Effectiveness of parenting education for expectant primiparous women in Asian countries: a quantitative systematic review protocol : JBI Evidence Synthesis

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Effectiveness of parenting education for expectant primiparous women in Asian countries: a quantitative systematic review protocol

Mori, Emi; Iwata, Hiroko; Maehara, Kunie; Sakajo, Akiko; Ina, Kei; Harada, Nami

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JBI Database of Systematic Reviews and Implementation Reports 17(6):p 1034-1042, June 2019. | DOI: 10.11124/JBISRIR-2017-003974
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Review question: 

What is the effect of antenatal parenting education on parenting stress, maternal depressive symptoms and maternal confidence, compared to usual care, for expectant primiparous women in Asian countries?


Becoming a mother can be a stressful and difficult process for expectant women, especially primiparous women (women who are pregnant for the first time). Studies have shown that primiparous women are more severely fatigued,1,2 depressed,1,3,4 and have more difficulty taking on the maternal role1,5 than multiparous women during the early postpartum period. Parenting education is generally designed to help expectant women and their partners prepare for parenthood. It may be offered before or after childbirth, and covers the elements of pregnancy, childbirth and parenting.6 Parenting education is typically broad and varied in its goals, content, delivery methods, onset, outcomes, providers and participants.7-9 The goals may include influencing health behaviors, preparing for childbirth, preparing for parenthood and developing social support networks. Parenting education may be offered individually or in groups, at hospitals or in the community, face-to-face, or via pamphlets, videos or online. The target population for parenting education may include pregnant women alone or with their partners.

There are many studies on parenting education, and an initial database search found several systematic reviews. For example, Pinquart and Teubert7 conducted a meta-analysis to assess the effects of parenting education during pregnancy or in the first six months postpartum. They included 142 studies with 133 interventions, and outcomes measured in both primiparous and multiparous women, but no details of the original countries in which each intervention were provided. Pinquart and Teubert7 concluded that parenting education had significant effects on outcomes, including parental stress, child abuse, health-promoting behavior of parents, the child's mental health, parental mental health and couple adjustment. Most interventions in the trials included in the review commenced postnatally. Only 10 interventions were held exclusively during pregnancy, and 38 covered both the pregnancy and the postnatal period. Whether the intervention started during pregnancy or after childbirth did not moderate the observed effect size in several outcomes, including parental stress or parental mental health. However, to determine the appropriate timing and content of parenting education in order to bring about maximum benefits for parents, the onset of the education (before or after birth component) should be clear.

Gagnon and Sandall8 conducted a systematic review to assess the effects of antenatal education covering childbirth or parenthood. They found nine trials conducted in the United States, Canada and Iran involving 2284 women with various interventions and inconsistent outcomes. The parity of participants was unknown in some studies. Because of the variation in the trials included in the review, no subgroup analyses were conducted to examine the effects of specific content, delivery method or target populations. The reviewers concluded that there was a lack of high-quality evidence from randomized controlled trials, and that the effects of antenatal education therefore remained largely unknown.

Fontein-Kuipers et al.9 conducted a systematic review to assess the effectiveness of antenatal interventions for the reduction of maternal distress. They found 10 trials involving 3167 women with six preventive interventions and three treatment interventions. The trials were conducted in Australia, the United States, Sweden, Northern Ireland, Iran and Taiwan. A subgroup analysis of the six preventive interventions found that three were provided during the antenatal period alone, and they had no beneficial effect on maternal concerns or problems such as depression, anxiety, parenting stress or fear of childbirth. The review found that antenatal education designed for health promotion, such as to improve maternal confidence, had no effect.

There are other systematic reviews on parenting education. Brixval et al.10 examined 17 studies from Western coutries and found considerable heterogeneity in interventions and outcomes. Gilmer et al.11 conducted a realist review and concluded that no single parenting education intervention was universally effective.

In summary, goals, content, delivery methods, providers and participants vary a great deal in antenatal parenting education. No single standardized parenting education program exists that meets the needs of all parents. It is therefore necessary to focus on specific interventions in determining their effects on specific outcomes in particular populations so providers of antenatal education can tailor interventions more appropriately.

