The experience of pain during labour is a complex, individual and multifaceted response to sensory stimuli generated during childbirth. Despite the fact that labour is painful for most women, a powerful myth of painless childbirth still prevails. Many alternative methods of pain relief are available that are safe and inexpensive. One of them is water birth. Water birth is the process of giving birth in a tub of warm water. The theory behind water birth is that the baby has been in the amniotic sac for nine months and birthing into a similar environment is gentler for the baby and less stressful for the mother. Adolescence is the time to prepare for understanding great responsibilities, a time for exploration and widening horizons, and a time to ensure healthy all round development. Puberty is also a time of behavioural changes when the reproductive capacities get established. Midwives are ‘with woman’, providing the family with supportive and helpful relationships as they share the deep and profound experiences of childbirth. To become skilled helpers nursing students need to develop reflective skills and valid midwifery knowledge grounded in their personal experiences and practice.

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2. Original Article
A study to assess the effectiveness of planned
teaching programme on water birth among
adolescent girls in a selected college at Mangalore
Darling Bibiana*, Jomy Cherian
Principal, Shree Devi College of Nursing, Maina Towers, Ballalbagh, Mangalore 575003, India
a r t i c l e i n f o
Article history:
Received 28 August 2012
Accepted 30 October 2013
Available online 18 November 2013
Keywords:
Effectiveness
Water birth
Planned teaching programme
Adolescent girls
a b s t r a c t
The experience of pain during labour is a complex, individual and multifaceted response to
sensory stimuli generated during childbirth. Despite the fact that labour is painful for most
women, a powerful myth of painless childbirth still prevails. Many alternative methods of
pain relief are available that are safe and inexpensive. One of them is water birth. Water
birth is the process of giving birth in a tub of warm water. The theory behind water birth is
that the baby has been in the amniotic sac for nine months and birthing into a similar
environment is gentler for the baby and less stressful for the mother. Adolescence is the
time to prepare for understanding great responsibilities, a time for exploration and
widening horizons, and a time to ensure healthy all round development. Puberty is also a
time of behavioural changes when the reproductive capacities get established. Midwives
are ‘with woman’, providing the family with supportive and helpful relationships as they
share the deep and profound experiences of childbirth. To become skilled helpers nursing
students need to develop reflective skills and valid midwifery knowledge grounded in their
personal experiences and practice.
Aim: The aim of the study was to assess the effectiveness of planned teaching programme
on water birth among adolescent girls in a selected college at Mangalore.
Method: An evaluative approach with quasi experimental, pre-test post-test design without
control group was used for the study. The data was collected from 60 adolescent girls using
simple random sampling technique. The study was conducted in selected college at
Mangalore.
Results: There was significant difference between per-test and post-test knowledge score
(t ¼ 44.23, p < 0.05). There was no association between the pre-test knowledge score and
selected variables.
Conclusion: All the subjects in the study group gained knowledge on water birth indicating
that planned teaching programme was an effective method for increasing knowledge.
Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.
* Corresponding author. Tel.: þ91 9886932378 (mobile); fax: þ91 0824 2451108.
E-mail addresses: bibiana_vijay@yahoo.co.in, vijaypt72@hotmail.com (D. Bibiana).
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.elsevier.com/locate/apme
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 8 4 e8 7
0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.apme.2013.10.011

3. 1. Introduction
Childbirth is a biological process which gives joy to the mother
and the family, and it is the culmination of a human pregnancy
or gestation period with the birth of one or more child from a
woman’s uterus. It is a crucial moment in a woman’s life. It
changes entire life of a woman. She becomes a mother e a
nurturer. Though the end result is rewarding e seeing the face of
her child, her flesh e the process is very exacting. Due to the
original sin, womankind was cursed to go through thispain. This
was the redemption for women. Today childbirth need not be a
painful process, where a woman has to undergo unendurable
pain.1
Birth is a normal, healthy part of a woman’s life. The
amount of pain a woman experiences during her labour is
influenced by many individual, physical, emotional, and
environmental factors. Some of these factors can be antici-
pated and actively controlled by the woman and/or her sup-
port team with preparation and information. Relaxation skills
and accurate knowledge about the birth process give a woman
confidence in her ability to work with her body.1,2
Alternative approaches to childbirth are more popular than
ever. Water, acupuncture and acupressure, and hypnosis are
some of the ways expectant mothers are coping with labour
pain. Underwater delivery or simply ‘water birth’ is becoming
increasingly popular worldwide. Water birth is a safe method
for painless delivery, which takes place in a pool or a tub filled
with warm water. Water being a cooling agent helps the
mother to relax physically and mentally. Water birth is a safe
method for painless delivery, which takes place in a pool or a
tub filled with warm water. Water being a cooling agent helps
the mother to relax physically and mentally.3
“Water birth has psychological benefits for the foetus. It
reduces ‘birth trauma’ in the child”. When a child enters the
world, it finds itself in a completely different environment and
setting. The change from a protective fluid-filled sac to a dry,
airy environment can trigger shock or trauma in the child.
