310
Refemces 1. Alexander GR, Comely DA. Prenatal care utilization: Its measurement and relationshipto pregnancy outcome. Am J Prev Med 1987; 3: 243-253. 2. Bruce SL, Petrie RH, Chao S, Williams AM, Imaigumi SO. Unregistered obstetric patients. New York State J Med 1979; 1374. 3. Hakala TH, Ylikorkalo 0. Effective prenatal care decreases the incidence of low birthweight. Am J Perinatal 1989; 6: 222-225. 4. Insler V, Larholt K, Hagay ZJ et af. The impact of prenatal care on the outcome of pregnancy. Eur J Obstet Gynecol Reprod Biol 1986; 23: 211-223. 5. Murray JL, Bernfield M. The differential effect of prenatal care on the incidence of low birth weight among blacks and whites in a prepaid health care plan. N Engl J Med 1988; 319 1385-1391. 6. Klein L. Nonregistered obstetric patients. Am J Obstet Gynecol 1971; 1 1 0 795-802. 7. Moore TR, Origel W, Key K, Resnik R. The perinatal and economic impact of prenatal care in a low socioeconomic population. Am J Obstet Gynecol 1986; 1 5 4 29-33.
8. Leveno KJ, Cunningham FG, Roark ML. Nelson SD, Williams
9. 10,
11.
12. 13. 14.
ML. Prenatal care and the low birth weight infant. Obstet Gynecol 1985; 66: 599-605. Cooney JP. What determines the start of prenatal care? Prenatal care, insurance and education. Med Care 1985; 23: 986-997. Kaliszer M, Kidd M. Some factors affecting attendance of antenatal clinics. Soc Sci Med 1981; 15D 421-424. McDonald TP, Coburn A. Predicton of prenatal care utilization. Soc Sci Med 1988; 27: 167-172. Poland ML, Ager JW, Olson JM. Barriers to receiving adequate prenatal care Am J Obstet Gynecol 1987; 157: 297-303. Joyce K, Diffenbacher G, Greene J, Sorokin Y. Internal and external barriers to obtaining prenatal care Soc Work Health Care 1983; 9 89-%. Miller CL, Margolis LH. Schwethelm B, Smith S: Barriers to implementation of a prenatal care program for low income women. Am J Pub1 Hlth 1989; 7 9 62-64.
Aust NZ J Obstet Gynaecol
1991; 31: 4: 310
Evaluation of an Antenatal Education Programme: Characteristics of Attenders, Changes in Knowledge and satisfaction of Participants Selina Redman, PhD’, Stephanie Oak, BA’, Peggy Booth, RNCMNS’, Jean Jensen, RNCM’ and Anne Saxton, RNCMNS’ Faculty of Medicine‘ and Mater Misericordiae HospitaP. Newcastle. New South Wales
EDITORIAL COMMENT:As the authors of thispaperpoint out there have been only 5 published studies exploring the opemtion of antenatal education programmes in Australia and New Zea(and -yet most obstetricians support the concept of antenatal education and recommend it to patients, especially their private patients. This paper provides the sort of data we need and will interest readers - reading it will hopefully encoumge obstetricians to support further studies of the best ways to deliver antenatal education to our patients and their partners/family members.
Summary: The evaluation of the efficiency and effectiveness of antenatal education programmes has been identified as a priority in improving maternity services in Australia. Tho hundred and ninety four primiparas completed a brief questionnaire in the 3 days following delivery; 82% of the women surveyed attended antenatal education classes. Women were less likely to attend if they were single, younger than 26 years, had lower levels of education, received care during pregnancy from the antenatal clinic and did not have private health insurance. Attenders at antenatal education were also more likely to plan on breast feeding, to be nonsmokers and to know of a greater number of community organizations to help new mothers. However, logistic regression analyses indicated that, with the exception of number of community organizations known, these differences were attributable to demographic differences between attenders and nonattenders. One hundred and forty two women and their partners attending the major provider of antenatal education classes in Newcastle were surveyed prior to and following classes. Significant increases in knowledge were evident following the programme among both women and their partners. Satisfaction with the programme was high as indicated by a large proportion of respondents attending all 4 classes, most programme components being reported as useful or very useful and only a small proportion of respondents experiencing problems with the programme Address for correspondence: Selina Redman, Behavioural Science in Relation to Medicine, Faculty of Medicine, University of Newcastle, New South Wales, 2308.