In recent times, the need for antenatal classes has shifted from birth-oriented to parenting-oriented.12 The transition to motherhood can be linked to both negative and positive experiences. New mothers often experience psychological distress, such as postpartum depression and parenting stress.13,14 Parenting confidence, defined as the individual's belief in her ability to succeed as a parent, is an essential component of parenting,15 and can have a major impact on maternal health and wellbeing. Nursing researchers are increasingly focusing on the factors that help mothers address the changes in their lives. This review will examine the outcomes of both negative and positive adjustments made by women after giving birth, and the specific interventions aimed at promoting a positive transition to motherhood. A meta-synthesis by Entsieh and Hallstrom6 found that the antenatal period was important in providing parenting education for primiparous couples. Providing parenting education during postnatal periods may have limited use in preparing for parenthood because new parents are usually fully occupied with childcare after childbirth. This review will therefore examine interventions starting during pregnancy, not after childbirth.

A preliminary search of existing systematic reviews on parenting education using CINAHL and MEDLINE found no review that had specifically examined the effectiveness of antenatal parenting education on parenting stress, maternal depressive symptoms and maternal confidence for primiparous women and their partners. The concepts of parenting confidence, parenting self-efficacy and perceived competence have similar definitions, but confidence is the most commonly used term in studies in both English15 and Japanese. This review will focus specifically on the following aspects of parenting education: i) interventions starting during pregnancy, not after childbirth; ii) a target population of primiparous women and their partners; and iii) outcomes including indicators of maternal psychological health, such as depressive symptoms, and indicators of parenting, such as maternal confidence and parenting stress.

Previous reviews have mostly examined practice in non-Asian countries, focusing on randomized controlled trials. This represents a gap that we seek to fill. An initial search of MEDLINE using outcomes of depression, parenting stress and maternal confidence suggests that there are a number of studies of antenatal education that may not have been previously included in systematic reviews, including some from Asian countries.16-22

The results of this systematic review will support the development of more specific and effective antenatal parenting education classes. It will be particularly helpful for promoting antenatal education in Asian countries and improving outcomes for expectant primiparous mothers and their partners, and will hopefully be applicable to clinical practice.

Inclusion criteria


The review will consider studies that include expectant primiparous women and/or couples who receive antenatal parenting education. All ages will be included. Ethnicities will be limited to those of Asian countries (see Appendix I) to ensure utility for developing services in this region for primiparous women and their partners.


This review will consider studies that evaluate antenatal parenting education for expectant primiparous women and/or couples. Studies will be included if interventions start during pregnancy and do not continue after birth. Antenatal parenting education includes any intervention provided to help people to prepare for parenthood. All interventions must have been provided by qualified professionals, such as registered nurses, midwives or certified antenatal teachers. Interventions should have been provided in either birthing facilities (hospital, clinic or midwifery clinic) or in the community, but the frequency and intensity may vary. Studies will be excluded if interventions are designed exclusively to cover specific issues such as alcohol use, smoking, infection, nutrition, adolescence, analgesia or caesarean section. The only exception will be studies focused exclusively on breastfeeding, because this is a major part of a new mother's role, and can affect maternal self-confidence.23


This review will include studies that compare the intervention to usual care. This is defined as either no intervention, standard antenatal care or other types of antenatal educational programs generally available.


This review will consider studies that include parenting stress, maternal depressive symptoms and maternal confidence as outcomes. Outcome measures will include but are not limited to:

  • i) Parenting stress, self-reported using forms such as the Parenting Stress Index (PSI),24 Parenting Stress Index-Short Form (PSI-SF),25 Perceived Stress Scale (PSS)26 or Swedish Parenting Stress Questionnaire (SPSQ).27
  • ii) Maternal depressive symptoms, self-reported using forms such as the Edinburgh Postnatal Depression Scale (EPDS),28 Beck Depression Inventory (BDI),29 Center for Epidemiological Studies Depression Scale (CES-D),30 Inventory of Depressive Symptomatology (IDS),31 Postnatal Depression Screening Scale (PDSS),32 Zung Self-rating Depression Scale (Zung SDS)33 and General Health Questionnaire (GHQ).34
  • iii) Maternal confidence, self-reported using forms such as the Maternal Confidence Questionnaire (MCQ),35 Parenting Sense of Competence Scale (PSOC),36 Karitane Parenting Confidence Scale (KPCS),37 What Being the Parent of a New Baby is Like-Revised (WPL-R),38 Parent Expectations Survey (PES),39 Postpartum Maternal Confidence Scale and Postpartum Maternal Satisfaction Scale.40

Types of studies

This review will consider both experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, before-and-after studies and interrupted time-series studies. Cohort studies will also be considered for inclusion.

