Original Research ajog.org
Psychoeducation for psychological issues and
birth preparedness in low- and middle-income
countries: a systematic review

Yetunde Oluwafunmilayo Tola, RN, RM, MSN, PhD; Oluwadamilare Akingbade, RN, RM, RPHN, MSc, PhD candidate;
Margaret Omowaleola Akinwaare, RN, RM, MSc, PhD; Emmanuel Olumide Adesuyi, RN, RM, MPH, PhD candidate;
Tomiike Mabel Arowosegbe, RN, RM, BNSc; Chizoma Millicent Ndikom, RN, RM, MSc, PhD;
Prisca Olabisi Adejumo, RN, MSc, PhD; Obrey Alexis, RN, PhD
BACKGROUND: Psychological issues usually accompany the pregnancy of first-time mothers, and psychoeducational interventions might be
effective in addressing these concerns and preparing first-time mothers for childbirth and the postnatal period.
OBJECTIVE: This study aimed to identify, analyze, and synthesize the components and determine the effectiveness of psychoeducational
interventions that are used for managing psychological issues and enhancing birth preparedness among primigravid women or couples in low-
and middle-income countries.
STUDY DESIGN: A systematic search of 12 databases (APA PsycINFO, EmCare, Embase, MEDLINE(R), Ovid Nursing, British Nursing Index,
Health & Medical Collection, ProQuest, CINAHL, Cochrane, Hinari, and PubMed) was conducted to identify relevant studies published between
1946 and October 2021. The quality of the included studies was appraised by the Joanna and Briggs Institute critical appraisal tool, and a narra-
tive synthesis was performed to analyze data extracted from included articles. The systematic review protocol is registered with the International
Prospective Register of Systematic Reviews (registration number: CRD42021237896).
RESULTS: The initial search yielded 8658 articles. Of note, 16 articles, including 7 randomized controlled trials and 9 nonrandomized trials,
met the inclusion criteria and were selected and reviewed for quality. In addition, 31 outcomes were measured in the studies, including psycho-
logical outcomes, birth preparedness outcomes, and other outcomes. The design of the interventions included antenatal education that was deliv-
ered through lectures, role plays, trainings, and antenatal counseling. All the psychoeducational interventions had a significant effect (P<.05;
Cohen’s d or Hedges’ g=0.2−1.9) on certain psychological outcomes, including childbirth attitude, fear of childbirth, depression, fear, and anxi-
ety, and birth preparedness outcomes.
CONCLUSION: Although first-time mothers experience a range of psychological issues during pregnancy, psychoeducational interventions
were beneficial in addressing their psychological concerns. It would seem that these interventions are less expensive and could be easily imple-
mented in low- and middle-income countries. However, rigorous research, such as randomized controlled trials, is hereby warranted to standard-
ize the interventions and outcome assessment tools.

Keywords: Psychoeducation, Psychological issues, Birth preparedness, Low- and middle-income countries, First-time mothers

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Introduction
Transition to parenthood is an impor-
tant life event involving both pregnant
individuals and their partners.1 Preg-
nancy of first-time mothers is oftenNIV

ERS
From the Institute of Nursing Research, Nigeria, Os
Medicine, The Nethersole School of Nursing, The C
Nursing, University of Ibadan, Oyo State, Nigeria (M
City University, Birmingham, United Kingdom (Mr A
Brookes University, Oxford, United Kingdom (Dr Al

The authors report no conflict of interest.

All data generated or analyzed during this study are

This study did not receive a grant from any grant-a

Cite this article as: Tola YO, Akingbade O, Akinwa
middle-income countries: a systematic review. Am

Corresponding author: Yetunde Oluwafunmilayo T

2666-5778/$36.00
© 2022 The Authors. Published by Elsevier Inc. This is an
http://dx.doi.org/10.1016/j.xagr.2022.100072

U

associated with issues affecting their
psychological functioning.2 This is so
because the period of pregnancy is usu-
ally associated with ambivalence and
frequent mood changes, varying from
ogbo, Osun State, Nigeria (Dr Tola,Mr Akingbade, M
hinese University of Hong Kong, Hong Kong, China
s Drs Akinwaare, Dr Ndikom and Prof. Adejumo); S
desuyi); Afe Bablola Multi-System Hospital, Ado-Ek
exis)

included in this published article (and its suppleme

warding agency or institution.

are MO, et al. Psychoeducation for psychological is
J Obstet Gynecol Glob Rep 2022;2:100072.

ola, RN, RM, MSN, PhD. tolayetunde702@link.cuhk

open access article under the CC BY-NC-ND license (http:
anxiety, fatigue, exhaustion, sleepiness,
and depression to excitement.3−5 To
some persons, the thoughts of preg-
nancy can bring about several worries,
which may be so intense that they
r Adesuyi and Mrs Arowosegbe); Faculty of
(Dr Tola and Mr Akingbade); Department of
chool of Nursing and Midwifery, Birmingham
iti, Ekiti State, Nigeria (Mrs Arowosegbe); Oxford

ntary information files).

