Clinical Practice Guidelines Antenatal Care — Module II

4.2Resources

AHMC (2010) National Maternity Services Plan.

Antenatal Care In: Minymaku Kutju Tjukurpa Women’s Business Manual, 4th edition. Congress Alukura, Nganampa Health Council Inc and Centre for Remote Health.

Bouverie Centre (2012) Guidelines for Healthcare Providers Working with Same-sex Parented Families. Melbourne: Bouverie Centre, LaTrobe University, Vic Health.

Kruske S (2011) Characteristics of Culturally Competent Maternity Care for Aboriginal and Torres Strait Islander Women. Maternity Services Inter-jurisdictional Committee for the Australian Health Ministers’ Advisory Council.

NHMRC (2009) Clinical Practice Guideline for the Prevention of Venous Thromboembolism (Deep Vein Thrombosis and Pulmonary Embolism) in Patients Admitted to Australian Hospitals. Canberra: National Health and Medical Research Council.

RANZCOG (2005) Termination of Pregnancy. A Resource for Health Professionals. Melbourne: Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Lifestyle considerations

DoHA (1998) Australian Guide to Healthy Eating. Background Information for Consumers. Canberra: Australian Government Department of Health and Ageing. [under review]

FSANZ (undated) Thinking About Having a Baby? Important Things You Need to Know About What You Eat and Drink. Food Standards Australia and New Zealand.

IOM (2009) Nutrition During Pregnancy. National Academy of Sciences, Institute of Medicine, Food and Nutrition Board, Committee on Nutritional Status During Pregnancy and Lactation, Subcommittee on Dietary Intake and Nutrient Supplements During Pregnancy, Subcommittee on Nutritional Status and Weight Gain During Pregnancy. Washington DC: National Academy Press; 1990.

Ministerial Council on Drug Strategy (2006) National Clinical Guidelines for the Management of Drug Use During Pregnancy, Birth and the Early Development Years of the Newborn. Sydney: NSW Health.

NHMRC (2005) Nutrient Reference Values for Australia and New Zealand. Canberra: National Health and Medical Research Council.

NHMRC (2013) Dietary Guidelines for Australian Adults. Canberra: National Health and Medical Research Council.

Prevention

National Cervical Screening Program (2005) Screening to Prevent Cervical Cancer: Guidelines for the Management of Asymptomatic Women with Screen Detected Abnormalities. Canberra: Department of Health and Ageing.

Domestic violence

Robinson E & Moloney L (2010) Family Violence. Towards a Holistic Approach to Screening and Risk Assessment in Family Support Services. Australian Family Relationships Clearinghouse. Canberra: Australian Institute of Family Studies.

Sexually transmitted infections

NSW STI Programs Unit (2013) General Practice Resources. Sydney: NSW STI Programs Unit.

Western Australia Silver Book

Queensland Sexual Health Clinical Management Guidelines,

Sexual Health Society of Victoria National Management Guidelines for Sexually Transmitted Infections

4.3References

NICE (2008) Antenatal Care. Routine Care for the Healthy Pregnant Woman. London: Royal College of Obstetricians and Gynaecologists Press.

4.4Preparing for pregnancy, childbirth and parenthood

Structured antenatal education that is suited to the individual can help women to be informed about pregnancy, birth and parenting. Psychological preparation for parenthood may have benefits for parents’ mental health, parenting and infant development.

Background

Structured education in preparation for childbirth and parenthood has come about as traditional methods of information sharing have declined (Gagnon & Sandall 2007). Many maternity health care providers, including public health departments, hospitals, private agencies and charities, and obstetricians’ and midwives’ practices, provide antenatal education for expectant parents. Antenatal education may be delivered one-on-one or in groups (eg in a women’s group, couples’ workshop or a class situation).

Antenatal education programs have a range of aims including (Gagnon & Sandall 2007):

influencing health behaviours;

preparing women and their partners for childbirth, including building women’s confidence in their ability to labour and give birth;

preparing women for the pain of labour and supporting their ability to give birth without pain relief (Leap et al 2010);

discussing breastfeeding;

enhancing maternal–fetal relationship (Rackett & Holmes 2010);

preparing for parenthood (eg changes in relationships, physical and emotional needs of the baby, balancing the needs of the newborn and other children) and promoting confident parenting;

developing social support networks; and

contributing to reducing perinatal morbidity and mortality.

