Parenthood Education in Swedish Antenatal Care: Perceptions of Midwives and Obstetricians in Charge

Abstract

The aim of this study was to describe perceptions of parenthood education among midwives and obstetricians in charge of antenatal care in Sweden. Focus group interviews of 25 obstetricians and midwives were conducted. Data were analyzed with a phenomenographic approach. Five main categories emerged: aim of the parenthood education, content and expectations, implementation, support to group leaders, and strategies for the future. There is a strong belief in parenthood education, and the overall aim was considered to be support in the transition to parenthood. Contents should focus on awareness of the expected child, confidence in the biological processes, and the changes of roles. Pedagogies training, cost effectiveness, development, and the need to reach target groups were emphasized.

INTRODUCTION

Education programs aiming to prepare parents-to-be for childbirth and the specific psychological and social aspects of parenthood are important parts of psychosocial preventive health care during pregnancy. According to the World Health Organization, the aim of antenatal care (ANC) is to assist women to remain healthy, to find and correct adverse conditions when present, and thus to aid the health of the unborn. ANC should also provide support and guidance to the woman and her partner or family to help them in their transition to parenthood (Chalmers, Mangiaterra, & Porter, 2001; World Health Organization, 2002, 2003).

In 1997, the Swedish Department of Health published a survey on parental education which drew attention to the need to promote the inquisitiveness, capability, and competence of the pregnant woman and her partner in the parenthood education program (Statens Offentliga Utredningar, 1997). The word “empowerment” was used to describe the desired level of parental participation. In addition, the Swedish national guidelines on public health highlight the importance of society's role in providing support for parents to improve children's position (National Institute of Public Health, 2003). The guidelines also emphasize that society's support should be based on parental participation.

Parenthood education in Sweden is a well-integrated part of the routine ANC system and is led by midwives. Around 80% of all first-time parents participate in the program (The Swedish Society of Obstetrics and Gynecology, 2003). Parenthood education classes (PEC) most often take place during the latter part of pregnancy. The design of the program may vary, from smaller groups to bigger classes. Although education programs for childbirth and/or parenthood are abundant and attended by a large percentage of pregnant women worldwide, their effects on knowledge, anxiety, sense of control, labor and birth support, pain, breastfeeding, infant-care abilities, and psychological and social adjustment still remain largely unknown (Gagnon & Sandall, 2008). In a Swedish cohort study, researchers found that participation in PEC during pregnancy did not seem to affect first-time mothers' experience of childbirth and assessment of parental skills (Fabian, Rådestad, & Waldenström, 2005).

Further research is required to ensure that the resources used for parenthood education programs meet the needs of parents and their newborn infants. To do this, it is important to analyze the opinions and the effect of PEC among parents-to-be and among the decision makers. The aim of this study was to describe perceptions of PEC among midwives and obstetricians in charge of ANC in Sweden.

METHODS

Focus group interviews were chosen for the collection of data. This method is useful for collecting data about attitudes, perceptions, and experiences (Kreuger & Casey, 2000; Morgan, 1997).

Study Sample, Procedure, and Measures

Thirteen midwives and 12 obstetricians responsible for ANC and parenthood education in Sweden were included. The midwives were aged between 39 and 64 (median 50) years old and had between 10 and 40 (median 25) years of experience. The obstetricians were aged between 48 and 63 (median 54) years old and had practiced between 6 and 34 (median 28) years. Four focus group interviews were conducted during the annual national meetings for managers of Swedish ANC in 2004. The sample selection (N = 25) was created by a strategic national range, and the participants constituted 26% of all the decision makers in Swedish ANC. Participating decision makers constituted a mix from rural and urban areas, from large and small ANC programs in various parts of Sweden, and of different ages. Overall, participants represented different ages and were responsible for large and small ANC programs in various parts of Sweden. The obstetricians were of mixed gender. All midwives were female. The participants received oral and written information before giving their consent to participate.

Two trained researchers conducted the focus group sessions. One stimulated the discussion by means of open-ended questions, and the other took detailed notes. There were two groups of obstetricians with six in each and two groups of six and seven midwives, respectively. The sessions lasted 1–1½ hours and were audiotaped.

