Do Birth Classes Improve Birth Outcomes? What do the studies show?

Is taking a childbirth class (also called prenatal classes, birth classes or pregnancy classes) worth it? What do the studies show about if it can improve your birth? Can it decrease cesareans, or your anxiety surrounding birth?

But, first — let’s talk about my own experience before we dive into this article.

FYI, I taught prenatal classes for my hospital, and I have my own prenatal education business. However, I am all about the studies and I wanted to see what they actually showed (and frankly, how I could make my own education better from the results).

With each of these studies you’ll see the “facts” with linked studies and then you’ll see my thoughts on each of them underneath it (in italics). Interpretation of studies is VERY important, and I would encourage you to look at the studies and see what types of conclusions you come to, don’t just take my thoughts as the truth.

I also reviewed this and more of my thoughts in a recent podcast episode:

Do Birth Classes Improve Birth Outcomes?

Almost all the studies point to positive outcomes from birth education include lower cesarean rate, less anxiety, decrease vacuum assisted deliveries, and possibly lower induction rates.

But, as with all studies it can be hard to interpret the data, so I want to point out three limitations in studies on prenatal classes that I found throughout the literature.

Issues with Studies on Birth Class Outcomes

The first issue has to do with who normally takes a birth class….

Who Takes a Birth Class?

Because all this talk about birth classes will be associated with those who take a birth class, let’s talk about who generally takes a birth class. This study had some interesting statistics

• Older Women (older than 35)
• People who are pregnant with their first baby (called nulliparous in the studies)
• Women who are higher educated
• Higher incomes, above the poverty line.

(Obviously, a lot of people that don’t fall into this take birth classes, but these people are more likely to take them).

Although that study also showed the highest rates of childbirth class participation amongst those 15-19 years old, I wonder if those women are in services that also included childbirth education (which I love).

But, people with higher privilege rates in general tend to take birth classes.

The second issue is that not all birth classes are created equal…

What is included in birth class?

The term “birth class” can be super vague and hard to really “pin” down as to what it is. Plus, with the advent of online birth classes who are not supported by any “center” they vary wildly.

• Birth classes taught by childbirth educators with little/no actual birth experience
• Birth classes taught by doulas with limited training and unknown birth experience
• Birth classes taught by doctors that skew highly medical and along the lines of how they practice
• Birth classes taught in hospitals where doctors/hospitals control what is taught in the class and may veer towards “compliance” rather than education
• Birth classes taught by registered nurses of varied experience (and may have no actual labor and delivery experience) and may echo more of what they see in their practice vs evidence-based information.

Don’t forget these issues too:

• Birth classes using only one way to educate (aka, video or writing) when couples may learn better with different methods like quizzes, asking questions, etc.
• Birth classes aimed only towards the birthing person vs with the partner
• Boring birth classes in which no one gets anything out of it because they’re not engaged.
• Birth classes that include a community so you can find support from others in your similar situation (think of the traditional in person birth class).

As you can tell the variables in “birth classes” can differ a LOT and if you are looking for birth education you want to look for:

• Someone with a lot of varied experience including “natural” birth and “medicalized” birth because you don’t know how your birth is going to go.
• Birth classes that include whatever method of teaching you find the most helpful — if you’re not sure, find one that has a lot of different types of information so you get what you need.
• If you’d like your partner involved, be sure to find one that suits them.
• Make sure to take a class with someone who is engaging. With the advent of online birth classes many educators offer free classes, you can see them on social media or on Youtube — so you get a sense of what type of educator they will be (and if it’s a good fit for you).
• If you think you’d like a community, consider an in-person class, or one that includes a network that you can engage with.

And finally, this one has to do with the studies themselves…

Small Sample Sizes

In a lot of these studies I found there to be VERY small sample sizes, often around 200 people. Considering HOW many people give birth it honestly doesn’t seem all that hard to do a larger study. But, keep that in mind. Some of the studies had less than 30 participants, and that just seems more like a report on their experience vs an actual study.

Ok, with those three very big limitations on these studies, let’s jump in to what they have to tell us.

Decreased Chance of Cesarean Section

8 Percent Lower Cesarean Rate with Childbirth Education

This study from the American Journal of Obstetrics and Gynecology (Afshar, Wang, Mei, Pisarska, Gregory 2016) shows that women who either had a birth plan or took childbirth education (which they reference as CBE) had a better chance at a vaginal delivery. For women who had not previously had a vaginal birth the control group delivered vaginally 64.1% of the time, and the group who had taken childbirth classes had a vaginal delivery 72.6% of the time — so about an 8% difference in c-section rates.

This study (Stoll & Hall 2012) also echo’d a decreased chance for cesarean sections even after adjusted for age, # of babies and income level.

However, this study (Ricchi, La Corte, Molinazzi, Messina, Banchelli, Neri, 2020) (although smaller) didn’t show a difference in cesarean rates.

