1 SUBMITTED 22 JAN 23 1 REVISION REQ. 27 FEB 23; REVISION RECD. 20 MAR 23 2 ACCEPTED 3 MAY 23 3 ONLINE-FIRST: JUNE 2023 4 DOI: https://doi.org/10.18295/squmj.6.2023.041 5 6 The Effect of Group Prenatal Care on Empowerment of Pregnant Adolescents 7 A randomized controlled trial 8 Fatemeh Malchi,1 *Parvin Abedi,2 Mina Iravani,2 Elham Maraghi,3 Eesa 9 Mohammadi,4 Najmieh Saadati5 10 1Department of Midwifery, Nursing and Midwifery School, 2Reproductive Health Promotion 11 Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran; 3Department 12 of Biostatics and Epidemiology, Faculty of Public Health and 5Department of Obstetrics and 13 Gynecology, Fertility Infertility and Perinatology Research Center, Ahvaz Jundishapur 14 University of Medical Sciences, Ahvaz, Iran; 4Nursing Department, Faculty of Medical Sciences, 15 Tarbiat Modares University, Tehran, Iran. 16 *Corresponding Author’s e-mail: parvinabedi@ymail.com. 17 18 Abstract 19 Objectives: This study aimed to evaluate the effect of group prenatal care on empowerment of 20 pregnant adolescents. Methods: In this randomized controlled trial, 294 pregnant adolescents 21 (aged 15-19) were randomly assigned into two groups of group prenatal care (GPNC, n=147) 22 and individual prenatal care (IPNC, n=147). GPNC group received 5 sessions of GPNC (90-120 23 min) during 16-20 weeks of pregnancy, while the control group received individual prenatal 24 care. The empowerment of participants in the two groups was measured using the empowerment 25 scale for pregnant women. Data were analyzed using the Chi-square test, independent t-test, and 26 adjusted regression test. Results: The mean total score of pregnant women’s empowerment in the 27 GPNC and IPNC groups after the intervention was 86.46±4.95 and 81.89±4.75, respectively [ β= 28 6.11, 95% CI: 4.89, 7.33, p<0.0001]. The improvement of dimensions of pregnancy 29 empowerment in GPNC versus IPNC was as follows: Self‐efficacy: 18.21 ± 2.12 vs. 16.19 ± 30 mailto:parvinabedi@ymail.com 2 1.79 [β= 2.52, 95% CI: 2.19, 2.86, p<0.0001], Future image: 19.57±1.57 vs. 18.95±1.54 [β= 31 0.67, 95% CI: (0.44, 0.9], Self-esteem: 21.79 ± 1.75 vs. 20.90 ± 1.85 [β= 0.69, 95% CI: 0.41, 32 0.97, P<0.0001], Joy of an addition to the family: 13.13±1.69 vs. 12.84±1.40 [β= 0.51, 95% CI: 33 0.28, 0.74, P=0.009], and Support and assurance from others: 13.70 ± 1.1 and 13.04 ± 1.07, [β= 34 0.76, 95% CI: 0.13, 1.65, P<0.0001]. Conclusion: Group prenatal care can improve adolescent 35 pregnant women’s empowerment. Results of the present study can serve as a useful foundation 36 for implementing the group prenatal care model in Iran. 37 Keywords: Adolescent pregnancy; Empowerment; Centering prenatal care; Group prenatal care; 38 Iran 39 40 Introduction 41 Adolescent pregnancy is defined as a pregnancy that occurs when the mother is aged between 13 42 and 19.1 It is one of the main concerns in developing and undeveloped countries.2 Every year, 43 about 21 million girls aged 15 to 19 years in undeveloped countries become pregnant, and 44 approximately 12 million of them give birth to their babies.3 Adolescent pregnant women may 45 have adverse pregnancy outcomes.4 For example, they are at a greater risk of preterm birth, pre-46 eclampsia, low birth weight, and maternal and neonatal mortality.5 In addition, they often have a 47 low level of education and come from poor socioeconomic status, which can lead to adverse 48 maternal and neonatal outcomes.4 In Iran, adolescent pregnancy is expected to increase due to 49 the recent changes in Iran’s new population policies aimed at promoting population growth and 50 increasing the young population.6 Appropriate prenatal care, however, can improve pregnancy 51 outcomes among adolescent pregnant women.7 Such a care aims to optimize the well-being of 52 the adolescent mother and her fetus through education and detection of pregnancy-related 53 adverse outcomes.8 Adolescent pregnant women’s access to high-quality prenatal care and their 54 increased knowledge during pregnancy both empower them and decrease pregnancy problems. 