The focus group discussions were transcribed and analyzed using the phenomenographic approach (Marton, 1981; Marton & Booth, 1997). The interviews were read several times, and answers to the same question from the different groups were horizontally compared. Categories were formed according to essential similarities. Finally, a comparative analysis focusing on differences between categories was performed. The objective was to establish a set of categories that accommodates the various qualitatively different views of the topics discussed and, yet, preserves the individual traits of the answers provided (Sjöström & Dahlgren, 2002). Each category describes a perception of the phenomena in question. Two researchers were involved in the analysis: one midwife and one educational psychologist. Proposals were discussed until agreement was reached about the final categorization. This process is called “negotiating consensus” (Wahlström, Dahlgren, Tomson, Diwan, & Beermann, 1997). A third researcher read the categories independently.

Ethical Considerations

The study was approved by the Regional Ethics Committee for human research of the Faculty of Health Sciences, Linköping University.

FINDINGS

Five description categories and 20 subcategories emerged from the analysis (see the Table). Quotations, identified in italics, illustrate the findings.

TABLE.

Distribution of Description Categories and Subcategories

Description categories	Subcategories
Aim	Transition to parenthood
	Confidence in the biological process
	Preventing psychological ill health in children
	Health education
Contents and expectations	Awareness of the expected child
	Confidence in the capacity of the body
	Introduction to parenthood
	Preparation for giving birth
	Roles and relationships
	Women's knowledge
Implementation	Pedagogies
	Group processing
	Availability
	Financing
Support to group leaders	Evaluation, research, and development
	Dialogue
	Difficulties in changing
Parenthood education for the future	Activity structures
	Target groups
	Collaborators

Aim

Four overall aims of parental education were identified, as described below.

Transition to Parenthood

When two individuals enter into a new caring and supporting relationship, supporting transition to parenthood is a fundamental element in their education. Parenthood is a lifelong commitment.

…our most important task is to support the parents into parenthood, in the great transition…from life as an individualist to life as parent… .

Confidence in the Biological Process

Parenthood education should strengthen confidence in the biological process among today's parents-to-be. Their ability to control the process of childbirth and parenthood is limited, a fact that may be hard to accept.

…something beyond control… it is not information they need…they need confidence.

Preventing Psychological Ill Health in Children

Caring for the children's psychological well-being is central to parenthood education. Respondents emphasized the importance of parent-child attachment and the prevention of psychological ill health in children. A harmonious first year is crucial to a child's future development.

…one of our most important obligations is to reflect on what can be done for children's psychological well-being.

Health Education

The respondents stated that parenthood education is health education as well as health promotion.

…we have to think prevention…our responsibility is to be health educational… a public-health approach.

Contents and Expectations

There are several key issues to cover in parenthood education, as described below.

Awareness of the Expected Child

Many parents-to-be are stressed by the strain of working life and societal expectations, which may interfere with their everyday life during pregnancy. Parenthood education can reduce some of this stress by helping the participants to develop an awareness of the child and the competence of the child in the woman's womb.

…it is important to talk about the child in the womb…what it looks like… and the dreams about it…to recognize the child.

Confidence in the Capacity of the Body

Parenthood education should strengthen the confidence of the parents-to-be in their body's capacity to handle the process of childbirth.

What they need is confidence in their own capacity and faith in the child's resources… that it will work.

Introduction to Parenthood

Many future parents think of parenthood as something that develops spontaneously when the child is born. To bridge this gap and support the transition, parenthood education must challenge the participants to reflect and talk about parenthood during the pregnancy.

The psychosocial part of the parenthood should be in focus, according to the national recommendations.

Preparation for Giving Birth

Parenthood education should bring up aspects such as different phases of the labor process, pain relief, breastfeeding, and psychological reactions in giving birth.

…give them knowledge, tools, to handle the delivery in order to prevent bad experiences.

Roles and Relationships

There is value in emphasizing the changes of roles and relations related to parenthood. Part of this is to highlight questions about gender perspective and sexuality, both during the pregnancy and as parents.

…the men's situation must be affirmed…we must involve men to a greater extent, they must not feel marginalized.

Women's Knowledge

An important theme is the unique women's knowledge about the transition to motherhood and the care of an infant. Today, many mothers-to-be live far from their relatives, and their stay in the postnatal ward is brief. The knowledge they need can be communicated through networks, which are formed during parenthood education.

…in those days there was a grandmother, a mother, and sisters… and they kept contact with other new mothers from the postnatal wards….

Implementation

Parenthood education in various groups can be organized, designed, and performed in different ways.

