Introduction:

Today, cesarean has a higher risk than vaginal delivery for mother. It causes complications such as endomyometrium, bleeding, urinary tract infections and thromboembolism. It can include premature child birth, tachycardia in newborn, persistent pulmonary hypertension of the newborn,and injuries such as wound, bruising or other injuries¹.

Decreased natural delivery in pregnant women shows the poor performance of the healthcare system. Since, the prevalence of natural and cesarean delivery in pregnant women in a country is one of the indicators for assessing the performance of maternal health programs².

Researches have shown that pregnant mothers do not presume normal delivery as safe as cesarean method³.

The study of Zasloff et al. (2007) showed that fear of delivery as the main cause of avoiding vaginal delivery has a significant relationship with age and older individuals have less fear⁴. One of the priorities of World health organization (WHO) health services, is health education of mother and child which has a prominent role in promoting the health of the community. Today, although pregnancy cares are routine in most countries, but many mothers die each year due to pregnancy and childbirth. Therefore, it seems that this healthcare is not provided according to the right principals of education⁵.

The pregnancy education is a psychological educational intervention. The goal of this educational approach is reducing pain, rapid recovery, psychological well-being and satisfaction of the mothers with the health care⁶.

A noted British researcher, Dick Reed, believes that the main cause of intensifying pain during delivery and prolonged delivery steps are fear and anxiety. Fear results in muscle stretching mechanism which tightens the uterus and cervix and increases resistance to cervical opening. Stretching of the muscles also stimulates the nerves of the uterus and intensifies the pain, but he believes pre delivery preparation classes can reduce muscle stretching and reduce the intensity of pain and prolonging the delivery⁷.

In these pregnancy classes, women learn how to effectively overcome delivery and increase decision-making power during pregnancy and delivery. Lack of awareness and fear causes anxiety for pregnant mothers⁸.

Delivery preparation classes include group or individual classes with the aim of training pregnant women and their husbands about deliver and childbirth, pregnancy care, nutrition and exercise during pregnancy and lactation, proper lactation, and other after delivery care⁹.

Lack of education and preparedness of pregnant mothers during this period increases the medical interventions and cause complications for the mother and the fetus, so holding deliver preparation classes during pregnancy may be a proper way for solving these problems¹⁰. Effective education could increase the knowledge and attitude of mothers during pregnancy and subsequently promote self-confidence and preparedness of pregnant mothers for accepting natural and safe delivery and without intervention. The aim of this study was to evaluate the effect of the deliver preparation classes on knowledge and the attitude of pregnant mothers about the type of delivery at Razi Hospital in Saravan.

Methods:

This interventional study is a Health System Research (HSR) that was done by analytical cross-sectional method during 2016 in Razi Hospital of Saravan in Sistan and Baluchestan province, Iran. Out of all the mothers that had the criteria for entering the study, 50 subjects were sampled and selected by a census method.

The inclusion criteria included pregnant women, gestational age of 20 weeks or more, no history of acute and chronic disease of the mother, no history of cesarean, willingness to participate in the study and completing the written consent consciously.

Exclusion criteria included unwillingness to attend the classes and premature delivery.

Mothers participated in deliver preparation classes during pregnancy for 8 sessions of 2 hours once in 2 weeks from the 20^th week of the pregnancy to the 34^th weeks and were trained by an experienced midwifery instructor. The content of these classes included the education of delivery stages, delivery pain, risk symptoms in pregnancy, physiological and physical changes in mother, common problems of pregnancy, nutrition and exercise during pregnancy and lactation.

At the beginning of each class, a pretest was conducted on the mothers, and then their awareness, beliefs, and concerns were discussed in the group and with the active participation of all mothers and based on their understanding, the new materials were taught. The lectures, plays and pamphlets were used for better learning. After completing the classes in 16 weeks, the mothers were provided with the same questions in the questionnaire as a post-test. By comparing the pre-test and post-test questions with statistical analysis including Chi-square test, Tukey's post hoc test, using SPSS version 18, the effect of delivery preparation classes on the awareness and attitude of mothers about the type of delivery was evaluated.

Results:

The research results showed that out of 50 volunteer mothers participated in the preparation classes , for delivery were 18-28 ages, and had diploma level of education (Tables 1, 2).also that, this study showed that there was a significant difference between the before and after the intervention (P <0.0001). The minimum score for knowledge in mothers was 0 and maximum was 20. The maximum and minimum scores for attitude were 0 and was 80, respectively and the positive attitude score was increased from 40.46 in before the training to 55.17 after the training, and the mean knowledge score of mothers was reached from 7.33 before the training to 18.5 after the training, which had a significant difference and confirmed that the provided training had a positive effect on knowledge and attitude of mothers participated in the course.

T-test was used to compare the mean of attitude score before and after the intervention. The results showed significant difference before and after the intervention (P <0.0001). Attitude score was increased.

ANOVA test was used to compare demographic characteristics and attitude scores before and after training, and Tukey's post hoc test was used in the case of significant difference in demographic characteristics.The mean knowledge of mothers before the training was 7.33 and reached to 18.58 after the training, and the difference was significant ANOVA test was used to compare demographic characteristics and attitude scores before and after the training, and in the case of significant difference in demographic characteristics, Tukey's post hoc test was used (table 3). The mean knowledge of mothers before training was 7/33 and reached to 18.50 after training, which showed a significant difference.

Discussion:

The results of the present study showed that the pregnancy training was effective on the knowledge and attitude of mothers about the type of delivery. In Sweden, pregnancy training classes showed that 74% of mothers became prepared for delivery and obtained enough knowledge in this field¹¹.

Pregnancy and delivery could be the mother's greatest moments, but the mother's concern and her lack of awareness lead to a negative attitude toward normal delivery, reduce self-confidence and cause depression in mothers.

Mirazo et al. (2012) in their study showed that increasing knowledge and skills in mothers during pregnancy by holding classes caused increased self-confidence, awareness and skill about pregnancy and delivery, and reduced the complications of premature child birth and also, mothers obtained knowledge about the importance of postpartum care¹².

The results of the study by Firouz Bakht et al. (2011) showed that the training of during pregnancy decreased the hospital anxiety and the intensity of delivery pain, and also decreased the need for episiotomy and emergency cesarean¹³.

The results of this study indicated that there was a significant difference in the attitude score before and after the intervention (P <0.0001) and the attitude score was increased.

The study of Vakilian and Mobasseri (2012) showed that the attitude of the mothers after the training of the delivery preparation classes was changed during pregnancy and became positive. Particularly, this attitude was significantly changed in relation to exercise during pregnancy and after delivery, and the performance of mothers during the pregnancy was remarkable for exercise¹⁴. These studies were in agreement with the present study and showed the effect of education and training and delivery preparation classes on changing the attitude to positive and increasing knowledge and the results of the attitude change finalize by following up the mothers and evaluation of the delivery type and investigation of the causes of probable cesarean^15-19.

Conclusion:

According to the results of this study and the aforementioned studies, it is recommended that more culturizing with media advertising such as television and radio about informing mothers about delivery preparation classes should be done leading to participation of more mothers in these classes and reducing the fear and anxiety about natural delivery, so that a decrease in the percentage of first time cesarean could be observed. It is also suggested that the presence of a companion midwife along with mothers should be more significant and mothers be informed of a companion midwife because the research has proven that access to a midwife during pregnancy and delivery caused the increased confidence of mothers and reduced unnecessary interventions.

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