SELINA REDMANET AI
The recent review of maternity services in Australia emphasized the importance of antenatal education programmes (1). Such programmes focus on preparation for childbirth and early parenting and are designed to increase informed participation in decision making during labour, early parenting skills and performance of preventive health behaviours. There is some evidence that antenatal education classes can improve labour by reducing the amount of medication used, pain experienced and the proportion of deliveries in which forceps are used (2-4). Antenatal education has also been shown to result in a more positive attitude towards labour (4). Although antenatal education programmes have been widely established within Australia and New Zealand, there is little information about their operation. Shearman identified evaluation of the efficiency and effectiveness of antenatal education programmes as a priority in improving maternity services in Australia (1). A literature review located 5 published studies exploring the operation of antenatal education programmes within Australia and New Zealand. Two of these studies explored the characteristics of attenders at antenatal education and indicated that women who are older and of higher socioeconomic status are more likely to attend antenatal education (5,6). However, both studies were undertaken a decade ago or more and, given recent improvements in the ability of health education to target high risk groups, may not reflect current attendance patterns. Three studies exploring the impact of antenatal education programmes were located. A New Zealand study suggested that, even when demographic differences between attenders and nonattenders were controlled for, there was no benefit of antenatal education in aiding childbirth (7); Hewson et a1 (8) found some association between breast feeding and attendance at antenatal education, although they failed to control for demographic differences between attenders and non-attenders; Lumley (9) reported that women attending classes at a birth centre found the classes to be very useful sources of information about childbirth. The impact of antenatal education classes on preventive behaviours or on participants’ knowledge of what to expect during childbirth has not been explored in Australia or New Zealand. The present study sought to provide information about several aspects of the operation of an antenatal education programme within Australia. First, the characteristics of women who do or d o not attend the programme were explored in order to assess the availability and acceptability of the service. Second, the impact of antenatal education on labour and the performance of preventive health behaviours during the first 4 months was assessed. Since both community and medical groups perceive that education classes are of considerable value (I), withdrawing the service from some women to enable random allocation to antenatal education was not possible. Attenders and nonattenders
311
were, therefore, compared on the variables of interest and statistical techniques were used to control for demographic differences between the 2 groups. Third, a sample of attenders at antenatal education were surveyed to examine whether their knowledge of childbirth and preventive behaviours improved after the classes and to determine their satisfaction with the programme. METHOD Phase I: Chamcterktics of attenders at the pmgmmme In order to assess the characteristics of women who attended antenatal education programmes and to explore reasons for nonattendance, primiparas giving birth in a large teaching hospital during a 4-month period were asked to participate in the study. Consenting women completed a questionnaire within 3 days of delivery. The questionnaire included items assessing: (i) demographic characteristics: age, marital status, education, country of birth, health care provider during pregnancy, health insurance status. (ii) preventive behaviours: smoking throughout pregnancy, intention to breast-feed and the number of known community groups or organizations which could help new mothers and their partners after the birth of their baby. (iii) satisfaction with delivery: using a 4-point scale ranging from ‘strongly agree‘ to ‘strongly disagree‘, women were asked to respond to 5 statements: ‘I did not feel like I had enough control’; ‘the staff involved me in all important decisions’; ‘the staff had enough time to deal with my problems’; ‘overall my labour was more painful than I had expected‘; ‘my labour was very long’. These items were selected since the areas of control, decision making and expectation of pain are frequently mentioned as areas on which antenatal education has a positive impact (1). (iv) interventions during labour: women were asked to indicate whether they had had an epidural or pethidine injection during labour or a forceps delivery. (v) attendance at antenatal education programmes. (vi) reasons for not attending antenatal classes.
Phase 2: Changes in knowledge and sat&faction with the programme The second phase of the study assessed changes in knowledge and satisfaction among attenders at the antenatal education programme conducted by the Mater Misericordiae Hospital in Newcastle. The programme run by the Mater Hospital was attended by the greatest proportion (68%)of women surveyed in Phase 1. Antenatal Education Classes at the Mater are run in small groups conducted by a trained professional, usually a midwife o r a physiotherapist. Classes include information about pregnancy, childbirth and parenting.