Antenatal education programs generally cover a range of topics and may include:

physical wellbeing (nutrition, physical activity, smoking, alcohol, oral health);

emotional wellbeing and mental health during pregnancy and after the baby is born (maternal-fetal attachment, adapting to change, expectations, coping skills, knowing when to get help);

labour (stages of labour, positions, breathing and relaxation, support, pain relief);

birth (normal birth, assisted births, caesarean section, perineal tears);

options for women with previous pregnancy or birth complications;

breastfeeding (skin-to-skin contact, benefits of early breastfeeding, attachment, breastfeeding as the physiological norm);

early parenthood (normal newborn behaviour, settling, sleep safety, immunisation, infant attachment); and

ways to find support and build community networks after the baby is born.

Antenatal couple education programs, which aim to enhance the couple relationship and the parent–child relationship are also available.

Discussing antenatal education

Summary of the evidence

The evidence on antenatal education is heterogeneous, with outcomes measured including experience of birth and parenting, postnatal mental health and experience of antenatal education.

Knowledge and health behaviours

A Cochrane review found that women gain knowledge from antenatal education but that the effect of this knowledge on childbirth or parenthood remains largely unknown (Gagnon & Sandall 2007). A prospective cohort study found that 74% of first-time mothers considered that antenatal education helped them to prepare for childbirth but only 40% considered that the education helped them prepare for parenthood (Fabian et al 2005).

Low level evidence suggests that antenatal education may improve some health behaviours during pregnancy (eg nutrition, physical activity)(Mirmolaei et al 2010) and in early parenthood (eg SIDS prevention) (Hesselink et al 2012).

Birth experience and outcomes

Studies have found no statistically significant difference in the overall birth experience between women who participate in antenatal education programs and those who do not (Fabian et al 2005; Bergstrom et al 2009; Maimburg et al 2010). Studies into specific outcomes have found the following.

Mode of birth: There is mixed evidence on the effect of antenatal education on mode of birth (Ferguson et al 2013). Antenatal education does not appear to significantly affect mode of birth among women in general (Fabian et al 2005; Gagnon & Sandall 2007) or among women with a previous caesarean section (Gagnon & Sandall 2007). Specific education on bearing down technique in labour did not affect mode of birth (Phipps et al 2009). Including a component on the risks of induction in antenatal education decreased rates of non-medically indicated elective induction of labour (Simpson et al 2010).

Pain: One study found that women who participated in antenatal education experienced lower levels of pain during birth (Ip et al 2009). Others have reported that participating women had lower epidural analgesia use (Maimburg et al 2010), higher analgesia use (Fabian et al 2005) or there was no difference in epidural analgesia use (Bergstrom et al 2009) or overall pain relief (Maimburg et al 2010).

Self-diagnosis of labour: Women given education about self-diagnosis of labour pains had a higher rate of correct self-diagnosis than women who did not (Lumluk & Kovavisarach 2011). However, a small systematic review found no evidence of criteria for identifying labour (Lauzon & Hodnett 2009).

While the overall experience and outcomes of birth do not seem to be affected by antenatal education, there is some evidence that it reduces anxiety about the birth (Maestas 2003; Ahmadian heris et al 2009; Ip et al 2009; Artieta-Pinedo et al 2010; Ferguson et al 2013), increases use of coping strategies (Escott et al 2005) and partner involvement (Ferguson et al 2013) and that participants experience greater childbirth self-efficacy (Ip et al 2009).

Recommendation 1 Grade B

Advise parents that antenatal education programs are effective in providing information about pregnancy, childbirth and parenting but do not influence mode of birth.

