PERINATAL EDUCATION: WOMEN’S NEEDS

Magdalena S. Richter

INTRODUCTION

Every woman has the right to receive quality perinatal education irrespective in which part of the world she is living. It is important to take into consideration the needs of women concerning perinatal education in order to reach the aim of perinatal education. This study was a component of a larger multi-method study, Standards for Perinatal Education in South Africa. Standards are imperative to ensure quality regarding perinatal education and to deliver a high quality and appropriate health care system. This study showed women have specific needs concerning the perinatal educator’s professional and personal traits, the educational activities and interventions offered and the content of the perinatal education.

THEORETICAL BACKGROUND AND LITERATURE REVIEW

Quality perinatal education promotes a healthy woman, pregnancy and baby outcome that lead to a healthy family and community. It should aim to share knowledge with all childbearing women and their support partners with the purpose to enable them to make informed choices, within the limits of their education, understanding and context of their everyday living.

Perinatal education includes teaching for the preparation of pregnancy, birth, baby care, as well as parenthood and family planning. It attends to the cognitive and affective needs of the mother and her family and aims at health promotion behavior to ensure a healthy pregnancy, birth and post partum period (1). A small part of the world’s population has access to high technology medical services, while the rest live under poor socio-economic circumstances with limited access to any health care services.  Developing countries are characterized by a high incidence of maternal and perinatal mortality and low birth weight babies. A large part of the population in these countries also has limited access to health services, is characterized by a low socio-economic status and a high incidence of single women and adolescent mothers. Research has shown that young single women and women of low socio-economic status will have low attendance in formal perinatal teaching. Obstacles like poor housing, low income and social isolation are also reasons why these women do not attend perinatal education classes (2).

Young single women have a high risk of developing psychological and maternal behavior problems. They also experience a high degree of stress, are less responsive and sensitive in interaction with their babies and provide less stimulation to the baby than older mothers (3).  Babies born to these mothers are inclined to have poorer health: it is unlikely that the mothers will make use of preventative behavior, continue with breastfeeding or have their babies fully immunized.  Different recruitment and presentation techniques are needed to increase a high attendance and interest from adolescent mothers and women of a low socio-economic status (4).  A worldwide trend in hospitals has developed that discharges mothers very early in the post partum period.  This tendency to discharge early poses extra challenges for perinatal education. Perinatal education should become a bigger priority and be accepted as an essential part of maternal and child health care. 

Most health care systems in the developed world function within a managed health care that aims at cost effective management, and entails the early discharge of the mother and her baby (5).  In the public sector, as well, early discharge of the mother and baby happens because of a shortage of manpower and facilities.  The mother and baby are often discharged without the opportunity to receive health education.  Morse et al. (6) suggest that pregnant parents should get all the help possible.  Meeting new parents’ knowledge needs has become an increasingly important nursing priority.  The focus on perinatal education and discharge planning is due to increased acknowledgement and understanding by medical personnel of skills required of new parents, and increased public awareness of the importance of health education.

Perinatal education should be presented within the context of a country’s culture, philosophy, ethical norms and economical and political development. The needs of the women in the perinatal period have to be taken into consideration if we want to reach this goal. Teaching intervention should be tailored to the women’s needs (7). This interaction between the perinatal educator and its client or also known in theoretical terms as dyad-level interactions can be explained by the Interdependence Theory, a social-psychological theory that explains how influence and communication between partners can affect behavior and outcome experience (8). This theory underlines the purpose of this study which was to describe the needs of women concerning perinatal education.

METHOD

To reach the objective of this study a descriptive qualitative design was used to understand the needs of women concerning perinatal education. South Africa has both well developed and developing regions. A small part of South Africa’s population has access to high technology medical services, while the majority has limited access to any health care services. The findings were verified with international literature. The population consists of women in the perinatal period at the time of the study. For the purpose of this study, the perinatal period is defined as the period from conception to 6-months post partum.

A purposive sampling was used; the women participants were chosen based on their knowledge of their perinatal education needs (9). Focus groups were conducted with women from a low socio-economic background (focus group 1), women from a high socio-economic background (focus group 2) and single pregnant teenage girls (focus group 3).  A semi-structured interview guide was used. 

