INTRODUCTION
Pregnancy and childbirth are transformative experiences in a woman’s life, accompanied by significant physical, emotional, and psychological changes1,2. As expectant mothers navigate this journey, they often face uncertainties, anxieties, and fears about the birthing process and their ability to care for a newborn3. In recent years, there has been growing recognition of the importance of antenatal education in preparing women for childbirth and early parenthood4.
Antenatal education, also known as childbirth preparation or prenatal classes, typically offers expectant parents information on pregnancy, labor, delivery, and early infant care5. These programs vary in content and delivery methods but aim to empower women with knowledge and skills to manage pregnancy, childbirth, and postpartum6. While the primary goal of antenatal education is to improve maternal and neonatal outcomes, its potential to influence psychological factors such as self-efficacy and fear of birth has gained increasing attention from researchers and healthcare professionals7,8.
Self-efficacy, introduced by Bandura9, refers to an individual’s belief in their ability to perform specific tasks or behaviors successfully. In childbirth and parenting, self-efficacy is crucial in how women approach and experience these life-changing events10. Higher levels of self-efficacy have been associated with improved coping mechanisms during labor, reduced pain perception, and greater satisfaction with the birthing experience11. Furthermore, mothers with higher self-efficacy in childcare tend to exhibit more positive parenting behaviors and adapt more readily to the challenges of early parenthood12.
On the other hand, fear of birth, also known as tokophobia, is a significant concern for many expectant mothers13. This fear can range from mild anxiety to severe phobia and may have detrimental effects on both maternal and fetal well-being14. Women experiencing high levels of fear of birth are more likely to request elective cesarean sections, experience prolonged labor, and report negative birth experiences15. Additionally, fear of birth has been linked to an increased risk of postpartum depression and difficulties in mother-infant bonding16.
Various sociocultural factors and healthcare system variables further complicate the relationship between antenatal education, self-efficacy, and fear of birth. Cultural beliefs and practices surrounding pregnancy and childbirth can significantly influence women’s expectations and experiences17. These cultural perspectives shape how women perceive their ability to cope with childbirth and their level of fear. Additionally, the structure and accessibility of healthcare systems play a crucial role in determining the quality and reach of antenatal education programs18. Factors such as healthcare policies, resource allocation, and the training of healthcare providers all contribute to the effectiveness of these interventions18. Moreover, the increasing trend toward digital health solutions has led to online antenatal education programs, offering new opportunities and challenges in preparing expectant mothers for childbirth and parenting19.
Antenatal education programs aim to improve maternal psychological outcomes and have significant implications for maternal and neonatal birth outcomes. These programs can influence various aspects of childbirth, including the mode of delivery, with studies showing increased rates of vaginal delivery and decreased rates of cesarean sections among participants. Additionally, antenatal education has been associated with better neonatal outcomes, such as higher Apgar scores and healthier birth weights. By equipping expectant mothers with knowledge and coping strategies, these programs can enhance maternal confidence and reduce anxiety, leading to more positive birth experiences and improved health outcomes for both mothers and their newborns.
Despite the growing body of research on antenatal education programs, there remains a significant gap in the literature regarding their comprehensive impact on both maternal psychological outcomes and birth outcomes. Previous studies have often focused on isolated aspects, such as self-efficacy or fear of childbirth, without providing a holistic view of how these programs influence a range of maternal and neonatal outcomes. Additionally, the variability in study designs and outcome measures has led to inconsistent findings, making it challenging to draw definitive conclusions. This meta-analysis aims to address these gaps by systematically evaluating the impact of antenatal education on maternal psychological outcomes, as well as its secondary aim of assessing the effects on birth outcomes, including mode of delivery, Apgar scores, and infant birth weight. By investigating these relationships, we aim to provide valuable insights that can inform the development and implementation of more effective antenatal education interventions.
METHODS
The current study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines and the Cochrane Handbook for Systematic Reviews of Interventions20,21.
Information sources and search strategy
We used generic terms to search databases like PubMed, Scopus, Web of Science, and Cochrane Library to identify relevant articles from inception to July 2024. The search was performed using relevant keywords and Medical Subject Headings terms related to antenatal education, self-efficacy, fear of birth, and maternal and neonatal outcomes. Additionally, we manually searched the references of published articles to identify trials not found in the other databases. The detailed search strategy and terms are shown in Supplementary file Table 1.
Study selection
To minimize bias, two independent reviewers (SEI and FHI) screened the titles and abstracts of all available records after removing identifying data such as author names and affiliations. They used a checklist of eligibility criteria to guide their screening process. A third reviewer (HHA) was available to resolve any conflicts. After this initial screening, the two reviewers evaluated the full texts of the selected articles for eligibility, comparing their results to resolve any remaining disagreements.
