Childbirth Education and Support During Labour: Association with Birth Satisfaction

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

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