Psychological preparation for parenthood

Studies into the inclusion of psychological preparation for parenthood in antenatal care vary in the content covered. Studies have found that at 6 weeks after the birth:

women with depression antenatally who participated in antenatal group education focusing on coping skills, recognising distress and seeking help had a reduced risk of subsequent postnatal depression (odds ratio [OR]: 0.83; 95% confidence interval [CI]: 0.65–0.98) (n=1,719) (Kozinszky et al 2012);

women who participated in antenatal sessions focusing on coping skills, cognitive restructuring, problem-solving and decision-making skills had an overall reduction in depressive symptoms compared with women in the control group (mean Chinese EPDS score 6.5 versus 8.9) and the effect persisted at 6 months (5.8 versus 7.6) (n=184) (Ngai et al 2009);

women who participated in antenatal interpersonal psychotherapy had fewer depressive symptoms (changes in EPDS score: –1.56 versus 0.94) and greater satisfaction with interpersonal relationships than women who received only antenatal education (n=194) (Gao et al 2010); and

antenatal education on psychosocial issues associated with parenthood had a positive effect on mood (mean EPDS score 4.5 compared with 11.4 at baseline) in women who reported low self-esteem antenatally (but not those with medium or high self-esteem antenatally) and partners were significantly more aware of the woman’s experience of parenthood (n=268) (Matthey et al 2004).

Recommendation 2 Grade B

Include psychological preparation for parenthood as part of antenatal care as this has a positive effect on women’s mental health postnatally.

Small randomised controlled trials (RCTs) have reported benefits from antenatal couple education programs that aim to enhance the couple relationship and the parent-child relationship (Shapiro & Gottman 2005; Feinberg et al 2010; Shapiro et al 2011; Petch et al 2012).

Parents’ experience of antenatal education

Parents have expressed satisfaction with antenatal education as preparation for childbirth (Fabian et al 2005; Bergstrom et al 2011). Mothers who were young, single, with a low level of education, living in a small city or who smoked were less likely to find the classes helpful (Fabian et al 2005). Male participants valued the inclusion of an all-male session (Friedewald et al 2005).

Studies into parents’ preferences for antenatal education have found that the following factors are valued:

style of education: information provided by a health professional in person rather than sole use of other impersonal media (Nolan 2009) and using a range of learning strategies (Svensson et al 2008);

discussion: parents value being encouraged to ask questions, seek clarification, and relate information to their own circumstances (Svensson et al 2006; Nolan 2009);

social networking: one of the core aims of antenatal education is to assist women to develop social support networks (Fabian et al 2005; Svensson et al 2006; Svensson et al 2008);

group size: small peer groups encourage participants to get to know and support each other, while larger groups make it harder for women to ask questions (Nolan 2009);

practising skills: parents value experiential learning with plenty of opportunity to practise hands-on skills (Svensson et al 2006; Svensson et al 2008);

content: parents have expressed a preference for antenatal education to include more information on psychoprophylaxis during labour (Bergstrom et al 2011), psychological care (Holroyd et al 2011), preparation for parenthood (Svensson et al 2006; Bergstrom et al 2011; Holroyd et al 2011) and breastfeeding (Svensson et al 2006); and

timing of education: education is helpful early in pregnancy when information needs are high (Svensson et al 2006), with a component offered postnatally (Nolan 2009; Svensson et al 2009).

Practice point e

Assisting parents to find an antenatal education program that is suitable to their learning style, language and literacy level may improve uptake of information.

Practice summary: antenatal education

When: At an early antenatal visit.

Who: Midwife; GP; obstetrician; Aboriginal and Torres Strait Islander Health Practitioner; Aboriginal and Torres Strait Islander Health Worker; multicultural health worker.

Discuss the benefits of antenatal education: Explain that, while antenatal education is unlikely to change the mode of birth, it may help women to prepare for the birth. It is also a good opportunity to establish a network of peers and to develop skills for adapting to parenthood.

Involve partner and/or family: Discuss the benefits of partners and/or other family members attending antenatal education with the woman.

Provide information: Support antenatal education by asking women about any topics on which they would like additional information and suggesting or providing appropriate resources (eg written materials suitable to the woman’s level of literacy, audio or video, web sources).

Take a holistic approach: Give information about locally available antenatal education programs and assist women to select a program that is suitable for them. Give expectant parents booklets/ handouts relating to emotional health and wellbeing during pregnancy and early parenthood.

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