This chapter should be cited as follows: This chapter was last updated:
Riedmann, G, Glob. libr. women's med.,
(ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10109
October 2008

Preconceptional counseling and prenatal care

Education for Childbirth

Gayle L. Riedmann, CNM, MS
Certified Nurse Midwife, West Suburban Midwife Associates, Ltd, Oak Park, Illinois, USA

INTRODUCTION

Childbirth education has influenced the practice of obstetrics remarkably during the past 50 years. In the early 20th century, most women gave birth in the comfort and familiarity of their own homes, but there also were high rates of maternal and infant mortality. Advances in obstetric technology and maternal–fetal medicine shifted birth from the home to the hospital. The likelihood for medical intervention during pregnancy and childbirth has subsequently increased, requiring more consumer education and preparation. As perinatal morbidity and mortality have declined, the expectations for a perfect outcome have increased. Women have become more knowledgeable, self-confident, and participatory in their childbirth experiences, shifting the focus to more family-centered maternity care. Involvement of the expectant father, once limited to pacing in the waiting room, is now routinely intimate. The women's movement has had an enormous impact on traditional childbirth. Women began to question the safety and necessity of obstetric interventions, anesthetics and analgesics, and routine hospital procedures. Women currently are demanding more knowledge about, and control over, their childbirth experience. In addition, women are having fewer children and consequently are spending more time and effort in preparation for parenting through attendance at various childbirth education classes. Information about reproduction and birth formerly obtained through the extended family now is based on scientific study and is obtained through formal childbirth education programs.

Childbirth education should be designed to assist expectant mothers and their families through pregnancy with preconception planning and continue in an organized fashion throughout pregnancy based on the physical and emotional changes occurring during each trimester. Accurate information concerning conception, nutrition, physiologic changes of pregnancy, labor and birth, and newborn care should be included. This information should be provided in the physician's office by written materials and through discussion during prenatal visits. Reinforcement and expansion of childbirth education also can be provided by the various classes available in the community. However, the availability of these classes should not supersede the teaching done by the physician or supportive office staff because antepartum, inpatient, and postpartum patient education are ultimately the responsibility of the obstetric-gynecologic providers.1

CONTENT OF CHILDBIRTH EDUCATION

The educational requirements for individual women clearly vary with their educational level and motivation for self-study. Basic information about pregnancy and birth may be a review for some women but may be altogether new to others.  The completeness or accuracy of previously acquired information cannot be assumed. Thus, all information should be reviewed in detail and adjusted to meet the needs of each individual. The following factors should be considered when discussing topics related to pregnancy and birth:

  Marital status: presence of a support individual;
  Income/economic status: ability to afford adequate nutrition, formal childbirth education classes, continued prenatal care, provisions for an infant;
  Culture/religion/ethnicity: nutritional variations/restrictions, modesty, pain management philosophy, refusal of blood products, attitudes about childbirth;
  Parity: previous experiences, previous problems during pregnancy; and
  Educational level: knowledge about reproduction and family planning.

The content of childbirth education should include minimum basic information, with additional information available through community programs or supplemental materials in the physician's office. An outline of the content follows. It is not intended to be all inclusive but serves as an example of information that would be included during the course of routine prenatal care.1, 2, 3

Preconception

  Reproductive anatomy and physiology
  Nutritional evaluation and information
  Genetic risk evaluation and counseling
  Medical conditions: immunity status, medications, acute and chronic illness
  Risk factors associated with pregnancy risk: smoking, alcohol, recreational and over-the-counter drugs
  Environmental/work hazards
  Counseling regarding safe sex, pregnancy planning, spacing of children, and contraception

First Trimester

  Content and timing of prenatal visits
  Reproductive anatomy and physiology, calculation of estimated date of confinement
  Nutritional needs of pregnant women, vitamins, iron supplements
  Genetic counseling/referral
  Physiologic and psychological changes of pregnancy
  Body changes: breast growth, acne, weight gain

  Common discomforts: nausea/vomiting, fatigue, constipation, headache, indigestion, faintness
  Self-help remedies for discomforts
  Fetal growth and development
  Laboratory and ultrasound testing/screening: standard and optional testing, advantages and disadvantages  

  Smoking, drugs, alcohol, caffeine, Nutra-Sweet and other food additives, avoidance of teratogens and infectious disease
  Pregnancy risks, Individual risk factors and management
  Travel guidelines
  Health habits: hygiene, exercise, Seat belt use, dental care, rest and sleep
  Sexual relations, safe sex
  Warning signs of the first trimester: bleeding, cramping, fever, severe vomiting  

