Search strategy

Prior to conducting the database search, an initial search of JBI Evidence Synthesis database and the Cochrane Database of Systematic Reviews was undertaken to identify any existing or ongoing scoping or systematic reviews addressing antenatal education for labour and postpartum pain. No current or recently published reviews with the same focus were identified, confirming the originality and relevance of the present review.

The following electronic bibliographic databases were systematically searched in November 2025 via EBSCOhost: CINAHL, Academic Search, PsycInfo, Education Source, SPORTDiscus, PsycArticles, and SocINDEX. In addition, PubMed, MEDLINE, Web of Science, and Cochrane CENTRAL. The search strategy was structured around the PICO/PECO framework, and the key search terms are presented in Table 1. The full search strategy, including Boolean operators, filters, and limits applied, is presented in Table 2.

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Table 1. Search terms and PICO/PECO framework.

https://doi.org/10.1371/journal.pone.0330399.t001

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Table 2. Search strategy.

https://doi.org/10.1371/journal.pone.0330399.t002

Study selection and eligibility criteria

The study selection process was completed by two independent and blinded authors (ES and EL) using Rayyan software. Duplicate studies were identified and removed before screening. First, the two authors independently screened all titles and abstracts against eligibility criteria. Then, the full texts of articles that were retrievable were screened independently by the same authors. Discrepancies were resolved through discussion with the third and fourth researchers (OE and AD). The search strategy also included forward and backward tracking. Forward tracking involved looking for eligible studies that cited the included studies. Backward tracking involved searching the reference lists of the eligible studies.

No study was excluded based on publication date. This scoping review considered primary research studies of any methodological design, including quantitative, qualitative, mixed-methods, and observational studies, that examined antenatal education programmes addressing pain during labour, or the postpartum period among nulliparous and/or multiparous women

The exclusion criteria were as follows: protocol-only publications, conference abstracts without full text, feasibility or pilot studies without sufficient intervention description, studies with insufficient detail on antenatal education content, male-only populations, and studies where pain was not a reported outcome or focus.

Data extraction and synthesis

Overall, data extraction focused on the contents and characteristics of the antenatal education interventions listed in the captured studies, as well as pain-related outcomes measures. Our data extraction tables were developed based on an iteration of a JBI extraction tool, which the screening process helped inform. For the interventional and observational studies, the extracted data consist of author, year of publication, country, clinical setting, study methodology, key findings, antenatal education content, frequency of education sessions, education delivery method, which profession delivered sessions, pain outcomes measured. Missing or supplementary data was acquired by contacting the study authors as required. For qualitative and mixed-methods studies, data relating to women’s experiences, perceptions, and reported use of antenatal education in relation to labour and postpartum pain were extracted where available and summarised as pain-related themes and key findings.

Study selection and characteristics of included studies

The details of the process of selecting studies in accordance with PRISMA-ScR standards can be found in Fig 1. A total of 5,959 studies were retrieved and screened against the inclusion and exclusion criteria. A total of 17 studies met the inclusion criteria, including seven randomised controlled trials (RCTs) [23–29], seven quasi-experimental studies [30–36], one pre-post-trial [37], and two qualitative studies [38,39].

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Fig 1. PRISMA flow diagram.

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The included studies were published between 2008 and 2025 and spanned populations from seven countries: Iran, Turkey, Thailand, Egypt, Hong Kong, Brazil, and the United States. Sample sizes ranged from 30 [26] to 832 [29]. A comprehensive overview of the characteristics of the selected studies can be found in Table 3 and Table 4.

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Table 3. Data extraction table for interventional and observational studies.

https://doi.org/10.1371/journal.pone.0330399.t003

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Table 4. Data extraction table for qualitative studies.

https://doi.org/10.1371/journal.pone.0330399.t004

Mode of antenatal education

Among the included studies, antenatal education was delivered in three of the following way: face to face, a hybrid of in person and online, and online only. 14 studies were solely face-to-face [23–28,31–33,35–39]. Two studies used a combination of face-to-face and virtual online materials [30,34]. One study utilised virtual online materials only which included audio-video media through a social networking application [29].

Frequency and duration of antenatal education

The frequency and duration of antenatal education sessions varied widely across all included studies. The length of the sessions varied from 20 minutes [34] to six hours [26]. Total time spent in antenatal education sessions ranged from 30 minutes [25] to 18 hours [26]. Two studies reported the same total time spent on antenatal education, 4.5 hours [27,32] while all remaining studies differed in total time [23–26,28–30,33–39]. Three studies reported their sessions were 90 minutes in length [23,27,30]. The number of antenatal education sessions ranged from one [25], to eight sessions [29,30]. Frequency of sessions ranged from daily for three days [26] to fortnightly [24].

