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Anxiety, self-compassion, perceived social support and resilience in two groups of primiparous pregnant women fully and not attending childbirth preparation classes

BMC Psychology volume 13, Article number: 467 (2025) Cite this article

Abstract

Background

Pregnancy involves a combination of physical, social, and emotional changes that can lead to mental health issues, potentially impacting fetal health, childbirth success, and breastfeeding. The present study was conducted to compare anxiety, self-compassion, perceived social support and resilience in two groups of primiparous pregnant women who were either not attending or, fully attending childbirth preparation classes.

Methods

This descriptive-analytic cross-sectional study included 210 pregnant women who attended comprehensive health centers in Khoy from 2023 to 2024. Participants were selected through random sampling. Data were collected using a demographic characteristics form, the Self-Compassion Scale - Short Form (SCS-SF), the Connor-Davidson Resilience Scale (CD-RISC), the Pregnancy-Related Anxiety Questionnaire - Revised 2 (PRAQ-R2), and the Multidimensional Scale of Perceived Social Support (MSPSS). The specific statistical tests (chi-square, independent t-test, Mann-Whitney U) were used in SPSS 16 software, at a significance level of p < 0.05.

Results

The mean score of anxiety was lower in the group of pregnant women fully attending the classes compared to the non-attending group of women (p < 0.001). Additionally, mean scores of self-compassion(p < 0.001), resilience(p < 0.001), and perceived social support (p < 0.001) were significantly higher among women fully attending these classes (p < 0.001).

Conclusion

Given the lower anxiety and higher self-compassion, resilience, and perceived social support observed in women fully attending childbirth preparation classes, healthcare providers should consider implementing supportive interventions to enhance maternal mental health.

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Background

Pregnancy is one of the most significant periods in a woman’s life, marked by physical, psychological, and social changes that can make women especially vulnerable to developing mental disorders [1]. Pregnancy-related anxiety includes excessive worries and fears about pregnancy, childbirth, the baby’s health, and future parenting roles [2]. The prevalence of pregnancy anxiety is moderate to high, with a rate of 54% reported in Iran [3]. While mild anxiety can motivate pregnant women to adhere to healthcare recommendations [4], severe anxiety may hinder maternal adaptation and increase the likelihood of cesarean requests, which can result in complications. High anxiety levels during pregnancy are associated with an increased risk of early pregnancy nausea, fatigue, preeclampsia, preterm birth, and low birth weight [5]. Resilience is an important factor to protect women from mental health conditions [6].

Pregnant women with high resilience are better able to manage their emotions, thoughts, and behaviors both during crises and in less stressful times. Recent research suggests that resilience acts as a protective factor against prenatal anxiety triggered by maternal stress, both directly and indirectly [7]. Pregnant women with high resilience are better able to manage their emotions, thoughts, and behaviors both during crises and in less stressful times. Previous study has discovered a negative association between anxiety and resiliency during pregnancy [8]. When a pregnant woman doubts her ability to handle labor, the resulting fear and anxiety may lead her to choose an unnecessary cesarean [9]. The mediating role of self-compassion in the relationship between resilience and health anxiety of pregnant women has been shown [10].

Self-compassion is a relatively new concept in psychology, introduced as a vital factor in modulating reactions to challenging situations [11]. It offers an effective way to handle anxiety and self-criticism in stressful conditions [12] and enables women to cope with life’s challenges, such as pregnancy and the transition to motherhood [13].

Since pregnancy and childbirth can be experienced as a temporary crisis due to their physical, psychological, and social demands, social support is essential for pregnant women to manage these changes and adapt to them. A lack of social support can negatively affect pregnancy outcomes [14], while adequate support promotes good mental health [15]. Poor perceived social support is associated with higher rates of preterm birth, postpartum anxiety, and depression, whereas appropriate social support encourages positive health behaviors and lifestyle changes [16].

Routine prenatal care fails to raise awareness and reduce women’s fear and anxiety about medical interventions during labor and delivery, which ultimately leads to increased adverse outcomes for the mother and baby [17]. In Iran, the Ministry of Health, Treatment, and Medical Education introduced “Physiological Childbirth Preparation Classes” in 2007. These classes are held over eight sessions from 20 to 37 weeks of pregnancy. Each session lasts approximately 90 min [18]. The content of prenatal education classes in many countries are based on basic theories such as Dick-Read, Bradley, and Lamaze. The content of classes includes physiological pregnancy changes, labor and birth process, prenatal care, healthy nutrition, mental health, complaints and high-risk situations, pain relief methods, postpartum examinations, abnormal symptoms, newborn care, pregnancy exercise and breast feeding [19].

