Provision of antenatal education by registered midwives is advocated by the Nursing and Midwifery Council (NMC) (NMC, 2012) as a means of preparation for parenthood and is identified by government health policy as a pivotal interactive event during which health promotion can be addressed (Scottish Executive, 2001; Scottish Government, 2011a). Antenatal education is offered in different formats, in varying circumstances and venues—midwives may find that they share antenatal information and advice during every antenatal encounter they have with a woman and her partner (Schott and Priest, 2002).
An antenatal education class can be defined as a gathering of pregnant women and their partners for the purpose of information provision to offer support and assistance during the transition to parenthood (McInnes, 2005). Emphasis is placed on the promotion of health and wellbeing throughout pregnancy and beyond (Health Improvement Scotland (HIS), 2011). Reasons for attending antenatal education classes are diverse; however, attendance may be viewed as a way to adapt to the challenges and alterations that pregnancy brings (Schott and Priest, 2002). The expectations and hopes held by some pregnant women may not reflect the reality of the birthing experience or environment (Eames, 2004). Sharing information with pregnant women and their partners attempts to develop knowledge and empower women to become active participants in the care they receive and with increased involvement it is hoped that the overall birth experience is enhanced (Baston, 2003).
Researcher role and reflexivity
As a registered midwife working in the hospital that encompasses the boundaries of the practice areas included in the sample, I am known to many of the community midwives. However, I have not worked as a student or qualified midwife in the community areas included in the study. Adopting a reflexive transparent approach is essential as acknowledging the impact I may have had on the participants, views expressed and analysis of findings is fundamental to the trustworthiness of qualitative research (Holloway and Wheeler, 2010). The ability to detach and isolate a researcher from the qualitative study in which they are engaged is viewed as impossible (Burns et al, 2012), instead immersion in all aspects of the study is vital. The researcher becomes united with the process and emerging themes and this is particularly the case when interpretive Hermeneutic phenomenology is embraced (Smith et al, 2009). Pre-existing relationships between participants and the researcher were acknowledged; however, no tension existed as there was no imbalance in hierarchy. In view of this, the researcher was perceived as having a ‘hybrid position’ due to familiarity with participants and subject area (Jootun et al, 2006) while still retaining some distance due to lack of extensive experience in the specific nature of antenatal education classes. The existence of pre-understanding within the context of this study was welcomed and accepted throughout the research process.
Background
Although the overall aims of antenatal education classes are honourable, they are not without fault. Research suggests that the information offered can be unrealistic and conflicting in nature, which may be compounded by the manner in which the information is presented (Lavender et al, 2000). Antenatal education classes in Scotland are primarily delivered by groups of midwives, particularly those based within the community, with input from physiotherapists and health visitors (Quality Improvement Scotland (QIS), 2007). However, critics of formal antenatal education classes believe that they encourage some pregnant women to become dependent on health professionals, with an emphasis placed on compliance with hospital policies and procedures (Murphy, 2008). This is significant as the underpinning philosophy of antenatal education is the fulfilment of learning needs rather than indoctrination into the practices of health professionals and institutions (Schott and Priest, 2002).
A QIS review of antenatal education classes revealed inconsistencies with only seven of the 15 NHS Boards in Scotland found to have a written syllabus outlining the goals and themes to be addressed within the programme (QIS, 2007). Variation in the quality of antenatal education classes across the country is unsurprising. In a national drive to reduce inequalities in the health of pregnant women, the Scottish Government (2011b) highlighted the importance of improved access to, and quality of, antenatal education through implementation of a national syllabus with additional resources and training.
The launch of the ‘Core Syllabus’ in Scotland offering clear standards and details of the content required for antenatal education programmes using adult education approaches attempted to address issues of inequality and access, suggesting that those facilitating antenatal education classes should complete a non-compulsory 2-day course (HIS, 2011). Through provision of the ‘Core Syllabus’ and the facilitator course there is a belief that those currently providing antenatal education classes are lacking in essential adult education skills or indeed understanding of pedagogical approaches; however, the key research used to substantiate this was carried out fourteen years ago (Underdown, 1998).
The success of antenatal education depends on the experience, knowledge and motivation of the facilitator (Gagnon and Sandall, 2007; Taylor, 2008). Jackson (2005) states that although midwives cannot be expected to excel in all aspects of their role those involved in antenatal education classes should ideally be motivated: ‘We can't all be good at everything…the outcome for everything is better if the person delivering the service has an interest, even a passion for what they are doing.’ (Jackson, 2005 : 32).
Therefore, it is essential to explore how community midwives feel when fulfilling their antenatal education responsibilities.
Review of literature
Using a robust search strategy the following databases were searched utilising the Knowledge Network platform: British Nursing Index, Medline, Emerald, CINAHL, EBSCO, MIDIRS and Journals@Ovid Full Text. Science Direct was accessed separately. The search was carried out between October 2011 and February 2012. Included was research in the English language dated between 1990 to February 2012. Research carried out in the UK was selected to ensure the relevance to provision of antenatal education classes in Scotland. Exclusion dates were chosen to reflect research carried out prior to, and following, implementation of health policy which placed emphasis on informed choice including the importance of information provision (Department of Health (DH), 1993). The following keyword terms were used and combined using Boolean logic: community midwives, midwifery, community health nursing and midwives with prenatal care, antenatal or prenatal and education or class, parenting education, parentcraft and antenatal education classes. The findings can be found in Table 1. A total of 10 papers were retained with one further paper obtained following scrutiny of reference lists. Manual searches of retrieved papers were necessary to identify research which considered the views of those facilitating antenatal education classes; more advanced use of Boolean logic could potentially have limited this process. The prevalence of research carried out between 1990 and 1993 was minimal with the majority of papers retrieved having been published from 1997 onwards, a possible reflection of the impact of implementation of policies focused on information provision and informed choice (DH, 1993).
| Major subject heading | Results | Comments |
|---|---|---|
| (Antenatal education classes) and (Midwives): Limited to 1990-12th February 2012 | 142 | 3 papers retrieved of which 3 were retained |
| Prenatal Care | 727 | 9 papers retrieved—of which 5 were excluded |
| Midwifery | 251 | 4 papers retrieved—of which 4 were excluded |
| Community Health Nursing | 128 | 1 paper retrieved—of which 1 was excluded |
| Prenatal Care Methods | 321 | 3 papers retrieved—of which 1 was excluded |
| Patient Education | 33 | 0 papers retrieved |
| Prenatal Diagnosis | 58 | 0 papers retrieved |
| Midwifery Methods | 200 | 0 papers retrieved |
| Nurse-Patient Relations | 84 | 1 paper retrieved—of which 1 was excluded |
| Expectant Fathers | 13 | 1 paper retrieved |
| Midwives | 63 | 2 papers retrieved—of which 2 were excluded |
When exploring the feelings community midwives experience when facilitating antenatal education classes, initial findings from literature suggest that many authors presented their impressions of the current situation with little supporting evidence. When providing commentary on the findings of an expert group considering the impact of antenatal education, Billingham (2011: 36) highlighted that ‘…health professionals feel ill prepared and unsupported in this work.’ However, health professionals did not appear to have been questioned. Exploration of midwives' feelings by asking midwives directly is required.
The study by Barlow et al (2009) was the only UK research including midwives which addressed the perceptions of stakeholders about provision of antenatal education in England. The study provided great insight into the feelings of midwives involved in providing antenatal education classes and relevant issues included levels of preparation, confidence and support for staff involved. While noteworthy, these findings formed only a small part of the original study and in view of the powerful comments reported by midwives with regards to providing antenatal education classes, for example ‘…to be endured rather than actually do it well…’ (Barlow et al, 2009: 18), the impetus to investigate further is compelling.
Research in the UK by Lavender et al (2000) attempted to discover what information women wanted to receive during antenatal classes and how they preferred this information to be presented. Antenatal education classes were identified as poorly timed during the pregnancy journey, with information condensed into too short a timeframe to enable effective learning. Conclusions were that women believed midwives to be too busy to provide sufficient information. It must be acknowledged that in the decade following completion of this research an increasing reliance on technology and internet usage may have a bearing on the findings.
In a review of qualitative studies Nolan (2009: 28) states that ‘…midwives receive limited training in leading groups for adult learners’, an assertion similar to the position adopted earlier by the same author in 1997, highlighting the difficulties when midwives assume the role of childbirth educators due to their training as clinicians rather than teachers. Furthermore, Nolan (2009) found that women appeared to adapt their manner and demeanour in an effort to please their midwife indicating the powerful influence midwives have when providing antenatal education classes.
Research question
This study aimed to answer the question:
What is the lived experience of community midwives when facilitating antenatal education classes?
Methods
The phenomenological approach
The research approach adopted must marry with the research questions; however, Moule and Heck (2011) highlighted that the approach must also resonate with the beliefs and abilities of the researcher. Therefore a phenomenological qualitative approach was adopted. Phenomenology relies on the researcher seeing beyond superficial analysis of life experiences by way of developing and applying philosophical understanding to reveal phenomena previously concealed (Bassett, 2004).
Hermeneutic phenomenology, in particular, allows examination of experiences which due to familiarity can be taken for granted and become lost in our everyday lives (Healy, 2011). Research must strive to move beyond the descriptive elements to reveal what is otherwise hidden with the aim of uncovering the truth. The approach developed by Martin Heidegger arose from the philosophical foundations of phenomenology evolving into a hermeneutical interpretive research methodology (Holloway and Wheeler, 2010). Specifically, interpretation is affected by the concept of ‘pre-understanding’ or ‘forestructure’, which Heidegger (1962) described as the existence of preconceptions, prior experiences and assumptions a researcher will bring to any encounter. This differs from the tenets of Edmund Husserl's phenomenological philosophy which stated that, in order to return to the lived experience, re-examination of phenomena must occur from a perspective which has been isolated from preconceptions through the use of bracketing (Smith et al, 2009). While bracketing reduces the description of an experience to allow the researcher to be free from their own assumptions and remove distractions, thereby returning to the essence of the phenomenon, Heidegger argues that the influence of the researcher, situation and environment are integral to understanding (Heidegger, 1962). Thus, interpretive Hermeneutic phenomenology has resonance with health research, becoming increasing popular particularly in nursing and midwifery, as it is orientated towards a holistic perspective considering the individual within context (Bassett, 2004). Interpretive Hermeneutic phenomenology offers an increased understanding of human experiences during illness but also during culturally specific experiences such as child birth and mothering (Kesselring et al, 2010).
Ethical considerations
Privacy of participants was ensured by removal of identifying features and use of the codes for transcripts with interview recordings deleted following transcription and analysis. To uphold the ethical principle of nonmaleficence advice was sought from the South East Scotland Research Ethics Service. Following consideration, the service designated the study as an opinion survey and as such did not require formal ethical approval from the NHS. Approval was sought and granted from the affiliated University's Faculty Research Ethics and Governance Committee.
Data collection and sampling method
Non-probability purposive sampling which relies on the researcher to select members of a population well placed to provide data relevant to the research was used for this study (Offredy and Vickers, 2010). All community midwives (n=32) were therefore approached within three practice areas via letter inviting participation in the study. A sample of six was selected from those who returned consent forms (n=16). All returned consent forms were dated on receipt and the first two participants from each practice area were selected. The number of participants was determined by the purpose of the study, which attempted to explore lived experiences and gather rich qualitative data, rather than generate generalisable findings (Rees, 2003). Restraints of time and resources were influential when sample size was determined; however, between six and eight participants are believed to be sufficient to provide saturation from a homogeneous sample (Holloway and Wheeler, 2010). Individual semi-structured interviews were used to create a partnership between the researcher and participant in acknowledgement of the role of the researcher within interpretive phenomenology (Mackey, 2005). An interview schedule was used to facilitate flowing and comfortable interaction (Smith et al, 2009) (Table 2). The interview schedule was piloted to highlight areas where flexibility was required and to provide the researcher with an opportunity to reflect on the experience prior to approaching the participants. Interviews were carried out in the participants' local area of work at their convenience and were audiotape recorded and transcribed subsequently by the researcher. A copy of the transcript was sent to each participant providing an opportunity to verify accuracy and approve the transcript (Rowley, 2012). All participants agreed with the content of their transcribed interview.
| Questions to establish background information |
| How long have you worked as a community midwife? Where have you worked previously? |
| How often are you involved in facilitating antenatal education classes? |
| How is this part of your role allocated? |
| Learning and teaching methods |
| How do you feel/believe adults learn? How do you learn? |
| Do you feel you apply your knowledge of learning and teaching approaches to the antenatal education classes you provide? |
| If the answer is no: What knowledge do you draw upon to guide you when preparing for and providing antenatal education classes? |
| Consider how you feel when facilitating antenatal education classes: Are there particular aspects you enjoy—and why? Are there particular aspects you dislike—and why? |
| Preparation for practice |
| Do you believe your initial midwifery education has prepared you for your role in facilitating antenatal education classes? |
| Do you believe your subsequent training has prepared you for your role in facilitating antenatal education classes? |
| Do you believe your continuing professional development (CPD) has prepared you for your role in facilitating antenatal education classes? |
Data analysis
Data analysis within hermeneutic/interpretive phenomenology does not attempt to generate objective, scientific concepts or theories but instead attempts to provoke others to consider the ‘mystery of what ‘is’…’ (Smythe et al, 2008: 1391). Instead of a prescriptive step-by-step process, the foundations of interpretation must be recaptured following the principles of the hermeneutic circle as suggested by Heidegger (1962). Allowing a fluid approach to analysis and interpretation where understanding moves back and forth between small parts and the understanding of the whole prevents the researcher from applying mechanistic approaches which would contaminate the essence of the experience (Smythe et al, 2008).
Interpretative Phenomenological Analysis (IPA) is an approach to data analysis founded on the values of psychology (Pringle et al, 2011a; 2011b) and attempts to analyse the participant's perceptions of their experiences (Smith et al, 2009). Although IPA provides guidelines which are user-friendly for novice researchers they are not prescriptive but flexible which may assist in making the process more manageable for those who are less experienced (Smith et al, 2009). As IPA offers guidance as to the process of data analysis and was congruent with hermeneutic phenomenology this approach was used.
Using the principles of IPA, each transcript was read to develop descriptive comments which consisted of key words and phrases used by the participants thus providing a tentative insight into the meaning of the experience. Transcripts were then re-read and sub-ordinate themes emerged following extraction and analysis of verbatim phrases from the transcripts and summarisation (Smith et al, 2009). Themes reflected the essence of participants' lived experiences in combination with the interpretive influence of the researcher. The robust nature of the research was maintained through acceptance of pre-understanding and utilisation of a reflexive approach throughout the analysis process. Before reviewing preliminary analysis, a transcript was read independently by research supervisors offering an opportunity to discover their interpretation of the data. The themes and meanings identified were found to be consistent with the analysis. Themes were then collated, analysed and reviewed to produce an overall interpretative understanding framed within the context of the participant's narrative (Table 3).
| Excerpt from transcript | Summary | Sub-theme | Sub-ordinate theme | Theme |
|---|---|---|---|---|
| ‘I suppose because we're in the job to meet the demands of the women not the demands of ourselves… see what the women want rather than what the midwife wants. But I do feel it is part of our role as a health educator.’ | Awareness that the needs of women must be met and not the wishes of the midwife | Views of antenatal education role | Being aware (of self) | Midwife Perceptions |
| ‘…but it can be quite scary I mean some people just don't like doing that. It is just something that I've kindda just grown with it is part of my job and I would hate any of them to leave and say oh god I was falling asleep…’ | Sense of anxiety, disliked by some midwives | Views of antenatal education role, feeling prepared, being challenged | Having self-confidence in skills as an educator | Educator skills and confidence |
Results
The sub-ordinate themes and themes that emerged following analysis of the transcripts are illustrated in Table 4.
| Sub-ordinate themes | Theme |
|---|---|
| Having self-confidence in skills as an educator | Educator Skills and Confidence |
| Having and applying knowledge | |
| Knowledge of client group | |
| Client satisfaction | Midwife / Client Satisfaction |
| Midwife Satisfaction | |
| Being Aware (of self and others) | Midwife Perceptions |
| Feeling challenged / questioning self | |
| Seeing potential solutions |
Educator skills and confidence
When participants were asked to consider their abilities and skills as educators leading antenatal education classes, sub-ordinate themes of having and applying knowledge and self-confidence in skills as educators were identified. Some described that although they found antenatal education challenging it was an expected and accepted part of their midwifery role.
‘I do enjoy the parentcraft but I think to do it all the time it's…far bigger and a lot more input than it was years ago…’
Acknowledgment that the provision of antenatal education classes was a recognised part of their role appeared to affect participants' level of acceptance and confidence.
‘I would say that it's part of our role in the community so no. I don't have problems that way.’
The issue of whether every community midwife should be expected to participate in the provision of antenatal education classes was raised by one participant.
‘…is there a better input from a midwife who maybe feels more comfortable doing it… should we have midwives who really want to do it rather than expecting every midwife?’
Although reluctance to participate in the provision of antenatal education classes was not expressed by the participants they reported a lack of enthusiasm in some of their colleagues.
‘I think it is part of our role. I don't shy away from it, I do it. It doesn't bother me. I know some of my colleagues don't like it.’
Midwife/client satisfaction
Midwife satisfaction appeared to be associated with the specific nature of the community location for the antenatal education class and the benefits which this entailed, including opportunities to share information with fewer restrictions on the time which can be spent with women and their families.
‘…the community midwife bit is great because you are more with the woman rather than just that initial intense part of being in labour so it's a whole more holistic care of the lady and when they come back for another baby it is even more lovely.’
However, dissatisfaction in the present state of antenatal education was voiced and, rather than feeling encouraged to provide a diverse and innovative approach, the participant expressed the belief that the current structure is restrictive.
‘I just feel that they are actually stripping away our parentcraft role rather than enhancing it…I don't think [the NHS division] is allowing the people to expand.’
Client satisfaction emerged as a theme when participants were asked to consider their feelings about antenatal education classes. Providing enjoyable classes and empowering women and their partners were seen as essential.
‘…it is important that women know it doesn't matter how they are delivered that they are still a success. I think that as long as the mum is fine and the baby is fine regardless of delivery it is a success story.’
Midwife perceptions
Participants voiced an awareness of self in that they had an understanding of their own abilities, strengths and values through reflection. This may impact on decision making when applying particular learning and teaching techniques.
‘I like to be shown and to do it and learn that way. I'm not a great reader so I don't read books an awful lot…but I listen to what people are saying I take it in and utilise it.’
The awareness of the strengths and weaknesses of midwifery colleagues was expressed in detail by one participant when describing her role in the current provision of antenatal education classes within her area.
‘…I probably do more than my colleague …my colleague doesn't feel as comfortable doing the sessions…I kind of lead them to be honest…not everybody feels comfortable in groups, to lead groups or even have the whole public speaking role really…’
Discussion
The majority of participants believed that provision of antenatal education classes was an accepted and important part of their role as a community midwife although some felt overwhelmed in response to the perceived expansion in the range of their responsibilities. Some participants appeared extremely enthusiastic and confident in their skills, believing that the opportunity to share information with women was a privilege whereas others viewed it as a task which had to be completed rather than enjoyed.
While participants did not directly express feelings of reluctance to be involved in antenatal education classes, an aversion and lack of enthusiasm was noted on behalf of some of their community midwife colleagues particularly with respect to working with large groups of women and their partners. Barlow et al (2009) asserted that some midwives found that antenatal education classes were viewed as an experience they had to suffer. This has particular importance when Taylor (2008) stresses high levels of learner and facilitator motivation are prerequisites to achieving a successful learning relationship. One participant highlighted the impact the midwife may have on the success of antenatal education classes and questioned whether all midwives should be expected to participate if they disliked, or were daunted by, this aspect of their role. Wickham and Davies (2005) believe that midwives should be supported to decline their role in antenatal education classes if they feel that they are expected to work out with their knowledge or skill base despite this being a fundamental component of the role of the midwife (NMC, 2012). It must be questioned as to who would assume this responsibility if a midwife declines this aspect of their role, particularly if their colleagues have similar reservations.
The opportunity to support women throughout their pregnancy beyond the perceived restrictions of the hospital environment was seen as empowering and fulfilling the underpinning ethos of midwifery—‘being with woman’. There appeared to be an inextricable link between midwife satisfaction and the midwife's perception of positive client satisfaction, with participants referring to informal and formal positive feedback from women being an aspect of the role that they particularly enjoyed.
Participants were sensitive to the effect they had on women and their partners with one participant displaying particular self-awareness as she discussed the influence of her personality on the group. This also included the ability to build a rapport which may rely on the midwife ‘giving’ something of herself to offer confidence and comfort to women to contribute during group discussions. Indeed, the reciprocal nature of this interaction continued with many participants reporting that they also learn from women. The conception of being aware of self and of being selfless emerged from the data when a participant stated that midwives must
‘..meet the demands of the women not the demands of ourselves…’
Strengths and limitations
The strength of any research is assessed on the methodological rigour which is applied; however, all have inherent limitations. As a qualified midwife working in the local hospital for over 10 years I was known to participants and was aware of some of the challenges faced by community midwives in relation to antenatal education provision. These factors may be perceived as both strengths and limitations in that familiarity may have encouraged community midwives to respond to the initial invitation to participate but may have deterred others who felt less positive about their role in antenatal education and were reluctant to reveal sensitive issues. Nonetheless, participants' narratives obtained were indeed lengthy and detailed and did not indicate any reservations. Pre-understanding in interpretive phenomenology is embraced rather than rejected (Smith et al, 2009) therefore any existing knowledge and previous associations with the participants were incorporated into the analysis of the data throughout the process of interpretation.
Conclusions
This study attempted to explore feelings which community midwives experience when facilitating antenatal education classes in Scotland. An interpretive phenomenological approach was employed (Heidegger, 1962) in an attempt to understand the everyday experiences of the participating community midwives. The main findings from the study suggest that the participating community midwives were overwhelmingly positive regarding their current role in providing antenatal education classes but they reported varying levels of enthusiasm and reluctance in some of their community midwifery colleagues. While reluctance was conveyed in an anecdotal manner it would be of interest to approach those midwives who choose not to participate in antenatal classes to discover their views and suggestions for the future of antenatal education provision; however, the challenges faced in accessing this population are acknowledged.