Pedagogies

The respondents related to different pedagogical approaches to increasing knowledge for parents-to-be. The participants' questions must be the starting point, instead of lecturing based on what the leader thinks is important. Sharing experiences and learning from each other, according to their knowledge, were considered positive. Parents-to-be should have the opportunity to discuss various aspects of parenthood as well as to be given information they cannot find themselves.

Group sessions are far more useful than lecturing in a huge class… the dynamics in the group is important… let the questions grow out of their knowledge, experiences, need, and requests.

Group Processing

The group process is a dynamic process, and the group leaders need to have skills to support this process. The group leader should function as a moderator rather than a lecturer, raise questions, guide discussions, initiate reflections, and help the participants to feel secure. This may stimulate further discussions between participants at home and may increase their critical thinking and willingness to seek additional knowledge even after completing the parenthood education. In the fathers-to-be groups, male leaders are recommended as mandatory.

…these group contacts can be a very important way of attaching to others for social contact and support…belonging is important… .

Availability

The respondents emphasized the importance of providing an activity that meets quality standards but is attractive in time and content to today's parents.

…if the health and welfare authorities cannot provide them with what they need, they will look for it elsewhere….

Financing

Finances are a harsh reality. In times of cost-cutting efforts, it is necessary to fight and prevent diminishing of programs. An urgent issue is to keep and develop good quality and cost-effective parenthood education.

Support to Group Leaders

Procedures were presented to facilitate and inspire group leaders with a focus on group processes, suitable pedagogical methods, and counseling. The aim is to prevent exhaustion among group leaders and to develop programs that correspond to the assignment and demands of the participants.

Evaluation, Research, and Development

It is essential to measure and report the results of parenthood education. Therefore, evaluation systems, quality assurance, and various research projects must be developed.

Research is important… we must provide evidence that parenthood education has effect…just not that we can feel this… it is not easy to demand resources for something we do not evaluate.

Dialogue

The group leader role offers two-way communication. The leader may be an expert on the actual subject but may not necessarily know what parents of today think. This dialogue to gain knowledge is a useful support for group leaders.

Difficulties in Changing

It is important to increase the status of PEC among midwives. Adding functional pedagogical methods, knowledge, and support may strengthen group leaders.

…week after week, year in and year out, have to do it all alone…use the same old routine… lecturing. We midwives are so determined and conscientious… we should let go a little bit…support each other to consider this work desirable and as competence development.

Parenthood Education for the Future

Three aspects of parenthood education in the future were highlighted, as described below.

Activity Structures

It is a duty to support and develop parenthood education within ANC, and future activity must focus on current demands using the concept of support rather than education. Parenthood sessions are, and probably will be, an expanding area within other organizations, with a wider range of topics than is currently arranged by the health and welfare authorities.

We have to make this very clear to the decision makers that this is one of our most… important assignments… it cannot be dismissed… nor handed over to educational program associations.

Target Groups

Should parenthood sessions be for all parents-to-be or for special target groups? Some parents mainly need knowledge, whereas others need more emotional maturity. Discovering those who are in the greatest need of parenthood support and encouraging participation is part of the assignment.

…an equivalent but not necessarily uniform parenthood education for all…how to engage those who have the highest needs…that is our utmost challenge.

Collaborators

Cooperation with child health care and family centers to establish early contact during the pregnancy is important. Other collaborators include physiotherapists, preschools, social services, and welfare officers. Collaboration is one way to work in the future to best utilize each collaborator's area of competence and to be more cost-effective.

Midwives are excellent but cannot be experts on everything… what can be done better by other caregivers we cooperate with… we should concentrate on our field of expertise.

DISCUSSION

The major results in this study are the strong belief in PEC during pregnancy and that PEC is considered to be an important part of the transition to parenthood. The high attendance rates in parenthood education indirectly function as a marker of its importance for parents-to-be (The Swedish Society of Obstetrics and Gynecology, 2003). Regarding the outcome of parenthood education programs, the interviewees focused on the parents' transition to parenthood. Becoming a parent is a passage from one phase in life to another. Transition is a well-known phenomenon and has been studied by numerous researchers (Meleis, Sawyer, Im, Hilfinger Messias, & Schumacher, 2000; Schumacher & Meleis, 1994). Their findings define the transition as changes in abilities or as a passage from one life phase and condition or status to another. A good transition is influenced by several factors such as expectations, levels of knowledge, and the parents' environment.