Eligibility criteria
Studies were eligible for inclusion if they met the following criteria: the study design had to be a randomized controlled trial (RCT); and participants were required to be pregnant women, focusing the review on antenatal education’s impact on maternal self-efficacy, fear of childbirth, and birth outcomes. Studies were excluded if they were not an RCT, did not involve pregnant participants, single-arm studies, or reviews. The incuded studies were grouped for the syntheses based on the specific outcomes they measured, such as self-efficacy, fear of childbirth, and various birth outcomes.
Data items
The intervention of interest was antenatal education programs, comparing their effectiveness to standard care or no intervention. In this study, there were changes in self-efficacy regarding childbirth and fear of childbirth. Self-efficacy in childbirth was typically measured using validated scales such as the Childbirth Self-Efficacy Inventory22 or similar scales. These scales assess women’s confidence in coping with labor and delivery, with higher scores indicating increased self-efficacy and a positive outcome. Fear of childbirth was commonly evaluated using tools like the Wijma Delivery Expectancy/Experience Questionnaire23 or other validated fear of childbirth scales. Lower scores on these scales indicate a reduction in fear, considered a favorable outcome. Secondary outcomes assessed maternal outcomes, such as the frequency of vaginal delivery, cesarean section, and episiotomy, as well as neonatal outcomes, including Apgar scores at 1 and 5 minutes, infant birth weight, and the incidence of low birth weight. All results compatible with each outcome domain in each study were sought, including all measures, time points, and analyses if applicable. If not all results were collected, methods used to decide which results to collect were based on the relevance and availability of data. Other variables for which data were sought included participant characteristics (e.g. age, parity, socio-economic status) and intervention characteristics (e.g. type, duration, and frequency of antenatal education). Assumptions were made about missing or unclear information by contacting study authors for clarification.
Data extraction and quality assessment
Data were extracted from the included studies using a standardized form. Extracted information included study characteristics, participant demographics, participants’ characteristics related to maternity history (e.g. gestational weeks), intervention details, outcome measures, and results. Two investigators (AAEA and NHA) independently extracted the data, and a third investigator (DAG) assisted in resolving disagreements.
The methodological quality of the included studies was assessed using the Cochrane risk of bias tool for randomized trials version 2 (RoB2). Two investigators (IHA and NMA) independently assessed each study, and no automation tools were used in this process24. We also employed the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria to provide a broader assessment of the confidence in the overall evidence supporting the outcomes of interest. We conducted publication bias analysis using funnel plots for primary outcomes using RevMan 5.4 software and considered statistical tests for funnel plot asymmetry, such as Egger’s test and Begg’s test.
Data synthesis
We performed meta-analyses using Review Manager RevMan software (version 5.4). For continuous outcomes, we calculated standardized mean difference (SMD) or mean difference (MD) with 95% confidence interval (CI). For dichotomous outcomes, we used risk ratios (RR). We used the fixed effect model with homogenous data.
Heterogeneity was assessed using the I² statistic and p-value of heterogeneity, with p<0.1 indicating high heterogeneity. The thresholds for the I² statistic were as follows: 0–40% might not be important, 30–60% may represent moderate heterogeneity, 50–90% may represent substantial heterogeneity, and 75–100% considerable heterogeneity20. When significant heterogeneity was detected (p<0.1), we used a random effect model and conducted sensitivity analyses by excluding studies that contributed significantly to the heterogeneity.
We decided which studies were eligible for each synthesis by tabulating the study’s primary and secondary outcomes and comparing them against the planned groups for each synthesis. Methods required to prepare the data for presentation or synthesis included handling missing summary statistics by contacting study authors for clarification or using imputation methods where appropriate and data conversions when necessary.
RESULTS
Our search yielded 5731 PubMed, Web of Science, Cochrane Library, and SCOPUS records. After removing 2059 duplicates, 3672 records underwent title and abstract screening, resulting in 3625 exclusions. The full-text screening was conducted on 47 reports, excluding seven additional records due to duplicates, having irrelevant controls, addressing psychotherapy instead of education, or focusing on fathers. Finally, 40 studies were included in the systematic review, with 31 eligible for meta-analysis (Figure 1).
