Effects of Guided Antenatal Education Support Programs on Postnatal Depression, Social Support, and Life Satisfaction among First-time Mothers in Kelantan, Malaysia

1School of Health Sciences, Universiti Sains Malaysia, Kelantan, Malaysia 2Department of Family Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia 3Nursing Department, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia 4Department of Obstetrics and Gynaecology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia


Introduction
Pregnancy is commonly associated with psychological and physiological changes which can change one's life and relationships with others (Afshari et al., 2020). The transition to parenthood is one of the challenging life events that cause significant distress, especially among first-time parents (Missler et al., 2020). First-time mothers have a higher risk of getting postnatal depression than mothers who experienced childbirth (Vismara et al., 2016). Preoccupations, worries, and anxiety that persist during pregnancy and postnatal periods increase the risk of developing postnatal depression (Vismara et al., 2016). Women's functioning, marital and personal connections, mother-infant interaction quality, and children's social, behavioral, and cognitive development are all adversely related to postpartum depression (Al Nasr et al., 2020). Various risk factors for postpartum depression have been reported in the previous studies, which include a lack of social support, marital conflict, existence of history depression, lack of breastfeeding, or recent stressful life events (Al Nasr et al., 2020;Kheirabadi et al., 2009). Unemployment, a lack of education, and an unwanted pregnancy have all been linked to an increased chance of getting postpartum depression (Al Nasr et al., 2020).
Positive social support from family and friends eases the transition to motherhood and may help increase parenting competence during the role-transition period (Esmaelzadeh Saeieh et al., 2017). Social support is one of the predictors for postpartum depression and maternal role competence. Maternal competency and pleasure with the maternal role are important to embrace the maternal role (Esmaelzadeh Saeieh et al., 2017). Becoming a mother for the first time is a significant developmental milestone in adulthood. The birth of a child is not only a significant event for couples, but it also causes concern for the entire family. First-time mothers may have a feeling of incompetence in their maternal role (Nelson, 2003). First-time mothers may need guidance and good social support to adapt to their new roles as mothers.
Life satisfaction may change during and after pregnancy, especially in first-time mothers, as they may experience parenthood. A previous study suggested that positive and negative life events may play an important role in determining overall life satisfaction (Ngoo, 2019). Life satisfaction may be influenced by family's social support, financial status, marriage satisfaction, and family planning (Munaf & Siddiqui, 2013). Human development, including any change in life events, is strongly associated with life satisfaction (Ngoo, 2019). Pregnancy and childbirth are important life events for a woman. The pregnancy and the first childbirth may have an impact on relationship satisfaction among first-time mothers (van Scheppingen et al., 2018).
Brief psychoeducational interventions are beneficial for providing information that may effectively reduce psychological distress (Missler et al., 2020). The social and psychological needs of pregnant women are important to be addressed as pregnancy changes their physical, psychological, and social status (Omidvar et al., 2018). In this regard, antenatal education is important and beneficial during childbirth and helps prepare for early parenthood (Hildingsson et al., 2013). The need for psychological support and education regarding pregnancy, birth, and postpartum in the antenatal education class is needed, especially among first-time mothers. However, there is still a lack of studies assessing life satisfaction and social support among firsttime mothers in Malaysia. Hence, it is necessary to highlight the importance of psychoeducation intervention during the antenatal period for new mothers. Accordingly, this study aimed to find out the effects of guided antenatal education support programs on postpartum depression, social support, and life satisfaction among first-time mothers.

Research design
A quasi-experimental study was conducted to determine the effects of guided antenatal education support programs on postpartum depression risk, social support, and life satisfaction among first-time mothers.

Setting and samples
The study was conducted among first-time mothers who attended an obstetric clinic in a public university's hospital in Kelantan, Malaysia, between January to May 2016. First-time pregnant women aged above 18 years old at their second and third trimesters of pregnancy (between 12 to 36 weeks of gestation) were recruited in the study using convenience sampling. They were equally divided into the intervention and control groups. Informed consent was obtained from all participants who agreed to join the study. Pregnant women who were single parents, recently or previously diagnosed with psychiatric illnesses, or had other medical illnesses were excluded from the study. The sample size was calculated based on the previous study for risk of postpartum depression, which used the Edinburgh Postnatal Depression Scale (EPDS) for data collection (Kamalifard et al., 2013). The minimum number of participants to include in the study sample was calculated using a power analysis (power=0.80, α=0.05) in the Power and Sample Size software version 3.0.43. The calculated number of participants with the addition of an estimated 20% dropout was 36 participants for each group. Thus, the total samples for both groups were 72 participants. Randomization was not used in the study. The participants were equally assigned into the intervention group (n=36) and control group (n=36) based on the researchers.