sues and birth preparedness in low- and

.edu.hk

//creativecommons.org/licenses/by-nc-nd/4.0/)

August 2022 AJOG Global Reports 1

http://crossmark.crossref.org/dialog/?doi=10.1016/j.xagr.2022.100072&domain=pdf
mailto:Corresponding author: Yetunde Oluwafunmilayo Tola, RN, RM, MSN, PhD.
http://creativecommons.org/licenses/by-nc-nd/4.0/
http://dx.doi.org/10.1016/j.xagr.2022.100072
http://www.ajog.org


AJOG Global Reports at a Glance

Why was this study conducted?
Evidence showing the extent of the positive effects and a suitable design for the
antenatal psychological and/or birth preparedness education in this cohort is still
lacking in most low- and middle-income countries (LMICs).

Key findings
Designing psychoeducational interventions based on evidence, culture, and
available resources in LMICs and implementing policies to allow spouses to
attend antenatal education with their pregnant partners can help to improve the
psychological status and birth preparedness of the first-time parents. Most of the
methods used to deliver the psychoeducational interventions resulted in a signif-
icant decrease in psychological outcomes and improved birth preparedness;
however, antenatal education was mostly used

What does this add to what is known?
Most instruments used to assess the outcomes in LMICs were self-designed, and
there is a need to standardize and validate instruments for assessing the out-
comes among this cohort.

Original Research ajog.org

N

acquire a feature of phobia.6 In most
countries, the physical healthcare of
pregnant women has improved signifi-
cantly, but there is still a long way to go
with psychological care.7 Most pregnant
women in low- and middle-income
countries (LMICs) have limited access
to information and a lack of psychologi-
cal care associated with pregnancy and
birth preparedness.8 This is especially
true for first-time mothers and
couples8,9 experiencing psychological
issues at the early stage of pregnancy,
which increases with the advancement
in pregnancy.10

According to Camoirano,11 a first-time
mother may experience emotional fluctu-
ations between positive feelings and nega-
tive ones during the first trimester of
pregnancy. During the second trimester
of pregnancy, the mood fluctuations con-
tinue, and the negative feelings could
sometimes lessen, and during the third
trimester of pregnancy, the negative emo-
tional feelings could intensify again.11

Nevertheless, with appropriate birth pre-
paredness through psychoeducation,
first-time mothers and their partners can
become empowered to cope with their
psychological concerns, hence transiting
safely into parenthood.11,12

Psychoeducation or psychoeduca-
tional interventions refer to activities
that combine education and counseling.
Psychoeducational interventions may be

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2 AJOG Global Reports August 2022
delivered individually or in groups.13,14

Often, the components of psychoeduca-
tion that enhance its effectiveness among
pregnant women usually include activi-
ties that vitalize the capacity of giving
birth, promote self-efficacy, provide psy-
chological support, and equip pregnant
women with realistic plans on transpor-
tation, delivery location, birth compan-
ionship, blood donors, materials for safe
childbirth, and other delivery-related
decision-making.12,15−18

A previous systematic review found
that the effects of psychoeducational
intervention delivered to pregnant
women only or with their partners can
have a far-reaching effect on the postpar-
tum period to ameliorate depression and
paternal negative effects.19 Another
study reported that psychoeducation for
pregnant women, especially first-time
mothers increased the rates of spontane-
ous vaginal delivery, reduced cesarean
delivery (CD) rates, and improved wom-
en’s delivery experience.20 Similarly, a
comparative study evaluating midwife-
led psychoeducation through counseling
on 53 fearful women reported positive
results in the intervention group com-
pared with the control group.21

Aside from the beneficial effects of
psychoeducational interventions, these
interventions are easy to implement
and less expensive.14 Thus, making psy-
choeducational interventions suitable

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for pregnant women and their partners
in LMICs. Therefore, this review aimed
to identify, analyze, and synthesize the
components and determine the effec-
tiveness of psychoeducational interven-
tions that are used for managing
psychological issues and enhancing
birth preparedness among primigravid
women or couples in LMICs.