Figure 1
Flow diagram of study selection and inclusion process of the systematic review for the role of antenatal education on maternal self-efficacy, fear of childbirth, and birth outcomes
Baseline and characteristics of the included studies
The included studies were conducted in diverse settings, such as Turkey, Iran, Jordan, Nigeria, Denmark, and the USA. The educational content of antenatal courses varied widely, covering reproductive system changes, pregnancy physiology, birth preparedness, postpartum care, and breastfeeding techniques. The study duration ranged from a few months to several years. Participants’ gestational weeks at the start of interventions ranged from as early as 12 weeks25 to the last trimester. Sample sizes ranged from 29 to 13737 participants. The mean age of participants also varied widely, with studies reporting means ranging from 18.20 to 32.8 years (Table 1)25-63.
Table 1
Summary and baseline of the included studies
| Author Year | Location | Study duration | Educational content | Gestational weeks | Sessions | Primary outcomes | Follow-up | Conclusions | Study arms | Sample | Age (years) Mean ± SD |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Aba et al.25 2017 | Turkey | August 2011 and October 2013 | Reproductive system, pregnancy physiology, maternal changes, exercise, postpartum care, breastfeeding | 12–17 | 6 | PSEQ, PPSEQ, NPI | The followup spanned approximately 30 weeks, from the 12th week of pregnancy to the fourth week after delivery | Antenatal education improved prenatal and early postpartum adaptation | AN | 35 | 18.20 ± 0.99 |
| Control | 35 | 18.03 ± 0.89 | |||||||||
| Abbasi et al.26 2017 | Iran | October 2015 and April 2016 | Pregnancy modification, exercises, breathing, relaxation | 32–36 | Weekly reminders | CBSEI | Till delivery | E-learning and booklets boosted childbirth confidence | AN-Software | 50 | 25.5 ± 3.8 |
| AN-Booklet | 51 | 25.9 ± 3.6 | |||||||||
| Control | 52 | 25.1 ± 3.2 | |||||||||
| Abuidhail et al.27 2019 | Jordan | - | Breastfeeding benefits, techniques, problems, storage | 29–36 | 2 weeks access | Breastfeeding knowledge, attitude, self-efficacy | Two weeks postpartum | No significant differences, but it may enhance selfefficacy | AN | 59 | 27.7 ± 4.9 |
| Control | 59 | ||||||||||
| Akinwaare et al.28 2023 | Nigeria | March 2019 and January 2020 | Birth preparedness, complication readiness | 20–24 | 20-min + 10-min interactive | BPCR, institutional delivery | Twelve weeks post-intervention | Enhanced birth preparedness and institutional delivery rates | AN | 200 | 27.4 ± 4.9 |
| Control | 200 | 27.1 ± 5.1 | |||||||||
| Aksoy Derya et al.29 2021 | Turkey | April and May, 2020 | Tele-education on pregnancy, birth, COVID-19 | Last trimester | 5 (15–20 min each) | Prenatal distress, pregnancy anxiety | After one-week tele-education intervention | Reduced distress and anxiety | AN | 48 | 28.70 ± 4.73 |
| Control | 48 | 28.06 ± 4.12 | |||||||||
| AlSomali et al.30 2019 | Saudi Arabia | - | Antenatal education on pregnancy, birth, COVID-19 | 28–33 | 2 (2 h 50 min each) | Prenatal distress, pregnancy anxiety | Pretest and posttest data collection | Boosted maternal self-efficacy | AN | 46 | - |
| Control | 48 | ||||||||||
| Aslantekin Özçoban et al.31 2022 | Turkey | July 2018 to April 2019 | Birth preparation | Second trimester | 15 (3/week, 5 weeks) | Pregnancy acceptance, motherhood role, birth fear, selfefficacy, health literacy | Pretest and posttest data collection | Improved most scales except birth fear | AN | 56 | - |
| Control | 73 | ||||||||||
| Citak Bilgin et al.32 2019 | Turkey | September 2015 to June 2017 | Delivery fear, birth stages, pain management, newborn care | Second trimester | 5/weekly | POBS, BSES-SF, VAS | One month post-birth | Improved birth perception and breastfeeding selfefficacy | AN | 65 | 27.54 ± 3.78 |
| Control | 57 | 27.23 ± 4.82 | |||||||||
