Childbirth Education - New Zealand Doctor

families commission research fundchildbirth education:antenatal education and transitions of maternitycare in new zealandDR SARAH DWYERIN CONJUNCTION WITH PARENTS CENTRESNEW ZEALAND INC AND PARENTING COUNCILREPORT NO 1/09MAY 2009

The Families Commission was established under the FamiliesCommission Act 2003 and commenced operations on 1 July 2004.Under the Crown Entities Act 2004, the Commission is designated asan autonomous Crown entity.The Families Commission Research Fund promotes substantial researchin areas of importance for families that would not otherwise be fundedas part of our core work programme. Projects in this fund aim to makea difference to outcomes for New Zealand families.For more information on the Families Commission Research Fund,visit www.nzfamilies.org.nzPublished research reports, which result from studies funded under the FamiliesCommission Research Fund are produced by independent researchers. The content ofthe reports and the opinions expressed by the author/s should not be assumed to reflectthe views, opinions or policies of the Families Commission.This report is copyright to the Families Commission. The copyright-protected material maybe reproduced free of charge for non-commercial personal use without requiring specificpermission. This is subject to the material being reproduced and attributed accuratelyand not being used in a misleading context. Requests and enquiries concerning thereproduction of information for any purpose other than personal use, requires thepermission of the Families Commission.Families CommissionPublic Trust BuildingLevel 6, 117-125 Lambton QuayPO Box 2839Wellington 6140Telephone: 04 917 7040Email: enquiries@nzfamilies.org.nzwww.nzfamilies.org.nzISSN 1177-815X (Print)ISSN 1177-8168 (Online)ISBN 978-0-478-32831-8 (Print)ISBN 978-0-478-32832-5 (Online)

families commission research fundchildbirth education:antenatal education and transitions of maternitycare in new zealandDR SARAH DWYERIN CONJUNCTION WITH PARENTS CENTRESNEW ZEALAND INC AND PARENTING COUNCIL

ACKNOWLEDGEMENTSThis research was prepared for the FamiliesCommission, Parenting Council and Parents Centres,with funding from the Families Commission. I wouldlike to thank the following people who gave their timeto talk to me about maternity and Well Child servicesin New Zealand: Vivienne Gurrey, Michelle Burton,Gillian Taylor, Jennie Valgre, Sharron Cole, Pat Tuohy,Karen Guilliland, Chris Hendry, Peter Glensor, AngelaBaldwin, Trudi Ashcroft.Thanks to Alison Hussey from Plunket who organisedto have data extracted from the Plunket database andco-ordinated other Plunket Centres to complete thequestionnaire about the type of antenatal educationservice they offered.Thanks also to Nicolette Fisher who transcribedtwo of the focus group recordings and helped withphoning all the DHBs to check on the progress of thedistribution of the questionnaire through maternityfacilities. She also provided useful first-handfeedback on the maternity system as she progressedthrough her own pregnancy and birth. A big thanksto Magda Kielpikowski who helped find contactdetails for all the CBE providers and then patientlyemailed questionnaires to each one and meticulouslyfollowed them up. Magda also provided invaluableassistance in completing the final data analyses.Thanks to Jennie Valgre for helping me pilot thequestionnaire for women. Thanks also to themany providers of CBE who gave up some of theirtime to talk to us about the service they offer and tomany helpful people in the DHBs who organised thedistribution of questionnaires through hospitals. Finally,thanks to the hundreds of women who completedthe questionnaire shortly after giving birth. Your timewas appreciated.2 Families Commission Research Fund

families commission research fundTABLE OF CONTENTSAcknowledgements 2Preface 6Executive summary 81. Background and research questions 131.1 Definitions used in this report 131.2 Key stakeholders 141.3 Parents Centres 141.4 Parenting Council 151.5 Context 161.6 Significance of the current research 181.7 Project objectives 191.8 Scope of the project 191.9 Overview of maternity milestones andservices, research questions and methods 202. Methods 232.1 Measures 232.2 Participants and procedure 232.2.1 Key informant interviews 232.2.2 Contact with each DHB 232.2.3 Focus groups 232.2.4 Brief questionnaire to women 262.2.5 Brief questionnaire to CBE providers 282.2.6 Accessing the Plunket database 292.2.7 Literature review 292.3 Confidentiality and ethical considerations 292.4 Analyses 303. Results: Answers to research questions 313.1 Antenatal care 313.1.1 What proportion of women have a leadmaternity carer (LMC)? 313.1.2 What proportion of LMCs are GPsobstetricians, or midwives? 323.2 Transition between LMC and CBE 323.2.1 What proportion of LMCs referwomen and their families andwhänau to CBE? 323.2.2 What are the contractualarrangements and obligations ofLMCs to refer women to CBE? 333.2.3 What process is used to managethe referral between LMC and CBE? 343.3 Childbirth education 343.3.1 Who are the providers of CBE? 343.3.2 What are the contractualarrangements and obligations ofCBE providers? 353.3.3 What are the minimum qualificationsof childbirth educators required bydifferent providers of CBE? 353.3.4 How is CBE funded and by whom? 373.3.5 What information do women andfamilies or whänau receive and valueas part of CBE and what resourcesand booklets are made availableto women? 373.3.6 How does CBE offered by differentproviders compare? 423.3.7 What proportion of women accessCBE? How does this differ acrossdifferent health regions? 453.3.8 How does the availability ofCBE differ across the differenthealth regions? 463.3.9 What are the demographics ofwomen and families and whänauwho access CBE and the bestpredictors of attendance? 483.3.10 Does CBE prepare parentsemotionally to have children? 523.3.11 What decisions do parents makebefore their child is born about howthey will consciously parent their childand what services are available tofacilitate this process? 563.3.12 The Revised Section 88 MaternityNotice describes the obligations ofLMCs and specifies parents’entitlements to maternity services.To what extent are parents aware ofthese entitlements? 593.4 Labour and birth 613.4.1 How long do women spend in hospitalafter giving birth? 61childbirth education: antenatal education and transitions of maternity care in new zealand3

3.5 Breastfeeding 623.5.1 What proportion of women havesuccessfully established breastfeedingby the time they leave hospital? 623.5.2 What resources are made available inhospital to help women successfullyestablish and maintain breastfeeding? 623.6 Transition between LMC and WellChild services 663.6.1 What are the contractual arrangementsand obligations of LMCs to referwomen to Well Child services? 663.6.2 How soon after the baby is born doesthe transfer between LMC and WellChild services occur in practice? 663.6.3 What process is used to managethe handover from LMC to WellChild services? 673.6.4 What processes do Well Childservices use to engage women andfamilies and whänau during thistransition? 683.6.5 To what degree is the transitionbetween LMC and Well Child servicesleft to the mother, father or familyor whänau? 703.7 Well Child services 723.7.1 Who are the providers of Well Childservices? 723.7.2 What are the contractual arrangementsand obligations of Well Child serviceproviders as they relate to transitions ofcare from LMC to Well Child services? 723.7.3 What are the demographics of mothersand families and whänau who receiveWell Child services? 733.7.4 What are the barriers to accessingWell Child services? 773.7.5 What screening is done for postnataldepression (PND)? 804. Discussion and conclusions 834.1 Summary of results 834.2 Gaps between the support that maternityand Well Child services aim to provide andwhat happens in practice 864.2.1 Information gaps 864.2.2 Identification and responsiveness gaps 864.2.3 Engagement gaps 874.2.4 Service gaps 874.2.5 Clinical or performance gaps 874.3 Implications 884.3.1 Content of antenatal classes 884.3.2 Format of antenatal classes 894.3.3 Skills and knowledge required bychildbirth educators 904.3.4 Interface between LMC and CBE 904.3.5 Transition between LMC and WellChild provider 914.4 Strengths of the research 914.5 Limitations of the research 924.6 Final comments 92References 94Appendix 1: Questionnaire for women 96Appendix 2: Questionnaire for providers 98Appendix 3: Key informant interviewquestions 100Appendix 4: Information sheet for womenabout focus groups 102Appendix 5: Questions for women infocus groups 103Appendix 6: Information sheet for womenabout brief questionnaire 104Appendix 7: List of hospitals and maternityfacilities through which questionnairewas distributed 105Appendix 8: Pregnancy and parentingeducation providers by DHB 1084 Families Commission Research Fund

families commission research fundAppendix 9: National service specificationfor pregnancy and parenting education 113Appendix 10: Topics covered by differentchildbirth education providers 118Appendix 11: Well Child providers by DHB 122Appendix 12: Clauses from the Well Childservices national service specificationsspecifically relevant to the transitionbetween LMC and Well Child services 126Appendix 13: Number and percentageof Plunket contacts from 1 July 2005 to30 June 2006 as a function of place ofcontact, type of contact (core versusadditional) and NZDep2001 score 128Literature review 1291. Effectiveness of antenatal education 1291.1 Introduction 1291.2 Search strategy 1301.3 Outcomes related to pregnancy 1311.3.1 Nutrition 1311.3.2 Substance use 1311.3.3 Social support 1321.4 Outcomes related to birth 1331.4.1 Expectations 1331.4.2 Amount of fear or anxiety 1331.4.3 Maternal sense of control andactive decisionmaking 1341.4.4 Amount of pain 1351.4.5 Use of medications to reducepain and coping strategies usedduring labour 1351.4.6 Birth experience and satisfactionwith the birth experience 1361.4.7 Caesarean rate 1371.4.8 Birthweight and preterm delivery 1381.5 Outcomes related to early parenting 1381.5.1 Bonding or attachment 1381.5.2 Breastfeeding success 1391.5.3 Relationship between couple 1411.5.4 Parenting self-efficacy and parentingknowledge 1421.5.5 Postnatal depression (PND) 1431.6 Outcomes related to specificpopulation groups 1441.6.1 Fathers 1441.6.2 Teens 1451.6.3 Minority cultural groups 1451.7 Discussion and conclusions 1471.7.1 Recommended future format andcontent of antenatal classes 1491.7.2 Implications for facilitators andchildbirth educators 1511.7.3 Future research 151References 154Appendix 1: The Lamaze philosophyof birth 163Appendix 2: The Bradley teaching goalsor philosophies 163childbirth education: antenatal education and transitions of maternity care in new zealand5

PREFACEI think the confidence I got as a result of going tothe classes meant that we could easily establish anemotional connection with [baby’s name] because…[it] … eliminated a whole lot of barriers and wecould just concentrate on falling in love with him… (mother discussing how CBE influenced herthinking about parenting p.58)It has been said many times that while pregnancy,childbirth and parenting might revolve around anatural process, the skills of mothering are not allinstinctive. Women learn much of how to look after theirunborn child, have a healthy birth and how to parent,from others.In traditional societies these skills are passed fromgrandmothers to mothers to daughters. In manymodern societies, however, families are more scattered;the role of maternity carer and parenting educatorincreasingly falls to those providing professionalantenatal and postnatal services.How do these services in New Zealand measure up?Are the services provided equally accessible throughoutthe country? Do they meet women’s needs? Are theyculturally appropriate? And is there a smooth referralprocess from the providers of antenatal care to theproviders of support for those vital first weeks of beinga new parent?The Families Commission, in association with ParentsCentres New Zealand Inc and the Parenting Council,commissioned research to look at these questions. Thestudy describes women’s access to, and perception of,childbirth education services offered by providers in the21 District Health Boards (DHBs). It also looks at howmothers are referred from the care provided by LeadMaternity Carers (LMC) to antenatal education, andfrom LMC to Well Child services.This report details the findings of that research. Itssupporting literature review examines how effectiveantenatal education has been in New Zealand andinternationally, and highlights the positive impactthat antenatal education can have on a mother andher baby.It raises some critical issues about women’s accessto childbirth education and the transition from maternitycare to parental support in New Zealand. It showsthat not all women and their families are able toaccess good antenatal education and support. It alsoshows that the quality of the information and servicesthey are getting differs greatly between thehealth regions.The study found that just over 41 percent of pregnantwomen attended childbirth education in New Zealand.Most of these women were first time mothers, tertiaryeducated, of New Zealand European ethnicity, andhigher income earners. Women less likely to attendwere less educated, of lower socio-economic status,and single.Mäori and Pasifika women were significantly underrepresentedas recipients of child birth education andthere were significant barriers (cultural, transport,childcare, language) to their participation.Many women were only vaguely aware of theirentitlements, such as the allowable length of postnatalhospital stay or the number of free LMC or Well Childhome visits they could receive. A number of womenreported having difficulties finding a Lead MaternityCarer in their area.The research found there were significant differencesin the availability and delivery of CBE across the DHBregions; and that some health boards do not meet theMinistry of Health expectation of CBE services beingavailable free of charge to 30 percent of all pregnantwomen each year. Further, not all providers base theircourses on national service specifications; there weredifferences between what topics providers covered, thelength and structure of their courses, and the trainingof facilitators.In some regions there were problems with referringmothers on to other providers (LMC to childbirtheducation and LMC to Well Child services). Thisresulted in many women being unaware of theavailable services, having to initiate contact with theservices themselves, or falling through the gap duringthe transition process.There were many women happy with the servicesprovided and the support and information theyreceived. Nevertheless, the Families Commissionbelieves the gaps and issues identified need tobe addressed.The Commission will advocate for an increase in thenumbers of women able to access free CBE classes.6 Families Commission Research Fund

families commission research fundWe want the regional variations in the availabilityof CBE across the DHBs to be addressed, and forall boards to meet the current Ministry of Healthexpectations for free classes for pregnant mothers.The Commission will also encourage DHBs to lookcreatively at how they can increase the numbers of freeservices for women.We also see an urgent need to address the problemswithin the maternity system that are leaving somewomen unable to access a LMC in their area.CBE will need to become more relevant and accessiblefor women from different cultural groups anddisadvantaged backgrounds. Services providers willneed to develop innovative ways to engage with familiesand look at how to break down barriers totheir participation.The Commission will advocate for the information onCBE and available services to be presented to womenand their families in a consistent way, so they can makeinformed decisions about their care arrangements.We support the recommendations outlined in the reportaimed at improving the transition of care between thedifferent services. and strengthening the content andformat of antenatal education. We also support furtherdiscussion to identify what knowledge and skills areneeded by childbirth educators.These findings are aimed at improving andstrengthening the quality of CBE in New Zealand. Thereport will be of considerable interest to the Ministryof Health, District Health Boards, childbirth serviceproviders and others involved in future planning of CBEin New Zealand.The Families Commission thanks Parents CentresNew Zealand Inc and the Parenting Council forundertaking this research. We are grateful to themothers who openly shared their childbirth educationexperiences and the childbirth providers and carerswho willingly participated in this study.Dr Jan PryorChief Commissionerchildbirth education: antenatal education and transitions of maternity care in new zealand7

EXECUTIVE SUMMARYThe perinatal period represents an ideal opportunityto engage women and families and whänau inpreventative health care. This research provides asnapshot of antenatal education and transitions ofmaternity care in New Zealand. The focus of theproject was on the quality and availability of antenataleducation. It was funded by the Families Commission,with the project objectives decided in collaboration withParents Centres New Zealand Inc and the ParentingCouncil. It was completed a few months after therevised Primary Maternity Services Notice (2007)pursuant to Section 88 of the New Zealand PublicHealth and Disability Act 2000 was released.MethodsThere were 30 research questions, each of whichrelated to one of 11 project objectives. Data werecollected from many sources using a range of methods,including key informant interviews; phone calls todistrict health boards (DHBs); focus groups withwomen; a brief questionnaire given out in maternityfacilities to women who had just given birth; a briefquestionnaire distributed to childbirth education(CBE) a providers; extracting data from the Plunketdatabase; and a comprehensive literature review on theeffectiveness of antenatal education. The main findingsrelated to each objective are summarised below.Results1. Identify the providers of CBE and Well Childservices in New ZealandThis project identified 90 providers of antenataleducation and 88 providers of Well Child servicesacross all 21 DHBs. DHB provider arms are the biggestprovider of free antenatal education in New Zealand,followed by Parents Centres. Plunket is the biggestprovider of Well Child services.There are three main ways that CBE is funded inNew Zealand:> publicly funded through DHB provider arms orcontracts that other providers hold with DHBs (whoreceive funding from the Ministry of Health)> privately funded or fee-for-service, where theprovider charges the participant to attendthe course> community funded through charities, philanthropicorganisations or fundraising activities.Of the 45 CBE providers that returned questionnaires,38 (84.4 percent) reported being DHB-funded, five(11.1 percent) fee-for-service (with two of them alsoreceiving some community funding), and one providerreported being fully community funded.2. Describe the contractual arrangements andobligations of CBE providersCBE providers that hold contracts with DHBs areobligated, through the national service specificationsfor Pregnancy and Parenting Education, to runcourses that are at least 12 hours in duration, facilitated‘preferably’ by someone with childbirth educationqualifications, and cover content relevant topregnancy, labour, birth and care after the birth. CBEproviders that do not hold contracts with DHBs haveno formal obligations. Eighty percent of CBEproviders based their courses on the nationalservice specifications.3. Describe and compare CBE offered towomen and their families and whänau by keyCBE providersTopics that women most frequently remembered beingcovered in classes were signs of labour and optionsfor managing pain, normal and other birthing methodsand the benefits of breastfeeding. Topics least wellremembered included the complaints procedure formaternity services, unplanned experiences, parentingprogramme options available and the role of Well Childservices and how to access them.Parts of antenatal education that women valued themost included information on pain relief options duringlabour and early experiences at home after the birth,social support, opportunities to get the father involvedand confidence from knowing what to expect duringlabour and afterwards. Parts of antenatal education thatwere least useful included poorly timed information onnutrition and a lack of information on bottle feeding,unexpected events and parenting after the birth ofthe baby.aIn this report the term ‘childbirth education’ is abbreviated to CBE for brevity and it is used interchangeably with the terms ‘antenatal education’and ‘pregnancy and parenting information’.8 Families Commission Research Fund

families commission research fundDHB-funded providers were more likely than nonfundedproviders to cover a range of topics, includingthe effects of smoking, the effects of alcohol and otherdrugs, warning signs of problems during pregnancyand the role of Well Child services. There were alsodifferences in the likelihood of different topics beingcovered by individual providers.In addition to content, there were differences betweenCBE providers in the length, structure and targetpopulation of their courses. Parents Centres, whooffer relatively structured courses and require theirfacilitators to have a qualification in CBE, comparedwell against other organisations on one of the items inthe women’s survey. After adjusting for confoundingvariables, women’s perception of the extent to whichCBE helped them prepare for the birth experience wassignificantly higher for women who had participated inCBE through Parents Centres (M = 3.93) comparedwith hospital-based classes (M = 3.58).4. Determine the proportion of parents whoaccess CBEOver 41 percent of all women who had just givenbirth had attended antenatal education; 80 percentof primiparous women (those giving birth for thefirst time) participated, but only four percent ofmultiparous women (those who had given birthbefore) attended antenatal education. The proportionof parents accessing CBE was relatively higher inAuckland (46 percent), Capital and Coast (52 percent)and Canterbury (51 percent) regions comparedwith Waikato (31 percent), Lakes (32 percent) andSouthland (35 percent) regions.5. Compare the availability of CBE across thedifferent health regionsIn 2006, DHBs funded enough CBE places foranywhere between 10 percent and 100 percent of theirfirst-time pregnant women. Capital and Coast regionhad the lowest availability of funded CBE places forfirst-time pregnant women, with only 10 percent offirst-time births potentially accommodated. (Therelatively high access rates to CBE in the Capital andCoast region suggest that a higher proportion of womenpay for courses in this region). Other regions that didnot fund sufficient CBE places to cover 30 percentof first-time pregnant women included Northland,Waitemata and Nelson-Marlborough.6. Determine the demographics of women andfamilies and whänau who access CBE and WellChild servicesMost women who participated in CBE were primiparous(95.1 percent) and were married or in de factorelationships (92.6 percent). Participants weresignificantly more likely than non-participants to have atertiary degree (one to four years), to be of New ZealandEuropean ethnicity and to be earning $70,000 or moreper year. Mäori and Pacific peoples were underrepresentedamongst women who attended antenataleducation. Only 10 percent of CBE participants wereof Mäori ethnicity and less than one percent were ofPacific ethnicity. After adjusting for all demographicvariables, the strongest predictors of women’sattendance at antenatal education were the women’sparity (number of previous births), whether the leadmaternity carer (LMC) had suggested the mother attendCBE classes, family structure and the DHB.The ethnic makeup of parents who receive PlunketWell Child services closely mirrors that of the generalpopulation of women giving birth. In 2004, births toMäori and Pacific mothers accounted for 19.9 percentand 10.1 percent of all births respectively. 1 BetweenJuly 2005 and June 2006, 22 percent of newPlunket enrolments were Mäori, 10 percent werePacific and 68 percent were ‘other’ (mostly New ZealandEuropean). However, Plunket clients are a less-deprivedpopulation than the general population of womengiving birth.7. Describe the contractual arrangements andobligations of LMCs as they relate to transitionsof care from LMC to CBE and from LMCs to WellChild careThere are no formal obligations for LMCs to refer womento antenatal education. However, LMCs have bothcontractual and professional obligations, specified in theSection 88 Maternity Notice and Midwives’ Handbookfor Practice, respectively, to inform women about theavailability of antenatal education. This is different fromrecommending that women attend antenatal education.Fifty-eight percent of women who completed the surveyreported that their LMC had suggested they attendantenatal education. For primiparous women, thepercentage was 92 percent and for multiparous women,the percentage was 26 percent.childbirth education: antenatal education and transitions of maternity care in new zealand9

In contrast, there are formal obligations, specifiedin the Section 88 Maternity Notice, for LMCs to referwomen to Well Child services. LMCs must provide awritten referral to Well Child services before thebaby is four weeks old and must have transferredcare to the Well Child provider before the baby is sixweeks old. In 2006, 67 percent of transfers to Plunketoccurred before six weeks, 27 percent occurredbetween six and 10 weeks and six percent occurredafter 10 weeks.8. Describe the contractual arrangements andobligations of Well Child service providers as theyrelate to transitions of care from LMC to WellChild careAccording to the Well Child framework and currentWell Child service specifications, Well Child servicesare formally obligated to register and make contactwith every family and whänau for whom they receivea referral. They are also obligated to provide services‘initially’ in the family home. Additional funding is givento Well Child providers to enable them to makecontact and conduct additional home visits withvulnerable families.9. Determine the extent to which the transitionbetween LMC and Well Child services is coordinatedby service providers or left to the motherand her family and whänauAlthough this transition is not generally left to theparents, in some regions problems with the transitionprocess between providers result in a substantialproportion of women or their families and whänauhaving to initiate contact with services themselves, oreven falling through the gaps.Factors contributing towards parents having to takeresponsibility for the transition include midwives failingto make a formal written referral, midwives sendingthe paperwork to Well Child providers late, midwivesforgetting to send the paperwork, midwives givingthe paperwork to the family instead of the Well Childprovider, philosophical differences between midwivesand Well Child providers, Well Child providers nothaving the capacity to follow up all referrals, WellChild providers failing to follow up all referrals, parentschoosing not to access Well Child services and a lack ofmonitoring of the transition process.10. Determine the extent to which women andtheir families and whänau are aware of theirentitlements, specified in the Primary MaternityServices Notice (2007) pursuant to Section 88 ofthe New Zealand Public Health and DisabilityAct 2000Women were only vaguely aware of their entitlements.They were not aware of the specific details ofentitlements, such as the length of postnatal hospitalstay or the number of LMC or Well Child home visits.They also seemed unaware of entitlements such as freenon-LMC care for urgent pregnancy problems. Lack ofknowledge of entitlements was a particular barrier tomaternity care for young women, women of differentethnic backgrounds (particularly non-English-speaking)and women who had not been living in New Zealand forvery long.11. Identify gaps between the support thatmaternity and Well Child services aim to provideand what happens in practiceFive types of gaps were observed between whatservices aim to provide and what happens in practice.1. Information gaps – Maternity and Well Childservices aim to provide women and families or whänauwith information on the services available so theycan make informed decisions about their care. Inpractice, there are many women and families andwhänau who are unaware of the services availableor receive poor-quality information. These gapsmay be addressed by providing more informationto professionals and the public about the servicesoffered by different maternity and Well Child providers;providing opportunities for different maternity and WellChild providers to get together and share information;and monitoring the quality of information and resourcematerials made available to women and their familiesand whänau.2. Identification and responsiveness gaps – Maternityand Well Child services aim to identify and respondappropriately to women and families or whänau whoare at risk of various adverse outcomes. In practice,many families and whänau are missed and sometimesthere are insufficient resources, or no system is inplace to follow up appropriately. These gaps maybe addressed by considering the systematic use ofscreening tools (such as those for postnatal depression10 Families Commission Research Fund

families commission research fund(PND)); developing appropriate information technologyinfrastructure to support monitoring systems (suchas Kidslink); developing primary mental healthcare services and workforce development on theidentification and optimal management of at-riskfamilies and whänau.3. Engagement gaps – Maternity and Well Childservices aim to successfully engage women and theirfamilies and whänau. In practice, women and familiesand whänau who have the greatest need are oftenthe most difficult to engage. These gaps may beaddressed by making services more attractive andsuitable for different client groups; finding innovativeways of reaching out to people; and addressing systemlevelbarriers to accessing services.4. Service gaps – Maternity and Well Child servicesaim to achieve good coverage of their targetpopulation and an equitable level of servicing acrossdifferent regions in New Zealand. In practice, thereare significant gaps in service coverage and largedifferences in the availability of services across differentregions. These gaps may be addressed by fundingmore maternity or Well Child services (for example,more midwives and more CBE classes), and offeringantenatal classes that are attractive to and meet theneeds of different population groups.5. Clinical or performance gaps – Maternity andWell Child services aim to provide services thatmeet consumers’ needs and are of a high quality. Inpractice, consumers’ needs are too often not met andthe quality of services is questionable. These gapsmay be addressed by requiring childbirth educatorsto have a minimum qualification in CBE; introducingquality-improvement processes such as auditing ofservices, rewarding particular targets, measurementand monitoring of outcomes and collecting regularconsumer feedback; critically re-examining the contentof programmes; and further workforce development.RecommendationsThis project has implications for the content andformat of antenatal education, the skills and knowledgerequired by facilitators of classes and transitions ofmaternity care.Antenatal class content> Cover information on nutrition earlier in pregnancy.> Do not push the benefits of vaginal childbirthand breastfeeding to the detriment of women’smental health.> Provide more information on parenting strategies.> Prepare women and families in a more realistic wayfor childbirth.> Include discussion of emotional and relationshipissues related to the transition to parenthood.> Refocus classes to concentrate on increasing selfefficacyand health literacy.Antenatal class format> Wherever possible, run antenatal classes withhomogeneous groups of women to facilitate thegrowth of friendships and social support.> Consider offering courses on a broader timescale toalign with parents’ information needs.> Base teaching on principles of adult learning andinclude experiential learning.> Consider basing classes on a structured curriculumwith some flexibility to tailor classes to the learningneeds of the group.> Design and offer antenatal classes that areattractive to and meet the needs of differentpopulation groups, such as Mäori, Pacific peoples,refugees or teenagers.Skills and knowledge required by facilitators ofantenatal classes> Ideally, childbirth educators should have knowledgeand skill in the use of adult learning principles;experiential learning; empowering parents andincreasing parental self-efficacy and health literacy;discussing difficult emotions and relationship issues;parenting strategies; being sensitive to participants’individual situations, cultures and learning desires;professionalism; and understanding how other partsof the maternity system work.Interface between LMC and CBE> Consider ways of influencing LMCs to recommendCBE to their clients more frequently.childbirth education: antenatal education and transitions of maternity care in new zealand11

Continue to strengthen relationships between LMCsand CBE providers.Transition between LMC and Well Child provider> Consider further standardising the handoverprocess from LMC to Well Child providers toincrease the reliability of the referral process.> Consider monitoring or auditing thehandover process.> Continue to strengthen relationships between LMCsand Well Child providers.> Increase resources to enhance the capacity ofLMCs to comply with formal referral requirementsand to increase the capacity of Well Child providersto follow up referrals.> Provide public education about entitlements,the services offered by maternity and Well Childproviders and why they are important.> Address the known barriers preventing womenand their families and whänau from accessingWell Child services, such as language, perceptionsor beliefs, cultural competence, stigma andmonitoring systems.Topics for further debate> Should facilitators of antenatal education berequired to have a minimum qualification in CBE?> Should it be a requirement for LMCs to formallyrefer primigravidae (those pregnant for the firsttime) to antenatal education?Strengths and limitations of the projectMajor strengths of the project are the variety ofresearch methods used, including both qualitativeand quantitative measures, as well as importantnew evidence obtained on antenatal education andtransitions of maternity care for the New Zealandcontext. The major limitations of the research arerelated to the size and representativeness of thesample of women who returned questionnaires.Overall woman and their families and whänau aresatisfied with CBE in New Zealand. The maternityand Well Child services available meet the needs ofthe majority of families and whänau, but refinementssuggested in this report could do much to maximise thepotential of antenatal education and better equip womenand their partners for the transition to parenthood.12 Families Commission Research Fund

families commission research fund1. BACKGROUND ANDRESEARCH QUESTIONS1.1 Definitions used in this reportAntenatal support: services provided for pregnantwomen and their families and whänau before birth,such as childbirth education or lead maternity care(LMC) support.Breastfeeding, artificial: the infant has had nobreastmilk but has had alternative liquid such as infantformula with or without solid food in the past 48 hours(before the survey). 1Breastfeeding, exclusive: the infant has never, to themother’s knowledge, had any water, formula or otherliquid or solid food. Only breastmilk (from the breast orexpressed) and prescribed medicines (as defined in theMedicines Act 1981) have been given to the babyfrom birth. 1Breastfeeding, fully: the infant has taken breastmilk anda minimal amount of water or prescribed medicines (asdefined in the Medicines Act 1981) but no other liquidsor solids in the past 48 hours (before the survey). 1Breastfeeding, partial: the newborn has taken somebreastmilk and some infant formula or other solid foodin the past 48 hours (before the survey). 1Childbirth education (CBE): a specific component ofantenatal support that aims to provide informationon wellness behaviours during different trimestersof pregnancy and to prepare the mother (andusually her partner) for labour and birth. It mayinclude information and advice on foetal growth anddevelopment, breathing techniques during labour, whatto expect during labour and delivery, caesarean birth,breastfeeding, maternal postpartum issues andinfant care.Maternity facilities, primary: facilities that do nothave inpatient secondary maternity services or 24-hour on-site availability of specialist obstetricians,paediatricians and anaesthetists. This includesbirthing units. 1Maternity facilities, secondary: provide additional careduring the antenatal, labour and birth and postnatalperiods for women and babies who experiencecomplications and who have a clinical need for eitherconsultation or transfer. They have the capability toperform caesarean sections. 2Maternity facilities, tertiary: facilities that provide amultidisciplinary specialist team for women and babieswith complex or rare maternity needs who requireaccess to such a team, including neonatal intensivecare units. Examples of complex needs include babieswith major foetal disorders requiring prenatal diagnosticand foetal therapy services or women with obstetrichistories that significantly increase the risks duringpregnancy, labour and delivery (for example, twoplacental abruptions). 1Maternity services: covering antenatal, perinatal andpostnatal support services up until a maximum ofsix weeks after the birth, but excluding Well Childservices. Consistent with the definition provided bythe then Health Funding Authority (2000), 2 maternityservices includes: LMCs; maternity facilities (usuallyin hospitals) that provide inpatient services duringlabour, birth and the immediate postnatal period andbirthing units; secondary and tertiary maternity servicesfor women and babies who experience complications;specialist neonatal services that provide inpatient carefor babies who are born with additional needs, andneonatal homecare services; pregnancy and parentinginformation; whänau ora maternity support services;regional units providing home support and mothercraftinpatient services where women are admitted ifthey need ongoing assistance with caring for theirinfant, including support for infant sleep and feedingdifficulties; and consumer information on how thematernity system works, including the options available,entitlements to maternity care and costing.Multiparous: refers to women who have given birth twoor more times.Parenting education: services that provide parentsand other caregivers with specific knowledge andchildrearing skills with the goal of promoting thedevelopment and competence of their children.Perinatal support: services provided for women aroundthe time of childbirth, including labour, birth and thepostnatal period.Postnatal support: services provided for women andtheir families and whänau after the birth, includingWell Child services and early parenting education up tothe time the baby is six weeks old. ‘Postnatal’ is usedinterchangeably with ‘postpartum’.childbirth education: antenatal education and transitions of maternity care in new zealand13