Eleven women participated in focus group 1.  Their ages ranged from 18 – 40, 2 were in the second trimester and 9 in the third trimester of their pregnancies.  Six women were primigravida’s, 4 multigravida’s and 1 a grand multigravida. Six women participated in focus group 2.  Their ages ranged from 28 – 40 years; 2 were in the third trimester of their pregnancy and 4 have already delivered and their baby’s ages ranged from 2 – 6 months. Ten single pregnant teenagers participated in the third focus group.  One teenager was in the first trimester, 2 in the second trimester and 7 in the third trimester of their pregnancy.  Three out of nine decided to give their baby’s up for adoption.

The focus group interviews were transcribed verbatim. The data were analyzed according to Tesch’s method (10). This method of interpreting the data in the basic sense of reflecting on the data until a better understanding of what is meant is achieved. Analysis of the data commenced as soon as the first data was collected and continued through the process of data collection (11).  Guba’s model (12) was used to ensure the study’s trustworthiness. Credibility was ensured by prolonged engagement in the perinatal education field, member checking and having group discussions with peers (academic colleagues and perinatal educators). Credibility improves the truth value of the study.  Transferability of the gathered data was ensured. The gathered data was representative because women in different stages of the perinatal period were included in the study. The study was contextual in the research field (women in the perinatal period). The researcher ensures dependability by giving a detailed description of the methods followed in this study. Such a description of methods provides information on how repeatable the study might be. Ethical approval to conduct the study was granted by the Ethical Committee at Pretoria Academic Hospital, Pretoria, South Africa. The ethical principles of autonomy, beneficence, justice, and nonmaleficence were adhered to at all times during the study.

RESULTS

Three categories emerged from the data: (1) Women’s needs concerning the perinatal educator’s professional and personal traits, (2) the educational activities and interventions offered and (3) the content of the perinatal education.

1. Needs concerning the perinatal educator’s professional status and personal traits

The perinatal educator plays an important educational role regarding the physical, psychological and social health of the mother, her baby and family. The quality of the information given and the approach of the mother, her baby and her family can play a decisive role in the health of the community.

The women had specific needs concerning the personal attributes of the perinatal educator. They expected the perinatal educator to “…be very experienced…”, “…she must be trustworthy…”, “…a professional person…” ,“…it is actually nice to have somebody, an educated person’s opinion that is not your mother or your friend…” ,“…someone that is qualified, so as at least you know they talk from a strong point of view; a qualified person…” ,“I feel I can contact her anytime…”, and “…things for me is availability…”.  It is obvious that experience in the field of perinatal health, availability and professionalism are important attributes of a perinatal educator.

Single pregnant teenager’s needs of the perinatal educator’s personal attributes differed from the other groups because of their unique circumstances. They expected the perinatal educator to have the ability to associate with teenagers, to have a positive nature, have respect for teenagers irrespective of their circumstances (not judgmental, not invoking fear, not denigrating and not giving negative feedback and to accept the pregnant teenager unconditionally. They express it as: “…must have experience of our situation…”, “…take part in our activities; he is not stuck up and treats us as equals…”, and “…must accept us, although we became pregnant at a young age…”

A second sub-category in this group concentrates on the perinatal educator’s behavioral status (qualities). The women expected the perinatal educator to empower the mother with knowledge, “…become personally involved…”, “make you feel you are doing OK” , “…make you feel more in control…”, “…must be a friend…”, “you need somebody that is relaxed”, “positive feedback”, “…emphatic…”, “…it almost empowers you…”, “you know she is going to help you through everything”, “she needs to be like a psychologist when you need to talk”, “…concentrate on the things you are doing right…”, and “…personal contact plays a role…”. Their needs concentrated around the personality traits and the quality of human interaction. The single teenagers needs of the perinatal educator’s behavioral status focused on the individual with its unique situation, support giving, particularly regarding emotional needs, communication at the same level as the teenager (use lay language - not medical terms), and the personal interest in the teenager and his/her circumstances. They said: “…everybody must be treated as an individual….”,“…hear what everyone has to say…”,“…he talks to us as if we are equals…”,“…there is a great need for emotional support, that they see the need; the emotional turmoil we go through…”,“we need to get the information in our own language, that which we can understand”. Acceptance as a human being in their unique circumstances was, according to the single pregnant teenagers, an important quality of the perinatal educator. 