55 9,10 Empowerment of pregnant adolescent women can improve maternal and neonatal health 56 outcomes.11 Empowerment during pregnancy includes promoting a feeling of satisfaction, 57 satisfaction, increasing independence, improving interaction with others, and increasing 58 psychological energy to achieve successful pregnancy and childbirth.12 59 60 3 In Iran, prenatal care in public health centers is provided individually by a midwife, while in 61 private clinics, it may be provided by a midwife or an obstetrician. Prenatal care is provided in 8 62 individual visits of 10 to 15 minutes. Based on this schedule, the average total length of prenatal 63 visits is nearly two hours during pregnancy. Thus, this limited time of perinatal visits does not 64 allow to meet the educational needs of pregnant women.13 65 66 Group prenatal care has been considered as an efficient and effective way to provide prenatal 67 care.14 One of the known models of group prenatal care is centering pregnancy, which is a 68 woman-centered model of group prenatal care that brings women together into groups.15 Group 69 prenatal care is unique in that it is a group, not a class. Instead of hierarchical transmission of 70 information, group prenatal care is based on facilitation of sharing experience and knowledge by 71 healthcare providers.15 72 73 In this model of care, 8-12 women with similar gestational age meet in prenatal care sessions 74 which last approximately 60-90 minutes. The pregnant women measure their height and weight 75 and share their experiences in the group session. Compared with individual prenatal care, group 76 prenatal care places emphasis on education and social support. In this model of care, pregnant 77 women are engaged in their health care and share their learning, skills, and experiences.15 78 79 Evidence suggests that group prenatal care improves pregnancy outcomes such as birth weight, 80 low birth weight (LBW), preterm birth, increased breastfeeding initiation, and increased family 81 planning uptake.16-18 82 83 Group prenatal care provides more time for pregnant women to improve their knowledge and 84 active participation in self-care. Active participation of mothers in self-care through GPNC can 85 increased their ability to improve their decision-making, self-efficacy, and empowerment.15,19 86 87 Given the importance of adolescent pregnancy empowerment in maternal and neonatal health 88 outcomes, and considering paucity of research on this issue in Iran, we conducted the current 89 study to evaluate the effect of group prenatal care on adolescent pregnancy empowerment. 90 91 4 Methods 92 This study was a parallel randomized controlled trial conducted between August 2021 and July 93 2022. The main objective of the study was to evaluate the effect of GPNC on the empowerment 94 of adolescent women. The specific objectives of the study were to assess the effect of group 95 GPNC on the dimensions of pregnancy empowerment, including self-efficacy, joy of an addition 96 to the family, self-esteem, future image, and support and assurance from others. This study is 97 part of a mixed-method study conducted to evaluate the effect of group prenatal care (GPNC) on 98 adolescent pregnancy outcomes in Ahvaz, Iran. The design of the study was approved by the 99 Ethics Committee of Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran (Ref. ID: 100 IR.AJUMS.REC.1400.235), and it was also registered in the Iranian Registry for Clinical Trials 101 (Ref No: IRCT20210703051764N1). Each participant signed informed written consent before 102 data collection. 103 104 Participants in this study included married adolescent pregnant women aged 15–19 who referred 105 to public health centers in Ahvaz, Southwest of Iran to receive prenatal care. Women were 106 eligible to participate in this study if they: were aged 15-19 years, had a gestational age of 16–22 107 weeks with singleton pregnancy, were gravida 1 or 2, and had low-risk and intended pregnancy. 108 Exclusion criteria included any medical complications that classified women in high-risk 109 pregnancies such as diabetes and high blood pressure. 