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Group psychoeducation with relaxation for severe fear of childbirth improves maternal adjustment and childbirth experience – a randomised controlled trial
Abstract
BACKGROUND: Previous studies on the treatment of women with fear of childbirth have focused on the delivery mode. Women with fear of childbirth often suffer from anxiety and/or depression, and treatment therefore also needs to target postnatal psychological well-being and the early mother-infant relationship. METHODS: Three hundred and seventy-one nulliparous women out of 4575 scored ≥100 in prospective screening (Wijma Delivery Expectancy Questionnaire, W-DEQ-A), indicating severe fear of childbirth. These women were randomised to psychoeducative group intervention with relaxation (n = 131; six sessions during pregnancy, one postnatal) or to conventional care (n = 240) by community nurses (referral if necessary). Psycho-emotional and psychosocial evaluations [Edinburgh Postnatal Depression Scale (EPDS), social support, Maternal Adjustment and Attitudes (MAMA), Traumatic Events Scale (TES) and the Wijma Delivery Experience Questionnaire (W-DEQ-B)] were completed twice during pregnancy and/or 3 months postpartum. RESULTS: Postnatal maternal adjustment (MAMA mean score 38.1 ± 4.3 versus 35.7 ± 5.0, p = 0.001) and childbirth experience (mean W-DEQ-B sum score 63.0 ± 29 versus 73.7 ± 32, p = 0.008) were better in the intervention group compared with controls. In hierarchical regression, social support, participating in intervention, and less fearful childbirth experience predicted better maternal adjustment. The level of postnatal depressive symptoms was significantly lower in the intervention group (mean sum score 6.4 ± 5.4 versus 8.0 ± 5.9 p = 0.04). There were no differences in the frequency of post-traumatic stress symptoms between the groups. CONCLUSIONS: In nulliparous women with severe fear of childbirth, participation in a targeted psychoeducative group resulted in better maternal adjustment, a less fearful childbirth experience and fewer postnatal depressive symptoms, compared with conventional care.
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“When comparing psychoeducational group sessions with standard care (SC) for women with severe FOB, fewer cesarean births, more positive birth experiences, and less depressive symptoms postpartum were found in the intervention group, however, with small effect sizes for the psychological variables [24-26].”
From Comparing internet-based cognitive behavioral therapy with standard care for women with fear of birth: Randomized controlled trial (2018) · cites this paper as [25]
In the citing paper
“When comparing psychoeducational group sessions with standard care (SC) for women with severe FOB, fewer cesarean births, more positive birth experiences, and less depressive symptoms postpartum were found in the intervention group, however, with small effect sizes for the psychological variables [24-26].”
From Comparing internet-based cognitive behavioral therapy with standard care for women with fear of birth: Randomized controlled trial (2018) · cites this paper as [25]
In the citing paper
“When comparing psychoeducational group sessions with standard care (SC) for women with severe FOB, fewer cesarean births, more positive birth experiences, and less depressive symptoms postpartum were found in the intervention group, however, with small effect sizes for the psychological variables [24-26].”
From Comparing internet-based cognitive behavioral therapy with standard care for women with fear of birth: Randomized controlled trial (2018) · cites this paper as [25]
In the citing paper
“When comparing psychoeducational group sessions with standard care (SC) for women with severe FOB, fewer cesarean births, more positive birth experiences, and less depressive symptoms postpartum were found in the intervention group, however, with small effect sizes for the psychological variables [24-26].”
From Comparing internet-based cognitive behavioral therapy with standard care for women with fear of birth: Randomized controlled trial (2018) · cites this paper as [25]
In the citing paper
“In Finland, a psychologist-led randomised control trial (RCT) of six group-based psychoeducation and relaxation sessions, found the intervention group reported more vaginal births, less fear, and fewer medical interventions.”
