Improving Online Childbirth Education: A Role for Active Learning

Abstract

Teaching online poses unique challenges for keeping participants engaged. To enhance the effectiveness of virtual childbirth education, this article explores how active learning techniques can guide the design of online prenatal classes. Active learning involves encouraging class participants to process and engage with ideas as the instructor presents them in class, rather than just hearing about concepts through lectures. This article draws from pedagogical literature on active learning and applies its key components to the needs of childbirth instructors in an online setting. Specific recommendations for activities to involve participants and create lasting learning are also provided for synchronous online classes.

INTRODUCTION

Expectant parents come to childbirth education classes for a variety of reasons. Research with parents-to-be indicates that they come to childbirth classes to connect with others going through similar experiences, to alleviate anxieties around labor and birth, and to seek critical knowledge of labor, birth, and the newborn period (Jones et al., 2019). Evaluations of the effectiveness of childbirth education classes have a long scholarly history, and the results of this literature suggest that comprehensive classes can alleviate stress and anxiety for new parents (Pasadino et al., 2020; Uçar & Golbasi, 2019) as well as lead to increased frequency of vaginal births and greater feelings of self-efficacy (Çankaya & Şimşek, 2021; Citak Bilgin et al., 2020). However, there are also studies indicating that attending prenatal education has a limited impact on maternal well-being or childbirth outcomes (Mousavi et al., 2022; Vanderlaan et al., 2023; Walker et al., 2009). One possible explanation for the inconsistency in the results of these studies is the limited information provided in published research regarding the particular teaching methods utilized in childbirth education courses. As a result, it is challenging to ascertain whether it is the childbirth education itself that is impacting the client’s outcomes or if it is the manner in which the classes were conducted.

With the COVID-19 epidemic and the pivot to an online format for most educational endeavors, many prenatal instructors had to quickly transition from face-to-face classes to virtual ones for the protection of their clients and themselves (Muza, 2020). As we move into a post-pandemic era, however, it appears that online classes may be here to stay (Pasadino et al., 2020), as online avenues for seeking information are a popular choice for parents-to-be (Bäckström et al., 2022; Roch et al., 2018). Thus, it is of utmost importance that instructors have the tools they need to design effective online classes to meet the needs of a new generation of parents. This article brings together the literature on active learning and online childbirth education to offer suggestions for designing effective virtual childbirth education classes. The author further details specific learning objectives relevant to childbirth education together with active learning activities for meeting those objectives in online perinatal classes.

Active Learning

Active learning is an instructional practice that asks the student to engage in the process of learning; essentially, a “learning by doing” approach (Ribeiro-Silva et al., 2022). Examples of active learning include a wide array of classroom activities, from discussions to model building, debates, and writing and sharing exercises. Active learning contrasts with traditional didactic approaches to teaching in which students passively receive information from the instructor. Rather, active learning encompasses student-centered learning in which the teacher guides student learning through discussions, problem-solving, and “doing things” in the classroom, all of which allow participants to engage with course content at a deeper level (Freeman et al., 2014; Ribeiro-Silva et al., 2022).

Active learning is based on the idea that “learning occurs when students are actively engaged in their educational process and can connect meaning with knowledge through experience” (Allsop et al., 2020, p. 418). The theoretical foundations of active learning trace back to Piagetian concepts of “constructivism,” namely, the concept that students must actively construct their knowledge for it to be lasting and meaningful. Key components of the constructivist philosophy are that students gain knowledge via an iterative process wherein they learn new information, relate it to their prior knowledge and understandings, and integrate and update their old knowledge structures (Allsop et al., 2020).

Student engagement with others in the classroom environment is also important in this form of learning, as students interact with classmates to gain new insight into class concepts and learn from one another. The instructor facilitates these interactions between students but does not necessarily dictate them. Instead of telling the students, the facilitator asks questions to prompt the students’ discovery of the information, either individually or within a group conversation (Brame, 2016; Wang et al., 2022).

An extensive body of research has been developed over the past 35+ years about the effectiveness of active learning within the face-to-face environment for adult learners. Students whose instructors utilized active learning techniques felt more inclined to participate, were more positive about their communication with other students and the teacher, and indicated a greater level of sense of community and connectedness in the classroom compared to students in a traditional lecture format (Allsop et al., 2020).

