Does Participation In Prehatai Courses Lead to Heavier Babies?
YVONNE ROBITAJLLE, PHD, AND MICHAEL S. KRAMER, MD
Abstract: In a prospective epidemiologic survey of 1,676
primiparous women delivering in four Montreal hospitals during an
eight-month period, we studied the impact of prenatal courses on
birthweight, maternal weight gain, and cigarette smoking. Women
who participated in prenatal courses were older and of higher
socioeconomic status and were less likely to be smokers than
non-participants. After adjustment for these differences, newborns
of course participants had similar mean birthweights compared to
those of non-participants (3286 grams vs 3271 grams), and the
Introduction
In its objectives for the nation, the US Department of
Health and Human Services has called for preventive edu-
cational strategies to reduce the number of low birthweight
infants.' Prenatal courses can be considered as one of these
educational strategies, especially since such courses usually
include, among their objectives, cessation of cigarette smok-
ing and improvement in nutrition during pregnancy.
Originally inspired by Dick-Read^ and Lamaze princi-
ples' and oriented toward labor and delivery, prenatal cours-
es began to include the health of the newborn among their
objectives during the 1970s. Amotig 14 evaluations of prena-
tal courses,"*"'' only four studies"•''''^" have considered the
impact of prenatal courses on birthweight, the principal
indicator of newborn health.'* In two of t h e s e , " "
birthweight was considered a secondary (marginal) outcome,
since the courses were aimed principally at facilitating
delivery rather than improving newborn health. Both studies
reported small increases in birthweight among newborns of
course participants. Two other studies'"*'" examined prenatal
courses whose aims included improved nutrition during
pregnancy; both reported increased biiihweight in course
participants. Neither controlled for confounders; one actu-
ally suggested that "exogenous variables (the demographic
difference between attenders and non-attenders) would have
to be controlled before further causal inference could be
drawn."''*'
In the province of Quebec, the popularity of prenatal
courses has increased dramatically over the last decade. In
1978, we began an evaluation of prenatal courses in the
Montreal region. We wished to measure the effectiveness of
these courses on three important outcomes—reduction in
cigarette consumption, gestational weight gain, and
birthweight—while properly controlling for confounding
variables. We did not intend to judge the overall value of
these courses. Since women will not readily accept random
From the Department of Community Health, Montreal General Hospital.
Address reprint requests to Yvonne Robitaille, PhD, Research Associate,
Department of Community Health, Montreal General Hospital, 1597 Pine
Avenue West, Montreal, Quebec H3G 1B3, Canada. This paper, submitted to
the Journal September 25, 1984, was revised and acceptated for publication
May 10, 1985. Dr. M. Kramer is Associate Professor in the Departments of
Epidemiology and Biostatistics, and Pediatrics, McGill University Faculty of
Medicine, Montreal, Canada. Dr. Kramer is a National Health Research
Scholar of the National Health Research and Development Program
(NHRDP), Health and Welfare Canada. An earlier version of part of this paper
was presented at the annual meeting of the Ambulatory Pediatric Association
in San Antonio, Texas, April 29, 1980.
© 1985 American Journal of Public Health 9909-0036.85$1.50
1186
difference for maternal weight gain was substantially reduced. Most
of the reduction in cigarette consumption occurred during the first
three months of pregnancy, even among later participants, suggest-
ing that something other than prenatal courses influenced cigarette
smoking reduction in course participants. We conclude that as far as
the birthweight objective is concerned, the format and content of
prenatal courses (as currently constituted in the Montreal region)
require re-examination, and new ideas and interventions need to be
developed and tested. {Am J Public Health 1985; 75:1186-1189.)
assignment to prenatal courses, a randomized clinical trial
was felt to be not feasible. Matchihg or stratification was also
deemed impracticable owing to the large numbers of potential
confounders. We therefore decided on another strategy:
covariance adjustment. This report presents the results of our
evaluation.
Methods
The. study population was drawn from four Montreal
hospitals during an eight-month period from June 1978 to
February 1979. The four hospitals comprise both university
and nori-university obstetric services, serve both English-
speaking and French-speaking communities, and represent a
reasonable geographical cross-section of the Montreal met-
ropolitan area. The four study hospitals account for 12 per
cent of the annual births in this area. We surveyed 1,747
prirhiparous women who gave birth in one of the four
hospitals during the study period. Data on prenatal course
participation, cigarette smoking in each month of pregnancy,
education of the mother, and occupation of the household
head were collected by means of questionnaires administered
by trained interviewers during the post-partum stay. The
response rate was 96 per cent. Biomedical data on mothers
arid infants were extracted from their medical records.
Using a telephone survey of the agencies offeHng pre-
natal courses, we determined the length of each course, its
content, and the amount of emphasis placed on cigarette
smoking and nutrition during pregnancy. This information
was then used to construct a scale of course participation
"potency" composed of course duration (adjusted for atten-
dance), gestational age at first session attended, time and
emphasis devoted to cigarette smoking, and time devoted to
nutrition during pregnancy. (Details and rationale for the
construction of this scale are available from the authors on
request.) The course attenders were then classified into one
of the following three groups according to their scores on this
scale:
1) the 20 per cent with the most potent course partici-
pation;
2) the 20 per cent with the least potent course partici-
pation; and
3) the 60 per cent with course participation of interme-
diate potency.
Variables known or suspected to be associated with the
three outcomes studied and with participation in prenatal
courses were considered as potential confounders. These
included: socioeconomic status (education of the mother and
occupation of the household head)," level of pre-pregnancy
AJPH October 1985, Vol. 75, No. 10
 IMPACT OF PRENATAL COURSES ON BiRTHWEIGHT

