Introduction

Health anxiety characterized by extreme fears and delusions about health and physical symptoms [1]. Health anxiety includes four emotional, cognitive, behavioral and perceptual components. The emotional component includes health concerns. The cognitive component refers to a strong belief that one is sick against medical evidence. The behavioral component includes reassurance-seeking behaviors in order to reduce the fear of illness, and the perceptual component includes mental preoccupation with physical symptoms and feelings [2]. People with health anxiety have many visits to medical centers and pay significant medical costs [3]. Health anxiety is often associated with other mental disorders. Additionally they are often not aware of the fact that their physical symptoms are caused by depression and anxiety [4]. According to the evidence, anxiety is one of the psychological problems of a pregnant mother. Prevalence of pregnancy anxiety has been various and commonly undiagnosed [5], additionally, the mental state of the mother during pregnancy is effective on childbearing process and the health of the baby [6]. This problem can take the form of illness and affect the mental health of the mother and the baby, associated with mental health problems in adulthood, and even have a profound effect on the whole life [7, 8]. Mother’s anxiety increases the possibility of shortness of breath in the newborn period, relationship between mother and baby and reduces the mother’s ability in the role of mother and baby, spontaneous abortion, premature birth and preeclampsia, cesarean delivery and bacterial vaginosis low birth weight, small head circumference, neuroendocrine disorders, low Apgar, crying and a more unstable condition in the baby, and decreases the production and secretion of breast milk in the postpartum period [9,10,11,12,13]. Anxiety and worry during pregnancy, has a significant relationship with the young age of the mother in the first pregnancy, lack of support from her husband and history of abortion [5].

There is not any specific vulnerable period of gestation; prenatal stress effects vary for different gestational ages possibly depending on the developmental stage of specific brain areas and circuits, stress system and immune system [14]. Drug therapy in order to reduce anxiety and worry during pregnancy is only one of the ways to deal with anxiety due to the many side effects on the baby [15]. Although some of nonpharmacologic interventions can be convenient and low cost, there is an inconsistent result of these modalities [13, 16,17,18].

Expectant mothers have high rates of anxiety and depressive disorders, and many are susceptible to a variety of stressors during pregnancy [13], and continuous childbirth education programs for pregnant women in different antenatal care settings are highly recommended [19]. Based on evidence encouraging and supporting women to attend the full course of educational classes has the potential to increase women’s preference towards vaginal birth, resulting in a reduction in the caesarean section rate and fear of childbirth, self-efficacy improvement, and satisfaction to cope with labor pain [20,21,22]. Since in Shahrekord city, the effect of courses held in clinics of comprehensive health service centers on the health anxiety of primiparous pregnant women has not been investigated, this study aims to “determine the effect of prenatal education on health anxiety of primigravid women referring to comprehensive health service centers of Shahrekord city”.

Materials and methods

Current study with ethic code: “IR.SKUMS.REC.1396.208” is a quasi-experimental in the population of primiparous pregnant women referring to Shahrekord (a city in the southwest of Iran and the capital of Chaharmahal and Bakhtiari province) comprehensive health service centers in 2019 was done. After receiving written consent, participants randomly divided into two intervention and control groups.

inclusion criteria included: first pregnancy, 20 weeks gestational age, uncomplicated pregnancy, without anxiety disorders and Depression based on the General Health Questionnaire (GHQ) score, and non-use of psychoactive and herbal drugs. Exclusion criteria included dissatisfaction with the continuation of the study, absence from courses, occurrence of stressful events during the study (such as the death of relatives) and pregnancy complications during the study (such as abnormality and death of the fetus during the study).

The sample size was obtained based on available continuous sampling and according to the information obtained from similar studies [15, 23] and the following formula, including 10% possible attrition, 65 people for each group. The file numbers of the selected pregnant women were written on one-shaped cards and put in a box, then they were randomly assigned to study groups (intervention and control groups).

The information was collected by the researcher using the health anxiety questionnaire and the pregnancy outcomes registration checklist. In the first stage of the study, both groups completed the questionnaires in the 20th week of pregnancy (before the intervention).

For measure health anxiety, the short form of the health anxiety questionnaire designed by Warwick and Salkoskis in 2002 was used. This questionnaire has three parts (18 questions) included as probability of contracting the disease, negative consequences of contracting the disease and general health concern [24]. In this questionnaire, option A is assigned a score of 0 (no health anxiety) and option D is assigned a score of 3 (most health anxiety). The range of scores of this test is between 0 and 54, and higher scores indicate more health anxiety. The studies have shown that the health anxiety questionnaire has good validity and reliability [25, 26].