110 111 Sample size 112 Based on the objectives of the study, and according to a previous study20 assuming the power of 113 80 %, α= 0.05, the sample size was calculated to be 132 women for each group using the 114 following formula. Given the possible 10% attrition rate, 147 women were considered for each 115 of the intervention and control groups. 116 117 Sampling 118 The lead researcher (FM) attended the 37 public health centers existing in Ahvaz and screened 119 the health records of eligible adolescent pregnant women who met the inclusion criteria. Eligible 120 5 adolescents were then called by phone and were briefed on the general objectives of the study. 121 Then individuals who were willing to participate in the study were invited to the health center. In 122 a face-to-face meeting, the participants were given detailed explanations about the study 123 objectives, duration, and method, along with confidentiality of information and their right to 124 withdraw from the study at any stage of the study. 125 126 Randomization 127 In this study, after recruiting the eligible women, randomization was performed based on block 128 randomization method (using a random sequence computer program) with a block size of four 129 and six and an allocation ratio of 1:1. To conceal random allocation, the type of intervention was 130 written on a paper and placed inside opaque envelopes, and all envelopes were kept by a person 131 who was not involved in sampling or data collection. Because of the nature of the intervention, 132 it was not possible to blind the researchers or the participants. However, both the researcher and 133 the participants did not know about the order of participation until the commencement of the 134 study. After informed consent was obtained, the participants were randomized to receive either 135 individual prenatal care (IPNC) (control group) or GPNC (intervention group) (Figure 1). 136 137 Setting 138 Six public primary health centers (PHCs) that had the largest number of adolescent pregnant 139 women among the 37 centers in Ahvaz were selected for sampling. Ahvaz, the capital of 140 Khuzestan province, is one of the most populous cities in Iran and is located in the southwest of 141 Iran. 142 143 Intervention 144 The first prenatal care visit was performed individually at 6–10 weeks of pregnancy. In this 145 session, the demographic questionnaire was completed through face-to-face interview. The 146 adolescents in the intervention group were classified into 25 groups. Each group consists of 5 to 147 6 adolescents at approximately the same gestational age who participated in 5 sessions of 90-120 148 min during their pregnancy. 149 150 6 At the beginning of each group session, the lead researcher (FM) individually measured fundal 151 height and auscultated the fetal heart in the space of group. In the first session, adolescent 152 women were taught how to measure their blood pressure and weight. At each session, blood 153 pressure and weight were measured under the supervision of a midwife. After these 154 measurements, the discussion for the session began. The group sessions were conducted in a 155 circle. The content of the discussion was based on a prenatal care booklet issued by the Iranian 156 Ministry of Health (Table 1). Groups were organized by the lead researcher. A topic that was 157 relevant to the gestational age of the group members was introduced, and the women were asked 158 to present their experiences about it. The adolescent pregnant women were encouraged to 159 participate in prenatal care educational sessions and express their ideas, knowledge, and 160 experiences with respect to care; then the necessary training was provided by the midwife in 161 simple language. The participants were also allowed to raise their questions and concerns about 162 pregnancy and childbirth. Other aspects of prenatal care, such as blood and urine tests and 163 ultrasounds, were performed individually by a laboratory technician and a radiographer, and the 164 participants were not involved in these measurements. There was a “private time” at the end of 165 each session dedicated for the participants to ask private questions and for evaluation of urine 166 and blood tests or ultrasounds. The ample time spent with a midwife and peers in GPNC allowed 167 the mothers to talk freely with each other and be more comfortable asking their questions. As a 168 result, they gained a vast amount of useful information. The control group received routine 169 individual prenatal care, provided by a midwife who was employed in the health center. 