Moreover, as researchers have predominantly evaluated active learning in college courses, they report that students in such classes perform significantly better on tests of knowledge compared to those in which the instructor utilized a traditional lecture format (Theobald et al., 2020). Students also demonstrate greater knowledge retention and greater overall learning (Allsop et al., 2020). Although childbirth instructors do not typically give exams on course material, it is helpful to know that this form of teaching does lead to more lasting knowledge for participants. Thus, the concept of active learning can be valuable for the childbirth instructor as they seek to design effective and meaningful experiences for their class participants.

Online Childbirth Education

Traditional childbirth classes such as the Bradley method (Hathaway & Hathaway, 2002) and Lamaze (Lamaze, 1972; Lothian & DeVries, 2017), as well as more recent programs such as Birthing from Within (England & Horowitz, 1998) and mindfulness-based education (Shorey et al., 2019), were all developed in the context of face-to-face classroom interactions and primarily as group-based classes (Fernández-Arroyo, 2019). Classes typically incorporate a teacher who encourages active participation from class members, guiding them in experiential learning practices. Participants may practice labor positions or breathing techniques, discuss coping mechanisms with peers, or participate in role-playing activities. Indeed, research suggests that women prefer classes that offer opportunities to interact with each other and the instructor and to link the learning material to personal situations (Hadjigeorgiou, 2022).

However, in recent years, there has been a dramatic increase in online learning opportunities for expectant parents, driven both by parents seeking this option and by the necessities of the COVID-19 pandemic (Chae & Kim, 2021; Mousavi et al., 2022). Thus, there is a need to adapt traditional childbirth classes to the online environment in a way that is both effective and impactful for parents. Pasadino et al. (2020, p. 369) report that “the delivery of information via a virtual modality may be preferable with this generation of expectant families”. To this point, Farewell et al. (2021) found that 45% of mothers in their study of 27 couples enrolled in a perinatal mindfulness-based course preferred remote participation to in-person learning in their evaluation of a remotely birthed mindfulness perinatal class, and one-third had no preference. Forty-six percent of participants also reported that their ability to participate was increased due to the online format of the course, and 36% reported no impact due to the online nature of the class. Participants reported that synchronous sessions with the instructor were most helpful, whereas homework assignments between sessions were least helpful. In general, online childbirth education also has the added benefit of reaching populations currently underserved by traditional in-person classes, such as working families, those with language differences, and rural families (Mueller et al., 2020).

Minimal research has been conducted on effective approaches for perinatal education online, despite its potential advantages. The sudden move to the online environment precipitated by the COVID-19 pandemic also meant that many instructors began teaching online with potentially little to no experience in this format (Kim, 2022; Muza, 2020).

Teaching online is a qualitatively different experience for the instructor than teaching in person, and the activities used in face-to-face teaching do not necessarily translate well into this virtual space. In the case of perinatal education, demonstrations, active practice of positions with direct feedback, modeling, visuals such as pelvis models and baby dolls, and games may prove ineffective in the online environment if not adapted for an online context. Indeed, as noted by Brewer and Brewer (2015), replication of the face-to-face classroom is not the goal of online education in general. Rather, there can be more than one path to achieving educational objectives.

What is the path to achieving effective online learning in virtual childbirth classes? The literature on effective pedagogical practices in online classes for adult learners suggests the importance of several key factors: the social presence of the instructor, implementation of activities that allow for student interactions and collaborations, and offering of learning opportunities that draw upon the participants’ personal experiences.

Instructor social presence in an online course involves being actively engaged in the learning of the students—participating in discussions, being responsive to questions, and setting the tone of interactions in the class (Gimpel, 2022). Instructors can increase social presence, defined as the extent to which students feel emotionally and socially connected to the instructor and others in the class (He et al., 2019), by addressing students by name, encouraging their participation with facial and verbal cues, acknowledging their contributions, and clarifying and summarizing content (Tyrväinen et al., 2021). Şat et al. (2022) also note how ice-breaker activities to introduce students to each other are an important aspect of building an online community and are also a practice students report finding very helpful (Martin & Bolliger, 2018). Lastly, instructors can make the chat feature available on the online platform, get to know the backgrounds of the participants (perhaps through an initial registration survey), and encourage having open student and teacher webcams (Khan et al., 2017, 2022).