Studies support that prenatal education reduces the fear of childbirth [20,21,22], anxiety at birth [23, 24], depression [20], perceived labor pain [21], and increase maternal attachment [25], and self-efficacy [22]. Gagnon and Sandall (2007) in their meta-analysis showed that the effect of prenatal education on women’s awareness, anxiety, sense of self-control, perceived labor pain, and social and emotional adjustment were controversial among authors [26].

Since the introduction of these classes over two decades ago, few studies in Iran have explored the relationship between childbirth preparation classes and maternal psychological aspects. This study aims to compare anxiety, self-compassion, perceived social support and resilience in two groups of prim parous pregnant women who were either not attending or, fully attending childbirth preparation classes.

Methods

Study design and participants

This descriptive-analytical cross-sectional study was carried out on 210 pregnant women aged 15–49 years who referred to comprehensive health centers in Khoy, West Azerbaijan province, North West of Iran from September 2023 to March 2024.

The sample size of 210 participants was determined according to the score of anxiety based on the results of a study conducted by Hassanzadeh et al. [20], using the following parameters and formula: µ1 = 29.4, µ2 = 25.9, σ12 = 6.9, σ22 = 7.9 µ1-µ2 = 3.5, α = 0.05, and 1 - β = 0.8.

$$\:n\:,=\:\frac{2{\sigma\:}^{2}{({Z}_{1-\frac{\alpha\:}{2}}+{Z}_{1-\beta\:})}^{2}}{{({\mu\:}_{1}-{\mu\:}_{2})}^{2}}$$

Participants were included based on the following criteria: willingness to participate in the study, age between 15 and 49 years, Iranian nationality, being primiparous, and having a gestational age of 35–37 weeks, absence of any medical or mental illness, no use of alcohol, tobacco, or drugs at the time of enrollment, no stressful events (e.g., accident or loss of a loved one) in the past six months, at least a fifth-grade education, a desired and planned pregnancy, cephalic fetal presentation, singleton pregnancy, and no use of assisted reproductive techniques. Incomplete completion of the questionnaires was an exclusion criterion.

Sampling and recruitment

All comprehensive health centers in Khoy were considered as the sampling centers. Pregnant women eligible for the study were divided into two groups: those who fully participated in childbirth preparation classes and those who did not attend any classes. A random sample was selected from each group to ensure proportional representation, resulting in 105 participants per group. After initial contact by phone, participants were invited to the health centers, where they completed self-report questionnaires in a quiet, private setting after providing written consent.

Data collection tools

The research tools included the demographic questionnaires, Pregnancy-Related Anxiety Questionnaire-Revised2 (PRAQ-2), Self-Compassion Scale-Short Form (SCS-SF), Multidimensional Scale of Perceived Social Support(MSPSS), and Connor-Davidson Resilience Questionnaire(CD-RISC).

The demographic questionnaire included items on age, education, occupation, spouse’s age, education, and occupation, gestational age, and family income.

The PRAQ-2, is designed by Huizink et al. for measuring the anxiety during pregnancy and includes 10 items and 3 structural factors: fear of delivery with 3 items (1,2,6); anxiety about giving birth to a physically or mentally handicapped child with 4 items (4,9–11); and anxiety about physical changes with 3 items (3,5,7). Responses are scored on a 4-point Likert scale (1 = definitely not true to 4 = definitely true), with scores ranging from 10 to 40. Higher scores indicate higher pregnancy anxiety [27]. The validity and reliability of the Persian version were confirmed by Bayrampour et al. [28]. In the present study, the reliability of this questionnaire was confirmed with a Cronbach’s alpha of 0.80.

The CD-RISC was developed by Connor-Davidson (2003). The original scale comprises 25 items, with a 7-point Likert scale, ranging from 1 (strongly disagree) to 7 (strongly agree); the total score ranges from 25 to 175. Scores over 145 indicate a high level of resilience, scores between 125 and 145 indicate a moderate level of resilience and scores under 125 indicate a low level of resilience. The higher this score is, the more resilient the respondent is, and vice versa. The scale consisted of five subscales including personal competence, high standards, and tenacity (8 items), trust in one’s instincts, tolerance of negative affect, and strengthening effects of stress (7 items), control (3 items)positive acceptance of change and secure relationships (5 items), and spiritual influence (2 items) [29]. Mohsenabadi et al. [30] reported a Cronbach’s alpha of 0.80 for the Persian version in Iran. In the present study, the Cronbach’s α coefficient was 0.82 for this scale.