And as in an underwater delivery the shift is from fluid to
fluid, the baby does not experience any trauma. Rather, a
water baby adapts to the environment better.4
A descriptive study was conducted in Tanzania among 135
adolescent girls to assess knowledge of pregnancy and child-
birth. The study finding revealed that only 33% of girls could
correctly identify the age at which a woman can conceive.
Regarding the duration of pregnancy, 77.3% could answer the
correct nine months. None of them have known about alter-
native birthing method. Knowledge about childbirth and other
related aspects were unknown to the adolescent girls. The
researcher concluded that poor knowledge of childbirth among
adolescence is related to lack of effective and coordinate in-
terventions to address reproductive health and motherhood
and they must provide with appropriate information regarding
childbirth through innovative school based programme.5
A comparative study was conducted in Switzerland among
5953 to assess the safety of alternative birth methods in general
and of water births. The results shows that 2014 spontaneous
births were water births, 1108 were Maia-birthing stool births
and 2362 were bed births. Results revealed that an episiotomy
was performed in only 12.8% of the births in water. Themothers’
blood loss is the lowest in water births. Fewer painkillers are
used in water births and the experience of birth itself is more
satisfying after a birth in water. The average arterial blood pH of
the umbilical cord as well as the Apgar scoring at 5 and 10 min
were significantly higher after water births. The researchers
concluded that water births and other alternative forms of
birthing such as Maia-birthing stool do not demonstrate higher
birth risks for the mother or the child than bed births.6
An evaluative study was conducted in London among 189
mothers about the responses to water birth who had experi-
enced water birth. The results showed that water birth is a
consumer-led trend, mainly pursued by educated middle class
women. The researcher concluded that better antenatal
preparation is needed to reduce the need for other forms of
analgesia when women are in water. Women’s responses to
the survey suggested that mothers perceived water birth as
therapeutic. Mothers demonstrated a strong desire for water
in labour. There were no significant behaviour differences
between water-born babies and non-water-born babies.7
Study findings revealed that the most commonly used
complimentary therapy was water birth and the decision
making regarding this was made with the help of midwives.8
Episiotomy needed for the water birth is very low.9
Water
birth is to be considered a safe method for a healthy mother and
a healthy full-term foetus with cephalic presentation.10
Water
birth in India is also gaining popularity. In India it is emerging as
a promising alternative to painful traditional delivery.11
Midwives are ‘with woman’, providing the family with
supportive and helpful relationships as they share the deep
and profound experiences of childbirth. To become skilled
helpers nursing students need to develop reflective skills and
valid midwifery knowledge grounded in their personal expe-
riences and practice. Midwife educators and practitioners can
assist nursing students and enhance their learning by
expanding the scope of practice, encouraging self-assessment
and the development of reflective and professional skills.
Nursing students have high expectations for gaining skills
and knowledge to prepare them to enter professional practice.
Through the experiences of learning and applying doula skills
to their professional nursing practice, new graduates will be
better prepared to enter the real world of nursing practice.
Objectives of the study were to:
Determine the existing knowledge score of adolescents
regarding water birth using a structured knowledge
questionnaire.
Find the effectiveness of planned teaching programme on
water birth among adolescents.
Find the association between pre-test knowledge score and
selected demographic variables
The conceptual frame work adopted for this study was
based on general system theory by Ludwig Von Bertalanffy.
2. Materials and methods
An evaluative approach with quasi experimental, pre-test
post-test design without control group was adopted for the
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 8 4 e8 7 85

4. study. Sixty adolescent girls from Shree Devi College of
Nursing, Mangalore were selected using simple random
sampling technique. Sample size was determined based on
the pilot study finding. The instrument used was a self-
administered knowledge questionnaire prepared by the
investigator. It consists of total 26 items related to knowledge
regarding water birth. There were two sections. Section A
consists of three items assessing the knowledge related to
female reproductive system. Section B consists of twenty
three items assessing the knowledge related to basic concepts
of water birth.
The knowledge score were classified based on the score
obtained as poor ( 40%), moderate (41e60%), good (61e80%)
and very good (81e100%). The prepared tool was validated by
seven experts. Reliability of structured knowledge question-
naire was assessed by split half method and the ‘r’ value was
r ¼ 0.89 and the tool was found reliable.