From The feasibility and acceptability of a single-session Acceptance and Commitment Therapy (ACT) intervention to support women self-reporting fear of childbirth in a first pregnancy. (2023) · cites this paper as Rouhe et al., 2015
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“As can be seen, two large randomized trials with an active control group [36, 37] and one nonrandomized trial [38] demonstrated small to moderate effects of psychoeducational based programmes on the reduction of FoC, while one small pre- and post-study evaluating cognitive behavioural therapy on FoC reduction in pregn…”
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“When comparing psychoeducational group sessions with standard care (SC) for women with severe FOB, fewer cesarean births, more positive birth experiences, and less depressive symptoms postpartum were found in the intervention group, however, with small effect sizes for the psychological variables [24-26].”
Relationship Between Fear of Childbirth and Psychological and Spiritual Well-Being in Pregnant Women
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“…FoC, participating in group psycho-education in combination with relaxation, exercises resulted in a more positive child-birth experience (36.1% versus 22.8%, p = 0.04), and decreased postpartum depressive symptoms (mean sum score 6.4 ± 5.4 versus 8.0 ± 5.9, p = 0.04) (Rouhe et al., 2013, 2015a).”
InfluentialThe Role of Intra-personal and Inter-personal Factors in Fear of Childbirth: A Preliminary Study
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“Likewise, addressing women during pregnancy through psycho-educational group therapy [47, 48] or individual therapy that is tailored to specific client needs (such as: bodily changes, attitudes and beliefs etc’), may reduce the presentation of this phenomena.”
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“It is seen that while three of the psychoeducation programs conducted by nurses and psychologists in the management of the FOC [21,24,27] were based on a holistic approach, two of them [22,26]”
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Bakhteh, A., Jaberghaderi, N., Rezaei, M., Naghibzadeh, Z. A.-S., Kolivand, M., & Motaghi, Z. (2022) · Journal of Reproductive and Infant Psychology · doi:10.1080/02646838.2022.2059458 · Cited by 27
“, seven studies were on psychological education (Boz et al., 2020; Fenwick et al., 2015, 2018; Ghazaei et al., 2018; Kordi et al., 2017; Rouhe et al., 2015, 2013), one study was on the effects of intensive therapy (Saisto et al., 2001), one was on mindfulness (Aminolroayaee & Aghaei, 2019), one was…”
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“In this regard, midwife-led (20) and groupbased psychoeducation along with relaxation (22, 59) had been practiced in other countries, implying a positive effect on severe FOC and increased maternal adjustment to labor pain and natural delivery and also improved psychological status of pregnant women such as decreased…”
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“Another RCT that compared group psycho-education with relaxation or conventional care among 371 women found that psycho-education was associated with a significantly more positive birth experience (WDEQ-B), decreased postpartum depressive symptoms, and more uncomplicated vaginal deliveries than conventional care (3, 4…”
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Stevenson, E. L., Trotter, K. J., Bergh, C., & Sloane, R. J. (2016) · The Journal of Perinatal Education · doi:10.1891/1058-1243.25.3.193 · Cited by 18
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“Evidence has further shown mothers with elevated fears often suffer from emotional distress [2, 8, 9], have a relatively poor adjustment in the postpartum period [10], or are even fearful of future pregnancies [11].”
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“[30] offered group-psychoeducation with relaxation to nulliparous women with FOB.”
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“Women with fear of childbirth usually skip the childbirth preparation and standard care classes [37] or sometimes they are interested in using epidural anesthesia, which can increase labour interventions leading to a sense of powerlessness and a negative birth experience [12].”
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“The group intervention (Rouhe et al., 2015; Saisto et al., 2006) consisted of 6 group sessions (once a week for 2 h), which were held during pregnancy (on average, starting in the 28th week of pregnancy), plus one session 6–8 weeks after delivery with the mothers accompanied by their infants.”
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Kadınların Kişilik Özelliklerinin Travmatik Doğum Algısına Etkisi
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“Sonuç olarak kadınlar doğum eylemiyle ilgili bilgi yetersizliği yaşayabilmekte ve travmatik doğum deneyimleyebilmektedir (27).”