| Brixval et al.33 2016 | Denmark | August 2012 to May 2014 | NEWBORN program | 25–35 | 3 (2.5 h each) | Epidural use | Till 9 weeks postpartum | No difference in pain relief or interventions | AN | 883 | 30.7 ± 4.1 |
| Control | 883 | 30.8 ± 4.1 | |||||||||
| Calpbinici et al.34 2022 | Turkey | August 2019 to February 2020 | Motivational interview for childbirth fear | 24–28 | - | W-DEQ A/B, CBSEI-SF | Till 24 hours after delivery | Reduced fear, increased selfefficacy, no impact on delivery mode | AN | 37 | - |
| Control | 36 | ||||||||||
| Çankaya et al.24 2020 | Turkey | April to September 2019 | Birth fear, dynamics, coping, postpartum care | 20–32 | 8 (4 h each) | Fear, self-efficacy, anxiety, stress, depression, delivery mode | 6–8 weeks postpartum | Significant clinical benefits during pregnancy and postpartum | AN | 57 | 26.4 ± 3.1 |
| Control | 59 | 25.3 ± 3.7 | |||||||||
| Dai et al.35 2021 | China | October 2018 to November 2019 | Simulationbased childbirth education | 24–32 | 4 (70 min each) | WDEQ-A, CBSEI | Till delivery | An effective method for childbirth education | AN | 26 | 28.42 ± 2.53 |
| Control | 30 | 28.20 ± 2.19 | |||||||||
| Desmawati et al.36 2019 | Indonesia | June 2016 to January 2017 | Non- pharmacological pain relief, Islamic praying | 32 | Daily until delivery | VAS, PBOS | Till delivery | Reduced pain, increased pain behaviors | AN | 41 | - |
| Control | 42 | ||||||||||
| Duncan et al.37 2017 | USA | In 2014 | Mindfulnessbased childbirth and parenting | 29–36 | 18-h weekend workshop | CBSEI | 6 weeks postpartum | Improved childbirth appraisals, reduced postpartum depression risk | AN | 15 | - |
| Control | 14 | ||||||||||
| Escott et al.38 2005 | England | February to October 2000 | Coping strategy enhancement vs standard | 32 | 5 (2 h each) | Coping strategy use, pain, emotional experience | Three days pot delivery | Enhanced coping strategy use and birth companion involvement | AN | 20 | 29 ± 5.9 |
| Control | 21 | 29 ± 6.7 | |||||||||
| Firouzan et al.39 2020 | Iran | February to September 2019 | BELIEF approach, telephone counseling | 20–23 | 2 face-to-face, 8 phone | W-DEQ, childbirth self-efficacy, preference | Post-test assessments after the intervention | Reduced fear, increased selfefficacy | AN | 35 | 26.27 ± 4.48 |
| Control | 33 | 25.87 ± 4.58 | |||||||||
| Franzon et al.40 2019 | Brazil | August 2015 to February 2016 | PRENACEL program | <20 | 4 texts/week | Preparedness, outcomes, intervention knowledge, care satisfaction | Until hospital discharge | Improved preparedness for birth | AN | 116 | - |
| Control | 440 | ||||||||||
| Gandomi et al.41 2022 | Iran | May to September 2017 | Self-efficacy focused intervention | 26–28 | 8 (90 min each) | Anxiety, neonatal outcomes | One month after the intervention | Reduced anxiety, improved pregnancy outcomes | AN | 30 | 23.8 ± 3.31 |
| Control | 30 | 23.3 ± 3.60 | |||||||||
| Gao et al.42 2012 | China | July 2008 to May 2009 | IPT-oriented childbirth education | >28 | 2 (90 min) + phone follow-up | PSSS, PSOC-E, EPDS, GHQ | Three months postpartum | Beneficial for first-time Chinese mothers | AN | 96 | 28.47 ± 2.80 |
| Control | 98 | 28.38 ± 2.73 | |||||||||
| Hatamleh et al.43 2019 | Jordan | July to September 2016 | Class-based program + WhatsApp | ≥32 | 3 (40 min each) | Birth outcomes, breastfeeding initiation | 48 hours post-birth | Increased spontaneous labor onset, earlier breastfeeding | AN | 64 | 32.8 ± 3.65 |
| Control | 64 | ||||||||||
| Hatamleh et al.44 2023 | Jordan | July to September 2016 | Individualized childbirth education | ≥32 | 3 (40 min each) | CBSEI, STAI | 3 weeks after completing all educational sessions | Enhanced coping, reduced anxiety | AN | 64 | 23.8 ± 3.91 |
| Control | 64 | ||||||||||
| Ip et al.45 2009 | Hong Kong | August 2003 and April 2004 | Self-efficacy and coping skills | 32–34 | 2 (2 h 50 min each) | OE, EE, anxiety, pain, coping | 24–48 hours after delivery | Promoted self-efficacy, reduced pain and anxiety | AN | 60 | 27.88 ± 5.07 |
| Control | 73 | 27.81 ± 5.09 | |||||||||
