Pregnant Women’s Knowledge Regarding the Practice of Antenatal Perineal Massage

Abstract

This study aimed to assess pregnant women’s knowledge regarding the benefits and practice of antenatal perineal massage (APM) and their acceptance of APM. A descriptive cross-sectional correlation design was applied to a convenience sample of 104 pregnant women who completed an online questionnaire. The online questionnaire was divided into four categories: (1) sociodemographic and obstetric history and general information about APM, (2) knowledge regarding the benefits of APM, (3) knowledge regarding the practice of APM, and (4) acceptance of APM. Data analysis was performed in SPSS v.26. Frequencies and percentages were taken from all qualitative variables. Most pregnant women had good knowledge: 78.8% had knowledge regarding the benefits of APM, 85.6% had knowledge regarding the practice of APM, and 54.8% reported acceptance of APM. There was a significant correlation between knowledge and practice of APM, indicating that a higher knowledge level leads to good practice of APM. This study highlighted participants’ significantly high amount of knowledge regarding the benefits and practice of APM. Additionally, based on the percentage of participants who had not heard about APM, the study revealed the failure of health-care providers to provide education regarding APM to pregnant women. Further research is needed to establish interventions that improve knowledge and encourage APM practice among pregnant women.

1. Introduction

Perineal trauma is common during vaginal delivery, especially for primipara mothers [1]. Routine episiotomies are no longer advised because of a lack of concrete, empirical evidence establishing any benefits of their use [2]. Incidences of perineal trauma are around 84.3% in primiparous women and around 43.9% in multiparous women [1]. A recent systematic review showed antenatal perineal massage’s APM effectiveness in reducing the risk of trauma and decreasing the use of episiotomy [3]. Moreover, conducting discussions with pregnant women during the antenatal period about methods such as APM and Kegel exercises can help reduce factors that lead to perineal trauma, increase the likelihood of maintaining an intact perineum or experiencing first-degree tear, and decrease the rate of episiotomies and their associated complications [4].

APM is a classic massage technique that ensures comprehensive health for the perineum and improves the perineal muscles’ elasticity and quality [5]. It is a technique that pregnant women or their spouses perform daily for 5–10 min with or without lubricants, starting from 34 weeks of gestation [5]. Its purpose is to prepare the perineal area for the natural birth process by stretching the muscles and promoting blood circulation in the area. This reduces the chances of needing an episiotomy and decreases the rate of discomfort associated with perineal trauma after childbirth [6,7]. Further, performing APM properly promotes women’s mental, physical, and psychological health by minimizing postpartum complications and perineal trauma [5].

A recent study noted that one out of four women have intact perinea after vaginal delivery, and perineal trauma is more common in women experiencing natural vaginal delivery for the first time [4]. Moreover, morbidity rates increase with perineal trauma (mainly when third- or fourth-degree tears occur) because of increased risk for wound disruption, stress or urge urinary incontinence, infection, delayed wound healing, postpartum dyspareunia, pelvic organ prolapse, and rectovaginal fistulas [5].

Women with perineal trauma are more likely to experience complications such as infections, stool incontinence, perineal and vaginal discomfort, and impaired sexual function; in the long run, they may struggle to meet their families’ needs [8]. A systematic review revealed that APM offers numerous advantages to women during labor and the postpartum period, including a reduced incidence of perineal injuries and discomfort. Nevertheless, it is evident that the duration of massage, the period and frequency of its performance, and the method of obtaining instruction and patient control vary among individual publications [3].

Antenatal education and instruction about APM could result in an intact perineum or the presence of only minor lacerations [4]. A recent meta-analysis showed the benefits of using APM, such as an increased sense of control during labor and delivery of the head; improved collaboration between midwives and mothers during the time of birth; reduced postpartum morbidity rates; reduced use of episiotomy, which is a leading cause of extended lacerations; and finally, decreased fecal incontinence and coital pain [4,5].

It is crucial to determine the level of patients’ awareness regarding antenatal perineal massage, given the clinical advantages of this procedure for patients who undergo vaginal childbirth. The knowledge, attitude, and acceptability of expectant women regarding antenatal perineal massage have been the subject of only a few international studies, including those from the United Kingdom [9], Thailand [10], and Brazil [11]. However, research on pregnant women’s knowledge and practice of APM in Arab societies is still lacking. Measuring the knowledge level and acceptance of APM among pregnant women can help establish a baseline to increase APM’s use and limit short- and long-term consequences of perineal trauma and episiotomy on women’s lives [5]. The current study aimed to assess pregnant women’s knowledge regarding the benefits and practice of APM and their acceptance of APM.