Second Trimester

  Physiologic and psychological changes
  Body changes: abdominal growth, striae gravidarum, chloasma
  Common discomforts: backache, constipation, hemorrhoids, indigestion, ligament pain, vaginal discharge
  Mood swings
  Self-help remedies for discomforts
  Fetal growth and development, quickening
  Laboratory and ultrasound testing and screening:  standard and optional testing
  Weight gain
  Travel restrictions (if any)
  Health habits: exercise, body mechanics, rest and sleep
  Sexual relations, safe sex
  Promotion of breast-feeding
  Warning signs of the second trimester: premature labor, vaginal bleeding, or fluid loss
  Introduction to outside resources
  Childbirth education classes
  Social services: Supplemental Food Program, housing support, financial support
  Substance abuse referral to treatment center
  Mental health treatment referral

Third Trimester

  Physiologic and psychological changes
  Body changes: see second trimester changes
  Common discomforts: constipation, shortness of breath, edema, heartburn, backache
  Fetal growth and development, tests for fetal wellness
  Ultrasonography
  Nonstress testing, contraction stress tests
  Fetal movement counts
  Laboratory and ultrasound testing: standard and optional testing
  Continuation of second-trimester instructions
  Signs of labor: contractions, rupture of membranes, bloody show
  Analgesia and anesthesia for labor and birth
  Discussion of birth plan: routine procedures for labor and birth

  Contacting the physician or midwife for labor, where to go
  Family roles and adjustment
  Warning signs of the third trimester: severe edema, headache, visual disturbances, abdominal pain, vaginal bleeding, premature labor, premature rupture of membranes

Postpartum

  Warning signs for immediate postpartum period
  Physiologic and psychological changes
  Body changes: weight loss, return of menses, resumption of intercourse
  Psychosocial adaptation to parenthood
  Family planning
  Child spacing
  Contraception
  Postpartum depression screening
  Nutrition, weight loss
  Health habits: hygiene, rest, exercise
  Health maintenance: breast self-examination, annual gynecologic examination, immunizations
  Resources
  Return to work

METHODS OF CHILDBIRTH EDUCATION

Current childbirth education programs have evolved throughout the past century.  A more focused effort in the 1980s recognized two distinct needs: better prenatal self-care and a means to cope with childbirth.4 The American Red Cross first recognized the need for better prenatal health care, hygiene, and infant care in the early 1900s. Organized classes were set up and taught to entice women to care for themselves better during pregnancy. This public health approach grew to include other organizations, such as the Maternity Center Association in New York and the Chicago Maternity Center. This type of childbirth class continues currently, offered by community groups, hospitals, and private offices are generally informational in nature, with few details on specific mechanisms to cope with the pain of labor. This type of education has diminished in recent years.

The second need that forwarded the development of childbirth education was the desire to find a means with which to cope with childbirth without the use of analgesics or anesthetics. In the 1930s, a British obstetrician, Dr. Grantley Dick-Read, recognized the need to assist women through childbirth without the use of medication. He observed that women who anticipated the pain of childbirth were more fearful. He surmised that their resulting tension interfered with the labor process and ultimately increased their pain. Dick-Read described his fear-tension-pain syndrome in his book, Childbirth Without Fear, published in 1944.5 He strongly advocated education and emotional support to reduce fear and break the fear-tension-pain cycle. His teaching included total body relaxation, as well as female anatomy and physiology, nutrition, hygiene, and breathing techniques. Unfortunately, Dick-Read was sharply criticized by his colleagues for his lack of scientific evidence and the spiritual nature of his writings. However, his work had a significant impact on current childbirth practices because it was the beginning of a more humanistic approach to women during childbearing.

The Russians experimented with hypnosis in the early 1900s but with limited success. They then began to explore the application of Pavlovian principles of behavior modification to the childbirth experience. Negative and painful responses to childbirth stimuli were deconditioned and replaced with other responses, such as breathing techniques and attention focusing. Introduced as the psychoprophylactic method of childbirth by the Russian Velvovsky, it was observed by Dr. Fernand Lamaze, a French obstetrician visiting the Soviet Union for a professional conference in 1951. Lamaze returned to France and adapted the psychoprophylactic method for use in his clinic, the Maternité.T de Metallurgiste. In his book, Painless Childbirth, Lamaze introduced a method that included teaching female anatomy, physiology of pregnancy, labor and birth, breathing techniques, and other exercises.6 Psychoprophylaxis as a method for childbirth spread rapidly throughout Europe and China and was introduced to the United States through the efforts of Karmel7 and Bing8 and referred to as the Lamaze Method. At a time when women were heavily sedated and husbands excluded from the birth process, Karmel and Bing promoted medication-free, prepared childbirth with active support from the husband. A few years later, the American Society for Psychoprophylaxis was founded. This organization set up official teacher training programs for the psychoprophylactic method. Classes include reproductive anatomy and physiology, nutrition, the process of labor and birth, anesthesia and analgesia, and cesarean birth. Now named Lamaze International, the method no longer teaches complicated breathing techniques for coping with the various phases of labor. The philosophy includes

