Midwife-Led, Synchronous, Online Antenatal Education, Childbirth Self-Efficacy, and Prenatal Maternal–Fetal Attachment Among Nulliparous Women in Saudi Arabia: A Quasi-Experimental Study

Background/Objectives: Childbirth self-efficacy and prenatal maternal–fetal attachment are important dimensions of psychological adaptation during pregnancy. Evidence regarding midwife-led, synchronous, online antenatal education that simultaneously addresses childbirth confidence and prenatal bonding in Saudi Arabia is limited. This study assessed whether structured online antenatal education was associated with greater childbirth self-efficacy and prenatal maternal–fetal attachment than routine antenatal care among nulliparous Saudi women. Methods: This quasi-experimental, nonequivalent control group pretest/posttest study was conducted at King Khalid University Hospital, Riyadh, Saudi Arabia, between April and July 2026. Allocation was nonrandom and sequential to reduce contamination: controls were recruited first, then intervention participants. The analytic sample included 127 women (intervention group, n = 64; control group, n = 63). The intervention comprised two 60–90-min midwife-led synchronous Zoom sessions integrating childbirth preparation, coping skills practice, woman-centered communication, and prenatal bonding activities. Outcomes were assessed using the Arabic Childbirth Self-Efficacy Inventory (CBSEI) Part II and revised 25-item Arabic Prenatal Attachment Inventory (PAI). Primary analyses compared individual pretest-to-posttest change scores between groups using two-sided Welch independent-samples t tests. A post hoc multiple-imputation adjusted GEE analysis examined whether these differences were similar when repeated observations and measured covariates were modeled. Results: Baseline PAI scores were comparable between groups, whereas baseline CBSEI Part II scores were higher in the intervention group. The primary change-score analyses showed greater improvement in the intervention group, with between-group differences in mean change of 21.15 points for PAI (95% CI: 18.42–23.87; p < 0.001) and 102.54 points for CBSEI Part II (95% CI: 82.88–122.19; p < 0.001). Post hoc adjusted GEE estimates were 21.33 points for PAI (95% CI: 18.54–24.12; p < 0.001) and 103.37 points for CBSEI Part II (95% CI: 82.93–123.81; p < 0.001). Conclusions: This approach was associated with greater short-term improvements in self-reported childbirth self-efficacy and prenatal attachment. Effects on actual behavior during labor and maternal or neonatal clinical outcomes were not assessed and remain unknown.