In classes built around active learning practices, the environment that the instructor establishes is particularly important. The instructor must work to create an environment where students feel comfortable discussing and interacting with others, as this is an important aspect of how students generate knowledge. However, when instructors ask students to share openly in a class setting, participants may experience feelings of unease and shyness. If students are to genuinely engage and actively participate in the creation of their knowledge and understanding, it is the role of the instructor to create a safe environment for all without “threat of embarrassment or shame, or fear of being made to feel uncomfortable in sharing with others” (Wang et al., 2022, p. 6). Instructors can work to create this environment by asking open-ended questions, being supportive of all attempts to participate, allowing time for participants to frame responses, and being authentic in interactions with the participants (Wang et al., 2022).

It is equally important for facilitators of a childbirth education class to engage partners along with the birthing parent so that partners feel invested in the course content. When partners are engaged in childbirth education, research suggests that they are more confident and more capable of assisting the birthing parent during labor and childbirth (Hauck et al., 2016; Urso, 2016). Essentially, instructors in online, active learning childbirth classes must create spaces and opportunities for interaction and learning to occur authentically (Wang et al., 2022).

Collaborative learning is also a key element of active learning in online education. Collaborative tasks provide opportunities for expectant parents to interact and share ideas and offer an effective means of building community in the online setting (Saldanha et al., 2021). Indeed, many parents come to childbirth education classes with the primary goal of meeting and connecting with others, even more so than learning practical knowledge of childbirth. Collaborative tasks in the online class can help fulfill this need (Jones et al., 2019). Opportunities for collaboration in an online class typically need to be designed intentionally by the instructor, as the virtual format may not naturally lend itself to such interactions. However, by utilizing open-ended discussion prompts, small group breakout rooms, and collaborative problem-solving, the childbirth instructor can incorporate cooperative activities into an online class.

Finally, active learning also involves drawing upon participants’ existing experiences and relating new content to this knowledge base (Allsop et al., 2020). In childbirth education classes, instructors are particularly teaching adults who have their own unique viewpoints, values, and needs as they approach their births, and the role of the instructor should be to guide and facilitate self-discovery in the learning process. Instructors can promote such a process by discussing realistic scenarios (Martin & Bolliger, 2018), tying material back to personal values, or allowing for a participatory approach to knowledge generation (Wang et al., 2022). In an effective online childbirth education class, the instructor recognizes the full range of experiences and knowledge that the participants bring to the class and draws these out to challenge, shape, and introduce new knowledge.

TIPS FOR DESIGNING ONLINE CHILDBIRTH EDUCATION CLASSES

Research has shown that careful planning, effective use of a range of technologies, and authentic social communication can all support the successful transfer of knowledge and the development of trust in the online environment (Brewer & Brewer, 2015; Gimpel, 2022). There is an array of techniques available to the online instructor, but for any educational endeavor, the most critical step is to first identify the learning objectives of the course. For instance, the instructor should identify specific topics for the course and expected learner outcomes. Once the instructor has identified these specific objectives and outcomes, then the instructor can apply the principles of active learning to determine activities that best meet these objectives.

Below are some common learning objectives for online childbirth education classes and possible methods for achieving these objectives with active learning techniques. These suggested activities are meant to serve as ideas for instructors and can be modified as per the needs of a specific class. They are by no means the only options for meeting these learning objectives. An overview of the objectives and accompanying suggested activities is available in Table 1.

TABLE 1. Sample Learning Objectives and Associated Active Learning Activities for an Online Childbirth Education Class.