Methodology
We conducted a systematic review to
identify psychoeducational interven-
tions and the designs of the intervention
used to address psychological needs and
improve birth preparedness of first-
time mothers in LMICs. The methodol-
ogy of this review followed the Preferred
Reporting Items for Systematic Reviews
and Meta-Analysis guidelines.22 We
searched 11 databases (APA PsycINFO,
EmCare, Embase, MEDLINE(R), Ovid
Nursing, British Nursing Index, Health
& Medical Collection, ProQuest,
CINAHL, Cochrane, Hinari, and
PubMed) for studies that were pub-
lished from the inception of the data-
bases to October 1, 2021 (Table 1). The
key words that were further adjusted for
all databases included “low- and mid-
dle-income countries,” “LMICs,” “first-
time mothers,” “first-time fathers,”
“expectant couple,” “primigravida,”
“psychoeducation,” “psychological edu-
cation,” “client education,” “antenatal
education,” “awareness program,”
“pregnancy support,” “antepartum edu-
cation,” and their combinations (Sup-
plementary materials). Additional
studies were identified from the referen-
ces of the included studies, and there
was no language and date restriction set
during the search. The definition of
LMICs was based on the World Banks’
data, which categorized countries based
on various indicators, including human
capital development (https://data.world
bank.org/country/XN).
The identified studies were screened

first to exclude the duplicates. Next, the
title and abstract were screened, fol-
lowed by full-text screening. Eligible
studies involved first-time mothers in
LMICs, with singleton pregnancies
attending antenatal clinics, aged
≥18 years, without existing mental

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https://data.worldbank.org/country/XN
https://data.worldbank.org/country/XN
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TABLE 1
Searched databases
Platform Serial number Databases Result

Ovid 1 APA PsycINFO (1946 to October 2021) 65

2 EmCare (1995 to 2021 week 40) 322

3 Embase (1910 to present) 479

4 MEDLINE(R) (1946 to October 01, 2021) 242

5 Ovid Nursing Database (1946 to October 2021) 204

7 Health & Medical Collection 3978

ProQuest 8 ProQuest Dissertations & Theses A&I 93

EBSCOhost 9 CINAHL Complete 158

6 British Nursing Index 557

Cochrane 10 Cochrane Trials 339

11 Hinari 10

12 PubMed 2211

Total 8658
APA, American Psychological Association; S/N, serial number.

Tola. Psychoeducation, psychological, and birth preparedness. Am J Obstet Gynecol Glob Rep 2022.

ajog.org Original Research

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health diagnoses, without medical or
obstetrics risks, and not planning to
undergo an elective CD. The studies
provided psychological, educational, or
a combination of psychological and
educational interventions and clearly
states the intervention procedure. Fur-
thermore, the studies provided inter-
ventions during pregnancy and assessed
at least 1 of the outcomes, including
anxiety, depression, self-efficacy, and
knowledge decision-making about the
birth method before birth and/or after
birth; compared an intervention group
with usual care group or other forms of
nonpharmacologic interventions; and
were randomized controlled trials
(RCTs) and nonrandomized interven-
tion studies with 2 groups and pre- and
posttest assessments.
O.A, E.O.A, T.M.A, and M.O.A

assessed the quality of the included
studies using the Joanna Briggs Institute
critical appraisal tool.23 Where consen-
sus could not be reached about the qual-
ity of a particular study, a fourth
reviewer (Y.O.T.) was consulted.

Data analysis
The studies retrieved during the
searches were screened for relevance,

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and data were extracted from the stud-
ies that met the eligibility criteria. Of
note, 2 authors Y.O.T. and O.A per-
formed the data extraction using the
Joanna Briggs data extraction form.
Information, such as the author’s name,
study date, location, setting, sample
size, data collection instrument, inter-
vention content, and result, were
extracted (Supplementary materials). A
narrative synthesis was performed to
describe the study design, intervention
characteristics, outcomes, instruments,
and intervention effects. The effective-
ness of the psychoeducation interven-
tions was reported on the basis of the
level of significance (P value) defined by
each study, whereas the effect size was
calculated and reported as Cohen’s d or
Hedges’ g value. A small effect size
ranged from 0.2 to 0.49, a medium
effect size ranged from 0.5 to 0.79, and
a large effect size is a Cohen’s d or
Hedges’ g value that is ≥0.8.24,25

Results
The initial search resulted in 8658
articles, which were screened for dupli-
cates. There were 4802 articles left after
duplicates were removed and 36 after
titles and abstracts were screened. Of

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note, 12 studies were eligible for inclu-
sion in this study after full-text screen-
ing, and 4 additional studies were
identified from the reference lists of the
eligible articles. Finally, 16 studies that
met the inclusion criteria were included
in this review (Figure). Most of the
studies in this review were conducted in
Iran (n=9) and Turkey (n=3). Other
studies included in this review were
conducted in Malawi (n=1), China
(n=1), Jordan (n=1), and India (n=1).
Studies included in this review were
RCTs (n=7), quasi-experimental studies
(n=3), clinical trials (n=3), and unspeci-
fied experimental design (n=3). Overall,
the studies had low to moderate meth-
odological quality (Tables 2 and 3).
Of note, 4 of the included studies

underpinned their intervention with
theories. However, each of the studies
used different theories. The theories
included the cognitive behavioral the-
ory,26 the Meleis transition theory,27 the
theory of planned behavior,28 and the
human caring theory.29 Studies
included in this review recruited women
carrying their first pregnancy with or
without their spouses. Most of the
women were recruited at approximately
≥20 weeks of gestation (n=14), and
only 1 study recruited participants start-
ing from 14 weeks of gestation.30 The
total sample size in all the included
studies was 1571 participants ranging
from 24 to 194 participants.
Overall, the included studies assessed

