Designing and Implementing a Parenting Resource Center for Pregnant Teens

Abstract

The Resource Center for Young Parents-To-Be is a longstanding and successful grant-funded project that was initiated as a response to an identified community need. Senior-level baccalaureate nursing students and their maternity-nursing instructors are responsible for staffing the resource center's weekly sessions, which take place at a public school site for pregnant adolescents. Childbirth educators interested in working with this population could assist in replicating this exemplary clinical project in order to provide prenatal education to this vulnerable and hard-to-reach group.

In many parts of the United States, pregnant adolescents are not typically among the participants in Lamaze childbirth preparation classes or hospital prenatal classes. In her study of 126 adolescent mothers, DeVito (2007) found that only 10% attended parenting classes and 13.5% attended classes for childbirth preparation. Barriers to participation include lack of transportation, lack of motivation or information, inadequate support or commitment to attendance from significant others, insufficient time, and embarrassment and discomfort in adult-focused settings. This article describes a strategy for providing prenatal classes that surmounts the barriers to attendance by pregnant adolescents.

ESTABLISHING THE NEED

In spring 1997, we discovered that child protection investigations in our parish (county) had increased 14% from 1990–1996 (Louisiana Children's Trust Fund, 1997). Within the wider eight-parish area, most valid child abuse allegations in 1996 were for neglect and physical abuse. Other data indicated that the most common perpetrator was 20–29 years old at the time of her child's birth, and the next most common perpetrator was an adolescent when her child was born. Knowing that parents’ lack of knowledge about children's development, needs, and care is often a factor contributing to child abuse and neglect, we decided to draw on our experience as prenatal educators and maternity nursing instructors in a baccalaureate nursing program at the University of Louisiana at Lafayette in order to design and implement prenatal parenting classes targeting pregnant women aged 13–29 years old. The goal of the project was to provide education and support, a form of primary prevention that would benefit these individuals who are at higher risk than others for child abuse and neglect.

FUNDING

An initial grant for $5,000 was obtained in July 1997 from the Louisiana Children's Trust Fund to purchase teaching supplies such as flip charts, easels, models, and handouts. Subsequent grants from the local Woman's Foundation and Junior League provided additional funding. Other grants included monies from local and regional family foundations for equipment such as handheld Dopplers, VCRs, supply cabinets, and shelving. Funding was also obtained from corporate foundations such as the Gannett Foundation. In addition, the University of Louisiana at Lafayette, where we are employed, awarded several small Instructional Mini-Grants for this project. A total of $36,798 in grant monies has sustained the project since its inception more than 10 years ago.

EVOLUTION OF PARENTING CLASS DESIGN AND POPULATION FOCUS

The initial project was established in fall 1997 in the local public health unit where low-income pregnant women and teens were receiving prenatal care. A room was provided and set up in a traditional class format, with a nursing student at the front of the room teaching the class, and the participants seated facing the student. The “Every Touch Counts” parenting curriculum, designed by a university-based family resource specialist and in wide use in Louisiana, mostly for teaching pregnant teens, was adapted for use. Teaching manuals and booklets for participants were purchased and distributed respectively to nursing students and pregnant participants. Four 1¼-hour classes were taught on each of six dates during each semester at the public health unit. A drawing for a small door prize was held for participants at each class.

From Class Format to Resource Center Format

Feedback from participants led to a redesign for the fourth and subsequent semesters of the project. The pregnant women had indicated that they wanted less lecture format, more hands-on experiences, more one-on-one interaction with the nursing students, and tangible rewards for attendance for all participants. In response, the Resource Center for Young Parents-To-Be was designed with learning stations for each of the six different topic areas; one topic area was available for each of the 6 days that nursing student clinical groups were assigned to this project. Each pregnant teen entering the resource center was assigned to a nursing student who facilitated her use of the learning stations of her choice. A different group of nursing students worked with the pregnant teens each week.

Transition to Teaching Pregnant Adolescents Only

In spring 2000, an additional clinical site—a school program for pregnant teens in our parish—was added as a pilot project. The public health unit site was phased out 1 year later, due to space limitations and other constraints. For a 3½-year period, the resource center was conducted in a teen pregnancy program in a neighboring parish as well. Since fall 2004, each of the six nursing student clinical groups per semester has been assigned to 2 days at the school program site in this parish only. The younger group of pregnant adolescents (ages 13–16 years old) comes to the resource center on the first day, and an older group (ages 17–18 years old) attends on the following day.