| Khademioore et al.46 2023 | Iran | February to April 2020 | Tele-midwifery application | 26–29 | 8 weeks, 3–4 msgs/day | FOC, self-efficacy, delivery mode | Two hours after birth | Reduced fear, increased self-efficacy, decreased C-sections | AN | 35 | 24.3 ± 3.5 |
| Control | 35 | 25.6 ± 3.5 | |||||||||
| Kronborg et al.47 2012 | Denmark | May 2006 to May 2007 | ‘Ready for Child’ program | 30–35 | 3 (3 h each) | Breastfeeding duration | One year postpartum | Increased breastfeeding confidence and knowledge | AN | 587 | 28.9 ± 3.7 |
| Control | 575 | 29.2 ± 3.7 | |||||||||
| Madhavanprabha- karan et al.48 2017 | India | Between 2004 and 2005 | Planned childbirth educational program | Third trimester | 3 | Anxiety, knowledge, pregnancy outcomes | Two weeks after the final educational session | Reduced anxiety and adverse outcomes | AN | 50 | - |
| Control | 50 | ||||||||||
| Maimburg et al.49 2010 | Denmark | May 2006 to May 2007 | ‘Ready for Child’ program | 30–35 | 3 (3 h each) | Birth process, interventions, experience | One year postpartum | Improved coping with the birth process | AN | 587 | 28.9 ± 3.7 |
| Control | 575 | 29.2 ± 3.7 | |||||||||
| Maimburg et al.50 2013 | Denmark | May 2006 to May 2007 | ‘Ready for Child’ program | 30–35 | 3 (3 h each) | Cambridge Worry Scale | One year postpartum | Lower worry levels, especially birth-related | AN | 587 | 28.9 ± 3.7 |
| Control | 575 | 29.2 ± 3.7 | |||||||||
| Mehdizadeh et al.51 2005 | Iran | July 2000 to March 2001 | Birth preparation classes | >20 | 8 | Pain, daily activity | Till delivery | Improved maternal and newborn health | AN | 100 | - |
| Control | 100 | ||||||||||
| Mohaghegh et al.52 2023 | Iran | December 2020 to June 2021 | Childbirth preparation + birth plan | 32–33 | 8 (90 min) + 1 | Birth mode, labor duration, satisfaction | 12–24 hours after birth | Increased normal births and satisfaction | AN | 150 | 29.11 ± 4.72 |
| Control | 150 | 28.90 ± 4.81 | |||||||||
| Mullany et al.53 2006 | Nepal | August 2003 to January 2004 | Pregnancy care, birth preparedness | 16–28 | 2 (35 min each) | Birth preparedness, healthcare utilization | Postpartum discharge | No significant differences in outcomes | AN | 148 | 22.0 ± 3.6 |
| Control | 149 | 22.6 ± 3.3 | |||||||||
| Noel-Weiss et al.54 2006 | Canada | August 2004 to February 2005 | Prenatal breastfeeding workshop | >34 | 1 (2.5 h) | Breastfeeding self-efficacy, duration | 8 weeks postpartum | Improved self-efficacy, increased exclusive breastfeeding | AN | 47 | - |
| Control | 45 | ||||||||||
| Öztürk et al.55 2022 | Turkey | November 2016 to January 2018 | Breastfeeding education | Pre-delivery | 2 (4 h each) | Breastfeeding self-efficacy, success | One week postpartum | Enhanced self-efficacy, increased success | AN | 34 | - |
| Control | 33 | ||||||||||
| Rahimparvar et al.56 2012 | Iran | October 2010 to February 2011 | Educational software (CD) | 28–32 | Accessible anytime | CBSEI, STAI | Till delivery | Improved self-efficacy in coping with labor | AN | 75 | 25.17 ± 3.89 |
| Control | 75 | 24.79 ± 4.21 | |||||||||
| Sabri Piro et al.57 2020 | Iraq | October 2017 to July 2018 | Breastfeeding education | 30–38 | 2 (60–90 min each) | BF knowledge, attitudes, self-efficacy | Two months after childbirth | Increased self-efficacy, promoted exclusive BF | AN | 65 | 26.80 ± 6.60 |
| Control | 65 | 26.38 ± 6.80 | |||||||||
| Serçekuş et al.58 2016 | Turkey | March 2012 to January 2014 | Comprehensive antenatal education | 26–28 | 8 (120 min each) | W-DEQ, CBSEI, MAI, PPAQ | 6 months postpartum | Recommended implementation in developing countries | AN | 31 | 28.8 ± 2.2 |
| Control | 32 | 27.7 ± 4.5 | |||||||||
| Turkstra et al.59 2017 | Australia | May 2012 to June 2013 | Telephone psychoeducation | 24–34 | 2 | WDEQ-A | 6 months postpartum | No enhancement in health-related quality of life | AN | 95 | 30.5 ± 4.98 |
| Control | 89 | 30.2 ± 5.82 | |||||||||
