Background: Fear of childbirth during pregnancy is considered normal up to a certain level. It is important when it is experienced in a discomfortingly and affects daily life. Psychological problems such as fear of childbirth and related anxiety cause deterioration of prenatal attachment. Therefore, psychological interventions in the antenatal period are gaining more and more importance in order to protect the mental health of women.
Objectives: The aim of this study is to determine the effect of psychoeducation applied in primiparous pregnant women on fear of birth, prenatal attachment and anxiety. Research is designes as pre-test post-test intervention.
Methods: The sample of the study consists of 12 primiparous pregnant women who admitted to the obstetrics and gynecology out patient clinic. Sociodemographic Data Collection Form, Prenatal Attachment Inventory, Beck Anxiety Scale and Wijma Birth Expectation/Experience Questionnaire (W-DEQ) Version A were used to collect research data. Along with the pre-test data, 8 sessions of psychoeducation program were applied. In the analysis of the data, IBM SPSS Statistics 20.0 package program, percentage, frequency and paired sample t test were used.
Results: The difference between the mean scores of Wijma Birth Expectation/Experience Questions Version A before and after the psychoeducation program was found to be statistically significant (p < 0.001). The mean prenatal attachment inventory score was 49.00 7.82 before the psychoeducation program. The mean score increased after the psychoeducation program and was 65.00 5.92. The mean score of the beck anxiety scale before and after psychoeducation was found to be statistically significant (p < 0.001).
Conclusion: This study shows that psychoeducation applied to primiparous pregnant women in their second trimester reduces fear of childbirth and anxiety, also increases prenatal attachment. This method is easy to apply and effective, so it is recommended to be applied to pregnant women by health care professionals.
Anxiety, Fear of childbirth, Prenatal attachment, Primiparous pregnancy, Psychoeducation
Pregnancy may cause fear of childbirth as it is perceived as a traumatic and stressful period that causes changes in the mental, social and physical life conditions of women [1]. Birth is experienced as one of the important desired events in women's lives and is a potentially painful process that can threaten the life of the expectant mother [2,3]. In studies comparing multiparous and primiparous women, it is reported that uncertainty, labor pain and fear of childbirth due to not being able to control this situation are more common and more severe [4-6]. In addition, education level, low self-perception, insufficient social support, weak relationship with spouse, not being ready for pregnancy and personality traits are among the factors that cause fear of childbirth [6,7].
Fear of childbirth during pregnancy is considered normal upto a certain level. It is important when it is experienced in a discomfortingly and affects daily life [8]. When the literature is examined, it is stated that one out of every five women experience fear of childbirth and 6-36% experience severe fear [9,10]. Therefore, it is common to experience antenatal mental disorders such as anxiety and depression during pregnancy [3,11].
Studies show that fear of childbirth and anxiety are related to three reasons. The first is that the pregnant woman perceiving her own situation as annoying and disturbing, the second is that watching someone else giving birth, and the third is that listening to false and negative horror stories about childbirth [5,12]. Fear of doing herself or newborn an injury, fear of death, traumatic birth experience, personality traits, negative and anxiety feelings to wards motherhood are counted among the biological factors for fear of childbirth and anxiety [13]. In a systematic review of 21 studies, it is shown that fear of childbirth is associated with anxiety and depressive symptoms [14].
Experienced fear of childbirth and mental problems may negatively affect prenatal attachment or the ability to establish a relationship with the newborn [15]. Prenatal attachment refers to a process that begins with pregnancy and continues and develops afte rbirth [16]. The healthy progress of prenatal attachment is related to the adaptation of the pregnant to motherhood and the development of emotional bond with the baby. In this context, the mother should have communication with her unborn baby, about plans for the future, fantasies and activities [15,17]. Mental or physical health problems such as fear of childbirth and anxiety are related to it may cause deterioration of prenatal attachment. For this reason, psychological interventions in the antenatal period are gaining more and more importance due to the prevalence of women's mental health problems and their negative effects on the child [16,18]. These interventions include cognitive behavioral therapy, mindfulness therapy, problem-solving therapy, psychoeducation, psychotherapy or inter personal therapy [19].