  • Birth is normal, natural and healthy.
  • The experience of birth profoundly affects women and their families.
  • Women's inner wisdom guides them through birth.
  • Women's confidence and ability to give birth is either enhanced or diminished by the care provider and place of birth.
  • Women have the right to give birth free from routine medical interventions.
  • Birth can safely take place in homes, birth centers and hospitals.
  • Childbirth education empowers women to make informed choices in health care, to assume responsibility for their health and to trust their inner wisdom.9, 10

Another method of childbirth originated in the late 1940s, conceived by an American obstetrician, Dr. Robert Bradley. The Bradley Method was based on his observations of the natural instinctual behavior of all mammals bearing their young and emphasizes a truly natural childbirth. Use of analgesia or anesthesia is strongly opposed, as is most routine obstetric interventions, such as intravenous fluids, continuous electronic monitoring, amniotomy, and episiotomy. Deep relaxation and a natural diaphragmatic breathing are taught for coping with labor, as well as female anatomy and physiology, exercise, nutrition, process of labor and birth, breast-feeding, and child care. Instructors are trained and certified by the American Academy of Husband-Coached Childbirth. Couples are usually extremely well prepared for the birth, understanding and anticipating common variations of labor and possible management. A birth plan is designed and presented to the physician or midwife weeks before the birth so that any conflicts can be worked through. Although some professionals find the Bradley method antagonistic to the medical profession, it is well known for its very consumer-oriented classes.

Other methods of childbirth education are increasing in popularity in the past decade, using various approaches. Hypnosis has been used since the 19th century to prevent or reduce pain, usually as an adjunct to other preparatory classes. The Mongan Method of Hypnobirthing uses relaxed, natural methods of education with self-hypnosis. Emphasis is placed on pregnancy and childbirth as well as the pre-birth parenting issues and unborn baby.11  A holistic or psychophysiologic approach is described by Peterson in her book, Birthing Normally.12 This method focuses on self-growth and an integration of mind and body to call upon one's own resources to cope with birth. The Gamper Method, originated by Margaret Gamper in 1946, is the foundation of the Dick-Read teachings and has been adapted over time to embrace the family-centered approach. Preparation for birth is accomplished through instillation of self-determination and confidence in the woman's ability to work with the natural forces of labor.13 It is less available as a method of childbirth, as instructors of this method are few.  A psychosexual approach promoted by the Kitzinger Method also is based on the early work of Dick-Read. This method uses the body's tactile and auditory sensory memory of past experiences to elucidate relaxation. Pregnancy and birth are viewed as only a part of the entire psychosexual life cycle; thus, the woman's relationships with her husband, parents, and children also are explored.14 Other classes, best referred to as nonmethod, teach pertinent information, relaxation, and breathing techniques but do not conform to any one childbirth pain theory.

Childbirth education is a key component to prenatal care.  Different models of providing education exist.  There are multiple external programs such as Bradley, LaMaze, Gamper, or Hypnobirthing. An internal clinic-based program recently gaining popularity called Centering Pregnancy brings groups together during prenatal care for assessment, education and support. The differences in the methods of childbirth preparation can have a profound impact on the relationship between the physician or midwife and expectant mother. Although all methods strive to educate expectant couples and assist laboring women to cope with pain, the approaches used to accomplish these goals vary considerably. The basic instruction provided by community or hospital prenatal classes informs women of expected routines and choices of analgesia or anesthesia but often contributes less about mechanisms to cope with pain other than use of narcotics or epidural anesthesia. This approach often leaves women more fearful, dependent, and more likely to be requesting medication or anesthesia early in their labor because they have no other resources. A provider is placed in a position of difficulty  how best to help a woman, particularly if she is close to delivery. Hospital-based Lamaze classes remain popular, but many have been forced to teach hospital routines instead of consumer choices. This approach may be helpful to reduce patient–provider conflict, but it is not necessarily in the best interest of a pregnant woman who accepts such routines without question. Entire classes may be dedicated to epidural anesthesia and the effects of narcotics, leaving expectant parents confused about the efficacy of the breathing techniques and lacking confidence. The techniques taught by Lamaze instructors have been credited with various amounts of helpfulness, often attributable to the enthusiasm of the instructor. The Bradley method promotes consumer-oriented choices for all aspects of pregnancy and childbirth, which sometimes are interpreted as demands instead of requests. Not only does this situation create an antagonistic relationship, but it may be dangerous if a couple refuses medically necessary interventions for the well-being of the mother or the fetus. Childbirth educators may foster an attitude of mistrust, and husbands are often left feeling overly responsible for the use of pain management or outcome of the birth. The various influences that a childbirth education program can have on a woman necessitates that the physician or midwife be cognizant to the type of childbirth method that is selected. Then it is possible for an understanding of individual expectations for pregnancy, labor, and birth.