| Uludağ et al.60 2022 | Turkey | October to December 2021 | 24–34 | 8 (4 h each) | OWLS, FOBS, PSEQ, FCV-19S | Post-test assessments after the intervention | Improved labor preparedness during COVID-19 | AN | 23 | 26.69 ± 4.93 | |
| Control | 21 | 25.66 ± 4.58 | |||||||||
| Xie et al.61 2018 | China | October 2011 to August 2012 | WHO materials via text messages | Throughout | Text messages | Maternal/perinatal outcomes | Within 42 days postpartum | No significant differences | AN | 6771 | - |
| Control | 6966 | ||||||||||
| Yesildag et al.62 2024 | Turkey | January to July 2022 | Web-based program + motivational interviews | 28–30 | 5 weeks | W-DEQ A, CSES, BHBS | Till 24 hours after delivery | Reduced fear, increased self-efficacy | AN | 37 | - |
| Control | 36 | ||||||||||
| Zafman et al.63 2023 | USA | April 2021 to April 2022 | Birthing online program | <20 | 5 courses | PrAS | Postpartum discharge | Reduced anxiety, decreased emergency care use | AN | 45 | 23.7 ± 4.5 |
| Control | 45 | 23.7 ± 4.7 |
[i] AN: antenatal. CBSEI: Childbirth Self-Efficacy Inventory. PSEQ: Prenatal Self-Efficacy Questionnaire. PPSEQ: Postpartum Self-Efficacy Questionnaire. NPI: Neonatal Perception Inventory. BPCR: Birth Preparedness and Complication Readiness. CBSEI-SF: Childbirth Self-Efficacy Inventory-Short Form. W-DEQ A/B: Wijma Delivery Expectancy/Experience Questionnaire A/B. POBS: Pain Outcomes Brief Scale. BSES-SF: Breastfeeding Self-Efficacy Scale-Short Form. VAS: Visual Analog Scale. NEWBORN: Newborn Care Program. PSSS: Perceived Social Support Scale. PSOC-E: Parent Stress Index-Early Childhood. EPDS: Edinburgh Postnatal Depression Scale. GHQ: General Health Questionnaire. FOC: fear of childbirth. OE: overall experience. EE: emotional experience. CSES: Coping Self-Efficacy Scale. BHBS: Breastfeeding and Health Behavior Scale. OWLS: Overall Wellness Scale. FOBS: Fear of Birth Scale. FCV-19S: Fear of COVID-19 Scale. PrAS: Pregnancy and Childbirth Anxiety Scale.
Quality assessment
Four studies were classified as having a high risk of bias using the RoB2 quality assessment tool, three of which showed high risk in the domain of missing outcome data and one study in the randomization process. Another five studies were classified as having some concerns, with four showing some concerns in the domain of the randomization process and one study in the selection of the reported result domain. The other 31 were rated as having an overall low risk of bias (Supplementary file Figures 1 and 2).
Primary outcomes
Change in self-efficacy on childbirth
The pooled analysis of 12 RCTs, involving 1116 pregnant women, showed a significant increase in the self-efficacy on childbirth in the group that received antenatal (AN) education compared with the control group (SMD=2.00; 95% CI: 1.06–2.95, p<0.0001) (Figure 2). The data showed unresolvable heterogeneity (p<0.00001, I2=98%), which could not be adequately explained or reduced even after conducting additional analyses (e.g. subgroup analyses, sensitivity analyses, or using different statistical models). Possible causes of heterogeneity among study results include variations in study design, population characteristics, and intervention protocols. There appears to be some evidence of publication bias for self-efficacy, as the funnel plot shows an asymmetrical distribution, suggesting a potential bias (Supplementary file Figure 3).
Change in fear of childbirth
AN education significantly decreased the fear of childbirth in pregnant women compared with the control group based on the pooled analysis of 12 RCTs, including 879 women (SMD= -1.26; 95% CI: -1.79 – -0.74, p<0.00001) (Figure 3). Still, the data showed unresolvable heterogeneity (p<0.00001, I2=92%), which could not be adequately explained or reduced after additional analyses. Possible causes of heterogeneity include differences in the measurement tools used and the timing of the interventions. The fear of birth funnel plot also shows some asymmetry, indicating a possible bias (Supplementary file Figure 4).