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Factors Affecting Fear of Childbirth Among Urban Women in India: A Qualitative Study
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“It has found in many studies that greater intensity of FOC has been shown to be associated with mental health problems such as depression, anxiety, and panic disorder before, during, and after childbirth, even in women without a history of depression (Raisanen et al., 2014; Rouhe et al., 2015; Storksen et al., 2012).”
BackgroundThe Effect of Warm Compress Bi-stage on Pain Strength in Labor Stages and After Delivery
Farahmand, M., Khooshab, E., Hasanzadeh, F., Amooee, S., & Akbarzadeh, M. (2019) · International Journal of Women s Health and Reproduction Sciences · doi:10.15296/ijwhr.2020.06 · Cited by 15
“Furthermore, pharmacological treatments are usually effective, but have adverse effects on the mother and fetus (18,19).”
BackgroundPsychodrama as a new intervention for reducing fear of childbirth: a randomised controlled trial
Bingöl, F. B., Bal, M. D., Dişsiz, M., Sormageç, M. T., & Çimen, B. Ö. (2022) · Journal of Obstetrics and Gynaecology Research · doi:10.1080/01443615.2022.2114329 · Cited by 5
“Holistic (Rouhe et al. 2013; 2015) and other approaches (Taheri et al. 2014) have proved successful.”
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“Cost savings of reduced medical interventions counterbalanced the group’s expense (Rouhe et al., 2015) and thus no additional expense was incurred.”
Backgroundde Mello, R. S. F., de Toledo, S. F., Mendes, A. B., Melarato, C. R., & de Mello, D. S. F. (2021) · Femina · doi:10.61622/0100-7254492202108 · Cited by 12
Yetwale, A., & Melkamu, E. (2021) · International Journal of Childbirth · doi:10.1891/ijcbirth-d-20-00029 · Cited by 12
Möller, L., Josefsson, A., Lilliecreutz, C., Gunnervik, C., Bladh, M., & Sydsjö, G. (2018) · Acta Obstetricia et Gynecologica Scandinavica · doi:10.1111/aogs.13503 · Cited by 12
Gebelerin Kendilerini Algılama Durumları ve Etkileyen Faktörler
Kaya, C. E., & ATASEVER, Z. (2022) · Gümüşhane Üniversitesi Sağlık Bilimleri Dergisi · doi:10.37989/gumussagbil.908030 · Cited by 10
Baas, M. A. M., Stramrood, C. A. I., Dijksman, L. M., Vanhommerig, J. W., de Jongh, A., & van Pampus, M. G. (2023) · Acta Obstetricia Et Gynecologica Scandinavica · doi:10.1111/aogs.14628 · Cited by 9
“One randomized controlled trial (RCT) that compared group psycho-education with relaxation ( n = 131) vs care- as-usual (CAU, n = 240) found that women who received psycho-education were significantly more likely to have a more positive birth experience 11 and vaginal delivery.”
Why do pregnant women with fear of birth prefer vaginal birth? A qualitative study in China
Zeng, T., Yuan, M., Wu, M., Chen, Y., & Zhang, K. (2023) · Frontiers in Psychology · doi:10.3389/fpsyg.2023.1110116 · Cited by 9
“Also, a systematic review revealed that a closer mother-infant relationship could enhance women’s resilience and have a positive impact on their psychological well-being (Rouhe et al., 2015).”
BackgroundJones, K., Freijah, I., Brennan, S., McKenzie, J. E., Bright, T. M., Fiolet, R., Kamitsis, I., Reid, C. J., Davis, E. C., Andrews, S., et al. (2023) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd014874.pub2 · Cited by 11
Reid, C. J., McKenzie, J. E., Brennan, S., Bennetts, S. K., Clark, Y., Mensah, F. K., Hokke, S., Ralph, N., Brown, S., Gee, G., et al. (2021) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd014874 · Cited by 7
Sharifipour, P., Kheirkhah, M., Rajati, M., & Haghani, H. (2022) · Trials · doi:10.1186/s13063-022-06358-x · Cited by 8
Mäkelä, T., Saisto, T., Salmela‐Aro, K., & Rouhe, H. (2023) · Journal of Psychosomatic Obstetrics & Gynecology · doi:10.1080/0167482x.2023.2210750 · Cited by 8
“Second, previous studies have recognized numerous factors that affect the subjective childbirth experience [2,4,8–12,14,22] and PTSD development [1,2,15,16,23], such as nulliparity or previous negative childbirth experience.”