Participants were asked to select the appropriate option that accurately describes their situation in the past 6 months. The second stage was completing the questionnaire in the 28th week and the third stage in the 37th week for both groups. The intervention group participated in 8 sessions of 1.5 h, once every two weeks, from week 20 to week 37. The educational content provided to the intervention group is shown in Table 1. During this period, the control group received routine prenatal care specific to Iran. In the maternity hospital, the researcher completed the checklist of pregnancy outcomes including (newborn weight, Apgar score, labor duration, type of delivery and first breastfeeding time).

Table 1 Educational content provided to intervention group
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Data analyze were used SPSS version 16 software developed by IBM. Data were expressed as frequency or mean and standard deviation. In order to analyze the data, Chi-square, t-test and regression analysis were used.

Findings

One hundred twenty-two primiparous pregnant women were included in the present study. Mean GHQ score was 21.68 ± 8.60, maximum 39 and minimum 6(. The attrition rate of the sample was 6.1 percent (totally 8 persons in intervention and control groups), because absence in the courses, pre-term labor and failure of filling the questionnaires.

Normal vaginal delivery was 80.3% in the intervention group and 88.5% in the control group. The comparison of the components of the health anxiety questionnaire in the study groups shown in Table 2. The probability of contracting the disease and the overall health concern score before the intervention in the intervention and control groups were significantly different (P < 0.05). There was no significant difference between the study groups in the 28th and 37th weeks (P > 0.05). In the 28th week, compared to before the intervention, the probability of contracting the disease, the negative outcome of contracting the disease, and the overall health concern score in the intervention group decreased by 2.21, 0.44, and 2.62, respectively, and in the control group, the probability of contracting the disease and the overall health concern score increased by 2.33 and 2.13 points, respectively, and the score of the negative consequence of contracting the disease was reduced by 0.2 points. In the 37th week, compared to before the intervention, the probability of contracting the disease, the negative outcome of contracting the disease, and the overall health concern score in the intervention group decreased by 3.42, 0.93, and 4.36, respectively, and in the control group, the scores increased by 2.82, 0.03 and 2.86, respectively.

Table 2 Comparison of the mean and standard deviation of the components of the health anxiety questionnaire in study groups
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The overall average of the various components of health anxiety before intervention vs 28th week, 28th week vs 37th week, before intervention vs 37th week didn’t significantly different (P > 0.05), but only the average score of “ negative outcomes of contracting the disease” in the 37th week compared to before of intervention significantly decreased (P < 0.03).

According to the results of Table 3, there was no significant difference of gestational age, mother’s weight gain, height, head circumference and Apgar score of the baby, duration of hospitalization, and first breastfeeding time between the two groups. The duration of the active and latent phase of labor in the intervention group was significantly less than the control group (P < 0.05). The weight of the baby in the intervention group was significantly higher than the control group (P < 0.05).

Table 3 Comparison of mean and standard deviation of pregnancy and childbirth outcomes in study groups
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Discussion

The present study was conducted with the aim of investigating the effect of prenatal education on health anxiety of primigravid women. In general, the results of the study show that the level of health anxiety in women participating in education courses decreased over time, but the control group experienced an increase in health anxiety from week 20 to week 37.

The components of the health anxiety questionnaire, in the 28th and 37th weeks in the intervention and control groups did not have a significant difference. This result could be due to the two groups not being the same in terms of the initial values of health anxiety, and in the intervention group, the health anxiety score before the intervention was significantly higher than the control group.

In the study of Doaltabadi et al. [27], Najafi et al. [28] and of Khorsandi et al. (2014) pregnant women who participated in labor preparation and relaxation courses had a statistically significant lower average fear of delivery than the group receiving usual care [27,28,29]. A quasi-experimental clinical trial by Mosavi et al. (2021) investigated the effect of virtual childbirth preparation training on primiparous women. The expected outcomes included the difference in pregnancy experience, the difference in fear of childbirth measured, the birth preference, and the type of delivery [21]. In the research of Hassanzadeh et al. (2022), participation in Attending prenatal classes was associated with positive childbirth experience and low postpartum depression score [30]. Delaram et al. reported in 2011 that counseling and informing women in the third trimester of pregnancy reduces their anxiety at the beginning of labor [31]. In [32] review, the relaxation program significantly reduced trait-state anxiety and stress in pregnant women [32]. In general, the lack of awareness increases fear and anxiety about pregnancy and labor, especially in primiparous women, and increases the possibility of morbidity and side effects during delivery and postpartum [7].