EFFECTS OF CHILDBIRTH EDUCATION

There is little recent literature evaluating childbirth education classes and obstetric outcomes. Research conducted during the past 50 years provides some evidence that women who are prepared for childbirth tend to require less medication, report less pain during labor and birth, have shorter labors, and have a more positive attitude about the childbirth experience.   Weaknesses in the studies can be identified in the small numbers of subjects, absent or unsatisfactory control populations, or subjective data. However, the bulk of the literature supports the contention that childbirth education is beneficial in several respects. No disadvantages to childbirth education have been demonstrated. Since there has been few studies published in the last decade, this review of the effects of childbirth education will include data published in the past 25 years, as well as older original research studies of interest.

Pioneering research reports published in the 1960s yielded data indicating that stress interferes with the process of parturition. In his series of early studies, Newton demonstrated that the presentation of stressful stimuli to parturient mice resulted in significant increases in the length of labor and the incidence of stillborn delivery.15, 16, 17  Because research regarding the effects of stress on human parturition is obviously constrained by ethical considerations, subsequent experimentation has been limited to descriptive and correlational surveys. Studies by Lederman and associates in the 1970s uncovered a relationship among anxiety, maternal attitudes, plasma catecholamines, uterine contractility, labor length, and infant Apgar scores. In the first of these investigations, it was found that self-reported anxiety and endogenous plasma epinephrine were significantly correlated and that epinephrine levels were correlated with uterine contractile activity, which in turn correlated with labor length. In subsequent studies, a surprisingly powerful relationship emerged between maternal attitudes and labor variables, including infant Apgar scores.18, 19 Lederman's results can be interpreted to suggest that anxiety is involved in the increased production of plasma epinephrine, which inhibits uterine contractile activity, thus increasing labor length.

Later studies support the contention that high anxiety levels are related to obstetric complications. Crandon20, 21 found that high self-reported anxiety scores were related to prolonged labor, forceps delivery, pre-eclampsia, and low infant Apgar scores. Gorsuch and Key22 uncovered a relationship between stressful life events, anxiety, and pregnancy abnormalities. Fridh23 found that several psychosocial and demographic factors were related to higher levels of pain during delivery, including age, parity, education, menstrual problems, history of abortion, unstable emotional feelings, unrealistic expectations of pain, and spouses' negative attitude toward the pregnancy. A study by Wuitchik and associates24 indicated that distress-related thoughts or high levels of pain during the latent phase of labor were related to longer labor, more difficult delivery, and neonatal distress.

Given that stress can interfere with the process of parturition, it is reasonable to expect that stress reduction might bring about a facilitation of the birth process. This is the foundation philosophy of most childbirth education methods.  Despite many variations in treatment application, most contemporary labor preparation programs include four relatively discrete components, the primary purpose of which is to reduce stress. First, virtually all include a series of lectures designed to provide information about pregnancy, labor, and delivery. Second, most teach a series of respiratory behaviors to be used during various phases of the labor process. Third, brief training is provided in muscle relaxation. Finally, many programs encourage participation by the husband (or significant other) in the birth process by timing contractions, giving massage, and providing verbal encouragement and support.

An early classic study by Thoms and Karlovsky provided early support for the continued development of childbirth education in the United States.25 Two thousand women completing a Dick-Read program of preparation for childbirth taught by certified nurse-midwives in a joint Yale—Maternity Center Association project were studied. The authors concluded that their program of preparation led to shorter labor, fewer depressed infants, fewer operative deliveries, less blood loss, and smoother recoveries. Although no control group of unprepared women was used, this study set the pace for future research. Later efforts to replicate this study yielded negative results.26, 27 However, the authors did find distinct differences in social, economic, and psychological factors between the prepared and unprepared groups. Women who elected prepared childbirth were found to be older, better educated, of a higher socioeconomic group, more positive, and less anxious about their pregnancies, and they planned to breast-feed. These demographic findings have been supported in numerous studies.28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41

