LEGAL articles which have been approved for the ethical

LEGAL AND ETHICAL Ethical considerations influenceand relate to many aspects of the research process and help researchers todecide whether a field of study or a specific investigation is ethicallyacceptable (Behi and Nodal, 1995). Most ethical guidelines require the notionof confidentiality which is underpinned by the principle of respect for autonomy,taken to mean that identifiable information about the individuals collectedduring the process of research would not be disclosed without permission (Wileset al 2008) (BSA, 2017). Furthermore,researchers must recognise ethical standards such as: the respect of thedignity; rights; safety and well-being of the people who take part (DoH, 2011),as well as following the NMC Code (2015) which states that midwives must act inthe best interests of people at all times, and respect human rights to promotethe wellbeing of the patients. The Human Rights Act (1998) alsodetermines that individuals should be protected and prior to any involvement,an informed consent of research proposal must be gained as NMC Code (2015) andDoH (2011) highlights. To ensure the informed consent is obtained, researchersshould ensure that subject has a global understanding of the research includingthe purpose of the study,  theprocedures, risks and benefits of the participation, as well as the signatureof the informed consent (Shahnazarian etal 2008). However, it is important to remember that subjects of theresearch can refuse to participate in one study and the decision should berespected and accepted as everyone has the right to freedom (Human Rights Act,1998). In addition, this systematic review is composed by articles which havebeen approved for the ethical committee and a written informed consent has beenobtained. DISCUSSION According to the results of thissystematic review, antenatal education during pregnancy has the ability toimpact upon maternal condition.

Addressing a specific antenatal educationprogramme or increasing the number of the sessions could impact on anxiety andpain perception of women in labour and decrease the epidural analgesiarequest.  The findings of Melzack et al (1975) showed that preparationclasses for childbirth, especially when the education was made by experttrains, could emotionally reduce labour pain by 30% with the McGill Scale. Thatfact complies with our findings. For the majority of womenchildbirth is a stressful experience.

Physical and mental stress situation canbe the origin of the pain by increasing the hormones such as adrenalin andepinephrine (Cheung et al 2007) (Higson, 2010) (Alehagen 2005). Anxiety andfear in labour are normally contributed to increase the intensity of labourpain (Saisto et al 2003) (Ryding, 1993). Therefore, non-medical approachesthrough antenatal education should be offered to all women in labour in the UK(NICE, 2014).The importance of proper antenataleducation is the key to reducing anxiety, pain and epidural analgesia in labouras previous literature has demonstrated. However, a big limitation of thesestudies are:  the non-specification ofthe routine care received by the women: Firouzbakht et al (2013); Pascual et al (2008);Maimburg et al (2010) and thenon-specification if the experimental group received routine care plus supplementaryclasses: Ip et al (2009); Escott et al (2005).

The difference between theroutine cares received can be dramatically different between studies andcountries. It could be argued that a review of the articles using the sameantenatal routine care may have helped to show results more accurately. Forexample, within these studies, women who attend the same antenatal routine careprogramme, and therefore the same number of sessions.Questionnaires have the advantageof being relatively cheap, a quick and efficient way to obtain large amounts ofinformation from a large sample of people. Furthermore, data can be collected quickly as the researches would notneed to be present when the questionnaires were completed (McLeod, 2014).

However, can be an unreliable means of data collection because respondents maylie due to social desirability. Bergstrom et al (2009) data collection wasrealized by using two questionnaires: at baseline before randomisation andthree months after birth. However, the information about use of epiduralanalgesia had previously found as a reliable because data was compared from theSwedish Medical Birth Register.Although theresults from Firouzbakht et al (2013)showed that women who received the educational classes had lower level ofanxiety on arrival and lower level of pain during the transitional stage(8-10cm), this study presented some limitations. HADS questionnaires werecompleted by the midwife on arrival, which can be an unreliable means of datacollection due to the variability in the stage of labour that women can presenton arrival. For example, women who arrive to the hospital in the transitionalstage (8cm-10cm) are more likely to present more anxiety than women who areadmitted during the early stage (3cm-4cm). Therefore, this study does notinclude a specific result concerning anxiety during the different stages as VASlevels of pain provides.

In addition, Firouzbakht et al (2013) explains that the presence of the doula during thelabour and child birth could be an influence on the reduction of childbirthstress and pain in labour. Stress and pain in labour could be altered because eachmother of the study trusted their doulas leading to emotional attachments,considering them as reliable and felt less worried and more secure duringdelivery. Ip et al (2009) and Firouzbakht et al (2013) conducted their studies inChina and Iran respectively. Therefore, may not represent the population in theUK because the pain can be experienced differently between the differentethnicities as (Peacock and Patel, 2008) highlights. Moreover, Firouzbakht et al (2013) used nulliparous or multiparouswomen, being the collection of the data quicker and easier. However, this typeof sample may under represent the perception of pain and anxiety because thefear of childbirth is higher in nulliparous women than in multiparas women andconsequently the perceived meaning of pain in labour is influenced by previousexperience (Spice et al 2009; Beigi et al 2010; Whitburn et al 2017).