The SCS-SF includes 12 items rated on a 5-point Likert scale ranging from 1 (almost never) to 5 (almost always) with a total score range of 12 to 60. The total score of self-compassion is obtained by calculating the mean scores of six subscales including: self-kindness (Items 2, 6), self-judgment (Items 11,12), common humanity (Items 5,10), isolation (Items 4, 8), mindfulness (Items 3, 7), and over-identification (Items 1, 9) [31]. The reliability and validity of the Persian version were confirmed by Saeedi et al., (2012) with Cronbach’s alpha values of 0.84 [32]. In the present study, the reliability of this questionnaire was confirmed with a Cronbach’s alpha of 0.86.

The MSPSS was first developed by Zimet et al. in 1998 [33]. It is a 12-item tool measures perceived support across three dimensions: family, friends, and significant others, with four questions per dimension. Responses are scored on a 7-point Likert scale (1 = very strongly disagree to 7 = very strongly agree), with a total score range of 12 to 84; higher scores indicate higher perceived support. The Cronbach’s alpha for the Persian version was reported as 0.9, 0.9, 0.8, and 0.88 for the friends, significant others, family subscales, and the total score, respectively [34]. In the present study, the Cronbach’s α coefficient was 0.86 for the whole scale and 0.86–0.90 for its subscales.

Statistical analysis

The normality of data was assessed using the Kolmogorov–Smirnov test. Categorical variables were reported as numbers and percentages, while continuous variables with normal distribution were reported as mean ± standard deviation. Consequently, nonparametric tests were used for variables with abnormal distributions, and parametric tests were applied to those with normal distributions. The independent t-test was used for comparison of quantitative variables between two groups. If the normality of the distribution of the variables was not met, The Mann-Whitney U test was used. Fisher’s exact test and chi-square test were used to compare qualitative variables between two or more groups. For this purpose, SPSS statistical software version 16 was used and the significance level of P value was less than 0.05.

Ethical considerations

Ethical approval was obtained from the ethical committee of Urmia University of Medical sciences (IR.UMSU.REC.1402.205). The anonymity and confidentiality of participants were maintained through anonymous surveys. Written informed consent was obtained, and participants retained the right to withdraw from the study at any time.

Results

A total of 210 pregnant women participated in this study, with 105 women in each group (fully attending and non-attending childbirth preparation classes). The mean age was 25.27 (SD = 6.84) years in the fully attending group and 24.21 (SD = 6.64) years in the non-attending group, with no statistically significant difference (p = 0.302). No significant differences were observed between the groups in terms of education level, economic status, occupation, gestational age, or the education and occupation of spouses (p > 0.05) (Table 1).

Table 1 Characteristics of the study participants (n = 210)
Full size table

According to the Kolmogorov-Smirnov test results, variables for self-compassion, social support from family, friends, and others did not follow a normal distribution, whereas anxiety, resilience, and total social support did. Using The Mann-Whitney U test, a statistically significant difference was found between the two groups for self-compassion, support from family, support from friends, and support from significant others (p < 0.05). Additionally, based on the Independent t-test, there was a significant difference between the groups in mean scores for anxiety, resilience, and total social support (p < 0.001) (Table 2).

Table 2 A comparison of the scores of self-compassion, anxiety, resilience, social support, and dimensions of social support in groups (n = 210)
Full size table

According to Fisher’s exact test, the distribution of perceived social support levels between participants who attended classes and those who did not is statistically significant, indicating a non-uniform distribution. Women who fully participated in the classes were significantly more likely to report high social support (97.1%) compared to those who did not participate (83.8%).

Discussion

In the present study, the mean score of anxiety was significantly lower in the group fully attending childbirth preparation classes than those in the non-attending group. In a study conducted by Hassanzadeh et al. (2020) in Iran, the mean score of anxiety was significantly lower in the group regularly attending childbirth preparation classes than in the non-attending group, but no significant difference was observed between the regularly-attending and irregularly-attending groups [20]. In a study by Kuo et al. (2021), an integrated childbirth education program decreased the scores of fear of childbirth, symptoms of anxiety, and depression at 36 weeks gestation, and 1 week postpartum [35]. Firouzbakht et al. (2013), and pouryousef et al. (2022), showed that prenatal training classes reduced anxiety, so that the mean score of anxiety was lower in the trained group [23, 36]. These results agree with the present findings.

