ABSTRACT
The aim of this qualitative study was to explore the perception of women regarding long-term effects of childbirth education on future health-care decision making. This qualitative study used a purposive sample of 10 women who participated in facilitated focus groups. Analysis of focus group narratives provided themes in order of prevalence: (a) self-advocacy, (b) new skills, (c) anticipatory guidance, (d) control, (e) informed consent, and (f) trust. This small exploratory study does not answer the question of whether childbirth education influences future health-care decision making, but it demonstrates that the themes and issues from participants who delivered 15–30 years ago were comparable to current findings in the literature.
Keywords: prenatal education, self-advocacy, control, informed consent, self-efficacy
PROBLEM STATEMENT
Childbirth is a life-changing experience for women. The impact of this event raises the question, To what extent do perinatal experiences influence future health-care behaviors? Many women choose to attend childbirth education classes during pregnancy to prepare for this life-changing event. The aim of this qualitative study was to explore the perception of women regarding long-term effects of childbirth education on future health-care decision making.
This study builds on current knowledge of health behaviors to explore the relationship or long-term benefits of childbirth education to influence future health-care decisions. Cook and Loomis (2012) studied the extent to which birth experiences provide a sense of empowerment and reported that a woman’s recollection of her birth experience was more related to “feelings and exertion of choice and control than to specific details of the birth experience” (p. 158). Lampron (2002), in a shared experience of her journey through breast cancer treatments, expressed how this journey was easier because of skills learned during pregnancy and birth. She shared how coping strategies learned in childbirth are lifetime skills.
What health-care providers do not know is whether the process of using the knowledge, skills, and attitudes acquired during childbirth education inform future health-care decisions. If researchers can establish a link between participation in childbirth classes and future health-care choices, it would bolster the efforts of health-care providers to advocate for childbirth education. The number of first-time mothers attending childbirth education classes revealed a significant drop from 70% in 2001–2002 to 59% in 2011–2012 (Lothian, 2006). Those numbers are even lower now. Many factors have likely influenced dropping attendance rates. Although health-care providers continue to view childbirth education as valuable and important, as few as 11% of women viewed childbirth education as a routine part of pregnancy (Declercq, Sakala, Corry, Applebaum, & Herrlich, 2013). Childbearing years are often a first exposure to the health-care system and a lifetime of decision making. Few studies have focused on the influence of health-care activities during the childbearing years on future behaviors. The current literature provides ample support that careful medical attention during the perinatal period impacts future health risk factors. For this reason, if an opportunity exists during the prenatal period to empower women to take a more active role in future health care management, then this issue warrants further exploration.
Although health-care providers continue to view childbirth education as valuable and important, as few as 11% of women viewed childbirth education as a routine part of pregnancy.
THE THEORETICAL FRAMEWORK
The health belief model (HBM) provided a framework to understand what influences preventative health behavior. According to the HBM, preventative behaviors are influenced by five factors that include perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy (Glanz, Rimer, & Lewis, 2002). The relevance of the HBM, as it relates to prenatal education, is cues to action and self-efficacy. A cue to action is a concept defined as a strategy to activate one’s readiness. Pregnancy is an event that might trigger women to instigate an action such as participation in prenatal education classes. To have self-efficacy is to have confidence in one’s ability to take action and may mean a person believes that change of a specific kind will cause a desirable outcome at a cost that is justifiable. Is the decision to attend prenatal classes an attempt to influence a positive outcome, and does learned behavior influence future health-care practices?
