Couples plan their birth and empower themselves during pregnancy, mostly by searching information with midwifes. With the covid19 pandemic, it was necessary to think of different strategies to maintain this support, particularly in what antenatal classes are concerned. Thus, midwifes had to think “outside the box” and find different ways to hold antenatal classes: livestreaming was possible but, considering couples availability, online (recorded classes) was also an option. After some months, as pandemic began to rise, the “in person” option started to be held. The aim of this study is to identify which factors may influence satisfaction with the birth experience, namely the type of pre-birth program. A questionnaire was applied consisting of several socio-demographic variables, perception felt regarding the birth experience and variables recognized as having a strong influence on satisfaction with childbirth, with the woman being asked to provide her position/opinion. We concluded that the type of antenatal classes undertaken has no influence on satisfaction with the moment of birth, which is mostly related to factors such as the place where the birth took place (private hospital) and who performed it (midwife). Although the moment of birth is a multi-factorial moment, there are, in this sample, factors that are more important in influencing the experience than the information held on antenatal classes. However, the various factors already known must continue to be taken into account, thus allowing couples to live in the moment in an informed and empowered way.

Keywords: birth satisfaction, antenatal classes

As time goes by, more and more couples plan their birth, search for specific information during pregnancy, talk to each other sharing experiences and write birth plans according to their dreams and ambitions considering the baby’s birth day and the postpartum period. This birth plan is discussed in advance with the midwife or obstetrician who follows their pregnancy, in order to increase its chances of making it happen. Of all resources existing in the community to help empower couples in the birth process are the birth and parenting preparation courses, also known as antenatal classes, which should be carried out by a midwife. These antenatal classes provide important and fundamental information about the entire pregnancy process, childbirth and postpartum, breastfeeding, adaptation to a new life as parents, among others.¹ All these processes increasingly allow couples to be informed and empowered. They allow couples to have the ability to be part of the decision-making process, to be aware of the entire process and the various options and demanding regarding their wishes for the day the baby is born. With the covid19 pandemic, several strategies had to be rethought to maintain support during pregnancy and postpartum. Birth preparation and parenting courses, not being activities considered as a priority, were no longer held in person and it was necessary to “think outside the box” so that couples could keep having this support. Programs were redefined and began to be held online, either livestreaming or recorded, and gradually, with the lifting of the pandemic, they began to be held in person, with all the security measures that the moment required.

Motherhood, more than childbirth, is a special and unique moment in a couple's life. It all starts with pregnancy and continues with the postpartum experience. Here, the way the birth experience unfolds can have beneficial consequences in the postpartum period. If the couple has a less positive experience it can become a factor of extra concern - it can lead to postpartum depression, less success and satisfaction with breastfeeding, less satisfaction with sexual activity and it can even induce the desire of a cesarean section on a next pregnancy with all the consequences that may result from this.² It is known that birth preparation and parenting programs enhance the information and empowerment of couples and allow, by having realistic expectations regarding the moment, their satisfaction with the birth experience to increase.^2–4 Even if we know that birth satisfaction is a multi-factorial experience that can be related to several factors, individual or spatio-temporal, we aim to identify which factors may influence satisfaction with the birth experience, namely the type of pre-birth program.

The Portuguese Order of Nurses licences midwifes as the only nurses qualified to work out and fulfil antenatal classes. This, as an exclusive area for midwifes, should consist in a specific moment of learning and reflection where couples feel effectively enlightened.¹ These programs must be designed by midwifes and include topics such as: pregnancy, signs of labor, labor and types of delivery, pharmacological and non-pharmacological pain relief techniques, breathing techniques in different stages, postpartum and the couple's relationship after the baby is born, breastfeeding, instructions on baby’s care (hygiene, crying, colic). The antenatal classes presented to this samples’ women, meets all the Portuguese Order of Nurses criteria and was presented to couples in different modalities (information and the program was exactly the same, regardless of the modality) – online (recorded), livestreaming videoconference and in person.

The program includes:

Day 1: Healthy lifestyle in pregnancy; Warning / risk signs in pregnancy; When to go to the emergency room and why, Kegel Exercises: Help Reduce Urinary Incontinence; Let’s go shopping! Baby’s clothes: what to buy and have at home, What to put in your maternity bag.

Day 2: Birth signs (being able to detect the correct time to go to hospital); Pain in labor: strategies for managing contractions, pain and anxiety until you reach the hospital; Breathing techniques at different stages of labor; Pain management in labor (epidural and other alternatives).

Day 3: Arrival at the emergency room; Labor: The Different Stages; Types of birth; The father (before, during and after childbirth); First baby care: skin to skin contact; Postpartum: puerperium (the first days/weeks for the mother, baby and couple); Parenting: becoming a father and mother (Blues and postpartum depression); Baby blues and postpartum depression.⁵

Day 4: The newborn: physical characteristics, competences and main reflexes; Their early days: adaptation to the extrauterine environment; Crying: motives for crying, how to identify them and the best strategies to solve them; Cramps: Different Solutions and Tips; Sleep (location, position, sleep routines, sudden death syndrome).

