Supporting parents-to-be through antenatal education classes has been recognised as an important prevention and intervention strategy (Department of Health, 2011). Key policy documents have highlighted the need for pregnant women to be offered opportunities to attend participant-led antenatal classes (National Institute for Health and Care Excellence (NICE), 2018), and in recent years there has been an increasing expectation for men to play a more active role in childbirth and preparation for parenting. A reviewed commissioned by the Department of Health and undertaken by Schrader McMillan et al (2009) identified gaps in provision and areas for improvement, in order to make classes more engaging and to meet the requirements of today's expectant parents.
A number of antenatal education programmes have been developed over the past few decades. A variety of approaches and models exist, with generic key features (Jaddoe, 2009). Despite a growing interest in how best to suit the needs of parents-to-be with respect to antenatal education, there is still a concern that antenatal education may not be meeting the needs and expectations of parents-to-be, particularly fathers. Findings from a large Swedish study to assess parent's expectations of antenatal education indicated that an increased focus on preparation for parenthood was the most common request, when expectant parents were asked to state what they most wanted from classes (Ahldén et al, 2012). Smyth et al (2015), reflecting on the findings from a literature review into the effectiveness of antenatal education preparation on fathers' transition to parenthood, suggested that the traditional focus of antenatal education on the needs of expectant women has led to the specific needs of fathers being overlooked. In a study of first-time fathers' experiences of antenatal preparation, in relation to the challenges met in early parenthood, Palsson et al (2017) found that fathers' preferences varied with respect to structure and delivery, with some fathers believing that the environment was not conducive to ‘opening up’. Overall findings showed that fathers wanted clear and honest information about the realities of life with a new baby (Palsson et al, 2017). Despite the growing evidence base, from which the content and the delivery style of antenatal education can be drawn, there are still gaps in knowledge about what parents-to-be expect from classes, and what they consider valuable.
| Demographic characteristics | Participants who completed T1, T2 and T3 (%) |
|---|---|
| Women | 79.6 |
| Married or living with partner | 90.7 |
| Paid employment | 81.5 |
| First baby | 75.9 |
| Second baby | 9.3 |
| Third (or more) baby | 11.1 |
| Age (mean, years) | 29.0 |
T1: the introductory session (second trimester); T2: the final session (third trimester); T3: the reunion session (3-4 months postnatal)
This study addresses some of the gaps, and outlines what parents expected and found most valuable from an antenatal nurturing programme. Findings from this study provide insight into the expectations and learning needs of parents-to-be, as they make the transition through pregnancy into parenthood.
Ethical approval to undertake the study was granted by the Faculty of Health and Social Care research ethics committee at the University of Hull.
Method
This article is based on data collected by open-ended questions that were asked to a sample of expectant parents who were transitioning from pregnancy to parenthood. The aim of the overall study was to evaluate the effectiveness of an antenatal parenting programme delivered by Family Links. The programme, called Welcome to the World, was an 8-week antenatal programme designed to help parents prepare for childbirth and parenthood. Sessions focused on improving attunement and bonding, increasing parental wellbeing, improving skills in breastfeeding and improving practical care of the baby.
The field work took place between August 2015 and September 2016. Areas for inclusion in the evaluation were Armagh, Coventry, Bingley, Bristol, Cookstown, Stanley, Bridlington, Barry, Caterham, Allerton, Creggan, Bradford, Liverpool, and Cwmbran. Sampling used a purposive design to recruit participants best suited to provide meaningful data. Attendees who were registered for the programme were sent an information leaflet about the evaluation and a pre-programme information pack by the parent group leader who was delivering the programme. They were informed of their right not to take part of the evaluation, and that this would not affect their attendance on the programme. They were asked in an introductory session if they had the information leaflet and if they wished to take part. If so, their consent for data collection was registered.
Data collection
This article reports on the findings from open-ended questions about the expectations that parents-to-be had in relation to the programme content, and whether or not their expectations had been met. Parents-to-be completed the open-ended questions at two time points in pregnancy and once during the postnatal period:
Data analysis
Answers to the open-ended questions were coded and analysed manually to identify core themes (Braun and Clarke, 2006). The overall research question that guided the analysis of the T1 data was, ‘What are the expectations of parents attending an antenatal nurturing programme?’
The question guiding the analysis of the T2 and T3 data was, ‘Which aspects of the programme were most valuable across the transition to parenthood?’
Data were searched to find repeated patterns of meaning, and issues of interest in relation to the research question. Labels were applied to important features in the data that were relevant to the overall questions, and codes were used to capture relevant concepts that emerged from the labelling process. Every data item was coded, all codes and relevant data extracts were collated (Braun and Clarke, 2013). Coded data were searched for similarities, and where similarities were found and agreed, the data was used to construct relevant themes. Two researchers independently identified the core themes. The researchers met and reviewed the essence of the themes for clarity in relation to the research questions, then debated the relevance of the themes to the overall ‘story’ of the data, before proceeding to name the themes appropriately.
Rigour was promoted by carefully monitoring the research process. Two researchers analysed the data independently and the final themes were identified through discussion (Jeanfreau and Jack, 2010). Credibility was maximised through repeat contact with previous participants of the programme, and was enhanced through discussion of the emergent themes.
Questionnaires were completed by 131 participants (96 women, 35 men) from 17 programme groups in 13 locations across the UK; however, only 54 participants (43 women, 11 men) completed the questionnaires at all three time points.
Findings
Women's needs and expectations
Relationships
Of key importance to women was developing relationships and this featured regularly across the three time points. Women's responses focused specifically on relationships with the baby, with other attendees and, to a lesser extent, with their partners. Most evident across the T1 data for women was their need to learn more about the relationship with the baby, both in utero and after birth. Women were keen to learn how to develop their relationship and the ways in which this could be encouraged. In particular, they were keen to understand more about creating a closeness to the baby before birth, and attachment after birth. Some of the responses to the question around expectations T1 are detailed below.
‘Knowledge re. Baby's development + interacting with baby.’
‘Gain more knowledge about different ways to bond + deal with having a baby.’
At T1, women also anticipated that the classes would be a good platform to form friendships with other attendees. They expected the course to provide them with a place that they could share worries, meet and gain experience from others and make friends:
‘To make new friends who are also first time mothers.’
‘Meet people in the same situation.’
‘Meeting people.’
‘New friends for me & my baby.’
At T2 and T3, women felt that this need to develop their relationship with their baby had been satisfied:
‘I feel it helped me bond with my baby prior to birth & open discussion with my husband on certain topics prior to birth.’
‘I loved the nurturing aspect, it was outstanding.’
There was also a sense that attendance addressed their need to meet and connect with other attendees:
‘Great support and friendship and a comfortable environment to share concerns – safe!’
‘It has been lovely meeting other expectant mums.’
‘I met some wonderful women.’
‘Everyone I met lovely friendly.’
‘Met some lovely people.’
Emotional wellbeing
For women, addressing emotional and mental health needs was also significant at this time. Data highlighted that women expected their engagement with the programme to reduce their anxieties and increase their confidence, providing an increased ability to ‘cope’ and feelings of reassurance.
‘More understanding of the thoughts and feelings of pregnancy. Am I normal in what I feel etc.’
‘Learn about emotions.’
‘To be less anxious and more confident about when the baby arrives.’
At T2 and T3, data suggested that for a number of women, emotional wellbeing was addressed in the classes.
‘Yes very much so. Normalised fears. Helped self mentally prepare.’
‘It has been very informative and has helped me cope with the emotional preparation for birth and becoming a mum.’
‘Was a great course, really helped us prepare for parenthood. Covered more topics than I expected. Emotional + practical support.’
Practical knowledge and advice
Albeit to a lesser extent, women also expressed a need for a degree of practical advice; particularly with respect to breastfeeding and in the early days of looking after a newborn baby, being in labour, and giving birth.
‘Better skills of hands on things (bathing).’
‘Learn about breastfeeding.’
‘To learn more about caring, feeding, & baby needs.’
New mums felt that this aspect of the course extremely helpful for them in the days and weeks after birth:
‘It provided a safe environment to prepare myself for the new baby, particularly feeding.’
‘Definitely. Just the information on breastfeeding, bathing, communication, breathing through.’
‘Just the information on breastfeeding, bathing, communication, breathing through labour. It was all very useful to be during my pregnancy and early weeks of parenthood.’
‘The course was really helpful in helping me prepare for having a baby. It was very informative. I particularly liked the sessions with the midwives – labour day & breastfeeding were particularly helpful.’
‘The course was positively helpful on the sections to do with bonding, labour and feeding.’
Men's needs and expectations
Generalised knowledge gain and preparation for parenthood
Men's needs and expectations were difficult to capture, as they tended to be less specific in articulating their needs and expectations from antenatal education. Similar to the study by Palsson et al (2017), this study highlighted that fathers seem to have difficulties in knowing what they needed to know. At T1, data indicated that for partners (n=11), all of whom were male, expectations were vague and more general. Data showed that for these fathers-to-be, the classes were seen as a place to:
‘Learn a bit more knowledge.’
‘Learn new things.’
‘Gain new tips.’
‘Learn things we haven't thought of yet.’
‘Learn the “baby basics.”’
‘Gain an understanding of what to expect.’
Partner data at T2 confirmed that the course had met their expectations, and that the valuable aspects of learning were aligned to expectations from T1: generalised knowledge gain and how to support their partners. In addition to this, by T2, men had understood that hands-on practical skill development was of value. There was a shift from a need for non-specific and at times vague aspects of knowledge gain, to T3, where the most valuable aspects of the programme were the support networks and the practical skills needed to provide hands-on care. Despite this shift, there were still some aspects of their learning that remained vague, such as a generalised ‘knowledge gain’. Table 2 shows the general needs and expectations of both men and women and compares these across the three time points.
| Question | Time point | Women (n=43) | Partners (n=11) |
|---|---|---|---|
| What are the expectations of parents attending an antenatal nurturing programme? | T1 |
|
|
| Which aspects of the programme were most valuable across the transition to parenthood? | T2 |
|
Learning how to support partner Learning the practical skill |
| T3 |
|
Learning practical skills to care for the baby Developing vital support networks |
Discussion
The data from this study forms one part of an evaluation of Welcome to the World classes; no claims are being made as to the wider transferability of the findings. The analysis set out to provide an insight into parents' expectations and learning needs, and the aspects of antenatal education that they found valuable, as they made the transition through pregnancy into the early weeks and months of parenthood. This data highlighted a number of aspects that act as a point of discussion with respect to calls for antenatal education to be more attractive and engaging.
The transition to parenthood is an important time for parents as they learn how to cope with their new roles and responsibilities. Of equal importance is the fact that pregnancy and birth is considered a ‘critical opportunity’ to effect change, when parents are especially receptive to offers of advice and support. Antenatal education programmes such as this are accessible to parents-to-be, either through self-referral, or referral through locally agreed arrangements. As the programme focused on bonding and emotional wellbeing, it demonstrated a responsiveness to the importance of the Government's 1001 Critical Days manifesto (Durkan et al, 2015).
A number of studies have highlighted a need for improvements in antenatal classes to meet the requirements of expectant parents (Deave et al, 2008; Billingham, 2011; Ahldén et al, 2012; Gilmer et al, 2016; Entsieh et al, 2016). For pregnant mothers in this study, their expectations and learning needs were clear and could be grouped easily into three overarching topics: ‘developing relationships (with baby, friends, and family)’, ‘emotional wellbeing’, and ‘practical aspects’. These remained fairly consistent across all time points. Women appeared satisfied that their needs were met, which is reassuring for the programme providers. Data from women illustrated that they had a strong awareness of the value of learning about the physical and emotional aspects of parenthood, the baby's wellbeing, and healthy social and emotional development.
On the other hand, meeting the needs of partners appeared to be more challenging. Smyth et al (2015) highlight the importance of helping fathers to understand how they could support their partners during pregnancy, labour and birth, and prepare them for parenthood. Maternity services are being urged to expand their notion of appropriate preparation of parenthood to include fathers (Schrader McMillan et al, 2009). In response to this, there is a now substantial body of evidence to show that father's engagement with antenatal education is improving (Hallgren et al, 1999; Redshaw et al, 2007; Smyth et al 2015). Despite these improvements, research suggests that fathers continue to feel frustrated by their lack of inclusion in maternity care, and the absence of targeted information (Deave et al, 2008; StGeorge and Fletcher, 2011; Smyth et al, 2015).
Encouraging attendance and involving fathers-to-be in discussions about learning needs is vital to ensure they feel included; however, the data from this study suggests that asking fathers what they would like to learn, or what they consider to be most valuable, does not seem to help tailor the classes to their needs. The data from this study indicates that many fathers-to-be do not appear to know what they want to know. This reflects previous research (Pallson et al, 2017), where fathers identified that their lack of previous experience created difficulties for them in anticipating what they might need to know and forming questions. The differences between fathers' and mothers' learning needs may reflect, as Draper (2003) points out, the traditional stereotypes, framed by hegemonic masculinity, that have clearly differentiated men and women's parenting roles over previous decades. Although the data portrays fathers as less engaged and less aware of their social and emotional needs, it may be that this is more a reflection of class structures being less conducive to them articulating their needs; consequently fathers are playing out their ‘strong and silent’ stereotypes.
While the fathers in this evaluation seemed generally happy with their levels of preparation for parenting, the data reflected a degree of vagueness in terms of fathers' awareness of their learning needs—or, at the very least, a reluctance to articulate those needs. One aspect of this evaluation that has provided a platform for further exploration of men's engagement with classes has been the differences in learning needs between expectant fathers and mothers. It would seem that by inviting fathers-to-be into antenatal education and asking them to identify their learning needs is not an appropriate method of gaining meaningful information to tailor antenatal education to the needs of fathers. What was noteworthy in this data was that, for some men, specificity of learning needs could increase as pregnancy progressed, and that increasing proximity to birth might be associated with an ability to formulate more relevant learning needs and expectations, based on increased knowledge gain. This may also be due to increased familiarity with the group, the environment and the overall process of antenatal preparation, so as expectant fathers become more comfortable with the classes and the other attendees, they are able to consider their needs in a more focused and meaningful way. It is important to state that this is not a universal experience for all fathers-to-be attending parenting education classes; rather, the intention is to demonstrate one approach to providing a greater understanding of fathers' needs.
Recent research indicates that fathers-to-be require something different from what is on offer. While previous research suggests that fathers felt frustrated with the lack of relevant information and tailored preparation for fatherhood (Palsson et al, 2017), other research indicates that, reflecting on their needs during pregnancy, fathers in early fatherhood would have benefitted from guidance towards creating a fatherhood identity, and finding information about reliable websites (Deave et al, 2008). This helps fathers undertake their own information-seeking, while helping them to be confident that their sources are accurate (Palsson et al 2017). This strategy of seeking their own information may also be more aligned to their perceived needs to be the ‘provider’ and the ‘protector’: they are providing the family unit with vital information, and at the same time, they are protecting the unit from potentially harmful or unreliable information. The creation of spaces (physical or virtual), where groups of fathers can informally share information, has been identified as an important aspect of preparation for parenthood and the early postnatal period (StGeorge and Fletcher, 2011). Recognising and providing strategies for times of role conflict—where fathers feel conflicted about being both the breadwinner and the nurturer—was also identified as an important aspect of preparing fathers for parenthood (StGeorge and Fletcher, 2011).
Conclusion
Antenatal classes such as Welcome to the World allows parents-to-be to express their feelings and expectations of parenting, and to align these to their learning needs. This evaluation set out to uncover parents' expectations of these classes with respect to knowledge and skills, with the aim of providing Family Links with an opportunity to tailor antenatal classes more closely to the parents' needs. Research on the needs of fathers in antenatal education is growing, and the findings from this evaluation contribute to this body of work. Findings indicate that expectant mothers and fathers have different learning needs at different times, and that while expectant mothers are clear about what they want to know from classes, fathers enter classes with unspecific learning needs. These become slightly more focused as pregnancy progresses, but generally speaking, remain fairly vague. Furthermore, it is unclear why in fathers-to-be, increasing proximity to delivery seems to be associated with an ability to formulate more specific learning needs and expectations. In attempt to address concerns that antenatal education may not be meeting the needs and expectations of fathers, this finding, alongside findings from the growing body of research on fathers and parenting, is worthy of further exploration and could help providers plan new strategies for engaging men in more meaningful ways.