Studies published in English or Japanese will be included. Studies published from database inception until the present will be included.


Search strategy

The search strategy will aim to locate both published and unpublished studies and gray literature. An initial limited search of MEDLINE and CINAHL has been undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the articles. This informed the development of a search strategy that will be tailored for each information source. A full search strategy for MEDLINE (English language) and Ichushi-Web (Japanese language) is set out in Appendix II. The reference lists of all studies selected for critical appraisal will also be screened to identify possible additional studies.

Information sources

The databases and other sources to be searched include: MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, PsycINFO and Ichushi-Web (Japan's medical literature database).

The search for gray literature will include Google Scholar and ProQuest.

Study selection

Following the search, all identified citations will be collated and uploaded into EndNote X8.1 (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will be screened by two independent reviewers for assessment against the inclusion criteria for the review. Studies that may meet the inclusion criteria will be retrieved in full and their details imported into JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI) (Joanna Briggs Institute, Adelaide, Australia). The full text of selected studies will be retrieved and assessed in detail against the inclusion criteria. Full-text studies that do not meet the inclusion criteria will be excluded and reasons for exclusion will be provided in an appendix in the final systematic review report. Studies will be included when they meet the quality appraisal criteria (see below). The results of the search will be reported in full in the final report and presented in a PRISMA flow diagram. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.

Assessment of methodological quality

Selected studies will be critically appraised at the study level by two independent reviewers for methodological quality using the standardized critical appraisal instruments available in JBI SUMARI for the following study types: randomized controlled trials,41 quasi-experimental studies,41 and cohort studies.41 Any disagreements that arise will be resolved through discussion, or with a third reviewer. The results of the appraisal will be tabulated and accompanied by a narrative to address the review objective. Studies will be included if they meet the agreed quality standards of a positive response to particular questions in the JBI critical appraisal checklists for each study type.41 For randomized controlled trials, studies will be excluded if they fail to receive a “yes” response to the following three questions: “were outcomes measured in the same way for treatment groups?”, “were outcomes measured in a reliable way?”, and “was appropriate statistical analysis used?”. For quasi-experimental studies, the three questions are: “were the outcomes of the participants included in any comparisons measured in the same way?”, “were outcomes measured in a reliable way?” and “was appropriate statistical analysis used?” For cohort studies, the three questions are: “was the exposure measured similarly to assign people to both exposed and unexposed groups?”, “were the outcomes measured in a valid and reliable way?” and “was appropriate statistical analysis used?”

Data extraction

Data will be extracted from papers included in the review by two independent reviewers using the standardized data extraction tool available in JBI SUMARI. The data extraction tool will be piloted before use. The data extracted will include specific details about the interventions, populations, study methods and outcomes that are important to the review questions. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.

Data synthesis

Where possible, papers will be pooled for statistical meta-analysis using JBI SUMARI. Effect sizes will be expressed as either odds ratios (for dichotomous data) or weighted or standardized mean differences (for continuous data), and their 95% confidence intervals will be calculated. Heterogeneity will be assessed statistically using the standard chi-squared and I-squared tests. The choice of model (random or fixed effects) and method for meta-analysis will be based on Tufanaru et al.42

Subgroup analyses will be conducted where there are sufficient data. These subgroups will cover the three different interventions (reducing parenting stress, depression prevention and increasing maternal confidence) and age groups, including, in particular, mothers under 20 years or over 35 years. Where statistical pooling is not possible, the findings will be presented in narrative form, including tables and figures where appropriate, to support data presentation.

A funnel plot will be generated to assess publication bias if there are 25 or more studies included in a meta-analysis. Statistical tests for funnel plot asymmetry (Egger test, Begg test, Harbord test) will be performed, where appropriate.

Assessing certainty in the findings

A Summary of Findings will be created using GRADEPro GDT software (McMaster University, ON, Canada). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach for grading the quality of evidence will be followed.43 The Summary of Findings will include the following information where appropriate: absolute risks for treatment and control, estimates of relative risk and a ranking of the quality of the evidence based on study limitations (risk of bias, indirectness, inconsistency, imprecision and publication bias).


The authors gratefully acknowledge the contribution of Dr. Patraporn Tungpunkom, Faculty of Nursing, Chiang Mai University, Thailand Centre for Evidence Based Health Care: a Joanna Briggs Institute Centre of Excellence. We thank Melissa Leffler from Edanz Group for editing this manuscript.