All studies designed to assess differences in outcome between prepared and unprepared women need to be controlled carefully for potential confounding variables that threaten their validity.42 Random assignment to control and experimental groups is not used, because it may be considered unethical to withhold important educational information from pregnant women. Another serious research difficulty arises when discriminating childbirth preparation effects from a placebo effect, such as occurring with attention, support, or positive expectations. Although placebo effects can be considered beneficial, it is important to be able to identify them as such. Finally, some individuals may be more responsive to treatment than others; thus, the effects of childbirth education would be different in women with different pain thresholds and anxiety levels. Therefore, it is important to note that although many of the studies discussed later attempt to control for confounding variables, there are few satisfactory research designs that would permit a cause-and-effect relationship between treatment and outcome.

A series of four studies by Geden and Beck43, 44, 45, 46 attempted to improve on the generalizability of prior labor preparation analogue studies by: (1) providing subjects with more extensive training, (2) presenting experimental pain stimuli that resembled labor contractions with regard to intensity and patterning, and (3) systematically evaluating the effects of the major treatment components of the Lamaze regimen as well as techniques derived from contemporary psychological research on pain, anxiety, and stress reduction.

The first study43 was an attempt to find a pain stimulus that was qualitatively analogous to labor pain and to develop a patterning sequence similar to the timing of labor contractions. This stimulus and pattern were used as the labor analogue in the three studies that followed.

The second of these studies44 compared the effects of five cognitive-behavioral pain coping strategies on the labor pain analogue. Of the strategies compared (relaxation training, pleasant imagery, sensory transformation, neutral imagery, and combined strategies), sensory transformation had the greatest effect on self-reports of pain. On measures of blood pressure, frontalis electromyography, and heart rate, no significant treatment effects were found. The third study45 compared the effectiveness of the component parts of the Lamaze training package, including informational lectures, relaxation training, and breathing techniques. Relaxation training was found to be the most effective component, with significant effects on self-report of pain, frontalis electromyography, and heart rate. Although some of the other components or combinations affected one dependent measure, only relaxation training had significant effects on all three dependent variables. The final study46 involved using sensory description, sensory transformation, systematic desensitization, modeling, relaxation, a pharmacologic treatment (50 mg meperidine hydrochloride [Demerol] intramuscularly), or combined strategies. Self-report data indicated that subjects using sensory transformation and those using combined cognitive and pharmacologic treatment (sensory transformation, sensory description, relaxation, and Demerol) experienced less pain than those in any of the other groups.

In what probably should be regarded as the most carefully controlled investigation of childbirth preparation completed, Harmon and co-workers47 studied 60 primiparous women who attended six sessions of childbirth education that entailed information about childbirth, relaxation training, and breathing techniques. Six additional sessions of exposure to painful stimulation induced by the submaximum effort tourniquet technique were provided by the investigators. In this context, patients were randomly assigned to two groups. The first group was asked to use the breathing and relaxation skills learned during childbirth education classes to cope with the pain produced by the tourniquet. The second group received a hypnotic induction procedure and was asked to concentrate on suggestions of hypnotic relaxation and analgesia. Women in both groups were provided with the rationale that this specialized training should produce less pain, greater relaxation, and a more enjoyable childbirth. Results of this study indicated that hypnotically prepared women had significantly shorter stage-one labors, used less medication (including tranquilizers, narcotics, and oxytocics), had more frequent spontaneous deliveries, and had higher infant Apgar scores than nonhypnotically prepared women. The benefits of hypnosis for management of labor pain is supported in a recent review published by the Cochrane Database as well48and in other descriptive studies49, 50

Although the reviewed studies are generally not wholly intact from a methodologic standpoint, their composite weight demonstrates positive effects of current preparatory methods, even though empirical support differs depending on the criterion chosen. Results seem particularly positive in regard to reduction of pain and probably anxiety as well, with a concomitant decrease in the use of anesthetics and analgesics. Reductions in labor length and complications appear to be on somewhat more tenuous grounds, based on the equivocal pattern of findings regarding these variables, particularly depending on how various sociodemographic characteristics are controlled.

Reduced Analgesia/Less Pain

An effort to control for the motivation to take classes to assess the true impact of childbirth preparation on pain as measured by analgesia use has been attempted in several studies. The earliest notable study by Laird and Hogan51 compared data from three groups: patients who requested and attended childbirth preparation, patients who did not request but attended classes once invited, and those who did not request and declined the invitation to attend. Twenty-seven percent of the patients who had requested classes required no analgesia, compared with 22% of the patients who were invited and did attend, and only 6% of those who received no childbirth preparation, demonstrating a dramatic decrease in use of analgesia in women who attended classes.   Bergstrom-Walan,33 Enkin and colleagues,52 and Huttel and associates53 conducted studies of similar controlled design. These authors reported similar results of less frequent analgesia use among women who attended classes. Subsequent studies have continued to support the contention that childbirth education reduces the use of analgesia30, 33, 34, 54, 55, 56, 57 and anesthesia33, 34, 52, 54, 55, 56, 58, 59 by laboring women.

