This paper examines the concept of maternal health literacy, defined as the cognitive and social skills that determine the motivation and ability of women to gain access to, understand, and use information in ways that promote and maintain their health and that of their children. Specifically, it investigates the feasibility of using the concept of health literacy to guide the content and process of antenatal classes. The paper reports on the results of focus groups and interviews conducted with a range of health care providers, pregnant women and new mothers to obtain different perspectives on the issues surrounding antenatal education and parenting. The results give us a realistic look at what women are learning from existing antenatal education and how it can be improved. Comparing the results from the educators and the women, the same basic issues surface. Both recognize that there are serious time limitations in antenatal classes. These limitations, combined with natural anxiety and curiousity about childbirth, generally ensure that the content of classes is confined to pregnancy and childbirth. The limitations of time are also cited as a reason for the teaching methods being heavily weighted towards the transfer of factual information, as distinct from the development of decision-making skills, and practical skills for childbirth and parenting The results indicate clearly that antenatal classes cannot possibly cover all there is to know about pregnancy, childbirth and parenting. If the purpose of antenatal classes is to improve maternal health literacy, then women need to leave a class with the skills and confidence to take a range of actions that contribute to a successful pregnancy, childbirth and early parenting. This includes knowing where to go for further information, and the ability to analyse information critically. The authors conclude that this would represent a very challenging change in orientation for both the educators and pregnant women included in this study. Work continues on the development of the tools that will be needed to support this change.
This paper examines the concept of maternal health literacy. It does so by considering the feasibility of using the concept of health literacy to guide the content and delivery of antenatal classes.
Health literacy has been identified as a measurable outcome of health education interventions (Nutbeam, 1996). The World Health Organization (WHO) defines health literacy as follows:
‘Health literacy represents the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use the information in ways which promote and maintain good health. Health literacy means more than being able to read pamphlets and successfully make appointments. By improving people's access to health information and their capacity to use it effectively, health literacy is critical to empowerment’ (WHO, 1998).
In an earlier paper in this series, a continuum of health literacy was proposed. This continuum includes basic or ‘functional’ health literacy, communicative/interactive health literacy and critical health literacy. Such a continuum suggests that the different levels of literacy progressively allow for greater autonomy in decision making and personal empowerment, demonstrated through the actions of individuals and communities (Nutbeam, 2000). By using the concept of health literacy to guide the content and delivery of health education, attention is focused on the development of the skills and confidence to make choices that improve individual health outcomes, rather than being limited to the transmission of information. Ideally, a level of critical health literacy will be reached in which an individual has the ability to seek out information, assess the reliability of that information and use it to exert greater control over the determinants of health, and make well informed health choices.
In applying this concept of health literacy to define the outcomes of maternal and child health education, we refer to maternal health literacy. Specifically, maternal health literacy can be defined as the cognitive and social skills which determine the motivation and ability of women to gain access to, understand, and use information in ways that promote and maintain their health and that of their children.
Pregnant women in general, and first-time mothers in particular are provided with a vast amount of information. Many women, especially first-time mothers, attend antenatal classes which prepare them for labour and delivery, and usually include basic babycare skills. Although this knowledge and related skills are important for a successful pregnancy and childbirth, women need different knowledge and skills for successful parenthood.
Knowledge about childbirth and parenting has historically been gained informally from other women, mainly family members, and through practical experience of assisting with child-rearing in extended families. However, changes in family structure and women's increased participation in higher education and the workforce, combined with the increasing medicalization of childbirth, have meant that women are far more likely to depend upon formally organized antenatal education as the mechanism through which they develop their knowledge and skills (Zwelling, 1996; Nolan, 1997b).