Secondary outcomes
Maternal outcomes
Frequency of vaginal delivery
The rate of vaginal delivery showed a significant increase among women who received AN education compared with the control group based on the pooled analysis of 18 RCTs involving 18873 women (RR=1.10; 95% CI: 1.04– 1.16, p=0.0004); however, the data were heterogeneous (p<0.00001, I2=69%). This heterogeneity was resolved by excluding the study of Mohaghegh et al.52 (p=0.10, I2=32%), and the results remained significant (RR=1.06; 95% CI: 1.03–1.10, p=0.0007) (Figure 4).
Figure 4
Forest plot of the effect of antenatal education on rate of vaginal delivery: A) Before resolving heterogeneity; B) After resolving heterogeneity
Frequency of cesarean section
In contrast, the pooled analysis of 18 RCTs, including 18873 women, revealed a significantly lower cesarean section rate in the AN education group compared with the control group (RR=0.80; 95% CI: 0.70–0.92, p=0.001). Still, the data showed heterogeneity (p=0.001, I2=57%). This heterogeneity was resolved by excluding the study of Mohaghegh et al.52 (p=0.37, I2=7%), and the results remained significant (RR=0.88; 95% CI: 0.82–0.94, p=0.0002) (Figure 5).
Figure 5
Forest plot of the effect of antenatal education on rate of cesarean section: A) Before resolving heterogeneity; B) After resolving heterogeneity
Frequency of episiotomy
There was an insignificant difference between the two groups in the episiotomy rate (RR=1.16; 95% CI: 1.00–1.34, p=0.06), and the data were homogenous (p=0.71, I2=0%) (Supplementary file Figure 5).
Neonatal outcomes
Apgar score after one and five minutes
There was an insignificant difference between the AN education and the control group of neonatal APGAR score after one and five minutes (MD=0.05; 95% CI: -0.04–0.14, p=0.24) and (MD=0.03; -0.03–0.10, p=0.30), respectively. The data were homogenous in both analyses (p=0.72, I²=0%) and (p=0.73, I²=0%) (Supplementary file Figure 6).
Infant’s birth weight
There was an insignificant difference between the two groups in the infant weight (MD=19.13; 95% CI: -81.23–119.48, p=0.71), but the data were heterogeneous (p=0.0006, I²=77%). Even after resolving heterogeneity by excluding Citak Bilgin et al.32 (p=0.14, I²=42%), the results remained insignificant (MD= -36.12; 95% CI: -99.16–26.92, p=0.26) (Supplementary file Figure 7).
Incidence of low birth weight (<2500 g)
Finally, there was an insignificant difference between AN education and control groups in the incidence of low birth weight (RR=0.98; 95% CI: 0.83–1.17, p=0.85), and the data were homogenous (Supplementary file Figure 8).
DISCUSSION
Our meta-analysis reveals that antenatal (AN) education programs significantly positively impact key psychological and clinical outcomes for expectant mothers. The primary results demonstrate an increase in childbirth self-efficacy and a notable decrease in fear of childbirth among women who participated in AN education compared to control groups. Secondary outcomes show improvements in maternal outcomes, such as increased rates of vaginal delivery and decreased rates of cesarean sections. These findings suggest that such programs effectively empower women with knowledge and confidence, potentially enhancing their ability to cope with the challenges of childbirth. The novelty of this meta-analysis lies in its comprehensive evaluation of both psychological and clinical outcomes, providing robust evidence for the multifaceted benefits of AN education programs.
The observed improvements in self-efficacy and reduced fear may be attributed to several factors inherent in antenatal education programs23. These programs typically provide comprehensive information about pregnancy, labor, and delivery, which can demystify the process and alleviate anxiety stemming from the unknown6. Additionally, many antenatal classes incorporate practical coping strategies and relaxation techniques, equipping women with tangible skills to manage pain and stress during childbirth64. The group setting of many programs may also foster a sense of community and shared experience, further bolstering confidence and reducing isolation-related fears65.
Our analysis revealed significant clinical benefits associated with AN education. Women who received AN education showed higher rates of vaginal delivery and lower rates of cesarean section. These outcomes may be directly linked to the psychological benefits observed. Increased self-efficacy and reduced fear could contribute to more relaxed and confident mothers, potentially facilitating smoother labor progression and reducing the likelihood of interventions66. Moreover, educated mothers may be better equipped to make informed decisions about their care, possibly leading to fewer unnecessary cesarean sections67.
Interestingly, we found no significant differences in episiotomy rates, Apgar scores, infant birth weight, or incidence of low birth weight between the intervention and control groups. This suggests that while AN education has clear benefits for maternal psychological well-being and mode of delivery, its impact on specific obstetric and neonatal outcomes may be limited. These results highlight the complex interplay of factors influencing childbirth outcomes and underscore the need for comprehensive prenatal care beyond education alone.