170 171 Measures 172 The data collection instruments were a demographic and obstetric questionnaire and the 173 empowerment scale for pregnant women. The demographic and obstetric questionnaire consisted 174 of questions about age, gestational age, gravidity, education, occupation, education and 175 occupation of the husband, and economic status. 176 177 The content validity of the demographic and obstetric questionnaire was confirmed. Participants 178 in the intervention and control groups were asked to complete the demographic and obstetric 179 questionnaire at the outset of the study. The empowerment scale for pregnant women was 180 completed in two phases, namely before intervention (6-10 weeks) and after intervention (38-40 181 7 weeks), by both the intervention and the control groups. The empowerment scale for pregnant 182 women was developed by Kameda et al. (2008).12 This questionnaire includes 27 questions in 183 five dimensions, namely self‐-efficacy (including 6 items related to the feeling of being able to 184 manage pregnancy and childbirth), future image (including 6 items related to the images and 185 aims regarding pregnancy, childbirth, hope for the future, and becoming a parent), self-esteem 186 (including 7 items related to acceptance of being pregnant and a mother), support and assurance 187 from others (including 4 items concerning acceptance and support) and a joy of an addition to the 188 family (including 4 items about enjoyment for the addition of a new family member). This 189 questionnaire was scored using a four-point Likert scale, ranging from 1 (strongly disagree) to 4 190 (strongly agree). The total scores of the questionnaire ranged from 27 to 108. A higher score 191 indicates higher pregnancy empowerment. The validity and reliability of this questionnaire have 192 been evaluated by Hajipour et al. in Iran in 2012.21 In this study the internal consistency of the 193 questionnaire using Cronbach's alpha was 0.72 with a sample size of forty participants. The 194 stability of the questionnaire using the test-retest method on forty participants with a two-week 195 interval was 80 percent. A midwife assisted the lead researcher with data collection. 196 197 Statistical analysis 198 All data were analyzed using SPSS version 22. The Shapiro-Wilk test was used for checking the 199 normal distribution of data. The independent t test was used to compare the age, BMI, and mean 200 total score of pregnant women's empowerment in the two groups. Chi-square test was used for 201 comparing categorical data such as gravidity, education, economic status, occupation, family 202 support, and extended family. Logistic regression was used to detect differences between the two 203 groups in terms of pregnancy empowerment after adjusting for confounding variables. P < 0.05 204 was considered statistically significant. 205 206 Ethical approval for this study was granted by the Ethics Committee of Ahvaz Jundishapur 207 University of Medical Sciences (Ref. ID: IR.AJUMS.REC.1400.235). 208 209 Results 210 At the end of the study, five participants dropped out (the reasons are listed in Fig. 1), and 289 211 participants completed the study. The socio-demographic characteristics of the participants in the 212 8 two groups of GPNC and IPNC are shown in Table 1. The mean age of participants was 17.42 213 and 17.40 in the GPNC and IPNC groups, respectively (p= 0.085). Most of the participants had 214 an elementary education and were categorized at a moderate level regarding their economic 215 status. The two groups did not have any significant differences in terms of age, parity, education, 216 economic status, family support, and occupation. (Table 2).The mean total score of the pregnant 217 women’s empowerment of the two groups of GPNC and IPNC before intervention was 78.29 218 ±3.81 and 78.07 ±1.20 respectively (p=0.579). In addition, the two groups had no significant 219 differences regarding all dimensions of empowerment before intervention. (Table 3). 