Typically, antenatal education tends to focus on facts surrounding pregnancy, labour and basic babycare skills. In addition, there are a range of options for pain management (both medical and non-medical) and obstetric interventions for women to learn about, which tend to take up a large amount of time in antenatal classes. As a consequence, what women do not necessarily gain from antenatal classes is the confidence and emotional insight traditionally gained through informal communication with other women, and the practical experience of child care in extended families (Nolan, 1997b). Thus, the content of antenatal classes prepares women to manage decisions during their pregnancy and childbirth, yet gives relatively little attention to preparing women (and their partners) for parenthood. The delivery tends to be instructional rather than oriented towards empowering women to make informed decisions about their health and the health of their baby.
Standards and guidelines
There are few examples of widely adopted standards or guidelines for antenatal education, and a lack of systematic certification for antenatal education teachers (O'Meara, 1993b). For example, in Australia, research into the quality of maternity services in Victoria and Western Australia identified concerns about effectiveness, curriculum content, standards of practice and teacher training for childbirth and parenting education programmes, despite acknowledgement of their importance (O'Meara, 1993b). Similar concerns emerged from a study done in the Australian Capital Territory regarding lack of teacher certification and standards for course content (O'Meara, 1993b). In the United States, standards of practice for antenatal education are also lacking with respect to the timing of classes offered, length and size of classes and most importantly, content of classes (Nichols, 1993). Certification of childbirth educators in the US, although it has existed for years, is not often required of employers or valued for its benefits (Zwelling, 1996).
Variations in quality
Because there are no widely applied guidelines or standards for antenatal education, childbirth classes vary widely in length, instructor training, sponsorship, goals, focus and content (Shearer, 1996). Each hospital, clinic or private childbirth educator designs a class as they see appropriate. Most health professionals would agree that antenatal classes are informative and they are highly recommended for expectant parents. They are something that ‘everyone is doing’, but are often found to be beneficial due to the socialization with other expectant parents, rather than the knowledge and skills transferred (Zwelling, 1996). Client satisfaction is generally used as a measure of success of antenatal classes. There are few studies on the effect of antenatal classes on birth outcomes. Generally these indicate positive benefits in terms of successful childbirth, and show that a positive childbirth experience may have a positive effect on the transition to parenting (Nichols, 1995).
Antenatal classes are often designed to prepare women for childbirth in that particular hospital or setting (Gilkison, 1991). Instead of learning all options available to them, parents may only hear about options available or preferred in the sponsoring hospital (Gilkison, 1991). This may produce positive results in terms of childbirth, but does not necessarily prepare women for parenthood or empower them to make informed health choices.
As well as being highly variable in content, the delivery of antenatal education often lacks grounding in the field of adult education (NSW Department of Health, 1998). Antenatal class teachers are most often trained as midwives, but may be nurses or physiotherapists (Nolan, 1997). These clinicians have good content knowledge, but are not necessarily trained and competent in teaching.
Preparation for parenthood
Research in the area of antenatal education shows that classes often do not have a suitable balance between preparation for labour and childbirth and preparation for parenthood (O'Meara, 1993c). The majority of antenatal classes cover the birthing process itself, and only a relatively small proportion of time available will focus on what to do after the baby is born. In these circumstances, women are leaving antenatal classes with a good knowledge of birthing options, but feel insufficiently prepared for what lies ahead. O'Meara, in her evaluation of consumer perspectives of childbirth and parenting education, found a high level of dissatisfaction among women attending childbirth education classes in Australia. She notes that women lacked timely knowledge for the caring of their newborn, and did not have the confidence to make decisions for the family's care (O'Meara, 1993c). Other research has indicated that women do not have a realistic understanding of the burden of parenthood, or the changes in lifestyle and relationships that come with it (Hillan, 1992). To address this deficiency, O'Meara suggests that a comprehensive curriculum designed to meet these expectations needs to be developed (O'Meara, 1993c).
It seems that many childbirth educators feel that their clients are not interested in parenting topics before childbirth and simply want to get through the labour and delivery. Yet Nolan's research indicates that couples desire a balance between labour and delivery and post-natal issues (Nolan, 1997a). Results from Nolan's study of antenatal education noted that both pre-natally and post-natally, fear of labour pain was only a ‘minor’ part of a woman's motivation for childbirth education (O'Meara, 1993c).