TABLE 1—Comparison of Prenatai Course Participants and Non-partic- status and less likely to be smokers than non-participants
ipants (Table 1). Among smokers, however, participants and non-
participants reported the same cigarette consumption before
Non-
Participants Participants Difference
pregnancy.
Demographics (n = 1162) (n = 514) (95% CI) In an attempt to judge possible bias in mothers' respons-
es to our postpartum questionnaire, we related cigarette
Age (years) % % smoking (as declared by the mothers) to infant birthweight.
<20 3.5 17.2 Table 2 indicates that for any cigarette consumption before
20-34 92.2 77.6 pregnancy, women who claimed to have reduced cigarette
§35 4.3 5.2
Mean 26.4 24.7 1.7 consumption during the last five months of pregnancy gave
(1.65, 1.75) birth to heavier babies than those who declared a constant
Education cigarette consumption. The strength and consistency of this
<8 1.5 6.7 relationship suggests that these maternal responses were
8-12 55.5 69.6
>13 43.0 23.7 reasonably valid.
Mean 12.9 11.3 1.6 Table 3 compares the outcomes for course participants
(1.56, 1.63) and non-participants. Without covariate adjustment, new-
Socioeconomic status* borns of course participants had a mean birthweight 127
Low (30-49) 5.2 15.7
Middle (50-69) 75.8 76.5
grams heavier than those of non-participants, a smaller
High (70-89) 19.0 7.8 proportion of low birthweight newborns, and a smaller
Mean 61.5 56.6 4.9 proportion of women who gained less than 9.1 kilograms (20
(4.79, 5.01) lbs) during pregnancy. Course participants reduced their
Smokers betore pregnancy
No 55.7 43.6 cigarette consumption by 8.7 cigarettes per day, compared
Yes 44.3 56.4 12.1 with 5.6 cigarettes per day in the non-participants. Thus
(12.05, 12.15) without adjustment for confounding variables, prenatal
Mean cigarettes 20.2 20.1 0.1 courses appear to be highly effective in improving these
(smokers only) (-2.15, 2.35)
Mother's pre-pregnancy weight outcomes. After controlling for confounders through the
<57kg (<125 lbs) 56.1 58.8 ANCOVA procedure, however, all these differences be-
57-67 kg (125-149 lbs) 34.9 29.8 tween the two groups were substantially reduced so that the
68-135 kg (150-299 lbs) 9.1 11.4 impact of classes could be termed unimportant with the
Mean lbs 123.6 122.9 0.7
(-1.68, 3.08) possible exception of smoking reduction.
Figure 1 displays mean cigarette consumption as a
*= Using Green's scale." function of month of pregnancy for three groups of smokers:
early participants, late participants, and non-participants of
prenatal courses. These results are adjusted for age, socio-
economic status, and cigarette consumption before pregnan-
cigarette consumption, pre-pregnancy maternal weight, ma- cy. Most of the reduction in cigarette consumption occurred
ternal age, and length of gestation. These variables were during the first three months of pregnancy, even among late
controlled by means of an analysis of covariance participants (who did not begin prenatal courses before the
(ANCOVA), after demonstrating their lack of statistical 20th week of pregnancy). These data suggest that something
interaction with course attendance.'^'* other than prenatal courses probably influences cigarette
smoking reduction in course participants.
Table 4 displays the outcomes of the 20 per cent with
Results most potent course participation and the 20 per cent with
Sixty-nine per cent of the 1,676 primiparas participated least potent course participation. No important differences
in prenatal courses offered by 80 different private or public were found. Furthermore, a multiple regression analysis of
agencies in the Montreal area. Women who participated in the individual elements of the potency scale (course duration,
prenatal courses were older and of higher socioeconomic time, and emphasis devoted to cigarette smoking, etc.), with