2. Results

A total of 104 pregnant women completed the survey. Regarding participants’ sociodemographic data, the vast majority of them (n = 98, 94.2%) lived in cities, whereas only a small portion (n = 6, 5.8%) lived in rural areas. Participants were split into three age groups: the majority were 30–35 years old (n = 41, 39.4%), followed by those who were 20–25 years old (n = 35, 33.7%), and 35 years old and over (n = 17, 16.3%). Furthermore, the majority (n = 93, 89.1%) of participants had a university education or more, whereas a small number of them (n = 8, 7.9%) had just a secondary school education. Next, (n = 53, 51%) of the participants were housewives, whereas (n = 51, 49%) were employed; and (n = 65, 62.5%) of the participants had 1–4 children, whereas (n = 33, 31.7%) did not have children.

Table 1. Participants’ obstetric history (N = 104).

Obstetric History	Number	Percentage (%)
Current gestational age
First trimester	23	22.2
Second trimester	25	24
Third trimester	56	53.8
Gravida
Primigravida	42	40.4
Two pregnancies	26	25
Three pregnancies	21	20.2
Four and more pregnancies	15	14.4
Para
Nullipara	31	29.8
Primipara	31	29.8
Two deliveries	19	18.3
Three deliveries	11	10.6
Four or more deliveries	12	11.5
Living children
No living children	31	31.3
One	30	31.3
Two	19	14.4
Three	12	11.5
Four or more	12	11.5
Abortion
None	81	78.2
One	16	15.8
Two	6	5.0
Three	1	1.0

shows the participants’ obstetric history.

We asked participants about their knowledge of perineal massage. According to the results, (n = 94, 90.4%) participants knew the correct anatomical location of the perineum, whereas only (n = 10, 9.6%) did not. Moreover, the majority of the participants (n = 100, 96.2%) thought it was important to massage the perineum before childbirth, whereas only (n = 4, 3.8%) did not.

Concerning participants’ knowledge regarding the benefits of APM, the mean score was (M = 26.03, SD = 3.22). This indicated that participants’ knowledge level regarding the benefits of APM was high. This knowledge was further divided into three categories (Figure 1). The results in the

Table 2. Knowledge regarding the benefits of antenatal perineal massage.

Phrase		Responses			Mean	Standard Deviation
		No	Do Not Know	Yes
Minimizes the perineal shearing procedure during childbirth.	Count	16	21	67	2.490	0.750
	%	15.4%	20.2%	64.4%
Strengthens the pelvic floor muscles.	Count	3	18	83	2.769	0.487
	%	2.9%	17.3%	79.8%
Reduces perineal pain after childbirth.	Count	8	40	56	2.462	0.637
	%	7.7%	38.5%	53.8%
Helps reduce fecal incontinence after childbirth.	Count	4	29	71	2.644	0.556
	%	3.8%	27.9%	68.3%
It improves blood circulation in the pelvic floor muscles.	Count	5	32	67	2.596	0.583
	%	4.8%	30.8%	64.4%
Helps tighten pelvic floor tissues and skin.	Count	4	25	75	2.683	0.544
	%	3.8%	24.0%	72.1%
Allows women to relax the pelvic floor muscles.	Count	3	9	92	2.856	0.428
	%	2.9%	8.7%	88.5%
Prevents perineal lacerations	Count	9	26	69	2.577	0.649
	%	8.7%	25.0%	66.3%
Speeds up the birth process.	Count	19	37	48	2.279	0.756
	%	18.3%	35.6%	46.2%
Positively affects the condition of the newborn baby.	Count	5	23	76	2.683	0.562
	%	4.8%	22.1%	73.1%
Total			Min.	Max.	Mean	SD
			18.0	30.0	26.039	3.230

indicated that participants’ knowledge level regarding the benefits of APM was high (78.8%).

2.1. Participants’ Knowledge Regarding Correct APM Practice

The results (

Table 3. Knowledge regarding the practice of antenatal perineal massage before childbirth.