In summary, antenatal education is valued both by prospective parents and by health care professionals as an important factor in achieving positive health outcomes for mother and baby. The content of antenatal education tends to focus on health during pregnancy, and on options for childbirth—often limited only to those preferred by the hospital or clinic. In delivery, antenatal educators are usually untrained in principles of adult education, and generally focus on knowledge transfer and the development of basic skills associated with childbirth. Although this approach to antenatal education undoubtedly contributes to safer and more successful childbirth, it represents a missed opportunity to develop the knowledge and skills that have more enduring application during the early years of parenthood. This failure to address issues of parenting has consistently been identified by parents after the birth of their children.
This paper reports on a series of interviews with health care providers, pregnant women and new mothers to explore how both the content and delivery of antenatal education could be improved to address some of these shortcomings. The concept of maternal health literacy was used to provide a framework for the enquiry.
A series of focus groups and interviews was conducted with a range of health care providers, pregnant women and new mothers. These were carried out at a large maternity hospital in Sydney and an early childhood centre in Central Sydney.
The questions were developed using the health literacy concept as a framework for enquiry. Specifically, the questions sought to explore the extent to which both the content and delivery of the teaching and learning supported the development of knowledge, skills and confidence to act, which characterize the different levels of health literacy described in an earlier paper (Nutbeam, 2000).
Those selected for the interviews and focus groups were volunteers, who were willing and able to give their time to explore these issues, and are not considered a representative sample of women or health care providers. All discussions were audio-taped and transcribed by the researchers. This data collection forms part of a larger research project that aims to develop and test an instrument to measure maternal health literacy in pregnant women.
Two focus groups were conducted. The first was a group of five pregnant women, all ≥28 weeks into their pregnancy and expecting their first child. These women were recruited by a health educator at antenatal classes at a large maternity hospital in Central Sydney. The health educator spoke briefly at the beginning of the classes about the purpose of the focus group and answered any questions. A flyer was also posted in the section of the hospital where the antenatal classes took place. Incentives were not offered but refreshments were served. The focus group lasted 45 min, and nine questions were put to the group for discussion. These included women's expectations of the classes, the breadth and depth of class content areas, confidence, personal attention in classes, pre- versus post-natal classes, and parenting. The discussion was facilitated by the health educator.
The second focus group comprised of seven new mothers, all with newborns ~5–6 weeks old. These women attended a weekly mother's group at an early childhood centre in Central Sydney. They attended daytime classes and were full-time mothers, and all seven had attended antenatal classes. This group was recruited by one of the centre's nurses, using one of the focus group flyers. Twenty-dollar gift certificates to a local babycare store were offered as an incentive to participate. An incentive was used because the researchers anticipated a low response rate compared with the focus group of pregnant women. A similar format to the antenatal group was followed, with questions regarding their expectations of motherhood before the birth versus reality with a new baby, reflections on which topics in antenatal classes they found helpful and what they thought was lacking, and advice they would give to pregnant women.
Interviews were conducted with five antenatal educators who taught classes at a large maternity hospital in Sydney. Their backgrounds varied, and the group included three practising mid-wives, one physiotherapist, and one Registered Nurse (RN) who was also a midwife but not currently practising. Each interview lasted 30 min to 1 h in duration, and included eight questions regarding their views on the needs of pregnant women, class expectations, parenting versus childbirth preparation interest, and their opinions on the best ways for women to prepare for parenthood. Names of interview candidates were provided by the Clinical Midwifery Consultant for Parent and Patient Education at the hospital, and all contacted agreed to provide an interview. The interviews were informal and all participants appeared to be highly motivated in their teaching.