Learning objective	Sample activity
Students recognize their perceptions of the birth process	Creation and discussion of a “word cloud” figure following the collection of participant-generated words related to labor and birth
Participants correctly organize a timeline of labor events	Use of a virtual whiteboard with “post-it” style notes that participants arrange in the correct order of labor events
Participants describe coping mechanisms for the transition to the birthing location	Use a virtual background of a hospital room to discuss arrival at the birthing location, followed by a group discussion
Participants identify comfort measures to help them during labor and birth	Participants collect personal comfort items from their home environment and share these with the class in a small group discussion
	Sharing a childbirth video and asking participants to note each example of a comfort measure they observe in the film, followed by a group discussion

Objective 1: Students Recognize Their Perceptions of the Birth Process

One learning objective that instructors may have, particularly early in a class, is to get students to recognize the beliefs, biases, and personal perceptions of birth that they bring to the class. The instructor might work to enhance participants’ self-awareness and pave the way for new learning to occur. Instructors can facilitate discussion on this topic through the following technique:

The instructor asks participants to complete an online survey at the beginning of a new class series. One easy format for doing this is through the creation of a Google form (or an alternative free platform such as SurveyMonkey). In one of the survey items, participants generate words or phrases that come to mind when they think of labor and/or birth. The instructor then takes the results of this survey item and creates a “word cloud” to discuss at the next session. A “word cloud” is a graphical depiction of qualitative data, such that words that respondents mention more frequently are larger and words that appear less frequently are represented in smaller text (see Figure 1).

Figure 1. Sample “word cloud.”.

Note: Example word cloud reflects words generated in response to the question, “Please list words that come to mind when you think about labor and/or childbirth.” Words in larger font represent words mentioned more frequently, and smaller font words reflect words mentioned less frequently.

Once the instructor generates the word cloud using either an online tool or a word processor add-in, the instructor can invite discussion from participants about words that appeared in the image and how this informs their emergent thinking about their expectations. The instructor may ask participants to think about why some words are more salient than others, what changes they would like to see in their perceptions by taking the class, how perceptions can drive expectations, and so forth. Furthermore, discussions can be held initially in small breakout rooms to facilitate participants getting to know one another and initiating community building; participants can then share with the larger class what occurred in their small group discussions (Khan et al., 2022). Such a technique of having small groups discuss a topic, followed by a larger group discussion led by the instructor, is a recommended pedagogical practice in active learning, as it allows students to process and form connections to material in a low-pressure interaction with a peer (Brame, 2016).

Objective 2: Participants Correctly Organize a Timeline of Labor Events

For learning objectives that involve getting students to understand the ordering of events, such as the sequence of events in labor, one technique is to take the idea of sticky notes on a board directly to the online environment. In an in-person classroom, for example, the instructor might write a description of an event on a sticky note and ask students to move the sticky notes around to demonstrate their understanding of how events may unfold during labor in a timeline activity. However, in the online environment, students cannot physically manipulate sticky notes, so the online instructor must look for an alternative.

For this activity, the instructor puts students in small breakout groups and shares a link to a Google “Jamboard” (Ahshan, 2021). The Jamboard is essentially a virtual whiteboard space on which the instructor can leave “post-it” style notes and students can comment, move the notes around, or add their own notes. After a brief overview of the events leading up to labor and then labor itself, students can work in breakout rooms to sort interventions into a timeline. On the Jamboard shared with each breakout room via a link, the instructor pre-places a random assortment of labor events in a random order. Students then re-arrange the events in order of first to last. Once students complete this activity, they can then reconvene with the other participants and the instructor to discuss their observations, get questions answered, and so forth. This activity is useful in that it encourages collaboration and discussion among participants, thus creating a greater sense of community in the online environment. It also allows students to apply and deepen their newly gained knowledge, promoting greater mastery and long-term learning. A similar activity could be designed to teach students how interventions early in labor can lead to further interventions later in the process, typically referred to as the “cascade of interventions” in childbirth classes.

Objective 3: Participants Describe Coping Mechanisms for the Transition to the Birthing Location

In this activity, the instructor can use what they have available in the online environment to their advantage to meet this learning objective. When discussing how participants might feel as they arrive at and transition to the hospital setting during labor, the instructor can share an image of a hospital room or, more effectively, can change their virtual background on their screen to discuss how it might feel to enter the birthing space they see represented on the screen surrounding the instructor. This technique allows students to actively envision themselves in the environment and discuss how they might feel. The instructor can then move them into a discussion of how to make a place feel safe and comfortable for their own birthing needs, such as by bringing in familiar objects, using dimmed lighting, and so forth.