39 outcomes. These outcomes can be
categorized as psychological outcomes
or birth preparedness outcomes, to
name a few. For the psychological out-
comes, fear of childbirth was assessed in
5 studies,26,27,29,31 whereas childbirth
attitude was assessed in 6 studies.31−35

Other psychological outcomes assessed
included maternal stress,36 acceptance
of pregnancy, and confidence in the
ability to cope with childbirth,37 anxi-
ety,28 and depression.38 Concerning the
birth preparedness outcomes, self-effi-
cacy was assessed in 4 studies27,31,38,39;
knowledge was assessed in 3
studies32,36; decision-making was
assessed in 2 studies32,35; and delivery
type selection,34 cervical dilation and
breastfeeding initiation,40 identification

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August 2022 AJOG Global Reports 3

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FIGURE
PRISMA flow diagram of the study

Records identified through database 
searching (n = 8658) 

Records after duplicates 
removed 

(n = 4802) 

Only titles and abstract 
screened to research criteria 

(n = 4802) 

Records excluded 
(n = 4766) 

Full-text articles assessed for 
eligibility 
(n = 36) 

Full-text articles excluded with reasons 
(n = 24) 
Non- English = 1 
No control group = 3 
No clear description of intervention = 1 
Conference abstract = 5 
Utilizes secondary data = 2 
Enrolled women after live childbirth =2 
Not specific for first-time 
mothers/couples = 11 
 

Studies eligible  
(n = 16) 

S
cr

ee
ni

ng
 

In
cl

ud
ed

 
E

li
gi

bi
li

ty
 

Id
en

ti
fi

ca
ti

on
 

Records included from hand search 
(n = 4) 

PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analysis.

Tola. Psychoeducation, psychological, and birth preparedness. Am J Obstet Gynecol Glob Rep 2022.

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of maternal role and birth concern,37

childbirth experience,36 childbirth satis-
faction,26 decisional conflict,33 outcome
expectancy,39 and vaginal birth prefer-
ence29 were assessed in 1 study each.
Other outcomes assessed included
acceptance of pregnancy and satisfac-
tion with motherhood37; spontaneous
onset of labor, Apgar score, and infant
birthweight40; duration of labor
stage26,40; amniotomy, induction of
labor, episiotomy, laceration, fetal dis-
tress, and pain26; childbirth companion
support27; satisfaction38; behavioral
belief, outcome evaluation, perceived
behavioral control, control beliefs, per-
ceived power, and normative belief28;
and birth type.29

For the fear of childbirth outcome, the
instruments used included the Wijma

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4 AJOG Global Reports August 2022
Delivery Expectancy/Experience Ques-
tionnaire (A and B),26,29,30 the Childbirth
Attitudes Questionnaire,27 and a self-
developed questionnaire.31 Childbirth
attitude was assessed using the self-devel-
oped questionnaires28,32,34,35 and Child-
birth Attitude Scale,33 whereas maternal
stress was assessed using the maternal
stress scale.36 The State-Trait Anxiety
Inventory was used to assess the level of
anxiety,31 whereas the Edinburgh Postna-
tal Depression Scale38 and the Postpar-
tum Self-Evaluation Questionnaire37

were used to assess depression and confi-
dence in the ability to cope with child-
birth, respectively. The birth concern
scale, labor observation form, prenatal
self-evaluation questionnaire and knowl-
edge evaluation form B,37 decisional con-
flict scale,33 self-developed birth outcome
datasheet,40 and childbirth experience
scale36 were used to assess birth prepared-
ness−related outcomes.
Most of the included studies had an

education component (n=13) delivered
in various forms, such as training, role
play, and lecture. However, other stud-
ies (n=2) used components related to
counseling. The intervention was deliv-
ered face to face in small groups of
approximately 4 to 10 participants. Of
note, 14 studies delivered the interven-
tion to pregnant women alone. The
number of sessions varied across studies
with the lowest being 1 contact session
(n=3) and the highest being 6 contact
sessions (n=2). Other studies delivered
their intervention within 3 sessions
(n=6), 2 sessions (n=20), 4 sessions
(n=1), and 5 sessions (n=1). Most of the

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TABLE 2
Methodologic quality of the included randomized controlled trials