The respondents' perception is that good education can promote the transition to parenthood. The transition for first-time parents presents a huge change in the relationship. Thus, parenthood education can be a vital key to sustaining and providing parents with knowledge about how to keep their relationship intact (Ahlborg, 2004).

Parenthood education programs and the design of the classes ought to apply to both women and men. There is an increased awareness of the father's role as an active parent in upbringing, establishing standards, and promoting emotional development (Hwang & Wickberg, 2001). Political initiatives such as legislation on parental leave to facilitate the father's participation in both the pregnancy and in taking active care of the child underscore this (Hallgren, Kilgren, Forslin, & Norberg, 1999; Hwang, 2005). There is concern among midwives that fathers-to-be should be included in ANC and parenthood education (Statens Offentliga Utredningar, 1997). From a gender perspective, this is a challenge for ANC because the programs traditionally focus on women's issues. The respondents' opinions were that having male leaders for the father-to-be sessions is very important, but such sessions are not sufficiently available. In Australia, parenthood education programs have used father-facilitators with good results (Friedwald, Fletcher, & Fairbairn, 2005).

Our findings illustrate various aspects concerning pedagogical methods and useful focus in parenthood education programs, highlighting a change from one-way teaching to group activity. Holding the PEC in groups is in line with guidelines from the Swedish National Board of Health and Welfare (Statens Offentliga Utredningar, 1997). Group activities have been used in several education programs with good results, which can be explained by learning processes focusing on adult learning (Lindroth et al., 1997; Schlundt, Flannery, Davis, Kinzer, & Pichert, 1999; Tingström, Kamwendo, & Bergdahl, 2005).

It is also necessary to bring parenthood education in line with the needs of today's parents-to-be. The opportunity to easily find information (more or less evidence-based) via the media and the Internet is far-reaching and should influence the content and implementation of PEC.

Pedagogical methodology is crucial, and parenthood education leaders must be given the opportunity to acquire and develop skills. Instead of one-way lecturing, the leader should guide the group process in order to gain reflection (Fyrenius, Bergdahl, & Silen, 2005). Interviewees expressed the need for continuous evaluation and further research. This was viewed as a need to provide evidence that parenthood education has effect, but also as a possibility to develop pedagogical competence.

Establishing a sustainable social network was also considered important. Formerly, parenthood skills were passed down through the parents' social network. Today's generations often lack that kind of network. Meeting others in the same situation is an important source of support, and parents-to-be can exchange experiences and learn from each other (Fyrenius et al., 2005). The respondents stated that finances and cost-effectiveness are stark reality. According to the Swedish National Board of Health and Welfare (Statens Offentliga Utredningar, 1997) and the Swedish National Institute of Public Health (Bremberg, 2006; National Institute of Public Health, 2003), the aim is to give parents and children a better situation in society. If parenthood education programs could promote a healthier transition to parenthood and help parents remain parents for life to a greater extent, they would be cost-effective.

Because parenthood education is relatively uninvestigated, a qualitative method was used in this study. Data were collected in focus groups, a well-established method in research and used especially to acquire a deeper understanding of different perceptions (Kreuger & Casey, 2000; Marton & Booth, 1997). A strength of our study is the strategic national range and that the participants constitute one fourth of all decision makers in Swedish ANC. A questionnaire study might have permitted a greater number of participants, but with more shallow information and without the interaction of the interviewees (Kreuger & Casey, 2000).

The parenthood education program must be in accordance with the national recommendations (National Institute of Public Health, 2003; Statens Offentliga utredningar, 1997). Further, it should be founded on evidence and justifiable with respect to cost utility (Bremberg, 2006). To date, most studies have focused mainly on birth outcome in relation to parenthood education (Bremberg, 2006; World Health Organization, 2002). A systematic evaluation of the qualitative effect of parenthood education concerning the transition to parenthood is a challenge.

Creating a parenthood education program that suits all participants, with their various expectations and needs, is a major challenge. Interviewees highlighted the importance of giving attention to parents with special needs. Results from a Swedish cohort study showed that nonparticipants were, to a greater extent, mothers with a low level of education, who were unemployed, who smoked, and who were of non-Swedish background (Fabian et al., 2005). To discover why they did not participate or what would have led them to participate in PEC is a subject for further research.

CONCLUSION

There is a strong belief in parenthood education programs among Swedish ANC managers. Moreover, in addition to the need of pedagogical renewal, it is necessary to evaluate the effect and adequacy of the outcome in order to organize effective parenthood education programs. The present study provides the basis for further research.