TABLE 2—iViean Birthweight (in grams) According to iUother's Daiiy Cigarette Consumption Before and
During the Last Five iVIonths of Pregnancy***

Consumption during the Last Five Months of Pregnancy

Pre-Pregnancy Number of
Consumption 0 1-4 5-9 10-19 20-29 30+ Total Subjects

0 3,348 • • • 3,349 867

1-4 3,407 3,111 • — — — 3,301 41
5-9 3,282 • • • — — 3,204 49
10-19 3,402 3,209 3,130 3,131 * * 3,204 237
20-29 3,477 3,457 3,213 3,128 3,054 * 3,151 380
30+ 3,336 * • 3,208 * 3,025 3,187 89
Total 3,356 3,259 3,158 3,123 3,080 2,981 3,269 1,663**

'Indicates mean suppressed because fewer than 15 subjects in cell.

"There are 13 missing values.
•"The mean birthweigtit adjusted for mother's age, socioeconomic status, pre-pregnancy weight and length of gestation is similar
to those shown in table.

AJPH October 1985, Vol. 75, No. 10 1187

 ROBITAILLE AND KRAMER

TABLE a—Outcome Results: Prenatal Course Participants vs Non-participants

Non-Adjusted Adjusted

Difference* Difference*
Participants Non-Participants (95% CI) Participants Non-Participants (95% CI)

Birthweight (g) (n = 1423)" 3321 3193 127 3286 3271 15

(66.0, 188.4) (-20.3. 50.3)
Birthweight <2500 g (n = 1423) 5.0 7.3 -2.3 6.2 4.7 1.5
(%) (-5.2, 0.4) (-0.8. 3.8)
Weight gain <9.1 kg (n = 1423) 13.1 19.2 -6.1 13.9 17.0 -3.1
(%) (-1.8, -10.4) (-7.0, 0.7)
Reduction in smoking (n = 670)"* 8.7 5.6 3.1 8.4 6.1 2.3
(cigarettes/day) (1.4. 4.8) (0.9. 3.8)

•Participants - Non-participants, CI = Confidence interval.