312
AUSF. 4ND N.Z. JOURNAL OF OBnETRlcS AND GYNAECOIOC~\
The programme uses a variety of teaching methods including discussion, didactic presentations, videos and visits to the labour ward. The programme consists of 4 classes, each of which lasts for about 2 hours. Classes were held on Tuesday, Wednesday and Thursday evenings, and on Saturday mornings. Women and their partners who wish to attend the classes are invited to enrol in 1 of the 5 series of classes which are held each month. All women and their partners who attended classes run over 3 consecutivemonths were asked to participate in the study. Pretest questionnaires were distributed to all attenders at the antenatal education classes for completion before the beginning of the first class. The post test questionnaire was distributed and collected at the end of the final class. The questionnaire included the following scales: Knowledge: A 30-item knowledge questionnaire was constructed using standard scale construction techniques (10). Content validity was established by interviewing midwives, general practitioners and a sample of women who were pregnant or who had recently delivered. The knowledge scale used a True/False/Don’t know format and sampled content from a series of domains as follows: prior to arrival at the hospital ( 5 items); early labour (11 items); late labour and delivery (5 items); postdelivery (4 items) and long-term (5 items). Satisfaction. Three measures of satisfaction were included in the questionnaire as follows: First, respondents were given a list of topics covered in the classes and asked to indicate how useful each component was using a Cpoint scale ranging from very useful to not at all useful; second, respondents were asked to indicate whether each of a list of potential difficulties with the antenatal education programmme had been a problem for them and to suggest any omissions from the programme; third, the average number of classes attended by participants over a 3-month period was calculated, with the assumption that continued attendance was likely to indicate satisfaction with the classes.
RESULls Phase I: Characteristics of attenders at antenatal education pmgmmme Sample description: Of 360 women asked to participate in the study, 349 consented giving a consent rate of 97%. Fifty-five women left hospital before a questionnaire could be completed, but 31 of these were contacted later for demographic details and attendance at antenatal education classes. The description of attenders at antenatal education is therefore based on 325 women or 91% of women giving birth during this period. The relationship between preventive behaviours and outcomes of labour is based on 294 women or 82% of women giving birth. Proporrion of women attending antenafaleducation classes 68% of the women attended the antenatal education class offered by the Mater Hospital, 9%
Tnble 1. Chnncteristics of Attenden at Antenatal Eduention Marital status Single Married/living as married Age
Refemces 1. Alexander GR, Comely DA. Prenatal care utilization: Its measurement and relationshipto pregnancy outcome. Am J Prev Med 1987; 3: 243-253. 2. Bruce SL, Petrie RH, Chao S, Williams AM, Imaigumi SO. Unregistered obstetric patients. New York State J Med 1979; 1374. 3. Hakala TH, Ylikorkalo 0. Effective prenatal care decreases the incidence of low birthweight. Am J Perinatal 1989; 6: 222-225. 4. Insler V, Larholt K, Hagay ZJ et af. The impact of prenatal care on the outcome of pregnancy. Eur J Obstet Gynecol Reprod Biol 1986; 23: 211-223. 5. Murray JL, Bernfield M. The differential effect of prenatal care on the incidence of low birth weight among blacks and whites in a prepaid health care plan. N Engl J Med 1988; 319 1385-1391. 6. Klein L. Nonregistered obstetric patients. Am J Obstet Gynecol 1971; 1 1 0 795-802. 7. Moore TR, Origel W, Key K, Resnik R. The perinatal and economic impact of prenatal care in a low socioeconomic population. Am J Obstet Gynecol 1986; 1 5 4 29-33.
8. Leveno KJ, Cunningham FG, Roark ML. Nelson SD, Williams
9. 10,
11.
12. 13. 14.
ML. Prenatal care and the low birth weight infant. Obstet Gynecol 1985; 66: 599-605. Cooney JP. What determines the start of prenatal care? Prenatal care, insurance and education. Med Care 1985; 23: 986-997. Kaliszer M, Kidd M. Some factors affecting attendance of antenatal clinics. Soc Sci Med 1981; 15D 421-424. McDonald TP, Coburn A. Predicton of prenatal care utilization. Soc Sci Med 1988; 27: 167-172. Poland ML, Ager JW, Olson JM. Barriers to receiving adequate prenatal care Am J Obstet Gynecol 1987; 157: 297-303. Joyce K, Diffenbacher G, Greene J, Sorokin Y. Internal and external barriers to obtaining prenatal care Soc Work Health Care 1983; 9 89-%. Miller CL, Margolis LH. Schwethelm B, Smith S: Barriers to implementation of a prenatal care program for low income women. Am J Pub1 Hlth 1989; 7 9 62-64.