In order to obtain the perspective of health care providers that saw women post-natally, three other health care professionals were interviewed. One was the Early Childhood Nurse Unit Manager at an early childhood center in Central Sydney, and the second was an RN at the same centre. The third person interviewed was the Nurse Unit Manager for the hospital's early discharge support programme. Nine questions, addressing the same topics asked of the antenatal educators, were discussed. The results are presented differentially for the four groups.
Priority topics in antenatal classes
In speaking with antenatal educators, the majority thought that the women in their classes were mainly concerned with getting through the labour and delivery. Most felt that fewer than half of the women attending classes were thinking past the birth, and that even those women seemed to be interested only in skills needed immediately after birth. The educators did feel that education tailored toward parenting, given in the antenatal period, would be useful but all had concerns about time restrictions and providing ‘too much’ information. They feared losing the attention of some participants who were more focused on only labour and delivery.
By contrast, one new educator said:
‘I'm just finding out now that women want less information on the birth and some more on parenting. From my expectations and training, I thought they did want mostly information on childbirth, but I just got back my first set of evaluations from the first class and they did express a desire for more parenting information.’
Pregnant women's interest in parenting information
On the topic of women's interest in parenting information, one antenatal educator said:
‘It doesn't seem to be an issue. The women don't believe what you tell them, and it's not until they have their baby and are at home that they realize how difficult it is.’
She said that the resources for them are out in the community but that many women are afraid to admit that they need help. Several educators shared this belief that society puts a lot of pressure on women to be able to take on new motherhood with ease, and that women fear that asking for parenting advice or assistance will be viewed as a sign of weakness.
Confidence was cited by the educators as one of the most important issues in antenatal classes. The educators commented that although a lot of women that attend have control over many aspects of their life, such as career or finances, they feel unprepared and lack the confidence to take on both labour and parenting. Women can be given information and even taught skills, but they also need confidence and reassurance in order to successfully apply what they’ve been taught.
Timing of parenting skills taught
When prompted about when the best time to teach parenting skills is, the majority of educators felt that post-natally would be the most appropriate. The reason for this was mainly due to time restrictions in antenatal classes as they are now structured. This was also due to the lack of interest in some of the participants with respect to information needed post-natally. By providing classes or drop-in information sessions in the post-natal period, many educators felt that women may be more likely to listen to the information provided. Time didn't seem to be a concern for those suggesting post-natal groups, however there may have been an underlying assumption that mothers will stop working and will have the time to attend.
Improving health literacy
One educator in particular explained that pregnant women are a vulnerable target group:
‘I tell them to push hard when buying something for the baby. People are out there to make money and many mothers can be naïve.’
She also discussed the use of the internet as an information source, and warns the women in her class to be sceptical because anybody can put information on the internet and it is not always reliable.
‘They need to know where to go if something comes up that we don't cover in class. We can't do everything.’
A similar view was expressed by a nurse midwife. She said that often women make decisions before they cover things in class, such as what kind of cot or car seat to buy, or whether or not they are going to breastfeed, before they have all the information. She tries to give women a range of options and let them decide what is best for them personally. Her vocabulary includes ‘I think’ rather than ‘the correct way is . . .’ so they understand her view is not the only view.
From the feedback gained from the antenatal educators, it's obvious that they believe that women need both factual information, as well as the opportunity to develop skills and confidence to cope with labour and parenting. The educators all seemed concerned that women needed more than just information transfer and all tried to incorporate that into their class, but they seemed somewhat reluctant to include a wider variety of educational strategies, partly due to the time restrictions they are faced with.
Priority topics in antenatal classes
In a focus group discussion with a group of pregnant women, the need for more parenting information was expressed, but it was secondary to the issue of labour and delivery and not brought up until the end of the discussion when the facilitator prompted specifically on the topic. When asked about expectations women had about antenatal classes, one woman commented:
‘I was pretty keen to get a lot of information on the actual labour. I know it's important to look beyond that and what to do with a newborn . . . but I was really expecting the main focus to be on labour . . .’