The effect of childbirth education on women's perception of pain during labor also has been studied. Several studies found that significantly less pain during labor and delivery was reported by women who had attended childbirth preparation classes.30, 33, 52, 53, 60, 61, 62 The knowledge and confidence a woman possesses, such as that imparted in childbirth education classes, has been shown to be a reliable predictor of reports of less pain.63 However, these findings have been disputed in other studies.59, 64, 65 Also, retrospective measures of labor pain have been criticized because of discrepancies between reports of pain during labor and the amount recalled postpartum.66, 67, 68, 69

Reduction in Anxiety or Tension

Childbirth education has been shown to reduce tension53, 57, 59 and anxiety33, 60, 70 during labor. Low levels of anxiety have been associated with patient reports of a more positive birth experience,65 whereas high anxiety enhances pain perception.60, 65 Only one study reported that a high level of anxiety after childbirth classes predicted a less painful birth.63 The most plausible explanation that the authors offered for this surprising finding was that women with high levels of anxiety tend to expect more pain and were relieved when labor was not as painful as anticipated.

Shorter Labor

The literature contains conflicting evidence regarding whether childbirth preparation shortens labor duration. Several studies found a significantly shorter labor among those who attended childbirth education classes.25, 33, 51, 53, 57, 58, 61 Other studies revealed no differences in the length of labor between women who attended classes and those who did not.26, 30, 34, 52, 54, 56, 59 Because confounding variables such as anxiety level, methods of pain control, and operative delivery may affect the duration of labor, this aspect of childbirth preparation is difficult to study. Thus, no clear conclusions can be drawn.

Decreased Forceps Use

A number of studies report less frequent use of forceps among women who received childbirth education.34, 51, 52, 54, 58 Although three studies found no difference in forceps use among prepared and unprepared women,26, 30, 34 the general belief is that childbirth preparation reduces the incidence of forceps use.

Improved Maternal or Infant Outcome

Thoms and Karlovsky25 reported fewer depressed infants at birth among women who had attended childbirth preparation classes, although their studies were poorly controlled. In a more controlled study, Hughey and colleagues associated a lower incidence of fetal distress and prematurity with childbirth education.55 This study also reported Lamaze-prepared patients had one fourth the number of cesarean section births. However, no difference in Apgar scores,30, 53, 54 fetal distress,54 or infant well-being34 was noted in other studies.54

More Positive Experience in Giving Birth

A more positive attitude toward the experience of labor and birth has been reported by several authors.30, 32, 52, 53, 59, 71, 72 This takes on particular significance in light of the fact that childbirth is viewed as extremely painful, albeit less so with preparation.62, 66, 68

It is difficult to draw a conclusions from the literature addressing the effects of childbirth education. There is a paucity of recent research, little standardization, and ill-defined outcomes.  A 2002 review of recent literature by Koehn concluded that childbirth education research demonstrates mixed results regarding effectiveness, although in previous decades birth satisfaction and perception of control had been identified as positive outcomes.  There are problems with methodology, sampling, and framework42. Women who elect childbirth preparation are often advantaged over other women in many ways: they are better educated, of a higher socioeconomic status, and more positive and less anxious about their pregnancies. Generally, they also are older and plan to breastfeed. The benefits of childbirth education have been demonstrated to various degrees, even when motivation to take classes has been carefully controlled. These benefits include reduction of reported pain during labor and delivery, decreased use of analgesics and anesthetics during labor, reduction of anxiety or tension during labor, decreased incidence of forceps use, and a more positive birth experience.

EFFECTS OF LABOR SUPPORT

The attendance of a labor support person has been addressed more fervently in recent years due to several studies indicating a reduction in cesarean section rate when a support person, or doula, is present. 

In a study investigating the effects of the presence of a supportive lay woman (“doula”) during labor, Sosa and co-workers randomly assigned a supportive person to 136 Guatemalan primigravidas in early labor with no existing medical problems. Length of labor was significantly shorter in the support group, and it was found that mothers who had a doula present during labor interacted with their infants more actively after birth.73  In a subsequent landmark study by Kennel and associates,74 the presence of a doula was found to positively impact labor and delivery. This prospective randomized study of 412 healthy nulliparous women reported a significant reduction in cesarean deliveries and forceps deliveries. The authors also reported decreased epidural use, less oxytocin use, shorter labors, and fewer perinatal complications among women who were supported during labor.