Phrase		Responses			Mean	SD
		No	Do Not Know	Yes
Prenatal massage of the perineum begins in the middle of the eighth month (the week) of pregnancy.	Count	30	18	56	2.250	0.879
	%	28.8%	17.3%	53.8%
Consultation with a doctor or midwife should be sought before beginning perineal massage.	Count	1	16	87	2.827	0.405
	%	1.0%	15.4%	83.7%
You must make sure that there is no fungal or bacterial infection before you start the perineal massage.	Count	0	6	98	2.942	0.234
	%	0	5.8%	94.2%
It is important to wash hands and trim nails before you start massaging the perineum area.	Count	3	8	93	2.865	0.419
	%	2.9%	7.7%	89.4%
Hands can be moistened with lubricating gel or natural (organic) oils before beginning the massage.	Count	49	25	30	1.817	0.856
	%	47.1%	24.0%	28.8%
Is it possible to use (baby oil, mineral oil, or petroleum jelly) to massage the perineum area?	Count	3	22	79	2.731	0.507
	%	2.9%	21.2%	76.0%
Begin massaging the perineum by placing one or two thumbs into the vagina and then pressing down (toward the anus) and to the sides until a stretch is felt.	Count	2	34	68	2.635	0.522
	%	1.9%	32.7%	65.4%
The perineal area massage is repeated once a day, at a rate of times a week.	Count	3	26	75	2.692	0.523
	%	2.9%	25.0%	72.1%
The massage lasts −0 min each time.	Count	17	11	76	2.567	0.760
	%	16.3%	10.6%	73.1%
Total			Min.	Max.	Mean	SD
			17.00	27.00	23.327	2.540

) indicated that knowledge of practice had a mean of (M = 23.326, SD = 2.540). These results indicated participants’ high knowledge level about the practice of APM. Knowledge level regarding the practice of APM was further divided into three categories (Figure 1), indicating that participants’ knowledge level regarding the practice of APM before childbirth was high (85.6%).

2.2. Acceptance of APM

The results revealed that participants’ acceptance had a mean of (M = 11.904, SD = 1.793), which was moderate (

Table 4. Participants’ acceptance of APM.

Phrase		Responses			Mean	Standard Deviation
		No	Do Not Know	Yes
I accept perineal massage before delivery.	Count	72	5	27	1.57	0.88
	%	69.2%	4.8%	26.0%
I have massaged the perineum before delivery during previous pregnancies.	Count	11	16	77	2.63	0.67
	%	10.6%	15.4%	74.0%
I will do a perineal massage in my current pregnancy.	Count	67	8	29	1.63	0.89
	%	64.4%	7.7%	27.9%
I feel awkward while massaging my perineum before delivery.	Count	48	13	43	1.95	0.93
	%	46.2%	12.5%	41.3%
I accept my husband’s help in doing a perineal massage before giving birth.	Count	3	26	75	2.69	0.52
	%	2.9%	25.0%	72.1%
Total			Min.	Max.	Mean	SD
			8.00	17.00	11.904	1.793

). To determine the level of acceptance of APM, the responses were divided into three categories. The results indicated that the level of APM was medium, with a percentage of 54.8%. The results showed that 69.2% of participants did not accept APM. Meanwhile, 74% had massaged the perineum during previous deliveries, and 72.1% had accepted their husbands’ help in practicing APM before giving birth (Figure 1).

2.3. Correlation Between Knowledge Regarding Benefits and Practices and Acceptance Factors

Significant results were found regarding the relationships among variables. For example, the results (B = 0.46, p < 0.001) showed a medium positive correlation between participants’ knowledge of the benefits and practice of APM before birth. The value of the determination coefficient indicated that knowledge contributed to 22.1% of the interpretation of the variance in practice. The results also indicated that every change in knowledge by the number of units led to a change in practice of 0.36 units. In contrast, there were no significant correlations among knowledge regarding APM’s benefits, knowledge regarding APM’s practice, and APM’s acceptance (

Table 5. Correlations among variables.

Correlations Among Variables	Pearson Correlation	p-Value
Knowledge regarding benefits and practice of APM	0.46 **	<0.001
Knowledge regarding practice and acceptance of APM	0.08	0.45
Acceptance and knowledge regarding benefits of APM	0.12	0.21

** Significant.

and

Table 6. The effect of knowledge regarding the practice of APM before childbirth.