Pregnancy and parenting education: often usedinterchangeably with the term ‘childbirth education’,but more accurately reflects the changing nature ofCBE that includes parenting education components.Pregnancy and parenting education involves groupantenatal education for pregnant women and theirfamily and whänau. The aim is to acknowledge andenhance participants’ own experience and knowledge,to empower them to trust themselves and to know howto seek additional maternity information and supportwhen they need it. Each course typically includes upto 12 pregnant women and involves a minimum of 12hours of education. 3 In this report the terms childbirtheducation (CBE), antenatal education and pregnancyand parenting education are used interchangeably.Primigravida or primiparous: gravida refers to a woman’snumber of pregnancies and parity refers to the numberof previous births. A woman who is pregnant for thefirst time is a primigravida and is nulliparous (having noprevious births). A primigravida becomes a primiparaonce she has given birth.Well Child services: health education and supportservices provided to women and their babies andchildren, typically from about six weeks of age,including developmental assessments of the baby atsix weeks offered through Plunket. According tothe New Zealand Well Child Framework, 4 Well Childservices encompass three domains: health educationand promotion; health protection and clinicalassessment; and family or whänau care and support.Note: For readability, all references are referencedthroughout the text in number format, 1 to 59 in themain report, and 1 to 236 in the Literature Review. Fullauthor details can be found in these reference sections.1.2 Key stakeholdersBelow is a list of the key internal and externalstakeholders for this project.Service providers> Parents Centres> Plunket> Obstetricians> New Zealand College of Midwives (NZCOM)> Nga Maia (Mäori midwife collective, directlyaffiliated with NZCOM)> SAMCL (South Auckland Maternity Care Limited)> Childbirth educators> District Health Boards (DHBs)> Primary Health Organisations (PHOs) and generalpractitioner (GP) groupingsEducation and certification> Aoraki Polytechnic, Timaru> The Childbirth Educators of New Zealand (CENZ)Government and Crown Entities> Ministry of Health (MOH)> Ministry of Education> Ministry of Social Development> Families Commission> Office of the Children’s CommissionerOther stakeholders> Parenting Council> College of GPs1.3 Parents CentresTo conduct this research, the Families Commissionprovided funding to the Parenting Council, of whichParents Centres is a member. Parents Centresemployed Dr Sarah Dwyer to manage the project andplayed a large role in deciding on the final researchquestions. The final report was prepared independentlyof Parents Centres. Below is more information aboutParents Centres and the Parenting Council.Parents Centres New Zealand Inc is a communitybased,not-for-profit organisation set up for parentswith 54 main Centres throughout New Zealand.Parents Centres represents one of the largest parentingsupport and education infrastructures in New Zealand.Their philosophy is for New Zealand society to valueparenting as fundamental to the wellbeing of allmembers of society. Their core business is servingparents of children aged 0–5 years, with a focus onpre-conception, coping skills, knowledge andinformation transfer, life skills and antenatal andpostnatal training.The Parents Centres movement commenced in 1952in New Zealand. Currently, Parents Centres providesservices to over 16,000 parents annually, and has14 Families Commission Research Fund

families commission research fundopportunities to touch families well in excess of 60,000times per annum. The organisation operates from aNational Office in Mana, Wellington, and supportsover 3,500 volunteers who run and offer Parents Centreprogrammes nationwide in both rural andmetropolitan areas.Parents Centres has two main work streams:community support and community education.Their community support stream comprisesinfrastructure and networks to deliver support whereneeded to parents in the community. Parents Centresprovides community support for various parentingissues, such as Sudden Infant Death Syndrome,sudden foetal death, miscarriage, breastfeeding andchild development. They also provide a toy library, playgroups and crèche.Their second work stream, community education,focuses on antenatal and childbirth education; parenteducation on coping skills, practical parenting,professional development for parents; and all aspectsof baby and toddler care to school age. The extentto which Parents Centres provides community supportor education is driven by the needs of thelocal community.Parents Centres services are open to all types offamilies and whänau. The National Support Team isplanning to introduce various additional projects in thecommunity, such as teen parents; parents in prison;intergenerational care; migrants as parents; Parentingwith Purpose through the SKIP initiative; and earlyindicators for intervention.1.4 Parenting CouncilThe Parenting Council was formed in April 2003 inorder to raise the profile of parenting in New Zealand,act as an advocate for parents and exercise somemonitoring of the parenting environment.The Council comprises a group of leading parentingorganisations with Päkehä, Mäori and Pasifikarepresentation who hold a common understanding thatgood parenting is essential in order for New Zealand tobe a peaceful, prosperous nation. The Council believesthat parenting behaviours need to be learnt, and thatparents need strategies to be able to nurture, guideand inspire their children in a social environment thatsupports them.The strategic objectives of the Parenting Council are to:> apply the knowledge, experience and insight ofits members to strengthen the ability of parentsand Government to work together effectively inachieving the prime purpose of parenting – wellnurturedchildren> be a recognised advisory body on parenting issues> provide recommendations and policy advice onparenting to the Government> promote the support and education needs of parents> facilitate, conduct or assist in research on currentand future issues relating to parenting> promote the interests of parents to the communityand to all political parties> network with parenting organisations in New Zealand.Members of the Parenting Council are:Viv Gurrey, Parents Centres New Zealand Inc – a longstandingprovider of antenatal and parenting educationand support delivered through 54 Centres aroundNew Zealand.Anne Wilkinson, Parent to Parent – a nationalinformation and support network for parents, caregiversand whänau of children with special needs.Lesley Max, Pacific Foundation for Health, Educationand Parent Support – responsible for HIPPY – HomeInstruction Programme for Parents and Youngsters in21 sites around New Zealand; developing the FamilyService Centre model (six sites); and advocacy.Steven Hayns, Triple P (Positive Parenting Program)– a parenting and family support strategy thataims to prevent severe behavioural, emotional anddevelopmental problems in children by enhancing theknowledge, skills and confidence of parents.Janine Kaipo, Otangarei Youth, Sports and RecreationTrust – a Whangarei-based multifaceted service thatincludes HIPPY, parenting programmes, budgeting andlife-skills services and a residential facility.Esther Cowley-Malcolm, Pacific Islands FamiliesResearch Study, President of Pacifica, faculty member,Institute of Public Health and Mental Health, AucklandUniversity of Technology.Bruce Pilbrow, Parents Inc – a nationwide providerof seminars and other resources that aim to inspireparents with the tools and confidence they require.childbirth education: antenatal education and transitions of maternity care in new zealand15

Council members are based in Whangarei, Auckland,Hamilton and Wellington. The Parenting Councilmembers each have primary responsibility in leadershiproles in their respective organisations. Their joint workis in the fields of research, public relations andadvocacy. The Council commissioned and produceda Systematic Review of Parent Support and EducationProgrammes in order to help determine theeffectiveness of various programme types. Other workhas included supporting a scientific retreat attendedby academics and officials, in association with a majorconference on parenting; representation on manyparenting issues, with particular focus on disabilityissues; the parents’ role in the early years; the need forimproved parent education; and a website (which isunder development).1.5 ContextThis research has been informed by a number of NewZealand documents that guide the practice of particularservice providers. These documents are listed belowunder the service for which they are most relevant,along with a brief description of their main purpose andrelevance to the current project.Lead Maternity Care> The Maternity Services Notice (2002) pursuant toSection 88 of the New Zealand Public Health andDisability Act 2000. 5 This Notice describes thelegal obligations of LMCs and specifies parents’entitlements to particular maternity services,such as midwifery services, urgent out-of-hourspregnancy care, hospital care, home visitsand transfer from LMC to Well Child provider.Particularly relevant to the current research isSection 4.5.4 of the Notice, stating that the transferfrom the LMC to the Well Child provider willnormally take place between four and six weeksfrom birth (p. 14). LMCs must provide a writtenreferral to the Well Child provider before dischargefrom the LMC or at four weeks, whichever is earlier.> The revised Primary Maternity Services Notice(2007) pursuant to Section 88 of the New ZealandPublic Health and Disability Act 2000 6 (from hereon referred to as the Section 88 Maternity Noticeunless it must be distinguished from the olderversion, in which case it is called the ‘revised’Notice). The revised Notice includes changes toservice specifications, quality requirements andclaiming processes, as well as recent legislativechanges. It is based on consultation with midwivesand other stakeholders undertaken in 2006.Section DA9 (p. 1061, Gazetted version) specifiesthat the transfer of care of the baby from LMC to aWell Child provider must (italics added) take placebefore six weeks from birth. LMCs must still providea written referral to the Well Child provider beforethe end of the fourth week following birth. TheRevised Section 88 Maternity Services Notice statesthat if the baby has unusually high needs, the LMCmay request that a Well Child provider becomesinvolved as early as two weeks from birth to provideconcurrent and co-ordinated care with the LMC.The revised Notice also requires LMCs to maintainlinks with different providers of health services,including providers of antenatal education (SectionDA11, p. 1061, Gazetted version). The revisedNotice came into effect from 1 July 2007.> Midwives’ Handbook for Practice (New ZealandCollege of Midwives, 2005). 7 This documentoutlines the philosophy, scope of practice, code ofethics and standards of practice for New Zealandmidwives. Several of the standards of practice referto LMCs sharing relevant information with women(Standards One, Two, Five, Seven and Nine). Alsorelevant to this project is the section on DecisionPoints for Midwifery Care which outlines the rangeof information to be shared at each major stageof pregnancy, including health information andeducation. Within the first 16 weeks of pregnancythe LMC should discuss with the woman herchoices for childbirth and parenting education(p. 26). By 24 weeks, the LMC should ensurethat women are aware of childbirth educationoptions (p. 27).Childbirth education> Pregnancy and Parenting Education National ServiceSpecifications (MOH, 2002). 3 These servicespecifications set out the standards requiredfor antenatal education classes delivered byservice providers who hold contracts with DHBs.Particularly relevant to the current research isSection 5, which lists the service components orrequired content of each antenatal course. Thedocument specifies that programme co-ordinatorsfor pregnancy and parenting education will16 Families Commission Research Fund

families commission research fundpreferably be childbirth educators with a recognisedqualification in CBE. If programme co-ordinators donot hold a CBE qualification, they may be midwivesor physiotherapists with additional recognisedqualifications in adult education and culturalawareness or Treaty issues, or he kuia whare tapuor other respected teacher, recognised by therespective rünanga (Section 5.5).> Parents Centres Handbook (Parents CentresNew Zealand Inc, 2006). 8 The purpose of thishandbook is to set guidelines for childbirtheducation classes run through Parents Centres. Itincludes information on the content that shouldbe included in each antenatal course.> Certificate or Diploma in Childbirth Education (AorakiPolytechnic, 2007). 9 Aoraki Polytechnic is theonly tertiary institution in New Zealand that offersformal qualifications in childbirth education. Thereare student handbooks for both their certificate(one-year course) and diploma (two-year course)in childbirth education. The handbooks set outthe requirements for students and the childbirtheducation curriculum. The main learning modulesinclude prenatal considerations, labour and birth,postnatal considerations, adult teaching andbicultural studies.Well Child services> Well Child – Tamariki Ora National Schedule (MOH,1996). 10 It provides a general framework for thetypes and number of services to be delivered toall New Zealand children and their families andwhänau from birth to five years. The scheduleoutlines a total of 12 core contacts (eight contactsfrom Well Child services) that every child and theirfamily and whänau are entitled to receive. Plunketwas given funding to provide services and countthe outputs according to this schedule. It has beenargued that under this schedule, people who werethe most able ended up receiving more servicesthan vulnerable families because of the way outputswere rewarded in the contract between MOH andWell Child services.> The Well Child Framework (MOH, 2002). 4 Thisframework is based on the Well Child – TamarikiOra National Schedule and provides an outlineof the service delivery and pricing frameworkparticular to Well Child services. This documentdescribes the three key areas of service delivery,the number of core Well Child contacts to whicheach family is entitled, the population groupseligible for additional contacts and the percentageof the population eligible for additional visits. Itrecognises that some families are more vulnerablethan others and weights resources according tothe deprivation of the location that families areliving in. This was an attempt to address gaps inservice delivery, particularly the need to addressinequalities. The contracts between MOH andWell Child providers, which are now based on thisframework, better reward outputs related to servingfamilies with higher need.> Well Child – Tamariki Ora National ScheduleHandbook (MOH, 2002). 11 This documentdescribes each of the components of the WellChild – Tamariki Ora National Schedule,including the age when each component is tobe delivered and the recommended process fordelivering the component. It also providesdetails to help providers understand the WellChild Framework.> Well Child Services National Service Specifications(MOH, 2003). 12 The service specification containsthe contractual arrangements and standardsrequired for Well Child services that hold contractswith the MOH or DHBs. It refers to eight core WellChild contacts provided from the time of handoverfrom the LMC through to five years of age. It setsout the conditions under which additional servicesmay be provided. An additional five contacts maybe provided for first-time parents or when thereare issues such as infant feeding or behaviourconcerns; an additional five to 10 contacts mayalso be provided to children and their familiesand whänau where there is an assessed needand where there is an opportunity to improvehealth outcomes. The contract also refers tointerrelationships with other Well Child services,service linkages and reporting requirements.> Well Child Services: Literature review and analysis(prepared by Allen & Clarke for MOH, 2006). 13 Thisreport outlines various health-related outcomesfor pre-school children that could be addressedby a Well Child intervention. It also provides a briefoverview of different models of Well Child care andtheir effectiveness.childbirth education: antenatal education and transitions of maternity care in new zealand17

There are also several reports that are relevant to thebroader maternity system. These include:> Maternity Services: A reference document (HealthFunding Authority, 2000). 2 This documentprovides a description of maternity services as ofNovember 2000, the history of maternity servicesin New Zealand (from 1970 to 1990) and keyissues and recommendations for the future ofmaternity services. This document provides a listof CBE providers. However, this list is now aboutseven years old and is out of date.> Report on Maternity: Maternal and newborninformation 2004 (MOH, 2007). 1 The purpose ofthis document is to report on maternal and newbornhealth, which is considered an integral part ofmonitoring the health of the overall population. Thereport, which has been produced annually for thelast four years, draws on data from two nationalsources: the National Minimum Dataset (NMDS)and the Maternal and Newborn Information System(MNIS). Amongst other things, it provides figures onthe percentage of women who did not register withan LMC; the number of live babies born each year;the number of hospital births; the median age ofwomen giving birth; the percentage of women givingbirth by normal vaginal deliveries, operativeor caesarean section births; the number ofneonatal deaths; and ethnicity trends for each ofthese variables.> Maternity Services: Consumer satisfaction survey2007 (MOH, 2008). 14 This report presents theresults of a survey of 2,936 women who wereusing maternity services in New Zealand duringMarch and April 2007. It updates satisfactioninformation obtained from previous large surveysof women who gave birth in 1999 and 2002. The2007 survey, which contained quantitative andqualitative questions, assessed women’s knowledgeof the maternity system, access to LMCs andexperiences of antenatal care, labour, birth andpostnatal care. The report contains a section onwomen’s experiences of antenatal classes. Of the1,267 respondents (43 percent) who attendedantenatal classes, 91 percent felt that the classeshad been either ‘very useful’ or ‘useful’. Only ninepercent considered the classes to have been ‘notuseful’. Many of the women’s qualitative responsesconcerning inadequacies in the classes relatedto wanting more preparation for the first fewweeks of parenting. A number of women alsosuggested having postnatal classes in the firstfew weeks after the birth to assist women withbasic tasks such as bathing the baby andcoping emotionally.In addition to the above documents, Dr Pat Tuohy,Chief Advisor for Child and Youth Health, has recentlyundertaken a review of Well Child services, includingissues related to the transition between LMC and WellChild services.1.6 Significance of the currentresearchThere are several critical periods on the path fromearly pregnancy to early parenting (six weeks afterchildbirth) where maternity and Well Child servicescan have positive effects on the health and wellbeingof the baby, his or her mother and their family andwhänau. A mother’s access to good antenatal support,LMCs, childbirth education and Well Child services isgenerally associated with better outcomes for mothersand their babies. The companion literature review onthe effectiveness of antenatal education highlightsthe positive effects that antenatal education is likelyto have. However, access to these services is notnecessarily universal and the quality of the informationgiven to women and families and whänau by differentproviders may vary. This research focuses on antenataleducation and support. In particular, it outlines themain providers of pregnancy and parenting education,describes the information and guidance they offerto women, families and whänau and examines howaccess is affected by the demographics of the motherand her geographical region. The research also focuseson the transitions between different providers ofmaternity care, particularly the transfer between LMCand Well Child services. An important aim is to findgaps between what these services aim to provide andwhat actually occurs in practice. The last review of CBEproviders occurred over five years ago, and so is nowout of date. 2 The current research is important becauseit has the potential to inform future funding decisionsand planning on how to improve access to and thequality of CBE and transitions of maternity care inNew Zealand.18 Families Commission Research Fund

families commission research fund1.7 Project objectivesThis project aims to:> Identify the providers of CBE and Well Childservices in New Zealand.> Describe the contractual arrangements andobligations of CBE providers.> Describe and compare the CBE offered to womenand their families or whänau by key CBE providers.> Determine the proportion of parents whoaccess CBE.> Compare the availability of CBE across the differenthealth regions.> Determine the demographics of women andfamilies and whänau who access CBE and WellChild services.> Describe the contractual arrangements andobligations of LMCs as they relate to transitions ofcare – from LMC to CBE and from LMCs to WellChild care.> Describe the contractual arrangements andobligations of Well Child service providers as theyrelate to transitions of care – from LMC to WellChild care.> Determine the extent to which the transitionbetween LMC and Well Child services isco-ordinated by service providers or left to themother and her family and whänau.> Determine the extent to which women andtheir families and whänau are aware of theirentitlements, specified in the Section 88 MaternityNotice.> Find gaps between the support that services aim toprovide and what happens in practice.1.8 Scope of the projectThe primary focus of this project is on antenataleducation. Accordingly, the companion literature reviewis concerned entirely with reviewing the evidence forthe effectiveness of antenatal education. A secondaryfocus is on the transitions of care between LMC andantenatal education, and between LMC and Well Childservices. Each of the 30 research questions (Section1.9) is relevant to one of the project objectives (listed inSection 1.7) and can be further summarised into threemain areas of focus:> Pregnancy and parenting education servicesoffered antenatally to women and their families andwhänau.> The interface or referral process between LMCand CBE.> The referral process and handover from LMC toWell Child provider after the baby is born.A detailed description of maternity or Well Childservices, other than antenatal education or transitionsof care, is outside the scope of the report.childbirth education: antenatal education and transitions of maternity care in new zealand19

1.9 Overview of maternity milestonesand services, research questionsand methodsTable 1 shows a pathway of maternity milestonesand services that can affect the health and wellbeingof child, mother, and whänau. Associated with eachmilestone or service are the research questions relevantto the current project. Table 1 also provides a summaryof the methods that were used to answer eachresearch question.TABLE 1. Overview of milestones and services, research questions and methodsMilestone/service Research questions Method 1Antenatal careTransition betweenLMC and CBE1. What proportion of women have a LeadMaternity Carer (LMC)?(see Section 3.1.1)2. What proportion of LMCs are GPs,obstetricians or midwives?(see Section 3.1.2)3. What proportion of LMCs refer womenand their families/whänau to CBE?(see Section 3.2.1)4. What are the contractual arrangementsand obligations of LMCs to refer womento CBE?(see Section 3.2.2)5. What process is used to manage thereferral between LMC and CBE?(see Section 3.2.3)Focus groups (see Section 2.2.3)Brief questionnaire to women(see Section 2.2.4)Literature review (see Section 2.2.7)Literature review (see Section 2.2.7)Key informant interviews (see Section 2.2.1)Brief questionnaire to women(see Section 2.2.4)Key informant interviews (see Section 2.2.1)Literature review (see Section 2.2.7)Key informant interviews(see Section 2.2.1)Childbirth education6. Who are the providers of CBE?(see Section 3.3.1)7. What are the contractual arrangementsand obligations of CBE providers?(see Section 3.3.2)8. What are the minimum qualificationsof childbirth educators required bydifferent providers of CBE?(see Section 3.3.3)9. How is CBE funded and by whom?(see Section 3.3.4)10. What information do women and theirfamilies/whänau receive and valueas part of CBE and what resources/booklets are made available?(see Section 3.3.5)Key informant interviews (see Section 2.2.1)Contact with each DHB (see Section 2.2.2)Brief questionnaire to CBE providers(see Section 2.2.5)Key informant interviews (see Section 2.2.1)Brief questionnaire to CBE providers(see Section 2.2.5)Literature review (see Section 2.2.7)Key informant interviews (see Section 2.2.1)Brief questionnaire to CBE providers(see Section 2.2.5)Key informant interviews (see Section 2.2.1)Brief questionnaire to CBE providers(see Section 2.2.5)Key informant interviews (see Section 2.2.1)Focus groups (see Section 2.2.3)Brief questionnaire to women(see Section 2.2.4)Literature review (see Section 2.2.7)1Main research methods were key informant interviews, contact with each DHB, focus groups, a brief questionnaire to women, a briefquestionnaire to CBE providers, the Plunket database and a literature review.20 Families Commission Research Fund

families commission research fundLabour and birthBreastfeeding11. How does CBE offered by differentproviders compare?(see Section 3.3.6)12. What proportion of women accessCBE? How does this differ acrossdifferent health regions?(see Section 3.3.7)13. How does the availability of CBE differacross the different health regions?(see Section 3.3.8)14. What are the demographics of womenand families/whänau who access CBEand the best predictors of attendance?(see Section 3.3.9)15. Does CBE prepare parents emotionallyto have children?(see Section 3.3.10)16. What decisions do parents make beforetheir child is born about how they willconsciously parent their child andwhat services are available to facilitatethis process?(see Section 3.3.11)17. The Revised Section 88 MaternityNotice describes the obligationsof LMCs and specifies parents’entitlements to maternity services.To what extent are parents aware ofthese entitlements?(see Section 3.3.12)18. How long do women spend in hospitalafter giving birth?(see Section 3.4.1)19. What proportion of women havesuccessfully established breastfeedingby the time they leave hospital?(see Section 3.5.1)20. What resources are made available inhospital to help women successfullyestablish and maintain breastfeeding,eg, access to nurses, written resources?(see Section 3.5.2)Key informant interviews (see Section 2.2.1)Brief questionnaire to women(see Section 2.2.4)Brief questionnaire to CBE providers(see Section 2.2.5)Brief questionnaire to women(see Section 2.2.4)Literature review (see Section 2.2.7)Contact with each DHB (see Section 2.2.2)Brief questionnaire to CBE providers(see Section 2.2.5)Brief questionnaire to women(see Section 2.2.4)Literature review (see Section 2.2.7)Focus groups (see Section 2.2.3)Brief questionnaire to women(see Section 2.2.4)Literature review (see Section 2.2.7)Focus groups (see Section 2.2.3)Focus groups (see Section 2.2.3)Literature review (see Section 2.2.7)Literature review (see Section 2.2.7)Key informant interviews (see Section 2.2.1)Focus groups (see Section 2.2.3)childbirth education: antenatal education and transitions of maternity care in new zealand21

Transition betweenLMC and Well ChildservicesWell Child servicesHealth and wellbeingof baby, mother andfamily/whänau21. What are the contractual arrangementsand obligations of LMCs to refer womento Well Child services?(see Section 3.6.1)22. How soon after the baby is born doesthe transfer between LMC and WellChild services occur in practice?(see Section 3.6.2)23. What process is used to manage thehandover from LMC to Well Childservices?(see Section 3.6.3)24. What processes do Well Child servicesuse to engage women and families/whänau during this transition?(see Section 3.6.4)25. To what degree is the transitionbetween LMC and Well Child servicesleft to the mother, father or family/whänau?(see Section 3.6.5)26. Who are the providers of Well Childservices?(see Section 3.7.1)27. What are the contractual arrangementsand obligations of key Well Childservice providers as they relate totransitions of care from LMC to WellChild services?(see Section 3.7.2)28. What are the demographics of mothersand families/whänau who receive WellChild services?(see Section 3.7.3)29. What are the barriers to accessing WellChild services?(see Section 3.7.4)30. What screening is done for postnataldepression (PND)?(see Section 3.7.5)Key informant interviews (see Section 2.2.1)Literature review (see Section 2.2.7)Key informant interviews (see Section 2.2.1)Focus groups (see Section 2.2.3)Plunket database (see Section 2.2.6)Key informant interviews (see Section 2.2.1)Focus groups (see Section 2.2.3)Key informant interviews (see Section 2.2.1)Focus groups (see Section 2.2.3)Key informant interviews (see Section 2.2.1)Focus groups (see Section 2.2.3)Key informant interviews (see Section 2.2.1)Contact with each DHB (see Section 2.2.2)Key informant interviews (see Section 2.2.1)Literature review (see Section 2.2.7)Plunket database (see Section 2.2.6)Key informant interviews (see Section 2.2.1)Focus groups (see Section 2.2.3)Key informant interviews (see Section 2.2.1)Focus groups (see Section 2.2.3)22 Families Commission Research Fund

families commission research fund2. METHODS2.1 MeasuresTwo brief measures were developed for this project.A two-page questionnaire was designed to assesswomen’s access to and perception of CBE, as wellas their demographic details. The measure containsquestions on the topics that were covered duringwomen’s antenatal classes and the extent towhich women felt that antenatal classes helped themto prepare for childbirth and to be a good parent(see Appendix 1 for a copy of the questionnaire forwomen). Before it was distributed throughNew Zealand maternity facilities, it was piloted withtwo small groups of women (nine women in total)who were attending antenatal classes in Auckland.The two groups were facilitated by the same childbirtheducator but one class was run through Birthcareand the other was run through Parents Centres. Thechildbirth educator handed the questionnaires outto women at the beginning of a class, collectedthem back when women had completed them andposted them back to the project manager. Thequestionnaire took about five minutes for womento complete and the piloting resulted in a coupleof minor wording and formatting changesto the questionnaire.The second measure, also two pages, wasdeveloped for CBE providers in order to learn moreabout the CBE service that they offer.This measure includes questions on the number ofcourses providers are contracted to deliver per year,whether classes are designed for a particularpopulation group, whether classes are based on thenational service specifications for pregnancy andparenting information and several other questionsabout the quality and content of the courses offered(see Appendix 2 for a copy of theprovider questionnaire).2.2 Participants and procedureThere were seven main methods used to answer the30 research questions. These were key informantinterviews, contact with each DHB, focus groupswith women, a brief questionnaire to women, a briefquestionnaire to CBE providers, accessing the Plunketdatabase and a literature review.2.2.1 Key informant interviewsKey informant interviews were conducted with eightrepresentatives from the key stakeholder organisations(listed under Section 1.2). Parents Centres suggestedthe initial list of key informants, which was expandedslightly as other key stakeholders were recommended.Each key informant held a senior position in theirorganisation and was selected for their relevantexperience in the maternity or Well Child sector.Each key informant was contacted by email or phoneto arrange an appointment time. Each interview wasstructured around a list of 20 research questions (seeAppendix 3 for a list of the questions asked in each keyinformant interview) and typically lasted for just overone hour. Because of differing areas of expertise (andtime constraints), not all questions were covered withall key informants. All interviews were recorded, latertransferred to computer and then transcribed using‘Express Scribe’ software.2.2.2 Contact with each DHBAs part of an environmental scan, each of the 21DHBs was contacted by phone and email to name theCBE and Well Child providers with whom they holdcontracts. A list was developed to keep track of thetelephone or email contact history with each DHB. Onaverage, six telephone or email contacts were initiatedwith each DHB (range = 2–18 contacts) before theinformation requested was received. In most cases, itwas the funding and contract managers who providedinformation on the CBE and Well Child providers withwhom their DHB held contracts.2.2.3 Focus groupsFocus groups were held to determine women’sexperiences and satisfaction with antenatal educationand the transitions between different providers of care.To be eligible to participate in a focus group, womenhad to be pregnant or have given birth within thelast six months. This was to ensure they had recentexperience with the maternity system or Well Childcare. Within these constraints, the aim was to includeas wide a variety of women in the groups as possible,including women who had attended (or were attending)antenatal classes, women who had not attendedantenatal classes, women from different cultural groupsand women from more disadvantaged circumstances.Women were recruited through all providers ofantenatal education and Well Child services inchildbirth education: antenatal education and transitions of maternity care in new zealand23

Wellington. Providers were found by talking to contactsat Capital and Coast DHB and Hutt Valley DHB. CBEproviders included:> Parents Centres New Zealand Inc> Wellington South Parents Centre> Wellington North Parents Centre> Kapiti Parents Centre> Mana Parents Centre> Lower Hutt Parents Centre> Upper Hutt Parents Centre> MATPRO (Wellington Maternity Project)> Hutt Valley DHB Provider Arm (hospital maternityservices with classes run by Birth Ed.).Well Child providers included:> Plunket> Te Rünanga O Toa Rangatira – Ora Toa HealthUnit, Porirua> Ati Awa ki Whakarongotai Inc – Hora Te Pai HealthServices, Paraparaumu> Maraeroa Marae Health Clinic, Porirua> Te Runanganui O Taranaki – Waiwhetu MedicalCentre, Lower Hutt> Pacific Health Service, Hutt Valley> Pacific Health Service, Strathmore.Next, six venues suitable for focus groups were bookedfor different locations around Wellington: PlunketRooms, Plimmerton; Johnsonville Community Centre;Waiwhetu Uniting Church, Lower Hutt; Rongotai FamilyCentre, Lyall Bay; Lower Hutt Family Centre; andHorouta Marae, Porirua. Four of these were booked for10:30–12:00pm during the day and the other two werebooked for 7:00–8:30pm in the evening.A targeted recruitment strategy was used to ensurethat women from different cultural groups and womenfrom disadvantaged backgrounds were represented inthe focus groups. Steps taken to increase the diversityof women represented in the focus groups includedrecruiting women through Mäori and Pacific WellChild providers; recruiting women through Plunket,who agreed to target women living in areas of highdeprivation; holding focus groups at sites where moresocio-economically disadvantaged women meet;following up several refugee women individually toobtain their views on the maternity and Well Childsystem; and providing an option for women who mightbe uncomfortable expressing themselves in a groupcontext to participate in a one-on-one interview instead.A letter inviting women to take part in the focus groupsand an accompanying information sheet (Appendix4) were distributed to CBE and Well Child providers.The letter explained the purpose of the project andinvited women to contact the project manager by phoneor email if they were willing to participate in a focusgroup about their maternity experiences. The letteremphasised that the discussion would be relaxed andwomen could say as little or as much as they liked. Italso informed women that they would be offered tea,coffee, something to eat and a voucher for a free packof Huggies nappies if they participated. The letter alsomade it clear that partners and other family or whänauwere welcome to participate and gave women theoption of talking one-on-one with the project manager ifthey preferred to discuss their experiences in private.The recruitment strategy used was slightly differentfor each provider. For Parents Centres, the letter andinformation sheet were emailed to several hundredwomen from the Parents Centre databases. Thenational body, Parents Centres New Zealand Inc,also included information about the focus groups intheir newsletter. The only Parents Centre that did nottake part was Upper Hutt Parents Centre. By the timeconsent was gained to distribute the letters to womenon their database, the focus groups were already fullybooked with women who had been recruited throughother providers. For the other two Wellington-basedproviders of CBE classes, MATPRO and Hutt ValleyDHB Provider Arm, the letter and information sheetwere photocopied and posted to childbirth educatorswho ran the classes, so that they could be handedout to women attending the antenatal classes. Fifteencopies were sent to MATPRO and 56 copies were sentto Hutt Valley DHB Provider Arm.For Plunket, a meeting was held at the Lower Hutt AreaOffice with the operations manager (for the Wellingtonregion) and several clinical leaders to explain theproject and agree on a recruitment strategy. In orderto achieve greater diversity of women within the focusgroups, Plunket agreed to target women living inhigh deprivation areas, including Taita, Naenae andNewtown, where a group of refugee women lived. Onehundred copies of the letter and information sheet wereleft with the clinical leaders who then distributed them24 Families Commission Research Fund

families commission research fundto Plunket nurses working in the agreed areas. Plunketnurses then handed the invitations out to individualwomen during their Plunket visits. To achieve betterrecruitment rates for disadvantaged women living inTaita, the Plunket nurse organised a separate (seventh)focus group to be held during the day (10:30am–12:00pm) at the Plunket rooms at Taita CommunityCentre, where women regularly attend for Well Childchecks. In order to include the views of refugee women,Plunket organised for the project manager to visit aplaygroup being held at a block of flats at Newtown.The project manager subsequently followed up withfour African refugee women individually.For Ora Toa Health Unit, the procedure involvedgaining permission from the CEO of their organisationand their Clinical Advisory Committee. After the ClinicalAdvisory Committee granted permission, their TamarikiOra nurse organised for Mäori women who attendedtheir service to participate in a separate (eighth) focusgroup to be held during the day (10:30am–12:00pm) atthe Ora Toa Health Unit, Porirua.For the three other Mäori Well Child providers,discussions were held with Tamariki Ora nurses(from Hora Te Pai Health Services and MaraeraoMarae Health Clinic) and the team leader, a GP (fromWaiwhetu Medicial Centre), who all agreed to invitewomen who attended their service to participate in oneof the focus groups.For the Pacific Health service at Hutt Valley,discussions were held with one of their clinicians whoorganised for Pacific women and two staff members toattend the focus group at Waiwhetu Uniting Church,which had been reserved specifically for Pacificwomen. For the Pacific Health service at Strathmore,a meeting was organised with their practice nurse whoprovided in-depth information about Pacific maternitypractices and agreed to find Pacific women to contactthe project manager for one-on-one interviews.The recruitment strategy resulted in 98 people (96women and two men) volunteering to participate ina focus group. Of these, 56 (including the two men)ended up participating in a focus group, 12 wereinterviewed individually and two responded by sendingthe project manager detailed emails about theirmaternity experiences. Of the 28 who did not end upparticipating, the majority (23) declined because therewas not a focus group being held at a time that wasconvenient for them. The other five initially indicatedtheir interest, but when they were emailed possiblefocus group times and venues, did not respondany further.When interested women made contact with the projectmanager, they were informed of the list of venues,times and dates and asked to select the focus groupoption that suited them best. A letter confirming thetime, date and venue of their preferred focus groupwas then emailed to each participant. One to two daysbefore each focus group, all enrolled women weretelephoned to remind them about the group and checkthat they still intended to participate. Each focus groupwas structured around a list of 10 research questions(Appendix 5) and typically lasted for 1.5 hours. Allfocus groups were recorded and transcribed.Eight focus groups were held in total, all during May2007. Five of the groups were made up of womenrecruited through Parents Centres, MATPRO or HuttValley DHB Provider Arm (the three CBE providers inWellington). One focus group was specifically forMäori women (organised through and held at Ora ToaHealth Unit, Porirua); one focus group was for Pacificwomen (organised through Pacific Health Servicesand held at Waiwhetu Uniting Church, Lower Hutt);and a third focus group was held in an area of highdeprivation (organised through Plunket and held atPlunket Rooms, Taita Community Centre). Each focusgroup included between four and 12 participants. Inthe three more disadvantaged groups, a staff memberwith whom the women were familiar also sat in on thefocus group.Table 2 shows the demographic characteristics of focusgroup participants. The women’s mean age was 32.7years and the majority (70 percent) were primiparous.Sixty-eight percent were New Zealand European, sevenpercent Mäori and nine percent of Pacific Island origin.The women who participated in focus groups weremostly married or in de facto relationships (88 percent),had high educational qualifications (80 percent withat least a tertiary degree) and were on good incomes(73 percent on $60,000 per annum or higher). The 12women who were interviewed individually had a similarmean age, but were of lower socio-economic statusthan focus group participants. Half of the women whowere interviewed individually were not of New ZealandEuropean ethnicity – four were refugees from Africa,one was Mäori and one was Tongan.childbirth education: antenatal education and transitions of maternity care in new zealand25