It is seen that psychoeducation applied in terms of early detection of pregnancy-related mental problems and contributing to problem-solving skills provides positive perinatal outcomes in pregnant women [20]. Psychoeducational intervention is a prenatal intervention method to support pregnant women to care for themselves or their babies. It increases compliance with pregnancy, to develop a positive perception of birth, and enhances knowledge and skills [20,21].
The aim of this study is to determine the effect of psychoeducation applied in primiparous pregnant women on fear of birth, prenatal attachment and anxiety.
This study is conducted with a pre-test post-test education intervention pattern in order to determine the effect of the psychoeducation program applied to primiparas at 20-34 weeks of gestation on fear of birth, prenatal attachment and anxiety.
The sample of the study consists of 12 primiparous pregnant women between 20 th and 34 th gestational weeks who admitted routine follow-ups in a gynecology and obstetrics clinic in Turkey between 02-2023 and 04-2023. The criteria for inclusion in the study were determined as non-risky pregnancy, being 18 years or older, having a single and live pregnancy, volunteering to participate in the study, and being between the 20 th and 34 th weeks of pregnancy.
The pregnant women who came to have their routine follow-ups were informed about the purpose of the study. An informed consent form was signed face-to-face in the interview room with the pregnant women who met there search criteria and agreed to participate in thestudy. The psychoeducation program was designed to increase prenatal attachment by reducing fear of birth, negative mood and anxiety symptoms within the scope of adaptation to pregnancy and preparation for childbirth in primiparous pregnant women [2,22].
The structure of the intervention was developed on the basis of psychological adaptation to pregnancy, labor symptoms and processes of labor, coping with contractions, and practices to increase prenatal attachment. The content of the training program is shown in Table 1.
Table 1: Content of the psychoeducational intervention. View Table 1
The data of this study were collected using the "Sociodemographic Data Collection Form", "Prenatal Attachment Inventory", "Beck Anxiety Scale" and "Wijma Birth Expectation/Experience Questions (W-DEQ) Version A" scales.
Based on previous studies, the researchers prepared a form questioning th eobstetric characteristics and sociodemographic data such as age, educational status, marital status and marriage age of participants [23,24].
The prenatal attachment inventory (PAI) was developed by Mary Muller in 1993 to measure the attachment level in the prenatal period by describing the feelings, thoughts and situations of women during pregnancy. The Turkish validity and reliability study of the scale was conducted by Dereli Yılmaz and Kızılkaya Beji in 2010. PAI is applied to pregnant women between 20 and 40 weeks. There are 21 items in the scale. Each item is scored between 1 and 4 (1: Never, 2: Sometimes, 3: Often, 4: Always). Scale scoring ranges from 21 to 84. A high score for the pregnant indicates that the level of attachment to her baby is high. The Turkish Cronbach Alpha reliability coefficient of the scale was stated as 0.84 [25].
The Beck anxiety scale was developed by Beck, et al. in 1988 to measure anxiety symptoms and reveal the cognitive aspects of anxiety. The Turkish validity and reliability study of the scale was performed by Ulusoy, et al. The scale consists of 21 items and is a four-point Likert type scale with a score between 0 and 3. Scale scoring ranges from 0 to 63. The Cronbach alpha value of the scale was found to be 0.93 [26].
The scale, developed by Wijma, et al. in 1998 to determine the level of fear of childbirth in pregnant women, was validated in Turkish by Körükçü, et al. (2012). W-DEQ version A consists of 33 items. Responses from 0 to 5 in the scale are numbered six-point Likert type. The scale is scored between 0-165. A high score indicates a high level of fear of childbirth. The Cronbach Alpha value of the scale for Turkey was found to be 0.88 for primiparous pregnants and 0.90 for multiparous pregnants [27].