Profession(s) delivering the antenatal education

In 12 studies, only one profession delivered the antenatal education [23,25–33,36,38] whereas in the other five studies, a combination of professions delivered the education [24,34,35,37,39].

Nurses delivered antenatal education in three studies [23,29,33] while midwives delivered in five studies [25,27,32,36,38]. In one study antenatal education was delivered by both nurses and midwifes [37]. Doulas [30], a Doctor of Nursing [31], ‘mindfulness instructors’ [26] and ‘healthcare workers’ [28], each delivered the intervention in one study respectively. A combination of healthcare staff including physiotherapists, nurses, physicians, midwifes, dietitians etc. delivered the antenatal education in four studies [24,34,35,39].

Control group among included studies

15 out of 17 studies included in the review had a control group. Only one interventional study was a pre-post-trial without a control group [37] and one qualitative study did not have a control group which received a routine antenatal care [38]. The control groups in eight of the reviewed studies received routine antenatal care [23–27,29,30,33]. Six control groups received no education nor intervention [31,32,34–36,39]. Mostly, control participants attended general antenatal sessions that covered basic pregnancy care, foetal development, and signs of labour, but did not specifically focus on pain management techniques [27,29]. Participants in the control group of one study received training on the benefits of breastfeeding and normal delivery [28].

Pain outcome measures

Nine of the 15 included interventional studies measured labour pain intensity using a visual analogue scale (VAS) [23,26,27,30–35]. Eight of these studies measured labour pain retrospectively [23,26,27,30–32,34], while one measured during labour [33]. Additional outcome measures used included: labour pain duration [30]; knowledge on pain management using a self-produced questionnaire [26]; sexual pain intensity postpartum [29]; pain catastrophising scale in labour [27]. One study measured postpartum pain, namely dyspareunia [29]. One study used Perception of Birth Scale [36] while another one used Oxford Worries about Labour Scale [37] both of which has pain as sub-domains. Two qualitative studies focussed on subjective pain experiences, coping skills, and pain related birth satisfaction [38,39].

Content of antenatal education packages targeting pain

Of the 15 included experimental and two qualitative studies, interventions/antenatal education programs were described to varying levels of detail. Generic and varied pain-related topics were listed in twelve studies [23,24,26,27,29,31,33–35,37–39] whilst five did not mention pain [25,28,30,32,36]. Only one of seventeen studies explicitly stated a proposed mechanism by which their intervention addressed pain [29], proposing their birth preparation program “may reduce anxiety and fear of childbirth and increase self-efficacy and confidence by offering knowledge and practical coping skills. This may influence the perception of labour pain and enhance birth experience and satisfaction” [29].

Antenatal education interventions covered a range of pain-related topics aimed at preparing pregnant women for labour and postpartum pain management. Four interventions included the distinction between “true and false labour pain”, helping participants recognise the signs of active labour [27,29,31,33]. Only one study reported including education on pain physiology [31]. Cognitive restructuring and self-efficacy training were also introduced in some programmes [23,32].

Non-pharmacological pain management techniques were commonly included in conjunction with antenatal education, such as breathing techniques, relaxation techniques, pelvic floor exercises, massage, and a birthing ball. Nine studies referred to breathing exercises and relaxation techniques within their intervention to help manage labour pain [24,25,29–35,37,39]. Five studies reported utilising massage [24,25,31,35,38]. Two studies reported using a birthing ball [31,34]. One study reported teaching pelvic floor exercises to facilitate pain reduction and improve comfort during labour [24].

Themes

Despite each of the included studies measuring a pain-specific outcome, only 12 of the 17 studies mentioned pain when describing the intervention. Furthermore, none of these 12 studies provided a detailed description of the education content specific to pain-management such that the programme could be replicated. Descriptions were often limited to broad statements such as “information was provided on the prevention of pain in pregnancy” [24]; “nature of labour pain” [27]; “Fear-Tension-Pain cycle” [33]. This lack of detail suggests either a limited depth in understanding of pain-related topics, absence of consensus about which pain-related topics should be prioritised within antenatal care, or both. On the other hand, qualitative studies provided richer descriptions of how specific techniques such as breathing, massage, movement, and pelvic floor awareness were learned, practiced, and applied during labour, and how these contributed to perceived pain coping and control [38,39]. Antenatal education services remain largely unregulated, and academics and clinicians in this area appear to share the view that these services should be standardised across healthcare settings [14,40]. Findings from this review reinforce the need for consistent, clearly defined, and reproducible pain-specific content within antenatal education programmes to optimise maternal outcomes.