One of the advantages of the online environment is the ability to use imagery to reach participants on an emotional level, engaging them visually as they begin to imagine themselves in their birthplace with their labor underway. By getting students to focus on these images, envision themselves in such an environment, and then relate this personal imagery to draw out their understanding of class concepts, the instructor can effectively use active learning to get students to process the course information in a more complex manner. It also allows for an entry into a discussion of coping mechanisms to help ease this transitional time from home to birthing location.

Objective 4: Participants Identify Comfort Measures to Help Them During Labor and Birth

One of the most common topics covered in childbirth education classes is to introduce expectant parents to comfort measures that they might use during labor and birth. Instructors teach this topic in a variety of ways in antenatal classes, but all classes can benefit from active engagement from participants. The techniques used in face-to-face classes often involve distributing objects, such as birth balls or massage instruments, and allowing class members to practice with tools. In conjunction with this, instructors may also demonstrate comfort measures themselves and encourage participants to practice on their own with feedback from the instructor. Some of this may translate well into the online environment, but often the tried and true techniques of the face-to-face classroom fall flat when moved online, as participants are not able to touch and feel the materials as they would in an in-person class.

To address this issue, the instructor needs to be creative about how to use the online environment to effectively teach participants about this topic in an engaging and active manner. One technique is to have the expectant parents think about materials they already have on hand in their home environments, where they are likely to be joining the class and bringing these to the online class. On the screen, they can share these items with others and discuss them in a group setting. For example, some participants may bring to the class meeting favorite pillows, music, candles, massage rollers, comfortable clothing, and so forth, all of which can be discussed in the context of how to bring comfort to a laboring parent. Sharing ideas like this in the community with other parents can also serve the purpose of strengthening relationships, cross-pollination of ideas, and increasing collaboration among class participants.

Another technique is to use video to demonstrate the use of comfort measures. For example, after presenting and discussing an array of comfort techniques in class, many of which might be self-generated by participants, the instructor could use a birth video as a teaching aid. During the video, the instructor might ask participants to create a list of any comfort measures they notice in the video. In doing so, participants can deepen their understanding of comfort measures by observing and then actively recognizing and noting the many ways in which comfort measures can be employed during a birth. Following the video, the instructor can lead the class in a discussion regarding what students observed in the video, pointing out aspects that participants might have missed or expanding on techniques that parents may practice on their own.

IMPLICATIONS FOR PRACTICE

Teaching online is a qualitatively different experience than teaching in person, and effective activities from face-to-face classes do not necessarily translate well into this new virtual space. Indeed, replication of the face-to-face classroom is not the goal of the online childbirth instructor. Instead, a comprehensive understanding of the pedagogical elements of active learning can provide a foundation for re-imagining an effective online class. Active learning is an instructional practice that asks the student to engage in and construct their own understanding of a concept, essentially, a “learning by doing” approach. Through active learning techniques, such as creating a positive instructor social presence, implementing activities that allow for interactions and collaborations among class participants, and offering learning opportunities that draw upon the participants’ personal experiences, the online childbirth instructor can design classes for a deeper understanding of course concepts for long-term learning.

CONCLUSION

In brief, there are a variety of techniques instructors can utilize to achieve learning objectives in their online childbirth education classes. Recent technological advances, such as virtual meeting platforms, online whiteboards, breakout rooms, and interactive polls and videos, can be used effectively to add engaging and meaningful learning opportunities to online classes. However, Khan et al. (2022) also recommend that the instructor be cognizant of the weariness that can occur with too much screen time during an online class. Thus, implementing mini yoga or stretch breaks throughout a lengthy class session can be useful for maintaining the energy level of the class.

In many cases, the specific method used to achieve a learning goal is less important than allowing for the basic need of engagement and communication between the instructor and the attendees and among the attendees themselves (Vlachopoulos & Makri, 2019). The overarching goals of online childbirth classes should remain like those of in-person classes, namely, to engage participants in a community so that their fears and anxieties are alleviated as they grow in knowledge and confidence in meeting their birth goals.

Biography

JENNIFER M. WEAVER is a developmental psychologist and a certified childbirth educator.

Funding Statement

FUNDING The author received no specific grant or financial support for the research, authorship, and/or publication of this article.

DISCLOSURE

The author has no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.