TABLE 2. Demographic characteristics of focusgroup participants (N = 56).Demographic characteristics % (n)ParityPrimiparousMultiparousNot answeredFamily structureMarriedDe factoSingleStepfamily marriedStepfamily de factoOtherNot answeredHighest educational qualificationNo qualificationsFifth Form CertificateSixth Form CertificateNZ Higher School CertificateTertiary degree (1–4 years)Master’s/doctorateNot answeredEthnic groupNew Zealand EuropeanMäoriSamoanCook Island MäoriTonganNiueanChineseIndianOtherNot answeredTotal household income per yearbefore taxUnder $15,000$15,001 to $20,000$20,001 to $25,000$25,001 to $30,000$30,001 to $35,000$35,001 to $40,000$40,001 to $50,000$50,001 to $60,000$60,001 to $70,000$70,001 to $100,000$100,001 or moreNot answered69.628.61.866.121.41.80.01.85.43.63.60.05.47.167.912.53.667.97.11.81.83.61.81.80.012.51.81.81.83.61.80.03.63.63.614.326.832.17.1Mean39161371210132203438723841121107111210222815184Age (N = 55) 32.73 4.97SD2.2.4 Brief questionnaire to womenFor a one-month period in 2007, women who gavebirth in New Zealand hospitals were asked to completea brief questionnaire, developed specifically forthis project (Section 2.1). The questionnaires weredistributed between May and June 2007, depending onwhen DHBs agreed to participate in the project. EachDHB was contacted to gain permission to distributethe questionnaire to all the maternity facilities in theirregion. In the first instance, the project manager askedto speak to the communications manager of each DHBand was typically re-directed to discuss the requestwith the midwife or maternity manager. Informationspecifically sought from the midwife managersincluded information on the maternity facilities in theDHB region; the number of births expected in thenext month; and the name and contact details of theperson who would take responsibility for distributingthe questionnaires. Seven DHBs required the requestto go through an official process to obtain approvalfrom an executive, ethics or Mäori committee, or aclinical midwifery group. The contact history witheach DHB was recorded. On average, 11 telephone oremail contacts were initiated with each DHB (range =4–26 contacts) before the information requested wasreceived. All DHBs ended up giving permission for thequestionnaire to be distributed.On the basis of 2003 figures, it was estimated that over4,500 women in New Zealand would give birth over aone-month period. It was expected that a response rateof between 15 and 30 percent would yield between675 and 1,350 completed questionnaires, providinga sufficiently robust sample size to determine theproportion of women attending antenatal classes andtheir demographics.In total, 5,821 questionnaires and information sheets(Appendix 1 questionnaire and Appendix 6 informationsheet) were posted to DHBs to be distributed throughtheir maternity facilities. For many DHBs, there was adifferent contact person for each maternity facility. SeeAppendix 7 for a list of hospital and maternity facilitiesthrough which the questionnaire was distributed. Thepackage of questionnaires and information sheetswas accompanied by a cover letter that confirmed thenumber of questionnaires in the package; requestedthat questionnaires be distributed to women who hadjust given birth in maternity facilities in the region;explained that the questionnaires and information26 Families Commission Research Fund

families commission research fundsheets had been folded into the reply-paid envelopes tomake distribution easier (only one thing to hand out);and requested that the LMC or midwife handing out thereply-paid envelopes bring the questionnaire inside tothe women’s attention. It also gave the start and enddate for distributing the questionnaires; explained thatif they started distributing the questionnaires later thanexpected then they should also extend the end dateaccordingly so that questionnaires were distributed forone full month; and mentioned that if questionnairescould also be distributed to women who had homebirths, then that would be a bonus.About two weeks after the questionnaires were postedto the DHB to begin distribution, each DHB or maternityfacility was contacted again to check that the relevantmanagers at each maternity facility had received copiesof the questionnaire and information sheet to distribute;that distribution had begun; the method by which thequestionnaire was being distributed; the maternityfacilities through which the questionnaire was beingdistributed; and that the person handing out the replypaidenvelopes was bringing the questionnaire inside towomen’s attention.Maternity facilities used several different methods todistribute the questionnaire, including inserting it intothe Well Child booklet, handing it out with the BountyPack, handing it out with birth registration papers andhanding it out on its own. Women were instructed tocomplete the questionnaire and return it in the replypaidenvelope supplied.A total of 878 completed questionnaires were returnedvia reply-paid post, representing a response rate of 15percent. This figure is a conservative estimate of theresponse rate, because many DHBs over estimatedthe number of questionnaires needed for the month toensure they did not run out. On the basis of the numberof unused questionnaires returned to the projectmanager, and the difference between the number ofexpected births (4,500) and number of questionnairessent to DHBs to distribute (5,821), it is estimated thatat least 15 percent of the questionnaires posted toDHBs were surplus and therefore never handed out towomen. Assuming that, on average, each DHBrequested 15 percent more questionnaires thanneeded, it is likely that closer to 4,948 questionnaireswere handed out to women. The true response rate istherefore likely to be over 18 percent. Unfortunately,after the questionnaires had been handed out, therewas no way of reminding women to complete themand the budget prohibited any real incentive beingoffered to women to return them. The lack of follow-up,coupled with the chaotic period that families are usuallyfaced with after the birth of a baby, makes the lowresponse rate unsurprising.Table 3 presents the demographic characteristicsof women who completed and returned theirquestionnaire. The women’s mean age was 31 yearsand roughly half (49 percent) were primiparous. Thewomen tended to be married (65 percent), with justover half (53 percent) having completed a tertiarydegree or higher. Forty-nine percent were on incomesof $60,000 per annum or higher. The majority ofwomen (69 percent) were of New Zealand Europeanethnicity, 14 percent of respondents were Mäori andtwo percent were of Pacific Island ethnicity. Mäori andPacific peoples were therefore underrepresented inthe sample of women who completed questionnairesrelative to their proportion in the total population ofchildbearing women. In 2004, births to Mäori andPacific mothers accounted for 19.9 percent and 10.1percent of all births respectively. 1The number of questionnaires returned from eachregion reflects both the population size of the region(and therefore the number of women giving birth)and the consistency of the approach used by eachDHB to ensure women received the questionnaires.In general, more questionnaires were returned fromthe larger regional centres, including Auckland(N = 95), Capital and Coast (N = 88), and Canterbury(N = 113). Two other DHB regions that had relativelyhigh numbers of returned questionnaires were Waikato(N = 82) and Bay of Plenty (N = 68). Just over half ofthe questionnaires (50.7 percent) were returned fromthese five regions.childbirth education: antenatal education and transitions of maternity care in new zealand27

TABLE 3. Demographic characteristics of womenwho completed questionnaires (N = 878)Demographic characteristics Total N = 878ParityPrimiparousMultiparousNot answeredFamily structureMarriedDe factoSingleStepfamily marriedStepfamily de factoOtherNot answeredHighest educationalqualificationNo qualificationsFifth Form CertificateSixth Form CertificateNZ Higher School CertificateTertiary degree (1–4 years)Master’s/doctorateNot answeredEthnic groupNew Zealand EuropeanMäoriSamoanCook Island MäoriTonganNiueanChineseIndianOtherNot answeredTotal household income peryear before taxUnder $15,000$15,001 to $20,000$20,001 to $25,000$25,001 to $30,000$30,001 to $35,00049.250.80.064.725.13.60.71.03.31.68.410.914.610.746.96.22.369.414.10.70.70.30.32.61.89.50.6% n2.53.12.24.35.24324460568220326929147496128944125420609124663323168352227193846$35,001 to $40,000$40,001 to $50,000$50,001 to $60,000$60,001 to $70,000$70,001 to $100,000$100,001 or moreNot answeredDHB regionNorthlandWaitemataAucklandCounties ManukauBay of PlentyWaikatoTairawhitiTaranakiLakesHawkes BayMidCentralWhanganuiCapital and CoastHutt ValleyWairarapaNelson-MarlboroughCanterburySouth CanterburyWest CoastOtagoSouthlandNot answered6.510.79.612.818.118.07.14.44.810.83.07.79.31.12.83.54.14.12.610.02.30.30.712.91.60.24.63.95.157948411215915862394295266882102531363623882036113142403445Mean 50Age (N = 802) 31.12 5.842.2.5 Brief questionnaire to CBE providersAll CBE providers who held contracts with DHBs andas many non-contracted providers as possible werecontacted via email, letter or phone and asked toparticipate in research about CBE services inNew Zealand. Providers were sent a questionnaireand were offered a telephone number and emailaddress to contact in the event they preferred tocomplete the survey via phone.Given that providers of antenatal education are notcentralised and that there is no formal registrationboard for such providers, it was difficult to track downall CBE providers, particularly the ones who did nothold contracts with DHBs. CBE providers who held28 Families Commission Research Fund

families commission research fundcontracts with DHBs were contacted through thefunding and contract managers in each DHB.Several methods were employed to find CBE providerswho did not hold a DHB contract. Firstly, the finalquestion of the survey (Appendix 2) asked participantsto list any other providers known to themin their area (who did not hold a DHB contract).Twenty-eight participants responded either that they didnot know of other providers in their area or that, to thebest of their knowledge, there were no other providers.Eight participants named Parents Centres. Theremaining participants left this question blank.Additional methods used to find providers not holdingDHB contracts included web searches, a Yellow Pagessearch, using a list of CBE providers developed by theHealth Funding Authority in 2000 2 and following upleads obtained during telephone conversations withproviders and with representatives of other relatedorganisations. The providers identified using theseadditional methods were also contacted and askedto complete the questionnaire about the service theyoffered. See Appendix 8 for a list of contracted andnon-contracted CBE providers.In total, 64 providers were sent the providerquestionnaire. Given the relatively high numberof Parents Centres and Plunket providers acrossthe country and the expected homogeneity in CBEcourses offered by the same provider in differentlocations, only one questionnaire was given to thenational offices of each organisation. Providers whodid not return the completed questionnaire by therequested due date were phoned and given the optionof answering the questions over the phone instead.Most providers declined the phone interview option andsaid they would return the completed questionnairevia email. Providers were contacted up to four timesto remind them to return the questionnaire. Thirtyeightcontracted providers and seven non-contractedproviders returned the survey, yielding a total responserate of 70 percent.2.2.6 Accessing the Plunket databaseA final step involved obtaining permission from Plunketto access their database. This was done to determinethe demographics of women and families and whänauwho access Plunket services. A request was made toextract the relevant data, and this was sent in summaryformat to the project manager.2.2.7 Literature reviewA comprehensive literature review was also conductedon the evidence for the effectiveness of antenataleducation on a range of outcomes related to pregnancy,birth, early parenting and specific population groups.The companion review (p.129) focused on thelast 10 years’ worth of publications (1997–2007)and involved searching four databases: PsycINFO;PubMed; Cinahl; and the Cochrane Library. Over 500articles were determined to be relevant to the review,including descriptive studies, cross-sectional studies,pretest-posttest designs with no control group, quasiexperimentalstudies (control or comparison grouppresent but participants not randomly assigned togroups), randomised controlled trials and systematicreviews. Sixty-seven specifically examined whether theoutcomes of interest varied as a function of attendanceat group antenatal classes. The literature review hasimplications for the future content and format ofantenatal classes and for the facilitators of classes. Thecurrent paper also highlights and utilises informationfrom several New Zealand reports that are vital to thematernity and Well Child scene (Section 1.5).2.3 Confidentiality and ethicalconsiderationsEthics approval was sought and obtained from Plunket(for the whole study) and from the Ministry of Health’sMulti-region Ethics Committee (for the questionnairesto be distributed to women through hospital facilities).All participants, including key informants, women (andtwo men) in focus groups, women who completedthe questionnaire, and CBE providers who completedthe questionnaire were informed that the informationcollected was confidential and that they would notbe individually identified in the final report. Thequestionnaire completed by women was totallyanonymous. All questionnaire data were entered in adepersonalised manner.Information sheets about the focus groups andquestionnaire for women (Appendices 4 and 6) madeit clear that declining to participate in the researchwould not affect the service provided to women or theirbabies in any way. The research outcomes will be madeavailable to participants to view at any time through theParenting Council or Families Commission, who will holdcopies of the final report for this purpose.childbirth education: antenatal education and transitions of maternity care in new zealand29

2.4 AnalysesQualitative analyses were used for the key informantinterviews and focus groups to gain an in-depthunderstanding of stakeholders’ and women’s perceptionsof antenatal education, Well Child services and thetransitions between different providers. Transcribed keyinformant and focus group data were categorised intothemes that represented each of the research questions.Quotes have been used in the results section to illustratethe ideas that emerged under each theme or researchquestion. Interview data collected from key informantswere compared with focus group data collected fromwomen to facilitate understanding of the gaps betweenthe support that services aim to provide and whatactually happens in practice.Quantitative analyses were used for the questionnairedata from women and CBE providers. Descriptivestatistics were used to summarise the demographiccharacteristics of focus group participants andwomen who completed the questionnaire. Inferentialstatistics were used to determine whether theorganisation through which mothers attended antenatalclasses was related to mothers’ perceptions of theeffectiveness of classes in preparing them for childbirthor parenthood; and the best predictors of attendanceat antenatal education programmes. The results of themultivariate analysis of variance (MANOVA),used for the first analysis above, are expressed asmeans and standard deviations. The results of thelogistic regression analysis, used for the secondanalysis, are expressed as odds ratios (ORs) and 95percent confidence intervals. The significance levelwas set at the conventional p < .05 (two-tailed)for all analyses. These analyses are described in moredetail under the relevant sections (3.3.6 and 3.3.9).30 Families Commission Research Fund

families commission research fund3. RESULTS: ANSWERS TORESEARCH QUESTIONS3.1 Antenatal care3.1.1 What proportion of women have a leadmaternity carer (LMC)?The survey of women revealed that 97.8 percent(N = 859) of women reported having an LMC for thebaby they had just given birth to. For primiparouswomen (first-time mothers), the percentage was 98.8percent (N = 427), and for multiparous women thepercentage who reported having an LMC was 97.1percent (N = 433). These figures are comparable tothose reported in the Report on Maternity: Maternaland newborn information 2004, 1 which suggestthat 98.8 percent of mothers in 2004 had an LMCregistered to provide them with care (and only 1.3percent did not). The proportion of women who registerwith an LMC may be increasing over time. In 2003,the proportion of women who registered with an LMCwas 93 percent.The proportion of women with an LMC is alsorelated to their stage of pregnancy. Data on utilisationrates of LMC services reported in 2000 in MaternityServices: A reference document 2 showed that virtuallyall women received a single service episode in theirfirst trimester (rates of claimed single service episodeswere actually greater than 100 percent of deliveries,but this is due to miscarriages and abortions). LMCcare was provided to 80 percent of women in theirsecond trimester and to 95 percent of women in theirthird trimester. The number of LMC home visits isrelated to ethnicity. Despite Mäori women being morelikely to have clinical risk factors, on average theyregister later with an LMC and have fewer antenatal(and postnatal) domiciliary midwifery visits thannon-Mäori. 2Despite the majority of women registering with anLMC, there seems to be a shortage of midwives toprovide LMC care. The latest Maternity ServicesConsumer Satisfaction Survey 14 shows that, in 2007,close to one in five women (19 percent) found itdifficult to find an LMC to provide care for them,compared with 11 percent in 2002. The main reasonsthat women gave for the difficulty in finding an LMCwere that midwives were too busy or that there was ashortage of midwives in the area.These results are consistent with focus groupresponses. Many women in the focus groups reportedhaving to make numerous phone calls in the searchfor a midwife. It was not uncommon for women toreport making 10–15 calls before giving up andbeing told to go through the hospital system (ie, usehospital midwives) instead. Some women had to makecompromises (in their choice of LMC or hospital) tosecure an LMC.Five months it was before I got a midwife.I had one [an LMC] at eight weeks because Iknew there was a problem [in finding a midwife inWellington].It’s just a joke in the books and they say, youknow, interview, you know, LMCs [first participant].There just aren’t enough available to do that[second participant].Well I rang. A few of them didn’t even come backto me which I thought was very rude. I think theyshould at least come back and say ‘Look I’m sorry’and then when I got the list I phoned some 0800number and got a list of ones in the area and all ofthem had like, pagers apart from the one I got, andshe had a mobile number.It took us three weeks to actually get somebodyto ring us. So okay, we’ve got one, so as if you’regoing to let that one go. I mean thankfully she wasgreat, she’s been fabulous but if you didn’t get onwith her then what would your option be, not haveone or…I couldn’t get a midwife because there’s notenough and that’s one of the reasons why I’m heretonight because I really wanted to voice that. Like Ihad a miscarriage first and then I had my babyand both times when I tried to get myself amidwife I couldn’t get one and I was ringing at sixweeks pregnant to try to get a midwife so it wasn’tlike I was leaving it to the last minute.It was a nightmare finding a midwife.I phoned 14 [midwives] and only three returned mycall to say they couldn’t take me.childbirth education: antenatal education and transitions of maternity care in new zealand31

While women were generally happy with the servicethey received from hospital midwives, the hospitalservice would be likely to decrease the continuity ofcare given to women, since women do not necessarilysee the same midwife at each visit. This is potentiallyproblematic because continuity of care has been shownto have benefits. In particular, women with continuityof care are more likely to attend antenatal educationprogrammes and less likely to use drugs for pain reliefduring labour. 153.1.2 What proportion of LMCs are GPs, midwivesor obstetricians?The majority of LMC care in New Zealand isperformed by midwives but GPs and obstetricians alsoprovide this service. Table 4 is from the Report onMaternity: Maternal and newborn information 2004 1and shows the percentage of women who hada midwife, GP or obstetrician as their LMC, both atfirst registration and at birth, in 2004.TABLE 4. Proportion of women registered with anLMC at first registration and at time of delivery, byLMC type, 2004LMC typeAt firstregistrationAt delivery% (n) % (n)Midwife 75.3 (33,482) 75.9 (33,482)Generalpractitioner5.6 (2,504) 4.5 (2,505)Obstetrician 6.1 (2,727) 6.0 (2,680)Other/unknownLMC types5.5 (2,445) 5.5 (2,463)Not stated 7.4 (3,297) 8.0 (3,567)Total 100 (44,455) 100 (44,430)Source: Report on Maternity: Maternal and newborninformation 2004. 1Table 4 shows that when women first register with anLMC, 75.3 percent of LMCs are midwives, 5.6 percentare GPs and 6.1 percent are obstetricians. The maindifference at delivery is that the proportion of LMCswho are GPs decreases to 4.5 percent. Close to 13percent of LMCs are of unknown type or not statedby women.3.2 Transition between LMCand CBE3.2.1 What proportion of LMCs refer womenand their families and whänau to CBE?This question is not about one provider transferringcare to another. Rather, LMCs and childbirth educatorsare expected to work together and it is usual thatwomen participating in antenatal classes will haveappointments with their LMC during this same period.Therefore, this question is about the interface betweenLMC and CBE and, in particular, whether LMCsroutinely recommend CBE to their clients. Whether ornot an LMC suggests attendance at antenatal classesmay depend on several factors: particularly the valuethe LMC places on CBE; her beliefs concerning whetherCBE is complementary or provides additive value tothe service she offers; and her perception of the matchbetween her client’s needs, wants or culture and whatshe believes CBE will offer. If LMCs are supportive ofwomen attending antenatal classes, it makes intuitivesense, and there is overseas evidence to suggest thatwomen are more likely to attend them. 16When key informants were asked to estimate theproportion of LMCs who refer their clients to CBE,there was a range of responses, depending on theorganisational background of the key informant. Onesuggested that all LMCs would discuss with womentheir options for CBE. Another suggested that less than50 percent of women would have CBE recommendedto them.I would say that it is less than 50 percent. I wouldsay that the perception out there is that it is morethan 50 percent but in reality, the likelihood is it ispossibly less.These polarised responses obscure the distinctionbetween the proportion of LMCs that refer women toCBE versus the proportion of women who are referredto CBE. It is possible, for example, that the vastmajority of LMCs refer at least some women to CBEclasses. However, when the proportion of pregnantwomen who are referred is examined, the percentagecould be much less, as a result of classes only beingrecommended for particular groups of women. Indeed,one key informant highlighted that primigravidae wouldbe more likely to be referred to CBE than women whohad previously given birth.32 Families Commission Research Fund

families commission research fundWell, I know that it is not reported and there isprobably no data. I could give an educated guessthat every first time-mother would be offered CBE.I would suspect that with subsequent pregnancies,it [CBE] wouldn’t necessarily be given/suggested,mainly because CBE programmes aren’t specificallygeared for second- and further-time mothers, soif, for example, there was an antenatal refresher,and I used to run those, then they [LMCs] wouldrecommend [the woman does the class], but theywouldn’t necessarily recommend to go to a [regular]CBE class.This latter statement from a key informant was themost consistent with survey results. Of the women whocompleted the survey, 58.4 percent (N = 513) reportedthat their LMC had suggested they attend or referredthem to antenatal classes. This figure was much higherfor primiparous mothers (91.7 percent; N = 396) thanfor multiparous mothers (26.2 percent; N = 117).These results suggest that LMCs do recommendantenatal classes to the majority of primigravidae butnot to most women who have previously given birth.3.2.2 What are the contractual arrangementsand obligations of LMCs to refer womento CBE?The contractual obligations of LMCs are outlined inthe Section 88 Maternity Services Notice. 6 Neither theolder nor the revised Notice requires LMCs to referwomen to CBE. There are therefore no contractualarrangements or obligations for LMCs to refer womento or to recommend CBE. There is, however, therequirement that LMCs inform women who are in theirsecond trimester of pregnancy about the availability ofCBE, and that LMCs maintain links with other providersof health services, including providers of antenataleducation. The following clauses from the Section 88Maternity Notice (Gazetted version) illustratethese requirements.Section CB7 (Information about primary maternityservices) (1): A maternity provider must ensure thatevery person who is eligible for primary maternityservices is given the appropriate information on theprimary maternity services that they are entitled toreceive (including their options). (p.1052)Section DA19 (Service specifications for first andsecond trimester) (2a): For a woman in the secondtrimester of pregnancy, the LMC must provide all of thefollowing services:(a) inform the woman regarding –(i) the availability of pregnancy and parentingeducation. (p.1064)Section CB9 (Maternity provider to co-operate withothers in order to promote safe and effective primarymaternity services): A maternity provider must maintaina range of linkages with and co-operate with othermaternity providers, practitioners, and communityagencies to promote safe and effective primarymaternity services. (p.1053)Section DA11 (Linkages with other services): Providersof LMC will also maintain linkages with the followinglocal organisations and providers of health services:(d) antenatal education services. (p.1061)The professional obligations for LMCs are outlined inthe Midwives’ Handbook for Practice. 7 This publicationcontains 10 Standards of Practice for midwives. Severalof the standards allude to LMCs sharing relevantinformation with women (Standards One, Two, Five,Seven and Nine). The handbook also contains a sectionon ‘Decision Points for Midwifery Care’ which outlinesthe range of information to be shared at each majorstage of pregnancy, including health information andeducation. Within the first 16 weeks of pregnancythe LMC should discuss with the woman her choicesfor childbirth and parenting education (p. 26). By 24weeks, the LMC should ensure that women are awareof CBE options (p. 27).Thus, while there are no formal obligations for LMCsto refer women to CBE, they have both contractualand professional obligations to at least inform womenabout the availability of pregnancy and parentinginformation. Despite these obligations, it is clear fromthe findings described in Section 3.2.1 that CBE isnot being suggested to all women. Indeed, two keyinformants questioned whether LMCs’ professionalobligation to inform women about CBE was adheredto, remarking:It [providing information about CBE] is a Standardof Practice and one that is not necessarily observed.If a woman doesn’t know that CBE exists, she mayor may not be informed by the LMC.childbirth education: antenatal education and transitions of maternity care in new zealand33

These key informants were of the view that LMCsshould be formally required to refer women to antenataleducation. On the other hand, one key informant felt itwas enough just to make sure that women were awareof the availability of CBE.You can’t make women go to CBE, but it is theirright to know what their options are.Key informants therefore held different views aboutwhether the current formal obligation of LMCs to informwomen about the availability of CBE goes far enoughtowards maximising women’s participation rates in CBE.3.2.3 What process is used to manage the referralbetween LMC and CBE?All six key informants who were asked this questionagreed that the process used to manage the ‘referral’or interface between LMC and CBE was informal andwould typically involve the LMC having a discussionwith the pregnant woman about whether she hadthought of attending antenatal classes and possibleoptions available in the area. Answers given by keyinformants suggested that it was up to the individualLMC to decide whether or not she recommended aparticular CBE provider.One key informant commented that the maindeterminant of whether an LMC actually recommendedthe mother attend antenatal classes is the relationshipshe has with the local providers of CBE; unsurprisingly,if the relationship is good, the LMC is much more likelyto recommend the mother attend the CBE classesoffered by that particular provider. One of the biggestproviders of antenatal education, Parents Centres,has a Memorandum of Understanding with theNew Zealand College of Midwives (NZCOM), whichwas commented on as providing the basis for a ‘terrific’relationship between the two organisations. Despite agenerally good relationship between LMCs and CBEs,historically there have been tensions between the twogroups. Contributing to the tension is a concern raisedby one key informant that the information given outby LMCs may sometimes conflict with the informationgiven out by CBEs. Another key informant commented:There was quite a lot of tension initially when westarted taking CBE differently, because midwivesdo feel that education is something that they shouldbe involved in, and I accept that, but I think theyare good at giving info, but there is a differencebetween education and information; and thereis probably more acceptance that it is a differentprofession if you like. Unless you are particularlytrained in education, then you probably won’t bea good educator, and because midwives are firstand foremost doing maternity, it’s quite difficult forthem to both acquire and then keep up the skillsthey need to be good educators. Some do it but notmany. They think education is giving information.Three of the key informants specifically suggested thatthere should be a more formal interface between LMCand CBE.It [a more formal referral process between LMCand CBE] would be helpful, particularly becausea lot of them [LMCs] aren’t referring early enoughand classes fill early. But it’s a bit like the handoverto Well Child Care – there has been a lot done totighten it up and improve it.One key informant pointed out that the interfacebetween LMCs and CBEs also involved CBEs informingLMCs about the availability and timing of their classes.One method that had been used to convey thisinformation both to LMCs and pregnant mothers wasposters displayed in hospitals. Another common meansused to inform women of the availability of antenatalclasses is through written information (pamphlets,leaflets, or flyers) received from GPs, LMCs, or hospitals(after women are booked in to give birth). If women areto have a home birth, then Home Birth Aotearoa(HBA) would typically provide information on CBEprovider options.3.3 Childbirth education3.3.1 Who are the providers of CBE?The last comprehensive list of CBE providers canbe found in Appendix 10 of Maternity Services: Areference document, 2 (p. 75). Providers are listedunder each of the four Health Funding Authoritylocalities that existed at the time. The document waspublished in 2000 and is now out of date. An updatedlist of CBE providers by DHB region can be found inAppendix 8 of this report. Providers can be dividedinto those who hold contracts with DHBs and thosewho do not hold contracts, as shown in Appendix 8.On the basis of the number of courses each provider iscontracted to deliver per annum, the biggest provider34 Families Commission Research Fund

families commission research fundof antenatal education across New Zealand is the DHBprovider arms. These services are usually hospitalbasedand may be contracted out to other providerssuch as Birthcare or BirthEd. The second biggestprovider of antenatal education is Parents Centres,who have 54 Centres around New Zealand. Plunket,who have 19 Family Centres throughout New Zealand,also deliver a number of antenatal courses. Providersdiffer across geographical regions. For example, in theAuckland/Waitemata/Counties Manukau region, themain CBE providers are Birthcare, MAMA (Mothers andMidwives Associated) and SAMCL (South AucklandMaternity Care Limited). In the Wellington/Hutt/Poriruaregion, Parents Centres provide most of the courses.Women who are interested in a home birth often accessantenatal education through Home Birth Aotearoa,a national organisation with many local branchesthroughout New Zealand. There are also manyindependent providers of CBE who may or may not holdcontracts with DHBs. These providers are most oftenmidwives, and a small but significant number of themhold membership with Nga Maia, a national collectiveof Mäori midwives who represent the interests ofMäori birthing.It should be noted that the number of CBE courses heldin each DHB region is likely to be underrepresented inAppendix 8. Contracted courses are likely to be underrepresentedbecause when DHBs were asked for thelist of CBE providers with whom they hold contracts,a few did not include their own DHB provider armservices. Non-contracted courses are also likely to beunder-represented because of the difficulty in obtaininga complete list of CBE providers who do not holdcontracts with DHBs.3.3.2 What are the contractual arrangementsand obligations of CBE providers?Only the CBE providers who hold contracts with DHBshave formal contractual obligations. The contractualarrangements and obligations of DHB-fundedCBE providers are outlined in the national servicespecifications for pregnancy and parenting information,published jointly by the Ministry of Health and DHBNZ(on behalf of all DHBs). These service specificationsform the basis of all contracts between DHBs andproviders of antenatal education. Eighty percent(N = 36) of CBE providers reported basing their courseon the national service specifications.The full service specifications for pregnancy andparenting information can be found in Appendix 9, butkey requirements outlined in the specifications include:> length of courses – a minimum of 12 hours> content of course – the content must cover:> access to maternity services> pregnancy care> labour and birth care> care following birth> qualifications of programme co-ordinators –they are ‘preferably’ childbirth educators with arecognised qualification in CBE. Alternatively theymay be midwives or physiotherapists with additionalrecognised qualifications in adult education andcultural awareness and Treaty issues, or he kuiawhare tapu or other respected teachers, recognisedby the respective rünanga> service links – establishing and maintaining linkswith LMCs, maternity facility providers, Well Childproviders, antenatal and postnatal support groups,and Family Start> quality – must be accessible (free, suitable venue,encouraging access by women at risk of adverseoutcomes); acceptable (responsive to individualneeds, resources of good quality); and effective(based on principles of adult learning, contentbased on reputable research, culturally safe)> reporting – number of courses provided.Contracts with DHBs also specify the minimum numberof courses that the CBE provider is expected to deliverover the contract period. Contracted providers may beaudited to ensure they are meeting these requirements.Providers who do not hold contracts with DHBs haveno formal obligations. Out of the seven providers whodid not hold a DHB contract, one based their serviceprovision on the national service specifications, threedid not and three were unsure.3.3.3 What are the minimum qualifications ofchildbirth educators required by differentproviders of CBE?There is only one formal qualification in CBEavailable in New Zealand. This is the CBE certificate ordiploma, offered through Aoraki Polytechnic, in Timaru,South Island.childbirth education: antenatal education and transitions of maternity care in new zealand35

All CBE providers who hold contracts with DHBs arebound by the national service specifications forpregnancy and parenting education to ‘preferably’use childbirth educators with a recognisedqualification in CBE. The service specifications alsoallow that childbirth educators may be midwivesor physiotherapists with additional recognisedqualifications in adult education and cultural awarenessand Treaty issues, or he kuia whare tapu or otherrespected teachers, recognised by the respectiverünanga. The service specifications therefore leaveconsiderable flexibility for providers to use differentfacilitators with a range of skills.Forty percent (N = 18) of CBE providers who returnedthe questionnaire indicated that it was compulsoryfor facilitators of their antenatal classes to hold acertificate or diploma in CBE (offered through AorakiPolytechnic in Timaru). This included 15 of the 38DHB-funded CBE providers and three out of seven ofthe non-DHB-funded providers. For the fournon-DHB-funded providers who indicated that theCBE certificate or diploma qualification was notcompulsory, the facilitators of their classes werereported as being midwives (N = 3), experiencedmothers (N = 1) or ‘other’ (N = 3) (numbers add upto more than four because providers could circlemore than one answer).Interviews with key informants suggested thatParents Centres is the only provider who insists thatthe facilitators of their classes hold a formal CBEqualification, and that, on the whole, there are variouspeople with different qualifications providing CBE,particularly amongst providers who do not hold DHBcontracts. It was reported that there is a limited numberof childbirth educators, particularly in rural areas.In these regions, providers (including some ParentsCentres) rely more on midwives or experiencedmothers to provide CBE. It was pointed out thatanyone can call themself a ‘childbirth educator’,and that unlike most health professionals, childbirtheducators do not have a council or nationalmonitoring body to oversee minimum qualificationsand requirements.The issue of whether childbirth educators shouldhave minimum qualifications was discussed. Two keyinformants felt that facilitators should be requiredto have a specific qualification in CBE.Childbirth educators need to participate in anongoing, comprehensive, professional developmentprogramme. Allowing non-qualified staff to runcourses is like treating the symptom but not thecause. It might improve accessibility of classes butit does not address the lack of funding to supportpractitioners to get the qualification and providea better quality service. If mandating minimumqualifications means decreasing accessibility inthe interim, we should do this in order to increasequality (and with funding, accessibility) in thelong term.Two felt that a specific qualification was not necessary.I mean, I think nowadays, the level of educationand understanding of people is such that actually,to be honest, if you gave that sort of specificationto any normal person, they could probably runthrough it and if they’ve had the experience... It’sthe icing on the cake to be able to get somebodythat’s childbirth-educator qualified, but I certainlyhave hesitations about midwives and people of ahealth profession taking it on; so what I mean is,because that diploma they do, it’s not a degree oranything, I’d hate to see that qualification going outof the reach of the average woman, and so I thinkit is wonderful if local women can be supported todo that, but I don’t think it should be the be-all andend-all.One of the key informants, who thought that a formalqualification need not be a prerequisite, neverthelessfelt that there should be robust monitoring ofchildbirth educators.You shouldn’t have to have a formal qualification.Having said that, I think there is a perfectly validfear of people espousing untrue or unsafe thingsin those classes so I think some monitoring ofminimum standards is appropriate and certainly avery robust system of quality control in terms of acomplaints or some kind of process so if someone isuneasy you’ve got a normalised process of checkingon the person.In summary, there is only one formal qualification inCBE in New Zealand and only 40 percent of providersrequire their facilitators to have it. Opinions regardingwhether the qualification should be compulsory forfacilitators were divided.36 Families Commission Research Fund

families commission research fund3.3.4 How is CBE funded and by whom?There are three main ways in which CBE is funded inNew Zealand: publicly, through DHB provider armsor contracts that other providers hold with DHBs(who receive funding from the Ministry of Health);privately, or fee-for-service, where the provider chargesthe participant to attend the course; or communityfundedthrough charities, philanthropic organisationsor fundraising activities. Of the 45 CBE providers whoreturned questionnaires, 38 (84.4 percent) reportedbeing DHB-funded, five (11.1 percent) fee-for-service(with two of them also receiving some communityfunding) and one provider reported being fullycommunity-funded.One key informant also suggested that the Ministryof Education still funds some CBE courses using acommunity education arrangement through whichCBE classes are offered as night schools. Oneprovider did indeed report receiving funding from theTertiary Education Commission (TEC), which receivesfunding from the Ministry of Education. Only five ofall participating providers (11.1 percent) reportedreceiving funding from more than one source.3.3.5 What information do women and familiesand whänau receive and value as part ofCBE and what resources and booklets aremade available to women?The high-level content that must be included in allDHB-funded CBE courses is outlined in the nationalservice specifications for pregnancy and parentinginformation (Appendix 9). The specifications aim tomove pregnancy and parenting education providersaway from duplicating the individual education thatLMCs are required to provide. 2Each CBE course must cover the following:> access to maternity services> the role of the LMC and otherhealth professionals> information on women’s support networksavailable in the community> the complaints procedure for maternity services> pregnancy care> health promotion during the antenatal period,including the benefits of avoiding smokingand alcohol> pelvic floor and stretching exercises> warning signs during pregnancy> labour and birth care> signs of labour> options available for women in labour and birthing> role of support person> common complications of labour and birth andpossible interventions> care following birth> physical and emotional changes including postnatal depression> self-care for the woman postnatally> early parenting skills> safety of the baby, including prevention of SIDs> the role of Well Child services and how toaccess them.The course content must also comply with the BabyFriendly Hospital Initiative and include:> the benefits of breastfeeding, including nutritional,protective and bonding and health benefits tothe mother> the importance of exclusive breastfeeding for thefirst four to six months> basic breastfeeding management, including theimportance of rooming in, the importance offeeding on demand, how to ensure there is enoughmilk and positioning and attachment.In order to determine the more specific contentincluded in CBE classes and the information receivedor remembered by women, it was considered of interestto calculate the percentage of women who reporteddifferent CBE topics being covered in the classes theyattended. Table 5 lists the range of topics that womenwere asked to consider and the percentage of womenwho indicated the topic had been covered in theclasses they attended.childbirth education: antenatal education and transitions of maternity care in new zealand37

