Women's Thoughts about Education Class for Awareness of Labor: A Qualitative Study

Abstract

Background: Childbirth education classes is not based on any philosophy or many different methods used rather than one of a particular philosophy. There have not been any comprehensive studies on effects of labor preparation classes based on a philosophy/philosophies on pregnancy and preparedness for labor. Aims The aim of the study is to investigate feelings, thoughts and opinions of the women attending Education Class for Awareness of Labor about pregnancy and labor. Methodology: This is a phenomenological study. A purposeful sampling was used. The sample included 13 pregnant women fulfilling sampling criteria and attending education. Semi-structured, in-depth interviews were conducted between 23 December 2014 and 4 April 2015. Content analysis was used to evaluate obtained data. Results: Two main themes and their subthemes emerged as a result of analyses The themes are "Preparedness for Labor: Belief in Ability to Give Birth" and "Change". The themes 'change' included the subthemes "positive change in spouses attitudes", "increased communication and interaction with the baby", "influence of sharing with other couples: support from others". The themes "Preparedness for Labor: Belief in Ability to Give Birth" included the subthemes "self-confidence and having knowledge", "increased power of decision making", "performing practices facilitating pregnancy and labor". Conclusions: Education programme may be useful as a guide in prenatal preparedness for labor and positive expectation and feelings about childbirth. Childbirth education classes, not designed in accordance with models yet, should be based on scientific evidence, should be varied, spread and supported by health policies.

Headnote

Abstract

Background: Childbirth education classes is not based on any philosophy or many different methods used rather than one of a particular philosophy. There have not been any comprehensive studies on effects of labor preparation classes based on a philosophy/philosophies on pregnancy and preparedness for labor.

Aims The aim of the study is to investigate feelings, thoughts and opinions of the women attending Education Class for Awareness of Labor about pregnancy and labor.

Methodology: This is a phenomenological study. A purposeful sampling was used. The sample included 13 pregnant women fulfilling sampling criteria and attending education. Semi-structured, in-depth interviews were conducted between 23 December 2014 and 4 April 2015. Content analysis was used to evaluate obtained data.

Results: Two main themes and their subthemes emerged as a result of analyses The themes are "Preparedness for Labor: Belief in Ability to Give Birth" and "Change". The themes 'change' included the subthemes "positive change in spouses attitudes", "increased communication and interaction with the baby", "influence of sharing with other couples: support from others". The themes "Preparedness for Labor: Belief in Ability to Give Birth" included the subthemes "self-confidence and having knowledge", "increased power of decision making", "performing practices facilitating pregnancy and labor".

Conclusions: Education programme may be useful as a guide in prenatal preparedness for labor and positive expectation and feelings about childbirth. Childbirth education classes, not designed in accordance with models yet, should be based on scientific evidence, should be varied, spread and supported by health policies.

Key Words: women, thoughts, education class, awareness, labor

Introduction

Numerous studies have focused on the effects of antenatal education on pregnancy, delivery and post-partum period. However, there is insufficient evidence to determine effects of antenatal education on psychological, physical and social adjustment Millions of women worldwide have been enrolled in structured or unstructured antenatal education programs (Gagnon & Sandall, 2007). Although antenatal education has been standardized through training programs in developed countries, there is no standard program in developing countries. As such, the quality and content of the education varies from one educator to another. Education Class for Awareness of Labor (ECAL) makes it possible to create a standart programme based on philosophies which enables expecting parents to discuss feelings and concerns. The researchers could provide other scholars with useful information on potential benefits of antenatal education class (ECAL) in women from the west part of Turkey.

Background: Rates of operational vaginal births and cesarean section have risen worldwide. Although the World Health organization (WHO) has recommended that the rate of cesarean section should not exceed 15%, it is 48.1% in Turkey (TDHS, 2013). The idea that couples should be offered education in the antenatal period to increase vaginal births rates has increasingly gained acceptance. Based on this idea, Turkish Ministry of Health has accelerated institutionalization of antenatal education programs.

The aim of antenatal education is to inform pregnant women about what will happen during labor, what health staff will perform and what the women can perform as a member of the labor team, to help them acquire necessary skills (Mongan, 2005; Komurcu & Ergin, 2008; Rathfisch, 2012). This education increases psychological and physical preparedness of couples for labor (Mongan, 2005; Rathfisch, 2012; Okumus, Mete, Aytur, Yenal & Demir 2002).