A systematically developed planned teaching programme
was designed to provide information on water birth with a
view to improve their knowledge on water birth, which in-
cludes criteria, preparation, benefits, risks, and labour care.
Pilot study was conducted among six subjects by using
random sampling technique. The subjects for pilot study
possessed the same characters that of the samples for final
study. It was found that the study was feasible, the ques-
tionnaire and PTP were relevant and time and cost of the
study was within the limit. Prior permission was obtained
from the concerned authority of the college. Data was
collected after informed consent of the sample. Pre-test was
conducted followed by the teaching programme. After seven
days a post-test was conducted using the same questionnaire
to evaluate the effectiveness of planned teaching programme.
3. Results
Descriptive and inferential statistics were used to analyse the
data. For the present study the significant findings were most
of them (61.1%) were in the age group of 20 years, about 88.3%
adolescent girls belonged to nuclear family. The highest per-
centage (46.6%) of the girls belonged to family income group of
Rs. 8001e10,001 and above and 48.3% of the girls received
health information from mass media (Table 1).
The total mean percentage of pre-test knowledge score
was 44.6% with mean Æ SD of 13.4 Æ 4.01 and the mean post-
test knowledge score was 89.3% with mean Æ SD was
23.22 Æ 1.20 showing an effectiveness of 44.5% with
mean Æ SD 11.57 Æ 1.73. Significance of difference between
pre-test and post-test was statistically tested by using paired
‘t’ test. The significance difference suggesting that the PTP was
effective in increasing the knowledge of the adolescent girls
t(59) ¼ 44.23, p 0.05. There was no association between pre-
test knowledge score and demographic variables.
4. Discussion
In pre-test it has been found that majority (70%) of the
adolescent girls had average knowledge. The mean post-
test knowledge score (23.22 Æ 1.20) was higher than the
pre-test knowledge score (11.57 Æ 1.73) which revealed that
gain in knowledge on water birth, by reducing the poor
knowledge category and increasing the excellent category.
The significance difference suggesting that the PTP was
effective in increasing the knowledge of the adolescent girls
t(59) ¼ 44.23, p 0.05. It is evident that PTP was effective in
improving the knowledge of adolescent girls regarding
water birth. The finding of this study is consistent with the
study conducted among 50 adolescent girls in the age group
of 16e18 years on effectiveness of PTP on normal vaginal
delivery in a selected rural area, Udupi. Findings revealed
that the mean differences between the post-test and pre-
test knowledge score of adolescent girls on normal vaginal
delivery found to be significant t ¼ 16.20, (p 0.05). This
suggested that the PTP was effective in improving knowl-
edge of adolescent girls.12
5. Implications
Planned teaching programme also helps the future nurses
to practice the alternative birth method and to guide their
patients to the appropriate treatment centres. Nursing stu-
dents as future nurses and midwives have a role in pre-
paring their clients for childbirth through proper guidance
and education. Planned teaching programme also helps the
future nurses to practice the alternative birth method and to
guide their patients to the appropriate treatment centres.
Nursing students as future nurses and midwives have a role
in preparing their clients for childbirth through proper
guidance and education.
Nurse administrator plays a vital role in the supervision
and management of nursing profession. The nursing admin-
istrator can plan and conduct education programmes which
are beneficial to nursing faculty, staff nurses and students.
There are only very few studies conducted on water birth.
More innovative teaching methods like reproductive health
issues package can be implemented and its effectiveness can
be evaluated.
Limitations of the study were that the sample size was
small so the generalization of the finding is limited.
Table 1 e Frequency and percentage distribution of
samples according to their demographic variables.
Demographic variables Frequency Percentage
Age
a) 19 yrs 18 30
b) 20 yrs 37 61.67
c) 21 yrs 5 8.33
Type of family
a) Nuclear 53 88.3
b) Joint 7 11.7
Family monthly income
a) Rs. 5001e8000/- 15 25.0
b) Rs. 8001e10,000/- 28 46.7
c) More than 10,001/- 17 28.3
Source of information
a) Mass media 29 48.3
b) Parents/relatives/friends 8 13.3
c) No information 23 38.3
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 8 4 e8 786

5. 6. Conclusion
The study supports the concept that planned teaching pro-
gramme for adolescent girls are an effective strategy to
improve knowledge on water birth. Water birth is an option
chosen by some women for pain relief during labour and
childbirth, and studies have reported that water birth in an
uncomplicated delivery helps to reduce the need for anal-
gesia, without evidence of increased risk to mother or
newborn. Hot water tubs are available in many hospitals and
birthing centres. It is the belief of midwives, birthing centres
and a growing number of obstetricians, that reducing the
stress during labour and delivery also reduces foetal
complications.
Conflicts of interest
All authors have none to declare.
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