220 221 The mean total score of pregnant women’s empowerment in the GPNC and IPNC groups after 222 the intervention was 86.46±4.95 and 81.89±4.75, respectively. Based on the results of 223 independent t- test, a statistically significant difference between the two groups was observed 224 after intervention (p<0.0001). After the intervention, the total score of empowerment and all its 225 subscales were higher in the intervention group compared to the control group. Based on the 226 result of adjusted linear regression analysis, there were significant post-intervention differences 227 between the two groups regarding the total score of empowerment and all its subscales except for 228 the subscale of “support and assurance from others”. The differences between the GPNC and 229 IPNC groups were as follows: 230 231 Self-efficacy: 14.65±1.95 vs. 14.72±1.58; [β= 2.52, 95% CI : 2.19, 2.86], Future image: 232 19.57±1.57 vs. 18.95±1.54 [β= 0.67, 95% CI: 0.44, 0.9), The joy of an addition a member to the 233 family:13.13±1.69 vs. 12.84±1.40 [β= 0.51, 95% CI: 0.28, 0.74], Support and assurance from 234 others: 12.16±1.30 and vs. 12.28±1.21 [β= 0.76 95% CI: -0.13, 1.65, P=0.094 ) (Table 3). 235 236 Discussion 237 This study aimed to evaluate the effect of GPNC on adolescent pregnancy empowerment. 238 According to the results, the mean score of the “self‐efficacy” dimension improved significantly 239 in the GPNC group compared to the control group after intervention. Active participation of 240 adolescent mothers in self-care increased their ability to improve their decision-making power 241 and self-efficacy which could contribute to empowerment. This finding was similar to the results 242 of Heberlin et al’s study.22 Furthermore, the Mckinnon et al. study found that GPNC improved 243 9 maternal self-efficacy.16In contrast to our findings, however, Somji et al. did not find statistically 244 significant differences in self-efficacy between the two groups.23 The difference between their 245 study and the current study could be due to the instrument used to measure pregnant women’s 246 self-efficacy. 247 248 Our results also showed that the subscale of self-esteem was improved significantly in the GNPC 249 group compared to the control group. Low levels of self-esteem can reduce access to healthcare 250 services and acceptance of effective interventions.24 By contrast, a high level of self-esteem is 251 effective in helping the mother cope with the challenges of pregnancy and childbirth.25 As a 252 result, it can affect the pregnant woman's experience and pregnancy outcomes.26 Social support 253 increases the mother’s competence and empowerment by improving her self-esteem and 254 reducing stress during the period of transition to motherhood.27 This study revealed that GPNC 255 affected the self-esteem dimension by providing information, peers, and midwife support. This 256 finding was aligned with Herman et al. who found that the information, support, and peer 257 relationships available in group care helped pregnant women to develop their skills and ability to 258 deal with stressful factors and increased promoted their self-esteem and empowerment.28 259 260 The result of the present study showed that the mean score of the “Future images” dimension 261 was significantly increased in the GPNC group compared to IPNC group. The future image 262 refers to a realistic picture of the long and short-term aims of pregnancy, childbirth, and 263 motherhood.12 Acquiring information and social support helped adolescent pregnant women to 264 improve their mood and self-image, reduce their worries related to pregnancy, and facilitated the 265 acceptance of childbirth.29 266 267 Our results showed that the mean score of the “Joy of an addition to the family” dimension in the 268 GPNC group significantly increased compared to the IPNC group after intervention. Adolescent 269 pregnant women have dual feelings about pregnancy. For some pregnant adolescents, having a 270 child gives them a meaningful life, and it can help them in their transition to adulthood. 