"There are 253 missing vaiues.
*"The anaiysis is done oniy on smokers before pregnancy; there are 135 missing vaiues.

birthweight as the dependent variable, confirmed these find-
ings.
Because of the possibility that prenatal courses might
have a greater impact on women at risk for low birthweight,
we also examined the results in an "at risk" subgroup:
women 19 years of age or younger who had not completed
grade thirteen. There were 92 women in that group, of whom
29 had participated in prenatal courses and 63 had not. The
mean birthweight of the children of these two groups were
3066 grams and 3114 grams, a difference of 47 grams (95 per
cent confidence interval: -113, 207 grams).
Discussion
In rigorous review and critique of the literature relating
to the effectiveness of preparation for natural childbirth.
Beck and Hall state factors or principles that are essential to
the validity of this type of research.^' These factors include
the use of random assignment of subjects to treatment and
control groups that receive placebo treatment. A randomized
clinical trial is not feasible for the evaluation of services freely
available from a variety of different sources and desired by
many women. Furthermore, such assignment would be
unethical.
In the Montreal area, where 60 per cent of prenatal
courses are available free of charge, course participants are
older, better educated, and less likely to smoke than non-
participants, confirming the findings of several previous
studies'"*"'"'* and indicating that, as with other preventive
services,^^ cost is not the only barrier to participation.
Our results suggest that prenatal courses have little if any
impact on the birthweight of infants. Our unadjusted results
are similar to those of Thordarson and Costanzo,'"* but the
adjusted results confirm that " . . . the type of person who
elects preparation is more important in determining its effect
than the preparation itself."'
Reduction in cigarette consumption was somewhat
greater in participants than in non-participants, even after
socioeconomic differences were controlled, but it is difficult
to attribute this difference to course participation. Our results
are thus similar to those of Donavan,^' who conducted a
randomized controlled trial in which the experimental group
received intensive individual anti-smoking advice in parallel
with hospital antenatal care. He too observed a reduced
cigarette consumption in late pregnancy in the experimental
group, but no corresponding increase in birthweight. Con-
trary to Donavan, however, we do not think that postnatal
declaration of prior cigarette consumption by our study
mothers is seriously biased, since the actual birthweight is
closely related to the degree of reduction reported.

TABLE 4—Comparison of Outcomes According to Potency of Prenatai

Smokers before pregnancy Course Participation (Adjusted Results)
22 " a
20
18 Course Potency
-a 16 Difference
Outconne Highest Lowest (95% Cr)
14 * • —"^ "• • •
12 - (n = 233) (n = 206)
g> 10
Birthweight (g) 3323 3292 31
" 8 a-a early attenders (< 20th week;
(-44.4. 106.4)
6 - A-ik late attenders (>20th week) Birthweight <2500 g (%) 7.3 6.9 0.4
4 •—• non-attenders (-3.8. 4.6)
Weight gain <9.1 kg (%) 14.9 11.6 3.3
2 20 th week
• 1 1 1 1 1 1 (-3.1,9.7)
Before 1 2 3 4 5 6 7 8 9 (n = 101) (n = 81)
pregnancy Reduction in smoking"
Month of pregnancy
(cigarettes/day) 8.8 8.8 0.0
'AiljHSlrilJ{ir aiie. siiriii nimmnir slalus. and fiuairllr nmsiimptiiiii Iw/cir piTunamr (-2.6, 2.6)
FIGURE 1—Cigarette Consumption by Month of Pregnancy in Early, Late,
and Non-Attenders of Prenatal Courses* *CI = Confidence interval.
"This anaiysis is done on smokers before pregnancy.

1188 AJPH October 1985. Vol. 75. No. 10


We do not mean to suggest that prenatal courses are
without benefit. They may well have a significant impact on
other important outcomes, such as improving the
psychologic well-being of the mother and facilitating a short-
er, less complicated labor and delivery. As to the birthweight
objective, however, we believe that the format and content of
these courses require re-examination, and that new ideas and
interventions need to be developed and tested. The public
health challenge is to incorporate effective methods, such as
counseling to reduce cigarette consumption,^"* into prenatal
courses or other widely available services providing health
education to pregnant women.
ACKNOWLEDGtVIENT:
This research was supported by grant 6605-1437-43 from the NHRDP.
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