 also no participation in birth and parent preparation was more frequent in the control group than among participants in the intervention group. We examined the impact of the concomitant education by excluding women that participated in other education and found that this exclusion did not alter our results noticeably. We hypothesised that the NEWBORN programme would increase childbirth self-efficacy and by this reduce the use of pain relief. We have examined the effect of the programme on the intermediate trial outcome; childbirth self-efficacy measured by three single items developed for the NEWBORN trial. In the intervention group, 4.1% of the women had low confidence in their own ability to cope with early phase of labour before going to the labour ward compared with 8.0% in the control group. Fewer women in the intervention group (5.0%) felt low confidence in their own ability to handle the birth process no matter how it turns out compared with the control group (7.4%). 42 Hence, these results suggest that although the intervention had no effect on the epidural analgesia, the programme may have the potential to enhance the women's childbirth selfefficacy. Former studies have found that women with higher levels of self-efficacy perceive pain as less intensive 17 and use less epidural analgesia during labour 18 compared with women with lower levels of self-efficacy. The potential associations between childbirth selfefficacy and experience of pain and use of epidural analgesia have not been investigated in the present study.
Only three randomised trials have examined the effect of attending antenatal education in small groups compared with other forms of education on outcomes, such as the use of pain relief or obstetric interventions. 19 24 25 Two of these trials were performed among women screened positive for fear of childbirth limiting generalisation of results to the general population. 24 25 One former Danish trial 19 examined the effect of antenatal education classes versus no education among 1193 primiparous women recruited among a diverse population group not limited to a high-risk population. This trial by Maimburg et al 19 is comparable to our NEWBORN trial regarding the included population, but they compared small classes versus no intervention. Maimburg et al 19 reported a statistically significant reduced use of epidural analgesia in their experimental group, but not of other types of pain relief and obstetric interventions. The two trials differ regarding the control intervention and we included primiparous and multiparous women, whereas Maimburg et al only included primiparous. Furthermore, we used 25 voluntary midwives with varying teaching experience, whereas in the trial by Maimburg et al classes were taught by four selected midwives. Also, the midwives in the Maimburg trial may have gained more teaching experience during the trial period compared with the midwives in the NEWBORN trial, as some of the midwives in our trial taught only a few classes.

Strengths and limitations
This randomised trial is to our knowledge the largest trial assessing the effect of antenatal education in small classes versus auditorium-based lectures. The intervention was developed using a systematic framework for health promotion programme planners. 29 This systematic framework aids effective decision-making at each step in intervention planning, implementation and evaluation. We focused on conducting a trial using standard care as control condition and tested a birth and parent preparation programme that would be feasible to implement in an everyday clinical practice setting if proven effective. We chose a control condition that is relevant to public health; standard care instead of a different antenatal intervention, and the study population was recruited among a diverse population group and not limited to a high-risk population. The attrition was low (3%) and distributed evenly between the intervention and control groups. It was not possible to blind participants or educators which may introduce bias. However, using an objective primary outcome, such as epidural analgesia, reduces the risk of bias due to lack of blinding. 43 44 The outcome assessors, midwives at the labour ward, were not informed about the women's participation in the trial but it cannot be ruled out that the women informed the midwife about their intervention status. However, we consider it unlikely that the decision to provide pain relief or perform obstetric interventions rely on the intervention status as such decisions are made by the midwives and physicians at the labour ward.
Initially, only primiparous women were eligible for inclusion in the trial. During the recruitment period, we allowed for inclusion of multiparous women. This was carried out for practical reasons to ensure adequate power in the analyses. Although this change was reported to the clinical trial register, the posterior inclusion of multiparous women must be considered a limitation.
Of the 8997 pregnant women invited to participate in the trial, only 19.6% were accepted and were randomised. Although we aimed to recruit a diverse population group to the NEWBORN trial, the participants were predominantly primiparous women and women with a higher education level compared to the general population of Copenhagen women in the same age group. 45 The high proportion of women with a university education in the trial population may imply that the women included in the trial find this teaching form more appealing than the general population. Moreover, the proportion receiving pain relief and obstetric interventions (except elective caesarean section) were higher among the trial population than among the total population of women giving birth at Hvidovre Hospital. 46 These discrepancies between the trial population and background population characteristics may limit the generalisability of the trial results, and the intervention might have different effects among multiparous or women of a lower educational level. It may be beneficial to conduct research focusing on the effect of the programme among subgroups, for example, women with lower educational level or vulnerable women. Also, further analyses taking adherence to the programme into consideration would contribute with more thorough knowledge of the impact of the programme. These issues need to be investigated before recommendation of implementation of the programme in clinical practice can be validly expressed.

CONCLUSIONS
The results from the NEWBORN trial showed no difference in use of epidural analgesia, other types of pain relief during labour, or obstetric interventions between women randomised to antenatal education in small classes versus standard lectures. The effects of the intervention on the secondary outcomes of the NEWBORN trial: perceived stress, parenting stress, and parenting alliance will be reported in later articles. the NEWBORN trial as well as the NEWBORN Trial Group 26 involved in the trial. They thank the Danish Cancer Society for funding of the trial. Moreover, they also thank Janus Engstrøm, Copenhagen Trial Unit, for development of the randomisation system and provision of allocation sequence; Steen Christian Rasmussen, Hvidovre Hospital, for extraction of data from the Obstetric Database and Bjarne Laursen, National Institute of Public Health, for valuable help with data management.
Contributors CSB, SFA, PD and VK developed the study design in collaboration with TW, JL and CG. PW wrote the statistical analysis plan. CSB, SFA and VK collected the data. CSB and LCT conducted the statistical analyses. CSB drafted the manuscript. All authors have been involved with interpretation of results, critical revision of the manuscript and final approval of the submitted manuscript.
Funding This work was supported by the Danish Cancer Society. The funders have not been involved in trial design, data collection and analysis, or decision to publish this manuscript.
Competing interests None declared. Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The authors commit to making the relevant anonymised patient-level data available on reasonable request. Please contact the corresponding author.
Open Access This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work noncommercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http:// creativecommons.org/licenses/by-nc/4.0/The Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) is positioning itself to be a major food producer for the Philippines in the future.
A recent virtual conference “Planting the Right Seeds: Agricultural Investment Opportunities in BARMM during this Pandemic” showcased the state of the agricultural sector in terms of food security and the future of the agricultural sector in BARMM.
“As an agricultural country in the midst of an uncertain pandemic, it is crucial that the value of locally-produced crops is understood. Besides, a portion of the food that people partake come from these crops. And while it is typical to look at this from an investment standpoint, a paramount issue would be sustaining peace in Mindanao, especially in BARMM, through building sustainable communities. This will involve introducing BARMM to the business community in other parts of the country to showcase BARMM’s potential to integrate in the agricultural supply chain,” said Antonio Peralta, chairman of the European Chamber of Commerce of the Philippines-Southern Mindanao Business Council (ECCP-SMBC) via Messenger.
The conference provided new opportunities to re-orient the food systems. The speakers focused on the areas of growth and the investment opportunities in agriculture in BARMM and the role of the major international food companies in the program was also presented that will be implemented in the coming year.
The activity was highlighted with the signing of partnerships of companies with the Bangsamoro Development Agency (BDA), which was tasked by the BARMM Government in helping rural communities, especially former Moro Islamic Liberation Front (MILF) Camps’ transformation to productive farms showcasing new farming technologies that can help improve farm outputs.
Six deals were inked through a Memorandum of Understanding (MOU) from the ECCP SMBC that will benefit the BARMM area: BDA and Marine Algae Products Inc.