TABLE 5. Percentage of women indicating topicsthat were covered in their antenatal classes(N = 364)Topic % (n)a. The role of the lead maternity carer(LMC) 62.9 229b. Information on women’s supportnetworks available in the community 58.0 211c. The complaints procedure formaternity services 17.3 63d. The effects of smoking on thehealth of mother and baby, andoptions available to help give up 55.2 201e. The effects of alcohol and drugs onthe health of mother and baby, andoptions available to help stop 55.8 203f. Mother’s and baby’s nutritionalneeds during pregnancy 73.4 267g. Screening and diagnostic tests(eg, ultrasounds, HIV, rubella,sugar, rhesus tests, nuchalscreening, amniocentesis) 43.1 157h. Warning signs of ill-health orproblems during pregnancy 65.1 237i. Physical changes during pregnancy(eg, pregnancy discomforts, nauseaand sickness) 76.9 280j. Emotional changes duringpregnancy (eg, tearfulness,mood swings)79.1 288k. Pelvic floor exercises 83.8 305l. Stretching and exercise 68.7 250m. Relaxation skills (eg, breathingawareness, use of massageand touch) 83.8 305n. Signs of labour 95.1 346o. Ways of managing pain during labour 96.2 350p. Description of normal and otherbirthing methods (eg, caesarean) 94.8 345q. Options available to women inlabour and birthing (eg, positionduring labour, drug interventions) 97.0 353r. Risks and benefits of differentbirthing methods 83.5 304s. The benefits of breastfeeding 94.2 343t. The importance of exclusivebreastfeeding for the first six months 75.0 273u. How to breastfeed and/or where togo for help 87.6 319v. Physical changes after birthw. Emotional changes after birth (eg,awareness of postnatal depressionand preventative steps) 83.0 302x. Early days at home (eg, ideas forcoping, tiredness) 69.2 252y. Self-care as a mother (eg, nutrition,exercise) 61.0 222z. Development of appropriatepersonal support 45.9 167aa.Unplanned experiences (eg, sickor premature infant, specialneeds babies) 39.6 144bb. Safety of the baby (eg, how toprevent SIDs – cot death) 77.7 283cc.Early parenting skills (eg, bondingwith baby, engaging with baby) 62.9 229dd. Parenting programme optionsavailable 38.5 140ee.ff.The role of Well Child services andhow to access them 31.0 113Vaccinations and tests after the babyis born 62.1 226gg. Other (please describe) 6.6 2438 Families Commission Research Fund

families commission research fundAs shown in Table 5, the information that womenmost frequently reported being covered in antenatalclasses related to the birth or breastfeeding. Over 90percent of women who had attended antenatal classesindicated that they had covered signs of labour; ways ofmanaging pain during labour; description of normal andother birthing methods; options available to women inlabour and birthing; and the benefits of breastfeeding.A high percentage of women (between 80 and 90percent) also remembered the following topics beingcovered: pelvic floor exercises; relaxation skills; risksand benefits of different birthing methods; how tobreastfeed and where to go for help; and emotionalchanges after birth. The topics that were leastfrequently recalled by women (less than 40 percent)included the complaints procedure for maternityservices, unplanned experiences, parenting programmeoptions available and the role of Well Child services andhow to access them.It was also of interest to determine which topics andinformation or features of CBE women valued mostfrom their classes. The Maternity Services ConsumerSatisfaction Survey 2007 14 included the followingquestion: What were the best things about the(antenatal) classes? The options to choose from wereinformation, social network and inclusion of partner.Although many chose to tick more than one box, 67percent of 1,267 respondents opted for ‘information’,57 percent selected ‘social network’ and 45 percentticked ‘inclusion of partner’.In the current study, focus group participants wereasked to list the most important things that they tookaway or learnt from CBE classes. These three themesconsistently emerged from focus groups as importantbenefits of participation in CBE. Most commonly, socialsupport was raised first.For me it was the contact with people afterwards;meeting other people about to have their first baby.I’d say the social side more than anything else.It’s probably less about what you learn than whoyou meet.I think the best thing I got out of it was the fact that Imet people who were going through the same thingand now we all get together and have coffee.The importance of making social connections throughthe classes was also highlighted by mothers who feltthat the diversity of people attending their groupsprevented them from ‘gelling’ and subsequently offeringsocial support to each other.I really, really wish that if I could turn back theclock, that we had paid [to attend a CBE class]… Ithink, you know, if we got that relationship out of thepeople that were there, then that would have beengreat. But we were quite disappointed because wewere going into it to meet people.A second important theme that emerged was thatwomen felt that CBE classes had helped to getfathers involved.Probably the most important thing [getting thefather involved]; I mean being a body therapistand stuff, I kinda understood what was gonnahappen and I’d read enough but my husband didn’thave a clue so it was really good for him to knowso that when it came to the birthing he was like,didn’t panic. Cause I’m like ‘The last thing I wannabe doing is looking after you!’ He felt a lot morecomfortable afterwards, so...I think for me there was the opportunity for mypartner to get more involved in the pregnancybecause up until that point, well I don’t know aboutyou guys, but my partner is not really into readingbooks. We probably all went away and talked withpeople and read books and thought about what washappening but he kind of didn’t really connect withit until he had that opportunity to talk with otherpeople and that was a really kind of important stepfor us. He sort of finally connected, like ‘Oh thisbaby is going to be mine’, it made it real to him.A third topic consistently raised was the informationlearnt about pain-relief options during labour.Yes, and options for pain relief, and even if youthink you’re gonna be hard-core and not haveanything [pain relief] you still need to know what’savailable, you really don’t wanna find that out atthe time…...but things like breathing and the exercises, mindexercises really and breathing for your early parts ofyour labour to get your mind off what’s sore downchildbirth education: antenatal education and transitions of maternity care in new zealand39

there because there’s, you know, pethadene and allthat sort of stuff, yeah great…They were pretty real about the pain, they werepretty real about what epidurals do and what thisdoes ... I had a natural birth, so from that point ofview it was nice to know about the other drugsthat were available and what was good and whatwasn’t good.Women reported that knowing what to expect duringlabour and afterwards gave them confidence.But yeah, it’s about knowledge about what’s actuallygoing to happen. Really big. That made me relax alot more.Yes, just knowing what was going to happen.Another aspect of some CBE classes that was raisedas being very useful was having someone who hadrecently had a baby come and speak to the class abouttheir early experiences at home.That [having someone who had actually had theirbaby, talk to the class] was probably the best.…they had a session where I think they had um,a new dad came along and talked about what hisexperiences were [first participant]. Yeah, that’s right[second participant]. That was good [third participant].We got to ask new parents questions; they broughttheir babies in. It helped to normalise that thingsdidn’t always go according to plan.There were a few topics that participants said werenot discussed enough during classes or that werenot particularly helpful. A general theme emergedthat while women understood the importance ofbreastfeeding, many women had struggled with it andthey found the lack of information provided on bottlefeedingvery frustrating.At our first big catch-up after we’d had the babiesevery single person there had used the bottle, atsome stage ... for some of us it meant going out lateat night and buying bottles, and you know working itout ourselves and working out how to use sterilisersand stuff, it would have been nice just to havesomeone to show it, you know.It was a total nightmare! ... the Family Centre herewas awesome .... I think, I don’t know whether I feltparticularly guilty about it, actually ... I didBirth Wise which is fully focused on naturalbirthing which was awesome and I came out ofit feeling really positive. But also the night onbreastfeeding was like ‘never give your baby formulaand soon as you top your baby up, it’s all bad’ and Iactually made some really bad decisions. I shouldhave read a little bit more about the other side... [baby’s name] got a bit sick and ended up inneonates for a while’ cause he was completelydehydrated, so...I asked a couple of questions to say ‘Well, what’sthe story with bottles?’ and how and, you know,‘What about formula?’ and ‘What’s the good wayto choose a formula?’ because there were two orthree of the girls, including me, who were interestedbecause there was one, for example, with invertednipples and she could not breastfeed; she can’t; itjust won’t work ... and we got very little informationout and it felt like we, kind of, you know, werepulling it out of her.In fact it’s something that our class found and mostof us did end up being able to breastfeed, but weactually, what’s the word? – resented the amountof pro-breastfeeding and the lack of informationabout where you could go for support if you can’tbreastfeed, or what sort of formula should you get,or what should you do.A related complaint expressed by women was thatantenatal classes prepared them well for a naturalchildbirth but not so well for the unexpected oralternative interventions, such as assisted birthsor caesareans.It didn’t really prepare you if you didn’t have anatural birth. Well it did and it didn’t. It just madeyou feel guilty if you didn’t have a natural birth. Itmade you feel guilty if you didn’t breastfeed.I think maybe if they, like I found physically it wasall fine having a caesarean but emotionally maybeit would have been nice just to have a wee talkabout how it’s alright if you don’t end up havinga natural birth.I had lots of things happen that I didn’t expect, thatweren’t talked about in class.I don’t think classes should scare women, butthey need to help women prepare better for these[unexpected] experiences.40 Families Commission Research Fund

families commission research fundThis view, however, was not shared by all thewomen. Some thought that their classes had coveredintervention options in sufficient detail.We had, we were split into groups and each groupwas given one type of intervention to investigate andto report back to the group on, and I found that itwas sufficient … We covered all different outcomes.A topic that was reported as not being particularlyuseful was nutrition. It was not the nutrition contentper se that women viewed as not useful, but rather thetiming of the content. This is because information onnutrition is most relevant early in pregnancy and themajority of women were completing antenatal classeslate in their pregnancies.We did our first or second session on nutrition andthings you shouldn’t be eating and we all found thatactually we had all been given the pamphlet andwe’d all been following this, but probably by thatstage about seven months.We’re all eight months pregnant or whatever it was,I think it is a bit too late to start telling us what Ishould have done, this kind of stuff.Some people were shocked by what they weren’tsupposed to eat.A topic that women felt should have been given morediscussion time during classes was parenting after thebirth of the baby.A bit more in-depth focus on not just the birthbecause so much of that nine months right afteris birth, birth, birth, birth, birth, and that’s only 12hours, or whatever, really, and then you’ve got thenext however months floundering around trying towork out how on earth you do this job.Yes, I mean women have been having babies in thefield for centuries and they tend to survive. I just,you know, going on, it was like weeks of talkingabout pain and the actual labour process and,content-wise, I would have been more interestedin the early development and early process of babyand how many times you can probably expect aone-week-old or two-week-old baby to be waking upand what do you do and what’s normal, what’s not.Those kinds of things.More time should be spent on what happenspostnatally, caring for the baby, and informationthat makes you feel more confident as a mother.There is only so much that you can do to preparefor the birth itself, but you can do more to preparefor after the birth.This finding is consistent with women’s qualitativecomments on the Maternity Services ConsumerSatisfaction Survey 2007. 14 Many women commentedthat they would have liked antenatal classes to preparethem better for the first weeks of parenting. Similarly,anecdotal evidence from key informants suggested thatwhen women are asked to evaluate their CBE classesafter the baby is born, they often comment that moreinformation on parenting was needed.One key informant made the point that the informationgiven by providers and received by women duringantenatal classes depended on participants’ receptivityto different topics.The age-old thing related back to what I said earlier.People take in knowledge when they are in aposition to receive it. That’s why I’m very scepticalabout postnatal evaluation of childbirth educationcourses because once they [new parents] enter theparenting bit they think ‘You should have … Whydidn’t we?’ But at the time they are yet to have thebaby, and I remember this myself – in the antenatalclasses we were doing the postnatal stuff and I wasthinking – ‘Look, I’ve just got to get through the birthfirst; I will worry about this stuff when I get to thatbit.’ And that’s the reality, that until they actuallymove beyond the birth into the reality of parenting,the reality hasn’t hit them and so getting themix right…In summary, women reported receiving a wide range ofinformation as part of CBE. Topics that were frequentlyrecalled on the survey as being covered in classes – thebirth itself and breastfeeding – were viewed as usefulto the extent that they helped prepare women for thebirth, accurately shaped expectations and increasedconfidence. To the extent that topics were seen asredundant or guilt-inducing, they were viewed as lessuseful. Thus, the topic of nutrition was considered awaste of time because it was covered far too late in thepregnancy to be of use. Information on breastfeedingwas readily available through classes, but focus groupresults suggested the emphasis on breastfeeding hadgone too far, resulting in guilt if breastfeeding did noteventuate, or frustration at the lack of information onchildbirth education: antenatal education and transitions of maternity care in new zealand41

ottle-feeding. Also noteworthy was that the topic ofearly parenting skills was not reliably recalled by womenas being covered in classes (nearly 40 percent did notcircle this topic), and yet focus group results suggestedthat this topic was particularly valuable and was notgiven enough attention in classes.The last part of this research question relates to theresources that are made available to women throughCBE. Key informants reported that there is a wide rangeof leaflets, pamphlets and information sheets availableon various topics related to pregnancy, childbirth andparenting. Examples include leaflets on oral health,family violence, healthy eating, breastfeeding andpain relief during the birth process. One key informantsuggested that many of the DHB-funded classesprovide participants with a ‘woman’s resource folder’.I said to them, show me what you give to thewomen and I guarantee every woman that goes to afunded CBE class will get exactly the same. It was agorgeous folder, honestly, and they were so worriedbecause the Warehouse had run out of them andit had like bears on it and things, you know, andyou open it up and they got all the little brochureson, you know, healthy eating and breastfeeding,and that is what they call the ‘woman’s resourcefolder’ and it is gifted to them on the first night. NowI would put my money on the same thing beingproduced because the brochures are free throughPublic Health, you see. So you just go and get themall and put them all together.These resources may be made available at antenatalclasses or be given to the woman by her LMC. One keyinformant noted that LMCs are likely to give out moreinformation to women who do not attend CBE classes.There is only one resource, mentioned by two keyinformants, that all women are supposed to receivewhen they make their hospital booking. This isavailable through the Ministry of Health and is calledYour Pregnancy 26 .We have one – there’s Your Pregnancy, which is aMinistry of Health publication and that is availablethrough Whitcliffe Press, so you can order it online.If you go to the Ministry of Health website, there is‘Health Promotion’ or ‘Health Resources’ and one iscalled Your Pregnancy, and that is available. I don’tthink it costs anything. Midwives can get it too ofcourse and that is meant to be given to all mumsat book-in, I think, but it is very basic and probablyneeds upgrading. That would be the only Ministryof Health resource that would be given to everybodyI think.In general, though, there is no standardisation of thetype or quality of information contained in handoutsthat is made available to women, even amongst DHBcontractedproviders. It was reported that ParentsCentres has a checklist of approved handouts but thatto date, there has been little monitoring of this.3.3.6 How does CBE offered by differentproviders compare?CBE providers who are DHB-funded base their classeson the National Service Specifications for Pregnancyand Parenting Education (Appendix 9). CBE providerswho do not hold a DHB contract are free to choosethe content and structure of their courses. One wouldtherefore expect a wider degree of variation in theinformation and structure of courses offered by CBEproviders who do not hold a DHB contract comparedwith DHB-funded CBE providers.Table A in Appendix 10 shows the percentage of CBEproviders who reported covering different topics intheir classes as a function of whether the providerwas DHB-funded or not. Caution must be applied ininterpreting these results. Because of the small numberof providers not holding DHB contracts (N = 7), thereliability of these percentages is unclear. For severaltopics, however, there were marked discrepancies(over 50 percent difference) between DHB-fundedand other providers in the likelihood of a particulartopic being covered in their classes. As a group, DHBfundedproviders were apparently more likely thanother providers to cover the following four topics (fromTable A, Appendix 10): the effects of smoking on thehealth of mother and baby, and options available tohelp give up; the effects of alcohol and drugs on thehealth of mother and baby, and options available tohelp stop; warning signs of ill-health or problems duringpregnancy; and the role of Well Child services and howto access them. There was also a large discrepancy (48percent difference) between DHB-funded and otherproviders on a fifth topic – the complaints procedure formaternity services – with DHB-funded providers morelikely to cover the topic. Other topics that may alsodistinguish between DHB-funded and other providers(over 30 percent difference) included mother’s and42 Families Commission Research Fund

families commission research fundbaby’s nutritional needs during pregnancy; screeningand diagnostic tests; stretching and exercise; andvaccinations and tests after the baby is born. For eachtopic, DHB-funded providers were more likely thanother providers to cover the topic in their classes. Whilethese results may give some indication of how the CBEinformation given by providers who use the NationalService Specifications for Pregnancy and ParentingEducation 3 differ from providers who are free to choosetheir own content, they do not provide any indication ofthe variation amongst individual providers.Differences in the information given by individualproviders can be further assessed by examiningwomen’s survey responses. Women who had attendedantenatal education were asked to indicate whichorganisation they attended classes through. TableB in Appendix 10 shows the percentage of womenwho reported different topics being covered inclasses organised through Parents Centres, hospitals,Birthcare, Plunket, Birth Wise, Home Birth and MAMA.Because of the small number of women who reportedattending classes through Plunket (N = 15), BirthWise (N = 9), Home Birth (N = 4) and MAMA (N =10), the percentages given for these providers must beinterpreted with caution. While the percentages givenfor Birthcare (N = 29) are marginally more robust,only the percentages given for Parents Centres (N =136) and hospital classes (N = 116) may beconsidered sufficiently robust for reliable comparisons.Results indicate that women remembered hospitalclasses being more likely (over 10 percent difference)than Parents Centres to cover the following topics(from Table B, Appendix 10): the complaints procedurefor maternity services; and the effects of smoking onthe health of mother and baby, and options availableto help give up. On the other hand, women’s responsesindicated that Parents Centres classes were more likelythan hospital classes to cover warning signs of ill-healthor problems during pregnancy, emotional changeduring pregnancy, risks and benefits of differentbirthing methods, development of appropriate personalsupport and parenting programme options available.Antenatal courses also differ according to the extentto which they are based on a structured curriculum ordecided by participating women and families orwhänau. Table 6 shows the percentage of CBEproviders who base their course on curricula of varyingdegrees of structure.TABLE 6. Percentage of CBE providers who basetheir courses on curricula of varying degrees ofstructure (N = 43).Degree of structureNo. CBEproviders% of CBEprovidersTotally structured(All content based on set curriculum) 8 18.6Mostly structured 21 48.8Combination 13 30.2Mostly unstructured 1 2.3Totally unstructured(All content decided by participatingwomen & families/whänau)0 0.0About half of providers reported using a ‘mostlystructured’ curriculum. This is considerably lower thanthe 80 percent of CBE providers who reported basingtheir course on the National Service Specifications forPregnancy and Parenting Education. Accepting thatthe specifications most strongly support the use of a‘mostly structured’ curriculum (ie, courses must coverset content but be flexible to accommodate the needsof different clients – see Appendix 9), these resultssuggest differences in the way in which providersinterpret and apply the specifications.The length and format of classes also varied amongproviders. The number of sessions ranged from two tonine with the average being 6.2 sessions. The durationof sessions ranged from one to six hours, with theaverage being 2.3 hours. Providers who offered coursesof between four and nine sessions allowed betweenone and three hours for each session. Providers whooffered courses of two or three sessions allowed four tosix hours per session. The total duration of each courseranged from eight to 20 hours with a mean of 13.2hours. Several providers offered classes in more thanone format, either spread out over several weeks, orrun in larger blocks across one or more weekends. Themost popular format was six to eight sessions run overconsecutive weeks, and two hours per session.The target groups also varied across different CBEproviders. Seventeen providers (38.6 percent) reportedrunning classes designed for a particular populationgroup. Table 7 shows the percentage of CBE providerswho targeted different population groups.childbirth education: antenatal education and transitions of maternity care in new zealand43

TABLE 7. Percentage of CBE providers whoseclasses are designed for specific populationgroups (N = 44).Degree of structureNo. CBEproviders 1% of CBEprovidersTeens 8 18.2Mäori 6 13.6Pacific peoples 4 9.1Vulnerable families 7 15.9Women expecting twins ortriplets1 2.3Women planning home births 2 4.5Women interested in ‘active’birth1 2.31These figures do not add to 17 because some providers havemore than one target group.Differences in the perceived usefulness of antenataleducation offered by different providers were examinedusing the women’s questionnaire data. For this analysis,the three dependent variables (DVs) were mothers’perceptions of the extent to which antenatal classeshelped them prepare for the birthing experience, theextent to which classes improved their confidence andability to be a good parent for the baby and whetherthe mother felt emotionally ready to have the baby. Allthree DVs were rated on a five-point Likert-type scalefrom 1 – ‘not at all’ through to 5 – ‘to a great extent’ or‘completely’. The main independent variable (IV) wasthe organisation through which the mother had attendedantenatal classes. Analysis of variance (ANOVA) wasused at the bivariate level to assess the relationshipbetween the three DVs and the main IV. Multivariateanalysis of variance (MANOVA) was then used to adjustfor potential confounders (such as DHB region, age,family structure, education level, ethnicity and income).At the bivariate level, the organisation through whichwomen attended CBE was significantly related to onlyone of the DVs – the extent to which women perceivedCBE helped them to prepare for the birthing experience(F = 3.00, p = .005). At the multivariable level, theoverall MANOVA showed that the organisation throughwhich women attended CBE did indeed make adifference for at least one of the three DVs(F 21, 708= 1.53, p = .061), after adjusting for alldemographic variables. Closer examination of thebetween-subjects effects confirmed the bivariatefinding that the extent to which CBE helped preparewomen for the birthing experience differedsignificantly across the different provider organisations(F 7, 236= 2.83, p = .008).Table 8 shows women’s mean scores reflectingtheir perception of the extent to which CBE helpedprepare them for the birthing experience, as a functionof the organisation through which they attendedclasses. Unadjusted and adjusted means differedby less than 10 percent, so unadjusted means arereported. As emphasised above, the small numbers ofrespondents who attended classes through several ofthese organisations mean that comparisons betweendifferent organisations should be made with caution.Antenatal education offered by Home Birth received thehighest scores from women on this DV, but with onlyfour respondents, the result is not reliable. Looking atonly the two organisations with the highest number ofrespondents, it appears that after adjusting forpotential confounding variables, women who attendedclasses through Parents Centres reported feelingbetter prepared for the birthing experience(M = 3.93, SD = 0.91) than women who attendedhospital-based classes (M = 3.58, SD = 1.07). Thedifference between these two means is statisticallysignificant (t 260= 2.85, p = .005) b .TABLE 8. Extent to which women perceived thatantenatal education helped them prepare forchildbirth as a function of the organisation throughwhich they attended classes (N = 364)Organisation n Mean StandarddeviationParents Centres 144 3.93 0.91Plunket 15 3.13 1.19Birthcare 29 3.45 1.15Birth Wise 9 3.33 0.87Home Birth 4 4.75 0.50MAMA 9 3.78 1.09Hospital-based classes 118 3.58 1.07Other 36 3.58 1.20bThe post-hoc analysis of differences between means was not used, since most multiple comparison procedures perform badly when thereare unequal group sizes or population variances differ between groups (Field, A. 2006. Discovering Statistics Using SPSS. London: SagePublications).44 Families Commission Research Fund

families commission research fundKey informants were asked to comment on how CBEcompares across different providers. Qualitative resultsreflect the differences between providers reportedabove in content, degree of structure, length and targetpopulation of courses. In interpreting the above results,care should be taken not to assume that courses thatcover more content, or are more structured, or target aparticular population group, are necessarily of higherquality. One key informant observed that the maindeterminant of the quality of classes is likely to be thestyle and delivery of the facilitator.The content of courses is fine. The way in which it[the course] is delivered is personal. It is really thestyle and delivery that could be an issue.Another key informant observed there is more variationin the courses offered by providers whose classes arerelatively unstructured compared with providers whooffer more structured courses.Parents Centres classes are structured around aprogramme and set content with some flexibility.Homebirth Association classes are not structured,they are totally group-focused. Each group includesa midwife and a facilitator, whose role it is to makesure the information being shared is correct andaccurate. There is therefore much more variabilityin the content of Homebirth Association classescompared with Parents Centres classes.A key informant also commented on how the length ofa course determines the amount of information that canbe covered and, to some extent, opportunities to formsocial connections.It depends on the length of the course, see; ParentsCentres classes are eight weeks which is quite along time. It’s a fifth of the pregnancy, isn’t it. Twohours for each class and when you look at ‘two,three, and three’ in terms of the breakdown of whatyou do, but a lot of providers only provide fourweekcourses for instance, so I think they are alot more rushed. There’s a lot of accent in ParentsCentres classes on networks and building up socialsupport networks, and that’s one of the things thatI think defines Parents Centres classes. A long wayout I have heard so many stories over the yearsof [participants of] classes that meet years later, Imean 30 years plus, not everyone obviously, somehave died, some have shifted away, but a core ofa class will still be meeting 30 years later. There’sa course that I met up with [the participants] inthe Wairarapa, 20 years on they were still meetingon Friday night for fish and chips which I thinkis amazing and I’ve heard it so often, it almost issomething that defines Parents Centres classes.In summary, the National Service Specificationsfor Pregnancy and Parenting Education provide aframework that encourages some consistency ofcontent and course duration across DHB-fundedproviders. There remains, however, a great deal ofvariation in antenatal classes across the country. Someproviders emphasise certain topics more than otherproviders; some classes are of longer duration or aremore structured than others. The structure and contentof courses offered through Parents Centres producedhigher scores on the perceived extent to which classeshad helped women prepare for the birthing experiencecompared with hospital-based courses. The qualityof classes is also undoubtedly related to the style anddelivery of the facilitator and its match to the uniquelearning needs of the group.3.3.7 What proportion of women access CBE?How does this differ across differenthealth regions?Across different countries, there is wide variation inthe proportion of women who attend classes, rangingfrom about 10 to 90 percent. 17,18 In New South Wales,Australia, about 35 percent of all expectant women 19and about 80 percent of first-time parents attendantenatal classes. 20The New Zealand figures are comparable withAustralian figures. Across all survey respondents, 41.5percent of women attended CBE. This rate is similarto figures from the Maternity Services ConsumerSatisfaction Survey 2007 14 showing that 43 percentof women reported attending antenatal classes. Asa result of response bias in both samples of womenwho returned questionnaires, the true populationparameter is likely to be slightly lower than this figure.The percentage of primiparous women who participatedin CBE was 80.1 percent in the current sample(compared with 78 percent in the sample of womenwho completed the Maternity Services ConsumerSatisfaction Survey). 14 This is much higher than thepercentage of multiparous women who participated inCBE (four percent in the current study; 12 percent inthe Maternity Services Consumer Satisfaction Survey 14 ).childbirth education: antenatal education and transitions of maternity care in new zealand45

Table 9 shows the percentage of women who accessedCBE from each DHB region. The overall chi-squaretest was not significant (chi-square = 26.08, p = .163),suggesting there was no obvious difference in theproportion of women accessing CBE across the differentDHB regions (or possibly a lack of power to detect asignificant effect). The figures can, however, be usedto determine the health regions where relatively fewerwomen currently access CBE, although care should betaken in interpreting the percentages associated withany region where only a small number of respondentsreturned questionnaires. Looking at only the regionswhere at least 30 women returned questionnaires, theaccess rate ranged from 30.5 percent to 52.3 percent.There were three DHB regions that had relatively lowaccess rates: Waikato (30.5 percent); Lakes (32.3percent); and Southland (35.3 percent); and threeregions with relatively high access rates: Auckland(46.3 percent); Capital and Coast (52.3 percent); andCanterbury (51.3 percent).TABLE 9. Percentage of women from each DHBregion who participated in CBE (Total N = 364)DHB regionNo. whoparticipatedin CBENo. whoreturnedqnaire% whoparticipatedin CBENorthland 17 39 43.6Waitemata 16 42 38.1Auckland 44 95 46.3CountiesManukau10 26 38.5Bay of Plenty 26 68 38.2Waikato 25 82 30.5Tairawhiti 5 10 50.0Taranaki 5 25 20.0Lakes 10 31 32.3Hawkes Bay 14 36 38.9MidCentral 16 36 44.4Whanganui 9 23 39.1Capital and Coast 46 88 52.3Hutt Valley 7 20 35.0Wairarapa 3 3 100.0Nelson-Marlborough3 6 50.0Canterbury 58 113 51.3South Canterbury 6 14 42.9West Coast 1 2 50.0Otago 16 40 40.0Southland 12 34 35.3Not answered 15 45 33.33.3.8 How does the availability of CBE differacross the different health regions?The availability of CBE was examined by comparingthe total number of births and the number of firsttimebirths in each DHB region with the total numberof funded CBE courses offered in each area in 2006.Data on the total number of births were obtainedfrom the NZHIS, who report data from the Maternaland Newborn Information System (MNIS) annually.Data on first-time births were obtained from StatisticsNew Zealand, who obtain birth data from the birthregistration form. This form includes a question onprevious births in the current relationship only – “Arethere other children born from the same parentrelationship?” The data reported below for first-timebirths therefore represent all primiparous births aswell as births to women who may have had childrenin a previous relationship but are giving birth to thefirst child of a new relationship. Data on the number offunded CBE courses offered in each area were obtainedfrom DHBs (and supplemented with data provided fromindividual CBE providers).Table 10 shows, for each DHB area, the total numberof births, first-time births and number of CBE coursesoffered in 2006. The National Service Specifications forPregnancy and Parenting Education specify that classsizes must not exceed 12 pregnant women (but a fullclass may consist of 24 individuals if each woman hasa partner). Assuming that each CBE course has placesfor 12 pregnant women, the percentage of births thatcan be accommodated by funded CBE courses can becalculated. For example, there were 24 funded CBEcourses in Northland in 2006. This equates to placesfor 288 pregnant women (24 x 12). The number offunded places can be examined as a percentage of allbirths (288/2,299 x 100) or first-time births (288/1,14446 Families Commission Research Fund

families commission research fundx 100) in Northland. The percentage of all births andfirst-time births whose parents potentially had fundedCBE places was 12.5 percent and 25.2 percentrespectively for the Northland DHB region in 2006.Since some data are missing on the number ofcourses offered by funded CBE providers, thesepercentages should be treated as a roughguide only.TABLE 10. Percentage of all births and first-time births accommodated by funded CBE courses in eachDHB region in 2006DHBTotal no. ofbirths 1No. of firsttimebirths 1, 2No. of fundedCBE coursesoffered% of all birthsaccommodated byfunded CBE courses 3% of first-time birthsaccommodated byfunded CBE courses 3Northland 2,299 1,144 24 12.5 25.2Waitemata 7,318 3,926 52* 8.5 15.9Auckland 6,285 3,541 150 28.6 50.8Counties Manukau 8,267 4,279 118 17.1 33.1Bay of Plenty 2,824 1,444 99 42.1 82.3Waikato 5,058 2,612 101 24.0 46.4Tairawhiti 747 374 48* 77.1 100.0Taranaki 1,479 788 40* 32.5 60.9Lakes 1,632 853 51 37.5 71.7Hawkes Bay 2,220 1,167 66 35.7 67.9MidCentral 2,270 1,215 43* 22.7 42.5Whanganui 895 491 16 21.5 39.1Capital and Coast 3,894 2,078 18 5.5 10.4Hutt Valley 1,999 1,058 50 30.0 56.7Wairarapa 523 267 10 22.9 44.9Nelson-Marlborough 1569 865 16* 12.2 22.2Canterbury 6,169 3,272 244 47.3 89.5South Canterbury 606 325 25 49.5 92.3West Coast 398 206 19 57.3 100.0Otago 1,970 1,068 55* 33.5 61.8Southland 1,471 778 51 41.6 78.71Includes live and still births.2Represents the number of first-time births in current relationships only. NB: This figure overestimates the number of true primiparous births.3Assuming each funded CBE course accommodates 12 pregnant women.* Figure likely to underrepresent the true number of funded CBE courses since some data are missing on the number of courses run by one ormore funded providers.childbirth education: antenatal education and transitions of maternity care in new zealand47

