1 Antenatal classes
In the 1950s and 1960s in Europe and North America, ‘natural childbirth’ and ‘psychoprophylaxis’ began as alternatives to what was perceived as over-medicalized obstetrics, with its liberal use of painrelieving drugs and operative delivery. Many different programs appeared at about the same time, all with a single common aim: the use of psychological or physical, non-pharmaceutical modalities for the prevention of pain in childbirth.
Modern antenatal classes have expanded their horizons beyond that simple objective. Most classes today have additional goals including good health habits, stress management, anxiety reduction, enhancement of family relationships, feelings of empowerment, enhanced selfesteem and satisfaction, successful infant feeding, smooth postpartum adjustment, and advice on family planning. A major objective is to enhance the woman’s sense of confidence as she approaches childbirth.
Because of their complex, often disparate goals and ideologies, one cannot make general statements about the effects of antenatal classes as if they were a single entity. Research on the effectiveness of antenatal classes over the years reflects their changing emphasis. The early studies focused on the effects of class attendance on labor pain, use of medication, and other qualities of labor. Later the emphasis shifted to study of the psychological effects, parenting behaviors, and the effectiveness of specific teaching, counseling, or labor-coping techniques.
The information content of modern antenatal classes may include the relation of pregnancy symptoms to underlying mechanisms, and suggest ways of alleviating these symptoms. The emotional shifts of pregnancy may be explored, and issues of sexuality, and relations with the partner and other children may be discussed as well.
Antenatal classes allow an opportunity to review the mechanisms of labor and birth in adequate detail, and to explain medical and obstetrical terminology, as well as the use of tests, medications, and other interventions. Information need not come from the instructor alone. Discussion with other participants allows for the reassurance and sense of community that comes from sharing experience and information.
In addition to knowledge and information, most antenatal classes attempt to impart skills for coping with the stress and pain of labor. These often include a variety of physical and mental relaxation techniques, various forms of attention-focusing and distraction, controlled breathing patterns, the teaching of comfort measures and laborsupport skills to the birth partners of the pregnant woman, and discussions of both pharmacologic and non-pharmacologic methods of pain relief (see Chapter 34).
Finally, antenatal classes can be a vehicle for attitude modification. On the one hand they may foster increased self-reliance and questioning of professional routines and recommendations. On the other hand, they may lead towards increased acceptance of, and compliance with, prescribed medical regimens.
1.3 Effects of antenatal classes
Antenatal class attendance results in the use of significantly less painrelieving medication. A Canadian trial of antenatal classes with a special focus on changes in the marital relationship concluded that such classes may enhance marital adjustment post-birth; however the trial was too small to draw definitive conclusions. No other important effects of antenatal classes have been clearly demonstrated. Nonrandomized cohort studies have reported a variety of other beneficial effects of antenatal classes, but the self-selection of the study and control groups introduces such major biases that the results of these studies must be largely discounted.
There are few studies comparing the pain-relieving effects of different methods of childbirth preparation. Two methods that were popular in the 1960s and 1970s, Read’s natural childbirth and Lamaze’s psychoprophylaxis, have never been compared systematically. Because today’s antenatal educators learn from a variety of sources, they are less likely to identify themselves with a particular method. Thus it is unlikely that direct comparisons of alternative methods will be carried out.
The benefits of antenatal education are difficult to document in a systematic manner. The adverse effects and potential hazards are even more elusive. The extent to which fear is created rather than alleviated by classes, and whether women succumb to peer or educator pressures to conform, or to refuse needed medication or intervention, is completely unknown. There has been little systematic evaluation of the extent to which negative feelings of anger, guilt, or inadequacy are engendered when a woman’s or her partner’s expectations, possibly raised by the antenatal classes, are not met. There has been equally little evaluation of the potential hazards of classes that teach women to comply with their caregivers’ routines, without adequate information.