2. Needs concerning the educational activities and interventions

Effective perinatal education can only take place if the education style or method considers the women’s choice. Perinatal women’s needs focused on educational activities and interventions. They preferred practical examples, practical training, video recordings, limited reading material, handouts with specific guidelines, personal contacts, direct communication with the educator, involvement of the father is important and support groups until 6 months post partum. They express it as follows: “…someone who does something practical”, “it helps if the husband can come and they know as well”, “…seeing someone else doing it. So, definitely the practical, but the videos are quite nice”, “we would like to have discussions group with our babies together”, “every month is an issue, so I would say the first 6 months, once a month a class or a thing to get information”, “...hear it first hand from somebody, it is actually that little extra touch”.

The single teenager’s needs of the educational style or method focused on practical demonstrations (“It must be practical. Somebody must come and sit here and breastfeed her baby.”), practical training and limited video recordings (“I mean I do not want to see it on the TV; the TV is acting. I want to see it here”), guest speakers that share their own experience (“...or somebody that themselves has given up their child for adoption”, “…they must be able to talk to us and say they understand how we feel”), separate for different interest groups – mothers who are married, single parent and different age groups (“…our lifestyle is different than schoolgirls. A working girl has more responsibilities than us”, “…it is unfair to patient units girls that give their baby up for adoption to sit and listen to a lecture on single parenthood”, “keep it individual”), and voluntary participation and a visit to hospital, labour rooms, operating theatre, neonatal unit (“…feel that we attend on our own and is not forced to participate”, “…take us to the hospital; we want to see it ourselves”).

3. The content of the perinatal education

The women’s needs of the content of the classes focused on bodily changes during the pregnancy, shopping options – safety of baby equipment (“Also shopping options. What is the best monitor to buy?”), early pregnancy symptoms (“Is it normal to have those illnesses like morning sickness?”), use of medicine during pregnancy (“Can you use aspirin during the pregnancy?”), diet during the pregnancy, pain relief, the whole process of giving birth (“different stages that you go through during labour”), baby care, exercise options, emergencies during birth (“My biggest worry is the umbilical cord. If it goes around the baby’s neck, can you suffocate your baby?”), induction of labour, sterilization procedure, breastfeeding (“Can I breastfeed with flat nipples”), and sexuality during pregnancy (“Any limitations on sexual intercourse?”). The educational needs specifically applicable to single mothers focused on adoption, emotional management associated with the adoptive process, single parenthood, and the management of the adoptive couple.

DISCUSSION

The Interdependence Theory is one of the social-psychological theories that states that a client is more likely to continue to interact with people (in this case the perinatal educator) who are best able to provide them with equivalent rewards. A reward is something a client gains from an interaction. The perinatal educator (health promoter) needs to be sensitive to the client’s needs and take particular responsibility to make sure the interaction is rewarding and “build opportunities for reciprocity into interventions that use influence and communication to change health behaviors.”(8 p244). The Interdependence Theory places emphasis on bases of power and health behavior change. Perinatal educators exert informational power by providing clients with access to information. To build a relationship that is mutual rewarding, the perinatal educator should use participatory or patient-centered communication with the client and include the use of similar language (8).

The findings of the study were consistent with those of other international researchers (13-32). The perspective of women in South Africa (mainly a developing country) does not differ from the perspectives of women in other parts of the world. It is evident that single pregnant teenagers are a unique group with special needs that have to be taken into consideration when you have contact with them during the perinatal period.

The women had a specific perspective of the perinatal educator’s professional status and personal traits. This perspective is also shared in international literature. Clement (13) recommended that the perinatal educators should possess efficient listening and communication skills. Factors like friendliness, respect, empathy, quality care, participation in decision making and the provision of opportunities for the pregnant women to take care of herself are important factors that have to be taken into consideration when you educate the pregnant women (14). Therapeutic communication can be learned by perinatal educators and should be used as a primary instrument when working with women in the perinatal period. 

The perinatal educators should be able to empower the women. They should aim to educate and support the mother to give birth with self-confidence and be skilled in handling the baby. The perinatal educator can empower the mother by accepting her, by showing respect and by giving information and not advice. The mother’s ability to make decisions must be respected. Giving advice suggests a lack of confidence and rarely has a positive outcome, even if the mother might be open for advice. Rather, give information and allow the expecting mother to make an informed choice (15). 