271 However, some of them consider pregnancy and motherhood as a negative event.30,31 272 273 10 The education and support provided for pregnant women through GPNC prepared them for the 274 transition to motherhood.22 Therefore, it seems that GPNC in the present study could instill the 275 feeling of joy of an addition to the family in adolescent pregnant women by preparing them for 276 motherhood. 277 278 Pregnant women are very concerned about their health and their baby’s well-being.32These 279 concerns are often due to inadequate information about the physical and emotional changes 280 associated with pregnancy.30 Knowledge acquisition during pregnancy enables women to adapt 281 to the physical and emotional changes associated with pregnancy.32 282 283 Holding group care sessions and providing ample opportunities for the mothers to talk about 284 their pregnancy concerns have been found to enhance their knowledge and reduced their 285 worries.22,33 Furthermore, interaction with peers in GPNC and the exchange of information and 286 pregnancy experiences provide peer support. Therefore, GPNC can lead to informational and 287 emotional support.34 Of course, preserving the privacy of participants may be a concern during 288 GPNC. In the current study, none of participants had any concern about lack of privacy. 289 Although, a number of studies such as Sultana et al. have shown that GPNC facilitates 290 informational and emotional support from peers and health care providers,35 others including 291 Kennedy et al. did not find any significant differences in social support measures, and their 292 participants wanted to have private time with the health care provider.36 In this study, although 293 adjusted linear regression analysis did not show any significant difference between the two 294 groups in terms of the subscale of support and assurance from others, there was a significant 295 difference between the two groups based on dependent t-test analysis. In the present study, it 296 seems that GPNC can promote the feeling of receiving support and approval from others. 297 298 According to the findings of this study, after intervention, the total empowerment score was 299 significantly improved in the GPNC group compared to the IPNC group. In other words, 300 compared with IPNC, GPNC has a greater effect on adolescent pregnancy empowerment. This 301 result was supported by El Sayed et.al who showed a positive effect of GPNC on pregnant 302 empowerment.37Additionally, the study by McKinnon et al. found that GPNC improved 303 empowerment in pregnant women.16 Trudnak suggested that women in GPNC received more 304 11 education and support and were more empowered to make decisions about their pregnancy and 305 childbirth. 38 On the contrary, Somji et al. found no differences between GPNC and IPNC groups 306 in terms of empowerment.23The difference between their study and the current study could be 307 attributed to the instrument used to measure pregnant women’s empowerment. 308 309 Strengths and limitations of the study 310 This is the first study to evaluate the effect of group prenatal care on adolescent pregnancy 311 empowerment in Iran. Despite its strengths, this study has some limitations. First, the 312 participants could not be blinded to the study condition. However, we used randomization to 313 minimize bias, and the women did not know their grouping before the commencement of the 314 study. Second, most of the participants in this study were from low-income families in Ahvaz 315 city, and this may affect the generalizability of the results. Third, the involvement of the 316 researcher in conducting the group discussion may be a source of bias. 317 318 Conclusion 319 Group prenatal care can improve adolescent pregnant women’s empowerment. Results of the 320 present study can serve as a useful foundation for implementing the group prenatal care model in 321 Iran. 322 323 Author’s Contribution 324 FM, PA, MI and ElM were involved in the design of the study. FM collected the data. FM, NS, 325 PA, ElM, and EeM contributed to data analysis and interpretation. PA and FM prepared the 326 manuscript. All authors read and approved the final manuscript. 