The Ministry of Health Service Coverage Schedule(2004) indicates an expectation of CBE services beingavailable free of charge to 30 percent of all pregnantwomen each year. Table 10 can be used to determinethe DHB regions where this target is not being met.There were 10 DHB regions that did not fund enoughCBE places to cover 30 percent of all their pregnantwomen: Northland, Waitemata, Auckland, CountiesManukau, Waikato, MidCentral, Wanganui, Capitaland Coast, Wairarapa and Nelson-Marlborough.Four of these DHBs (Northland, Waitemata, Capitaland Coast and Nelson-Marlborough) did not fundenough CBE places to even cover 30 percent of theirfirst-time mothers. Capital and Coast DHB regionprovided funded places for only about 10 percent offirst-time mothers.It is interesting to compare the availability of antenataleducation (Table 10) with actual access rates (Table9). One of the DHBs with a relatively low percentage offunded CBE places – Waikato – also had a relatively lowaccess rate. It could be hypothesised that increasingthe number of funded CBE positions in the Waikatoregion may help to improve access rates. Capital andCoast DHB had a small percentage of funded CBEpositions but good access rates. This may reflect amore affluent population who are prepared to pay a feeto attend CBE in this region. Other regions, includingLakes and Southland, had a relatively high percentageof funded positions but relatively low access rates. Itcould be that the CBE courses in these areas are beingrun with fewer women per class, or that women inthese areas are choosing other sources of informationon childbirth and parenting. At least one DHB –Canterbury – had good availability of courses and goodaccess rates.In summary, there are large differences in theavailability of funded CBE courses across New Zealand.DHBs funded enough CBE places for anywherebetween 10 percent and 100 percent of their firsttimepregnant women. However, the differences inavailability of CBE across regions are not necessarilyreflected in the access rates, so care should be takennot to assume that low access rates may automaticallybe improved with better availability of courses. Ofcourse, not all pregnant women choose to participate inantenatal education, but on the basis of the percentageof primiparous women who participated in CBE in thecurrent research (80 percent), for many regions thereremains a discrepancy between the number of publiclyfunded CBE courses and the number of primigravidaewho want to attend a course.3.3.9 What are the demographics of womenand families and whänau who accessCBE and the best predictors of attendance?Table 11 shows the demographics of women andfamilies who participated in CBE versus thosewho did not participate in CBE. Chi-square testswere performed to consider the significance of theassociation between attendance at antenatal educationand each demographic variable. As expected, thevast majority of women who participated in CBE wereprimiparous (95.1 percent) and were married or in defacto relationships (92.6 percent). Participants weresignificantly more likely than non-participants to have atertiary degree (one to four years), to be of New ZealandEuropean ethnicity and to be earning $70,000 per yearor more. Both Mäori and Pacific peoples were underrepresentedamongst women who attended antenataleducation. Only 10 percent of CBE participants were ofMäori ethnicity and a much lower percentage were ofPacific ethnicity. Of the four refugee women from Africawho were interviewed individually, none had attendedCBE, nor had their LMC suggested they attend.Participants were also less likely to be single than nonparticipants,although this did not reach significance.These findings are consistent with other studiesshowing that women who attend classes are more likelyto be first-time mothers, more educated, of highersocio-economic status and less likely to be of Mäori orPacific ethnicity or single compared with women whodo not attend classes. 14, 21, 22 Interestingly, participantswere significantly younger than non-participants, afinding contrary to previous research. 22 In any case, thedifference in ages was small (30.4 vs 31.6 years) andprobably not important.48 Families Commission Research Fund

families commission research fundTABLE 11. Demographic characteristics of women and families and whänau who accessed CBE and thosewho did not access CBE (N = 878)DHBParticipated inCBE (n = 364)Did not participatein CBE (n = 514)P value% n % n Chi-square 1Parity

Further analyses were conducted to determine thebest predictors of attendance at antenatal education.Logistic regression modelling was used to control forpotential confounding variables. For this analysis, theDV was attendance at antenatal education (yes/no) andthe IVs were all the demographics from above (mother’sparity, family structure, education level, ethnicity,income and age) as well as two additional variables:whether the LMC had suggested that the mother attendantenatal classes; and DHB region.Table 12 shows the results from the multivariablelogistic regression analysis. Variables with ORs greaterthan one indicate demographics or events that, incomparison with the referent, increase the likelihoodof attendance at antenatal education. Variables withORs less than one represent demographics or eventsthat, relevant to the referent, decrease the likelihood ofattendance at antenatal education. There can be moreconfidence in the predictive power of a variable whenthe CI for its OR is narrow and does not span one.Consistent with the results in Table 11, the strongestpredictor of attendance at antenatal education was themother’s parity (OR = 145.60, CI = 46.42–456.72).The odds of attending antenatal education were 146times higher for women having their first babies thanfor women having their second or subsequent babies.Although the CI was very wide, the lower limit (46) wasmuch higher than one, suggesting a strong predictiverelationship between parity and attendance at CBE. Thesecond strongest predictor of attendance at CBE wasthe LMC suggesting the mother attend (OR = 20.74,CI = 5.87–73.31). The odds of attending antenataleducation were 21 times higher for women whose LMChad suggested they attend CBE than for women whoseLMC had not.Two other significant predictors of attendance atantenatal education were family structure and DHB.Specifically, families with non-traditional structures(marked ‘other’), were significantly less likely to attendantenatal education than married (two-parent) families(OR = 0.08, CI = 0.01–0.81), and families livingin Southland were significantly less likely to attendantenatal education than families living in Auckland(OR = 0.13, CI = 0.02–0.85). Two other variablesapproached, but did not reach, statistical significance:ethnicity and household income. The odds of Mäoriwomen attending antenatal education were lowerthan New Zealand European women attending (OR= 0.35, CI = 0.11–1.05). Families earning between$70,001 and $100,000 per year had greaterodds of attending antenatal education than familiesearning below $15,000 per year (OR = 8.16, CI =0.74–90.20).In contrast to the findings presented in Table 11where the effects of all the variables were controlledfor, age and educational qualifications were notsignificant predictors of attendance, whereas familystructure became a significant predictor. Thesefindings suggest that age and educational qualificationsmay only be associated with attendance at antenataleducation because of their association with othervariables that predict attendance, such as parity,ethnicity or household income. Family structure, onthe other hand, may have emerged as a significantpredictor because of the relative discrepancy in thelikelihood of families from non-traditional structuresaccessing antenatal education compared with marriedcouples. Alternatively, the first chi-square analysismay have been under-powered because of smallnumbers in some cells.50 Families Commission Research Fund

families commission research fundTABLE 12. Logistic regression analysis todetermine the best predictors of attendance atantenatal education (N = 561)Variables 1Mother’s parityMultiparous (referent)PvalueOddsratioLower95% CI 2 forodds ratioUpperPrimiparous

Women who did not participate in CBE were asked toindicate the reason for their non-attendance. Table 13shows the percentage of women who indicated eachpossible response on the survey. The most commonreason given for not attending CBE was that classes hadbeen attended during an earlier pregnancy (60.5 percentof responses). The next most common reason was thatinformation had been obtained from other sources (30.0percent of responses).TABLE 13. Percentage of women who circled eachreason for not attending CBE (N = 514) aReason for not attending CBE % (n)a. I did not know about these classes 2.7 14b. I was aware of these classes butthey are not available in my area 2.5 13c. The classes cost too much 1.6 8d. I attended CBE or antenatal classesduring an earlier pregnancy 60.5 311e. I did not think CBE or antenatalclasses would be helpful or useful 7.4 38f. I obtained the information I wantedfrom other sources (eg, LMC, family/whänau, books, internet)30.0 154g. Other 13.8 71aTotal N in Table 13 adds up to more than 514 becauseparticipants could circle more than one answer for this question.Other New Zealand research has been conductedto investigate reasons why women do not attendantenatal education. Ora Toa Health Unit in Wellingtonrecently undertook a survey of 30 Mäori women. Themost common reasons given by Mäori women for notattending antenatal education were:> venue not appropriate> the style of delivery of the facilitator (how thefacilitator comes across)> poor relationship between midwife and mother (soCBE options not given)> never knew antenatal classes were available> lack of transport> single parent so felt they would not fit intothe group.In summary, women and families and whänau whoattend antenatal education are different from thosewho do not attend. In general, women who attend aremore likely than non-attenders to be primigravidae,of New Zealand European ethnicity, tertiary educatedand on higher family incomes. When the effects of alldemographic variables are controlled for, primiparitystill emerged as an important predictor of attendance,along with whether the woman’s LMC suggested sheattend CBE. The woman’s DHB and family structurealso predicted attendance. Improving women’s accessto CBE will require providers to make CBE moreattractive to those groups who are currently less likely toattend, improve the availability of CBE in some regionsand address some of the reasons for non-attendance.A large proportion of women and families not attendingprefer to get their information from other sources. Atthe same time, access to pregnancy and parentingeducation services improves when there is both a Mäoriand a mainstream provider in the region. 23.3.10 Does CBE prepare parents emotionally tohave children?The survey of women included the following question:“do you feel emotionally ready to have this child?”Women could circle an answer from 1 (‘not at all’)through to 5 (‘completely’) (see Question 11 on thebrief questionnaire for women, Appendix 1). The meanresponse for primiparous women who had completedCBE was 4.41 (SD = 0.74) and for primiparouswomen who had not participated in CBE it was 4.23(SD = 0.88). The difference between the two meansapproached, but did not reach, significance (p = .061),suggesting that differences in emotional preparationbetween women who did and did not participate in CBEwere marginal.The extent of emotional preparation afforded by CBE wasmore closely investigated by examining the percentageof participants and non-participants who had circled 1(not at all ready) through to 5 (completely ready) on thisquestion. Results are presented in Table 14.52 Families Commission Research Fund

families commission research fundTABLE 14. Percentage of primiparous CBE attendersand non-attenders who circled each response forQuestion 11 – “do you feel emotionally ready to havethis child?”Answer circled Attended CBE Did not attend CBE% (n) % (n)1 - Not at all 0.0 0 2.3 22 1.8 6 0.0 03 10.0 34 15.1 134 33.9 115 37.2 325 - Completely 54.3 184 45.3 39The chi-square for this analysis was significant(p = .015), because primiparous women who attendedCBE were more likely than non-attenders to circle 5(indicating they felt completely ready to have theirchild). The percentage of primiparous women whoreported that they did not feel emotionally prepared(circled 1 or 2 for Question 11) was slightly higherfor women who had not participated in CBE (2.3percent) compared with women who had participated(1.8 percent), but the number of women circlingthese responses was too low to infer any meaningfuldifference between groups. The low numbers ofwomen circling 1 or 2 also suggests that, on the whole,participants felt at least some degree of emotionalpreparedness to have their child, regardless of whetherthey had completed CBE.The finding that primiparous women who attended CBEwere more likely to feel completely emotionally ready tohave their child than non-attenders is a positive one forCBE providers, but it does not prove a causal relationshipbetween participation in CBE and women’s emotionalpreparation. This finding may simply reflect differencesin the types of women who choose to attend antenataleducation compared with those who do not attend.Two other questions on the brief questionnaire wererelevant. Women who had participated in CBE wereasked to rate the extent to which participation in theclasses had helped them prepare for the birthingexperience (Question 8) and the extent to whichparticipation had improved their confidence and abilityto be a good parent (Question 9). The results arepresented below in Figure 1 and Figure 2.FIGURE 1. Women’s responses to Question 8 “Towhat extent did your attendance at CBE classes helpprepare you for the birthing experience?”No. of women1401201008060402001 (Not at all) 2 3 4 5 (To a greatextent)Extent to which CBE helped mother prepare for birthFIGURE 2. Women’s responses to Question 9 “Towhat extent did your attendance at CBE classesimprove your confidence and ability to be a goodparent for this baby?”No. of women1401201008060402001 (Not at all) 2 3 4 5 (To a greatextent)Extent to which CBE helped mother prepare for parentingThe mean response for Question 8 was 3.70 (SD =1.04), and 58 percent of women who had completedCBE circled 4 or 5 for this question. The meanresponse for Question 9 was 3.46 (SD = 1.10), and 51percent of women circled 4 or 5. Women were morelikely to respond that CBE had helped them prepare toa great extent for childbirth rather than for parenting.Importantly, 12 percent of women who participatedresponded that classes had not helped them preparefor the birth experience (circled 1 or 2 for Question 8)and 19 percent responded that classes had nothelped them prepare for parenting (circled 1 or 2 forQuestion 9).On the whole, focus group results were more consistentwith the idea that CBE does not help parents to preparechildbirth education: antenatal education and transitions of maternity care in new zealand53

emotionally to have children, although a number ofwomen did acknowledge that it had helped them.I found the classes helpful, they helped me, I thinkthey helped me emotionally prepare a little. Theycan’t prepare you for the hormones and the upsand downs but you know, the antenatal class I wentto the lady was very good ... she wasn’t Einstein butshe got the information across ... she said basicallyif ... the first however many weeks: have very lowexpectations, you won’t be able to have any controlover things, you’ll just be feeding and trying tosleep, but when you are told that and you acceptthat it’s just gonna be mayhem, then you’regonna be better prepared than if you have noinformation whatsoever.…one of the sessions that I found really useful inour antenatal class was a discussion about ... thingsthat you might not expect and it was to do with thelate pregnancy and the birth and afterwards as well.Some of the things that people put on that list. Wewere kind of asked to come up with a list and thenwe discussed them. They went from everything likemum and baby dying to having to bottle feed whenyou had hoped to breastfeed, having a caesareanwhen you had hoped to have a natural birth. Allof those kind of things that kind of went against. Idid actually, when you were talking before aboutemotional preparation, I found that session actuallyreally good. I was quite fortunate that none of thethings down that far end happened, but in someways acknowledging that things do go differently tohow you…We had a really good teacher at antenatal and shejust kept on saying every now and then and shewould use her own children as an example, orher own experiences with her own children as anexample, just kept on backing up these ideals andeverything but it could all go out the window and beprepared to adjust.Yeah, I think it’s to do with the way the whole thingis presented really because obviously that’s going toaffect emotions. I just felt really emotional actuallyduring them. I thought God, I haven’t been a tearfulperson and suddenly here I am feeling like wantingto cry every night. It was kind of embarrassingreally. I don’t know, something about the way itwas presented.Yes, classes can help you to understand what isgoing on and this helps you to prepare emotionally.Comments from two women who were interviewedindividually suggested that CBE could have preparedthem better to cope with difficult emotions theyexperienced relating to a previous miscarriage and atraumatic birth.It was a difficult time. I was trying to be happy butcouldn’t focus on anything but the loss. I just criedand cried and cried for three hours. It wouldn’t havebeen inappropriate to help prepare women betterfor these emotions in CBE class.We had no opportunities [during CBE] to thinkabout how you would feel emotionally with adifficult trauma during birth. I had an emergencycaesarean; my partner was excluded from the roomand wasn’t even told when the babies [twins] wereborn. They were taken to the neonatal room andall hooked up to wires before he was told. We weretold that the babies would not be taken anywherewithout one parent being there, but the reality isdifferent from the ideal. During the class we talkedabout the technical aspects of caesareans but notabout how you would cope if it happened to you.There was nothing about the emotional side.Other comments from women suggested that emotionalpreparation was an ambitious aim to achieve in a groupcontext and that it might be better achieved by one-toonecontact with the midwife.I almost think that’s probably more the midwife. Wetalked about expectations and that sort of thing withher and because it is quite an intimate thing. It’shard enough you and your partner dealing with yourbaggage and everything else that might come outwhen you do something that gets to that point. Andyeah, the midwife probably dealt with that a littlemore for us...I mean the class might have planted the odd seedthat you talked about on the drive home. But itwasn’t really the forum to get too deep-in emotional.I think some people find it easy because they justlike to talk and share everything ... they’re veryopen. Other people aren’t as open. It’ll take a lotmore for that trust and sort of sharing personalinformation, especially the time when you don’t54 Families Commission Research Fund

families commission research fundknow if your coffee group is going to continue. Whyshould you share all this personal information? So Ithink it’s probably quite hard.The CBE class helped a bit but my midwife helpedmore with the emotional preparation.Most commonly, though, women’s responses suggestedthat CBE does not prepare parents emotionally to havechildren, and that, in fact, nothing can.Like if somebody told me this is what it’s going to belike, I’d go yeah, yeah, yeah, whatever.…at the moment I work harder than I used to workin that job and, you know, [baby’s name] is not ableto say thank you for anything I do and so you’re notgetting that feedback that you’re used to getting, butum, and I think some of that’s quite hard for people.I found it quite hard being at home by myself allday without contact but I don’t think, I don’t thinkanyone would believe you when you actuallysay that…Nothing, frankly, nothing. Because it’s such atransition…We got home and nothing could have prepared usfor that, because we weren’t even, we knew it wasgoing to be mayhem in a way but we didn’t knowthat we wouldn’t sleep for 36 hours. We didn’t sleepfor 36 hours, I think I got a 10-minute catnap at onepoint and you’re dealing with the postnatal pain, soyou’re dealing with a Caesar, or whatever, um, yourboobs are gushing, you’re still bleeding, you know,you’re doing all this stuff, and you’ve got theseamazing little things that you just hopefully totallyadore and want to do everything for and they won’tshut up. So you can’t do anything, you know. That’swhy I guess, that’s why even though they said it wasgoing to be mayhem, and I’ve remembered now butI hadn’t before, nothing can prepare you for thatreally, not really...I was totally emotionally unprepared. I was like mostpeople. I don’t know, probably looking back now,like now I’ve got two children, it took me a lot longerto bond with my first baby compared to my second.I just found the whole process more difficult interms of milk coming in, the baby blues were worse,and the second time around things just seemed togo better because I knew what to expect.Practical coping wasn’t it, not so much emotional.A couple of weeks [length of time after birth thatCBE classes help you to practically prepare for].But the practical things you could learn before. Iguess it’s kind of hard now to think, could we havelearnt what we think we needed to know beforehandto cope afterwards ? Like it wouldn’t have actuallygone in.I think there’s actually quite a lot of maybepatronising information out there and I think,I probably got told a billion times when I waspregnant ‘nothing will prepare you’, and I thinkthat’s probably reasonably accurate. I mean you,everyone here obviously went to a course andprobably read things or watched videos or whateverand um, you can pick up some knowledge but Imean the application of that knowledge or whatit’s actually like to ... be pleasant to someone whenyou’ve been up three or four times in the night andit actually took you an hour to feed the baby tenminutes on each side, um, yeah, or you know it just,I don’t think you can actually do it, and I helped outin one of tots and toddlers course teaching, tryingto explain to some high school kids what it’s liketo have a baby and they absolutely looked aghastwhen I said [baby’s name]’s breastfed so I can’t bemore than three hours away from the baby.These comments highlight the life-changing natureof having children and the challenge in emotionallypreparing for such a transition. When making ajudgement about the effectiveness of CBE in helpingparents to emotionally prepare, it is importantto acknowledge the many factors that influenceparents’ emotional preparedness to have children.For example, it is likely that the social support thatwomen unanimously named as an important benefit ofparticipation in CBE is conducive to promoting parents’sense of emotional preparedness.It should also be noted that all women completingquestionnaires and the majority of women whoparticipated in focus groups had already had theirbaby. Comments from parents on how well preparedthey are to have children are generally more positiveif they are asked immediately after the antenatalprogramme, compared with after the birth. 23Gager et al conclude that the vast majority of mothersand fathers are prepared for their new responsibilitieschildbirth education: antenatal education and transitions of maternity care in new zealand55

as parents. 24 However, as in this study, they found thata small percentage of parents felt unprepared forthe role. There are many factors that influence parents’emotional preparation for parenthood; antenatal classesmay be one factor. There are many benefits thatparents derive from CBE, as outlined inSection 5.3.5, that could contribute to their overallemotional preparation.3.3.11 What decisions do parents make beforetheir child is born about how they willconsciously parent their child and whatservices are available to facilitate thisprocess?Focus group participants were asked to think aboutwhether they had made any decisions before theirchild was born concerning how they would consciouslyparent their child. There was a great deal of discussionabout this topic, and most of the responses suggestedthat women do think about their parenting role andmake many related decisions before the baby is born....definitely, now that I’m on maternity leave and it’ssort of getting closer, definitely thinking about it. ButI’m trying to be realistic. I know quite a few peoplewith babies and things just don’t really go to plan.So sort of not trying to be too this way.But I think most people who are going to havechildren have usually talked about their parentingphilosophies themselves years before they mighteven have children, or depending on when they’vegot together, and I can think of lots of things thatwe’ve sort of decided to do that we decided beforewe’d even really thought about having children,years ago.Yes, and I got pregnant so easy so it was a surpriseand I was worried about having this extra persontake over my life and I thought well, that’s not fair.So I’ve in my mind, it’s like as much care andlove and all the things that she needs, that’s fine,I accept that, but she’s joining my family. Like[partner’s name] and I are already a family, the twoof us, and she’s joining in so she has to fit in.…Yes, but thinking about a good environment, Ihad to raise them, my sons. Lots of things I thinkabout, because this is my first-born so everything Ineeded for him is the best thing before the secondson came along. So I had to share.…I had very strict rules about who I wanted therein the early days as well because I was… I reallywanted the three of us to bond as a new family andI knew it would be hard.I knew that she needed instruction, caring, teachingabout good and bad.Some comments implied that women who had previousexperience with babies were likely to have alreadythought about how they would parent theirown children.My Mum and Dad went to work during the day, andafter school it was my duty to look after [my babybrother] while my aunty that looked after him duringthe day had to go to work.Well I actually had two-step kids before I waspregnant and I was like the mother already withthem because I brought them up. They were young.She’s practically been in my life.Many comments revealed the specific types ofdecisions parents made before the birth.…I think the other thing was also just we often sortof made plans, but we really kept reviewing them alot. So we made a plan but didn’t feel … tried reallyhard to not … we planned about everything rightfrom the birth to how we were going to feed, to howwe were going to deal with someone going back towork, to all sorts of different things. Who was goingto get up at night. All those kinds of things.I’m going to give her all the options. She needs tolearn music when she is young because I didn’thave that and he will say, but we’re not going toforce her because I got forced.The first thing that comes into it, how are you goingto parent, I think from the very early days you getcountless advice on our kids. How you let your babysleep and you can let it cry. We, from day one werelike, there’s no need to let her cry. If she wants tocuddle I’m going to cuddle her.I knew I definitely wanted to be a stay-at-homemum. I wanted my child to be able to count on thefact that Mum or Dad would be there.The bond with my child is more important than thehousework. It will be important to spend time withmy child.56 Families Commission Research Fund

families commission research fundParents had thought about wanting to be good rolemodels for their children.At the time, I just think I had to make a goodexample and that the baby like me or like his father.Yeah, I guess for us there was a lot around the roleof the father because he didn’t know his father forquite a long time. So, yeah, what, how he woulddo that, having not had the role model to do it, andwhat, and how painful that was and things like that.One of the most common themes to emerge wasthat parents planned to do things differently fromtheir own parents.…But also on that, my husband, because he’s hada more challenging childhood and he had a hugegoal that we were going to create quite a differentenvironment than that to what he came from, andthat was definitely something that we spoke quite alot about. And I don’t think that was brought up somuch at antenatal. It was the joy of finding how tobe parents and what we wanted to do around that.…I think we did the same. [Partner’s name] wasvery much the same and so we talked a lot abouthow, what we wouldn’t do.I think things like that we’ve seen over the years,like our parents used to smack us physically. So Ithought, oh no, that’s never going to happen to mybaby, and a lot it’s going to be verbal discipline andjust the different techniques we will use…To me at six months, reality kind of hits. Like myhusband and I have always thought about, there isalways going to be lots of love, caring, that sort ofthing. The things that we weren’t going to do werethings that our families did to us when we werelittle. And his family is very dysfunctional and hesort of doesn’t really want to do much of the Indianway that they did. They were quite a dysfunctionalfamily. My family didn’t show much love, so I justwanted to…I want to raise my child differently from how I wasbrought up. Education was not offered to me, but Iwill support my child to get an education.It was also common for women to report having thoughtabout how they wanted to parent, but then not adheringto these decisions after the baby was born.And one thing, like I had quite strong views of whatI would and wouldn’t do as a parent before I hada baby and I pretty much have done the completeopposite. So it was just like things like the babywill be in their own room and neither of them havebeen, and just, you know, things like that. Butwhat I found more challenging is having an olderchild. I think babies are easier in lots of ways. Anolder child are the ones that really start pushingboundaries.Every time [participant 1]. And you get it all wrong[participant 2].I used to look at others, like my sister-in-law, theway she brought up her kids and I don’t like thatway or I don’t think I’ll do that when I’m a parent,and I used to really look. I think I judged people andthought no, that’s a really bad way, I’m not going todo that. But it’s all rubbish, you do it.Well I think we all have nice ideas and you readall the books, and it’s sort of like, I’ll never give mybaby a dummy, I’m never gonna have them in bedwith me and, it’s just different, you kinda think youcan, because every child’s different.Yes, I made decisions, but they changed after thebaby was born.Some parents made specific reference to resourcessuch as books or television shows that had helped themto make parenting decisions.We would watch [‘bad kid’ shows] and then wewould kind of use that as a starting point. Like howdid they get to that point? What were the parentsdoing? How could it go so wrong? What do you thinkdiscipline should be and what would you do if yourkid did this and that? So we kind of had discussionsaround it and compared.What to expect in those first days I think is quitetricky too and that because we, like I have readall the books, every book, about the sleep plans,feeding levels and whatever else. We were like, wehad kind of decided what we wanted our approachto be and we did do it.I read a book, ‘Becoming Baby-wise’. It coveredleaving the baby to cry so they learn to sleep. Ifound it not as simple as in the book.childbirth education: antenatal education and transitions of maternity care in new zealand57

We watched ‘Super Nanny’ on TV and talked aboutwhat we thought would be a good idea.Some women commented on how CBE had influencedtheir thinking about parenting.I think for me that it didn’t happen sort of asstraightforward as how you’ve just described it, butI think the confidence I got as a result of going tothe classes meant that we could easily establishan emotional connection with [baby’s name]because that was, we felt confident, so it just, yeah,eliminated a whole lot of barriers and we could justconcentrate on falling in love with him, kindof thing.I think the process, there’s something about theprocess that you go through, the nights where yougo home excited because of something or becauseyou’ve seen a real baby being born or the nightsyou go home going, ‘oh my God’, and that processmethod of learning, and again it’s the togetherthing. I’m sorry for people who are on their own, butgoing through that together and talking throughit together…Classes are an opportunity to pick up handy hints, ifnothing else.Collectively, these themes suggest that many womenprepare and plan much for parenthood before the birth,regardless of outcomes. However, it was acknowledgedthat there might be less preparation for women whowere younger or who were from more disadvantagedsocio-economic circumstances.I’m assuming it would be somewhat different ifeveryone had accidental pregnancies and theirrelationships weren’t secure.Or teenagers. But yeah, whereas, I like, we triedfor a hell of a long time to get him and so yeah, wewere well prepared.At the same time, some women reported that they didnot put a lot of thought into how they would parent theirchild. There were many reasons for this. Some women’sresponses suggested that they just took things asthey came.I just kind of deal with it as it comes, kind ofthing really.I guess you haven’t really talked about it as whatsort of parents we were going to be, that kind ofquestion. But just more or less dealt with thingsas we’ve needed to, like we got the sleep video,watched that together and decided what we weregoing to do to get that going right.I just want some time with him.A couple of responses implied that they had just copiedtheir parents’ parenting style without thinking too muchabout their own parenting role.I did, with my parents I could go until Sunday andcome home wasted and my parents would say ‘ohyes she’s still got a pulse’, so that’s what I say to myson now, you’ve still got a pulse. This one here [newbaby], my husband puts his foot down. I can’t goout as much as what I used to, you know…Some women were more focused on the birth than theparenting afterwards.What’s going to be your philosophy for parenting orwhatever, because I think what [participant’s name]said is that you are focused on the birth and that’swhat you need to be focused on.I think beforehand you’re really focused on the birthas well. I mean you sort of, you know there is goingto be an after, but when you’re pregnant that’s, youkinda can’t get past that bit.In summary, comments from the focus groupssuggested that many people make decisions aboutwhat they will be like as parents before their child isborn. Parents make decisions about loving theirchild, setting limits, how they will discipline, how theywant their child to feed or sleep, whether to let theirinfant cry, how they will establish an emotionalbond with their child, what they will or will not do withtheir child, whether to do things differently or the sameway as their parents, creating a good environment fortheir child, being a good role model for their child,working as a team with their partner, who will get upat night, how to deal with going back to work andwhat activities they want to involve their childin. Undoubtedly, parents make many other decisionsnot listed here. Some parents, however, thoughtmuch less before the birth about how they would goabout parenting their child, and many parents who didmake conscious decisions before the birth didnot keep to these decisions after the baby was born.Many parents recognised the need for being realisticand flexible.58 Families Commission Research Fund

families commission research fundIt is clear that CBE can influence some women’sdecisions about parenting, but as with the processof emotional preparation, there are many factors thatdetermine both parenting decisions before the baby isborn and the subsequent parenting style after the birth.Antenatal education, LMCs, books, television shows,friends and family were all viewed as potentially usefulresources in planning how to be a parent beforethe birth.3.3.12 The Revised Section 88 Maternity Noticedescribes the obligations of LMCs andspecifies parents’ entitlements to maternityservices. To what extent are parents awareof these entitlements?It was of particular interest to find out if women wereaware of the following entitlements (specified in theSection 88 Maternity Notice):> free LMC care (if provided by a midwife or GP)> free LMC postnatal visits to care for the motherand baby up until six weeks after the birth. Womenare entitled to receive a daily LMC visit while stillin postnatal inpatient care and between five and10 home visits by a midwife (and more if clinicallyneeded), including one home visit within 24 hoursof discharge from a maternity facility> phone advice and community or hospital-basedassessment for urgent problems available from LMC24 hours a day, seven days a week> free urgent normal and out-of-hours pregnancycare from a GP, midwife, or obstetrician, other thanthe woman’s LMC, if the woman has already triedunsuccessfully to access her LMC (where she isregistered with one) or her enrolling PHO practice(where she is in the first trimester)> access to appropriate information on topics suchas immunisation, screening tests, the availability ofpaid parental leave, maternity services entitlementsand the maternity services available (such aspregnancy and parenting education)> the hospital stay after giving birth. If a birth hasoccurred in a maternity facility, the LMC, indiscussion with the woman and the maternityfacility, must determine when the woman isclinically ready for discharge> free Well Child services (by a Well Child provider)after handover from LMC> postnatal contacts from Well Child services. Womenare entitled to eight core contacts (initially in thehome) over the first five years of their child’s life (asoutlined in the Well Child – Tamariki Ora NationalSchedule). 10When focus group participants were asked if they wereaware of their entitlements to maternity services, initialresponses were mostly negative.No, I have no idea [what my entitlements are].The first time around, I was not aware of anything. Ipaid for every GP visit.No-one told me what I was entitled to. I wentthrough an obstetrician.When women were then given specific examples ofentitlements, they did indicate awareness of some. Inparticular, most women were aware of their entitlementto free antenatal LMC care or if they weren’t aware,usually found out at their first GP visit to confirm thepregnancy. Some women reported that their midwifehad explained that visits would start off monthly, moveto fortnightly, and then end up being weekly as thepregnancy progressed.Yes, I found out [about LMC care] with this one.I wasn’t, I think maybe because I’m British I hadno idea about the system so I just did what I woulddo in Britain, which was toddle along to the GPand then she said ‘Oh, here’s your pack you needto go find a midwife’ and then, um, I still don’tquite understand the system about people withspecialists, um, it’s still just a bit of a murky areato me and I came out ok in the end but I find thewhole system very confusing.Women’s responses suggested that they viewedreceiving appropriate information as an expectationrather than an ‘entitlement’. They reported havingmany discussions with their midwives and otherpractitioners about relevant information, such asVitamin K injections and the pros and cons of differentpain-relief options.Yeah. I found that our midwife covered those fairlywell as they came up. ‘Now we need to considerthis and next week you can make a decision. I’llgive you the information now that will tell you aboutit.’ I think she did really well.childbirth education: antenatal education and transitions of maternity care in new zealand59