Aust NZ J Obstet Gynaecol
1991; 31: 4: 310
Evaluation of an Antenatal Education Programme: Characteristics of Attenders, Changes in Knowledge and satisfaction of Participants Selina Redman, PhD’, Stephanie Oak, BA’, Peggy Booth, RNCMNS’, Jean Jensen, RNCM’ and Anne Saxton, RNCMNS’ Faculty of Medicine‘ and Mater Misericordiae HospitaP. Newcastle. New South Wales
EDITORIAL COMMENT:As the authors of thispaperpoint out there have been only 5 published studies exploring the opemtion of antenatal education programmes in Australia and New Zea(and -yet most obstetricians support the concept of antenatal education and recommend it to patients, especially their private patients. This paper provides the sort of data we need and will interest readers - reading it will hopefully encoumge obstetricians to support further studies of the best ways to deliver antenatal education to our patients and their partners/family members.
Summary: The evaluation of the efficiency and effectiveness of antenatal education programmes has been identified as a priority in improving maternity services in Australia. Tho hundred and ninety four primiparas completed a brief questionnaire in the 3 days following delivery; 82% of the women surveyed attended antenatal education classes. Women were less likely to attend if they were single, younger than 26 years, had lower levels of education, received care during pregnancy from the antenatal clinic and did not have private health insurance. Attenders at antenatal education were also more likely to plan on breast feeding, to be nonsmokers and to know of a greater number of community organizations to help new mothers. However, logistic regression analyses indicated that, with the exception of number of community organizations known, these differences were attributable to demographic differences between attenders and nonattenders. One hundred and forty two women and their partners attending the major provider of antenatal education classes in Newcastle were surveyed prior to and following classes. Significant increases in knowledge were evident following the programme among both women and their partners. Satisfaction with the programme was high as indicated by a large proportion of respondents attending all 4 classes, most programme components being reported as useful or very useful and only a small proportion of respondents experiencing problems with the programme Address for correspondence: Selina Redman, Behavioural Science in Relation to Medicine, Faculty of Medicine, University of Newcastle, New South Wales, 2308.
SELINA REDMANET AI
The recent review of maternity services in Australia emphasized the importance of antenatal education programmes (1). Such programmes focus on preparation for childbirth and early parenting and are designed to increase informed participation in decision making during labour, early parenting skills and performance of preventive health behaviours. There is some evidence that antenatal education classes can improve labour by reducing the amount of medication used, pain experienced and the proportion of deliveries in which forceps are used (2-4). Antenatal education has also been shown to result in a more positive attitude towards labour (4). Although antenatal education programmes have been widely established within Australia and New Zealand, there is little information about their operation. Shearman identified evaluation of the efficiency and effectiveness of antenatal education programmes as a priority in improving maternity services in Australia (1). A literature review located 5 published studies exploring the operation of antenatal education programmes within Australia and New Zealand. Two of these studies explored the characteristics of attenders at antenatal education and indicated that women who are older and of higher socioeconomic status are more likely to attend antenatal education (5,6). However, both studies were undertaken a decade ago or more and, given recent improvements in the ability of health education to target high risk groups, may not reflect current attendance patterns. Three studies exploring the impact of antenatal education programmes were located. A New Zealand study suggested that, even when demographic differences between attenders and nonattenders were controlled for, there was no benefit of antenatal education in aiding childbirth (7); Hewson et a1 (8) found some association between breast feeding and attendance at antenatal education, although they failed to control for demographic differences between attenders and non-attenders; Lumley (9) reported that women attending classes at a birth centre found the classes to be very useful sources of information about childbirth. The impact of antenatal education classes on preventive behaviours or on participants’ knowledge of what to expect during childbirth has not been explored in Australia or New Zealand. The present study sought to provide information about several aspects of the operation of an antenatal education programme within Australia. First, the characteristics of women who do or d o not attend the programme were explored in order to assess the availability and acceptability of the service. Second, the impact of antenatal education on labour and the performance of preventive health behaviours during the first 4 months was assessed. Since both community and medical groups perceive that education classes are of considerable value (I), withdrawing the service from some women to enable random allocation to antenatal education was not possible. Attenders and nonattenders