Table 1. Description of guided antenatal education
The participants received an extra 15-minutes of a face-to-face discussion with the researcher on the topics presented in the powerpoint slides at the end of the third session (guided antenatal education support). Open discussions on the topics presented during the antenatal class and postpartum issues written in the postnatal guidebook were discussed and explained to the participants in the intervention group. They also received a postnatal support guidebook developed by the researcher. The guidebook consisted of information regarding postpartum depression, including symptoms and signs of depression after giving birth, the triggering factors that contribute to depression, recommendations, and the ways to get support from family members when having depression during the postpartum period. The information in the guidebook was adapted from the national standard protocol and World Health Organization (WHO) guidelines. The participants in the intervention group were encouraged to share the information in the guidebook with their family members. The participants in the control group only received antenatal education class sessions. Both groups were evaluated after the intervention phase at six weeks postpartum when they came for postnatal follow-ups. The flow of the study is shown in Figure 1.

Measurement and data collection
Self-administered questionnaires were utilized to collect data during the pre-intervention phase and post-intervention phase. These questionnaires consisted of baseline characteristics and sociodemographic data (age, gestational age during data collection, race/ethnic, occupation status, education status, duration of marriage, and plan of the pregnancy) and the Edinburgh Postnatal Depression Scale (EPDS), Multidimensional Scale of Perceived Social Support (MSPSS) and Satisfaction with Life Scale (SWLS) to assess postnatal depression risks, social support, and life satisfaction, respectively. Before the intervention phase, participants in both groups were requested to complete the questionnaires using pens and papers. Similarly, after the intervention phase, another collection of data at six weeks postpartum was done for post-intervention assessment. The assessment of postnatal depression risk, social support, and life satisfaction was also conducted using the similar instruments (i.e., EPDS, MSPSS, and SWLS).

Edinburgh Postnatal Depression Scale (EPDS)
The risk of postnatal depression was assessed using the EPDS. The EPDS is a self-evaluated questionnaire consisting of 10 items in the Likert scale format developed by Cox et al. in 1987(Cox et al., 1987. The total score ranged from 0 to 30, and a higher score foreshadows psychological pressure or a risk of depression. The validated Malay version was used in the study. A cut-off score of 11.5 or higher had a sensitivity of 72.7%, and the specification is 95.1% to detect postnatal depression and a positive predictive value of 50% (Azidah et al., 2006). The internal consistency of the Malay version EPDS was at a level of 0.86 (Azidah et al., 2006).

Multidimensional Scale of Perceived Social Support (MSPSS)
The MSPSS was used to measure various dimensions of sufficient social support from family, friends, and significant others (Ng et al., 2012). It consists of 12 items scale with 7 seven-point Likert scale format (1=truly disagree, 7=fully agree) and possible responses to each statement (scored 0-6) give a score out of a maximum of 72 with a higher score indicating greater perceived social support. The MSPSS measures the perceived adequacy of social support from three sources, including family members (items 3, 4, 8, and 11), friends (items 6, 7, 9, and 12), and significant others (items 1, 2, 5, and 10). The overall count of social support means for all items used in the research mean score shows strong social support. The original version of the MSPSS has a very good internal reliability score with an α coefficient of 0.88 for the total scale, 0.87 for the family subscale, 0.85 for the friend subscale, and 0.91 for the significant others subscale (Zimet et al., 1990). The original version of the MSPSS is a 12-item. The Malay version of MSPSS Cronbach's alphas for family, friends and significant others were 0.89, 0.90, and 0.94, respectively, in the non-psychiatric group (Ng et al., 2012).

Satisfaction with life scale (SWLS)
The SWLS was developed in 1985 by Diener et al. (Diener et al., 1985). It has 5 items with 7point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). SWLS was used to assess subjective emotional well-being and life satisfaction (Aishvarya et al., 2014). The total score ranges between 5 to 35, with higher scores indicating a more significant life satisfaction. A validated Malay version of SWLS was used in the study. The SWLS factor has high internal consistency, with Cronbach's alpha of 0.86 (Aishvarya et al., 2014).