Childbirth education provides women with the knowledge, skills, and attitudes to prepare them for pregnancy, labor and delivery, and early postpartum days. The literature provides limited insight into whether knowledge gained during childbirth classes actually translates into an improved ability to handle common pregnancy discomforts as well as feelings of empowerment. Exploration revealed a lack of consistency in defining childbirth education. Some hospitals advertise prenatal courses that include limited amounts of content, a quick tour of the facility, and an overview of the rules and routines of the facility. Some childbirth educators describe hospital-based courses as orientation to hospital rules on how to be a compliant patient. Conversely, the purpose for childbirth education according to the Lamaze International position paper is to “empower women to make informed choices in health care, to assume responsibility for their health, and to trust their inner wisdom” (Lamaze, 2013, p. 1). It is with this view that the researchers sought to understand if an improved sense of self-efficacy developed during childbirth education is of benefit later in life.
The purpose for childbirth education according to the Lamaze International position paper is to “empower women to make informed choices in health care, to assume responsibility for their health, and to trust their inner wisdom.”
RESEARCH QUESTION
The following question guided this qualitative study: How do women with a history of attending childbirth education classes perceive the influence of childbirth education during subsequent health-care decisions? This question directed the process to explore how women perceive what, if any, the impacts and/or long-term benefits of childbirth education are and if childbirth education affects subsequent health-care decision making.
The significance of the study was to determine the potential of childbirth education to empower women in future health-care decision making and to determine whether women perceive prenatal education as influencing their knowledge, skills, and attitudes toward participation in health-care decision making. Few studies have focused on the effects of childbirth education on self-efficacy later in life as women make choices related to their health care. Current evidence supports that childbirth education classes have an immediate impact during the perinatal period and thus have the potential to reduce exposure to adverse outcomes and rising costs related to medicalization of childbirth. Medical interventions, although sometimes useful to improve outcomes, in certain situations have become routine, and childbirth has become a medical condition rather than a normal physiologic event (Jansen, Gibson, Bowles, & Leach, 2013). In a recent survey of 100 leading health-care experts, the question of how to improve and provide high-value maternity care resulted in 11 critical areas in need of change (Jolivet & Corry, 2010). This list includes the need to improve decision making and consumer choice. Currently, women face a lack of balanced information about risks and benefits as well as alternatives during childbirth. In order for women to be true partners in the process of childbirth, decision making should not be because of institutional norms and preferences of the health-care providers.
A multidisciplinary committee created during a national Childbirth Connection symposium in 2009 prepared a blueprint to improve maternity care in the United States. According to Angood et al. (2010), in this action plan, in the section on decision making and consumer choice, expert recommendations for healthcare providers was to
1) expand opportunities and capacity for shared decision-making processes and to provide tools and resources to facilitate informed choices in maternity care; 2) design system incentives to reward provider and consumer behaviors that lead to healthy pregnancies and high-quality outcomes; 3) revive and broaden the reach of childbirth education through innovative teaching modalities and, 4) promote a cultural shift in attitudes toward childbearing. (p. S20)
If health-care providers determine that shared decision making during the perinatal period prepares a more informed health-care consumer, then perhaps a shift will occur to search for opportunities to build self-efficacy during the perinatal period and to encourage lifelong habits of participation in decision making.
METHODOLOGY
This study used a descriptive qualitative approach to data collection. The source of data was focus groups to provide an opportunity to collect descriptions of the lived experiences of women that had attended childbirth classes. This data collection related to a particular time—the perinatal period—and provided researchers with improved understanding of what shaped participants’ current health practices. Researchers employed an outside expert in leading focus groups using a set of expert-created semistructured questions. Data were stored on microcassettes and then transcribed for later analysis. Researchers used a process of content analysis to look for common themes among the transcribed narratives from the women in the focus groups. Because researchers found no recent studies that specifically examined long-term impact of childbirth education on health-seeking behaviors later in life, they used open-ended questions in each focus group to elicit experiential themes useful for future quantitative research.
Assumptions
These researchers acknowledge there are assumptions and bias among all researchers and this study is value laden because each of the researchers has personal experiences with childbirth and childbirth education as students, teachers, and/or attendees. The experiences as certified maternal child nurses potentially created additional bias. The use of an experienced focus group leader minimized researcher bias. Although findings are not generalizable, a careful approach to how researchers conducted the study and the process used for data analysis assisted the researchers in determining whether further quantitative research will benefit maternity care practices.