311
were, therefore, compared on the variables of interest and statistical techniques were used to control for demographic differences between the 2 groups. Third, a sample of attenders at antenatal education were surveyed to examine whether their knowledge of childbirth and preventive behaviours improved after the classes and to determine their satisfaction with the programme. METHOD Phase I: Chamcterktics of attenders at the pmgmmme In order to assess the characteristics of women who attended antenatal education programmes and to explore reasons for nonattendance, primiparas giving birth in a large teaching hospital during a 4-month period were asked to participate in the study. Consenting women completed a questionnaire within 3 days of delivery. The questionnaire included items assessing: (i) demographic characteristics: age, marital status, education, country of birth, health care provider during pregnancy, health insurance status. (ii) preventive behaviours: smoking throughout pregnancy, intention to breast-feed and the number of known community groups or organizations which could help new mothers and their partners after the birth of their baby. (iii) satisfaction with delivery: using a 4-point scale ranging from ‘strongly agree‘ to ‘strongly disagree‘, women were asked to respond to 5 statements: ‘I did not feel like I had enough control’; ‘the staff involved me in all important decisions’; ‘the staff had enough time to deal with my problems’; ‘overall my labour was more painful than I had expected‘; ‘my labour was very long’. These items were selected since the areas of control, decision making and expectation of pain are frequently mentioned as areas on which antenatal education has a positive impact (1). (iv) interventions during labour: women were asked to indicate whether they had had an epidural or pethidine injection during labour or a forceps delivery. (v) attendance at antenatal education programmes. (vi) reasons for not attending antenatal classes.
Phase 2: Changes in knowledge and sat&faction with the programme The second phase of the study assessed changes in knowledge and satisfaction among attenders at the antenatal education programme conducted by the Mater Misericordiae Hospital in Newcastle. The programme run by the Mater Hospital was attended by the greatest proportion (68%)of women surveyed in Phase 1. Antenatal Education Classes at the Mater are run in small groups conducted by a trained professional, usually a midwife o r a physiotherapist. Classes include information about pregnancy, childbirth and parenting.
312
AUSF. 4ND N.Z. JOURNAL OF OBnETRlcS AND GYNAECOIOC~\
The programme uses a variety of teaching methods including discussion, didactic presentations, videos and visits to the labour ward. The programme consists of 4 classes, each of which lasts for about 2 hours. Classes were held on Tuesday, Wednesday and Thursday evenings, and on Saturday mornings. Women and their partners who wish to attend the classes are invited to enrol in 1 of the 5 series of classes which are held each month. All women and their partners who attended classes run over 3 consecutivemonths were asked to participate in the study. Pretest questionnaires were distributed to all attenders at the antenatal education classes for completion before the beginning of the first class. The post test questionnaire was distributed and collected at the end of the final class. The questionnaire included the following scales: Knowledge: A 30-item knowledge questionnaire was constructed using standard scale construction techniques (10). Content validity was established by interviewing midwives, general practitioners and a sample of women who were pregnant or who had recently delivered. The knowledge scale used a True/False/Don’t know format and sampled content from a series of domains as follows: prior to arrival at the hospital ( 5 items); early labour (11 items); late labour and delivery (5 items); postdelivery (4 items) and long-term (5 items). Satisfaction. Three measures of satisfaction were included in the questionnaire as follows: First, respondents were given a list of topics covered in the classes and asked to indicate how useful each component was using a Cpoint scale ranging from very useful to not at all useful; second, respondents were asked to indicate whether each of a list of potential difficulties with the antenatal education programmme had been a problem for them and to suggest any omissions from the programme; third, the average number of classes attended by participants over a 3-month period was calculated, with the assumption that continued attendance was likely to indicate satisfaction with the classes.
RESULls Phase I: Characteristics of attenders at antenatal education pmgmmme Sample description: Of 360 women asked to participate in the study, 349 consented giving a consent rate of 97%. Fifty-five women left hospital before a questionnaire could be completed, but 31 of these were contacted later for demographic details and attendance at antenatal education classes. The description of attenders at antenatal education is therefore based on 325 women or 91% of women giving birth during this period. The relationship between preventive behaviours and outcomes of labour is based on 294 women or 82% of women giving birth. Proporrion of women attending antenafaleducation classes 68% of the women attended the antenatal education class offered by the Mater Hospital, 9%
Tnble 1. Chnncteristics of Attenden at Antenatal Eduention Marital status Single Married/living as married Age