BackgroundSelf-citationRoncallo, C. P., Barreto, F. B., & de Miguel, M. S. (2018) · Early Child Development and Care · doi:10.1080/03004430.2018.1495630 · Cited by 7
“On the other hand, negative or traumatic birth experiences may result in greater emotional and physical vulnerability during early parenting (Rouhe et al., 2015).”
BackgroundPrenatal wellbeing of mothers, their partners, and couples: a cross-sectional descriptive study
Mäkelä, T., Saisto, T., Salmela‐Aro, K., Miettinen, J., Sintonen, H., & Rouhe, H. (2023) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-023-05790-4 · Cited by 7
“Both in women and partners, FOC has been related to various adverse effects, such as poor mental health [10, 13, 14], dissatisfaction with the relationship [14], increased (emergency) caesarean section rates [12, 15, 16], negative childbirth experience [15, 17, 18], and viewing or experiencing parenthood as more diffi…”
BackgroundSelf-citationroman, M. P., Aggarwal, S., & Doumouchtsis, S. K. (2023) · European Journal of Obstetrics & Gynecology and Reproductive Biology · doi:10.1016/j.ejogrb.2023.09.010 · Cited by 7
Najafi, T. F., Dashti, S., Bolghanabadi, N., Rezvanifard, M., Andaroon, N., Abadibavil, D., Golkhatmy, F. T., & Bahri, N. (2021) · Archives of Psychiatric Nursing · doi:10.1016/j.apnu.2021.03.009 · Cited by 7
Ali, N., Elbarazi, I., Al‐Maskari, F., Loney, T., & Ahmed, L. A. (2023) · PLoS ONE · doi:10.1371/journal.pone.0268214 · Cited by 7
“Research has shown that psychoeducational programs during pregnancy can facilitate expectant mothers to develop the appropriate coping mechanisms to reduce anxiety and negative emotions related to childbirth [30] Although some previous studies have shown that happier pregnant women tend to be older, unemployed, or hav…”
BackgroundHan, Q., Min, G., Ren, F., Duan, D., & Xu, X. (2020) · Experimental and Therapeutic Medicine · doi:10.3892/etm.2020.9011 · Cited by 12
Shaliha, F., Jafarzadeh-Kenarsari, F., Khalesi, Z. B., Maroufizadeh, S., & Alimoradi, Z. (2024) · Journal of Education and Health Promotion · doi:10.4103/jehp.jehp_870_23 · Cited by 6
“[5] This amount is reported to be 10% in Western countries [6] and about 5–20% in Iranian pregnant women.”
BackgroundZhou, J., Zhu, Z., Li, R., Guo, X., & Li, D. (2025) · Frontiers in Psychology · doi:10.3389/fpsyg.2025.1530311 · Cited by 10
Predictors of Fear Related to Childbirth among Iranian Primigravidae
Matinnia, N., Rahman, H. A., Ibrahim, F., Ghaleiha, A., Akhtari‐Zavare, M., Jahangard, L., & Ghaleiha, A. (2016) · Global Journal of Health Science · doi:10.5539/gjhs.v9n3p266 · Cited by 6
“The increasing frequency of CS is mainly caused by Cesarean delivery on maternal request (Gamble, Creedy, Mccourt, Weaver, & Beake, 2007; Ryding et al., 2014; Zwelling, 2008), the most common reasons of choosing CS include having had a previous CS, a previous negative birth experience, complicated…”
BackgroundEide, K. T., Morken, N., & Bærøe, K. (2020) · Midwifery · doi:10.1016/j.midw.2020.102764 · Cited by 6
Testing the birth attitude profile scale in a Swedish sample of women with fear of birth
Hildingsson, I., & Rubertsson, C. (2020) · Journal of Psychosomatic Obstetrics & Gynecology · doi:10.1080/0167482x.2020.1729118 · Cited by 6
“[6], telephone support [7], cognitive behavioral therapy [8,9], continuous Labor support [10] and con-”
BackgroundPoorjandaghi, M., Vakilian, K., Khorsandi, M., & Abdi, M. (2020) · International Journal of Women's Health and Reproduction Sciences · doi:10.15296/ijwhr.2022.07 · Cited by 5
“The other study also revealed the positive effects of psychoeducative group therapy in nulliparous women with fewer depressive symptoms and FOC (21).”