This study (Gluck, Hiaev, Rubinstein, Bar, Kovo 2018) also showed that women who took a childbirth class had a MUCH lower “failed induction” rate (3.3% for those who took the class vs 24.5%).

Less Likely to Request a Cesarean Section

This study (Stoll & Hall 2012) showed that people who hadn’t been pregnant before were less likely to request a cesarean section at prenatal appointments if they took a birth class (vs those who had not taken a class).

TOLAC and VBAC rates (Vaginal Birth after Cesarean)

This study (Stoll & Hall 2012) showed that women who’d previous had a caesarean section were more than twice as likely to attempt a VBAC than those who had not attended childbirth education.

Also Changes in Non-Surgical Birth Interventions

This retrospective study (Gluck, Hiaev, Rubinstein, Bar, Kovo 2020) compared women who did or did not take childbirth education during their pregnancy. Not only did they have a higher rate of normal vaginal delivery 80% vs 50% in the control (which is WELL Below the national average, so I’m not exactly sure what a “normal” vaginal delivery was). BUT it also showed a lower rate of vacuum extraction 7.5% vs 22% in the control group.

FYI, A vacuum delivery is where the birthing person is assisted by the Dr in delivery by applying a vacuum to the baby’s head to help pull the baby out.

Hilary’s Thoughts on Decreased Cesarean Rate through Childbirth Education:

I thought LONG and hard on this, because in my experience your chance of a c-section depended on 3 things

1. How big your baby is
2. Baby’s position in your pelvis
3. Your provider

And birth classes don’t change ANY of those things (although we can help with nutrition to get baby to a more-normal size in some cases).

BUT, birth classes do:

• Give you realistic expectations on what to expect so you’re not giving up early
• Talk about how important movement is to help baby find their best spot in your pelvis throughout the birthing process
• Help you communicate better with your healthcare team and understand decisions are ultimately up to you

I really believe those three are the reasons C-section rates are lower (and also for assisted deliver rates — like when they use a vacuum), even when adjusted for all the variables above. But, you’ll want to look for a class that teaches you realistic expectations, movement during labor and how to communicate with your team to make sure you get this benefit.

With all these benefits, you may wonder if birth classes are covered by insurance.

Ok, let’s move on to changes in induction rates….

Inductions with Childbirth Education

This study (Stoll & Hall 2012) showed there wasn’t much of a difference in those who were induced or augmented into labor.

This study (Mueller, Webb, Morgan, 2020) showed women were less likely to be induced if they took prenatal education (17% for those who took classes vs 29% for those who didn’t).

Hilary’s thoughts about decreased Inductions with childbirth education:

It’s hard to say which is true. There doesn’t seem to be a whole lot of data on this, and with the limited scope with a lot of these studies it’s hard to say. For this type of thing you’d need a wide variety of hospitals as many have very restrictive induction policies.

In fact, with the Arrive trial showing that inductions may be helpful past 39 weeks, it’s hard to say what childbirth education should say in relationship to induction. Personally, I just give out the data on what the study said, and my thoughts on how the study was done and let people make their own choices with their providers based on their situation at 39+ weeks.

That being said, I do believe that quality prenatal education helps participants make joint decisions with their healthcare team throughout pregnancy and labor, so that’s a big win and will likely lead to less un-necessary inductions (and inductions on unfavorable cervixes, because they will understand what that means more).

Pain Management Options

This study (Stoll & Hall 2012) showed that the use of epidural anesthesia was highest for women who hadn’t been pregnant and also did not attend childbirth classes (although they don’t call it statistically significant). They did not see a difference in those who had already had a baby.

This study (Ricchi, La Corte, Molinazzi, Messina, Banchelli, Neri, 2020) showed that there was a lower frequency of epidural use for women who took a prenatal class. They also showed they were more likely to use breathing or natural pain management techniques during labor.

This study (Bennett. Hewson. Booker. Holliday 1985) showed that women who attended more of childbirth education were less likely to use the epidural, more likely to breastfeed,

Hilary’s thoughts about pain management usage after prenatal education:

Clearly, decreased use of the medical pain management options is true of people who take prenatal classes.

This in area where education is key. We’re just not taught a whole lot of coping techniques (especially for pain) in everyday life, so teaching those techniques is key in a class.

Also, having an idea of what the pain will be like, and how it will progress is super important.

Decreased Pain in Early Labor

This study (Al-Kerdy etal 2017) showed that patients who had taken prenatal education had less pain in early labor. They believe it was because women knew what to do on their own (self-efficacy) and felt more prepared

I’d have to agree — I think it’s scary when you are in pain and now have to go into the big unknown!

Changes in Levels of Anxiety

This study (Stoll & Hall 2012) showed there weren’t significant differences between the levels of anxiety at birth between those who did take a class vs those who didn’t (although they didn’t test a change in the level of their anxiety and I also don’t believe they tested anxiety levels after birth either).