Participants
Researchers initially used purposive sampling to recruit women who attended prenatal childbirth education classes between 15–30 years ago. Ten women participated in this study recruited by flyers posted in the local community and by e-mail invitations. The university Institutional Review Board approved the study, and all participants provided informed consent. Participants initially completed a questionnaire at the onset of each focus group to provide demographic data. All 10 women self-identified as either White or Hispanic with an average age of 57 years, ranging from 43 to 65 years. The average number of deliveries reported was two. Five participants reported taking childbirth education classes in a hospital setting, one in a university setting, and four in either a community or private setting. Most participants recalled that the content of their education classes covered hospital procedures, infant feeding choices, pain control options, and newborn care with some emphasis on decision making. All participants practiced breathing and relaxation exercises.
Most participants agreed that their classes prepared them for their labor and delivery and that they remember participating in decisions regarding their labor and delivery. Seven women reported being satisfied with their birth experience, whereas three women were neutral or strongly disagreed. Six reported they have since attended other types of classes and/or support groups related to their own or their families’ health.
A Likert scale survey provided data regarding participants’ current health-care practices. Most participants described themselves as healthy and compliant in getting routine physicals. One participant identified herself as a smoker, and more than half reported they exercised regularly. Nine participants identified themselves as overweight or obese. All participants indicated they seek out information related to their own and their family’s health so that they could fully participate in their health care and that their families depend on them to find information to make informed health-care decisions. All participants either agreed or strongly agreed that they were confident in their ability to make health-care decisions for both themselves and their families.
Procedures
A panel of education experts created a questionnaire to guide the focus group interviews. Semistructured questions facilitated group discussion and allowed participants to talk freely. The environment was casual with participants sitting around a large table in comfortable chairs with a cassette recorder. Questions explored feelings, beliefs, and attitudes related to the phenomenon of having experienced childbirth education classes and investigated feelings, beliefs, and attitudes toward health-care decision-making practices. Researchers emailed content analysis results to the participants to seek confirmation or clarification of any findings.
The facilitator reviewed the consent form and purpose of the study. Participants completed a short questionnaire that introduced the topic and obtained baseline data on the participants’ knowledge, attitudes, and practices regarding childbirth education. After collecting the questionnaires, the focus group facilitator initiated discussion and instructed participants to respond to the open-ended statements listed on the Focus Group Facilitator Guide (Table 1). Each session lasted approximately 1.5 hours.
TABLE 1. Focus Group Facilitator Guide.
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Data Analysis
An experienced transcriber transcribed the recorded discussions verbatim. Members of the research team, working independently, wrote notes in the margins of a transcribed narrative and then compared those notes to arrive at key content and themes. Throughout the entire research process, the team focused on experiences related to childbirth and current health-care practices. A software program, Nvivo, assisted researchers to manage, analyze, and report on the unstructured data based on the transcribed narratives. After the team identified six themes, the team used a process of member checking of participants to review the results of the analysis to determine congruency with participant perceptions. Researchers placed narrative content into appropriate nodes to determine the prevalence of content to support the themes.
FINDINGS
The frequency that content in the narrative matched the themes were recorded in the software package. Themes as illustrated in Figure 1 were categorized in order of prevalence: (a) self-advocacy, (b) new skills, (c) anticipatory guidance, (d) control, (e) informed consent, and (f) trust. The more prevalent theme was self-advocacy.
Figure 1. Themes categorized in order of prevalence.