ResultPilewska-Kozak, A. B., Dziurka, M., Bałanda-Bałdyga, A., Monist, M. J., Kopiel, E., Jurek, K., Łęcka, A. F., & Dobrowolska, B. B. (2024) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-024-06579-9 · Cited by 5
“Furthermore, participation in psychoeducation on pre-labour anxiety in nulliparous women was associated with a diminished number of symptoms of post-partum depression and better preparation for labour and maternity [17].”
BackgroundNasrin, M., Shahmohammadi, S., & Farkhondeh, A. S. (2015) · DOAJ (DOAJ: Directory of Open Access Journals) · Cited by 5
Tocophobia: overwhelming fear of pregnancy and childbirth
Donel, J. (2019) · International Journal of Reproduction Contraception Obstetrics and Gynecology · doi:10.18203/2320-1770.ijrcog20194915 · Cited by 5
“Study revealed a significant effect of group psycho-education classes and relaxation exercise during pregnancy on experience of childbirth in 3 months of postpartum among women suffering from severe fear.(29) Another single-arm pilot study tested the effect of a mindfulness-based childbirth education as a new model of…”
The Effect of Peer Education on Fear of Childbirth in Pregnant Women: A Randomized Clinical Trial
Rahmani, R., Moghadam, F. Y., Hadizadeh-Talasaz, F., & Rahmani, M. R. (2019) · International Journal of Women s Health and Reproduction Sciences · doi:10.15296/ijwhr.2020.33 · Cited by 5
“Mothers who are afraid of having a childbirth have problems with mother-child compliance (5,6).”
BackgroundGebelerde Doğum Korkusu Düzeyi ve İlişkili Değişkenlerin İncelenmesi
Kanbur, A., & Koç, Ö. (2023) · Mersin Üniversitesi Tıp Fakültesi Lokman Hekim Tıp Tarihi ve Folklorik Tıp Dergisi · doi:10.31020/mutftd.1162395 · Cited by 4
Alivand, Z., Nourizadeh, R., Hakimi, S., Esmaeilpour, K., & Mehrabi, E. (2023) · BMC Psychiatry · doi:10.1186/s12888-023-05414-3 · Cited by 5
“In literature review, different interventions, such as group psychotherapy [17], relaxation [18], music therapy [19], massage therapy [20], aromatherapy [21], individual counseling by midwives [22], childbirth preparation classes [23, 24], haptonomy [25], CBT [26], and mindfulness-based counseling…”
BackgroundStevenson, E. L., & Silva, S. G. (2017) · Research and theory for nursing practice · doi:10.1891/1541-6577.31.3.295 · Cited by 5
“, 2014), relaxation techniques (Rouhe et al., 2014), and mindfulness (Woolhouse, Mercuri, Judd, & Brown, 2014).”
BackgroundHealth, obstetric outcomes and reproduction in women with vulvar pain or primary fear of childbirth
Möller, L. (2019) · Linköping University medical dissertations · doi:10.3384/diss.diva-156622 · Cited by 5
GEBELERDE DOĞUM KORKUSUNUN BELİRLENMESİ: RANDOMİZE KONTROLLÜ ÇALIŞMALARIN SİSTEMATİK DERLEMESİ
Özlem, A. K. I. N., & Erbi̇l, N. (2023) · Karya Journal of Health Science · doi:10.52831/kjhs.1166887 · Cited by 4
Onchonga, D., Hammoud, S., Kuriakose, S., & Muhammad, E. A. K. (2021) · Sexual & Reproductive Healthcare · doi:10.1016/j.srhc.2021.100605 · Cited by 4
den Boer, I., Hendrix, Y. M. G. A., Knoop, H., & van Pampus, M. G. (2021) · Journal of Psychosomatic Obstetrics & Gynecology · doi:10.1080/0167482x.2021.2013797 · Cited by 4
Rahimi, F., Rabiepor, E., & Alinejad, V. (2023) · Nursing and Midwifery Journal · doi:10.61186/unmf.21.1.25 · Cited by 4
Ben-Rafael, S., Bloch, M., & Romano, G. A. (2022) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2022.02.015 · Cited by 4
Tokophobia—Extreme Fear of Pregnancy and Birth and Implications for Care: A Case Report
Barton, K. D., Wilson, R. E., Sniffen, S., Kelly, P., Leavitt, K., Evans, V., & Louis‐Jacques, A. F. (2024) · The Journal of Perinatal Education · doi:10.1891/jpe-2022-0021 · Cited by 3
Ghavami, B., Abad, B. A. Q. H., Saffarian, M. R., & Khakpour, M. (2020) · Journal of Research and Health · doi:10.32598/jrh.10.1.11 · Cited by 3
Amiri, N. P., Ahmadi, A., Mirzaee, F., Mirzai, M., & Shahrokhi, N. (2021) · Revista Brasileira Ginecologia e Obstetrícia · doi:10.1055/s-0041-1728780 · Cited by 3
Silvan, E., Saisto, T., Mäkelä, T., Salmela‐Aro, K., Gissler, M., & Lampio, L. (2025) · Reproductive Health · doi:10.1186/s12978-025-01949-8 · Cited by 2
Self-citation
Metadata
- Authors
- Rouhe, H., Salmela-Aro, K., Toivanen, R., Tokola, M., Halmesmäki, E., Ryding, E.-L., & Saisto, T.
- Affiliations
- Helsinki University Hospital (FI)
- Karolinska Institutet (SE)
- Corresponding author
- Rouhe, Hanna
- Venue
- Journal of Psychosomatic Obstetrics & Gynecology
- Publisher
- Informa UK Limited
- Published
- 2014-11-24
- Volume
- 36
- Issue
- 1
- Pages
- 1-9
- ISSN
- 0167-482X (ISSN-L)
- 1743-8942
- OpenAlex
- W2092434157
- Cited by
- 129
- References
- 64
- Citations by year
- 2026: 2 · 2025: 7 · 2024: 13 · 2023: 12 · 2022: 12 · 2021: 17 · 2020: 16 · 2019: 14 · 2018: 16 · 2017: 8 · 2016: 10 · 2015: 2
- FWCI
- 6.60
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Psychosomatic Obstetrics & Gynecology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Maternal Mental Health During Pregnancy and Postpartum
- Health Sciences › Medicine › Obstetrics and Gynecology › Maternal and Perinatal Health Interventions
- Health Sciences › Medicine › Obstetrics and Gynecology › Pregnancy-related medical research
- Keywords
- fear of childbirth, group psychoeducation, relaxation training, maternal adjustment, childbirth experience, postpartum depression, social support, posttraumatic stress symptoms, nulliparous women, pregnancy, postpartum period
- MeSH terms
- Adaptation, Psychological, Fear, Female, Humans, Mothers, Patient Education as Topic, Pregnancy, Pregnancy Complications, Psychotherapy, Group, Surveys and Questionnaires, Relaxation Therapy, Social Support, Parturition, Delivery, Obstetric, Pregnant People, Postpartum Period
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