Model		Unstandardized Coefficients		Standardized Coefficients	T	Sig.
		B	Std. Error	Beta
1	(Constant)	13.93	1.82		7.66	0.000 **
	Knowledge regarding the benefits of APM	0.361	0.07	0.46	5.21	0.000 **

R = 0.459, R² = 0.221, F = 27.198, ** Significant at 0.01.

).

3. Discussion

3.1. Sociodemographic Characteristics of Participants

In the current study, 104 participants completed an online questionnaire. The results concerning sociodemographic data were consistent with those of other studies in the literature. Regarding the places of residence of participants [12], we obtained almost similar findings. However, the results showed that many participants were from urban areas. The participant recruitment and data collection methods used could be behind this result.

Regarding age groups and education levels, Metwally and Attas (2020) conducted a study in Saudi Arabia exploring mothers’ awareness and acceptance of APM [13]. Their participants were aged 33 on average, almost corresponding to the participant ages in the current study. Al-Rowais et al.’s and Alharbi’s participants were in a similar age group and at a similar education level as the current study’s participants [14,15]. They were also similar in regard to occupation. However, only Al-Jaradi et al.’s study conducted in Sana’a, Yemen, had participants who had achieved a secondary level of education [12]. This difference was probably due to the fact that Al-Jaradi et al.’s study was conducted during wartime [12].

Regarding occupation status, Batumalai et al. (2020) conducted a study in the city of Kuala Lumpur, Malaysia, about the effectiveness of APM [16]. The percentage of working people in the study was 63–78%. This was in contrast to Dieb et al.’s (2019) study conducted in Egypt, where the majority of participants were housewives [17]. This disparity in results could be attributable to the Egyptian and Saudi communities’ various cultures, economic structures, and career opportunities. Women and families’ perspectives are also important. Families encourage wives and female family members to study and work rather than stay at home in Saudi Arabia, in line with the vision of women becoming an integral part of Saudi society in the future [18]. The percentage of working women in the current study showed an almost equal split between employed women and housewives.

3.2. Participants’ Obstetric History

Obstetric history explores current and previous pregnancy. More than half of the participants in this study were in the third trimester. Participants with one child came first, followed by those with no children. Three-quarters of the participants did not have a history of abortion. This indicates that the primipara and para one groups focused on improving their knowledge regarding their health.

Regarding the state of the perineum in prior deliveries, the results showed that episiotomy was the most common perineal status after delivery (37.6%), whereas tears were the least common (4%). In contrast, Metwally and Attas (2020) found that tears were present in 47.6% of participants [13]. This discrepancy in the results could be related to participant differences: pregnant women in the current study were primigravida and primipara (32.7% of the total); therefore, they were the most susceptible to having an episiotomy.

3.3. Participants’ Sources of Information About APM

In this study, participants’ sources of information on APM were investigated. Half of the participants learned about APM through social media, 21.8% learned about it through the internet, and 15.8% learned about it from health-care providers. Meanwhile, Metwally and Attas (2020) found that the majority of their participants learned about APM from television and the media, and only 3.5% learned about it from health-care providers [13]. In another study, a higher score for learning Kegel exercises was reported for the media, followed by family and friends, and health-care providers [15].

Moreover, in a study conducted in Tokyo, Japan, participants commented on how useful websites were for learning about APM [19]. A systematic review showed that pregnant women used the internet to seek information about their pregnancy [20]. This commonality regarding using social media and the internet to obtain information about a certain topic could indicate that pregnant women from different countries and cultures trust, and find it simple to obtain information from, websites and media. Meanwhile, doctors and nurses play a small role in delivering post-event information to women regarding APM. This may increase the risk of pregnant women facing complications because the internet and social media can contain untrustworthy information. The findings of another systematic study highlighted the relevance of encouraging health-care providers to advise pregnant women to start APM at 34 weeks.

A study conducted in Baruah village on 92 pregnant women in the third trimester demonstrated that pregnant women who received counseling from a health-care provider had high awareness of APM. This variance could be due to the fact that the study was conducted in a small village with a population of 4500 individuals, allowing beneficiaries quick access to care [21].

3.4. Participants’ Previous Knowledge Regarding APM

The current study showed that most participants (57%) had never heard about APM before. Metwally and Attas (2020) showed that 69% of participants had not heard about APM [13]. Moreover, Takeuchi and Horiuchi analyzed the feasibility of using a smartphone app to support APM in pregnant women. The results indicated that some pregnant women had heard about APM for the first time through the app [19]. Another recent study shows similar results that 46.25% Saudi women were hearing about APM for the first time [22]. A lower percentage of pregnant women had heard about APM in Saudi studies, indicating the need to continuously raise awareness of APM among pregnant women in Saudi Arabia.