Data analysis
Data analysis was performed by using SPSS version 21 (IBM corp. USA). The p-value was used to determine the statistical significance, and the p-value of <0.05 was considered significant. The paired t-test was used to determine the mean score differences in the control and intervention groups pre and post-test. The independent t-test was used to determine the significant mean score differences between the two groups. The Pearson's correlation analysis was also conducted to determine the relationship between postnatal depression and life satisfaction, and the relationship between postnatal depression and social support.

Ethical considerations
Informed consent was obtained from all participants who agreed to participate in the study. All participants signed the written informed consent prior to the recruitment and data collection.

Characteristics of respondents
As presented in Table 2, the mean age of the participants in both groups was 26.3 years old. Most participants in each group were Malay ethnic, and the marriage duration was less than two years. More than half the participants in both groups planned for their pregnancy. In addition, more than half of the participants in both groups had higher education levels. Table 3 shows that the EPDS score had a more significant reduction in intervention group as compared to the control group. Paired t-test showed a significant mean difference between pre and post-intervention phases. The finding showed that those participants in the intervention group who received guided education had a lesser risk for postpartum depression than those in the control group (p<0.05).

Effects of guided antenatal education on social support
Table 3 also shows that those who received the intervention had a significant increase in the mean score of MSPSS after the intervention compared to the control group. Paired t-test showed a significant difference in the mean score of MSPSS in pre and post-intervention (p<0.05) for the Nurse Media Journal of Nursing, 11(2), 2021, 238 Copyright © 2021, NMJN, e-ISSN 2406-8799, p-ISSN 2087-7811 groups. In addition, social support was higher among participants in the intervention group than the control group, as shown in Table 3.

Effects of guided antenatal education on life satisfaction
The SWSL score was significantly increased among the participants in the intervention group after receiving the intervention as compared to the control group. The analysis of paired t-test showed significant mean score changes in the SWSL (p<0.05), as shown in Table 3.
In addition, the Pearson's correlation analysis showed a significant negative relationship between postnatal depression and life satisfaction at 6 weeks postpartum (r=-0.347; p<0.05) among first-time mothers. In contrast, there was no significant relationship between postnatal depression and social support of first-time mothers in the intervention group before and after delivery (pre-intervention, r=0.03; p>0.05, post-intervention, r=0.01; p>0.05).

Discussion
This study showed that first-time mothers who received guided antenatal education had a significant reduction in their EPDS scores. Thus, we found that guided antenatal education is effective in reducing the risk of postpartum depression. Our study findings are consistent with previous research, which also reported that antenatal education is beneficial for lowering the risk of postpartum depression (Ortiz Collado et al., 2014). A focus on antenatal education targeted at disseminating knowledge about postpartum depression and its risk factors, together with anticipating postnatal issues, may be beneficial for first-time mothers who are experiencing a new role in motherhood. We provide a guidebook to pregnant women, and they could share the information with their families. A study has suggested that education targeting parenting difficulties is important to reduce depression and anxiety postnatal for first-time mothers (Milgrom et al., 2011). Antenatal education, especially the one-to-one approach or guided approach, is beneficial to the mother as they will receive information about their pregnancy, including postnatal care information (Swift et al., 2020). An antenatal class focusing on both education during the prenatal and postnatal period was suggested in the previous study (Entsieh & Hallström, 2016), and it has become one of the platforms to deliver information to pregnant women and their spouses regarding the childbirth process and information about early parenting (Chikalipo et al., 2018). The preparedness for the consequences of the pregnancy and its postpartum issues may reduce maternal distress and help reduce the risk for postpartum depression. The previous study reported that anxiety or depression during pregnancy increases with trimester and influences the preparedness for motherhood (Dere et al., 2019). The previous study suggested that one-to-one midwifery antenatal education is helpful in reducing childbirth fear, and assessment on the need for care for pregnant women can be done at this time (Swift et al., 2020).
We also found that guided antenatal education was effective in increasing the satisfaction of life among first-time mothers. This finding is consistent with another study which suggested that increment in life satisfaction is observed if the mothers received good emotional support during pregnancy and the postnatal period (Gebuza et al., 2014). Spiritual well-being also is one of the factors influencing life satisfaction (Niaghiha et al., 2019) which was not assessed in our study. A previous study in Faisalabad showed a significant negative relationship between postnatal depression and life satisfaction among postpartum women (Yaqoob et al., 2021). Similarly, in our study, we found a negative relationship between postnatal depression and life satisfaction at six weeks postpartum. Higher life satisfaction lowered the risk for postnatal depression. A study done