Additional subsequent studies of the effects of labor support have been conducted in clinical labor and delivery settings. Evidence suggests that laboring women who have the presence of a support person report less pain and receive less medication, have fewer epidurals, have shorter labors, lower forceps, vacuum and cesarean section rates and higher rates of breastfeeding.75, 76, 77, 78, 79, 80, 81

Although labor support, or doulas, are not necessarily childbirth educators per se, the importance of labor support as a component of childbirth education programs is supported by scientific evidence. Physicians and midwives should emphasize and encourage the presence of a support person for a laboring woman regardless of whether the patient elects to enroll in a childbirth preparation program.

The positive effects of preparation for childbirth make it clear that childbirth education should be an integral part of every prenatal care program. Childbirth education classes should be made readily accessible to all pregnant women, including special groups with unique childbirth education needs.

CHILDBIRTH EDUCATION FOR SPECIAL NEEDS GROUPS

Many childbirth education classes have been developed to specifically address concerns of select groups.

 

Cesarean Birth/Vaginal Birth After Cesarean

The cesarean section rate has risen dramatically in the past three decades.  Efforts to reduce the cesarean section rate through vaginal birth after cesarean has also yielded support groups such as the International Cesearean Awareness Network, and classes referred to as VBAC Class.  These classes are for women who have experienced a prior cesarean birth to promote a vaginal trial of labor for subsequent pregnancies as an option. Vaginal birth after cesarean has been supported for select women by the American College of Obstetricians and Gynecologists.1  Women may be uncertain whether they want to incur the risk, and may be hesitant to experience the unpredictability or the pain of labor. These classes provide supportive information, dispel fears and misconceptions, and are also psychologically supportive to couples who were disappointed with their previous cesarean birth outcome.

Preparation for cesarean delivery is an area that deserves considerable future attention because of both the frequency with which cesarean delivery is used and the fact that this procedure probably puts even more stress on patients than vaginal delivery. To help patients cope with the experience of cesarean birth, a variety of special types of teaching and other interventions have been applied. Preoperative teaching programs provide patients with information about anesthesia and analgesia, the recovery room care of the incision, breast-feeding, and ambulation. Support groups consisting of women who have undergone cesarean deliveries provide information, peer emotional support, and role models and give patients an opportunity to help others.

Low Income Women

The benefits of childbirth education are of great value when designed for women with economic constraints. Childbirth education has been show to improve health behaviors such as exercise, nutrition, relaxation and confidence and communication.82, 83, 84  Low-income women are at greater risk for various health problems during pregnancy because of inadequate nutrition, poor facilities for good hygiene, and insufficient access to health care. Preterm delivery, intrauterine growth restriction, pregnancy-induced hypertension, and a host of other problems create significant risk for poor maternal or infant outcome. The information provided by basic childbirth preparation classes can promote self-responsibility for better nutritional habits and early recognition of warning signs. Hospital and public health care services often provide free childbirth education programs as part of routine pregnancy surveillance. The importance of childbirth preparation and its benefits should be emphasized to increase interest and attendance at such programs.

High Risk Pregnancy

 Women with high-risk pregnancies have particular childbirth education demands that cannot be met by customary classes. Conditions such as diabetes, hypertension, preterm labor, multiple gestation, and other medical problems require special education for nutritional needs, warning signs, and events distinctive to their individual labor and birth experience. Often hospitalized for extended periods, these women are denied access to organized classes and thus often enter labor with little or no preparation. Once born, the infants of high-risk pregnancies are often admitted to intensive care nurseries, delaying maternal contact. This can interfere with attachment and the development of normal parenting behaviors. Anticipatory guidance through childbirth education classes can be provided while these women are hospitalized, thus decreasing anxiety, increasing preparedness, and allowing for a more positive pregnancy and childbirth experience.