Confidence and reassurance was a key issue for these women, in both labour and parenting. One woman commented that information, in and of itself, brings a sense of reassurance. When asked about what women still didn't feel confident about, one reply was that
‘there is so much to learn, that you just can't learn until you’ve got the baby, and until you are actually home . . .’
Time restrictions and other barriers
Just as the antenatal educators were concerned with time restraints, so too were the expectant mothers. One woman felt that she was already saturated enough to receive more information about parenting while still pregnant.
Aside from time restraints and interest area, the women agreed that they simply wanted to enjoy their new baby without any pre-conceived ideas of what makes good parents, or what they should be doing or not doing. In other words, discovering the baby's personality before worrying about what parenting skills to apply.
Timing of classes
When asked about post-natal classes for new parents, the women were definitely interested, not simply for learning new information and skills, but for the support and contact with other new parents.
In one woman's reasoning as to why parenting education would be best left until the post-natal period, she said:
‘I think that is why antenatal classes are so good that they are so focused on labour and what happens immediately afterwards . . . you feel like you are in an emergency situation, like “I need to know this right now”.’
Post-natal health professionals
Preparation for parenthood
Those health care professionals that saw women post-natally were all in agreement that women are never really prepared for how difficult parenthood really is. One RN at an early childcare centre said that in her opinion:
‘how prepared a woman is for parenthood depends a lot on their age, insight, reading prowess, experiences with kids, relationships and job—but not necessarily their education level.’
The same RN described labour almost as a ‘mental obstacle’ needed to get over before women could open themselves up to more parenting information.
‘They are prepared for labour, but for the parenting part, they'll prepare after the event. The fear of labour, survival of the baby and survival of themselves has been nullified, so then they can go to the next step.’
With regards to the topic of antenatal education, one RN said ‘projected knowledge is good, but not useful’. She explained that it doesn't always fit a woman's experience, particularly with respect to culture.
‘The cultural gap is a huge chasm. There is community culture, family culture etc.’, noting that even within families, cultural beliefs can be different.
When asked what their thoughts were on the best way to prepare women for parenthood, all those interviewed suggested some kind of real-life experience with children—however, all acknowledged that the idea was not very realistic. Suggestions included having high school students be paired with a family with a new baby, and having mothers in the maternity ward come down to antenatal classes.
Priority topics in antenatal classes
Focus groups results with new mothers revealed that these women would have liked to have more information concerning experiences after the birth in their antenatal classes. However, most women agreed that they were not sure whether or not they would have been receptive to it before the birth, since labour was their primary concern. They simply didn't realize what it would be like until they were actually home with their babies. ‘You can't quite prepare yourself for the emotional change that you are going through’ said one new mother. ‘You can't really explain it, you have to go through it’ expressed another.
When asked specifically how well they think their antenatal classes prepared them for their experiences after the birth, most women said that they were not very helpful. One woman said:
‘It was good at the time because you felt like you needed to do something, but in retrospect, no, it wasn't really that good.’
In response to inquiries about the amount of time spent on labour versus parenting, one woman said they spent about an hour on post-natal issues, and:
‘The labour was nothing compared to what I felt when I got home with the baby.’
In an attempt to sum up the comments about antenatal classes, one new mother said ‘I think the thing with antenatal classes is it's virtually impossible to talk about after the birth because no one wants to think about after the birth . . . It's just that your mind can't cope with that as well.’ Another said ‘I had good classes, but I would have liked more psychological stuff for after the birth.’
Preparation for parenthood
Retrospectively, all mothers agreed that they would have liked more post-natal information, but were at a loss for suggestions of the best way to provide that information. Having information to take home with them was helpful because although they might not have been interested in it at that time, they knew they had something to refer to later. Those women that had prior experiences with children, such as nieces and nephews, discussed how helpful it was when they had their own baby. Those with children in their extended families felt strongly that this helped them make the transition to parenthood.