The philosophical framework of the International Childbirth Education Association (ICEA) sums up the personal and behavioral attributes of the perinatal educator. These attributes were also verified in this study. The perinatal educator must advocate pregnant women’s rights to receive health care that is affordable, accessible and acceptable; support a midwifery system that does not discriminate against anyone on the basis of race, age, marital status or method of payment and acknowledge that the birth process can be a safe experience in the hospital, the birth centre or at home. The perinatal educator should function as an advocate of the natural birth process; protect the right of pregnant women to be accompanied during antenatal visits, the labour process, birth and the post partum period; respect the right of the pregnant woman to take informed decisions based on a knowledge of the advantages, risk factors and alternatives; encourage the involvement of the father and family during childbirth; encourage maternal, baby and family-centered maternal care as well as breastfeeding and parent-child bonding. They should advocate for maternal care that is not based upon the needs of the caregivers and suppliers, but in total on the needs of the mother, child and family; favor open communication and shared decision making with all members of the health team; co-operate with doctors, midwives, community nurses and social support services, and with other members of the health team. The vision that parents are a peer group, that is able to understand pregnancy-related information and take responsibility for their own health and the health of the baby, should be acknowledged. Perinatal educators should provide accurate and factual information based on resent research; identify the need for accompaniment and referral; respect the parents’ views regarding the birth, and help the parents to set realistic goals concerning the birth and early parenthood (16).

Expecting mothers have access to a great variety of information and advice, such as friends, family members, specialized literature, women’s magazines, television and radio programs, birth education classes, their general practitioners and other categories of health care workers. The women that participated in the study gave an indication that they need more information concerning the pregnancy and childbirth. Mothers consistently referred to the provision of quality information as of major importance. The education style should adapt according to the women’s’ socio-economic and marriage status. Literature and perinatal education classes are the biggest source of information. 

The language that is used during perinatal education and in educational material should be of such a nature that the perinatal women can understand it. Emphasis is recently placed on the term ‘health literacy’. Health literacy is the ability to read, understand and act on health care information (17).  Health literature often has problems with technical language, overloading of information, long word, complex sentences and a shortage of graphics. The purpose of educational material is to serve as a source of information for the women and her family, after discharge (18).  Perinatal educators play an integral and collaborative role in promoting health literacy in women in the perinatal period. It is important that the perinatal educator recognize the women that are more vulnerable to low health literacy such as those who are unable to read, the poor, immigrants and women with multiple and chronic problems. It is important to keep in mind that the women with limited health literacy have well established behavioral patterns and can easy hide their inadequacy. It is important that the perinatal educator create an environment that makes the mother and her significant others comfortable to ask questions. Interaction, with women in the perinatal period, should be slowed down. The educators should engage with the new mother at her level and ensure privacy to facilitate exchange of knowledge. Verify that communications are mutually understood, and provide information that is easy understood, retained and used. Suggested approaches include the following: Limit the amount of information provided at each session, use words and examples familiar to the patient, use pictures or models to explain important concepts, minimize use of text, use simple visual, and lots of white space and use materials and props that the patient will use at home (19).

The women participants indicated that they need support to 6 months post partum. Continuous care is very purposeful during the ante partum, intra partum and post partum periods (20).  Moran, Holt & Martin (21) mentioned that the retention of the information, which women receive during the perinatal classes during the post partum period, is not sufficient. Today women are discharged early; these women only develop a need for information when they are already home. A follow-up service should be supplied for post partum women that need help and information (22,23). The women in this present study indicated that they prefer the involvement of their partner or father of the baby. Men and women have different developmental processes and different stress and adaptation behaviors during pregnancy (24). Expecting fathers are sometimes jealous of the woman’s ability to procreate or reproduce. They often find the emotional reaction to the pregnancy, the development of the parental role, the clumsiness with baby care skills and the burden of being the breadwinner, as very stressful. The perinatal educator should act as a mediator between parents to improve the contact between them. Parents can share experiences, positively affecting the relief of anxiety and enhancing the learning process concerning the birth and parenthood (25). The perinatal educator should aim at involving the father in learning baby care skills and parental roles (24).