I think the information was empowering actually too.That sounds similar to our experience and becausewe were constantly being informed by the midwifeand she knew from halfway through we startedtalking about what sort of birth we hoped we couldhave and what pain relief we’d want. So, it wasn’tthat these decisions came because you were gettingscared. These decisions were coming when youwere more in your informed kind of phase and thatmeant that she could kind of help you stick to whatyou really wanted, not what your pregnant crazybrain wanted.We were very strongly made aware of the optionalentitlement to not have your baby given things likethe Vitamin K injection, or to actually haveto consent…To a couple of those things which happen very soonafter the birth and people at antenatal classes andthe midwife and the obstetrician were all really keenthat we read the information and that we were fullyaware of disadvantages and advantages of sayingyes or no and making fully informed decisions.Some women had made special efforts to find out aboutleave entitlements, including paid parental leave andextra unpaid leave, typically finding out about suchentitlements through human resources websitesor staff.I went on the website to find out with respect towork and the leave entitlement and stuff. I wentto, I think I might have Googled it and got the rightgovernment department that way, the right website.That was quite easy…I thought about entitlements related to work. I foundout about the parental payment scheme.Many women were also aware that at some point afterthe baby is born, they are entitled to care by a WellChild service. One woman reported that she had foundout about the number of Well Child home visits thatwould occur through the Well Child (Plunket) booklet.We just got told that after six weeks we change frommidwife to Plunket, Well Child ... and one of thePlunket nurses actually came a bit before six weeksand sort of took details and things down…I didn’t really know until I looked in the Well Childbook, the Plunket book and I just phoned her and Iknew how many visits they were going to do.In general, though, women were not aware of any ofthe detail associated with entitlements. For example,women were asked whether they knew how long theywere allowed to stay in hospital. One woman’s responsesuggested she was aware of the entitlement, but mostwomen did not know. Women offered different opinionson the length of time they should be entitled to stayin hospital.You can stay for as long as it’s clinically necessaryand breastfeeding is established and breastfeedingis a clinical necessity, so……I still don’t know what you’re actually entitled toin terms of staying in hospital. Someone had saidto me, no you’re actually legally entitled to 14 days.They can’t officially kick you out but I don’t knowanyone that’s younger than my Mum’s generationwho has been there that long.Other women commented that the length of hospitalstay was related to how busy the hospital was, withpressure being put on some women to leave to free upbeds. Others felt that it depended on whether they hadtheir own room, and that women who had to share aroom with other women and their babies were muchmore likely to want to go home.While women were vaguely aware of their entitlementsto postnatal LMC and Well Child care, they were notaware of the particular number of midwife or Well Childhome visits to which they are entitled.It’s not written down anywhere for people to findout, I only knew cause I’d read the contract, notmany people do that.There’s something else we weren’t told in myantenatal classes, that when you, after you’ve givenbirth your midwife will see you for six weeks thenyou’ll be referred to Plunket and you’re with themfor five years or whatever and no-one actually saidthis is what’s available.Yeah well my midwife just, you know, turned up andthen she’d come and say ‘I’ll be back in a couple ofdays’ and then all of a sudden it was, you know, aweek and one of my friends used the same midwifeand she said, you know, she was around everyday, and so I had no idea how much [home visitsentitled to]...There were exceptions, however, with some womenreporting that they knew how many postnatal LMC60 Families Commission Research Fund

families commission research fundhome visits they were entitled to because their midwifehad told them.Our obstetrician had told us at the beginning of theprocess but that got repeated when the midwivescame to us, postnatally they sort of kept lettingus know.Lack of knowledge about entitlements was highlightedas a particular barrier to health care for young womenor women of different ethnic backgrounds who had notbeen in New Zealand very long.She knew [that she was pregnant] but she thoughtbecause she had come straight from Samoa thatshe had to pay to see a doctor and that she had tobe working here. She was only 15 and she didn’tknow, she thought she’d get a hiding.Many women felt strongly that entitlements should bemade clearer.I think it needs to be laid out who, like, what yourmidwife is supposed to provide for you.Definitely information on what the midwife issupposed to be doing for you because when Ichanged to my second one at 33 weeks, the firsttime I saw her she said, ‘Right, so has your firstmidwife talked to you about this?’. ‘No.’ ‘Ok, welldid you discuss this?’. ‘No.’ ‘Has she given youthis?’ ‘No.’ And it was no to everything, there wereall these things, about Vitamin K and, you know,all the decisions you need to make and, um, youknow, I went for my scans but that’s about all thathappened when I was with the first one. It would begood to have some literature saying this is what willhappen every time you go and see your midwife andthen if it doesn’t, you can say ‘Why aren’t you givingme urine tests?’Women also had some suggestions for particularavenues through which entitlements could be madeclearer, including brochures and pamphlets, books,internet sites, 0800 Healthline, advertisements on TV,GPs, midwives, antenatal classes, hospitals, schoolsand colleges.I picked up an excellent book called ‘New ZealandPregnancy Guide’, by Sue Pullon. It was brilliantand very relevant to New Zealand.In summary, women who participated in focus groupswere usually aware of general entitlements such asfree LMC care and access to appropriate information.However, they were unaware of specific details ofentitlements such as the length of postnatal hospitalstay or the number of LMC or Well Child home visits.Entitlements such as free LMC or non-LMC care forurgent problems were not raised by women in any ofthe focus groups.3.4 Labour and birth3.4.1 How long do women spend in hospital aftergiving birth?In 2000, the average length of postnatal hospital staywas 1.96 days for normal vaginal delivery and 4.08 daysfor an uncomplicated caesarean section. 2 The averagelength of postnatal stay is longer for women who givebirth in tertiary facilities compared with primary facilities.This is because the majority of women with complexconditions give birth in tertiary hospitals. 1 Table 15shows the average length of postnatal stay by type ofmaternity facility over the last six years (data reported bythe NZHIS).TABLE 15. Average length of postnatal stay (indays) for mothers by type of facility and yearYearType of facilityPrimary SecondaryTertiaryTotal1999 2.7 2.9 3.2 3.02000 2.7 2.8 3.0 2.92001 2.8 2.8 2.9 2.92002 2.8 2.7 2.9 2.82003 2.6 2.8 2.7 2.72004 2.7 2.7 2.6 2.6These figures suggest that the total average length ofpostnatal stay has declined slightly since 1999. They areconsistent with the latest Maternity Services ConsumerSatisfaction Survey, which showed there was a significantincrease in the percentage of women returning homewithin 12 hours of giving birth (from eight percent in2002 to 14 percent in 2007). 14 Shortened postnatalstays are sometimes considered to be detrimental tobreastfeeding rates, but research has demonstratedno difference in breastfeeding rates between mothersdischarged from hospital at two or three days andchildbirth education: antenatal education and transitions of maternity care in new zealand61

mothers discharged after five days, so long as sufficienthome-based support is provided. 25 Irrespective ofwhen they left hospital, 13 percent of women whocompleted the Maternity Services Consumer SatisfactionSurvey reported not feeling ready to leave hospital. 14When asked why they did not feel ready to leave, thewomen mentioned needing more rest, feeling unwell,breastfeeding issues, facility issues, the baby needingspecial care and medical reasons, as well as feelingpressured to leave.3.5 Breastfeeding3.5.1 What proportion of women have successfullyestablished breastfeeding by the time theyleave hospital?New Zealand has a comparatively high rate of initiationof breastfeeding, with approximately 93 percent ofwomen breastfeeding at discharge from hospital. 2However, many women stop breastfeeding relativelyearly, with a much lower percentage exclusivelybreastfeeding at three months. The percentage ofbabies who are breastfed at two weeks of age isextracted from the MNIS and reported in the last twoReports on Maternity (for 2003 and 2004). 1 Table 16presents these results.TABLE 16. Percentage of babies breastfed at twoweeks of age, by breastfeeding status and yearYearBreastfeeding status 1Exclusively Fully Partially Artificial UnknownTotal2003 53.8 13.2 9.9 9.0 14.1 100.02004 57.4 9.6 9.2 8.7 15.1 100.01Exclusively breastfed refers to babies who have never, to theirmother’s knowledge, had any water, formula or other liquid orsolid food. Fully breastfed refers to babies who have takenbreast milk only, no other liquids or solids except for a minimalamount of water or prescribed medicines, in the previous 48hours. 1Data for breastfeeding rates for babies over five weeksof age are supplied by Plunket and available in thesame report. Table 17 shows the percentage of babieswho were fully breastfed at three months of age overthe last few years.TABLE 17. Percentage of babies exclusively or fullybreastfed by age and yearYear5-6 weeks%3 months%2000 65.1 50.72001 65.6 50.94-6 months%2002 66.3 55.2 23.02003 67.4 54.8 23.12004 66.6 55.7 24.5Examination of the figures in Tables 16 and 17suggests that the rate of full breastfeeding at twoweeks went down between 2003 and 2004, probablybecause the rate of exclusive breastfeeding went up.Between 2001 and 2002, there is an upwards trendin the percentage of babies still exclusively or fullybreastfed at three months of age, but this trend has notobviously continued over subsequent years. Althoughit is not shown here, it should also be noted that Mäoriand Pacific women have lower rates of exclusive or fullbreastfeeding for any given age of the baby thanNew Zealand European women.The apparent increase in early exclusive breastfeedingrates may be due to the Baby Friendly Hospital Initiative(BFHI). This is a joint UNICEF and WHO project aimedat increasing breastfeeding rates (particularly forexclusive breastfeeding) from birth. The New ZealandBreastfeeding Authority was contracted in 1999 bythe then Health Funding Authority to establish theBFHI in New Zealand. The BFHI documents werelaunched in August 2000, followed by an audit of athird of maternity hospitals, funded by the Ministry ofHealth, in 2001. Current maternity service contractsrequire all facilities to work towards becoming BFHIaccredited. Ongoing data collection will allow trends inbreastfeeding rates to be monitored and help determinethe long-term impact of the BFHI.3.5.2 What resources are made available inhospital to help women successfully establish andmaintain breastfeeding?When key informants were asked this question, onlyone respondent named a particular resource. This keyinformant said there was only one ‘official’ resource:62 Families Commission Research Fund

families commission research fundYour Pregnancy, To Haputanga, which is publishedby the Ministry of Health. 26 This booklet containsinformation on being pregnant, labour and birthand what to expect after the birth, including smallsections on breastfeeding and the benefitsof breastfeeding.Most comments from key informants revolved aroundthe quantity and quality of breastfeeding resourcesmade available to women in hospital. They wereuniformly of the opinion that there was an adequatequantity of resources available (for example, in the formof pamphlets and support from nurses), but they weredivided over the quality of these resources. Of the fourkey informants who made specific comments about thequality and quantity of resources, two suggested thatthe BFHI had made a difference.Well these days with BFHI, the resources aroundbreastfeeding in hospitals are just much better.They are consistent; they are up-to-date; they’reaccurate, which is much better; 100 percentimprovement.The other two key informants had concerns overthe quality of information and resources available.One suggested that women often feel intimidated bythe system, and that nurses tell women they mustbreastfeed, but that women don’t fully understand thereasons why exclusive breastfeeding is important. Thesame key informant expressed the opinion that womenneed to be better empowered and educated about theright questions to ask. The other key informant withconcerns about quality expressed a worry that therewas a huge range of resources but no central oversightof their quality.…I think there is a wide range. There is the stufflike Le Leche put out; most hospitals develop theirown or else they just get them from different places.One of the issues around resources that concernsme is that a lot of groups just pull stuff off the netad hoc and there is no overall overview … localleaders might put together a resource kit, but theredoesn’t seem to be any central oversight of whatis in the resource kit as to whether the informationthat is going in is accurate or inaccurate or corrector misleading or whatever. So we end up getting awide range of materials provided which may or maynot be of any validity…Women’s comments suggested that, more often than not,support was available in the hospital to get breastfeedinggoing. They mentioned several different types of supportthey had received for breastfeeding while still in hospital.(1) Advice from hospital staff or midwives aboutbreastfeeding position.That was the first time but I still couldn’t evenget my son to latch on and that’s when I foundout about the rugby ball as well, but this one, helatched on straight away.Yep, and I got them to help me try differentpositions and sometimes I was exhausted or upset.I would just kind of be lying there in the bed andthe midwife would actually hold her on and organisethings and help the breasts produce the milk andthey provided all the sterilising gear and the breastpumps. No one showed me how to use them.(2) Advice from hospital staff or midwives about gettingthe baby to latch on properly.My midwife was great. I mean she showed me whenhe was first born and showed him how to attach.They just grab hold of it.…But you know they said to me every time youwant to feed, ring the bell and someone will come inand make sure that they’re latched on properly.Mine was really good with both, with having acaesarean and then a natural birth, well, a naturalbirth the second time … the second time I wantedthem to check, you know I was getting them tocheck that I was, that she was latching on properlyjust it had, you know, been a while since I hadbreastfed and things like that and I found that theywere quite, really quite good…(3) Advice from hospital staff or midwives about painrelief for sore breasts.I mean you see those black women on tele … andstuff, far out man. I mean I was freaking, I was soshocked. I mean when I was in the hospital, mymother’s going ‘don’t worry about that, put thebubba on’ but I’m not worried about the bubba.You know my sister and I were comparing it toour thumbs. I still remember that day, they [mybreasts] were just so big and they were so sore andvery freaky and painful and you know it was a reliefwhen I was told to put the cabbage leaves on.childbirth education: antenatal education and transitions of maternity care in new zealand63

…Like with the breastfeeding I was starting to getquite sore nipples and she made an appointmentfor me to go and see the … had like a special ozonetherapy room for like steam and ozone on yournipples and she arranged for a person to come andwheelchair me down there and stuff. It was reallygood. She took the time to care about it.(4) Written informationThere’s an awesome pamphlet [about how tobreastfeed and where to go if you have problems].It’s purple … it’s really good, yes.Yeah, and also we got lots of information, um,brochures and things, and a pack the, um, BountyPack, yeah.I got a bag with the Plunket book and otherpamphlets. One was on ‘healthy eating forbreastfeeding women’.(5) PostersI just got posters … they were on the wall…Yes all over the place there were breastfeeding signs…Yeah, I had a very positive experience at the Huttand, yeah, there was the charts in the room sayingthat our policy is to basically encourage you tobreastfeed and not give you formula or whatever inthis list of things…(6) Lactation consultantOh yes, yes and they’ve also got a specialist atthe hospital.It was just like that for four days and after the thirdday they said ‘Right, we’re gonna get the lactationconsultant to come and see you’ and, um, it wasn’tanything I was doing wrong apparently, it was justthe shape of my bosoms and that’s when theyintroduced the breast shields.…the lactation specialist because [baby’s name]had been unwell for the first couple of days andthen he stopped feeding and they put it down tohim being tongue-tied. So we got that fixed, but thelactation specialist, we saw her for five minutes andthen she went to go help somebody else and shewas supposed to come back and see me. Itwas more like five hours later that we saw herbriefly again.(7) Generally supportive hospital staffYes, but they were really helpful up there.I still had the same support, if not more this timearound with baby.I found at the Hutt Hospital they were fantasticand I had some very good advice from a friend.She said it doesn’t matter how good you feel aboutbreastfeeding, if you’re in the hospital, every timeyou give it a go, hit that button and get someone into look.…They always said to me as soon as you’re feedingjust press the buzzer and one of us will come.I pressed the buzzer almost daily because theyalways sort of came and said just press the buzzerand one of us will come.…But I just found them very proactivebreastfeeding of course, but very supportive ofletting me find my own way of doing it too which Iquite liked.However, many other comments also revealed thatsome women felt they had not received adequatebreastfeeding support or that they had to be quiteassertive to get the support they needed.I did buzz her and say to my midwife can you comeand check that he’s on properly because I justwanted to have that checked out. But other thanthat ... but then I didn’t get any help in the hospitalat all. None.I did buzz that I need help with this. It is gettingridiculous. I thought they come in and check. Howare you going? I was like well how do you do it?Where’s she gone?No, nothing. She had a caesarean. So because shehad a caesarean she felt I can’t breastfeed ... shedidn’t really try and the hospital said formula...What you don’t want to feel is rushed, I think, in thatsituation, because it just adds to your stress, and Ithink the difficulty is they are so busy that you kindof inevitably, very few of them are able to give thatkind of service without making you feel sort of…I was surprised in hospital, with the second, thatum,’ cause we had to stay and she got Strep B andah, we had to stay in for eight days and the firstnight we had her in neonates and they said ‘So do64 Families Commission Research Fund

families commission research fundyou just want us to, we will just give her a bottle ifshe cries,’ cause I was up in the maternity ward andI said ‘No, I’m feeding her’, because you know theemphasis is on breastfeed if you can breastfeed,and I breastfed my first, you know, and it all wentwell and that, and there were the neonates, it wasa nurse and she wasn’t very pleasant and she justwanted to shut her up if she cried I guess, andshove a bottle in her mouth, which you know, I’vegot nothing against bottles, don’t get me wrong, butI said ‘No, call me I’m just a couple of floors away.’Women also perceived the difficulty in obtaininginformation on formula feeding as unhelpful, and thetheme of feeling guilty when breastfeeding did noteventuate was common.I think we all know, like all women know, thatbreastfeeding is best but what we don’t want isfor us to feel guilty if we can’t do it and that we’vetried and we can’t do it. And at the end of the dayit is our decision what we do. But for people not tojudge us, because I’ve seen a lot of Mums, they arereally in despair because they can’t breastfeed, theyfeel guilty.And they refused [to give information on formula].I tried every midwife and they said ‘Look, I’m reallysorry, I’d lose my job’.Personally everything is very focused onbreastfeeding and things like that, but becauseI had a caesarean and I’m older, I have all thesekind of different things, it took like seven daysbefore I had milk and nobody prepared me forthe fact that you’re probably going to have to [giveformula], at some point. What’s the right point thatthey’re going to give formula; that colostrum won’tbe enough? Like we had no problem latching andbreastfeeding and that all went fine, except shewasn’t getting anything. I just was devastated whenthey were saying ‘Well, you’re going to have to givethe formula.’ No, that won’t help. She is breastfed.There wasn’t things. It is almost like a dirty word totalk about the formula, where the fact is, you know,I was never breastfed and I turned out ok. Like, it’sok that you have to use some other tactics and shegot formula when she was a little bit, then until mymilk came in, and then she had some top upslater on.Other comments revealed that hospital staff or midwivesgave lots of advice on breastfeeding, but that differentnurses often gave different or conflicting advice.I think the first two or three days I got a lot ofconflicting different advice and there I wasworking out what worked for me becauseobviously all the advice was right. It was just alla bit different.But the first nurse was really good. One of the firstthings she said was ‘Look, everyone is going to showyou how to do things differently and everyone isgoing to tell you different things, but just listen andthen just do what you feel is right.’And every nurse was different ... and had their owndifferent ways. One would say squeeze here, onewould say squeeze here, or they would squeeze itfor me. Do you mind?…I ended up just going home because I justcouldn’t handle every single different person justgrabbing at me, grabbing at the baby and I just…Ijust gave him formula at the end of the nightbecause I was beside myself, he was beside himselfstarving. Yeah, there was a few good ones, but justsome did it their way.…the experience that every eight hours you’ve got adifferent strategy, a different technique, but none ofthem actually really explain what their technique isand why. They don’t talk about the whys at all.In summary, women generally receive writteninformation and support from hospital staff ormidwives for breastfeeding. Although some womenreported a lack of support in hospital with establishingbreastfeeding, the quantity of support was more of anissue with respect to the lack of available resourceson formula feeding, and with the sheer volume ofconflicting advice about how to breastfeed fromdifferent nurses. The Section 88 Maternity Noticespecifies that LMCs must give assistance with andadvice about breastfeeding and the nutritional needs ofthe woman and baby. It is clear that this is occurring.However, the large number of women who reportfeeling guilty for not being able to fully breastfeedsuggests that hospital staff and LMCs should be carefulnot to provide this information at the expense of themother’s mental health.childbirth education: antenatal education and transitions of maternity care in new zealand65

3.6 Transition between LMC andWell Child services3.6.1 What are the contractual arrangements andobligations of LMCs to refer women to WellChild services?The Section 88 Maternity Notice sets out thecontractual arrangements and obligations of LMCsto refer women to Well Child services. 6 The relevantsection from the Notice is reproduced below.DA9 Service linkages: transfer to Well Child services(p. 1061, Gazetted version)(1) A transfer of the care of the baby from the LMC toa Well Child provider must take place before six weeksfrom birth.(2) The LMC must give a written referral to a Well Childprovider that meets the guidelines agreed by theNew Zealand College of Midwives and providers ofWell Child services, before the end of the fourth weekfollowing birth.(3) If the baby has unusually high needs, the LMC mayrequest that a Well Child provider becomes involved asearly as two weeks from birth to provide concurrent andco-ordinated care with the LMC.Therefore, LMCs must refer women to Well Childservices. The referral must be written, must be given tothe Well Child provider, and must take place before thebaby is four weeks old. The actual transfer must takeplace before the baby is six weeks old.All five key informants who were asked this questionsuggested checking the Section 88 Maternity Notice.One also suggested checking the NZCOM professionalStandards of Practice, outlined in the Midwives’Handbook for Practice. 7 Although the standards arenot legally binding, they provide the benchmark formidwives’ practice and describe a series of actionsimportant for midwifery care. The goal of Standard Nineis for the midwife to negotiate the completion of themidwifery partnership with the woman. This involvesorganising ongoing care from other health professionalsand community agencies as necessary.3.6.2 How soon after the baby is born does thetransfer between LMC and Well Childservices occur in practice?Key informants provided different estimates of thetiming of the transfer between LMC and Well Childservices in practice. The majority of estimates rangedfrom two weeks to six weeks.Most LMCs make the referral within two weeks.I think in practice it is occurring at around fourweeks, mostly, but it differs really depending on thearea, I think, and how good the Well Child servicesis (by good I don’t think there is any bad WellChild service); how resourced and how less underpressure the Well Child services are.Well I would say BY six weeks and I would say – yousee there has been a real focus on auditing Section88 around postnatal so it would be a foolish LMCthat didn’t actually do the required number of visitsand all of the forms have got the copy; you know,you have to have your copy of the Well Child referralstuff to get paid, so, yeah…Transfer occurs anywhere between two tosix weeks. The majority of primip women aretransferred by four weeks. Women who have notbeen transferred by then are often women withdifficulties. If the baby is the woman’s second,third, fourth baby, the transfer often occurs attwo weeks.The remaining key informants suggested that the timingof the transfer varies greatly, with one key informantestimating that transfers may occur as late as10 weeks.In practice, it is hugely variable … the transferoccurs from as early as two weeks to as late as 10,but the bulk of them are around six weeks, five tosix weeks. That’s been the last couple of years – inpractice…Other responses also highlighted that the transfer maynot occur at all.Wide variability, if the transfer occurs at all. Whenthe transfer does occur, LMCs tend to duck outearly in the process [soon after the baby’s birth],leaving a gap before the woman is picked up by aWell Child service.In some areas, say 80 percent are transferredbefore six weeks; in other areas 50 percent are. Itdepends on the practice of the LMC. Some aren’ttransferred [at all], and some of that just seems tobe … they don’t get around to doing the bookwork or…66 Families Commission Research Fund

families commission research fundWomen in focus groups (or who were interviewedindividually) were asked to pinpoint when they hadbeen transferred between LMC and Well Child services.All except five women indicated that they had beentransferred to Well Child services before their baby wassix weeks old. There was no obvious difference in thetiming of transfers associated with different WellChild providers. Of the five women who indicated theyhad been transferred later than six weeks, two gavegood reasons for the transfer occurring at sevenweeks, two gave no reason for the transfer occurringbetween seven and eight weeks and one indicatedthat she had had to initiate the transfer around eightweeks because the LMC had not referred her to WellChild services.Ours was marginal I think, because it was aroundChristmas, that six-week period…I think we mighthave had like the Newlands Plunket nurse comeand see us at seven weeks or something.I actually saw the Plunket nurse when he was aboutseven weeks but that was only because I was awaythe previous week.Plunket came when she was between seven to eightweeks old.He is six weeks old now. Plunket will come atseven weeks.The first, um, my first midwife didn’t, she told meshe’d referred me but she hadn’t and so I rangPlunket and that was at eight weeks.Several women who had been transferred before thesix weeks expressed a wish that the transfer could haveoccurred later.I think four weeks, yeah. I would have loved mymidwife to carry on to six weeks.But I know this is kind of atypical to what we foundat antenatal group. A lot of them felt like they’dbeen turfed at three weeks.We were handed over at three-and-a-half weeks,which was just the cusp of what’s sort ofallowed so…Data were also collected from Plunket to further clarifythe timing of transfers between LMCs and Well Childservices. Table 18 shows the percentage of transfersin January to December 2006 that had occurred bydifferent time points after the baby’s birth.TABLE 18. Percentage of women transferredfrom LMC to Plunket in the period from Januaryto December 2006, by time since thebaby’s birthTime since baby’s birth% of womantransferred< 1 week 12 weeks - 5 weeks, 6 days 666 weeks - 9 weeks, 6 days 2710 weeks - 15 weeks, 6 days 316 weeks - 7 months, 4 weeks 27 mths, 4 wks, 1 day - 13 mths, 4 wks 1These figures suggest that, in reality, the majority oftransfers, at least to Plunket, do occur before six weeks(67 percent). However, a significant number occurbetween six and 10 weeks (27 percent), and a smallpercentage occur after 10 weeks (six percent). It islikely these figures differ across different DHB regions.There was an attempt to tighten up the timing oftransfers during the recent revision of the Section 88Maternity Notice. During the consultation phase for therevision of the Notice, there was a proposal to move thetransfer of care from the LMC to a Well Child providerto four weeks from birth (instead of six weeks). 27However, this proposal was rejected by the sector andthe final Revised Section 88 Maternity Notice retainedthe maximum timing of the transfer at six weeks. Thetiming of transfers between LMCs and Well Childservices has received further attention in the review ofWell Child services recently undertaken by the Ministryof Health.3.6.3 What process is used to manage thehandover from LMC to Well Child services?Both key informants and women in focus groups wereasked about the process used to manage the handoverfrom LMC to Well Child services. Responses depicteda series of commonly followed steps to manage thehandover.1. The LMC discusses the handover to Well ChildServices with the mother and her family andwhänau. The LMC may give the mother a choiceof Well Child provider (if available) or simply informthe mother that she will be referred to Plunket.childbirth education: antenatal education and transitions of maternity care in new zealand67

2. Usually by four weeks, the LMC provides a writtenreferral with the family’s details to the Well Childprovider. There is a standard referral form availableto LMCs. The referral is often faxed through to theWell Child provider.3. Shortly after the Well Child provider receives thewritten referral, they phone the mother or familyand whänau to organise the first appointment in thehome.4. Usually by six weeks, the Well Child providerconducts a home visit with the family. Before thehome visit, the Well Child provider often calls themother again to confirm that she will be home forthe appointment.Variations on the handover process that emerged wereusually related to the way in which the LMC gave thereferral to the Well Child provider. Although faxing thereferral form was the most common method used, keyinformants raised several other methods, including:> referral form handed over from LMC to Well Childprovider face-to-face> referral form given to the mother to give to WellChild provider> referral form posted to the Well Child provider> referral form dropped into Well Child premises> LMC ringing the Well Child provider and leaving amessage.…They are required to get that to the WC providersomehow, so I don’t know if we specify exactly howthey have to do it, but maybe they give it to themother who gives it to the WC provider or maybethey post it or drop it in to the clinic or somethinglike that…Yeah. Sometimes someone [an LMC] might ringand leave a message.Women from focus groups raised a couple of extrasteps that may be involved in the handover process,but it is unclear how widely used they are. One motherreported that the LMC had given her the name of herintended Plunket nurse in a handover pack before thefirst visit by Plunket. A different mother emphasisedthat her LMC had made a special effort to ensure thetransfer had occurred effectively.She [the midwife] said that she had called Plunketand the Plunket nurse’s name was in a form withinmy pack … so I knew that [the Plunket nurse] hadbeen informed about me and she came to visit.One thing I would just like to say about that wasthat our midwife was also checking with me that I’dheard from Plunket around that time. I rememberat one of the visits she said, you know, ‘Have youheard from the Plunket nurse yet?’ ‘Yep, yep.’ ‘Ohok, good, what are they doing?’ She wasmaking sure.In summary, comments from both key informantsand focus group participants revealed a commonprocess used to manage the handover between LMCand Well Child service. The steps described meetthe requirements of the Section 88 Maternity Notice;however, there is some variation in the way in whichLMCs give the referral to Well Child services that maydecrease the likelihood of a successful handover. It ispossible that some of this variation may be reducedin the future as a result of the release of the RevisedSection 88 Maternity Notice in July 2007, which makessome of the handover requirements clearer than theywere in the previous version.3.6.4 What processes do Well Child services useto engage women and families and whänauduring this transition?As described in Section 3.6.3, the standardengagement process that Well Child services use whenthey receive the referral from the LMC is to phonethe mother or family or whänau to arrange the firstappointment. The first face-to-face contact the motheror family or whänau has with the Well Child provider isalmost invariably in the family’s home.Comments from focus group participants confirmedthese engagement processes.Yeah. So I ended up making an appointment [forthe Plunket nurse] to come out, which was quitenice. The first visit I had was at home, so that wasquite nice because it is sort of that transition but itis still within your home……one of the Plunket nurses actually came a bitbefore six weeks and sort of took details and thingsdown. It wasn’t a visit as such but it sort of felt likean administration thing, and she said ‘Now we’llmake an appointment for your first real...’However, the number of home visits that womenreported receiving from Well Child providers differed.68 Families Commission Research Fund

families commission research fundI’ve had three at home. I got my first three at home.I’ve had the first two at home.Women’s responses suggested that after the first orsecond home visit, further home visits may be made onthe basis of need.But she has always said, ‘Look if you’ve got any realproblems coming up, let me know and I’ll rearrangeand come to see you.’An arrangement for women to visit the Well Child clinicwas raised as a potential barrier to engagement forsome women.I know one lady who has got two kids … she ismoaning about the Plunket nurse ... but this is onewith two, reckons that she always has to go to theclinic and we have for the last few, yeah, they’ve allbeen at the clinic. That’s fine with me because itis just around the corner and I don’t mind anyway.It’s not too much trouble. I can imagine with two[children] it would be quite an effort, especially ifone is sleeping or whatever and she has got a caras well.Another comment suggested that Well Childengagement processes may differ depending onthe individual style of the Well Child nurse and thetime available.…And one of my friends has actually just swappedto our Plunket nurse because she’s moved and shewas just astounded. She said, ‘She [the Plunketnurse] sat with me for like half an hour and shelistened and she actually talked about the baby’sdevelopment’, whereas the Plunket nurse she hadbeen with previously, it had been completely in andout; not really, but she said she got the feeling thatshe was really not interested in listening to you orhelping her or anything.Women raised several other processes that may beused by Well Child services to engage women. Forexample, the Well Child, Tamariki Ora Health Book isgiven out to women (usually in hospital) and severalwomen reported that they had been told that PlunketLine or Helpline were available if needed. However, inquite a few cases, women reported taking the initiativeto get in contact with the Well Child service.…I rang Plunket Line to start off with and they weresort of like, ‘Ok, you need to ring the Hutt Valley coordinator’and the co-ordinator said ‘Oh ok, wheredo you live? Your Plunket nurse will be such-andsuchperson.’Comments from key informants highlighted theimportance of the Well Child provider receiving thereferral and good handover information from the LMC inorder to begin the engagement process.And see, part of the problem is the name youhave might be a different name, they might havechanged their name, it is all that sort of stuff –so if you don’t actually get a good handover ofinformation, there is so much more opportunity tohave a vulnerable family fall in a gap…Key informants suggested that, in the event of the WellChild service not receiving the correct contact detailsor the family not answering the phone, the Well Childprovider may go back to the midwife for more details ordrop into the family’s home.Well, then people would go back to the midwife …yeah, or they would go to the GP.If they can’t get them on the phone, if they werepassing in the area, they would drop in. Somehow theytry and contact them to set up some appointment.Several additional processes that Well Child providersmight use to engage families were highlighted by keyinformants. One Mäori Well Child provider describedmaking contact with the woman during theantenatal stage.Yeah, on occasions, because now we have amidwifery clinic here once a week and so if they’reover there for their antenatal visit and we’re overthere we’ll introduce ourselves and I’ll go ‘Kiaora, I’m [name], I’m the baby nurse, you mightbe coming to me.’ Or if they come over here to,because we have a class … so they might comeand see [provider’s name] who’s the communityhealth nurse and she’ll go ‘Oh, you’ve been herebefore’ and just show them our place and just say‘Oh, this is what we do after you have baby; if youwant to come to us that’s cool.’ So we can initiatethat contact with them before.The same provider reported that word of mouth was animportant way to engage women in their service.Word of mouth is huge here. Huge. I think it’s aMäori Pacific thing. Yes, very much so. And thenone of the nannies will come down, ‘My moko’spregnant, you’ve got to go up and see her.’childbirth education: antenatal education and transitions of maternity care in new zealand69