327 328 Acknowledgments 329 This study was a part of PhD dissertation of Midwifery and is a part of a larger mixed method 330 study on the effect of group prenatal care on pregnancy outcomes, a mixed method study. The 331 authors would like to thank the Research Deputy of Ahvaz Jundishapur University of Medical 332 Sciences. Also, we would like to thank all the women who participated in this study. 333 334 12 Conflicts of Interest 335 The authors declare no conflicts of interest. 336 337 Funding 338 This study was supported by Ahvaz Jundishapur University of Medical Sciences (Grant No: 339 RHPRC-0014). 340 341 References 342 1. Mann L, Bateson D, Black KI: Teenage pregnancy. Aust. J. Gen. Pract 2020, 49(6):310-316. 343 DOI: 10.31128/AJGP-02-20-5224 344 2. 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Trudnak TE: A comparison of Latina women in CenteringPregnancy and individual prenatal 450 care: University of South Florida; 2011. 451 https://doi.org/10.12765/CPoS-2022-02 https://doi.org/10.12765/CPoS-2022-02 https://doi.org/10.1111/hir.12200 https://dx.doi.org/10.5812/semj.70685 https://doi.org/10.1089/whr.2020.0113 https://doi.org/10.1371/journal.pone.0218169 https://doi.org/10.7205/MILMED-D-10-00394 16 452 Figure 1: Flow diagram of recruitment and retention of participants in the study. 453 454 Assessed for eligibility (n = 530) Eligible women giving consent randomized (n = 294) Allocated to control group (n = 147) Follow-up (n = 145) Moved away (n = 1) Intra uterine fetal death (n = 1) Analyzed (n = 145) Allocated to intervention group (n = 147) Follow-up (n = 144) Moved away (n = 1) Not attending group care sessions (n = 2) Analyzed (n = 144) Excluded (n = 236) Not meeting inclusion criteria (n = 220) Declined to participate (n = 16) E n ro lm e n t A ll o c a ti o n F o ll o w -u p A n a ly si s 17 Table 1: Topics discussed in group prenatal care sessions. 455 Sessions Content First 16 to 20 wk Danger signs in pregnancy, dental hygiene, discomforts and common complaints of pregnancy, nutrition, and supplement. Second 24 to 30 wk Mental health, sexuality Third 31 to 34 wk Childbirth and the benefits of natural childbirth, how to check fetal movement. Fourth 35 to 37 wk Preparation for childbirth, breastfeeding, neonatal care Fifth 38 wk labor symptoms, the right time for the next pregnancy 456 18 Table 2: Socio-demographic characteristics of the participants in GPNC and IPNC groups 457 Variables GPNC n=147 IPNC n=147 P value Mean ± SD * or N (%) Age (y) 17.42±1.31 17.40±1.28 0.858 Gravidity 0.064 1 138(93.9) 135(91.8) 2 9(6.1) 12(8.2) BMI at base line(kg/m2) 22.48±2.51 22.50±2.31 0.857 Education 0.769 Primary 24(16.6) 21(14.3) High school 100(68) 102(69.4) High school diploma 24(16.3) 23(15.6) Economic status 0.656 Good 37(25.1) 42(28.6) Moderate 72(49) 70(47.6) Poor 38(25.9) 35(23.8) Occupation 0.498 Housewife 145(98.6) 147(100) Employee 2(1.4) 0(0) Family support 0.526 Very good 124(84.4) 121(82.3) Good 22(15) 25(17) Fair 0(0) 1(7) Inappropriate 1(0.7) 0(0) Extended family 0.48 Yes 118(80.3) 112(76.2) No 29(19.7) 35(23.8) * Standard deviation 458 459 19 Table 3: The scores of total empowerment and its dimensions in the GPNC and IPNC groups. 460 Variables Groups P- value β * CI ** 95% GPNC n=147 IPNC n=147 Mean ±SD Self‐efficacy Before 14.65±1.95 14.72±1.58 0.997 After 18.21±2.12 16.19±1.79 <0.0001 2.52 (2.19, 2.86) Future image Before 18.12±1.68 18.09±1.66 0.824 After 19.57±1.57 18.95±1.54 <0.0001 0.67 (0.44, 0.9) Self‐esteem Before 20.94±1.66 20.63±1.75 0.069 After 21.79±1.75 20.90±1.85 <0.0001 0.69 (0.41, 0.97) Joy of an addition to the family Before 12.36±1.28 12.34±1.22 0.986 After 13.13±1.69 12.84±1.40 0.009 0.51 (0.28, 0.74) Support and assurance from others Before 12.16±1.30 12.28±1.21 0.394 After 13.70±1.1 13.04±1.07 <0.0001 0.76 (0.13, 1.65) Total score of empowerment Before 78.29 ± 3.81 78.07 ± 1.20 0.579 After 86.46±4.95 81.89±4.75 <0.0001 6.11 (4.89, 7.33) *Estimating the regression coefficient; **Confidence interval 461