SPSS 20.0 package program was used to evaluate the research data. The statistical significance of the data was evaluated at the p < 0.05 level. The normal distribution of the data was checked by Kolmogorov-Smirnov test and homogeneity was checked by Levene's test. Descriptive statistics (percentage, frequency) were used in the evaluation of demographic data, and paired sample t-test was used in the analysis of data before and after psychoeducation.
The permission of Tokat Gaziosmanpaşa University Clinical Research Ethics Committee was obtained for their search. Oral and written consent was obtained from all pregnant women participating in the study.
In the demographic characteristics analysis, it was determined that 58.3% of the participants were between the ages of 26-43, 58.3% were high schoolgraduates, 75% were unemployed, 66.7% had a nuclearfamily, and 41.7% lived in the province. It was found that 75% of them were between 18 and 24 years of age at marriage (Table 2).
Table 2: Distribution of pregnant women according to their sociodemographic characteristics (n = 12). View Table 2
It was found that 83.3% of the participants had planned pregnancy, 58.3% had the desired baby gender, 58.3% did not have regular follow-up, and 75% did not have any problems in their marriage due to pregnancy. 58.3% stated that they had pregnancy-related problems in their daily life (Table 3). The mean week of gestation was 27.25 ± 2.13 (min: 24 weeks; max: 31 weeks).
Table 3: Distribution of pregnant women according to their obstetric characteristics (n = 12). View Table 3
Table 4 presents the W-DEQ A Versions core averages of the pregnant women before and after the psychoeducation program. While the mean W-DEQ A Version score of the pregnant womenwas 69.00 ± 10.29 before the psychoeducation program, it was found to be 46.33 ± 7.05 after the psychoeducation program. The difference between the mean scores before and after psychoeducation was found to be statistically significant (p < 0.001). While the average PAI score of the pregnant women was 49.00 ± 7.82 before the psychoeducation program, it was found that the average score increased after the psychoeducation program and was 65.00 ± 5.92. The difference between the mean scores before and after psychoeducation was found to be statistically significant (p < 0.001). In the examination of BAS score averages, it was determined that the score before the psychoeducation program was 34.08 ± 3.34 and after the psychoeducation program the average score decreased to 18.58 ± 4.33. The mean BAS score of pregnant women before and after psychoeducation was found to be statistically significant (p < 0.001) (Table 4).
Table 4: W-DEQ A, PAI, and BAS score averages before and after psychoeducation. View Table 4
Fear of childbirth is a common problem among all pregnant women. However, it is reported that this fear is experienced more in primiparous women due to the obscurity about childbirth, contractions experienced during childbirth, and the inability to control this situation [6]. Psychological problems such as fear of childbirth and related anxiety cause deterioration of prenatal attachment [18].
In our study, those who scored medium and high in WDEQ version A scale in the pre-test data of 12 primiparous pregnant women were selected. We found that psychoeducational interventions are important to reduce the fear of childbirth in pregnant women who have fear of childbirth. The results of this study show that a psychoeducational intervention given by a nurse to pregnant women between 24 and 31 weeks of gestation is significantly effective in reducing women's fear and anxiety of childbirth and increasing prenatal attachment. The differences in the findings of the study may be caused by factors such as the definition of fear of childbirth and anxiety, the difference in demographic and obstetric characteristics, and the quality of health care received.
The findings of the study show that the psychoeducational intervention effectively reduces the fear of childbirth and anxiety symptoms. The research is similar to other studies in which the psychoeducation program was applied and that the fear of childbirth decreased. Toohil, et al. reported that the fear of childbirth decreased in pregnant women who received five sessions of psychoeducation [28]. In another study, it is shown that a 3-session psychoeducation program was effective on fear of childbirth [2]. Saisto, et al. reported that the rate of natural vaginal delivery was higher than the control group as a result of five sessions of therapeutic group psychoeducation and relaxation program applied to primiparous women with fear of childbirth [29]. Scherer, et al. showed a significant decrease in anxiety levels with six sessions of psychoeducation applied to both multiparous and primiparous pregnant women [30].