Insufficient evidence about education programs for labor preparations can be due to methodological insufficiency of studies and lack of approaches based on theories and philosophies (Gagnon & Sandall, 2007). Qualitative studies have focused on content, duration, satisfaction with trainers and effects of the education on mothers and motherhood (Schneider, 2001; Ho & Holroyd, 2002; Deave, Johnson & Ingram, 2008; Tighe, 2010). How structured antenatal education programs based on birth and education philosophies affects pregnant women is also questionable. There have not been any comprehensive studies on effects of labor preparation classes based on a philosophy/philosophies on pregnancy and preparedness for labor.

Education Class for Awareness of Labor Programme: Labor preparation education has long been incorporated in curricula and various programs of this education have been adopted in practice in Turkey. They started in the 1990's. Some of the programs are not based on any philosophies while others are based on either one philosophy or more than one philosophy. The education program in this study was based on the labor preparation philosophies proposed by Dick Read, Hypnobirthing, Lamaze and Bradley and the educational philosophies social cognitive learning theory and adult education principles proposed by Bandura. It was named Education Class for Awareness of Labor (ECAL) (Mete, Ertugrul & Uludag, 2015). ECAL was offered for two hours a week for a total of four weeks. General and weekly objectives of the program were determined. Many relaxation exercises and games were incorporated into the program to create interaction. The program allowed the couples to actively participate in it. ECAL program content is included in the Table 1.

Aim: The aim of this study to investigate feelings, thoughts and opinions of the women attending ECAL about pregnancy and labor.

Methodology

Design: This is a phenomenological study.

Setting and sample: A purposive sampling was used (Yildirim & Simsek, 2013). The sample included 13 pregnant women fulfilling sampling criteria and attending ECAL at the university.

Sampling criteria,

* Voluntarily accepting to participate in the study

* Having attended ECAL

(The sampling criteria for ECAL were as follows: being nulliparous and older than 20 years, not having a diagnosis causing high risk, having gestational weeks of 24 or more, attending ECAL together with spouses or someone to give support).

The age of the women ranged between 27 and 37 years. Ten percent of the women were university graduates and three women had an MA degree. The women had gestational weeks of 28-37. All of them attended the education program with their spouses.

Data collection tools and methods: Data were collected with a descriptive characteristics form and a semi-structured interview. The questions written by the researcher, were revised in accordance with comments from three experts (Yildirim & Simsek, 2013). The pregnant women meeting the sampling criteria and wanting to attend ECAL, lasting for four weeks, were informed about the content of the education program (Mete, Ertugrul & Uludag, 2015) and the aim of the study. The couples took courses once a week after working hours for four weeks. Each class lasted for 120 minutes (theoretical education for 90 minutes and exercise for 30 minutes).

The researcher has attended several courses and congresses as a participant, trainer or a member of organization committees and has been conducting ECAL as a HypnoBirthing® trainer since 2014. The study was performed between 23 December 2014 and 4 April 2015. In-depth interviews were conducted face to face at either the participants' homes or at hospital depending on their decisions after an appointment with them was made within one week of ECAL. They took place in a well-lit, well-ventilated, silent room and were recorded with a voice recorder.

Before the ECAL program and interviews, the aim of the study, how it would be conducted and how voice recording would be performed were explained and written informed consent was obtained from the pregnant women voluntarily accepting to participate in the study. ECAL was offered by the researcher. A pre-interview was conducted with a pregnant woman, but data obtained were not included into analysis. Each interview had 22.10-50.22 minutes. Age and gestational weeks of the pregnant women were provided between brackets at the end of quotations for example "{22y, 36w}".

Interview Questions

1) Could you please evaluate the education program?

2) What were the effects of the education on you? How did it influence you?

3) What do you think of the experience or phenomenon of pregnancy?

4) What do you think of labor? How do you feel about it?

Analysis: Content analysis was used to evaluate obtained data (Y ildirim & Simsek, 2013).

