The mechanism of natural childbirth is a physiological process, spontaneous and without the need for intervention, which has been going on for years with its natural course [1]. Natural childbirth is the best way to give birth in most pregnant women, and with increasing cesarean section, the rate is declining. Vaginal childbirth is associated with the lowest risk in terms of both maternal and fetal complications [2]; among other things, it does not require anesthesia and is less likely to become infected and bleed afterwards, and is considered cost-effective. Therefore, increasing cesarean section not only increases labor consequences for both mother and baby, but also imposes health care costs [3]. The presence of side effects associated with cesarean section prompted the World Health Organization to consider 15% as an adequate range for incidence of cesarean section [4]. Today, the high rate of cesarean section in the world has become a concern in the field of community health [5]. Maternal mortality from selective cesarean section is 2 to 3 times that of normal delivery. Also, the number of lost years of life due to premature death and disability-adjusted life year (DALY) for cesarean section is 22.1 years and for normal delivery is 8.8 years per thousand deliveries [6]. Cesarean delivery is 30% in the United States, Canada, and Australia, and 39% in Italy (8, 7). Statistics show that in recent years, the tendency to cesarean section in Iran has increased and is several times higher than the global standard, and in the second row after Brazil in terms of cesarean section statistics. It is also the number one cesarean section in the Middle East [9]. In Iran, 50-60% of deliveries are performed by cesarean section [10] and the rate of cesarean section in public hospitals in Hamadan is 47.5% and in private hospitals is 79.1% [11]. Statistics show that about 75% of cesarean sections in Iran are unnecessary and selective [12]. Reducing cesarean section among low-risk women is one of the goals of the 2020 Healthy People Plan [9].
One of the unexplained medical reasons for increasing the number of cesarean deliveries is the lack of awareness and misinformation before the delivery of pregnant mothers [14]. According to Gamble and Creedy's study of the determinants of women's preference for all types of delivery, the reason why most women choose cesarean section is due to labor pain and not being aware of the risks of cesarean delivery [15]. One way to increase people's awareness is through counseling. Counseling is the process of helping ordinary people to better adapt to themselves and others, emotional and social development, independence, and acceptance of responsibility [16].
Therefore, considering the increase in cesarean section index, despite numerous interventions in the field of preparation classes for childbirth and culture of natural and safe childbirth, also considering the importance of counseling and pre-pregnancy education in providing maternal and infant health, it was decided to conduct a study entitled the effect of group counseling on awareness about childbirth in women referring for prenatal care.
 

The present study is a randomized clinical trial study designed in two groups (test group and control group) with two stages of pretest and posttest. Based on the results of the study of ShahrakiSanavi et al., the mean score in the control group before the intervention was 10.68 ± 2.54 and in the intervention group was 12.30 ± 1.92 [25]. Considering the test power of 90% and the alpha coefficient of 5% and taking into account 20% of the drop, the sample size was calculated using the Sampsi command in the Stata-13 software for each group of 50 people.
This research was conducted in the comprehensive health centers of Hamadan city and the sampling was done in several stages. The first stage was performed as a cluster; in this way, the city of Hamadan was divided into 4 districts of north, south, east, west, and in the second phase, two centers were selected from each district by accident, and a total of 8 comprehensive health centers were selected. In the third stage, 240 women with pre-pregnancy cases from the SIB System of 8 selected comprehensive health centers were randomly selected. The women then entered the study according to the entry criteria. A total of 100 women were eligible to enter the study. Also, individuals were assigned to two test groups (50 people) and control (50 people) using the quadruple allocation sequence (ABAB, ABBA, BAAB, AABB, BBAA, BABA). A was the test group and B was the control group. The criteria for entering the study were: married women 18-35 years of age, no history of miscarriage and pregnancy, desire to become pregnant in the next year and referral for pre-pregnancy, infertility, chronic diseases such as diabetes, chronic hypertension, no history or known mental illness based on the electronic file of the SIB System. Criteria for leaving the study also included relocation during study and absence for more than once in counseling sessions. Prior to the study, the researcher explained the objectives and method of the study in general in a briefing session after introducing himself. They completed the survey under supervision. All the information of the studied persons was kept completely confidential and in none of the stages of collecting, entering the data and preparing the final report, the information of the studied persons or their names were revealed and it was not given to any natural or legal person. People were allowed to leave the study whenever they wanted.
The data collection tool was a questionnaire including demographic and midwifery information, knowledge questions about the methods of delivery. The data were analyzed using SPSS 20 (SPSS Inc., Chicago, IL., USA). P-value less than 0.05 was considered significant.

Our results showed that the two groups were statistically similar in demographic features. According to the results, mean scores of perception of spouse support and attachment of mother and infant after counseling in intervention group were statistically significant compared with control group (P<0.05). In the intervention group, there was a statistically significant difference between the mean scores of spouse support and maternal attachment with infant before and after the intervention (P<0.05).

Table 1. Comparison of awareness scores in the pre- and post-intervention phase and intra-group comparison in the two groups of test and control

The mean post-test of women's test scores were higher than before the intervention; as a result, group counseling was effective in raising awareness. Nosratabadi et al.'s study also found that health counseling is effective in raising awareness and helping to make informed choices about their delivery method [9In this study, counseling sessions were used to raise awareness and create a positive attitude toward natural childbirth. In a casi-experimental study, Malakuti et al. found out that education in the intervention group causes the mean score of pregnant women's awareness toward natural childbirth increase from 2/8 ± 3.9 to 12.3 ± 4.6, which was statistically significant, but in the control group there was no significant increase in the mean score [29].
Pre-pregnancy care training and counseling, as a preventative medicine for midwifery, plays an important role in maternal and fetal health. It also provides ample opportunity for women's awareness and sustainability, and ultimately their proper functioning. As a result, by starting training and counseling and continuing it in prenatal care, the main goal of proper behavior can be achieved. Due to time constraints, this study did not follow the type of obstetric delivery of women, which is recommended in future studies with increasing study time and also the continuation of counseling in pregnancy care of the type of delivery of women.

 

The results of this study showed that group counseling can lead to increased awareness of the choice of natural childbirth. Therefore, by taking advantage of the least possible opportunities in prenatal care for education and counseling, women can be guided to the conscious choice of the type of delivery. Also, the repetition of training and counseling in pregnancy care causes changes in attitudes and performance of women.


 

This article is taken from the dissertation of the master's degree course in midwifery counseling approved by the Research Council of Hamadan University of Medical Sciences and Health Services. Also, this research has been approved by the ethics committee with the special ID of IR.UMSHA.REC.1397.404 and has been registered in the clinical trial database number 29N20120215009014IRCT. The authors appreciate the support of Hamadan University of Medical Sciences, the cooperation of Hamadan Health Center, as well as the women participating in the research.

 

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.