RELATIONSHIPS WITH PRACTICE PARTNERS

After the Resource Center for Young Parents-To-Be was piloted in the adolescent pregnancy school program, the participating teachers in the program evaluated the educational format and the nursing students’ performance as excellent, and they requested a return in the next academic year. Similar services that were offered at the school program through other agencies were discontinued because the adolescents preferred the activities and strategies provided by the resource center and the opportunity for individual interaction with and support from the nursing students. In addition, the teachers evaluated the teaching content, use of the teaching materials, resource center structure, and the interactions between the pregnant teens and the nursing students, and were impressed by the level of quality they observed. The nursing instructors work closely with the teachers in the adolescent pregnancy school program to provide services that are acceptable and attractive to the teens and to the school. Negotiations for space in the school setting and for the time to implement the resource center's sessions have been successful. The teachers are fully supportive of the content of the resource center's sessions, reinforce the information provided (e.g., encouraging the teens to breastfeed), and promote attendance by the teens who are in their classes.

IMPLEMENTATION

Six lesson plans were developed for the Resource Center for Young Parents-To-Be. Topics covered in these lesson plans include: (a) caring for yourself and your baby during pregnancy; (b) nurturing your newborn; (c) handling, bathing, and diapering; (d) safety for babies and young children; (e) guiding children in positive ways; and (f) feeding babies from birth to 1 year. Each lesson includes 12–16 stations or teaching components. Specific age-appropriate interactive activities were designed for each of the stations, teaching materials were purchased with grant funds, and detailed instructions were written for the nursing students. Lessons include games such as Pregnancy Bingo or matching games to engage the pregnant adolescents. Many of the stations have objects for the students to hold and examine to emphasize specific concepts. For example, when the topic of handling, bathing, and diapering is taught, life-sized dolls are provided for the pregnant teens to practice and facilitate the learning process. In the first session on caring for yourself and your baby during pregnancy, each teen is encouraged to hold and examine the fetal model that is closest in age to her own pregnancy. For some learning stations, nursing instructors or students designed handouts and posters to appeal specifically to pregnant adolescents, especially adolescents with low reading levels.

Several years after the introduction of the program, an additional optional station was introduced for girls in their third trimester. At this station, the nursing students measure fundal height, complete Leopold maneuvers, and auscultate fetal heart tones with a hand-held Doppler. Each teen is given the opportunity to hear her baby's heart sounds. The nursing student gives the teen feedback on the baby's position, weeks of gestation, fundal height measurement, fetal movement felt by the nursing student, and any other data that the nursing student has assessed that can promote the teen's attachment to her fetus (e.g., evidence that the baby is hiccupping, identification of the baby's foot pushing against the maternal abdomen, etc.). Each pregnant teen receives her own gestation wheel to keep, which she can use to follow her baby's progress through the pregnancy, and to use at subsequent sessions to review pertinent data for each stage of the pregnancy. Also at this time, additional content was added on the labor and birth process.

Each lesson is set up in the university's College of Nursing's learning resource lab approximately 1 week before the scheduled teaching experience so that the nursing students can become familiar with the topics, the materials, and content of the lesson they will teach. The students are oriented by their clinical instructor to the specific lesson topic and, more specifically, to their role as prenatal educators to a pregnant adolescent population. They are advised to work in small groups with the pregnant adolescents and to spend time at the beginning of the lesson visiting with the girls and gaining their trust before teaching the lesson content.

Pamphlets specific to each lesson topic and parenting magazines are assembled and placed in bags beforehand. The day of the teaching experience, the nursing students assist with loading the teaching supplies and handouts into the school van to transport to the teaching site. Large plastic boxes with wheels and a poster carrier were purchased to help transport teaching materials. After the van arrives at the teaching site, the nursing students assist with the unloading and setting up of the materials in the classroom before the pregnant adolescents arrive. The nursing students decide how to arrange and display the teaching materials. Often, they choose to cluster several stations together at a table and place chairs for the pregnant adolescents to sit whenever possible. The nursing instructor functions as a resource for students and helps at the fetal heart tone station in an adjacent room, using a foldout cot provided by the school. The nursing students are reminded about the importance of developing rapport with the pregnant adolescents before attempting to teach new concepts and to maintain a nonjudgmental attitude.