This study was supported by the Grants-in-Aid for Scientific Research (A), No. 17H01612, Japan.

Appendix I: List of Asian countries, as defined by the Ministry of Foreign Affairs, Japan

Bangladesh, Bhutan, Brunei, Cambodia, People's Republic of China, Hong Kong, India, Indonesia, Japan, Republic of Korea, Laos, Macao, Malaysia, Maldives, Mongolia, Myanmar, Nepal, North Korea, Pakistan, Philippines, Singapore, Sri Lanka, Taiwan, Thailand, East Timor Democratic Republic, Viet Nam.

Appendix II: Search strategy


  1. “Mothers” [MeSH Terms]
  2. “Pregnant Women” [MeSH Terms]
  3. expectant mother [All Fields]
  4. expectant wom [All Fields]
  5. 1 or 2 or 3 or 4 [All Fields]
  6. “Prenatal Education” [MeSH Terms]
  7. “Prenatal Care” [MeSH Terms]
  8. prenatal OR antenatal OR pregnan [All Fields]
  9. intervention [All Fields]
  10. 8 AND 9 [All Fields]
  11. “Programs” [MeSH Terms]
  12. 8 AND 11 [All Fields]
  13. 6 OR 7 OR 10 OR 12 [All Fields]
  14. “Parenting” [MeSH Terms]
  15. “Child Rearing” [MeSH Terms]
  16. parent stress [All Fields]
  17. matern stress [All Fields]
  18. 14 OR 15 OR 16 OR 17 [All Fields]
  19. matern confidence [All Fields]
  20. matern competenc[All Fields]
  21. matern self-efficacy [All Fields]
  22. parent confidence [All Fields]
  23. parent competenc[All Fields]
  24. parent self-efficacy [All Fields]
  25. motherhoood [All Fields]
  26. parenthood [All Fields]
  27. matern role [All Fields]
  28. 19 OR 20 OR 21 OR 22 OR 23 OR 24 OR 25 OR 26 OR 27 [All Fields]
  29. “Depression” [MeSH Terms]
  30. “Depression, Postpartum” [MeSH Terms]
  31. matern depression [All Fields]
  32. matern depressive symptom[All Fields]
  33. 29 OR 30 OR 31 OR 32 [All Fields]
  34. 5 AND 13 AND (18 OR 28 OR 33) [All Fields]
  35. limit 34 to (English language)

Japanese literature: Ichushi-Web by Japan Medical Abstracts Society

  1. haha OR hahaoya (mother/mothers) [All Fields]
  2. ninpu OR nin-sanpu (pregnant woman/women, expectant mother/mothers) [All Fields]
  3. 1 or 2 [All Fields]
  4. syussan-mae-kyouiku (prenatal/antenatal education) [All Fields]
  5. syussyou-mae OR syussan-mae OR ninsin (prenatal/antenatal/pregnancy) [All Fields]
  6. kainyuu (intervention) [All Fields]
  7. 5 AND 6 [All Fields]
  8. puroguramu (program/programs) [All Fields]
  9. 5 AND 8 [All Fields]
  10. 4 OR 7 OR 9 [All Fields]
  11. oya-yakuwari OR oya-rashisa (parenting) OR oya OR ryousin (parent) [All Fields]
  12. ikuji OR kosodate (child-rearing) [All Fields]
  13. sutoresu (stress) [All Fields]
  14. 11 AND 13 [All Fields]
  15. 12 AND 13 [All Fields]
  16. ikuji-sutoresu (parenting/child-rearing stress) [All Fields]
  17. 14 OR 15 OR 16 [All Fields]
  18. jisin (confidence) [All Fields]
  19. nouryoku (competence) [All Fields]
  20. jiko-kouryoku-kan OR serufu-efikashi (self-efficacy) [All Fields]
  21. hahaoya-yakuwari (maternal role) [All Fields]
  22. 18 OR 19 OR 20 OR 21 [All Fields]
  23. utsu (depression) [All Fields]
  24. utu-syoujou (depression symptoms) [All Fields]
  25. sango-utu (postpartum depression) [All Fields]
  26. 23 OR 24 OR 25 [All Fields]
  27. 3 AND 10 AND (17 OR 22 OR 26) [All Fields]
  28. limit 27 to (Original paper)


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Maternal confidence; mothers; parenting stress; postpartum depression; prenatal education