Self-Advocacy
Discussion revealed that participants learned of the need to be their own advocate. Many indicated that it was because of their experiences during childbirth that they learned to take action to have future input into decisions that affect their bodies. The concept of self-advocacy was evident as one participant describes how she learned to stand up for herself: “I just do not think I ever really stood up for myself, until I had her.” Another participant described how after her first childbirth experience, she had learned she needed to change and shared, “I went to [childbirth classes] to get prepared for the second one. Because I knew I had not been prepared for the first one.” Being proactive was a similar concept as one participant explained how she learned that to get the best care, you cannot just let things happen and stated, “I’ve learned to be a real advocate, big time!” Whether participants were discussing their own health-care needs, the needs of their children, or the needs of their extended family, the theme of self-advocacy was the most frequent theme.
The 2013 Listening to Mothers III (LTM III) provided valuable insight into more current experiences and perspectives of childbearing women in the United States. The lived experiences of the participant of the focus groups were compared to the results from this landmark survey. The importance of self-advocacy as reported during the focus groups versus current childbirth education classes may be an issue that has changed, evolved, or warrants further exploration. In the latest LTM III study, women cited the major focus of childbirth classes was on the labor and birth process and of what to expect when giving birth in the hospital. Only 20% of women reported that the major focus of their childbirth education included benefits and harm of each intervention (Declercq et al., 2013). With minimal exposure to the benefits and harms of interventions and options, it would be interesting to know if an emphasis on the need to advocate for oneself has lessened.
New Skills
“When I lay down at night, I realize she taught us how to relax from our toes,” stated one participant when asked what skills learned in childbirth classes do you still use. Another participant agreed that breathing and relaxation skills are part of her routine at night to relax and go to sleep. Another shared how she still uses conscious relaxation skills when she goes to the dentist for procedures. Empowerment as a new skill was prevalent among participants. A participant articulated the theme of empowerment when she shared that after delivering an almost 10-lb baby, “I can conquer the world” and after that experience, “no one was going to ever tell me what to do.” Reflecting back on her childbirth classes, one participant stated, “I took childbirth classes so I could have control over something that did not feel like I had control of . . .”
Anticipatory Guidance
The research team was not surprised that anticipatory guidance was a theme that emerged especially because it related to attending childbirth classes because the reason most women attend childbirth education classes is to receive guidance in anticipation of childbirth. The theme of anticipatory guidance found support in the comment, “I knew that my teacher was a nurse, and so she knew what she was talking about.” Another participant shared “I think the childbirth classes just made me feel safer with my body.” One woman stated, “Classes helped me know what questions to ask, what to be curious about, and therefore, I could be informed about who I trusted.” Some participants reported fear as a motivation for attending childbirth education classes as they sought out guidance in anticipation of childbirth. Participants stated,
I was just scared to death just being pregnant.
It was really hard for me because I just had no clue what to expect.
I felt really prepared and I think we all have that intent and then you get to the hospital and that is when things start not going well.
According to the 2013 LTM III survey, mothers continue to list anticipatory guidance up to 70% of the time as a reason to attend childbirth education classes. Experienced mothers listed childbirth education classes, second only to their providers, as an important source for information. Usefulness of childbirth education classes to provide anticipatory guidance on drug-free methods for labor pain relief was also evident in the survey. More women who took childbirth education classes listed drug-free methods for pain relief such as breathing techniques, massage, visualization, birth balls, or immersion in a tub or pool (Declercq et al., 2013).
Lothian (2006) stated that women who took childbirth education classes in the past are not of the same mindset as pregnant women today. Today, many women do not trust their bodies and consider labor and delivery to be a medical condition, not a natural process. The acceptance of the medicalization of childbirth is at an all-time high. Mixed into the dialogue of fear was the prevailing premise that women must have a choice, and for many women, that choice is a scheduled, safe, pain-free medical procedure or an unscheduled risky natural birth. The medicalization of childbirth has amplified fear and perceived risk even though evidence indicates that birth is a simple and safe process. The reoccurring theme of fear was an important one, and it is worth noting that not all participants found that childbirth classes decreased fear, as one participant questioned, “Did Lamaze classes relieve those fears or did they cause those fears?”