The same lesson is taught to each group of students on 2 consecutive days, with the younger group coming the first day and the older group coming the following day. The nursing students divide into groups of two or three and divide the adolescent students into small groups of three to four, depending on class size. The pregnant adolescent students make name tags and decorate them with stickers during each class. The nursing instructor documents attendance, and the pregnant adolescents earn points for attending each of the lessons. The teens are informed during the first lesson that a baby shower will be held after the last lesson and they will be able to “shop” for baby items with the points earned from attending the prenatal education classes. This provides additional motivation for the girls to attend and participate in the prenatal classes. Small prizes of baby items are also given for winners of games played during each lesson. The lessons originally lasted approximately 90 minutes; however, due to scheduling changes at the adolescent pregnancy school program, the time was reduced to approximately 70 minutes each day. The series of six lessons is taught during the fall and repeated in the spring semester by two different groups of nursing students to two different groups of pregnant adolescents.

The baby shower, scheduled during the final morning, is the highlight of the semester for both the pregnant adolescents and the nursing students. Small baby items such as toys, books, clothing, and infant feeding and grooming materials are purchased, and point values are assigned with a sticker on each item. These are displayed on tables organized according to their point values. For example, a plastic juice cup with a 1-point sticker is placed on the 1-point table, and a rattle and teething ring with 2-point stickers are placed on the 2-point table. Each pregnant adolescent receives a shopping bag and a card with her name and the number of points she accumulated during the semester. Baby shower games, planned ahead by the nursing students, are played and enjoyed by all. The pregnant adolescents enjoy shopping with their point cards while the nursing students assist them and deduct the points as the girls shop. The nursing instructor and nursing students provide a baby shower cake and juice, which are shared with all in attendance. For several semesters, thanks to a generous grant from a local organization, car seats were distributed to the teens who had completed all six prenatal classes.

EVALUATION

The Resource Center for Young Parents-To-Be is evaluated in several ways. Feedback is obtained after each session from both the pregnant adolescents and the nursing students. In addition, the teachers in the school's program evaluate the center and its impact on the pregnant teens.

Evaluation by Pregnant Adolescents

The pregnant adolescents who participate in the lessons complete on-site evaluations. A questionnaire is distributed at the end of each lesson and completed anonymously by the pregnant adolescents. The nursing instructor reviews the evaluations with the nursing students in a postconference and facilitates discussion on ways to approach the topics or improve teaching methods on the second day.

Examples of what the pregnant adolescents stated were “the best thing” about the center:

• “listening to my baby's heart beat”;

• knowing “what would happen to my body” as they prepare to give birth;

• “watching videos” on topics such as Sudden Infant Death Syndrome;

• “making music books”;

• “learning how to breastfeed”; and

• “the nursing students were very good at explaining things.”

Examples of new information that the pregnant adolescents learned:

• “facts about giving birth”;

• “information about circumcision”;

• child safety, including “not giving my baby small toys”;

• “ages to start solid food”;

• “the best way to clip the baby's nails”;

• “how to latch your baby on your breast”; and

• “breastmilk is good.”

Things that the pregnant adolescents stated they would do differently:

• “placing my baby on her back when she sleeps”;

• “not letting the baby go to sleep with the bottle”;

• “taking time and being patient with my child”;

• “not getting mad at my child”;

• “not to shake my baby”;

• “swaddle my baby”;

• “how to burp my baby”;

• “remembering to bond with my baby as much as possible”;

• “not to spank”; and

• “being less nervous taking care of my baby.”

Evaluation by Nursing Students

The second method of evaluation is to have the nursing students answer specific questions related to their teaching experiences as well as reflect about the experience in their clinical journals. A review of nursing student journals highlighted several themes. One of these themes was a generational connection between the nursing students and the adolescent population. The majority of the nursing students participating in this program are in their early 20s. One nursing student stated:

I think that it is really great that we go and do teaching to these young girls. They need to have some positive practical teaching coming from people closer to their age, simply because they listen more to “students” because we are not like adults telling them what to do. (C. Moore, personal communication, April 8, 2008)

Some nursing students have experienced teen pregnancies themselves and choose to share their experiences with the pregnant adolescents they teach. This helps build rapport and also serves to role model possible future life choices for the pregnant adolescents. One nursing student wrote:

I was 18 when I had my first daughter. I had finished high school, the dad and I were together and we had a lot of support from our families. With all of that it was still hard, being a mom at that age. My heart goes out to them and all girls in that situation. They still have a chance at doing something great with their lives. It's just so much harder…. I would really like to work more with this population because I've been there and today I'm in a good place. It just took me more time. (J. Landry, personal communication, April 8, 2008)

Another theme was the importance of establishing rapport and having a nonjudgmental attitude. The challenge of establishing rapport was observed by one nursing student:

When we first began teaching the girls, most of them were quiet and did not respond overtly. There was one girl who was very open and, once we had established a rapport with her, the other girls began to participate in the dialogue. (P. Babin, personal communication, May 9, 2008)

Another student stated:

I asked them to share with the group the number of weeks gestation, expected due date, sex of the baby if known. This was the icebreaker before teaching. At first, the girls seemed a bit shy, but after the icebreaker, they began to feel more comfortable and really opened up. (T. Arceneaux, personal communication, May 9, 2008)

Another student suggested, as a way to help the adolescents relax and open up sooner, asking a question such as, “What is one tradition that your family does that you want to pass on to your baby?” (J. Landry, personal communication, April 8, 2008). Another nursing student observed the support the adolescents received from each other during the baby shower:

I like the fact that they shared winnings with the others who had not won anything or the ones who did not have a lot of points…. I thought this was very thoughtful of them. I must say that they appear to have formed a family unit and are supportive of each other. (T. Arceneaux, personal communication, May 9, 2008)

Evaluation by Teachers in the School

The teachers in the pregnant adolescent school program frequently offer informal positive and/or constructive feedback before, during, or after the sessions. Additionally, at the end of each academic year, the teachers are asked to complete a standard form, “Agency Evaluation of Clinical Component.” They consistently rate the relationships between staff and students as well as those between staff and faculty as “Excellent,” with a typical comment being that the nursing students “present a professional and caring attitude when working with our young, pregnant students.” The nursing students are viewed as frequently making positive contributions to the care of the pregnant girls: “[the nursing] students showed a personal interest in our students” and “establish excellent rapport with the pregnant girls.” One summary statement indicated, “The nursing students are well-prepared, dynamic, and well-informed. My students look forward to the sessions, respond/interact openly with the…nursing students, and appreciate the information presented to them.” Another teacher wrote, “I would not change anything. This is an excellent program.”

DISCUSSION

Tilghman and Lovette (2008) highlight the unique needs of the pregnant adolescent, stating, “Neither adolescents nor any other population group responds well to health educators or caregivers who do not understand and appreciate their cultural environment and values” (p. 51). Senior-level baccalaureate nursing students serve as a unique group of beginning-level nurse educators to provide pregnant adolescents with accurate and thorough information that will assist the young mothers to care for themselves and their babies. The nursing students, being students themselves, relate to and connect with the adolescent population. The pregnant adolescents seem to respond to the nursing students and feel comfortable asking questions and learning. The school classroom setting in which the teaching was implemented was familiar and convenient to the pregnant adolescents. This convenient and reassuring setting is an important factor identified by Tilghman and Lovette (2008) for effective prenatal education to occur for the adolescent population.

Communicating with pregnant adolescents can present unique challenges to health-care providers. King-Jones (2008) highlights the importance of eliminating assumptions and biases, implementing active listening skills, and building partnerships with pregnant adolescents. Nursing students are in a unique position of relating to pregnant adolescents at their level as students. Most of the nursing students identified the importance of having a nonjudgmental attitude with the girls and developing a good rapport or partnership with the pregnant adolescents before and during communication of the prenatal education topics.

