and type of antenatal education and birth experience factors specified in metric variables (birth satisfaction, the number of types of obstetric violence and physical wellbeing after childbirth) using ANOVA.
Pearson Chi-square tests were performed to explore the association between the type of support during labour and type of antenatal education and birth experience factors specified in qualitative variables (the mode of birth and experience of obstetric violence).
We analyzed obstetric violence both as a qualitative variable (the fact of experienced obstetric violence) and as a metric variable — the total number of types of obstetric violence a woman experienced during childbirth.
All statistical procedures were adjusted for covariates (maternal age at the time childbirth, time since birth, gestational age at the time birth) and random factors (the place of childbirth, education, marital status).
The statistical analysis was performed using IBM SPSS 25 software.
Results
The main characteristics of the sample are presented in Table 1 in the following OSF repository: https://osf.io/75
trvh4.As you can see, the majority of the participants are officially married (94%), have higher education (91.8%), and gave birth in big cities in Russia with population >1 million (60.2%).The majority of the participants were primiparous (59%), gave birth in a maternity care hospital under state compulsory health insurance (62%) and had vaginal births (69%).58% of the participants reported that their labour support plan could not be fulfilled due to COVID-19 restrictions.More than a quarter of the women (27.7%) experienced minimum one type of obstetric violence, most often in form of verbal aggression and rudeness (15.6%).Two thirds of the participants reported that they used some type of antenatal education (75.1%), most often — self-education (45.2%).The overall majority of the participants (73%) gave birth without individual labour support.
3.1 Association between the type of antenatal education and birth experience
We identified four types of antenatal education: none, self-education, educational courses and mixed educational strategies (where a woman used several types at the same time).We also analyzed presence or lack of antenatal education in general.We did not find any significant association between birth satisfaction and type of antenatal education (F=0.151 (3; 10, 263), p=0.70).No significant association was found between presence of antenatal education and the mode of birth (Pearson Chi-Square=3.201, (3), p=0.074).We also did not find any statistically significant association between the type of antenatal education and women’s physical wellbeing after childbirth (F=10.192 (3; 7, 637), p=0.72).
The results show a statistically significant association between the number of types of obstetric violence a woman experienced during birth and antenatal education (F=12.438 (3; ,654), p<0.001).The lowest mean number of types of obstetric violence was in the group of women who did not have any antenatal education (Table 2).
3.2 Association between individual labour support and birth experience
After the data processing, we identified four types of labour support: none; partner; partner + private midwife or doula; private midwife or doula (Table 3).We found significant differences in the level of birth satisfaction depending on
Table 2 .Mean values of the main variables depending on the type of antenatal education
Type of antenatal education |
Birth satisfaction (within 0—12 range) Mean/Standard deviation |
Obstetric violence (within 0—4 range) Mean/Standard deviation |
Wellbeing after childbirth (within 0—10 range) Mean/Standard deviation |
None |
7.83 / 3.18 |
0.24 / 0.59 |
6.27 / 2.74 |
Self-education |
7.48 / 3.25 |
0.43 /0.83 |
6.33 / 2.80 |
Educational courses |
7.78 / 3.05 |
0.45 / 0.84 |
6.44 / 2.78 |
Mixed educational strategies |
7.59 / 3.37 |
0.67 / 1.03 |
6.58 / 2.72 |
the type of labour support (F=13.094, (3; 9.819), p<0.001).The lowest mean values of birth satisfaction were observed in the group of women who gave birth without labour support (Table 3).There were significantly higher rates of obstetric violence experienced by women who gave birth without labour support (PearsonChi-Square=21.483, (3), p<0.001).There were also significant differences in the number of types of obstetric violence a woman experienced during birth depending on the group (F=9.910 (3; ,648), p<0.001): the highest mean number of types of obstetric violence was found in the group of women who gave birth without labour support (Table 3).
We found a statistically significant association between labour support and the mode of birth (PearsonChi-Square=25.731, (3), p<0.001).The rate of CBs was higher among women who gave birth without labour support (PearsonChi-Square=4.484 (3), p=0.034).
The ratings made by a woman on her physical wellbeing after childbirth also correlated with the type of labour support (F=6.534, (3; 7.560), p<0.001): the highest mean rating was seen in the group of women who were supported by a private midwife or doula (Table 3).
Discussion
This is the first in Russia study exploring antenatal education and individual labour support within one cohort at the same time to compare their effects on the mode of birth, number of types of obstetric violence, birth satisfaction, and women’s physical wellbeing after childbirth.
We did not find any statistically significant association between antenatal education, birth satisfaction, and birth outcomes, which corresponds with a study in Spain by Artieta-Pinedo et al.[13] who assumed that it is associated with high medicalization of childbirth in Spain where antenatal education cannot impact the general birth culture and actions of healthcare professionals.The maternal healthcare system in Russia also often fails to consider the needs of labouring women and remains rather medicalized [32; 10], which is confirmed by our study in the previous year on a Russian sample 84.6% of which reported that they experienced at least one medical intervention during their childbirth [37].Medicalization of childbirth is understood as high rates of medical interventions, including their use for non-medical problems, and intensive medical control over childbirth process [9; 30].
Table 3 . Mean values of the main variables depending on the type of labour support
Type of labour support |
Birth satisfaction (within 0—12 range) Mean/Standard deviation |
Obstetric violence (within 0—4 range) Mean/Standard deviation |
Wellbeing after childbirth (within 0—10 range) Mean/Standard deviatio n |
None |
7.33 / 3.32 |
0.49 / 0.89 |
6.18 / 2.80 |
Partner |
8.24 / 2.83 |
0.25 / 0.54 |
6.81 / 2.60 |
Partner + private midwife or doula |
8.52 / 2.97 |
0.20 / 0.50 |
6.91 / 2.79 |
Private midwife or doula |
8.67 / 2.62 |
0.23 / 0.55 |
6.99 / 2.55 |
Conclusions
This is the first in Russia study exploring association between antenatal education and individual labour support and birth outcome and subjective birth experience.Our results showed no direct association between antenatal education and birth satisfaction and birth outcomes.However, we revealed an important trend: women that prepare to childbirth more often recognize unacceptable behavior of healthcare professionals, specifically, obstetric violence.This means that women are getting more and more involved in the process of their childbirth, are aware of their rights, and want respectful attitude from medical staff.Our results show that individual labour support is very important for significant improvement of childbirth experience and outcomes.Non-medical labour support can potentially reduce the rates of CBs and obstetric violence and improve maternal physical wellbeing and quality of life in general.
Thus, it is important that perinatal specialists, maternity care hospitals, and society in general ensure continuous individual labour support both by a partner and any other companion of choice, including a private midwife or doula.
Limitations and Future Research Directions
The main limitation of our study is that the data were collected anonymously and online.The researchers and participants do not have any direct contacts, which may reduce the participants’ trust to the researchers and as a result impact the reliability of their responses.Second, all the data are based on self-reports, with no medical records such as statements from medical charts.Finally, the third limitation is related to the characteristics of our cohort: the majority of the respondents are officially married, have higher education, and live in big Russian cities, which may limit the generalizability of our results to other social strata.
An important direction for future research would be a more detailed study of the content of antenatal education courses and self-education to explore significance of effects of their different components on birth satisfaction.Phycological components of labour support also need further in-depth research.
Access to childbirth medical records would have enabled more substantial conclusions based on our data.
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