The topic of distinguishing between “true and false labour pain” was reported in four of the included studies [27,29,31,33]. True labour pain may be defined as regular, increasing uterine contractions that cause progressive cervical dilation and lead to childbirth, whereas false labour pain can be categorised as irregular, non-progressive contractions that do not cause cervical changes and do not result in labour. Misinterpreting false labour as true labour may increase fear and anxiety, particularly among nulliparous women, potentially contributing to unnecessary obstetric interventions [41]. Heightened fear of childbirth is identified as a common reason for caesarean delivery [42], and thus a deterrent from pre-existing plans for physiological birthing. Furthermore, unnecessary hospital visits may place additional strain on midwives and the health system, potentially detracting from their care of women in true labour [43]. These reasons may partially explain the emphasis of this topic within the included interventions. Conversely, there was limited focus of antenatal education on pain self-management techniques during labour. NICE guidelines [44] recommend the use of water, TENS, and music during intrapartum care, however none of these interventions were discussed in the included studies. However, qualitative findings suggest that when women are taught practical coping strategies alongside labour education, they feel more confident in managing contractions and remaining active during labour [38,39]. Future antenatal education interventions should therefore integrate labour recognition education with structured, conservative pain-management strategies.

This review found an absence of explicitly stated mechanisms by which pain was managed. Similarly, only one study reported including the topic of pain physiology [31]. Inferred mechanisms across the remaining studies were predominantly psychological, such as enhancing self-efficacy, reducing fear, and improving coping. Contemporary understanding of pain science has significantly developed in the last two decades. The recency of such developments, and a growing dependence on medicalised birth [45], may suggest this knowledge of pain has not yet been understood, adopted, nor incorporated by midwives and other professionals involved in labour pain-management. This gap may help explain the absence of pain physiology in the included studies, as well as the lack of proposed mechanisms of action. Qualitative studies in this review implicitly supported psychological mechanisms, with women describing increased control, confidence, and active engagement in labour as central to pain coping [38,39]. Understanding the neurophysiological mechanisms of pain modulation has proven effective in reducing rates of medicalised birth: in their meta-analysis of nonpharmacologic approaches for labour pain management, Chaillet et al. [11] highlighted an association between interventions based on central nervous system control, including pain education, significantly reduced rates of caesarean delivery and pain medication usage. This prompted the 2018 Canadian Obstetric Guideline No. 355 that recommended educating staff on neurophysiology of pain perception to increase physiological birth rates [46]. These findings underscore the need for greater integration of pain science and explicit mechanistic frameworks within antenatal education.

Of the included studies, seven explored labour pain intensity with a version of the VAS, while only one included a postpartum pain-outcome, dyspareunia. The VAS is a psychometric measure of subjective pain experience used widely within research and clinical practice [47]. Among other benefits, the VAS is supported for its simplicity and versatility. However, the VAS reduces pain to a unidimensional experience, which conflicts with modern understanding of pain as a complex and multidimensional phenomenon [48]. Further, most studies captured pain retrospectively potentially introducing recall bias. In contrast, qualitative studies captured experiential dimensions of pain, including perceived control, coping strategies, and satisfaction with labour, highlighting aspects of pain not adequately reflected in intensity scores alone [38,39]. Therefore, future research would benefit from incorporating outcome measures that better capture both the quantitative and qualitative dimensions of labour pain [49].

Duncan et al. [26] were the only researchers to use the pain catastrophising scale as an outcome measure. Pain catastrophising behaviour throughout pregnancy has consistently been associated with poor labour and postpartum outcomes. These include perineal trauma and persistent perineal pain following vaginal delivery [50,51]; postpartum depression; poor social adjustment after delivery [52]. These emotional and social aspects of postpartum health are important as they have been shown to contribute significantly to a woman’s experience of pain [53] alongside socioeconomic status and culture backgrounds and beliefs [44]. Qualitative findings from this review align with this literature, as women described how antenatal education enhanced confidence, reduced fear, and supported active coping during labour-factors known to mitigate catastrophising tendencies [38,39]. Increasing women’s knowledge of pain has been shown to reduce pain catastrophising scores [54]. Interventions utilising pain neuroscience education during pregnancy have shown improvements in pain knowledge, birth self-efficacy, labour coping and lower rates of caesarean delivery and epidural use [55,56]. Therefore, to target pain catastrophising and other positive birth outcomes, it is recommended that future experimental studies develop and refine pain neuroscience education for labour and postpartum pain management.