Trustworthiness: The trustworthiness of the data was based on the credibility, transferability, dependability, and confirmability (Yildirim & Simsek, 2013). Credibility was established by two authors who had prolonged engagement with the participants and their professional experience. The first author had 5 years' experience, and the second author had 15 years' experience. The two authors had been trained in qualitative methods. The authors also cross-checked and discussed the results of the analysis to reach a consensus. Tape-recordings of the interviews provided a complete and accurate account of individual responses, thereby increasing data reliability. Confirmability, making sure that themes and categories were a true representation of the participants' experiences and perceptions, was established by making note of participants' quotations to support the results. Auditability was established by maintaining an audit trail to record the context and background of the study, evaluation of the findings, and decisions made and actions taken during the whole research process.

Ethical and research approvals: This study was approved by the Institutional Review Board of the university.

Results

Two themes and their subthemes are presented in the following sections (Table 2).

THEME 1: Change

The theme 'change' included the three subthemes.

Positive change in spouses' attitudes

The women reported that their confidence in their spouses increased after ECAL. Their spouses learned about practices they could implement during pregnancy and labor and became more aware of these period and they spent time together. Also the women admitted that their spouses had more fears about labor before ECAL, but they had fewer fears after attending ECAL. The women added that their spouses perspectives about ECAL changed positively.

"I know my husband supports me both psychologicaly and physically. I've had more confidence in him in all aspects after ECAL" {32y, 28w};

"He used to watch news and politics related programs on TV before ECAL. Now, we listen to music for relaxation at least twice a week and we adjust our environment" {34y, 34w};

My spouse used to think labor was something very bad and extremely painful. After ECAL, he realized that it was not so bad and he was relaxed (laughing)" {36y, 33w};

"My husband didn't want to join because he had a busy work schedule: he is a soldier. However, his attitude completely changed after the first class, his attitude towards pregnancy changed" {33y, 30w}

Communication and Interaction with the Baby

The women stated that their spouses' communication, interaction and bond with their baby enhanced after ECAL.

"After ECAL, my husband's communication with me and our baby was strengthened" {32y, 28w}

Influence of Sharing with Other Couples

The women commented that spending time with others experiencing the same things and worries during ECAL made them feel relaxed. The women admitted that they acquired a lot of information from other women during ECAL. The women noted that experiences shared on social networking sites by other women giving birth after ECAL were encouraging.

"You can't go out, so you feel lonely. During ECAL, you can get rid of this feeling of loneliness when you spend time with other pregnant women having similar experiences." {35y, 31w};

"Listening to other women attending ECAL has contributed to what I already know. This has helped me take advantage of different viewpoints." {27y, 30w};

"Interaction between the members of our group was very good. As other women gave birth, they shared their experiences through WhatsApp, which is very useful. Their achievements are encouraging for us". {29y, 29w}

THEME 2: Preparedness for Labor: Belief in Ability to Give Birth

The theme preparedness for labor: belief in ability to give birth was composed of the three themes.

Self-confidence and having knowledge

The women felt more self-confident about pregnancy, preparedness for labor and labor itself after ECAL. The women commented that they learned practices they can perform before, during and after labor and did not experience anxiety. The women explained that they had positive attitudes and opinions about labor after attending ECAL. The women noted that they waited for labor excitedly and impatiently.

"I know what to do during contractions, I won't feel stressed out. The education offered increased my self-confidence about labor." {32y, 28w};

"I'm aware of everything and I'm ready because I've been equipped with necessary knowledge and the rest is up to good luck. Now I know that the more I go for a walk, get rid of stress and follow a balanced diet, the better birthing experience I'll have" {35y, 31w};

"We've understood the process very well including all details and there is nothing disturbing or causing restlessness." {27y, 30w} ;

"It made me understand that labor is natural and that all women can give birth." {34y, 34w}

Increased Power of Decision Making

The women said that they made clear about the labor team and the hospital where they would give birth and visited the hospital they chose after ECAL. The women reported that they talked to the labor team about the type of labor they preferred and decided the type of labor with the team.

"After completing the course, I went to the hospital. I met a midwife and she allowed me to see the delivery room and the ward. I liked it and felt relaxed." {31y, 32w};

"My husband asked whether I had to have epidural anesthesia. They (the labor team) told us that it wasn't a must, but that they usually recommended it and so on." {36y, 33w}

Performing Practices Facilitating Pregnancy and Labor

The women admitted that using non pharmacological methods made them feel relaxed physiologically and psychologically. Some women said they could not do breathing exercises regularly while others said they performed the exercises regularly and felt relaxed. The women mentioned that they used expressions having positive connotations while communicating with their babies and thinking about labor. The women had already selected pieces of music and started to listen to them and did relaxation exercises.