3.5. Participants’ Knowledge Regarding Perineal Massage

Each participant who completed the questionnaire had knowledge of APM, and 90% of them demonstrated where the perineum area was located. Furthermore, more than three-quarters of the participants thought that perineal massage is important before delivery. This is in line with Veverková et al. (2017), who examined pregnant women’s awareness of primary and secondary prevention of childbirth trauma [23]. That study found that the level of awareness was high, but the practice of APM was low. Further, the study showed that perineum massage was a widely used method by 29% of participants. Compared with Okeke et al. (2020) [24], the majority (71%) of participants in Veverková et al.’s (2017) study had heard about Kegel exercise, and 38% had practiced them [23]. Alharbi (2019) demonstrated that most of the participants correctly defined Kegel exercises, similar to the current study’s findings regarding the definition of APM and the perineal area [15]. Regarding the posture of APM, no results were found in comparison with those of our study. Similarly, poor knowledge (84.17% women) was demonstrated in another Saudi study [22].

3.6. Knowledge Regarding the Benefits of APM

The current study reported high participant knowledge regarding the benefits of APM (78.8%). This was almost consistent with Alharbi (2019), who found that 62.7% of participants had knowledge of the benefits of Kegel exercises [15]. Al-Rowais et al. (2020), who examined knowledge of antenatal exercise among 384 pregnant women, showed that the total mean score regarding knowledge of APM’s benefits was high (1741 and SD = 0.297), with a weighted mean score from 0 to 2 [14].

In the present study, 90% of participants agreed that APM minimizes various types of perineal damage during labor. Again, the findings were similar to those of a study conducted in Saudi Arabia by Metwally and Attas [12], in which more than half of the participants said that APM helped reduce fecal incontinence and strengthen and tighten their pelvic floor tissue and skin in the postpartum period. These results were also similar to those in other studies [14,15,24] that identified the benefits of Kegel exercises for preventing incontinence and strengthening pelvic floor muscles.

Most of the participants in the current study knew about the benefits of APM, consistent with previous research that found that women understood these benefits. Half of the participants were aware that APM reduces fecal incontinence and improves the condition of newborn babies. Likewise, most participants stated that APM improves blood circulation in the pelvic floor area, increases pelvic floor muscle strength, and aids in the delivery process. This indicates that the internet and social media provide such information clearly. Health education groups and health-care providers should be encouraged to promote the use of media and websites to raise awareness and prevent misunderstandings or misconceptions.

Further research could explore the potential benefits of incorporating perineal massage into rehabilitation programs for various female health issues beyond just childbirth. By educating women on the importance and effectiveness of perineal massage, health-care providers could help overcome any reluctance or lack of knowledge that may currently exist. Additionally, considering the success of self-massage in other areas, such as the abdomen for constipation, it seems logical to further investigate the potential benefits of self-performed perineal massage for women’s health [25,26].

3.7. Participants’ Knowledge Regarding the Practice of APM and Acceptance of APM

Our research showed that the average knowledge level with regard to the practice of APM was high among participants (85.6%). Likewise, another study demonstrated participants’ knowledge and awareness of health practices during pregnancy in Jeddah. More than 60% of participants had accurate knowledge of health practices during pregnancy [27].

More than half of the participants in our study correctly identified APM’s time, frequency, and duration. Furthermore, more than three-quarters of the participants correctly stated that they would seek advice before beginning APM to ensure there was no vaginal infection, would wash their hands, and would trim their nails. Meanwhile, Metwally and Attas [12] found that participants’ overall understanding of APM was minimal, with the majority of responses being “I do not know”. Ismail and Emery (2013) reported a low percentage of participants’ correct answers regarding time, frequency, and duration, which could be due to the different types of sample populations used in the study [9].

The current study noted that half of the participants agreed that hands should be lubricated with gel or organic oil, but they did not know that baby oil, petroleum gel, and mineral oil are contraindications for use in vaginal and perineal areas. This is consistent with the findings of Metwally and Attas [13], which showed that only 23% of participants knew oil could be used for perineal massage. Subsequent studies focused on websites and media sources that explained APM and mentioned safe and useful lubricant use.