Another key informant highlighted that in someareas, Well Child services are at full capacity, makingengagement of further families very difficult. In suchcases, the family may end up seeing only the GP.Well the GP is the default, so the GP shouldn’t beat capacity. The mother will hopefully have met withthe GP before so even though the GP will not beproviding a full Well Child service, from the point ofview of the health promotion/health education sideof things, they will at least have an opportunity tocheck the mother and baby out – ok, and then theGeneral Practice may be able to find another WellChild provider after the six weeks are up…A potential solution that was offered as a means ofhelping Well Child services to plan their services andengagement strategies was the ‘Kidslink’ system. Onekey informant explained that this system involvednotifying Well Child services when a baby was born.But there aren’t many [women] whom we wouldn’tget to that first visit. Eventually we would find them.This is where if you have a system like a Kidslinksystem, it just all makes so much more sense –because you actually have a denominator. Part ofthe problem is that a baby hasn’t been seen, but dowe even know if the baby has been born? Unlessyou have a system where you actually know thebaby has been born...In summary, in order to engage women and theirfamilies and whänau, most Well Child services relyfirst on receiving the referral from the LMC. Followingreceipt of the referral, Well Child providers phone thefamily to organise the first appointment in the homeand then conduct a home visit. Other methods usedby Well Child providers to engage families includedistributing the Well Child book in hospital, PlunketLine, recontacting the midwife for accurate contactdetails, dropping into the family’s home, introducing theWell Child service while the mother is still pregnant andword of mouth.3.6.5 To what degree is the transition betweenLMC and Well Child services left to themother, father or family and whänau?If the transfer from LMC to Well Child services goesas intended, then it should not be left to the motheror family at all. Rather, it is the joint responsibility ofthe LMC and Well Child services to co-ordinate thehandover. However, it is ultimately up to the motherand family and whänau to decide if they want to accessWell Child services.Most comments from focus group participants wereconsistent with a smooth handover in which the transferwas not left to the family.They completely made contact with me, whichwas great.The midwife did all the work.I think my midwife phoned them and gave all …contacted them with all my details about threeand-a-half,four weeks because she wanted them[Well Child provider] to have phoned me beforeshe finished and I only got a phone call about twodays before her last visit and then they [Well Childprovider] came to see me after about two weeks, ora week after she’d finished...Yeah, my second midwife was from Kenepuru soshe was a lot more on hand there. So she changed.I hadn’t heard from them [Plunket] even after she[the midwife] had finally actually handed me over.She [the midwife] rang me up one day and said hadthey [Plunket] got in contact with me. I said no. Shechased it up for me, so that was really good.However, a few women indicated they had takenresponsibility for contacting the Well Child providerthemselves. Usually this was because they had notheard from the Well Child provider at the expectedtime. Other women reported that their LMC hadfinished with them sooner than desired and they did notwant to wait for the Well Child provider to contact themin order to access ongoing support.At four weeks my midwife said, ‘I’ll do the referralto Plunket and hand you over and you should hearfrom them within a week … and I didn’t hear fromthem and by the beginning of the next week said,‘Oh’; of course he’s coming up to six weeks by thatpoint. So I started ringing round.Yeah I did [have to chase] as well ... so the referralwas done at four weeks and I had my midwife againat five [weeks] and then nobody turned up at six[weeks]. They were supposed to have rung melike in the first half of that week and so I rang mymidwife back and said ‘Nobody has contacted me.’So she came back and did another visit and thenthe week after that I left messages with all sorts ofpeople in Plunket and somebody did ring me back70 Families Commission Research Fund

families commission research fundand then came at seven weeks. So I didn’t have agap at all, but my midwife, I suppose, did an extravisit that she probably wasn’t supposed to do.... my first midwife didn’t, she told me she’dreferred me but she hadn’t and so I rang Plunketand that was at eight weeks.I think quite a bit of that was proactive on thewomen’s behalf – hunting Plunket out because theywere really struggling.Key informants acknowledged that the transitionbetween LMC and Well Child provider was sometimesleft to the parent.In some areas [of the country], it is often left to thewoman or her family to a large degree...In reality, in some areas, it is totally [left to thefamily], but they don’t know it has been left tothem … a midwife has said if they want Plunket,they can ring.Further comments from key informants yieldedinformation on why the transition was sometimes leftto the family. An obvious reason that women do nothear from the Well Child provider is that the referralfrom the LMC is late or not made at all. Key informantsdiscussed some of the underlying reasons for problemswith referrals.…what we found with some people is that theywould say they had referred to the Well Childservice on this date, but then it took them a monthto post the stuff.Yeah, yeah, and sometimes the midwives are sobusy that they’ve forgotten to put the referral in.We get it two months old. So there’s a lot of ‘I’msorry’. Unfortunately we don’t know about thebaby prior if we haven’t got a referral … weactually don’t know about them. And then they[mothers] go ‘Well I haven’t been seen’; thebaby is nearly three months old. It has happenedabout three or four times so far and we feelstink about it but, you know, we need to work reallywell with the midwives to make sure that theygive us the referrals.…we do know that some parents think they havebeen referred and nothing happens and a referralhas never gone, so they sit around waiting for aPlunket nurse to turn up…The parents have a choice about what servicethey want and if they don’t want their name handedover, well then that’s up to them. What we havefound is that there are a few individual midwiveswho perhaps see it, it’s like it is a part of theirpractice, that the family doesn’t need anotherservice. Because you sort of see, one of thethings about having a national organisation is thatyou see patterns, and then the family comes tous much later but it seems to be very rare thatthey do not come [at all]. They eventually startturning up.It might [also] be no referral. The referral might bedone in a way that doesn’t work well – it might begiven to the mother or something like that and formost mothers that would be fine but for some, itmight be just too difficult…Only one key informant raised the possibility ofproblems with the transition potentially being due toWell Child providers having a lack of capacity to followup referrals.…it might be a Well Child provider capacity issue. Ithink all of those provide opportunities for mothersto fall through the gaps really.Another key informant pointed out that sometimes afailure in the transition process was due to parentschoosing not to access Well Child services.Referrals need to be followed up. Short of draggingpeople along that don’t want to do it, I can’t believethat between the LMC and Well Child, that theyhaven’t gone to every means. There will be peoplewho do not attend, and it might be the sixpercent who don’t get immunised; but I suspectthat just about every baby in the country must,because there must be some who choose not toget immunisation…One of the issues raised that contributes to problemswith the transition between LMC and Well Child serviceis a lack of monitoring.Well it’s very hard to get information which gives usenough depth on this because it’s not somethingwe normally collect, exactly how that transitionoccurred. We know when it occurred and that sortof stuff. In some situations obviously the mother orthe parents have the opportunity to say they don’twant a referral; however once the WC provider haschildbirth education: antenatal education and transitions of maternity care in new zealand71

got the referral, then the parents have identifiedthem as their provider, then they are obligedeffectively to go and visit them, but at the end ofthe day if someone hands on a referral and nothinghappens then there is no action, we don’t knowanything about it and there is no action that wecould take, there is no monitoring effectively ...all we require from Plunket or another Well Childprovider is that they provide a certain volume ofservices; there is no obligation to pick up anyparticular one that is referred to them.Despite these issues, a key informant reported therehad been big improvements in the reliability of thetransition process in the past couple of years, mainlyas a result of changes in the referral processes usedby midwives.Yeah, it is [left to the parent]. But you know therehave been big improvements in this area in the lastcouple of years. A couple of years ago, I went tothe College [of Midwives]; we work very well aroundthese things; they asked me to present our dataabout ... you know, factual information on when wereceived referrals, and they were quite shocked.In summary, the transition between LMC and Well Childprovider is not generally left to the parent. However,comments from women and key informants suggesteda lack of consistency in the transition process in someareas of the country that contributes to women andfamilies either having to take the initiative themselvesin order to receive ongoing support, or falling throughthe gaps. The reasons given for problems with thetransition process were midwives failing to make a formalwritten referral, midwives sending the paperwork toWell Child providers late, midwives forgetting to sendthe paperwork, midwives giving the paperwork to thefamily instead of Well Child provider, philosophicaldifferences between midwives and Well Child providers,Well Child providers having a lack of capacity to followup all referrals, Well Child providers failing to follow upall referrals, parents choosing not to access Well Childservices and a lack of monitoring of the transition process.3.7 Well Child services3.7.1 Who are the providers of Well Childservices?The names of the Well Child providers in each regionwere supplied by DHBs and are listed in Appendix11. Most of these providers hold contracts with theirlocal DHB to deliver Well Child services, with the majorexception being Plunket, which holds a national contractwith the Ministry of Health to deliver Well Child services.Plunket is the biggest provider of Well Child services.Over 90 percent of babies are seen by Plunket forWell Child services. 28 The rest are seen by Mäori, iwiproviders, Pacific providers, public health nurses, childhealth nurses (through Primary Health Organisations)or GPs.Comments from key informants were consistent withthe information supplied by DHBs.…It varies around the country – in some DHBsPlunket provides 100 percent (of Well Childservices), in others, they provide 70–80 percent.On top of Plunket, there are about 50–60 otherproviders of Well Child services which are small,often Mäori or Pacific providers; some of them arealso Primary Health Organisations…3.7.2 What are the contractual arrangements andobligations of Well Child service providersas they relate to transitions of care fromLMC to Well Child services?The contractual arrangements and obligations of WellChild service providers are outlined in The Well ChildFramework 4 and the national service specificationsfor Well Child services. 12. The Well Child Frameworkrequires Well Child providers to register all childrenhanded over by LMCs. Appendix 12 contains theclauses from the national service specifications that arespecifically relevant to the transition of care betweenLMCs and Well Child services.The Service Specification requires Well Child services to:> enrol or register the client on their system whenthey receive the written referral from the LMC (byfour weeks after birth)> provide services ‘initially’ in the client’s home andonly change to the clinic setting if the client canmake the transition> undertake an initial assessment of the family> have ‘formal links’ with LMCs> report on the total number of children enrolled withthe service at the end of each quarter.More specific information was obtained from keyinformant interviews. Well Child providers are expected72 Families Commission Research Fund

families commission research fundto make contact with each family that is referred tothem. The first visit is in the home for all new babycases, and there are usually two home visits (decidedbetween parents and nurse). It is recognised that somefamilies will require more effort to contact than othersand that considerable persistence will be needed insome cases. Clients living in areas of higher deprivationare more likely to have ongoing contacts at home.That is up to them [the number of attempts to makecontact with a family], but in actual fact, we expectthem to [make contact].…All new baby cases are visited at home for a firstvisit; usually there are two home visits [decidedbetween parent and nurse]. Clients in dep. 8–10are more likely to have ongoing contacts at home.Well, the reality is that serving high-needpopulations is difficult and just to keep in contactwith them, whether it is first, second or thirdcontact, is no different, and what we find is thatstaff working in those areas become quite skilled,and we work with The Well Child Framework abouthow we are serving areas living in high populationneeds. We are actually serving them so much betternow than we were, say, in 2002, and much higherproblem proportions because the difference from2002 until now is that our funding recognised thatit actually took more resources to see these people.Up to that point, it [the funding] didn’t.Therefore, under the current system, Well Childservices are obligated to register and make contactwith every family and whänau for whom they receivea referral. They are also obligated to provide servicesinitially in the family home. There is an expectationthat Well Child services will keep trying until successfulcontact is made with a family. However, there are nodetailed specifications on how this should be achieved(for example, nowhere is it specified the number oftimes a Well Child provider should attempt to makecontact with a family) and, under the current system,there is no way of monitoring the number of familiesthat are not followed up. The current funding modeldoes, however, allocate additional resources for makingcontact and conducting additional home visits withvulnerable families.3.7.3 What are the demographics of mothersand families and whänau who receive WellChild services?Over 90 percent of babies receive Well Child servicesfrom Plunket. Plunket records the ethnicity and levelof deprivation of all new babies they enrol. Level ofdeprivation is based on Statistics New Zealand’scomposite measure of socio-economic deprivation,called the New Zealand Index of Deprivation (orNZDep2001 scores). NZDep2001 combines ninevariables from the 2001 Census which reflect differentdimensions of deprivation. NZDep2001 provides adeprivation score for each meshblock in New Zealand.Meshblocks are geographical units defined by StatisticsNew Zealand, containing a median of approximately90 people in 2001. NZDep2001 scores range from 1to 10. These scores divide New Zealand into tenths,with a value of 1 indicating that the meshblock is in theleast deprived 10 percent of areas in New Zealand anda value of 10 indicating that the meshblock is in themost deprived 10 percent of areas in New Zealand. 29Table 19 shows the number and percentage of all newbaby enrolments with Plunket from 1 July 2005 to 30June 2006, categorised according to ethnicity andNZDep2001 score.TABLE 19. Number and percentage of Plunket new baby enrolments from 1 July 2005 to 30 June 2006 byethnicity and NZDep2001 scoresDep. 1 – 7 Dep. 8 – 9 Dep. 10 TotalEthnicity n % n % n % n %Mäori 5,296 15 3,528 31 2,785 41 11,609 22Pacific 1,601 5 1,713 15 2,106 31 5,420 10Other 28,336 80 6,205 54 1,823 27 36,364 68Total 35,233 100 11,446 100 6,715 100 53,393 100childbirth education: antenatal education and transitions of maternity care in new zealand73

As shown in Table 19, 22 percent of new Plunketenrolments were Mäori, 10 percent Pacific and 68percent ‘other’. These figures are comparable to the ethnicbreakdown of all women giving birth. For example, in2004, births to Mäori and Pacific mothers accounted for19.9 percent and 10.1 percent of all births respectively. 1Out of all new Plunket enrolments, 66 percent hadNZDep2001 scores of 1 to 7, 21 percent had NZDep2001scores of 8 to 9 and 13 percent were in the most socioeconomicallydeprived areas, with NZDep2001 scores of10. These scores reflect less deprivation compared withNZDep2001 scores for all women giving birth. In 2004,58.4 percent of women giving birth had NZDep2001scores of 1 to 7, 26.6 percent had NZDep2001 scores of8 to 9 and 14.9 percent had NZDep2001 scores of 10. Adisproportionate percentage of Mäori and Pacific babiesenrolled by Plunket were living in the most deprived areas.The demographics of families and whänau who receiveWell Child services can be expected to differ dependingthe nature of the contact. From the time of handoverfrom LMC until the child is five years of age, all familiesare entitled to receive eight core contacts from WellChild services. These contacts are outlined in theWell Child – Tamariki Ora National Schedule. 10 Anycontacts outside of the core contacts described inthe schedule are ‘additional’ contacts. First-timefamilies and those experiencing difficulties or havingan assessed need are entitled to additional contacts.Both core and additional Well Child contacts may be‘received’ in various places, including the home, clinic,mobile clinic, family centre, early childhood centres, orMäori settings such as marae or Köhanga Reo. Table20 shows the number of Plunket contacts from 1 July2005 through to 30 June 2006, as a function of placeof contact, type of contact (core versus additional)and NZDep2001 score of the family. See Appendix 13for an expanded version of Table 20, which includesungrouped NZDep2001 scores.TABLE 20. Number and percentage of Plunket contacts from 1 July 2005 to 30 June 2006 as a function ofplace of contact, type of contact (core versus additional) and NZDep2001 scoresPlace of contactBus – mobile clinicClinicEarly childhood centreFamily centreType ofcontactCoreAdditionalCoreAdditionalCoreAdditionalCoreAdditionalDep. 1-7n (%)290(0.1)1,232(0.4)120,753(36.1)53,770(16.1)943(0.3)1,319(0.4)1,728(0.5)19,515(5.8)NZDep2001 scoreDep. 8-9n (%)351(0.3)1,120(0.9)22,868(19.1)13,364(11.2)411(0.3)560(0.5)467(0.4)4,614(3.9)Dep. 10n (%)673(0.9)1,536(2.0)6,975(8.9)4,978(6.3)398(0.5)717(0.9)169(0.2)1,262(1.6)Total N(%)1,314(0.2)3,888(0.7)150,596(28.2)72,112(13.5)1,752(0.3)2,596(0.5)2,364(0.4)25,391(4.8)74 Families Commission Research Fund

families commission research fundCore81,506 37,060 26,755 145,321Home(24.3) (31.0) (34.0) (27.3)Additional53,069 37,838 33,975 124,882(15.8) (31.6) (43.2) (23.4)Core185249292726Köhanga Reo(0.1)(0.2)(0.4)(0.1)Additional496716816 2,028(0.1)(0.6)(1.0)(0.4)Core16201551Marae(0.0)(0.0)(0.0)(0.0)Additional697371213(0.0)(0.1)(0.1)(0.0)Total N 334,891 119,711 78,632 533,234Total % 62.8 22.4 14.7 100The biggest proportion of Plunket Well Child contactsis made up of core contacts at the clinic (28 percent),followed closely by core contacts in the home (27percent). These contact types are then followed, inorder, by additional contacts in the home (23 percent),additional contacts in the clinic (14 percent) andadditional contacts at the family centre (five percent).A small percentage (one percent) of Plunket contactsare additional contacts via a bus or mobile clinic and aneven smaller percentage (

Core19,538 6,664 124,394 150,596Clinic(17.4) (11.4) (34.4) (28.2)Additional9,418 3,236 59,458 72,112(8.4)(5.5) (16.4) (13.5)Core457288 1,007 1,752Early childhood centre(0.4)(0.5)(0.3)(0.3)Additional740415 1,441 2,596(0.7)(0.7)(0.4)(0.5)Core36976 1,919 2,364Family centre(0.3)(0.1)(0.5)(0.4)Additional2,676675 22,040 25,391(2.4)(1.2)(6.1)(4.8)Core36,727 22,064 86,530 145,321Home(32.6) (37.6) (23.9) (27.3)Additional38,383 23,151 63,348 124,882(34.1) (39.5) (17.5) (23.4)Core6293859726Köhanga Reo(0.6)(0.1)(0.0)(0.1)Additional1,77596157 2,028(1.6)(0.2)(0.0)(0.4)Core3611451Marae(0.0)(0.0)(0.0)(0.0)Additional161844213(0.1)(0.0)(0.0)(0.0)Total N 112,522 58,623 362,089 533,234Total % 21 11 68 100These percentages show that Mäori and Pacific familiesare more likely than ‘other’ families to receive core andadditional Well Child services in mobile clinics, earlychildhood centres, Köhanga Reo and especially thehome. Mäori are also slightly more likely than eitherPacific or other families to receive Well Child servicesin the marae setting. Families categorised as ‘other’(mostly New Zealand European) were more likely thanMäori or Pacific to receive core or additional Well Childcontacts in the clinic or family centre. All together,48.3 percent of Mäori contacts were additionalcontacts; 49.4 percent of Pacific contacts wereadditional contacts; and 40.8 percent of ‘other’contacts were additional.In summary, the ethnicity of mothers and families andwhänau receiving Plunket Well Child services closelymirrored the ethnicity profiles of all women givingbirth. This is perhaps not surprising, given the highpercentage of babies who receive Well Child servicesfrom Plunket. On the other hand, the NZDep2001scores of Plunket clients reflected, on average, lessdeprivation than the NZDep2001 scores of all womengiving birth. This suggests either that the most deprivedwomen and families and whänau access Well Childservices through alternative providers, or that Plunkethas more difficulty in engaging families and whänaufrom the most socio-economically deprived areas.Family demographics also differed depending on76 Families Commission Research Fund

families commission research fundthe place and type of Plunket contact (core versusadditional). The percentage of contacts in non-clinicalsettings such as the home was higher for families andwhänau living in areas of high deprivation and for Mäoriand Pacific families. A greater proportion of contactsin high-deprivation areas were additional contactscompared with less deprived areas. Similarly, a greaterproportion of Mäori and Pacific contacts were additionalthan contacts with families of ‘other’ ethnicity.3.7.4 What are the barriers to accessing WellChild services?Several barriers were recognised by key informantsand focus group participants. They can be categorisedinto characteristics associated with the familiesand whänau, service or system (with some barriersoperating at more than one level).Barriers at the family and whänau level:1. Culture and ethnicityKey informants viewed white women as big users ofWell Child services, and Mäori or Pacific women as lesslikely to use mainstream services. They felt that Mäoriand Pacific women were more likely to view mainstreamservices as unsuitable or not culturally sensitive.Educated white women are big users of services –they may lack confidence, want to be perfect, needreassurance.Some of the Pacific women spend a day cleaningthe house for the provider to visit; they are not verycomfortable.Mäori focus group participants and a Pacific keyinformant suggested that shyness is a barrier,preventing women from asking questions.Maybe shyness … don’t like to ask [firstparticipant]. And that could be a cultural thing too.It’s not as much now as it used to be. Culturally youdidn’t ask a lot of questions [second participant].Pacific women are very polite, so often they do notsay what is wrong.Mäori participants also suggested that differences inculture may mean they do not identify with the provideror may feel intimidated.And I feel sometimes people might feel intimidatedbecause their understanding is not what, I don’tknow, those that are providing; they’re not on thesame level, on the same wavelength.2. LanguageLanguage was raised as a barrier by Pacific focus groupparticipants and refugees.I guess with my experience some people from thePacific, they came here on a budget and things arevery strange for them. It’s a new environment andthey’re not used to new people, and language, that’sa big barrier.Because we have been new here, we don’t knowanything about the Pacific health nurse or Plunketor whatever and the language is the problem. Theycan’t communicate.If you don’t have the language, you don’t haveanything; you can’t explain what is wrong.For Pacific women who don’t speak English, theyrely on whänau.3. Socio-economic statusSocio-economic status was explicitly listed as abarrier by only one key informant. However, both keyinformants and focus group participants named lack ofresources, such as transport problems, as a barrier.Yeah, that could be one [a barrier]. Not being ableto get there…Pacific women don’t attend the clinic because itwould mean hauling children into the clinic andoften they don’t drive.Although Well Child services do make contact withthe majority of families and whänau across all socioeconomicstrata, successful contact and engagementrequires more persistence with families who havegreater need. Families and whänau living in moredeprived areas are also less likely to proactively seeksupport from Well Child services, therefore are morelikely to fall through the gaps if the transfer from LMC toWell Child provider is not well co-ordinated.4. Family mobilityKey informants raised the issue of transient families.Families who move house frequently are more difficultto keep track of and may be less likely to access WellChild services.5. Violence and drugs in some housesIn some areas, violence and drug use are barriers tofamilies seeking support from Well Child services, andalso act as barriers to Well Child providers conductingchildbirth education: antenatal education and transitions of maternity care in new zealand77

home visits. One key informant reported that becauseof safety issues, providers in some areas only go out tohouses in pairs.6. Perception or beliefsTwo key informants suggested that some families andwhänau perceive services as unnecessary or do notaccept they have a need for them.Some parents, especially parents who have hadseveral children, feel as though they don’t need WellChild services.7. Lack of knowledgeLack of knowledge was thought to be a significantbarrier. Specifically, there is a reported lack ofknowledge about the availability of Well Child services,entitlements to Well Child services and the type ofservices that Well Child providers offer. When asked tolist barriers, key informants commented:Knowledge of Well Child services.Knowledge of entitlements.Comments from focus group participants included:…not knowing what you are entitled to.They [families and whänau] probably don’tunderstand.Lack of information.For some families, something as basic as not knowingwhere the Well Child service is located could be abarrier after the initial home visits.…but you don’t know where the place is, that’sthe problem.8. Relationship with Well Child providerKey informants raised the relationship between theparent and Well Child provider as a potential barrier toaccessing services.Sometimes there are personal issues; sometimesthey didn’t like their nurse or provider, in a way …and so they found them too bossy or something…Focus group participants also talked about theirrelationship with the Well Child provider as a barrier ifthey did not like them.I think, also, if you don’t particularly like yourPlunket nurse it can be a bit off-putting to gobecause you feel uncomfortable.Barriers at the service level:9. Lack of trust or rapport between Well Child providerand the family and whänauThe family’s relationship with the Well Child providermay be influenced by their own personal issues, asdescribed above. Equally, the level of trust and rapportis determined by the actions (or lack thereof) of theWell Child provider. A Mäori Well Child provider,sitting in on one of the focus groups, discussed theimportance of developing rapport.Here, we’re always aware of how we communicatewith our clients and every new client we need toget that rapport, that trust and then work out, youknow, how we say things…’You tell us somethingabout you, like your family’, so it feels like they’renot just a number but we really do care about ourconversation. It’s more than just walking in andgoing ‘Ok, we’re going to do this, ok we’ll do that.’ IfI don’t walk in and say ‘Oh hi, I’m [name], I’m from[name of place]’ and try and get some sort oftrust going, then I know I might not be gettinganother visit.10. Lack of cultural competenceFocus-group participants named providers’ lack ofunderstanding of their culture as a barrier to accessingWell Child services. This could be manifested in aprovider failing to explain something in a way someonefrom a different culture would understand or in aprovider being intolerant of or impatient with the waysomeone from a different culture explains something.I think, not being racist, but I think a lot ofEuropeans don’t understand the background ofour Pacific Island people and where they’recoming from…11. Relationship between LMC and Well Child providerA poor relationship between LMC and Well Childprovider is a barrier to access. One key informantdescribed this barrier as “professional violence” andwhen asked to elaborate, said:Well you know just – and these are the exceptions,not the rule – that the LMC might say that I can’trefer to Plunket because they will wean the baby, orsomething like this; this sort of nonsense.Focus group participants pointed out that the LMC mayhave a large role in determining the Well Child providerto which a family and whänau is referred.78 Families Commission Research Fund

families commission research fundAnd also at the same time they [LMCs] are givingthem [mothers] the choice of whether to go to thePacific providers or to Plunket…12. Lack of sharing of knowledgeOne key informant raised the lack of sharing ofinformation between LMCs and Well Child providersas a barrier. Her point was that information about thefamily that may be valuable in engaging and workingwith them may not be passed on from LMCs to WellChild providers.…it is also the lack of the sharing of knowledge. Iguess one of the frustrations, and it is somethingthat we hope to work with the College of Midwivesthis year, you know the midwives work with thefamily; they know if there is family violence or stuffthere. We pick up the family and none of thatinformation comes with it … we’ve got to keep thefamily as the focus; I think that gets a bit lost.13. Problems with the handover process from LMC toWell Child providerAs described in Sections 3.6.3 and 3.6.4, Well Childproviders rely on LMCs providing a written referral toinitiate the engagement process. Sometimes there areproblems with the handover process that may preventfamilies and whänau accessing Well Child services.These are summarised in Section 3.6.5.Most people access Well Child services; it’s just thatsome aren’t able to access it until much later. Andwe get calls from people – ‘Why haven’t you visitedus?’ – and yet there has been no handover.14. Unrealistic time-slotsFocus group participants described some time-slotsfor appointments with Well Child services as unrealisticand viewed the poor timing of the appointment as abarrier to access.…shy away from anything before 10:30 in themorning, definitely. Getting to it can be a realmission. And you know if you are going to a 20-minute slot and you’re running 10 minutes late,you’re really buggered.Barriers at the system level:15. Availability of the serviceLack of awareness of the availability of the service wasa barrier, but the actual availability or existence of theservice was cited by one key informant as a barrier too.In some areas, there are greater demands for WellChild services because of a higher number of birthsor fewer providers. In such circumstances, Well Childproviders may lack capacity to follow up all referrals,and the chances of a family and whänau not receivingservices increase.16. RuralityThree key informants listed rurality or geography as abarrier. Women and families living in rural areas mustoften travel greater distances to access services. Thisrequires more time and finances.17. StigmaOne key informant listed stigma or fear of being judgedby providers as a potential barrier.18. Lack of monitoringAs described in Section 3.6.5, one of the issues thatcontributes to families missing out on services is alack of monitoring or tracking of individual familiesthrough the system. One key informant suggested thathaving a national database of births would be helpfuland referred to the Kidslink system in South Aucklandas a potential model. All babies born in the area (atMiddlemore Hospital) are entered into the Kidslinkinformation management system. Kidslink trackschildren who have missed their scheduled Well Childchecks or immunisations. Local services find thesechildren and link them with a health provider.Well, I think that having a national database that allbirths went on, and one could have a system – likeKidslink in South Auckland… I mean the SouthAuckland DHB and all the Well Child providers andthe GPs are actually part of the Kidslink systemof sharing information and they share informationabout Well Child checks and immunisations – upto-date,simple stuff, but gosh, it highlights thefamilies who are actually missing out. And peoplecan put around the system – does anyone know;has anyone seen this family? ... because often themost vulnerable family members are mobile ones.19. Cost of accessing serviceAlthough the core visits that all children are entitled toare free, there are still costs associated with getting tothe clinic (after initial home visits), the time needed tohave the session and time away from work (if the parenthas returned to work).childbirth education: antenatal education and transitions of maternity care in new zealand79

In summary, many of the barriers to accessing WellChild services listed by key informants and focus groupparticipants are the same as barriers to accessing otherservices throughout the world, and include financialdifficulties, lack of transportation, language barriersand attitude. 30 The New Zealand Government hasaddressed several common barriers by funding eightfree core visits (and more for high-needs families)and requiring the initial visits to be home visits. TheWell Child Framework has undoubtedly contributed toimproved access rates, particularly for higher needsfamilies. 4 Work is needed to continue to addressbarriers to access.3.7.5 What screening is done for postnataldepression (PND)?PND occurs in 10–20 percent of women by threemonths after giving birth. 31 There is evidence thatPND is more common among women who havehad previous mental health problems 32 and it isassociated with various poor developmental outcomesfor children. 33 The Section 88 Maternity Noticespecifies that midwives must do an assessment forrisk of PND (and in some cases family violence),with appropriate advice and referral, as part of themodule of services following birth. In addition, it isa midwifery standard of practice (number three) to“collate and document comprehensive assessmentsof the woman and/or baby’s health and wellbeing”. 7As part of their assessment, midwives are supposed tocollect information which includes women’s physical,psychological and emotional wellbeing.Key informants confirmed that many midwives doscreen for PND, at least informally.I would say, I can’t believe the LMCs wouldn’tassess women for that [PND]. And again, inour maternity notes, it has a box for postnataldepression, so I can’t believe that people wouldn’tassess them.If a midwife thinks a mother is at risk, shewould screen.There was also, however, discussion about howmidwives were not necessarily the best workforce tobe screening for PND, mainly because symptomsfrequently emerge after the six-week handover toWell Child services.LMCs are not really the workforce for PND becauseclinical symptoms often don’t emerge until threemonths after birth.Key informants reported that Well Child providers dosome selective screening.…every Mum who came to the Family Centre withfeeding or sleeping or other difficulties, there was anexpectation they would do an Edinburgh [EdinburghPostnatal Depression Scale 37 ] on the Mums when theycame in, so that wasn’t universal screening, that wasa selected population with Mums who were havingtrouble who were much more likely to get PND.And there are some PND support groups.Many centres have PND support groups.Some of our Family Centres provide postnatalsupport groups, PND support groups and in twoto three places, we have postnatal adjustmentprogrammes funded through the DHB and so theywork seamlessly.However, screening by Well Child providers is notformal, routine or universal.Not in a formal screen such as using the Edinburgh,but informally, yes.This [screening] is random and ad hoc; verysubjective.Screening is not done routinely, although it maybe introduced.There were several reasons given for the lack ofscreening, including a lack of staff time, the structureof the existing Well Child services and a lack ofback-up services.…The problem is the amount of time that staffhave, and also it is not only that – say we find thescore indicates high, so what are we going to doabout it? It is about what services are there.But the nurse who does home visits has about a20-minute contact with the parent and there is awhole lot of stuff to do within that. If we are reallygoing to address the PND issues, we actually haveto look at it in a broader context; so you’ve identifiedthis depression, you can’t just say ‘Yes, you havedepression’, and not do something, whereas the80 Families Commission Research Fund

families commission research fundway The Well Child Framework is set up, we mightnot see them for three months. That would beridiculous.In this grey area, I see a Well Child nurse being ableto do this, do the work, but it is interfacing aroundwhen should we be doing this referral and havingsomeone to refer to.One key informant suggested there should bemultiple screens.There should be more than one screen – thereshould be LMC and Well Child screens. The GPshould have a red flag to check for PND when amother with a young baby visits.Consistent with comments from key informants, themajority of comments from focus group participantssuggested that their LMC had at least informallychecked how they were feeling.Yes, [my midwife checked] to see how I was… Iwas exhausted and I cried a lot but I don’t know ifit was depression. I think it was just hormones andgetting over an operation and I was bored and Icouldn’t do a lot of what I used to be able to.I think our midwife did. We had a really closerelationship with our midwife and she was actually ourantenatal class educator. We changed to her after wemet her at antenatal class and we had a really closerelationship with her and she was very, very supportiveand I think her approach was very much sort ofchecking on how I was going and how I was feelingabout things so I could always tell her when I’d hadcrying outbursts in the middle of the night and all thatkind of thing. I think she did that but I think it was justsort of part of who she is, the kind of support that shewas providing across the board.My [midwives] were good in asking about, like, howyou are going and do you need anything……My midwife certainly did postnatally.Both my midwife and Plunket asked me how Iwas feeling.Two comments from different women suggested thatmidwives also checked how the father was feeling.At times when my husband was there in the firstweek the midwife certainly did ask him how hewas doing.Yes, I remember she asked [my partner] a lottoo how he was going, it was like she was equallyinterested in both of us.Some women reported being checked by their WellChild provider (Plunket).The Plunket, they asked.The Plunket nurse asked me.A couple of focus group participants who hadexperienced depression in the past reported beingaware of multiple informal checks.Both midwife and Plunket were really [good]; I’vehad depression in the past so that was in my notesfrom my obstetrician so the midwife at that six-weekvisit said ‘Look, you’re going to need to be awarethat sleep deprivation and tiredness could bring thisback and we are going to need to really keep an eyeon it together’, and she actually also was speakingto my husband about that and signs and things tolook for and then … I mean we had only met herat the 36-week visit but she was great and I getalong with her so I felt I could tell her anything, andthen Plunket, I don’t know whether it got, I assumeit must have got transferred in my notes, but ourPlunket nurse has been really … proactive aboutasking how I’m feeling and how I’m doing and howI’m getting along with it and everything, but we’vealso had a very good GP as well.My midwife did, and Plunket; I actually had a fewepisodes of depression while I was pregnant so Iwas worried that I would be a PND jobbie but as ithappened, I was fine and I was just getting it out ofmy system while I was pregnant.One mother who was interviewed individually reportedthat her midwife had encouraged her to get helpfor PND.I told my midwife that I was sad and crying all thetime. She arranged for counselling and I got to seethe GP.A smaller number of comments suggested that therehad been a lack of screening for PND, or, that in thecurrent system, adequate screening was difficult.No, (no-one checked) – my husband was workingfull-time, and my aunty, she was in Petone so wenormally just meet at the weekend but I foundduring the week it was a bit lonely.childbirth education: antenatal education and transitions of maternity care in new zealand81