I thought this study (Pinar, Avsar, Aslantekin 2016) was pretty interesting (I couldn’t read the whole thing, just the abstract). It showed that prenatal class participants had less anxiety, and more knowledge about the birthing process. BUT most exciting it said that they adapted better to their pregnancy and postpartum life. Which is huge because it’s SUCH A big change!

This large study out of Poland (Ciochoń, Apanasewicz, Danel, Galbarczyk, Klimek, Ziomkiewicz 2022) showed a decrease in anxiety and depression in those who took prenatal classes. It did show the highest decrease was in those who took an in person class, followed by those who took an online class, and then the most anxiety in those who did not take a childbirth class.

This study from Iran (Hassanzadeh, Abbas-Alizadeh, Meedya, Mohammad-Alizadeh-Charandabi & Mirghafourvand 2020) showed that fear of childbirth, anxiety and depression were significantly lower in those who take prenatal education vs those who do not. It also showed the results to be significant even if the mom only sporadically attended the classes.

This study (Dai et al, 2021) out of china showed that prenatal education did decrease fear of childbirth.

This study (Sanaati et al, 2017) showed that education, especially about postpartum adjustments when given to both partners can really help decrease anxiety in that adjustment period. It stressed how important it was to train both mothers and their partners in what will happen and how to cope.

Many of the studies show that childbirth education increases self-efficacy, which per the APA means: an individual’s belief in his or her capacity to execute behaviors necessary to produce specific performance attainments — which, frankly seems awesome!

Some studies like this one do show that improper prenatal education can increase fear — so it’s really important that people be thoughtful in the education they choose!

Hilary’s thoughts about anxiety after prenatal education:

Great news in this section too! I think overall people have a decrease in anxiety relating to birth with prenatal education. I LOVE that it also showed that people were more easily able to adapt to life after delivery as well, as that’s a big part of my own classes.

Anxiety is often tied to depression, so it’s a big win when you decrease both of them.

A couple of thoughts:

• I think moms who are more nervous about birth in general seek out prenatal education (and thereby may still show anxiety at birth, but it will be strongly less due to their education)
• I like that the study in Iran showed that even sporadic education was better than nothing, which is likely true.

This definitely echo’s what I see in my own practice. Patients who took a prenatal class just LOVED their birth more. They were less nervous in the delivery room, more confident and were like 2 steps ahead of other people both experiencing birth and trying to figure out what was going on.

Is Online Education Good Enough

This study (Uludağ et al 2022) showed that online education did decrease worries about labour, fear of childbirth, just like “in person education” — which is great news for busy parents!

Breastfeeding and Childbirth Education

This study showed that although breastfeeding initiation rates were higher amongst those that attended classes, they didn’t find it statistically significant.

Hilary’s thoughts about breastfeeding with prenatal education:

Makes sense. I strongly believe in a separate prenatal class and breastfeeding class (I just don’t think that people who are good at one are necessarily good at the other). I also think you only need a general overview of breastfeeding and nothing too long to prepare you for what you’ll do in the first few days, and then I’d reach out to professional to help with you and your needs.

My favorite breastfeeding class is The Breastfeeding Mama’s. I also have some great coupon codes once people are in my course that you can used to buy a couple of my favorite classes. 🙂

Overarching Themes in the Studies in Birth Education

This study (Levett,Smith, Bensoussan, Dahlen 2016) showed that people who took a class that included both birth instruction as well as natural pain management options (such acupressure, visualization, breathing, etc) had a reduced rate of augmentation, cesarean section, a shortened length of the second stage (active labor), and less perineal trauma (so tearing or an episiotomy) and less newborn resuscitation.

But, this study showed basically no real benefits or adverse outcomes from attending childbirth classes… sigh.

Which brings us back to my feelings at the top…. it really depends on the person’s needs, the educator, and what is taught — and how that affects the pregnant person and her support team.

I do plan to look for further research and studies on childbirth education, so if you know of one I missed please do let me know. I think this type of thing is SO facinating!

I am currently “studying” how much better people feel after taking my own class, I’d love it if you’d come join me in there.

The Online Prenatal Class for Couples is created by someone who is highly educated, and experienced. It values lots of different types of learning with its written material, video, quizzes, key points and more AND it involves your partner in whatever way they want to show-up. PLUS I try to give community with my Facebook group which is open to all class participants.

It is a risk-free purchase, so you can decide if I’m the right teacher for you (and if I’m not, I’ll give you your money back). Stay tuned for what the data ends-up telling us on that class specifically!

Don’t miss my great big post on everything you need to know about birth classes << for more information this important subject!

And, if you’re not quite sure you’re ready for that whole thing, check out my free prenatal class. It’s your first step toward getting in the driver’s seat of your birth.