A study in Bangkok, Thailand, evaluated the acceptability, attitudes, and knowledge of antenatal perineal massage among 22-week pregnant Thai women. Results showed 83% of participants had a positive attitude toward the practice, with 15% aware of its benefits. Reasons for declining massage included lack of knowledge, pregnancy difficulties, discomfort, perceived ineffectiveness, and previous successful deliveries. The study suggests routine explanation and presentation of the massage to pregnant women to reduce perineal injury and postpartum aftereffects [10].

A study by Gondim et al. found that 51% of Brazilian women had inadequate knowledge about pelvic floor muscle preparation (PFM) for labor. Only 4% participated in PFM training during pregnancy, and 4% were pursuing information on preventing perineal injury. The study highlights the need for health education on PFM care during and after pregnancy, especially for younger, low-educated, and low-salary pregnant women [11].

The present study showed that the level of acceptance among participants was medium compared to that in [13]. That study reported that around 38.1% of participants performed APM before delivery. This contrasted with Ismail and Emery, who showed a high percentage of acceptance among participants at 61.4%. This variation could be due to the different sample populations and study locations [9].

It is important to note that the questionnaire used in this study was specifically designed to assess pregnant women’s knowledge and acceptance of prenatal perineal massage, and did not include a validated scale to measure quality of life, pain, distress, or other related topics. This limitation should be acknowledged as it may have impacted on the overall findings of the study. In future research, it would be beneficial to incorporate validated scales to provide a more comprehensive evaluation of the effects of prenatal perineal massage on various aspects of pregnant women’s well-being. Other limitations of this study include difficulties in finding participants with previous knowledge about APM, missing data, and timeline constraints affecting the study. The low number of articles on the topic also limited the depth of analysis. Additionally, technical issues at the start of data collection impacted the study’s results. Despite these limitations, the study underscored the importance of tailored programs for women to increase awareness about APM health.

4. Materials and Methods

4.1. Study Design

A cross-sectional descriptive correlation study design was used.

4.2. Sample/Participants

Nonprobability convenience and snowballing sampling were used. Participants were recruited through an electronic questionnaire sent to groups of families, friends, and health-care providers on WhatsApp. They were asked to send the questionnaire to all the pregnant women they knew using different social media platforms. WhatsApp, Instagram, Snapchat, Facebook, Telegram, and so on were used to gather the largest possible number of participants who met the search criteria. The inclusion criteria include pregnant women aged 18 and above who were Arabic readers, Saudi residents, and speakers and who had heard of and/or performed APM before. These criteria ensure that participants can understand and follow instructions related to APM techniques during the study. Exclusion criteria for the study included pregnant women under the age of 18, those who were not fluent in Arabic, and individuals who had no prior knowledge or experience with APM.

Utilizing online Epi-info’s electronic calculator https://www.openepi.com/SampleSize/SSCohort.htm (accessed on 1 August 2021), the sample size was determined using the following criteria: the overall knowledge of women about APM was 41% in a recent [13], margin of error (σ2), p-value of 0.05, statistical power of 80%, and 95% confidence interval; the estimated sample size was 52. Missing data were compensated for by adding 10%, estimated to be pregnant women.

4.3. Recruitment and Data Collection Tool

The researcher developed a structured tool, which four experts in the field reviewed and modified. Data were collected using a self-administered electronic questionnaire. Participants had to first read the inclusion criteria before signing the formal consent form and then filling out the survey. The estimated time to complete the survey was around 3–5 min. Data were collected from December 2021 to March 2022.

The tool consisted of two sections (Supplementary Materials). The first section covered sociodemographic and obstetric history and had 24 questions: seven questions about demographic data; 12 obstetric questions such as number of pregnancies, number of deliveries, number of abortions, and status of perineal area after delivery; and five questions about general information on APM, including definitions of the perineal area and APM, participants’ opinion regarding the importance of APM, positions available to perform APM, and sources of information.

The second section assessed participants’ knowledge. It was divided into three parts and had closed-ended questions to be answered with “Yes”, “No”, or “I do not know”. The first part consisted of 10 items focusing on pregnant women’s knowledge regarding the benefits of prenatal perineal massage. The second part consisted of nine items focusing on pregnant women’s knowledge regarding the practice of APM. Finally, the third part focused on the extent to which pregnant women accept APM.

Each response to an item in the checklist was given a score of 3 for a correct answer, 2 for an “I do not know” answer, and 1 for a wrong answer.