The research team had not considered as an outcome how participants of childbirth education classes might come to value the usefulness of community learning. As a response to a question of whether participants learned preparation for other things as result of childbirth education, the participant stated, we learned “If there is an issue and we want to know more about it that it was okay to learn about it in the community rather than to learn about it as individuals.” Another participant shared that because of their experience with childbirth education classes, she and her husband later took many community classes such as parent effectiveness training. One commented that Lamaze class was “the first thing they did as a couple that was health-related and that the classes help them learn how to reach a goal together.” In one focus group, this led to a discussion of how many of the participants have been involved in other community support groups.
Control
Gaining and maintaining control was a prevalent theme among focus group participants. Some participants signed up for childbirth education classes in an effort to have control during their birth experiences. Others reported that their perceived lack of control during their birth experience caused them to learn to seek control in future health-care decisions. For example, a participant that called herself a “Militant Bradley” with a clear vision of wanting control stated she went to classes to learn how to avoid health care. She stated she “knew that if you stay away from health care, you are not going to have as many interventions.”
A participant stated that childbirth experience makes you “more aware that we can question and not take things at face value.” The research team found a connection between the themes of control and trust, in that participants wanted to trust health-care providers, but when they perceived a lack of control, they lost trust in their health-care provider. Some participants indicated they were not provided options and choices and thus learned to “fire their doctors” or never went back to them. As a result, they did not perceive they had control over choices made on their behalf. Participants’ comments related to a perceived lack of control and trust included the following comments:
I do not go to him [her doctor] anymore.
I am never going back to see her [physician] again, and I did not.
The theme of control remains a prevalent issue among women giving birth today. For example, among women in the latest 2013 LTM III survey, 48% of women indicated they were interested in the option of a vaginal birth after a cesarean (VBAC), but as many as 46% were denied that option, often for reasons unrelated to the prior cesarean (Declercq et al., 2013). Mothers in the LTM III survey reported having pressure to accept interventions such as labor induction, epidural anesthesia, or cesarean surgeries (Declercq et al., 2013). Up to 25% of women reported they received pressure to receive an induction. Control and the concept of shared decision making remains a pertinent issue because mothers reported the final decision regarding either an induction or cesarean was their own decision, but many women report their doctors made strong recommendations for an induction, especially in women with a previous cesarean, often citing concerns to the mother that the baby might be large. When asked “who made the decision to have a primary Cesarean 63% of women indicated the doctor was the decision maker” (Declercq et al., 2013, p. 23).
Informed Consent
Informed consent is an effort to either gain control over decision making while knowing one’s options, benefits, and risks. Few will argue that informed consent is part of an ethical health-care system. Unfortunately, as mothers shared their story, there was a lack of congruence between personal birth experiences and current evidence-based research. This raises questions regarding the extent of informed consent by mothers. In a review of medical interventions, Jansen et al. (2013) discussed many unintended consequences of intrapartal practices such as bed rest, continuous electronic fetal monitoring, limited oral hydration, induction, and labor augmentation that are commonplace in today’s maternity centers. Each intervention has the potential to lead to more interventions and so “when interventions become necessary for valid indications the mother must be made aware of both the necessity and risks of the intervention to give informed consent” (p. 84). According to findings in the Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences (LTM II), most mothers did not know the potential complications of common interventions (Declercq, Sakala, Corry, & Applebaum, 2007).
Women who attend childbirth education classes do so because they want to be informed. One participant shared how she took her first childbirth class during her second pregnancy because her first delivery, with no information, was such a bad experience. For one participant, classes did not prepare her for her labor and delivery experience, and she responded when asked, “In childbirth classes were you ever prepared for the outcome that you actually had” with an emphatic “no.” This raises a question regarding who is responsible to provide enough information so mothers feel informed enough to have a voice in their labor experience. When asked how many of participants in the focus groups recalled participating in decisions regarding their labor and delivery, five participants felt strongly that they participated, but of those five, only three were satisfied with the birth experience.