Moreover, the results are consistent with studies showing that psychological interventions other than psychoeducation are also effective in reducing the fear of childbirth among pregnant women who experience fear of childbirth. It has been reported that both the fear of childbirth and the level of anxiety decreased in pregnant women with the five-session psychotherapy program implemented by Abdollahi, et al.[31]. In another study, it was reported that 2-hour birth training by midwives significantly reduced the fear of childbirth [10]. In addition, an 18-hour mindfulness-based motherhood preparation program has been shown to improve self-efficacy as well as fear and labor pains in pregnant women [32]. In a study conducted in the Netherlands, it was observed that there was a decrease in anxiety levels with two sessions of mindfulnes straining on 75 pregnant women [33]. Khojasteh, et al. reported that the fear of childbirth decreased in pregnant women who received four sessions of cognitive behavioral therapy [34]. Although all counseling and training programs reduce fear of childbirth and anxiety, there are differences between this study and previous studies in terms of the number of sessions, number of participants, cultural differences and methodology. It is thought that the psychoeducation program is effective in reducing the fear of birth and anxiety symptoms thanks to the normal processes of birth, the ability to cope with the physiological and emotional difficulties and the increase in knowledge. According to the literature, relaxation and daydreaming affect pregnancy and childbirth by both affecting the autonomic nervous system and providing comfort [35]. It was observed that the inclusion of relaxation exercises, daydreaming and emotional expressions in the psychoeducation program applied in our study increased the adaptation of pregnant women to pregnancy and childbirth and was effective in reducing the fear of childbirth.
Interventions to improve prenatal attachment are effective with theoretical and practical trainings. Emphasizing behaviors such as the pregnant touching her belly, learning about the physiological changes in pregnancy, and imagining the position of the fetus in the mother's womb [36]. The common points of these interventions are seen as touching the baby and counting the fetal movements.
In this study, it was shown that fetal movement count and daydreaming towards the baby applied in the psychoeducation program increased the level of prenatal attachment. The results of this study are consistent with previous studies. Abbasi, et al. evaluated the effect of fetal movement count on prenatal attachment level in 83 primiparous women and showed that attachment level increased significantly in the intervention group compared to the control group [37]. Akbar-Zadeh, et al., in their study on attachment behaviors, found that mothers' anxiety decreased and mother's attachment increased significantly in the 32 nd and 35 th weeks of pregnancy [38]. In addition, we think that fear of childbirth, anxiety level and psychological factors in pregnant women may affect prenatal attachment and cause differences in outcomes.
Counting fetal movement and being careful about it may affect prenatal attachment as well as increase the knowledge of them other about her baby and help her realize the presence of her baby [36]. Serçekuş, et al. also showed that prenatal adjustment training is effective in increasing prenatal and postnatal adjustment [39]. It has been stated that there is an increase in compliance with pregnancy and prenatal attachment with the educational intervention under midwife counseling by Arasteh, et al. [40].
A small sample size of 12 pregnant women does not include all pregnant women in Turkey who have fear of childbirth. Since there search was conducted in a single center in Turkey, the findings cannot be generalized to the whole population.
This study shows that psychoeducation applied to primiparous pregnant women in their second trimester reduces fear of childbirth and anxiety and increases prenatal attachment. As a result of the applied psychoeducation program, the physiological and psychological changes that occur during pregnancy and the increase in the knowledge level of pregnant women about labor and newborn care provide a more positive perception of birth. Thus, it reduces the level of fear of birth and anxiety. Expression of feelings to wards the baby, counting fetal movements, touching the tummy, and conversations with the baby have increased the level of prenatal attachment as the pregnant woman thinks of her baby as an individual and becomes aware of it. We recommend that this method be applied to primiparal pregnancy by professionals who provide health care services, since it is an easy and effective model to use.
The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose.
On behalf of all authors, the corresponding author states that there is no conflict of interest.
The data sets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.
Tokat Gaziosmanpaşa University Social and Human Sciences Research Ethics Committee permission was obtained for the research. Oral and written consent was obtained from all pregnant women participating in the study.