The women indicated that they have a need to visit the hospital, labour rooms, operating theatre, and neonatal unit. A tour to the labour rooms can help to orientate the expected parents and is very important to decrease anxiety during the antenatal period. The expecting parents can be informed about patient unit procedures and policies during this tour. Expecting fathers should be encouraged to attend the tour to help them feel part of the birth process. The women participants indicated that the perinatal classes should be presented in groups that are homogeneous concerning age. Groups like teenagers, primigravidas, older primigravidas and single parents should be educated separately (26).  Pregnant teenagers can develop a lack of self-confidence, find it difficult to ask questions in the presence of older, married women, and experience a sense of stigmatization.

It is necessary that all health personnel should give routine education, with every contact with pregnant women, according to a report on confidential enquiry into maternal deaths. This includes education on healthy lifestyle choices, such as exercise, diet, smoke and substance abuse as well as safety around the house and workplace. Women should be informed about the safe use of safety belts during pregnancy. All pregnant women should be made aware of the signs and symptoms of pre-eclampsia and other illness that contribute to maternal deaths such as bleeding, sepsis and heart diseases (27,28). The International Childbirth Education Association recommends that perinatal education classes should attend to the following information: the natural physiology and psychological changes during pregnancy, birth and the post partum period; general abnormal and unexpected variations in the normal patterns of the childbearing years; maternal and baby feeding, general medical interventions and procedures during the birth processes, such as obstetric procedures, vaginal births, Caesarean sections, and vaginal birth after a Caesarean section, analgesics and anesthesia, indications, contra-indications, advantages and risks involved with above-mentioned types of deliveries, alternatives to these types of deliveries (16).

The following can be added when a more extensive class is given: anatomy, physiology of reproduction and sexuality during the childbearing years; fetal development and the characteristic of the newborn; emotional changes of the father in each stage of the pregnancy, birth and post partum period; advantages of support during labour; the impact of pregnancy and parenthood on the relationship of the parents; family development; sources to handle unexpected outcomes; perinatal examinations and diagnostic procedures; teratogenic and iatrogenic procedures; the history and philosophy of perinatal education; and the philosophy and practice of family-centered perinatal care (16).

Single pregnant teenagers are a special group and should be handled that way. The needs of the pregnant teenagers are based on their unique developmental needs and social interests, for example their needs concerning continued education, financial support and parenting skills (4,29,30).  Perinatal education of the pregnant teenager poses a specific challenge; it should empower them to experience a positive pregnancy, to develop strategies to manage the birth and use appropriate sources to make decisions. Icebreakers and group work are excellent tools to encourage openness and problem solving solutions. A guest speaker, that had similar experiences as they, can be used effectively. The pregnant teenagers experience feelings of depreciation; this implies that the perinatal educators should strengthen the mothering role of the teenager by teaching her skills and equips her with knowledge. “Interventions making use of the pregnant adolescent’s longing for respect can foster responsible self-care activities that positively affect the baby’s health and development throughout and beyond the pregnancy period” (3 p14). It is important that the expecting parents, and in this case the pregnant teenager, take active part in decision making and to receive support from their caregivers (31).

Pregnant teenagers must be handled with empathy and helped to develop problem solving solutions and communication skills. They expect respect, as part of her new mothering role. Counseling of the pregnant teenager should be comprehensive and all alternative choices should be discussed with them. Teenagers have the legal right to protect their privacy and it should be respected (32).

IMPLICATIONS FOR PRACTICE

·               Every contact with women in the perinatal period should be used as an opportunity for education.

·               Adapt and tailor perinatal education according to the educational, socio economic and cultural background and age of the women recipients.

·               Involve the partner, father of the baby or significant other part of the perinatal education process.

·               Create an environment that makes the women and her significant other more comfortable to ask questions.

·               Recognize those women that are more vulnerable for low health literacy.

·               Single pregnant teenagers are a special group. Accept them as human beings in their own right. Allow them to participate in decision making concerning their pregnancy and health.   

CONCLUSION

The needs of the women concerning perinatal education are important if you want to reach your goals with this teaching. The purpose of perinatal education is to identify the women’s needs and apply the appropriate theory and methods. It is essential to understand the emotional context in which learning occurs. The perinatal educator must develop a partnership with the learner; in this case the women in the perinatal period. The real aim of perinatal education should be to take into consideration the needs of women concerning their learning and support of their partners. They should be informed within the limit of their education and extent of their daily lives to such an extent that they are able to make decisions and choices if they wish to. 

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