According to the results of the present study, there was no significant difference between the mother’s weight gain, gestational age, height, head circumference and Apgar score of the baby in the group participating in the training courses and the control group. The weight of babies in the group participating in labor preparation courses was significantly higher than the control group. In the study of Mehdizadeh et al., in line with these results, no significant difference was observed between the height, head circumference and Apgar score of the newborn in the two groups of participants in the training courses and the control group, but, but in the intervention group, the baby weight was slightly higher [33]. In the study by Bastani et al. in 2006, in pregnant women participating in the relaxation program, the number of premature babies with low birth weight was significantly less compared to the control group, which is in line with the present results [34]. In general, psychological stress and distress of pregnant mothers is one of the main predictors of adverse pregnancy outcomes, including low birth weight and preterm babies [35]. During pregnancy, during exposure to stress and anxiety, various hormones, including corticotropin-releasing hormone (CRH), adrenocorticotropin-releasing hormone (ACTH), cortisol, noradrenaline and beta-endorphin, are released in large amounts in the blood [36]. Increased beta-endorphin levels are associated with decreased placental-fetal blood flow, leading to fetal hypoxia [35]. Maternal stress and increased secretion of catecholamines can cause contraction of blood vessels, which can lead to a range of fetal injuries, including brain damage [37]. Mother’s mental stress is a strong predictor of low birth weight and preterm infants, which are among the major causes of mortality and morbidity in infants [38].Therefore, the increase in the weight of babies of women participating in pregnancy preparation courses compared to the control group is due to the reduction of their stress and anxiety, which has led to the improvement of pregnancy outcomes, including the weight of the baby. In the present study, the length of latent and active phase of labor in the case group was significantly less than the control group. In line with the present results in Mehdizadeh et al.’s study (2005), the duration of the latent phase of labor in the group participating in labor preparation courses was significantly less than the control group. The duration of the active phase of labor was significantly longer in the control group than in the group participating in labor courses [33]. Reducing the duration of labor can also be due to the effect of the courses in reducing the fear and anxiety of the mother and her feeling of comfort. In the present study, there was no significant difference in prevalence of normal delivery between the two groups. This is while in the study of Mehdizadeh et al., and Najafi et al. in pregnant women participating in labor preparation courses, rate of normal delivery was significantly more than control group [33, 34]. In Hassanzadeh et al. study (2021), women reported that participation in childbirth preparation classes prepared them well for a vaginal birth, and these classes were perceived to be associated with a positive childbirth experience [20]. In the studies of Sydsjo et al. (2014), Najafi et al. [28] and Bastani et al.’s study (2006) the rate of emergency cesarean in pregnant women participating in training courses and relaxation program was reported to be significantly lower than in the control group [28, 34, 39].

Training during pregnancy is a dynamic process in which parents get information about the physical and mental changes of pregnancy, childbirth, parenting, neuromuscular exercises and support techniques in pregnancy. These factors reduce the effect of various psychological and biological stressors created during pregnancy and increase the comfort and confidence of pregnant women [19, 32, 40]. Nerum et al. [41], reported that a discussion with women who had fear of delivery and chosen cesarean section, most of them (93%) changed their decision and preferred normal delivery [41].

In the present study, there was no significant difference between first breastfeeding time in the control group and the intervention group. The first breastfeeding time in the intervention group was slightly longer than the control group, which could be due to more cesarean births in this group, and the results may be different in the larger community.

Limitations and implementation problems of research

Occurrence of pregnancy complications such as premature birth, which were excluded from the study. Cases of pregnant women not returning to participate in the courses, we tried to prevent them from leaving the study by following up on the phone and considering a gift for them.

Conclusion

In the present study, the score of the components of the health anxiety questionnaire showed a decrease in the group under labor preparation courses, which indicates the effect of the educational courses in reducing health anxiety, the length of the active and latent phase and increased of baby. According to the results of this study, suggested that labor preparation courses be offered as a method without complications to reduce the health anxiety of pregnant women. To ensure the health of the population, policy makers should consider pregnancy education courses during health programs.