Questions
Authors Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13

Gao et al,38 2012 Y N Y N N N Y N Y Y Y Y Y

Abedian et al,32 2017 N N U N N N Y Y Y Y Y Y Y

Alipour et al,43 2020 Y N Y N N N Y N Y Y Y Y Y

Darmian et al,34 2018 Y N N N N N Y N Y Y Y Y Y

Hatamleh et al,40 2019 Y N U N N N Y N Y Y Y Y Y

Kordi et al,30 2017 Y N Y N N N Y Y Y Y Y Y Y

Navaee and Abedian,35 2015 N N U N N N Y Y Y Y Y Y Y

Uçar and Golbasi,26 (2019) N N Y N N N Y N Y Y Y Y Y

Valiani et al,44 2014 N N U N N N Y Y Y Y Y Y Y

Boz et al,29 2021 Y Y Y Y N N Y N Y Y Y Y Y

Vasegh et al,39 2012 Y N Y N N N N Y Y Y Y Y Y

Ghasemi et al,31 2018 Y N Y N N N Y Y Y Y Y Y Y
Q1 = randomization; Q2 = participant allocation; Q3 = similarity at baseline; Q4 = participant blinding; Q5 = intervener blinding; Q6 = outcome assessor blinding; Q7 = similar treatment of the treat-
ment group; Q8 = follow-up completion; Q9 = analysis based on assigned group; Q10 = similar assessment tool; Q11 = reliable assessment method; Q12 = appropriate statistics; and Q13 = appro-
priate trial design.

Y, yes; N, no; U, unclear.

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interventions were delivered once a
week (n=8). Only 1 study delivered their
intervention once in 2 weeks,33

although another study permitted the
participants to have the intervention
anytime they liked.39 Moreover, 3
studies28,29,38 did not report the fre-
quency of their intervention delivery.
The duration of the intervention deliv-
ery ranged from 20 minutes to 4 hours
per session. Most of the studies
employed the help of an expert toERSIT
TABLE 3
Methodologic quality of the included

Authors Q1 Q2 Q3

Pinar et al,37 (2018) Y Y Y

Munkhondya et al,27 2020 Y Y Y

Andaroon et al,33 2020 Y Y Y

Ghasemi et al,28 2017 Y Y Y
Q1 = variable clarity; Q2 = participant similarity; Q3 = similarity of
sessment; Q6 = complete follow-up; Q7 = similar outcome
Q9 = appropriate statistics.

Y, yes; N, no.

Tola. Psychoeducation, psychological, and birth preparedn

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develop the intervention but were
mostly delivered to the participants by
the researcher.

Antenatal education intervention
Of note, 9 studies delivered their inter-
vention using an educational method.26
−29,36−40 Some of the studies reported
that antenatal education has a signifi-
cant effect on psychological outcomes,
such as attitude (P<.001; Hedges’
g=0.91),28 fear of childbirth (P<.05;

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nonrandomized studies

Questions
Q4 Q5 Q6 Q7 Q8 Q9

Y Y Y Y Y Y

Y Y Y Y Y Y

Y Y N Y Y Y

Y Y N Y Y Y
usual care; Q4 = use of control group; Q5 = pre- and postas-
assessment; Q8 = reliability of outcome assessment; and

ess. Am J Obstet Gynecol Glob Rep 2022.
Cohen’s d=�1.018 to 4.339),26,27,29 and
depression (P<.01; Hedges g: T1=0.538
and T2=�0.312).38 Moreover, antenatal
education was effective for some birth
preparedness outcomes, including birth
concern (P<.01; Hedges’ g=�1.018),37

cervical dilation (P=.03; Cohen’s
d=0.392), breastfeeding initiation
(P=.03; Cohen’s d=�0.881),40 knowl-
edge (P=.001; Cohen’s d=2.766),36 and
childbirth satisfaction (P=0.33; Hedges’
g=�1.201).26 The significant effect of
antenatal education on self-efficacy and
efficacy has low to very large effect sizes
across the studies that assessed self-effi-
cacy and efficacy,27,28,38,39 and the
effects of antenatal education on out-
come expectancy (P<.01; Cohens
d=10.987) was large.39

In addition, antenatal education was
reported to significantly influence vagi-
nal birth preference (P=.12).29 Similarly,
antenatal education resulted in a statis-
tically significant effect on other out-
comes, including acceptance of
pregnancy,37 spontaneous onset of labor
(P=.02),40 duration of stage II labor and
pain (P=.033; Hedges’ g=�0.469), satis-
faction (P=.001; Hedges’ g=0.626),26
August 2022 AJOG Global Reports 5

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Original Research ajog.org
childbirth companion support (P=.001;
Cohen’s d=2.440),27 social support
(P<.01; Hedges’ g: T1=0.760 and
T2=0.334)38 and behavioral belief
(P<.001; Hedges’ g=0.99), perceived
control (P<.001; Hedges g=0.54), out-
come evaluation (P<.001; Hedges’
g=0.62), and control beliefs (P<.001;
Hedges’ g=0.45).28