Face-to-face delivery was the predominant mode of antenatal education across included studies. In-person clinics often include physical examinations alongside education, which cannot be completed virtually. Primiparous women across cultural and socio-economic backgrounds report a preference for in-person sessions to facilitate asking questions and connecting with other expectant parents [57]. However, the COVID-19 pandemic initiated a cultural shift towards telehealth, with its use increasingly prevalent [58]. An integrative review of women’s experiences of online antenatal education identified flexibility as a key benefit, accommodating geographical barriers, illness, and complex social situations [59]. Additional advantages included enhanced comprehensibility, the ability to revisit content, timely information delivery, and broader accessibility. Despite this, those with lower e-health literacy may face difficulties accessing digital information, contributing to a ‘digital divide’ [59]. Pregnant women are known information seekers, yet challenges exist regarding the trustworthiness of online sources [60,61], with many women citing difficulty distinguishing reliable from false pregnancy and labour information [62]. When reliable, evidence-based information is used and delivered effectively, digital education has been shown to play an important role in antenatal care. A recent study evaluated a mobile application that included pain neuroscience education combined with mindfulness training to prepare for birth [56]. A large sample size was studied and improved pain knowledge, improved self-efficacy in birth as well as lower rates of caesarean birth and epidural use were demonstrated as a result of the intervention. Such findings considered alongside two studies included in this review which used a hybrid approach [30,34], that included online resources, point to the potential innovative digital modes of care provision provided quality control measures to ensure rigor are fulfilled.

There was wide disparity in the frequency and duration of antenatal education interventions, ranging from one 30-minute session to five three-hour sessions. Pain-specific content formed only a portion of each session, meaning actual time spent on pain education was less than stated. No included country currently has mandated recommendations on the number, frequency, duration, or timing of antenatal sessions. This heterogeneity may reflect that clinical delivery is not meeting current guidelines based on service pressures [63]. While any antenatal education was linked to reduced pain medication use and increased physiological birth, these outcomes improve with more sessions, although it remains unclear if this trend eventually plateaus [64]. Delivery varied across studies: midwives and nurses led the majority, despite pain education representing less than 1% of programme hours in their training [65]. Conversely, physiotherapy courses included the most pain-related content, suggesting pelvic health physiotherapists may be well-placed to deliver pain-specific education. One study used doulas, non-medical professionals who have demonstrated effectiveness in reducing labour pain, anxiety, and caesarean rates [66]. Despite lacking medical training, doulas may offer a more cost-effective solution and help reduce health disparities [67]. Which profession is best placed to deliver pain-related antenatal education remains unclear and warrants expert consensus.

Analysing pain outcomes highlighted a stark lack of focus on the postpartum period. This may be reflective of the lack of support for women beyond childbirth [6,67,68]. In many countries, six weeks after delivery, responsibility for maternal care shifts from the midwife to the woman’s general practitioner or other services. Unfortunately, poor maternal health after this period is either being missed or is costing healthcare systems more because of higher healthcare utilisation for conditions such as persistent postpartum pain and depression, despite many cost-analyses proving the financial worth of screening for such conditions [69,70]. Although qualitative studies in this review primarily focused on labour experiences, women’s emphasis on confidence, coping, and satisfaction suggests that antenatal education may have longer-term implications for postpartum pain adjustment [38,39]. This represents a clear opportunity for future research to examine the role of antenatal education in preventing persistent postpartum pain.

Strengths and limitations

Firstly, this scoping review involved a comprehensive and systematic search across twelve major electronic databases, ensuring a broad capture of relevant literature. To our knowledge, this is the first scoping review to specifically map the content and characteristics of antenatal education programmes focused on pain management through pregnancy, labour, and the postpartum period. The use of rigorous methodology, including adherence to PRISMA-ScR and JBI guidelines, independent and blinded screening by multiple reviewers, and efforts to contact authors for missing data, further enhances the robustness and credibility of the findings. Additionally, the focus on programme content, delivery, dosage, and pain outcomes addresses a critical gap in maternal health education and may help inform future practice and research

One limitation of this review is the reliance on authors’ descriptions of antenatal education interventions, which may have been incomplete or imprecise. Additionally, heterogeneity in study design, populations, and outcome measures limits direct comparison across studies. Although qualitative studies were included, they were few in number and varied in timing and focus, which may restrict the generalisability of experiential findings.

Implications for future research

This review highlights a need for high-quality, theory-informed studies that evaluate antenatal education interventions specifically targeting pain management during labour and the postpartum period. Future research should integrate pain neuroscience education tailored to pregnant populations, clearly articulate mechanisms of action, and employ multidimensional outcome measures that capture both pain intensity and lived experience. Greater attention to postpartum pain outcomes is urgently required. Research should also explore optimal dosage, delivery modes, and professional roles, informed by qualitative insights into confidence, control, and coping. There is a clear need for agreement on core pain-related educational domains and delivery principles to support the development of consistent, standardised, and evidence-based antenatal education programmes.