"If I go on doing physical exercise, I feel that I'll give birth very easily. It makes me relax both mentally and physically" {34y, 34w}; "When Braxton Hicks contractions appear, I focus on my breathing and thus postpone the feeling of pressure. Breathing exercises help change the body part one focuses on and create a feeling of relaxation." {35y, 31w};

"I frequently make use of self-affirmation especially while I talk to my baby and about the time of giving birth. You (the researcher) told us that we could write and post them on the refrigerator." {29y, 29w};

"We have chosen a piece of music to use for relaxation, Four Seasons by Vivaldi. We listen to it before going to bed." {28y, 28w};

"I have a USG image of my daughter and I've taken a photo of it. I look at it and daydream. I use it to concentrate." {27y, 30w}

Discussion

Discussion will be considered in terms of emerging themes.

Theme I: Change

Women consider their spouses as the primary source of support in the perinatal period. However, it has been shown in the literature that many men do not know what they are expected to do during pregnancy and what expectations they must have for childbirth (Fenwick, Bayes, Johansson, 2012; May, Fletcher, 2013). In the present study, the women reported that they felt relaxed and trusted their spouses since they knew what their spouses would do. Consistent with this finding, in a study by Koehn, the women defined labor as a goal which they would achieve together with their spouses (Koehn, 2008). During ECAL, the spouses were taught how they could support their wives, performed some practices together with their wives and were encouraged to continue these practices at home.

Increased confidence in spouses will make women relax and make them feel that they are not lonely. Therefore, both male and female parent candidates should be involved in antenatal education classes together and males should get prepared for their parenthood roles in pregnancy and postpartum period. However, in the present study, some spouses mentioned that they came to the first class because their wives forced them and that labor preparation education was unnecessary. It may be that this education is not part of Turkish culture. When they became aware of the quality and benefits of the education, they changed their mind.

The women commented that their spouses' interaction and communication with their babies increased. The couples were made to do exercises to improve the bond with their unborn babies. These exercises can be effective to enhance mother-baby interactions. According to Hypnobirthing and Lamaze philosophy, pregnancy is an opportunity for parents to create strong ties with their babies likely to continue for lifetime (Mongan, 2005; Mete, Ertugrul & Uludag, 2015).

During ECAL, the couples were asked to sit around a circle so that communication could be achieved in accordance with adult education principles. They were given badges on which their names were written. Using names during education creates the feeling of belonging to a group and relaxation in individuals (Mete, Ertugrul & Uludag, 2015). During classes, an appropriate atmosphere allowing to discuss, ask questions and express feelings was created. The participants of this study admitted that they were satisfied with the education offered in groups.

Consistent with the present study, it has been reported in the literature that women seek forums allowing them to express their worries about labor related issues (Gibbins, Thomson, 2001; Lothian, 2008). Adults want to share their experiences with other adults and like interactions in a group and comfortable and a dynamic learning environment (Widarsson, Kerstis, Sundquist, Engström, Sarkadi, 2012). Comparable with the literature, in the present study, pregnant women increased their social support network (Banta, 2003) and continued their communication with their classmates in the postpartum period (Deave, Johnson, Ingram, 2008; Tighe, 2010; Fabian, Radestad, Waldenström, 2005).

Theme II: Preparedness for Labor: Belief in Ability to Give Birth

The women reported that they acquired new information about pregnancy and labor during ECAL. In a qualitative study, the women found content offered in classes useful (Tighe, 2010; Sercekus, Mete, 2010). In another qualitative study, the women considered information as the source of strength (Lee, Holroyd, 2009; Martin, Robb, 2013). In the present study, the women stated that they could get accurate information and revised formerly acquired wrong pieces of information. It is important that educational needs and expectations of couples should be fulfilled. Hypnobirthing and Lamaze and Bradley philosophies also require that women should be provided with information about the labor process (Mongan, 2005; Mete, Ertugrul, Uludag, 2015).