In the present study, the mean score of resiliency was significantly higher in the group fully attending childbirth preparation classes than those in the non-attending group. It seems that pregnant women gain the necessary ability to cope with stressors such as childbirth by gaining knowledge and receiving support from resources such as midwives and family members who attend classes. Monfarednia and Ahangar (2021) reported that muscle relaxation beside mental imagery has significant effect on perceived stress and resilience of pregnant women [37]. The findings of a study showed that pregnant women seeking natural childbirth had a higher score in the resilience component than pregnant women seeking cesarean delivery [38]. In the study conducted by Khodabakhshi-koolaee et al., the mean resilience score in pregnant women with an accompanying midwife was significantly higher than those without an accompanying midwife [39]. Indeed, the special intervention in childbirth preparation classes improve resilience of pregnant women gave them the capacity to cope better with stressful events and problems.

In the present study, the mean score of self-compassion was significantly higher in the group fully attending childbirth preparation classes than in the non-attending group. The results of a study conducted by Hulsbosch et al. (2020) showed that mean score of self-compassion in pregnant women participating in an online mindfulness-based group increased [40]. In a study conducted by Papini et al. (2022), brief self-compassion meditation intervention in the intervention group, reduced significantly body shame and body dissatisfaction and improved body appreciation and self-compassion compared to women in the control group [41]. Therefore, specific interventions or training programsfor providers to help women build self-compassion, and culturally tailored interventions are recommended.

In the present study, the mean score of social support was significantly higher in the group fully attending childbirth preparation classes than those in the non-attending group. In line with this finding, Jamali et al. (2018), reported that a spouse’s presence in these classes helps reduce childbirth fear by fostering supportive, responsible behaviors toward mothers. Implementing training programs for pregnant mothers with spousal involvement is therefore recommended [42]. Zarrabi et al. also noted that childbirth preparation classes enhance mothers’ sense of social support, making them feel valued and respected. This support extends into challenging life events, as mothers feel cared for and hopeful about receiving help from others when needed [43]. Firouzbakht et al. (2014), concluded that formal education during pregnancy, combined with emotional and psychological support, can reduce anxiety, pain, and unnecessary interventions during childbirth [36]. Therefore, it is vital for policymakers and maternity care providers to develop targeted social support programs to help alleviate mental health issues in pregnant women. This research has some limitations. Firstly, this study is its self-reported data, which may be subject to social desirability bias. Secondly, this study was not designed as a clinical trial. finally, childbirth educational classes were not held by researchers. The strengths of our study are random sampling and the first study that investigate the psychological effects of childbirth preparation classes in Khoy city-Iran.

Conclusion

Participating in childbirth preparation classes leads to increased resilience and self-compassion, support from the family and service provider, and subsequently the level of anxiety in them decreases. Therefore, it is possible to plan and assess the needs of pregnant mothers in order to educate and inform about the benefits of participating in childbirth preparation classes and remove obstacles for pregnant women to participate in these classes, as well as design and implement suitable training packages in the direction of resilience and self-compassion.

Data availability

The data used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

This work was supported by Urmia University of Medical Sciences. The authors would like to give their gratitude to all women participating in the study for their cooperation.

Funding

This study was financially supported by Urmia University of Medical Sciences.

Author information

Authors and Affiliations

  1. Student Research Committee, Urmia University of Medical Sciences, Urmia, Iran

    Hadiseh Hajihatamloo

  2. Department of Midwifery, School of Nursing and Midwifery, Urmia University of Medical Sciences, Urmia, Iran

    Marzieh Ebrahimi & Roghieh Bayrami

  3. Department of Biostatistics, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran

    Vahid Alinejad

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Contributions

H.H. and R.B. conceptualized and designed the study. H.H., and R.B. coordinated and supervised data collection. V.A. conducted the statistical analyses. H.H., R.B., and M.E. participated in designing the analytic plan and article structure and also drafted the initial manuscript. Each coordinated in drafting the manuscript or revising it; all authors read and approved the final manuscript.

Corresponding author

Correspondence to Roghieh Bayrami.

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Ethics approval and consent to participate

All procedures were approved by the Institutional Review Board at Urmia University of Medical Sciences and are in compliance with all ethical guidelines (Approval code: (IR.UMSU.REC.1402.205) Also, the written informed consent was obtained from study participants. All methods were carried out in accordance with Declaration of Helsinki guidelines and regulations.

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Not applicable.

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The authors declare no competing interests.

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Hajihatamloo, H., Ebrahimi, M., Alinejad, V. et al. Anxiety, self-compassion, perceived social support and resilience in two groups of primiparous pregnant women fully and not attending childbirth preparation classes. BMC Psychol 13, 467 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s40359-025-02723-y

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s40359-025-02723-y

Keywords

BMC Psychology

ISSN: 2050-7283

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