IMPLICATIONS FOR CHILDBIRTH EDUCATORS

Childbirth and prenatal educators who are also nursing instructors could readily design and implement programs similar to the Resource Center for Young Parents-To-Be. Other childbirth and prenatal educators who are not involved in nursing education could partner with maternity, pediatric, or community nursing instructors to facilitate similar programs. Academic faculty members are expected to obtain grants, conduct research, and publish in their professional literature as well as perform community service; in some academic settings, establishing a faculty practice is expected (Broussard, 2001). Establishing a resource center for pregnant teens would facilitate these achievements for nursing instructors anticipating tenure and promotion decisions. The “real clinical phenomena” observed in the resource center can “inform their research and publication activities” (Broussard, Delahoussaye, & Poirrier, 1996, p. 84) as well as guide grant-writing endeavors and inform teaching approaches. In addition, community-focused clinical activities and service learning are increasingly encouraged in nursing education. Indeed, the Resource Center for Young Parents-To-Be encompasses all four recommended elements for service learning (Broussard, 2001): (a) it is designed to meet human needs or solve a community problem; (b) it facilitates experiential learning for nursing students; (c) students and faculty alike adopt a perspective of reciprocity toward the pregnant teens and their teachers; and (d) nursing students reflect on their experiences in the center via several strategies, including reflective journaling, a writing-to-learn strategy that can increase critical thinking and help students synthesize practice and theory (Reynolds, 2001). Nursing education programs that consider the needs of vulnerable populations would find that establishing a resource center for pregnant teens is a viable strategy for giving nursing students access to this at-risk group.

Childbirth educators who wish to utilize best practices in planning a program need to incorporate designs that accommodate the learning and social needs of pregnant teens. Tilghman and Lovette (2008) point out that “prenatal care, including childbirth education designed for the typical population, is unlikely to best serve the needs of the pregnant adolescent” (p. 50). They indicate that prenatal education offered at a hospital site may be inconvenient for pregnant teens, and they recommend local churches as sites. Bringing prenatal education to the adolescents’ own school sites would seem, however, to be the most convenient solution to this problem, and being in this familiar environment would be reassuring to the teens. Based on her study of 53 adolescent mothers and their breastfeeding experiences, Spear (2006) suggests several clinical implications, including, “design and promote prenatal breastfeeding classes that specifically target adolescent mothers” and “schools have unique access to childbearing adolescents and can do much to promote a positive breastfeeding culture” (p. 112). The experience of the Resource Center for Young Parents-To-Be is that more adolescents who attend the session on breastfeeding are considering nursing their babies (and successfully breastfeeding) now than prior to the existence of the resource center.

Tilghman and Lovette (2008) indicate that having pregnant teens working with others in the same situation “is an effective way to build a support network” (p. 52). DeVito (2007) writes that when adolescents do not have social support that is dependable, their self-perceptions of parenting can be negatively influenced, and that social support factors strongly in the adjustment of adolescents who are mothers. Evidence from research on CenteringPregnancy, a prenatal care model that incorporates group educational and support sessions during and after pregnancy, reveals greater satisfaction and improved outcomes within groups of pregnant teens (Carlson & Lowe, 2006). Childbirth educators can foster a sense of community, promote positive group dynamics, and build group communication, rapport, and support via a resource center designed specifically for pregnant adolescents.

Another research-based best practice may be to teach pregnant adolescents in groups according to their ages. DeVito (2007) recommends:

An awareness that younger adolescent mothers may lack parenting skills and have more physical and emotional needs than older adolescent mothers should be developed in providing perinatal care and childbirth education. Consideration of the differences between the older and younger adolescent mother is also important for the childbirth educator, because the study's results clearly indicate that these groups are at distinctly different developmental ages, necessitating specific approaches and interventions. (p. 22)

This best practice is illustrated by the current structure of the Resource Center for Young Parents-To-Be. Although the resource center's design evolved because of practical considerations, it has been found more effective for teaching pregnant adolescents than the previous arrangement of teaching students of all ages within the same group.

Soliciting ideas directly from the teens for class content and identifying the adolescents’ values is another research-based best practice. In their study of 16 adolescents, Cox et al. (2005) found that the adolescents desired information about prenatal medical health and fetal development. Fostering reciprocity by seeking the feedback of pregnant adolescents is essential to the success of any educational program for pregnant teens.

CONCLUSION AND SUMMARY

The Resource Center for Young Parents-To-Be offers a unique teaching and learning partnership for the pregnant adolescent population it serves and the nursing students involved in the teaching process. The adolescents who have attended have given the resource center and the nursing students high marks. The teens learn parenting skills, and their babies benefit as well. The nursing students build confidence in their teaching skills, further their understanding of societal problems, and explore community nursing roles. The nursing instructors/prenatal educators who guide the center fulfill their nonteaching roles in academia as well as provide an opportunity for their nursing students to have guided and structured clinical experiences with a vulnerable, at-risk population. Childbirth educators interested in working with pregnant adolescents could assist in replicating this program in order to provide prenatal education to this unique population.