The women pointed out that their labor related fears disappeared, which is an important outcome of ECAL. According to the fear-tension-pain cycle described by Dick Read, fears cause tension in the body and tension lengthens labor and increases perceived pain (Mete, Ertugrul, Uludag, 2015). The women whose anxiety disappears have increased self-confidence and have a calmer pregnancy (Lothian, 2008; Lee, Holroyd, 2009; Ahldén, Ahlehagen, Dahlgren , Josefsson, 2012; Artieta-Pinedo ETC ALL, 2010).

According to the hypnobirthing philosophy, thoughts change into feelings which turn into beliefs and the beliefs translate into behaviors. Avoidance of negative thoughts reduces secretion of stress hormones and has a positive effect on pregnancy. A positive change in thoughts enable women to have a more pleasant pregnancy and wait for birthing impatiently (Mongan, 2005; Mete, Ertugrul, Uludag, 2015).

Although it has been reported that the type of birthing is determined by doctors in a high number of women (Vatansever, Okumuş, 2013), in the present study, the women revealed that they talked to the labor team about it. It is important for pregnant women to select the place of birthing and the labor team. In a qualitative study, the women indicated that they felt safer when they met their midwives well before birthing (Gibbins, Thomson, 2001). In the present study, the women were recommended to make and hand in their birthing plan at the end of ECAL to enhance their control over labor and their decisionmaking. They participated in a role-play about how to talk to the labor team. As indicated in this study, meeting the labor team and talking to them about their preferences of birthing can allow women to give birth under the supervision of a team respecting their wishes and can increase their satisfaction with labor.

The most important expectation of women from labor is to experience little or no pain. Therefore, they use nonpharmacological methods. These methods have one thing in common: enabling women to focus on a point other than pain and to make them relaxed and get rid of their anxiety Komurcu, Ergin, 2008; Smith, Collins, Cyna, Crowther, 2006). Bahadoran et al. (2010) in their study on an evaluation of exercises taught in labor preparation classes found that these classes have important physical and emotional effects in terms of healthy pregnancy behavior and help women adapt to changes in body image towards the end of pregnancy (Bahadoran, Asefi, Oreyzi, Valiani, 2010). In another study, of all the women attending pregnancy preparation classes, 85% were found to do exercises at home and 70% were found to do them during labor (Bergstro'm, Kieler, Waldenstro'ma, 2009). It may be that women adopt different philosophies. In fact, Lamaze philosophy places more emphasis on muscle exercises while hypnobirthing emphasizes relaxation exercises more (Mongan, 2005; Mete, Ertugrul, Uludag, 2015). Breathing techniques help women relax and increase the pain threshold if they are used properly (Komurcu, Ergin, 2008). The relaxation exercises like daydreaming, visualization and music can be utilized in combination Mongan, 2005; Mete, Ertugrul, Uludag , 2015; Okumuş, Mete, Yenal, Tokat, Sercekus, 2009). It has been shown in the literature that music has a calming effect (Chang, Chen, 2004). According to Bandura's theory, it is important to keep behavior in mind and repeat it in order to change it into a habit. Hypnobirthing helps women get prepared for relaxation during pregnancy and underlines the role of relaxation in labor (Mete, Ertugrul, Uludag , 2015). In the present study, the women commented that they used affirmative words while daydreaming and talking to people around them. Hypnobirthing allows women to reveal fears and negative feelings and to get rid of them. For example, they prefer contractions or waves instead of pain. Negative words are replaced by positive ones (Mongan, 2005).

The women included in this study reported to be more confident to give birth after ECAL. As the women explained, the couples had a positive attitude towards pregnancy and labor and trusted each other more, their knowledge increased and the women fears decreased after ECAL. As a result, it can be suggested that this education program may allow pregnant women and their spouses to have more positive experiences and get well-prepared for pregnancy and labor and thus may help going through a more positive labor and postpartum period.

Limitations: Both ECAL and the interviews were conducted by the same researcher. The participants were interviewed one week after a four-week education program were made. This might have restricted expressing negative feelings. Since the education program was voluntary, all the members of the group applying for it were university graduates. Therefore, effects of other education levels could not be revealed.

Acknowledgements: All pregnant women have made a substantial contribution to the manuscript.

References

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