Informed consent continues to be an issue during pregnancy and birth. Although women that participated in the LTM III survey agreed that birth is a process that “we should not interfere with unless medically necessary” (p. 35), the number of medical interventions reported for these women was very high (Declercq et al., 2013). For example, a significant number of women reported labor inductions for nonmedical reasons that include matters of convenience, concerns about a potentially large baby, or for being overdue. For those women with a potentially large baby, 18% of mothers discussing a possible induction with their provider indicated that the discussion with the provider did not include a framework of choice, and often, the provider suggested that in their opinion, they would recommend an induction. Only 18% of women reported a maternal health problem as the reason for an induction. This raises a red flag for health-care providers regarding issues of informed consent for medical interventions that includes all the benefits and risks.
In the LTM III survey, mothers were asked a series of statements regarding adverse effects of inductions and cesarean surgeries. Mothers demonstrated a clear lack of knowledge about the impact of these interventions. For instance, contrary to current clinical guidelines, mothers believed that if “a baby appeared large at the end of pregnancy 57% of women thought it made sense to induce labor” (Declercq et al., 2013). This belief was more prevalent in women that had experienced an induction. Only 21% of women identified 39 weeks’ gestation or beyond as full term and therefore safe for delivery (Declercq et al., 2013). The lack of consumer knowledge to define “full term” raises ongoing concern regarding informed consent, especially in light of the high numbers of scheduled inductions and cesarean births.
Trust
The question of who is responsible to provide informed consent initiated a discussion regarding the relationship that mothers have with health-care providers. If trust is the foundation of a health-care relationship, then perhaps mothers feel they do not need much information because they anticipate professionals will attend to them during labor. This view of blind trust was evident as one participant, who was very unhappy with her first birth experience, stated that “back then you just relied on what the doctor told you and what the nurse told you. I had no options. We had faith in whom we went to and in the nurse who is taking care of us.” Childbirth education classes, according to Lothian and Hotelling (2012), may help “women to view birth as inherently safe and to see themselves as competent and capable of giving birth safely without routine medical interventions” (p. 248). Trust in health-care providers appeared to be similar in the LTM III study because women continued to rely on health-care providers as “very valuable” sources of information. They indicated their health-care providers were either completely trustworthy or very trustworthy 80% of the time (Declercq et al., 2013). Lack of trust in health-care providers to provide informed consent is an issue that warrants further research.
IMPLICATIONS
This study explored whether knowledge, skills, and attitudes acquired during childbirth education informed future health-care decision making. This small exploratory study does not answer the question of whether childbirth education influences future health-care decision making, but it demonstrates that the themes and issues from participants who delivered 15–30 years ago are comparable to current findings in the literature. Themes that emerged from the focus groups included self-advocacy, new skills, anticipatory guidance, control, informed consent, and trust.
Recommendations are for future research to determine if a link exists between childbirth education and future health-care decision making. It is useful for consumers to advocate for themselves and/or their families and to seek full informed consent and control over their future health care. The health-care community benefits from a knowledgeable, skilled, and informed consumer. If researchers establish significant evidence of a long-term impact of childbirth education to empower families to be better consumers of their future health care, then providers will need to develop creative and innovative ways to ensure access to quality childbirth education for all pregnant women. Such findings would bolster the efforts of health-care providers to advocate for childbirth education. Childbirth educators need to appreciate fully the possible long-term implications of knowledge skills and attitudes they impart to childbearing families.
Biographies
JANE LEACH is an associate professor of nursing at Wilson School of Nursing at Midwestern State University.
BETTY BOWLES is an associate professor of nursing at Wilson School of Nursing at Midwestern State University.
LAUREN JANSEN is an associate professor of nursing at Wilson School of Nursing at Midwestern State University.
MARTHA GIBSON is an associate professor at Spring Hill College.
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