The results in this systematicreview suggest that each added session or a structured antenatal training isessential to reduce the epidural use during labour (Pascual et al 2008; Maimburg et al 2010; Levett et al 2017). These results indicate strong evidence against thenull hypothesis as the p value was < 0.01 (Donata et al 2016). However, this hypothesis was contrasted by Bergstrom et al (2009), which affirmed naturalchildbirth preparation with psych prophylactic training compared to standardantenatal education group, did not decrease the use of epidural analgesiaduring labour (p<0.0001).Pascual et al (2008) and Levett et al (2017) used two differenthospitals to collaborate in the study. Multicentre studies can be easier andquicker when recruiting the necessary number of women; however, they requiremore attention in order to maintain quality assurance concerning admission andfollow ups (Messerer et al 1987).

Forexample, within these studies, a highly coordinating organisation is requiredto collect all the data successfully. Longitudinal studies are able toidentify and relate events to particular exposures, however, can be incompleteand interrupted follow-up for individuals with notable threats to the representativenature of the dynamic sample (Caruana etal 2015). Pascual et al (2008)used HAD scale to measure the degree of anxiety during the dilatation period,always before the start of the expulsion period and satisfaction once deliveryhad ended.

However, the study used telephone interviews one and a half monthsafter childbirth, possibly an inadequate time for observational study becauseafter childbirth women do not completely forget labour pain and recall is oftenvivid, but it does not always entirely accurate as Niven and Murphy-Black(2000) highlights. In addition,the risk of bias in the study undertaken by  Pascual et al (2008) stems fromthe assumption by the authors that there would be 40% of women choosing not toattend, unfortunately for the researches only 7% of women chose no antenatalcare and this altered the statistical power of the study. This type of similar datacollection was also realized by Escott etal (2005) as suggested that the study was limited by measuring women´s useof coping strategies in labour by self-report postnatally (72 hours), asassessments based on memory may contain biases. Ip et al (2009) also collected pain and anxiety levels using VAS andChildbirth Coping Behaviour Scale (CCB), which may impact upon the results.Unfortunately, due to the results depending on the women´s self-reportedanxiety 24-48 hours after their delivery, this study may have developed biasesand it is not representative of the anxiety levels in labour Furthermore, it is suggested that abetter, more reliable method of data collection would be through observation ofwomen´s behaviour in labour. For example, developing direct observation asFirouzbakht; et al (2013); Bonapace et al (2013) did in their studies.  However, Bergstrom et al (2009) used women´s own reporting three months after thebirth to measure the use of epidural analgesia.

This study found self-reporteduse of epidural analgesia had previously been found as reliable information (previouslydiscussed) when compared with data from the Swedish Medical Birth Register. Escott et al (2005) and Bonapace etal (2013) showed that woman who attended antenatal specific classes hadless pain intensity in comparison to the routine care group. Bonapace et al (2013) used a sample of 25 women,which is considered a small sample, and the validity of the study could not begeneralised to the population because it can undermine the validity of thestudy (Faber and Fonseca, 2014).  Thisfact was also a limitation for the small UK study undertaken by Escott et al (2005) who used a sample size of41 nulliparous women. Escott et al(2005) used also a convenience sample for recruitment, which was affordable andeasy, and the subjects were readily available. However, convenience sampling is likely to be biased due to the lack ofa significant representation of the population (Etikan et al 2016) (Mackey and Gass, 2005). For example, in this study, itwas not possible to randomly allocate women to either CSE or standard classesbecause women decide in advance which evening they prefer to attend.  Furthermore, the year of publication of thisstudy was 2005 which means that is slightly old.

However, this study wasconducted in the UK and all the results can be more representative of thepopulation, and therefore a systematic review. This literature review has producedcontradictory findings on other physical effects of antenatal education inlabour and birthing outcomes.  Ip etal (2009) showed that women who received the extra educational programme hadlower perception of pain during the early and middle stages oflabour whereas Firouzbakht et al(2013) suggested that women who received the supplemental educational classesdid not display anything quantifiably different during the second stage in comparisonwith the control group. Moreover, Pascual etal (2008); Maimburg et al (2010)and Levett et al (2017) relatedreceiving more antenatal education with less epidural anaesthesiaadministration during the birth. However, these results were contradicted by Bergstrom et al (2009) who affirmed that extraantenatal education training is not effective in decreasing the use of epiduralanalgesia in labour.

Further research is required inunderstanding the efficacy and the importance of antenatal education on women´sbirthing anxiety and pain, as well as analysis of the impact of the antenataleducation training programmes to reduce the epidural rate use duringchildbirth. CONCLUSION This literature review hasidentified some positive aspects between supplemental antenatal education andthe reduction of pain, anxiety and pain analgesia during childbirth. However,it seems that antenatal education does not consistently reduce the epiduralrates as Bergstrom et al (2009)described in their study. In general, it has been demonstrated that betterpreparation for childbirth is associated with antenatal education in pregnancy.

More research is required toexplore the impact between antenatal education in pregnancy and birthingoutcomes such as anxiety, pain and epidural analgesia.