Our results align with those of Zanetti et al.8. Our meta-analysis demonstrates a significant increase in childbirth self-efficacy (SMD=2.00; 95% CI: 1.06–2.95, p<0.0001). Zanetti et al.8 also observed significant improvements, reporting outcome expectancy scores of 16.00 and efficacy expectancy scores of 20.44. Both studies highlight the positive impact of AN education on self-efficacy, with our standardized mean difference offering a more generalizable effect size. We found a significant increase in vaginal delivery rates (RR=1.10; 95% CI: 1.04–1.16, p=0.0004), consistent with the Zanetti et al.8 findings of increased frequency (OR=1.28). Both studies indicate that AN education is associated with higher rates of vaginal delivery, with our larger sample size yielding a more precise estimate. We found no significant difference in episiotomy rates (RR=1.16; 95% CI: 1.00–1.34, p=0.06), aligning with the Zanetti et al.8 results.
Our study explored additional outcomes not covered by Zanetti et al.8 including fear of childbirth, cesarean section rates, and various neonatal outcomes. This comprehensive approach provides a broader perspective on the effects of antenatal education. Our meta-analysis, encompassing 40 studies in the systematic review and 31 in the meta-analysis, offers potentially more robust and generalizable conclusions than the Zanetti et al.8 analysis of nine studies.
Nevertheless, our findings on the fear of childbirth are consistent with Stoll et al.68, who reported that psycho-education interventions effectively reduce the fear of childbirth. Our study further corroborates this by focusing on antenatal education programs and their impact on fear and self-efficacy. Meanwhile, our results indicating increased vaginal delivery rates and decreased cesarean section rates align with the Cochrane review by Sandall et al.69, which found that midwife-led continuity models of care, often incorporating comprehensive antenatal education, are associated with higher rates of spontaneous vaginal birth.
The consistent positive effects of AN education on maternal psychological outcomes and mode of delivery have significant implications for maternity care practices. These findings suggest that investing in comprehensive and accessible AN education programs could be a cost-effective strategy to enhance maternal experiences and clinical outcomes. By boosting self-efficacy and reducing fear, these programs may lead to more positive birth experiences, potentially lowering the risk of postpartum depression and improving mother-infant bonding. However, the lack of significant impact on certain neonatal outcomes indicates that while AN education is beneficial, it should be part of a broader prenatal care approach. This approach may include addressing social determinants of health, ensuring adequate nutrition, and providing comprehensive medical care throughout pregnancy. From a policy perspective, these results support the integration of high-quality AN education as a standard component of maternity care. Healthcare systems and providers should prioritize developing and implementing evidence-based education programs that are culturally appropriate and accessible to diverse populations.
Strengths and limitations
A key strength of our study is its comprehensive nature, including many randomized controlled trials (RCTs) and a substantial combined sample size. This provides strong evidence for the effectiveness of antenatal education. Additionally, our analysis considered both psychological and clinical outcomes, offering a comprehensive view of the impacts of these programs. Another strength of our study is that we exclusively included RCTs as part of the inclusion criteria for study selection.
However, several limitations should be noted. The potential risk of bias in the included studies and the high heterogeneity observed in some analyses suggest considerable intervention and outcome variability across studies. While partly resolved through sensitivity analyses, this heterogeneity indicates the need for caution in interpreting and generalizing results. Furthermore, the potential publication bias identified for primary outcomes suggests that positive results may be overrepresented in the literature. Another limitation is the variability in antenatal education programs’ content, duration, and delivery methods across studies. Publication bias in this meta-analysis may arise from several factors, including the tendency to publish studies with positive findings, selective outcomes reporting, and excluding studies not in English. Despite these biases, the results of our meta-analysis can still be generalized to a broader population due to the large sample size and the inclusion of diverse study settings. However, caution should be exercised when interpreting the findings, and further research is needed to confirm these results in different contexts and populations. This makes it challenging to identify specific components that are most effective. Most of the studies included were conducted in middle- to high-income countries, which could restrict the applicability of the findings to low-resource settings.
CONCLUSIONS
Our meta-analysis provides strong evidence for the benefits of antenatal education in improving maternal psychological outcomes and promoting vaginal delivery. These findings underscore the importance of integrating high-quality antenatal education into routine prenatal care. Future research should focus on identifying the most effective components of these programs and exploring their long-term impacts on maternal and child health. Additionally, efforts should be made to develop and evaluate culturally adapted antenatal education interventions for diverse populations, particularly in low-resource settings. Policymakers and healthcare providers should prioritize the implementation and accessibility of evidence-based antenatal education programs as a key strategy to enhance maternal and neonatal outcomes.