For assessing knowledge regarding the benefits of APM, the score range was 10–30. The scores were categorized as follows: good knowledge, 24 or more (≥80%); moderate knowledge, 17–23 (56–79%); poor knowledge, 10–16 (≤55%).

For assessing knowledge regarding the practice of APM, the score range was 9–27. The scores were categorized as follows: high knowledge, 21 or more (≥80%); moderate knowledge, 15–20 (56–79%); low knowledge, 9–14 (≤55%).

For assessing knowledge regarding the practice of APM, the score range was 9–27. The scores were categorized as follows: high knowledge, 80% or more; moderate knowledge, 56–79%; low knowledge, ≤55%.

For assessing acceptance of APM, the score range was 5–15. The scores were categorized as follows: high acceptance, 11 or more (≥80%); moderate acceptance, 6–1 (56–79%); low acceptance, ≤5 (≤55%).

Four experts reviewed the questionnaire tool’s content and face validity. Four experts reviewed the questionnaire tool’s content and face validity. Overall, the experts found the questionnaire tool to be well designed and comprehensive in assessing the desired outcomes. They provided valuable feedback on areas for improvement, such as clarifying certain questions and adding additional response options. Their input was instrumental in refining the tool before it was implemented in the study. The questionnaire was first developed in English, and then back-to-back translations were made to ensure accuracy and clarity in other languages. The translation process involved bilingual experts who carefully reviewed each question to ensure cultural and linguistic appropriateness. This rigorous translation process will help ensure that the questionnaire maintains its validity and reliability across different languages and cultural contexts. Additionally, pilot testing was conducted with a diverse group of participants to further refine the tool and ensure its effectiveness in capturing the desired outcomes. Pilot testing included 29 subjects to ensure the tool’s validity and reliability. The participants in the pilot study were not included in the final sample. Overall, the meticulous attention to detail in developing and translating the questionnaire helped guarantee the success of the study and the accuracy of the data collected. The final version of the questionnaire was approved for use in the study, demonstrating its effectiveness in capturing the desired outcomes. The tool used for measurement was reliable as it consistently produced results within the range of 0.701–0.761 for each factor measured. This range was considered acceptable [28] and indicative of the questionnaire’s reliability. The total Cronbach’s alpha for all the questionnaire items was 0.728, which was also considered acceptable.

4.4. Data Analysis

Statistical analysis was conducted using the IBM Statistical Package of Social Sciences version 26. Descriptive statistical analysis techniques, including frequencies, means, standard deviations (SDs), and mean percentages, were used to describe the levels of participants’ knowledge regarding the benefits, knowledge of practice, and acceptance of APM. A Pearson correlation test was conducted to find correlations among knowledge regarding benefits, practice, and acceptance of APM. Parametric tests can be applied when the sample size is substantial, specifically greater than 100, as the central limit theorem suggests that a large sample size approximates normality [29]. Additionally, simple linear regression was performed to predict an effect of knowledge regarding the benefits of APM on knowledge regarding the practice of APM before childbirth. p-value ≤ 0.05 was considered significant in all tests.

5. Conclusions

According to recent research, APM during the antenatal period can help pregnant women manage their physical and psychological problems during labor and the postpartum period. A daily 5–10 min massage should be conducted with antepartum pregnant women from 34 weeks until delivery. Although APM is approved in Arab nations such as Egypt and Saudi Arabia, only a small number of women practice it during pregnancy.

Women’s understanding and acceptance of APM would have a direct impact on its use. Providing effective APM education to pregnant women during their antenatal periods, as well as promoting the practice of APM in the community, necessitates a thorough understanding of pregnant women’s attitudes toward APM.

It was concluded in light of the study findings that most women had adequate knowledge of APM. Furthermore, women obtained information on APM from a variety of sources, including social media and the internet. These were their primary sources of knowledge in addition to the literature, family, and friends as well as health-care providers in some cases.

The majority of the women in this study agreed that APM was beneficial, and no significant relationship was discovered between pregnant women’s awareness and practice and several of their demographic factors, such as age, level of education, place of residence, and occupation.

The results suggested the need to build and develop an antepartum nurse or educator role to monitor and assist in promoting APM practice in hospitals and primary health-care centers as well as to provide a hotline for antepartum women inquiries. For future research, we suggest measuring pre- and post-knowledge among pregnant women using various research methods