While in years past, antenatal classes appealed primarily to middleclass women or couples, they are now routinely offered free of charge or at low cost in many clinics, health departments, and schools in developed countries. The effects of antenatal classes depend not only on the characteristics of those who attend, and the competence and skills of the teacher, but also, to a large extent, on the underlying objectives of the program. Some classes are taught by independent childbirth educators or co-ordinated by large consumer groups. Others are offered by official health agencies; still others by doctors for their own patients, or by hospitals for the women who plan to deliver there. The curricula outlined for these classes may be similar, and there may be little difference in the information taught, or the skills imparted. Nevertheless, there may be great differences in the attitudes that are encouraged. As a general rule, community-sponsored childbirth education classes are structured to incorporate the interests of parents into the curriculum. Hospital-based classes may be directed at explaining and justifying, rather than questioning, existing policies, offering alternatives, or helping parents decide their own birth plans.
It is possible that the actual existence of antenatal classes is more important than the details of what is taught. The full impact of childbirth education cannot be assessed solely by its effect on the individual woman giving birth, for there may be indirect effects that engender significant changes in the ambience in which all women give birth. Once a critical mass of mothers becomes aware of the fact that options are available to them, major changes in obstetrical practice may ensue.
If information on risks, benefits, and alternatives to conventional care remains a major focus among a large proportion of antenatal classes, we may expect increasingly influential and well-informed consumer involvement in the future patterns of childbirth practices. If, on the other hand, the ideology of classes shifts toward an acceptance of conventional obstetric practices, the group consciousness among expectant parents may fade, reducing their impact and their influence on the direction of maternity care.
2 Print, audio-visual, and electronic media
There are thousands of books and pamphlets, as well as many magazines and videotapes, aimed at childbearing women and their families, and even more Internet websites offering information and advice. The quality of information and advice varies widely, from excellent to inaccurate and potentially dangerous. There is a clear need to develop strategies to help consumers to evaluate the quality of the information in these resources.
There is limited evidence of the impact of mass media on consumer behavior, and none that specifically focuses on childbearing women and their families. A review of 17 studies of the impact of mass-media campaigns on health services utilization, concluded that massmedia campaigns can be an important influence on primary and secondary preventive health behavior. The burgeoning worldwide use of the Internet as a resource for information, as well as contact with others with similar health problems, particularly by adolescents and young adults (e.g. those entering their childbearing years), suggests that the Internet may soon become a powerful influence on the healthrelated decisions of childbearing women and their families.
In developed countries, the widespread popularity of antenatal classes testifies to the desire of expectant parents for childbirth education and peer support. As there are benefits in terms of amount of analgesic medication used and in some aspects of satisfaction with childbirth, and as significant adverse effects have not been demonstrated, such classes should continue to be available. The objectives of the classes must be made clear to the participants and unrealistic expectations of what the classes can achieve must be avoided. A variety of different types of classes, whose goals are explicitly stated, may help women or couples choose the program most likely to meet their needs.
The quality of information and advice found in printed, audiovisual, and electronic media varies widely, from excellent to inaccurate and potentially dangerous. There is an urgent need to develop strategies to help consumers to evaluate the quality of the information in these resources.
Effective care in pregnancy and childbirth
Simkin, P., Non-pharmacological methods of pain relief during labour. In: Chalmers, I., Elkin, M.W. and Keirse, M.J.N.C. (1989) Effective Care in Pregnancy and Childbirth. OUP, Oxford.Find this resource:
Simkin, P. and Enkin, M., Antenatal classes. In: Chalmers, I., Elkin, M.W. and Keirse, M.J.N.C. (1989) Effective Care in Pregnancy and Childbirth. OUP, Oxford.Find this resource:
Gagnon, A., Antenatal education for childbirth/parenthood [protocol]. The Cochrane Library, Issue 4 (1999) Update Software: Oxford.Find this resource:
Grilli, R., Freemantle, N., Minozzi, S., Domenghetti, G. and Finer, D., Mass media interventions: effect on health services utilisation. The Cochrane Library, Issue 4 (1999) Update Software: Oxford.Find this resource:
Jadad, A.R. and Gagliardi, A. (1998). Rating health information on the Internet: navigating to knowledge or to Babel? JAMA, 279, 611–4.Find this resource: