Improving Childbirth Practice for Parents to Be

Volume 28 Number 2 April 2013 | International Journal of Childbirth Education | 25

Proposed Model for

Improving Childbirth Practice for Adult Parents-to-Be

by Natsai L. Zhou, PhD MSN FNP-BC BSN-RN BA LNC

Abstract: Whether a childbirth educator is a novice or veteran in teaching, chal-lenges exist during prenatal classes. Many participants of prenatal classes are first time parents-to-be who come with vast life experiences, social responsibilities, and values. Although freedom in teaching strategies is encouraged for prenatal edu-cators, an approach that focuses on adult education is proposed to guide childbirth educators in prenatal classes. In addition, parenthood, literacy, socioeconomic sta-tus, and cultural differences can be con-sidered to guide parents-to-be in making comfortable, appropriate, and satisfying childbirth choices.

Keywords: Childbirth educator, Adult learner, Prenatal/Childbirth, Parents-to-be

IntroductionHow do individuals who have decided to teach prenatal

classes to mothers and possibly fathers-to-be proceed to present themselves in the most effective manner to transfer their wealth of information to expecting parents? What are the most significant characteristics of these mothers and fathers-to-be to consider while teaching these classes? It is likely that most of the parents in these classes will be adults. Most, if not all, will be first time parents. Some will be from a different culture with different belief systems and values from that of the childbirth educator. They will come from

different levels of education or literacy and socioeconomic status. These factors affect how childbirth educators teach prenatal courses and how the parents-to-be learn.

The Parent-to-BeBefore initiating teaching, prenatal educators are urged

to consider the parent learners’ attitudes and perceptions, and, that some of them may be anxious and reluctant learners. A study by Morton and Hsu (2007) revealed that much to the educator’s shock and dismay, “pregnant women viewed childbirth education as an extra task or burden that they could forego with little consequence” (p. 27-28). Mothers who worked full time, or two jobs, felt that they did not need the classes, and therefore, expected short and focused courses (Morton & Hsu, 2007). In addition, there has been a shift in cultural orientation toward pain and child birth choices that has stirred women to commit to epidural or C-section births, and thereby seeing little need to attend prenatal classes (Morton & Hsu, 2007). Furthermore, the internet has given parents access to vast information accessed from medical websites or allowed them to share experiences with other parents from all over the world. Prenatal practices are most effective when they utilize educators who are open to changes that meet the demands of parents-to-be, and in turn are called to be innovative, and adaptive to evolving childbirth phenomenon.

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Natsai Zhou

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Childbirth EducationEffective childbirth education goals include prenatal

educators first examining childbirth education’s goals as well as their own. The overall goals focus on providing parents-to-be with prenatal information that helps them make the right choices for themselves as well as experience a satisfying childbirth (International Childbirth Education Association [ICEA], 2010). Prenatal educators are masters in concepts and theories of childbirth. Although they are the experts and understand that these classes are important and valuable sources for parents, it is important to keep in mind that participants in the class look up to them as the knowledge-able professional. Yet the educators’ vision might not be equally shared by all. In one study, educators expressed that “women achieving satisfying births does not only involve dis-seminating the wealth of information you possess, it includes encouraging women to accept the responsibility to make active choices” (Morton & Hsu, 2007, p. 35). According to the ICEA (2008), “a prenatal teacher provides informa-tion on physiology, psychology, and sociology of pregnancy, childbirth, postpartum, and early parenthood, as well as skills to assist women and their support persons to cope with pregnancy, childbirth, postpartum, and early parenthood” (p. 35). A holistic unbiased approach to teaching prenatal classes is then warranted. This holistic approach involves all aspects of the individuals’ lives such as physical, mental, emotional, spiritual, and socioeconomic. Everything is connected, the body and its surroundings. When any one of these elements is off balance, then the whole person is affected.

The goal of prenatal information is to allow parents to make informed choices for themselves for a satisfying childbirth.

Tips to Improve PracticeThere is no standardized technique for teaching prenatal

classes. However, the ideal teaching approach is conducive for learning, keeping in mind that individuals have different learning styles. Visual, auditory and kinesthetic approaches can be implemented. In addition, the presentation does not have to follow a traditional school room format, but can

include such formats as discussions, role playing, and experi-ments. As the prenatal educator considers types of learning facilitating methods, the teaching approach should be free of bias. Morton and Hsu (2007) state that unbiased teaching should include equal measures of scientific clinical research evidence, beliefs of individual preference, cultural practices, and personal experience because everyone is different.

Adult as a LearnerSince it has been established that most participants in

the prenatal classes are likely to be adults who come with lived experiences, and have different issues revolving around them, an andragogy approach to teaching prenatal classes is recommended. Andragogy is a strategy that focuses on teaching adults. Knowles (1980) conceived the andragogy model based on the idea that adult education requires a unique way of teaching. Knowles (1980) assumed that:• Adultsareindependentorself-directedlearners.• Theyhavevastexperiencesthatcanbeusedasafounda-

tion to learning.• Theirreadinesstolearnisrelatedtothedevelopmental

tasks of social roles.• Theirtimeandcourseperspectivesareimmediacyofap-

plication and are performance-centeredness.Using this model as a foundation might facilitate learn-

ing of information to adult parents-to-be, and decrease challenges that might be faced by the prenatal educa-tor. Adult learners come with unique characteristics. For instance, adults feel that they need to know why they should learn something, therefore, for them learning is based on what they perceive as beneficial (Knowles, 1996). In addi-tion, Knowles (1996) acknowledged that adult learners have a deep need to be self-directing, be responsible for making their own decisions and being in charge. Therefore, prena-tal education can incorporate as much self-discovery and involve as many options for learning as possible (Knowles, 1996).

Adult learners bring into the learning environment a background of life experience that affects the way they learn. Adults have a broader base of experience on which to attach new ideas and skills and give them richer meaning. Childbirth education activities can be designed to reflect the skills that can actually be performed by the parents. These activities can permit parents-to-be to be able to compare the theoretical models with the expected experiences (Knowles, 1996). The more explicit these skills are made through


Proposed Model for Improving Childbirth Practicecontinued from previous page


discussion and reflection, the deeper, meaningful, and more permanent the learning will be (Knowles, 1996). Open-ended questions can be used to draw out any knowledge and experiences the parents-to-be might have. This will honor any experiences and values they bring.

Adult learners enter into a learning experience with a task-centered, problem-centered, or life-centered orienta-tion to learning (Knowles, 1996). Although childbirth might be the most important thing in their lives during pregnancy, it is surrounded by demanding events such as jobs and other family and social roles. Therefore, prenatal educa-tion information is provided in a manner that is more than just knowing the information, but providing how and when it is applied, and whether it will take care of the issue at hand. Research has revealed that if education does not have specific results in mind or does not lead to expected results, mothers tend to drop out of childbirth classes (Morton & Hsu, 2007).

Adult learners become ready to learn when life situa-tions bring a need to know in order to perform more effec-tively and satisfyingly (Knowles, 1996). Childbirth education emphasizes the critical importance of the woman’s own emotionalresponsetoherlaborandbirth;withthegoalthatshe remembers it as a satisfying experience (Morton & Hsu, 2007). Childbirth education can then relate or apply directly to the parents’ perceived needs, be timely, cost effective, and appropriate for their current lives, beliefs and values.

Rationale for PracticeBest healthcare practice and education are evidenced-

based, or based on a rationale for the intervention. The goal of effective childbirth education classes is to give parents-to-be skills necessary to get through their pregnancy, labor and birth. Therefore, the intention is to provide information that prepares parents-to-be for childbirth, help make informed decisions, and minimize fears. These classes also provide skills and techniques for relaxation, coping with labor and pain, basics of breastfeeding and newborn care, information on signs of labor, normal progress of labor and birth, how partners can help during labor and when to call the doctor or midwife (Baby Center, 2012). Childbirth classes also pro-vide a great opportunity for parents to meet and share with other expectant parents.

Based on the content to be taught, every identified issue should have possible interventions, and the interventions should have rationales (Health Leaders Media, 2010). Previ-ously identified issues that childbirth educators can focus on are parenthood, education level or literacy, socioeconomic status, and cultural differences and/or personal beliefs and values. According to Patricia Turner, president of Internation-al Childbirth Education Association (ICEA), a good prenatal class should give an overview of options and be realistic about the kind of experience childbirth educators may have including every possible scenario (Baby Center, 2012).

ParenthoodWith childbirth comes parenthood, which results in

fears and anxieties of whether parents-to-be will make the right choices about childbirth, whether to have the baby at home or in hospital, whether the birth will be natural or C-section, and whether the baby will be healthy. Anxieties and fears are based on concerns about risks for perinatal infec-tions, impaired parent/infant attachment, and interrupted family process (North American Nursing Diagnosis Associa-tion [NANDA], 2013). Anxieties and fears are also rooted in perceived threat to physical and emotional integrity and change in role functions (NANDA, 2013). To address these issues during prenatal education, appropriate childbirth education can facilitate ways of learning new ways to reduce anxieties and fears, encourage self-efficacy, as well as assess-ing and strengthening coping skills. According to the ICEA guidelines for childbirth educators, the challenge lies in enhancing the parents’ sense of self-efficacy and presenting child birth as doable (ICEA, 2010).

LiteracyNot every parent-to-be will have the same education

background. In addition, even those with high level of education will not necessarily have healthcare education, let alone prenatal education. In any case, no matter how educated one is, when one is a new parent, childbirth is new territory due to lack of exposure to the experience. Knowledge deficit in prenatal education is not only related to those with limited cognition, but applies to everyone, and therefore during prenatal classes, childbirth educators have to be careful to avoid jargon. Parents-to be will already be overwhelmed with the unknown, anticipation, and expecta-tions, therefore prenatal education should accommodate



28 | International Journal of Childbirth Education | Volume 28 Number 2 April 2013

every level of understanding, fill the gap of inadequate comprehension, and provide reasons for learning.

Socioeconomic StatusChildbirth educators should also keep in mind that

parents-to-be come from different socioeconomic back-grounds. Therefore, sensitivity is called for when suggesting products and resources useful in prenatal care. Consider-ation should be given to possible inadequate social support system, availability of resources, finances, and equipment. Recent research states that pregnant women often experi-ence pregnancy in the midst of various life stressors, and do not attend or finish prenatal classes because they feel that they have no one to go with or are unable to coordinate it (Bessett, n.d).

Cultural Differences: Personal Beliefs and Values

Immigrant populations in the US are growing at a fast pace and births in the US account for a national population increase of 2.3 million people per year (Camarota, 2005). It is therefore, likely that prenatal classes are also increasingly becoming culturally diverse. In addition to culture, classes will also consist of individuals with personal and spiritual beliefs and values on childbirth. Therefore, to inspire and provide prenatal knowledge, childbirth educators have to consciously set aside any personal judgment about choices parents-to-be make, avoid stereotyping, and make and incor-porate cross-cultural approaches. Leininger (1991) identified some healthcare decision and action modes that achieve culturally congruent healthcare.• Culturalpreservationormaintenance.• Culturalcareaccommodationornegotiation.

Due to diversity, some parents-to-be might feel uncom-fortable being in cross-cultural prenatal classes related to per-ceived threat to their own value system, or receiving multiple sources of information that can lead to clouding personal values, beliefs, and moral obligations (NANDA, 2013). Therefore it is crucial that childbirth educators incorporate cultural competence, be aware of differences, promote and maintain individuality, spiritual well-being, and allow and accommodate for personal or traditional non-medical ap-proaches such as use of doulas and breast feeding.

Most important is the observation of the mothers’ pain and discomfort during childbirth. It is essential that child-birth educators view labor pain and its meaning through the eyes of the different cultures represented in the classroom. Due to personal, cultural, or spiritual beliefs, some parents-to-be may decide to take a different approach to childbirth than suggested by the childbirth educators, leading to guilt for not picking the childbirth educator’s choice, which in turn may result in dissatisfaction. Therefore, it is important for the childbirth educator to present all childbirth pain management options in an unbiased way.

When teaching prenatal or childbirth education classes, childbirth educators need to consider that the class will mostly likely be comprised of:• Firsttimeparents-to-be.• Adultlearnerswithdifferentlearningneeds.• Adultlearnerswithvastexperiencesandsocialchallenges• Culturallydiverseparticipantsinneedofsensitivity.

When prenatal care education is taught, keeping in mind that the learner is an adult with personal characteristics and needs, childbirth educators can empower parents-to-be to make their own choices about childbirth. It is important for childbirth educators to examine their own perceptions about personal values within the framework of individu-als and families. It is also crucial for childbirth educators to provide efficient and practical education, with all options that afford the parents-to-be to make appropriate choices and experience satisfying births.



Natsai Zhou


ReferencesBaby Center. (2012). Childbirth classes. Retrieved from http://www.baby-center.com/0_childbirth-classes_161.bc

Bessett, D. (n.d.). Defining the “normal” pregnancy: Knowledge, emotion, and embodied experience of women in stratified reproduction (Dissertation in progress, Department of Sociology, New York University).

Camarota, S. (2005). Birth rates among immigrants in America: Comparing fertility in the U.S. and home countries. Washington, DC: Center for Immi-grant Studies. Retrieved from http://www.cis.org/articles/2005/back1105.pdf

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Leininger, M. (1991). Culture care diversity and universality: A theory of nursing. New York: National League for Nursing Press.

Morton, C. H. & Hsu, C. (Fall, 2007). Contemporary dilemmas in American childbirth education: findings from a comparative ethnographic study. Jour-nal of Perinatal Education, 16(4), 25–37. doi: 10.1624/105812407X245614

American College of Nurse-Midwives (ACNM). (2013) Retrieved from http://mymidwife.org

North American Nursing Diagnosis Association (NANDA). (2013). NANDA nursing diagnosis list. Retrieved from http://www.nandanursingdiagnosislist.org/

Rochester Institute of Technology. (2013). Adult learner. Retrieved from http://online.rit.edu/faculty/teaching_strategies/adult_learners.cfm

Schultz, J. M., & Videbeck, S. L. (2009). Lippincott’s manual of psychiatric nursing care plans: Manual Psychiatric Nursing Care (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Dr. Natsai L. Zhou is a Family Nurse Practitioner who co-owns a family practice clinic. She is an adjunct faculty at the Univer-sity of Phoenix teaching undergraduate and graduate nursing and healthcare students. Natsai sits on the Advisory Board of Breckenridge School of Nursing. She is also a board member in a non-for-profit organization (Zimcouncil) that leverages Zimba-bweans in diaspora, health, and education resources to improve the quality of life of citizens in Zimbabwe.

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Improving Childbirth Practice for Parents to Be