This paper reports on results from a study that forms part of a larger project to design a diagnostic instrument to measure maternal health literacy. The paper reports on exploratory work with groups of women who may be labelled ‘highly motivated’, rather than representative of the wider population of pregnant women, new mothers and health professionals. The results should be treated with caution for these reasons.
The findings indicate that even within a single hospital there is variability in the goals and educational methods in the delivery of antenatal education. Despite this, the findings seem to confirm that the antenatal education that is offered ensures that mothers are well prepared to achieve successful childbirth by following the established procedures of the institution. Our purpose in conducting this study is not to replace these successful processes and their outcomes, but to consider whether there is more that could be achieved through the unique educational opportunity represented by antenatal education.
The results from interviews and discussion describe the similarities and differences in perceptions of the experience of antenatal education from the perspective of both the educators and the women participating in the programme. It explores the extent to which antenatal education is engaging women in understanding factors influencing successful childbirth and their capacity to navigate the early period of parenthood successfully.
Comparing the results from the educators and the women, the same basic issues surface. Both recognize that there are serious time limitations in antenatal classes. These limitations, combined with natural anxiety and curiousity about childbirth, generally ensure that the content of classes is confined to pregnancy and childbirth. This outcome is reflected in the views of both the educators and pregnant women. Although there is some interest in addressing issues of parenthood among pregnant women, it is only among the group of recent mothers that there is strong support for more parenting information in the content of antenatal classes.
In addition to the constraints on time, there is a view reflected among educators in particular, that the pregnant women attending antenatal classes are just not ‘ready’ for information on parenting at that stage.
The limitations of time are also cited as a reason for the teaching methods being heavily weighted towards the transfer of factual information, as distinct from the development of decision-making skills, and practical skills for childbirth and parenting; the latter approach reflecting better the concept of health literacy than the former.
The results from the study indicate scope to develop both the content and delivery of antenatal education in ways that better reflect the health literacy concept, but is less conclusive on the extent to which classes can be developed to address the skills and knowledge needed for early parenthood. The results are also useful in illuminating some of the potential barriers to the changes in content and delivery that might better reflect the health literacy concept, including the extent to which antenatal education is empowering rather than passive in its effects on women.
Antenatal classes cannot possibly cover all there is to know about pregnancy, childbirth and parenting. If the purpose of antenatal classes is to improve maternal health literacy, then women need to leave a class with the skills and confidence to take a range of actions that contribute to a successful pregnancy, childbirth and early parenting. This includes knowing where to go for further information, and the ability to analyse information critically.
In developing this study, our hypothesis has been that a focus on improving health literacy as an outcome may help reframe thinking about the content and method of antenatal classes. By focussing more on providing women with skills they can use, and empowering women to make educated choices, it is hypothesized that educators won't have to struggle to include everything there is to know about labour, delivery and parenthood in the education programme. Clearly, this represents a very challenging change in orientation for both the educators and pregnant women included in this study.
Building confidence and self-esteem, as well as encouraging parents to take responsibility for their families' health, have previously been advocated as an integral part of antenatal education (Nolan, 1997b).
‘The aim of antenatal education now must be to work with the information, skills, and life experience the woman already has and to build on those in order to help her grow in confidence as a consumer of the maternity services and as the mother of their child.’ (Nolan, 1997a)
The health literacy concept offers us the opportunity to shift our thinking in antenatal education away from a simple transfer of knowledge, to a more active process of empowering women for parenthood. The results from interviews and focus groups gives us a realistic look at what women are learning from existing antenatal education and how it can be improved. By working towards the development of health literacy as an outcome in antenatal education, we may be able to bring women the confidence and emotional insight which they no longer gain from extended families and other women (Nolan, 1997b). We may better equip women with skills and confidence, so that when the labour process is over, the reality of parenthood is a positive, healthy experience.