Adolescents

Adolescents represent another group with special needs for childbirth education. Adolescents have additional nutritional requirements and unique social, emotional, and educational needs, and they are faced with higher rates of anemia, toxemia, and premature births. Pregnant adolescents often are unwed, drop out of school, and come from economically disadvantaged homes, thus further complicating efforts to provide comprehensive prenatal care addressing their particular needs. The location and content of childbirth education for teenagers must be customized to these circumstances to be effective. Classes held at school or with peers improve acceptance, as does including the adolescent's mother or the expectant father in the classes.85 Emphasis on hospital procedures, body changes, nutrition, and parenting are vital to a successful outcome.86

Elective Single Parenting

Changes in societal mores and attitudes have induced more single women to become parents without the benefit of an involved partner. Although in the past many single women with unplanned pregnancies relinquished their infants for adoption, the current trend is to raise the child as a single parent.  Unfortunately, most formal childbirth education programs are structured to include the expectant father and place emphasis on his role. This program structure often is alienating to a single expectant woman, even if she has willingly chosen her circumstances. In this situation, the classes can be altered slightly so that the advantages of childbirth education can be extended to include single women comfortably. They should be encouraged to take the preparation classes with a friend, sister, or mother as support. Some communities offer classes specifically for single women to address the social and economic issues that confront them as single parents.

 Gay/Lesbian Couples

Greater availability of advanced reproductive technologies and acceptance of same-sex parenting has given great opportunity to gay and lesbian couples. Health care providers who are knowledgeable and sensitive to the unique needs of lesbian clients can support their search for appropriate childbirth classes.  Larger cities may have support groups which offer specialty classes.  The concerns of these couples are different that heterosexual couples, and health care outcomes can be improved when education is directed specifically to their situation.87

Physically Challenged Women

Physically impaired women encounter many barriers in their lives. Greater frustration is experienced when they are excluded from the group process involved in formal childbirth education classes. Like women of every age and social class, disabled women are entitled to the same learning opportunities to prepare for childbirth and parenting. They should be encouraged to seek an instructor willing to adapt the classes to accommodate their disability, such as a sign language translator for the deaf couple or a wheelchair-accessible location. Exceptional concerns, such as labor and birth management for a paraplegic woman, can be addressed separately. In this manner, pregnant women with physical impairments can participate in and benefit from formal childbirth education instruction while also considering their individual needs.

FUTURE DIRECTIONS

Advances in obstetric technology and intervention in recent decades have paralleled the growth of childbirth education programs. A rise in the Cesarean section rate, and the introduction of primary elective cesarean section has created more consumer-driven support networks to counter the trend.  With this growth, controversy has arisen on many fronts. Consumers, educators, and professionals debate acceptable credentials for the educator, class content, and birth setting. Little factual information on which components of childbirth preparation produce the most therapeutic benefits is available. Further research must be directed toward assessment of the most effective pain-coping strategies.  Teaching women various coping mechanisms that they may use during labor and birth will instill confidence in the natural process of birth.

Some classes teach hospital routines that mold women to the requirements of the health-care system; others teach consumer rights to nonintervention and control of the birth experience. Some women accept hospital and physician routines without question, whereas others struggle with their providers over each potential intervention. This conflict between a woman and her health physician or midwife can be damaging as they fight over control of the childbirth experience. Women have a right to information concerning the advantages and disadvantages of any procedure or intervention, regardless of what is hospital or provider routine. Women are no longer passive participants in the birth process, and this must be recognized by obstetricians, midwives, and educators. An effort must be made to integrate what is taught and what is actually likely to occur during the birth process. For this to happen, a change in attitude by both educators and providers is necessary, focusing on women's right to information and choice.

Physicians and midwives are largely responsible for the obstetric care of women, including childbirth education. When unfamiliar with the philosophy and content of preparation programs, they are unable to assess adequately patient knowledge and needs. When a patient selects a method of preparation diametrically opposed to the provider's own management philosophy, conflict occurs. However, this conflict has benefits in promoting a change in attitudes toward management of birth that is more consistent with consumer rights. As this trend continues, physicians in obstetric residency must be educated about the benefits of childbirth preparation and alternatives in birth methods. Practicing physicians and midwives must keep abreast of current research and trends in obstetrics and must educate themselves on the methods of childbirth preparation available to their patients.

Childbirth education has expanded greatly with consumer interest and request for more knowledge. The early classes designed to teach expectant women reproductive anatomy and physiology, nutrition, hygiene, and exercises to cope with labor and birth continue today. In addition, an entire repertoire of specialty classes is offered to address specific aspects of pregnancy and birth. It is not uncommon to find diverse topics to select from, including: preconception preparation, early pregnancy classes, prenatal exercise,  cesarean birth, vaginal birth after cesarean delivery, breast-feeding, infant care/parenting, and infant massage. For the siblings, there are tours and discussions about the new baby; for grandparents, there are classes about babysitting and child care; and for babysitters, there are classes teaching infant cardiopulmonary resuscitation. This refocusing of pregnancy and childbirth toward a more family-centered approach will continue to have an impact on obstetric care in the future. Women will continue to seek knowledge and control, altering the way obstetrics is practiced, particularly for low-risk women.

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