Day 5: Breastfeeding: Advantages for mom, baby and couple; The correct latch; Technique and Basic principles for successful breastfeeding; Positions for breastfeeding; Breast milk extraction and preservation; Major difficulties and how to overcome them, Breastfeeding psychology.

Day 6: Newborn Baby care: hygiene, umbilical stump, clothing, sleeping habits, intestinal habits, security (with practical bath, changing cloth, umbilical stomp care...).

All these general topics are detailed in two-hour sessions, for a total of 12 hours trainning. An exploratory, descriptive and cross-sectional study was desisgned. A questionnaire was built and carried out with the following parts: a) socio-demographic information; b) obstetric and childbirth history; c) experience and perception of the birth experience. A pre-test was previously carried out with 10 women and some questions on socio-demographic characterization and birth experience were adjusted. The final questoinnaire was sent via email and the answers collected in January 2024.

The population included women who attended any of the programs indicated above, in a private institution in the área of Lisboa, Portugal. The sampling was intentional – collaboration was requested to all women which birth happened in 2023 or 2023. Babies had to be, at least, 1 month old (excludes baby blues influence in answers). An informed consent was requested and participation was voluntary and all participants were offered 15 minutes of relaxation massage as a reward.

Our sample included 102 women, with an average age of 35.74 (sd 4.49). Most of the sample is married (92,2%) and have a degree or masters at university (95,1%). With regard to parity, 78,4% experienced their first birth and have only 1 baby (there were no twins in the sample) with pregnancy followed in the private sector (45,1%). All the sample attended antenatal classes: 30,4% online, 21,6% livestreaming and 48% in person, with their partner (89.2%). This gave them information to make some dicisions as writting a birth plan (61.8%), deciding where the baby should be born (42,2% in public hospital and 57,8% in private hospital). Considering birth 52% were induced births, that end up in eutocic birth (26,5%), dystocic vaginal birth (27,5% ) and cesarean sections (46.1%). Most of them were performed by an obstetrician (90,2%) and only 9,8% by midwife. Regarding the perceived perception of the birth experience, scores were found between 3 and 10, on a scale of 1 (very negative) to 10 (very positive). Satisfaction with childbirth was then assessed using a scale, with items adapted from the literature. The aim was to assess satisfaction with the birth, according to the following factors (Table 1).

From the answers we can find that antenatal classes were considered an excellent help in ensuring a positive birth experience (8.27 in 10, sd 1.819), they helped with breastfeeding (7.87 in 10, sd 2.003) and in the postnatal period childbirth (7.85 out of 10, sd 1.864). In general, despite women felt some anxiety (5.89 out of 10), they also felt that time passed quickly (7.20 out of 10), that they were an active part of the process (7.13 out of 10) and that there was good communication with the healthcare team (7.91 out of 10).

By searching relations between the scale and the other study variables, we conclude that women who report having had a better experience with childbirth are those who did not have an induced birth (p=0.009). Also, births carried out by midwifes (p=0.046) and births carried out in a hospital private (p=0.031) gave them the feeling of having a better experience with birth. The number of children (p=0.668), place of pregnancy monitoring (p=0.249), literary (p=0.947) and the type of antenatal classes undertaken (p=0.277) do not show any influence on satisfaction with childbirth.

Pregnancy is a period surrounded by many discoveries, many new experiences, uncertainties and doubts, especially when expecting a first child, where everything is new. This moment of greater uncertainty leads more and more couples to seek antenatal classes, in order to raise information and help them feel more prepared for the moment that is approaching. This helps to reduce anxiety and allow them to feel empowered and qualified to be a part of the decision process. It would be expected that different conditions and presentations of antenatal classes could influence anxiety regarding childbirth, however this was not observed in this sample. Couples questioned felt informed and considered that antenatal classes, whatever format they attended, were a strong contribution to the way they felt and experienced childbirth, breastfeeding and the postpartum period.

From all the factors explored, we found out that births carried out by midwifes and also births carried out in a private hospital gave to women the feeling of having a better experience with birth. It would perhaps have been important to explore more specific factors related to childbirth – such as the duration of hospitalization after birth, duration of the latent phase, duration of the active phase and even factors related to the presence of the father vs doula during labor. It would also be interesting to explore and compare these results with women who have not attended antenatal classes, also in the context of their first child.

None.

The authors declare that there are no conflicts of interest.

1. Order of nurses. Recommendations for preparing for birth. 2012.
2. Goodman P, Mackey MC, Tavakoli AS. Factors related to childbirth satisfaction. J Adv Nurs. 2004;46(2):212–219.
3. Wan IP, Tang C, Goggins W. An educational intervention to improve women's ability to cope with childbirth. J Clin Nurs. 2009;18(15):2125–2135.
4. Miquelutti MA, Cecatti JG, Makuch MY. Antenatal education and the birthing experience of Brazilian women: a qualitative study. BMC Pregnancy Childbirth. 2013;13:171 .
5. Salmon P, Drew N. Multidimensional assessment of women's experience of childbirth: relationship to obstetric procedure, antenatal preparation and obstetric history. J Psychosom Res. 1992;36(4):317–327.