Antenatal training
Of note, 2 studies that used antenatal
training reported a significant effect on
the psychological outcomes assessed.
Antenatal training resulted in a statisti-
cally significant difference with a
medium effect size (P=.007; Hedges’
g=0.450) on the fear of childbirth30 and
childbirth attitude toward CD and nor-
mal vaginal delivery (NVD).34 The
effect size of the intervention in the
study of Darmian et al34 was calculated
on the basis of 3 groups, and it was
found that antenatal training between
the optimism training group and the
control group and between the NVD
training group and the control group
had medium effect size, respectively, on
childbirth attitude toward CD (P=.002;
Hedges’ g=�0.789) and NVD (P<.001;
Cohen’s d=�0.787). Moreover, antena-
tal training between the optimism train-
ing group and control group and
between the NVD training group and
the control group had a large effect size
(Hedges’ g=�2.055 and Cohen’s
d=�2.255, respectively) on childbirth
attitude toward NVD.34 However ante-
natal training (optimism training and
NVD training) was not significantly
effective (P>.05) for the birth prepared-
ness outcome related to delivery type
selection (Table 4).34

Role play
Of note, 2 studies delivered their inter-
vention using role play and usual ante-
natal lecture for the intervention group
and control group, respectively.32,35

Role play resulted in a statistically sig-
nificant difference with medium effect
size in psychological outcomes, such as
childbirth attitude (P=.003; Hedges’
g=0.537)32 and fear of childbirth
(P=.007; Hedges’ g=0.677).35 However,
there was no statistically significant

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6 AJOG Global Reports August 2022
difference in birth preparedness out-
comes related to delivery method deci-
sion-making.32

Counseling
Of note, 2 studies delivered their inter-
vention through antenatal counseling.
Antenatal counseling resulted in a sta-
tistically significant effect on psycho-
logical outcomes (P<. 001) and birth
preparedness outcomes (P<.01). The
psychological outcomes included fear
of childbirth and anxiety31 and child-
birth attitude.33 However, the birth
preparedness outcomes included deci-
sional conflict,33 self-efficacy, and
expected outcome.31

Fear, anxiety, self-efficacy, and
expected outcome were assessed imme-
diately after the intervention and in the
last month of pregnancy in the study of
Ghasemi et al,31 and antenatal counsel-
ing resulted in a large effect size
(Cohen’s d) both immediately after the
intervention (fear of childbirth, �3.762;
anxiety, �2.304; self-efficacy, 3.207;
expected outcome, 2.608) and in the last
month of pregnancy (fear of childbirth,
�2.316; anxiety, �1.687; self-efficacy,
2.081; expected outcome, 2.359), respec-
tively. Similarly, antenatal counseling
also resulted in a large and medium
effect size for childbirth attitude and
decisional conflict (Cohen’s d=0.978
and 0.742), respectively.33 The sum-
mary of the effects of the intervention is
presented in Table 4.

Discussion
This systematic review narratively ana-
lyzed and synthesized relevant evidence
on psychoeducational interventions
used for addressing psychological issues
and promoting birth preparedness
among first-time mothers in LMICs. Of
note, 16 studies were included in this
review, including 7 RCTs, 3 quasi-
experimental studies, and 6 non-
randomized experimental studies. The
studies were conducted in 5 LMICs,
such as Iran, Turkey, Malawi, Jordan,
and India. The included studies were
riddled with several methodological
issues. For the RCT studies, only 1 study
blinded the participants and conducted
allocation of concealment. None of the

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studies performed outcome assessor
blinding. None of the studies was con-
ducted with the intention-to-treat prin-
ciple during the data analysis. In RCTs
studies, bias can be minimized through
allocation concealment, participant and
assessor blinding, and analysis of all
recruited participants into the group in
which they were recruited whether they
dropped out or not.41 Most of the
included studies did not use any theory
to underpin their intervention. How-
ever, the few studies that used theories
used different types of theories, such as
the Meleis transition theory, cognitive
behavioral theory, theory of planned
behavior, and human caring theory. It
remains unclear whether the outcomes
assessed in these studies26−29 were
derivatives of the theory that under-
pinned their intervention.
The interventions in the included

studies were delivered through antena-
tal education,26−29,36−40 counseling,31,33

and role play.32,35 The outcomes
assessed included psychological out-
comes, birth preparedness outcomes,
and other outcomes. This review
revealed that although some studies
assessed similar outcomes, most of the
similar outcomes were not assessed
with the same tools. Most of the tools
used were developed by the researchers
for that study. This implies that the
validity and reliability of the instru-
ments were not well established; hence,
it cannot be concluded that the out-
comes were assessed in a reliable way
for most studies. This is a major chal-
lenge with studies conducted in devel-
oping countries as some researchers
and students lack the skills and knowl-
edge about validity and reliability
testing.42

