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Antenatal education
1 Antenatal classes
1.1 Introduction
1.2 Content of antenatal classes
1.3 Effects of antenatal classes
2 Print, audio-visual, and electronic media
3 Conclusions
1 Antenatal classes
1.1 Introduction
In the 1950s and 1960s in Europe and North America, natural child-
birth and psychoprophylaxis began as alternatives to what was
perceived as over-medicalized obstetrics, with its liberal use of pain-
relieving 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, enhance-
ment of family relationships, feelings of empowerment, enhanced self-
esteem and satisfaction, successful infant feeding, smooth postpartum
adjustment, and advice on family planning. A major objective is to
enhance the womans 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 medica-
tion, 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.
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SOURCE: Murray Enkin, Marc J.N.C. Keirse, James Neilson, Caroline Crowther, Lelia Duley, Ellen Hodnett, and
Justus Hofmeyr. A Guide to Effective Care in Pregnancy and Childbirth, 3rd ed. Oxford, UK: Oxford University
Press, 2000.
DOWNLOAD SOURCE: Maternity Wise website at www.maternitywise.org/prof/
Oxford University Press 2000
1.2 Content of antenatal classes
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 obstet-
rical 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 tech-
niques, various forms of attention-focusing and distraction, controlled
breathing patterns, the teaching of comfort measures and labor-
support skills to the birth partners of the pregnant woman, and discus-
sions 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 ques-
tioning 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 pain-
relieving 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. Non-
randomized 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, Reads natural childbirth and Lamazes
psychoprophylaxis, have never been compared systematically. Because
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todays 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 com-
pletely unknown. There has been little systematic evaluation of the
extent to which negative feelings of anger, guilt, or inadequacy are
engendered when a womans or her partners 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 middle-
class 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 explain-
ing 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 indi-
vidual 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 prac-
tice may ensue.
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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 maga-
zines 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 inac-
curate 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 mass-
media 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 health-
related decisions of childbearing women and their families.
3 Conclusions
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
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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, audio-
visual, and electronic media varies widely, from excellent to inaccurate
and potentially dangerous. There is an urgent need to develop strate-
gies to help consumers to evaluate the quality of the information in
these resources.
Sources
Effective care in pregnancy and childbirth
Simkin, P., Non-pharmacological methods of pain relief during labour.
Simkin, P. and Enkin, M., Antenatal classes.
Cochrane Library
Gagnon, A., Antenatal education for childbirth/parenthood [protocol].
Grilli, R., Freemantle, N., Minozzi, S., Domenghetti, G. and Finer, D.,
Mass media interventions: effect on health services utilisation.
Other sources
Jadad, A.R. and Gagliardi, A. (1998). Rating health information on the
Internet: navigating to knowledge or to Babel? JAMA, 279, 6114.
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