NewPreBP: Project Newborn -Preparation for Birth and Parenthood. A Large Interdisciplinary Randomised Trial on the Effect of Birth and Parent Preparation
Antenatal education Today Danish antenatal classes are primarily offered in auditoriums as
lectures with a minimum of interaction with the audience. The Danish regions currently aim
in time to implement antenatal birth and parent preparation classes in small groups for all
expectant parents. However, it is unknown if 1) antenatal preparation in small groups is
superior to standard care; 2) what elements the preparation should encompass to meet the
needs of expectant parents today; and 3) what the cost-effectiveness of antenatal
preparation in small groups is compared to large-scale preparation in auditoriums.
Trial objectives and purpose The primary aim is to compare parenting resources, health and
thriving, and use of healthcare services in newborn families enrolled in a research-based
standardised antenatal birth and parenting program in small groups with those allocated to
Development of the program: We have developed a comprehensive, theoretically founded
parenting program in collaboration with midwives, health care visitors, a psychologist and
family therapist, parents, and leading national and international researchers and clinicians
in this field.
Process evaluation: Focus group interviews with service providers, group facilitators and
participants will be carried out. Program fidelity e.g. whether the protocol is followed in
program delivery, and how much of the intended program the participants are receiving, as
well as program reach e.g. what proportions of the intended groups are participating in the
program, has an impact on the effect of an intervention (16). We will evaluate whether the
protocol is followed in program delivery and how much of the intended program the
participants are receiving. Participants will be asked to fill in an electronic
questionnaire on-site at the end of each session. The questionnaire will highlight whether
the intended subjects of the session have been covered as well as to what extent the
participants found the information given useful. Group facilitators will be asked to fill in
a similar questionnaire with the opportunity to explain why certain topics may have been
Non respondent/non-participation: What proportions of the intended groups are participating
in the program will be explored by examining demographic characteristics of those who
declined to participate in the trial via the national registers, as well as examining
characteristics of those who accepted and then did or did not show up for the sessions.
Cost-effectiveness analysis: Finally the incremental societal cost of the intervention will
be calculated and compared to the measured outcomes in a cost-effectiveness analysis. Direct
health care costs as well as productivity costs in terms of labour market participation and
sickness absence. For this we will use data from the obstetric database at Hvidovre
Hospital, national registers and questionnaires.
Trial design Individually randomised trial sited at a large birth clinic in the Copenhagen
Capital Region, Hvidovre Hospital.
The intervention will have two arms:
1. A research-based parenting program described in more detail below.
2. Standard care (control group). The pregnant woman and her partner are offered two
antenatal lectures on birth and breastfeeding in an auditorium.
The intervention arm: Groups of approximately 6-7 couples (or mothers) will meet three times
during pregnancy and 1 time 5 weeks after expected due date, for the duration of 2.5 hours
per session. (The aim is to create groups of 6-7 couples; however, due to fluctuations in
uptake groups of 4-9 couples will be deemed acceptable). The sessions will include
information and discussions about emotions and expectations related to birth and parenting,
identification of social network resources, couple communication, breastfeeding,
parent-child attachment, directions on taking care of a newborn, and recognising common
signs of mood disorders and how to react. A website with parenting information and exercises
will be created and parents will be encouraged to use this material alongside the sessions.
In addition to gaining knowledge about issues related to birth and parenting, and creating
an environment where parents can discuss their feelings and concerns, the program aims at
enhancing expectant parents' awareness of their own resources and problem-solving
strategies. Furthermore the way the groups are composited will enable participants to
establish relations with other expectant parents in their local area. All sessions will be
led by a midwife. The postnatal session will be conducted in collaboration with a health
visitor, to increase knowledge on available resources in the local communities Informed
consent All participants considered for this trial will be provided with written and oral
information on this trial so that participants can make an informed decision about their
participation in this trial. A project phone line will be established where participants can
contact a project member throughout the trial if she has further questions, or wishes to
withdraw her consent for participation in the trial.
Data collection Data will be collected from both parents using web-based questionnaires at:
baseline (approximately 18 weeks gestation) (Tp0), 37 weeks gestation (Tp1), 9 weeks after
expected due date (Tp2), 6 months after expected due date (Tp3), 1 year after expected due
date (Tp4). Participants will be contacted via e-mail, when due to answer a questionnaire.
Two reminders will be sent via additional e-mails, the first after a week and the second
after 14 days. Data will also be obtained from the hospital obstetric database and the
Concomitant medication/treatment All participants are free to make use of concomitant
antenatal/postnatal services and parent groups. As use of other services and parent groups
may influence the outcomes that we are interested in, use and services will be examined,
documented and given careful consideration in the analyses.
In addition to primary and secondary outcomes, there are following explorative outcomes:
Post-natal depressive symptomatology and anxiety - questionnaire data, EPDS, MDI, The
Hopkins Symptom Check List (SCL-25) first 10 items (tp 1,2) Breastfeeding - questionnaire
data (tp0,1,2,3) Use of healthcare services i.e.: for the parents obstetric intervention
i.e. augmentation of labour, vacuum extraction, caesarean rate - data from the hospital
obstetric database (tp2), and contact to healthcare professionals for depressive
symptomatology and unscheduled postnatal visits- questionnaire data (tp2,3). For the child
i.e. neonatal readmissions to hospital, contacts to accident and emergency departments (A &
E), GP and doctor on call during the child's first year of life (composite measure). Also
use of the regional emergency phone line - data from the national registers (tp4).
Family medicine use - questionnaire data (tp2,3) and register data (tp4) Smoking -
questionnaire data (tp1,2) Satisfaction with relationship and family break-ups -
questionnaire data (tp 0,2,3), and data from the national registers on divorce and break-ups
(tp4): mental well-being (tp1,2,3)
In this trial the intermediate outcomes of interest are:
Parenting resources: trust in own ability to cope with: 1) birth (tp1), 2) discharge (tp1)
3) parenting (tp1,2,4) breastfeeding (tp0,1); couple communication (tp0,1,2,3); social
support/network (tp0,1,2,3) Statistical plan and data analysis Sample size and power
estimations We are planning a trial of independent experimental and control participant with
1 control per experimental participant. 2011 data from the HH Obstetric Database
(unpublished data) indicate that epidural use among pregnant women is 30%. If the true
epidural use for experimental participants is 25%, we will need to include 1,175
experimental participants and 1,175 control participants be able to reject the null
hypothesis that the epidural use for experimental and control participants are equal with
probability (power) 90%. The Type I error probability associated with this test of this null
hypothesis is 5% Power estimation for the secondary outcome Perceived Stress Scale We are
planning a trial with 1175 experimental participants and 1175 control participants. In a
previous study the Perceived Stress Scale response within each participant group was
normally distributed with standard deviation 6 (18). If the true difference in the
experimental and control means is 1, we will be able to reject the null hypothesis that the
population means of the experimental and control groups are equal with probability (power)
98.1%. The type 1 error probability associated with this test of this null hypothesis is
Power estimation for the secondary outcome Swedish Parenthood Stress Questionnaire In a
previous study the Swedish Parenthood Stress Questionnaire response within each subject
group was normally distributed with standard deviation 0.5 (19). If the true difference in
the experimental and control means is 0.1, we will be able to reject the null hypothesis
that the population means of the experimental and control groups are equal with probability
(power) 99.8%. The type 1 error probability associated with this test of this null
hypothesis is 0.5.
Statistical methods Reporting will follow the guidelines of the CONSORT-statement.
Statistical analyses will be intention to treat as well as per protocol. The level of
significance will be 0.05.
The analysis of the primary binary outcome will be done using logistic regression.
The results of this analysis will be subjected to a worst case and a best case scenario
analysis of the potential impact of missing values. In the analysis of the two secondary
outcome measures a mixed model with repeated measures will be used. The fixed effects will
include a linear and a quadratic time component and their corresponding interactions with
the intervention indicator. An unstructured covariance matrix will be used initially. If
convergence cannot be obtained the spatial power law covariance structure will be tried and
then the compound symmetric model.
Using the general linear univariate model it will be tested if the mean values differ
between the two intervention groups at time 1 (9 weeks following birth).
If the assumptions of the above analyses cannot be fulfilled with reasonable approximation
the groups will only be compared at time 1 using a nonparametric test (Mann Whitney).
The unadjusted analyses are the primary analyses. If possible all analyses will be repeated
adjusted for the protocol specified stratification variable and the baseline value.
Three explorative subgroup analyses may be conducted in each case provided the subgroup
interacts significantly with the intervention.
Dealing with multiplicity, gate keeping will be used to adjust the observed p values for
primary and secondary outcomes. Both observed and adjusted p values will be reported.
Direct access to source data/documentation
The trial will be carried out in accordance with the Declaration of Helsinki in its latest
form as well as national laws and regulations. The investigators permit audits and
inspection by providing direct access to source data/documentation. The trial will be
monitored by an unrelated research group at the National Institute of Public Health. eCRFs
will be checked, and as minimum the following will be monitored locally:
All patients for existence (If the CPR number is correct), All patients for documented
Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Single Blind (Outcomes Assessor), Primary Purpose: Prevention
Epidural use during will be measured using data from the hospital obstetric database
Pernille Due, MD
University of Southern Denmark
Denmark: The Regional Committee on Biomedical Research Ethics
Nyfødt -DP -269