All psychoeducational intervention
modes, such as antenatal education,
antenatal counseling, antenatal training,
and role play, had a significant effect on
some of the psychological outcomes
assessed, including childbirth attitude,
fear of childbirth, depression, fear, and
anxiety. These findings further reiterate
that psychoeducational interventions
provided during the antenatal period
can be quite effective for controlling
psychological issues in pregnant women

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TABLE 4
Comparison of the effectiveness of the psychoeducational interventions
Mode of
intervention

Psychological
outcomes P value; effect size (Cohen’s d or Hedges’ g)

Birth preparedness
outcomes P value; effect size (Cohen’s d or Hedges’ g) Other outcomes

P value; effect size (Cohen’s d or
Hedges’ g)

Antenatal
education

Attitude P<.001; Hedges’ g=0.91 (Ghasemi et al,28 2017) Birth concern P<.01; Hedges’ g=�1.018 (Pinar et al,37 2018) Acceptance of pregnancy P=.041; Hedges’ g =0.351 (Pinar et
al,37 2018)

Fear of childbirth P<.001; Hedges’ g=�1.018 (Uçar and Golbasi,26 2019)
Antenatal: P<.05; Cohen’s d=�1.159
Postnatal: P<.001; Cohen’s d=�1.808 (Bolz et al, 2020)
P=.001; Cohen’s d=�4.339 (Munkhondya et al,27 2020)

Cervical dilation P=.03; Cohen’s d=0.392 (Hatamleh et al, 2019) Duration of stage 2 labor P=.033; Hedges’ g=�0.469 (Uçar and
Golbasi,26 2019)

Depression T1: P<.01; Hedges’ g=�0.536
T2: P<.01; Hedges’ g=�0.342 (Gao et al,38 2012)

Breastfeeding initiation P>.01; Cohen’s d=�0.881 (Hatamleh et al, 2019) Pain P<.001; Hedges g=�1.201 (Uçar and
Golbasi,26 2019)

None Knowledge P<.01; Hedges’ g=2.766 (Nair et al,36 2015) Childbirth companion or social
support

P=.001; Cohen’s d=�2.440 (Munkhon-
dya et al,27 2020)
T1: P<.01; Hedges’ g=0.760)
T2: P<.01; Hedges’ g=0.334 (Gao et
al,38 2012)

Self-efficacy P=001; Cohen’s d=�4.136 (Munkhondya et al,27

2020)
T1: P<.01; Hedges’ g=0.574)
T2: P<.01; Hedges’ g=0.347 (Gao et al,38 2012)
P=.01; Cohen’s d=12.680 (Vasegh et al,39 2012)
P<.001; Cohen’s d=3.207 and 2.081 (Ghasemi et
al,28 2017)

Satisfaction P=.033; Hedges’ g=�0.626 (Uçar and
Golbasi,26 2019)

None
Behavioral belief P<.001; Hedges g=0.99 (Ghasemi et

al,28 2017)

Perceived control P<.001; Hedges g=0.54 (Ghasemi et
al,28 2017)

Outcome evaluation P<.001; Hedges g=0.62 (Ghasemi et
al,28 2017)

Outcome expectancy P=.01; Cohen’s d=10.987 (Vasegh et
al,39 2012)

Control beliefs P<.001; Hedges g=0.45 (Ghasemi et
al,28 2017)

Antenatal training Fear of childbirth P=.007; Hedges’ g=�0.450 (Kordi et al,30 2017) None

Childbirth attitude
toward CD and NVD

CD: P=.002a; Hedges’ g=�0.789b and Cohen’s d=0.787c

NVD: P<.001a; Hedges’ g=�2.055b; Cohen’s d=�2.255c

(Darmian et al,34 2018)

Role play Childbirth attitude P=.003; Hedges’ g=0.537 (Abedian et al,32 2017)

Fear of childbirth P=.007; Hedges’ g=0.677 (Navaee and Abedian,35 2015)

Counseling Fear of childbirth P<.001; Cohen’s d=�3.762 and �2.316 Decisional conflict P<.001; Cohen’s d=�0.742 Expected outcomes P<.001; Cohen’s d=2.608 and 2.359

Anxiety P<.001; Cohen’s d=�2.304 and �1.687

Childbirth attitude P<.00; Cohen’s d=0.978 (Andaroon et al,33 2020) None

CD, cesarean delivery; NVD, normal vaginal delivery.
aP value among 3 groups.
bEffect size of optimism training vs control group.
cEffect size of NVD training vs control group.

Tola. Psychoeducation, psychological, and birth preparedness. Am J Obstet Gynecol Glob Rep 2022.

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Original Research ajog.org
and postpartum women.14 Hence, the
findings of this review about psycho-
education interventions in this review
were consistent with the findings of a
previous systematic review conducted
by Park et al.19 Similarly, all psychoedu-
cational intervention modes were effec-
tive for improving birth preparedness
outcomes, including birth concern, cer-
vical dilation, breastfeeding initiation,
knowledge, self-efficacy, and decisional
conflict. Moreover, this finding held for
other outcomes, such as acceptance of
pregnancy, duration of stage 2 of labor,
pain, childbirth companion support of
social support, satisfaction, behavioral
belief, perceived control, outcome eval-
uation and expectancy, and control
beliefs. The findings from this review
revealed that depending on the inter-
vention mode, the effect sizes for each
outcome ranged from small to large
effect size.
Despite the effectiveness of the psy-

chological interventions on most psy-
chological, birth preparedness, and
other outcomes assessed in the included
studies, this review revealed that psy-
choeducational intervention was not
effective in managing some outcomes,
including the mother’s confidence to
cope with motherhood; satisfaction
with motherhood and infant care; iden-
tification with a motherhood role37;
birth information, such as anxiety dur-
ing active labor, duration of stage 1 and
2 labor, fetal distress, episiotomy, induc-
tion of labor, laceration, and
amniotomy26,27; Apgar score at 1 and 5
minutes; gestational age at delivery;
length of the first and second stage of
labor, and infant birthweight.40 Others
included childbirth experience, mater-
nal stress,36 normative belief, perceived
power and perceived behavioral con-
trol,28 birth preference,29 decision-mak-
ing about the type of delivery, and
mode of delivery.32,34,35 This nonsignifi-
cant effect of psychoeducational inter-
vention on these outcomes could be
because several of these outcomes are
influenced by several physiological,
environmental, and cultural factors.
Overall, the findings from this review

have indicated that in LMICs, psycho-
educational interventions have been

UNIV
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8 AJOG Global Reports August 2022
used to address several psychological
issues and enhance birth preparedness
among first-time mothers; and it was
found to be significantly effective. This
review was not without limitations, one
of which was the inability of included
studies to be used in a meta-analysis
because of the differences in the design
of the study and data collection instru-
ment. Another limitation was the inclu-
sion of studies that focused on women
who did not have existing mental health
diagnoses. Therefore, because of the
methodological quality and different
instruments used in the included studies
and the exclusion of studies that
included only women who did not have
existing mental health diagnoses, cau-
tion needs to be taken when interpret-
ing and using the findings of this
review.

Research implication
The first research implication is the
need for standardized data collection
tools for measuring outcomes in future
studies. The second research implica-
tion is that future research needs to use
a robust methodology, such as RCTs,
and involve spouses of first-time moth-
ers in their research.

Strengths and limitations
The strength of this review lies in the
utilisation of previously tested critical
appraisal tools as well as the pooling of
evidence through rigorous search of
data from all the low - and middle -
income countries as defined by the
world bank. Nevertheless, the study is
not without limitation. Due to the
diverse research methodologies and
data collection instruments, the data
from the included articles could not be
pooled into a meta-analysis.

Clinical implications
This review has some clinical implica-
tions. First, although psychoeducation
has proven useful, hospitals and health-
care facilities in LMICs attending to
pregnant women, especially first-time
mothers and their partners, need to
incorporate the various methods of psy-
choeducation (education, role play,
counseling, and training) to manage

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psychological issues and enhance birth
preparedness. Second, nursing leaders
and policymakers in LMICs need to
develop policies that can enhance the
implementation of focused psychologi-
cal care and birth preparedness for first-
time mothers and their partners.
Conclusion
Primigravid women or first-time moth-
ers and their partners face several psy-
chological issues during pregnancy and
immediately after the birth of their baby
because of their need to adjust to the
physiological changes in the body and
parenthood. However, engaging primi-
gravid and their partners through psy-
choeducation is effective for addressing
psychological issues, and no doubt, it
could enhance birth preparedness. Psy-
choeducation is an intervention that is
less expensive for pregnant individuals
and their spouses from LMICs com-
pared with high-income countries
where pregnant individuals and their
spouses may be able to afford private
birthing sessions or employ the services
of a personal midwife. Therefore, there
is a need for this intervention to be used
routinely in LMICs for first-time moth-
ers and their partners. &

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Supplementary materials
Supplementary material associated with
this article can be found, in the online
version, at doi:10.1016/j.xagr.2022.
100072.

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https://doi.org/10.1186/s12978-020-0877-4
http://www.ajog.org

	Psychoeducation for psychological issues and birth systematic review
	Introduction
	Methodology
	Data analysis

	Results
	Antenatal education intervention
	Antenatal training
	Role play
	Counseling

	Discussion
	Research implication
	Strengths and limitations
	Clinical implications
	Conclusion

	Supplementary materials
	References