I found it quite hard because we never had amidwife. We had three midwives because we hadthe hospital team and we had different people comein. I saw different people throughout the pregnancy,and then have your baby and have whoever’s onthat night, and then afterwards the home visits wereagain different people coming. There were threeladies but they, a different one would come eachtime and there was one I felt like I made more ofa connection with so I started to actually schedulethe home visit so that she would come, like make itso it would fit with her, but I think that if I had beendepressed, and I wasn’t, everything was good, but ifI had been, I don’t know if they would have pickedit up because I felt like one particular lady wouldcome in, ‘How are you going love?’, she didn’t knowmy name, she didn’t know anything about me…Another consideration is that up to seven percentof women suffer symptoms of post-traumatic stressdisorder (PTSD) following birth. 34 Some of theassociated behaviours and feelings look a lot likedepression, and PTSD or trauma may be misdiagnosedas PND. To confuse matters, the two are oftenco-morbid. It is important that LMCs and Well Childproviders can recognise PTSD following birth. Midwivesnow attend continuing professional education (CPE)workshops on both PND and PTSD. There are supportgroups available for women and their families andwhänau on both PND and PTSD.In summary, there is a considerable amount ofliterature on the nature of emotional changes followingbirth and it is likely that the majority of LMCs are awareof the risk of PND and informally screen their clientsfor it. 35 The same is probably also true of Well Childservices. It was clear, however, that the screening forPND is not systematic or universal and often takesthe form of the provider simply asking the motherhow she feels. Such an approach is highly subjectiveand inevitably results in some women with PND beingmissed. The work of Horowitz suggests that detectionof PND could be increased significantly by adaptingresearch-based screening procedures to clinicalcare. 36 The systematic use of an instrument such asthe Edinburgh Postnatal Depression Scale would beone such example. 37 Reliable methods to detect birthtrauma (PTSD) are also needed. The possibility ofsystematically screening for PND is currently beingconsidered as part of the Ministry of Health’s reviewof Well Child services and may be a reality in thenear future.82 Families Commission Research Fund

families commission research fund4. DISCUSSION ANDCONCLUSIONSThis project provided data relevant to the quality andavailability of antenatal education in New Zealand and thetransitions of care between LMC and CBE and betweenLMC and Well Child services. Data were collected frommany sources using several methods: key informantinterviews; phone calls to DHBs; focus groups and someindividual interviews with women; a brief questionnairegiven out in maternity facilities to women who had justgiven birth; a brief questionnaire distributed to CBEproviders; extracting data from the Plunket database; anda literature review. There were 11 objectives. The mainfindings relating to each one are summarised below.4.1 Summary of results1. Identify the providers of CBE and Well Child servicesin New ZealandThis project identified 90 providers of CBE and 88providers of Well Child services (counting providers withmore than one centre per DHB only once per DHB).DHB provider arms (running hospital-based courses)are the biggest provider of antenatal education in NewZealand, followed by Parents Centres. Plunket is thebiggest provider of Well Child services. CBE and Well Childproviders are listed by DHB in Appendix 8 and Appendix11 respectively.2. Describe the contractual arrangements andobligations of CBE providersOnly the CBE providers who hold contracts withDHBs have formal contractual arrangements. Thesearrangements are described in the National ServiceSpecifications for Pregnancy and Parenting Education. 3Courses must be a minimum of 12 hours in duration, be‘preferably’ run by a facilitator with CBE qualifications andcover content on access to maternity services, pregnancycare, labour and birth care, and care following birth.Eighty percent of CBE providers reported basing theircourse on these specifications. Of the DHB-fundedproviders, only 39.5 percent reported that it wascompulsory for their facilitators to hold a certificate ordiploma in childbirth education.3. Describe and compare CBE offered to women andtheir families and whänau by key CBE providersThe topics women most frequently remembered beingcovered by CBE providers were related to labour (signsof labour and options for managing pain), birth (normaland other birthing methods) and breastfeeding (benefitsof breastfeeding). A high percentage of women alsoremembered topics such as pelvic floor exercises,relaxation, risks and benefits of different birthing methods,how to breastfeed and emotional changes after birth.The four topics women least remembered being coveredin classes were the complaints procedure for maternityservices, unplanned experiences, parenting programmeoptions available and the role of Well Child services andhow to access them.Women perceived topics such as pain-relief optionsduring labour and early experiences at home after thebirth as particularly useful. Other benefits of antenataleducation that women valued even more were socialsupport, opportunities to get the father involved andconfidence from knowing what to expect during labourand afterwards.Women perceived other topics as unhelpful or felt theywere not discussed in enough detail to be helpful. Forexample, nutrition was generally considered a waste oftime because it was covered too late in the pregnancy tobe of use. Topics that some women felt were not coveredin enough detail were bottle feeding, unexpected eventsand alternative interventions and parenting after the birthof the baby.Comparisons between DHB-funded and non-funded CBEproviders showed differences in the likelihood of differenttopics being covered in their classes. DHB-fundedproviders were more likely than non-funded providersto cover a range of topics, including the effects ofsmoking, the effects of alcohol and other drugs, warningsigns of problems during pregnancy and the role ofWell Child services.At the level of individual organisations, Parents Centreswere more likely than hospital-based classes to covertopics such as warning signs of ill-health or problemsduring pregnancy, emotional change during pregnancy,risks and benefits of different birthing methods,childbirth education: antenatal education and transitions of maternity care in new zealand83

development of appropriate personal support andparenting programme options available. Hospital-basedclasses were more likely than Parents Centres to coverthe complaints procedure for maternity services, and theeffects of smoking on the health of mother and baby andoptions available to help give up.In addition to content, there were differences betweenCBE providers in the length, structure and targetpopulation of their courses. Parents Centres, who offerrelatively structured courses and require their facilitatorsto have a qualification in CBE, compared well againstother organisations on one of the items in the women’ssurvey. After adjusting for confounding variables, women’sperception of the extent to which CBE helped themprepare for the birth experience was significantly higherfor women who had participated in CBE through ParentsCentres (M = 3.93) compared with hospital-basedclasses (M = 3.58).4. Determine the proportion of parents who access CBEAcross all survey respondents, 41.5 percent of womenattended antenatal education. The percentage ofprimiparous women who participated in CBE (80.1percent) was much higher than the percentage ofmultiparous women (four percent). The proportion ofparents accessing CBE was relatively higher in Auckland(46 percent), Capital and Coast (52 percent) andCanterbury (51 percent) regions compared with Waikato(31 percent), Lakes (32 percent) and Southland(35 percent) regions.5. Compare the availability of CBE across the differenthealth regionsThere are large differences in the availability offunded CBE courses across New Zealand. In 2006,DHBs funded enough CBE places for anywherebetween 10 percent and 100 percent of their first-timepregnant women. Capital and Coast region had thelowest availability of funded CBE places for first-timepregnant women, with only 10 percent of first-timebirths potentially accommodated. The low availabilityof funded CBE courses coupled with the relatively highrate of access to CBE in the Capital and Coast region,suggest that a higher proportion of women and theirfamilies or whänau, pay for courses in this region.Other regions that did not fund sufficient CBE placesto cover 30 percent of first-time pregnant women wereNorthland, Waitemata and Nelson-Marlborough. Theseregions funded enough places to accommodate 25percent, 16 percent and 22 percent of first-timebirths respectively.6. Determine the demographics of women andfamilies and whänau who access CBE and WellChild servicesWomen and families and whänau who attend CBE aregenerally different from those who do not attend. Mostwomen who participated in CBE were primiparous (95.1percent) and were married or in de facto relationships(92.6 percent). Participants were significantly more likelythan non-participants to have a tertiary degree (one tofour years), to be of New Zealand European ethnicity andto be earning $70,000 per year or more. Both Mäori andPacific peoples were under represented amongst womenwho attended antenatal education. Only 10 percent ofCBE participants were of Mäori ethnicity and less than onepercent were of Pacific ethnicity. Participants were alsoless likely to be single than non-participants, although thisdid not reach significance.After adjusting for all demographic variables, the strongestpredictors of women’s attendance at antenatal educationwere women’s parity, whether the LMC had suggestedthe mother attend CBE classes, family structure andDHB. Ethnicity and household income also predictedattendance but did not quite reach statistical significance.The ethnic makeup of parents who receive PlunketWell Child services closely mirrors that of the generalpopulation of women giving birth. On the other hand,the NZDep2001 scores of Plunket clients reflect a lessdeprived population than the general population ofwomen giving birth. From July 2005 to June 2006,22 percent of new Plunket enrolments were Mäori, 10percent Pacific and 68 percent were ‘other’ (mostlyNew Zealand European). Out of all new enrolments inthis time, 66 percent had NZDep2001 scores of 1–7, 21percent had NZDep2001 scores of 8–9 and 13 percenthad NZDep2001 scores of 10.Family demographics also differed depending on theplace and type of Plunket contact (core versus additional).The percentage of contacts in non-clinical settingssuch as the home was higher for families and whänauliving in areas of high deprivation and for Mäori andPacific families. A greater proportion of contacts in highdeprivation areas were ‘additional’ contacts comparedwith less deprived areas. Similarly, a greater proportion ofMäori and Pacific contacts were additional compared withcontacts with families of ‘other’ ethnicity.84 Families Commission Research Fund

families commission research fund7. Describe the contractual arrangements andobligations of LMCs as they relate to transitionsof care from LMC to CBE and from LMCs to WellChild careThere are no formal obligations for LMCs to refer womento CBE. However, LMCs have both contractual andprofessional obligations, specified in the Section 88Maternity Notice 6 and Midwives’ Handbook for Practice, 7respectively, to inform women about the availability ofantenatal education. This process typically takes the formof the LMC asking the pregnant woman if she has thoughtof attending CBE classes and then discussing possibleoptions available in the area. It is clear, however, that CBEis not being suggested to all women. Fifty-eight percentof women who completed the survey reported that theirLMC had suggested they attend antenatal education. Forprimiparous women, the percentage was 92 percent andfor multiparous women, the percentage was 26 percent.In contrast, there are formal obligations, specified in theSection 88 Maternity Notice, for LMCs to refer women toWell Child services. LMCs must provide a written referralto Well Child services before the baby is four weeks oldand must have transferred care to the Well Child providerbefore the baby is six weeks old. In practice, LMCstypically discuss the handover to Well Child serviceswith the mother and fax a written referral to Well Childservices. The majority of transfers occur between two and10 weeks. In 2006, 67 percent of transfers to Plunketoccurred before six weeks, 27 percent occurred betweensix and 10 weeks and six percent occurred after 10 weeks.8. Describe the contractual arrangements andobligations of Well Child service providers asthey relate to transitions of care from LMC toWell Child careWell Child services rely on receiving referrals from LMCs inorder for them to initiate their side of the transfer processfor individual families and whänau. According toThe Well Child Framework 4 and Well Child current servicespecifications, 12 Well Child services are formally obligatedto register and make contact with every family andwhänau for whom they receive a referral. They are alsoobligated to provide services ‘initially’ in the family home.After Well Child services receive the referral from theLMC, they typically phone the parent to organise the firsthome appointment, which is then usually conducted bysix weeks. If Well Child services cannot get in contact withthe family and whänau, they often go back to the LMCfor more details. Additional funding is given to Well Childproviders to enable them to make contact and conductadditional home visits with vulnerable families.9. Determine the extent to which the transition betweenLMC and Well Child services is co-ordinated byservice providers or left to the mother and her familyand whänauIf the formal obligations of both LMCs and Well Childproviders were adhered to, then the transition betweenthese two services would not be left to the mother and herfamily and whänau. Although in practice the transition isnot generally left to the parents, it was clear that in someregions, problems with the transition process betweenproviders result in a substantial proportion of women ortheir families and whänau having to initiate contact withservices themselves or – even worse – falling throughthe gaps.Factors contributing towards parents having to takeresponsibility for the transition include midwives failingto make a formal written referral; midwives sending thepaperwork to Well Child providers late; midwives forgettingto send the paperwork; midwives giving the paperwork tothe family instead of the Well Child provider; philosophicaldifferences between midwives and Well Child providers;Well Child providers having a lack of capacity to followup all referrals; Well Child providers failing to follow upall referrals; parents choosing not to access Well Childservices; and a lack of monitoring of the transition process.10. Determine the extent to which women and theirfamilies and whänau are aware of their entitlements,specified in the Section 88 Maternity NoticeWomen were only vaguely aware of their entitlements. Ifthey did not have prior knowledge, they typically found outabout free LMC care when they visited their GP to confirmtheir pregnancy. Similarly, they often found out about freeWell Child care through their LMC or antenatal classes.Women expected to receive appropriate information butdid not necessarily regard information as an entitlement.Women were not aware of the specific details ofentitlements such as the length of postnatal hospital stayor the number of LMC or Well Child home visits. They alsoseemed unaware of entitlements such as free non-LMCcare for urgent pregnancy problems.Lack of knowledge of entitlements was highlighted asa particular barrier to maternity care for young women,women of different ethnic backgrounds (particularly non-English-speaking) and women who had not been living inNew Zealand for very long.childbirth education: antenatal education and transitions of maternity care in new zealand85

The eleventh objective, to find the gaps between thesupport that services aim to provide and what actuallyhappens in practice, is discussed in further detail inSection 4.2.4.2 Gaps between the supportthat maternity and Well Childservices aim to provide andwhat happens in practiceOn the whole, New Zealand has a very good maternitysystem. Comments made by refugees, and, indeed, justwomen from other countries, highlighted the strengths ofNew Zealand’s maternity care system, which essentiallyprovides continuous care from early pregnancy toearly parenthood.Personally I think it is a pretty good set-up, thewhole midwife, Plunket thing. I think there couldbe a little bit finer tuning between handover. But Ithink it’s a really good set-up really. We’re not shortchanged… I know my sister has just gone to livein Germany, the one I keep talking to… They don’thave anything like Plunket over there. They don’treally have lots of organised groups either becauseshe is trying to find things now. They have a reallygood set-up here. Yeah and the doctor, not havingto pay is amazing. I didn’t actually realise that untilthe second or third go and then I finally went in andsaid, ‘So we don’t have to pay’. ‘Oh no, no, not untilthey’re five.’In Somalia, there is only a midwife at the hospitaland there are no home visits or Plunket. There iscivil war.However, this project has revealed some gaps betweenwhat services aim to provide and what happens inpractice. Five types of gaps were noted: information gaps;identification and responsiveness gaps; engagement gaps;service gaps; and clinical or performance gaps.4.2.1 Information gapsMaternity and Well Child services aim to provide womenand their families and whänau with information to helpthem know what services are available, understandthe types of services they provide and make informeddecisions about their care. In reality, there are manywomen and families and whänau who are unaware ofthe services available. About three percent of womenwho did not participate in antenatal education said it wasbecause they did not know about the classes. A muchlarger percentage of women lack understanding of thetypes of services offered by different providers. Only 31percent remembered the topic on the role of Well Childservices being covered in their antenatal classes and only39 percent remembered providers discussing parentingprogramme options available. Even the relatively educatedfocus group participants had only a vague understandingof their entitlements. Women also reported that providersfailed to give them information on specific topics thatmight have aided informed decision making. Such topicsincluded unexpected events, bottle feeding,and parenting.The information gap exists for providers as well as thegeneral public. One key informant commented that therewas a lack of understanding amongst professionals aboutthe role of midwives and that this contributed to mistrustbetween different providers. Key informants also felt therewas a lack of information shared between providers thatmight enable them to better understand families andwhänau and co-ordinate services for them.These gaps might be addressed by providing moreinformation to professionals and the public about theservices offered by different providers. Providers takingthe time to get together and talk to each other might alsofacilitate the building of trust, respect, information sharingand links between services.4.2.2 Identification and responsiveness gapsServices aim to identify and respond appropriately towomen and families and whänau who have higher needsor are at risk of a range of adverse outcomes. In practice,many families are missed. For example, facilitators ofantenatal education may fail to detect women who are notemotionally ready to have children and LMCs or Well Childproviders may not recognise that a woman is sufferingfrom PND. This project highlighted the informal andsubjective nature of current screeningfor PND. Under such a system, women who do nothave severe PND are less likely to be detected andsupported adequately.Part of the problem is a lack of systematic screening ormonitoring, and the other part is a lack of responsiveness.Issues such as loneliness and family violence will often bedetected by LMCs but sometimes there are just not theresources or system to follow up appropriately.86 Families Commission Research Fund

families commission research fundAddressing this gap will require careful considerationof screening tools (such as those for PND or wellbeingof the family), development of appropriate informationtechnology infrastructure to support monitoring systems(such as Kidslink), embedding of systematic proceduresand continuing workforce development.4.2.3 Engagement gapsServices aim to successfully engage women and familiesand whänau. This includes achieving good accessrates, rapport between provider and family whänau,and retention of families and whänau in the service.It is widely recognised that families living in the mostdeprived areas, with the greatest need, are often the mostdifficult to engage. Some funding models, such as thatdescribed in The Well Child Framework, acknowledgethis and accordingly allocate a higher level of resourcesfor engaging high needs families. 4 Despite considerablegovernment financial commitment to target resourcestowards those most in need, the ‘law of inverse care’stubbornly persists and large gaps remain in engagementrates for vulnerable families and whänau. The 20 percentof primiparous women who do not participate in antenataleducation are significantly more disadvantaged thanwomen who do participate. The NZDep2001 scores ofwomen who received Plunket services in 2005 and 2006were lower (representing less deprivation) than womenwho did not receive Plunket services. Many of thebarriers to accessing Well Child services, described inSection 3.7.4, contribute to the gaps. These includelanguage barriers, lack of cultural competence, lack ofknowledge, relationships and links between providersand lack of monitoring, to name a few of the barriers withidentifiable solutions.To address the engagement gap, providers need tounderstand engagement as an ongoing process, findinnovative ways of reaching out to people, consider howtheir services are packaged and make services moreattractive to and suitable for different client groups. Forexample, many disadvantaged families find themselvesalienated from the education system. Offering antenataleducation in the form of ‘classes’ therefore immediatelycreates a barrier for them. In addition, focus groupparticipants almost unanimously agreed that they feltmore comfortable and benefited more from the socialsupport afforded by homogeneous groups of women. It isno surprise, then, that single, teenage mothers generallydo not attend antenatal classes with married, educated,older women or that refugee women are absent fromthese courses. Distinctive differences between differentpopulation groups will need to be catered for.4.2.4 Service gapsServices aim to achieve good coverage of their targetpopulation and an equitable level of servicing acrossdifferent regions in New Zealand. This project highlightedgaps in both service coverage and equity of servicingacross regions. For example, a common complaint fromfocus group participants was the shortage of midwivesin Wellington, evidenced by the difficulty women hadfaced in finding an LMC in the Wellington region. Theresult was that many women in this region registered latewith an LMC or resorted to going through the hospitalsystem, where they potentially missed out on the benefitsassociated with the continuity of having just one midwifeas LMC.One of the reasons given by a key informant for notintroducing systematic screening for PND is a lack offollow-up options for women who are recognised as havingmild to moderate PND. Specialist mental health servicesprovide services only to people with severe mental healthproblems. Primary mental health care, which is a moresuitable setting for treating mild to moderate mental healthproblems, is still in an early phase of development inNew Zealand. By the end of 2008, most primary healthorganisations (PHOs) will have established primarymental health initiatives. However, funding for primarymental health care is still relatively small and services arebeing provided to only a small number of patients. Thereremains a significant gap in service delivery for people withmild to moderate mental health problems.This project also found that the availability of antenataleducation varied greatly in different regions, with someDHBs funding sufficient CBE places for 100 percent oftheir first-time mothers (Tairawhiti and West Coast) andother DHBs funding places for as few as 10 percent oftheir first-time mothers (Capital and Coast). Many of theseservice gaps will only be properly addressed throughincreased funding or reprioritisation of resources forthese services.4.2.5 Clinical or performance gapsProviders aim to provide services that meet consumers’needs and are of high quality. Unfortunately, consumers’needs are all too often not met and the quality of servicesis questionable. While providers of antenatal educationaim to help mothers and families and whänau prepare forthe birth experience and early parenting responsibilities,childbirth education: antenatal education and transitions of maternity care in new zealand87

about 12 percent of women who participated respondedthat the classes had not helped them to prepare for thebirth experience (circled 1 or 2 on a 5-point Likert scale)and 19 percent responded that classes had not helpedthem to prepare for parenting. Clearly, this represents agap between the aims of antenatal education andits performance.One of the factors that might contribute to this gap is thevariability in the qualifications and experience of classfacilitators. As shown in this study, only 40 percent ofproviders required their facilitators to hold a qualification inCBE. While qualifications do not necessarily make a goodfacilitator, they tend to decrease the variability betweenclasses and are an important measure of quality.Other providers also have performance gaps. While therehave been improvements in the transfer process betweenLMC and Well Child services, clearly not all obligationsrelated to this transition are being met. This is evidencedby the 33 percent of transfers to Plunket that occur aftersix weeks, not to mention the transfers that do not occur atall. Key informants went so far as to say that in some areasof the country, parents are often left to take responsibilityfor the transition themselves.These types of gaps may be addressed by qualityimprovementprocesses such as auditing of services,rewarding particular targets, measurement and monitoringof outcomes and collecting regular consumer feedback.Clinical outcomes that consistently fall short of aims willnecessitate re-examining of the content of programmes aswell as further workforce development.4.3 Implications4.3.1 Content of antenatal classesThe CBE topics that women remembered beingcovered related to labour, birth and breastfeeding,were also topics that focus group participants valuedand considered useful. However, women also voiced anumber of concerns about topics covered or not coveredin antenatal classes that have implications for the existingcontent of classes. Several women commented on howvaluable class time was spent discussing nutrition-relatedinformation that was unlikely to be of benefit to womenwho were usually in their third trimester of pregnancy.Clearly, if classes are to make a difference to women’snutritional status, they must be initiated early inthe pregnancy.Although there are good reasons for focusing on natural(vaginal) childbirth and the importance of breastfeedingin antenatal classes, the comments of many womensuggested that these topics had been emphasised to thedetriment of women who did not, for whatever reason,end up having a vaginal childbirth or breastfeeding. Thesewomen reported feeling guilty or inadequate becausethey had not been able to do the best thing for their babyor themselves. There are good grounds for New Zealandantenatal classes to continue to emphasise the benefitsof vaginal childbirth and breastfeeding, but these topicsshould not be pushed to the detriment of women’smental health.A related issue is women not being prepared forunexpected events or alternative interventions. Consistentwith the comments of several focus group participantsin this study, English women expressed concernin interviews that the emotional impact of operativedelivery had not been considered as part of antenatalpreparation. 38 Emotional preparation for such events isnot easy but antenatal classes may have more successif they help women have realistic expectations. A lackof realism or honesty in classes has been blamed forwomen feeling unprepared for deviations from the normalcourse of labour 39 and may be a reason why coupleswho strongly wish to avoid pharmacological methods ofpain relief during labour frequently do not achieve theirgoal. 40 It is therefore important that antenatal classes aimto help parents achieve realistic expectations of the birthexperience and transition to parenthood.Consistent with anecdotal evidence, parents wanted moreinformation on parenting. Several studies have argued thatantenatal classes should focus more on parenthood 41,42,43and the psychological impact of having a child. 44 One ofthe main issues concerning the inclusion of content onparenting has been the timing of the classes. Parentsappear more receptive to information delivered when itis most needed and Australian research suggests thatparents are not predisposed to absorb information aboutpostnatal issues during the prenatal period. Similarly, ithas been argued that men and women are possibly sopreoccupied with the issues of labour and childbirth thatthey are not ready to absorb information on relationship,lifestyle changes and parenting until the challengebecomes a reality. 46 On the other hand, antenatalprogrammes should not be compromised by educatorswho believe that pregnant women cannot learn. 47 Inaddition, Nolan’s research indicates that couples desire88 Families Commission Research Fund

families commission research funda balance between labour and delivery and postnatalissues. 41 Furthermore, there is now good evidencethat information provided during antenatal classes onparenting has positive effects on parenting knowledgeand self-efficacy after the birth. 42 Therefore, informationon parenting should form a key component of antenatalclasses, rather than a small section covered right at theend of the course.Many focus group participants felt there was a need forpostpartum classes, although when they did attend them,these classes were often perceived as less useful thanthey could have been because of the timing of whenthey were offered. Women typically attended postpartumclasses five to six weeks after giving birth, by which timethey had already had to work out many of the baby careissues that were covered in the classes (such as bathing,sleeping and nappies).One of the things women most valued about CBE classeswas the opportunity to get fathers involved. No otherlife event has a more profound impact on a couple’srelationship, and there is growing evidence that couplesare more concerned about emotional and relationshipissues than practical issues of childbirth and infant care. 48Classes should therefore include discussion of emotionaland relationship issues related to the transition toparenthood. Such discussion may also provide an explicitopportunity for educators to recognise vulnerable womenand families and whänau and organise for them to receiveadditional support.Finally, there is considerable room for improvement in thedegree to which antenatal education prepares parentsemotionally to have children. Providing more informationon parenting strategies might help to address this issue.Another potential modification to antenatal education thatdeserves consideration is to refocus classes to concentrateon developing in participants the related concepts ofempowerment and health literacy. Empowerment refersto acquiring self-help abilities and attitudes during adifficult period and involves not just allowing parents toparticipate in classes, but showing them how to developthe tools to solve their own problems. 49 A health literacyapproach focuses on the development of the skills andconfidence to make choices that improve individual healthoutcomes, rather than being limited to the transmissionof information. 50 The resulting increases in skills andconfidence may help parents emotionally prepare to havechildren and may reduce pressure on childbirth educatorsto cover everything relevant to pregnancy, childbirth andparenting in their classes.4.3.2 Format of antenatal classesThe finding that women who participated in antenatalcourses offered through Parents Centres rated the classesas more helpful in their preparation for childbirth thanwomen who attended courses through other providers(such as hospital-based classes) deserves closer attention.Parents Centres courses are based on the national servicespecifications, have a structured curriculum with someflexibility to tailor classes to the learning needs of thegroup and are facilitated by qualified childbirth educators.They are generally attended by a relatively homogeneousgroup of women (particularly the courses that women andfamilies and whänau pay to attend).The quality of an antenatal course cannot be determinedby any of these variables in isolation. For example, thereare likely to be courses of equally high quality that haveminimal structure and are run by facilitators who do nothold CBE qualifications. Nevertheless, the consistencyin topics covered by Parents Centres and the CBEqualifications required of their facilitators ensure lessvariability in the quality of their classes, undoubtedlycontributing to positive outcomes.Other important determinants of the quality of classesare likely to be the extent to which facilitators base theirteaching on principles of adult learning and provideopportunities for experiential learning. There have beenconsistent calls for classes to be based on principles ofadult learning. These principles include allowing choiceand self-direction in the learning process; having clearlydefined goals; respecting current viewpoints; buildingon previous experience and providing opportunities forparents to learn from each other’s experiences and ideas;incorporating small-group discussions (including samesexdiscussion groups); and being treated as equals in thelearning process. Experiential learning (learning by doing)involves providing time for women and men to practise theuse of strategies.Homogeneity of classes may also be important. Commentsfrom focus group participants suggested that homogenousgroups ‘gelled’ better, provided an environment in whichwomen felt more comfortable with asking questions andresulted in more ongoing social contact and supportfrom other participants in the group. Such comments areconsistent with refugee women’s expressed preference forattending classes with women who spoke their language,and underscore the importance of offering kaupapa Mäoriand Pacific courses. Homogeneous classes may also allowbetter matching of information given with the learningneeds of participants.childbirth education: antenatal education and transitions of maternity care in new zealand89

Consideration should also be given to offering courseson a broader timescale to better align with parents’information needs. For example, such a programme mayinclude content on nutrition and substance use earlyin the pregnancy, classes on coping with labour laterin pregnancy and classes on infant care and parentingeither late in pregnancy or soon after the baby is born.Robertson suggests that spreading the sessions overseveral months in this way helps people to developfriendships and support networks, as it gives them longerto connect, compared with the shorter duration ofmost programmes. 524.3.3 Skills and knowledge required bychildbirth educatorsThe content and format recommendations above haveimplications for who should be delivering antenataleducation. At present, it is clear that facilitators ofantenatal classes are not necessarily trained in CBE orthe principles of adult education. 53 Only 40 percent ofproviders in the current study required their facilitators tohave a qualification in CBE. Brown found that, of the 14childbirth and parenting educators she interviewed in oneAustralian state, only one had undertaken a short eighthourcourse. 54 The consequence of this is that childbirtheducators generally rely on didactic teaching methods andfocus on knowledge transfer and the development of basicskills associated with childbirth and potentially miss theopportunity to facilitate deeper emotional preparation andthe skills that have more enduring application during theearly years of childhood. 55An important question is: Should facilitators be requiredto have a minimum qualification in CBE? There is anargument for and against such a requirement. On theone hand, making CBE qualifications compulsory forfacilitators is a way of maintaining a minimum standardof professionalism and competence which may ultimatelybenefit women and their families and whänau. On theother hand, making the qualification compulsory wouldrestrict the number of people who could run antenatalclasses and, at least in the short term, decrease theavailability of facilitators. Requiring facilitators to havethe CBE qualification also fails to acknowledge themany women with enormous experience who have noqualification but who are currently offering the classesquite competently. It seems fairly clear that, as long as thefacilitator has good ‘people’ skills, there are certain topicsthat do not require a tertiary degree. It is equally clear thatthere are topics which do require special knowledge andskills. The jury is still out on this debate.Making a decision on the minimum qualificationscompulsory for facilitators will require a larger question tobe answered: What do we want to achieve with antenataleducation? If the answer is to focus on improving healthliteracy, empower women, offer more parenting strategies,address relationship and emotional issues and betterprepare parents emotionally for the whole experience,then educators are likely to need more training.Encouragingly, different studies have shown that only asmall amount of additional training may be necessary toachieve positive outcomes. For example, in Svensson etal’s study, childbirth educators who had received onlyan additional four hours of training could refocus thecontent and process of their classes to include moreexperiential activities, small group learning and parentingcontent. 42 The changes resulted in increased selfefficacyand knowledge for parents, relative to parentswho had completed the standard course. Similarly, inDiemer’s study, childbirth educators received only brieftraining in how to shift the focus from preparation forlabour to parental adaptation and a more father-focusedcurriculum, including small-group methods. 56 Therefocused classes resulted in benefits for fathers overstandard antenatal classes that had been run by thesame educators.Regardless of qualifications, it is critical that facilitatorsmaintain a professional role and provide evidence-basedinformation rather than advocating a particular approachon the basis of personal experience or opinion alone.Ideally, childbirth educators should have knowledge andskills in the use of adult learning principles; experientiallearning; empowering parents and increasing parental selfefficacyand health literacy; discussing difficult emotionsand relationship issues; parenting strategies; beingsensitive to participants’ individual situations, cultures andlearning desires; professionalism and understanding howother parts of the maternity system work.4.3.4 Interface between LMC and CBEThe Section 88 Maternity Notice obligates LMCs to informwomen about the availability of antenatal education. Evenif LMCs inform all women about the availability of CBE,this is not the same as suggesting to women that theyattend antenatal education. In this project, 58 percentof women reported that their LMC had suggested they90 Families Commission Research Fund

families commission research fundattend CBE. This figure was much higher for primiparouswomen, but eight percent of primiparous women still didnot remember their LMC recommending they attend CBE.The finding that an LMC’s recommendation to attendCBE was a significant predictor of mothers’ attendancesuggests that, if the aim is to increase rates of attendanceat CBE, it is worth considering ways of influencing LMCsto recommend CBE to their clients more frequently.Short of formalising the referral process between LMCand CBE, there are a couple of different options. Themajor group of women whom LMCs do not send onto CBE are multiparous. This is because LMCs do notperceive classes are useful or relevant for multiparouswomen. To change recommendation rates, providersneed to either change this perception (amongst LMCs andwomen) or to offer a greater range of refresher courses formultiparous women. Similarly, a higher rate of Mäori orPacific women might be recommended classes by LMCsif there were more providers who offer kaupapa Mäori orPacific antenatal courses. CBE providers may also need toincrease their efforts to develop good relationshipswith LMCs.4.3.5 Transition between LMC and WellChild providerRecently, much attention has been paid to the transitionbetween LMC and Well Child services. Although thereliability of the transition has improved in recent years,there are still problems on both the LMC and Well Childprovider sides that contribute to families and whänaufalling through the gaps. Further improvement of thehandover process, so that more families and whänau aretransferred before six weeks, may require a combinationof steps, including auditing of the process; bettercommunication and opportunities for relationship buildingbetween LMCs and Well Child providers; increasingresources to enhance the capacity of LMCs to comply withformal referral requirements and to increase the capacityof Well Child providers to follow up referrals; and publiceducation about entitlements and the services offered byWell Child providers and why they are important.4.4 Strengths of the researchThe strengths of this research project are listed below.> Several different research methods were used,including both qualitative and quantitativemeasures. This allowed comparison of resultsobtained by different methods, more thoroughexploration of research questions and easierrecognition of gaps between providers’ aims andwhat happens in practice.> A significant number of women completed the briefquestionnaire shortly after giving birth (N = 878).Questionnaires were returned from all DHB regionsin New Zealand.> A reasonable percentage of women who returnedquestionnaires were Mäori (14 percent).> Multiple methods were used to identify CBEproviders, resulting in a total of 45 CBE providerswho completed questionnaires. This represented 70percent of the provider organisations that were sentthe questionnaire.> Efforts were made to include women of low socioeconomicstatus and Mäori or Pacific ethnicity infocus groups, including holding one focus groupfor Pacific women, one for Mäori women, and onein a disadvantaged area of Wellington. Individualinterviews were held with refugee women andwomen who could not attend focus groups.> Two new quantitative measures were developed –one for women, one for CBE providers – which maybe of use again in the future.> The project produced an updated list of CBE andWell Child providers in New Zealand (see Appendix8 and Appendix 11 respectively).> Multivariable modelling allowed relationshipsbetween variables to be tested while controllingfor the effects of confounding variables. Therelationship between mothers’ perception of theeffectiveness of classes in preparing them forchildbirth or parenthood and the organisationthrough which mothers attended antenatal classeswas explored (Section 3.3.6) and the strongestpredictors of attendance at antenatal educationwere isolated (Section 3.3.9).> Data obtained on the number of births in 2006,the number of first-time births in 2006 and thenumber of funded CBE places in 2006 allowed theavailability of antenatal education to be comparedacross different DHB regions.> Research questions helped to provide clarity aboutthe contractual arrangements and obligations ofLMCs and Well Child providers as they relate totransitions of care (Sections 3.6.1 and 3.7.2).childbirth education: antenatal education and transitions of maternity care in new zealand91

The data collected provide a snapshot of thestate of antenatal education and transitions ofmaternity care in New Zealand. New evidence wasobtained on:> the proportion of women who access antenataleducation across the different DHB regions(Section 3.3.7)> the availability of antenatal education across thedifferent DHB regions (Section 3.3.8)> the demographics of New Zealand womenand families and whänau who attend antenataleducation (Section 3.3.9)> the proportion of women whose LMCssuggest they attend antenatal education(Section 3.2.1)> the proportion of CBE providers who requirefacilitators to hold a qualification in CBE(Section 3.3.3)> the proportion of women who rememberdifferent topics being covered in their CBEclasses (Section 3.3.5)> differences between CBE providers on thetopics covered in their classes (Section 3.3.6).4.5 Limitations of the researchThe project also has a number of limitations.> Sample size – although 878 women returnedquestionnaires, the cell sizes for some analyseswere small, meaning that robust comparisonsacross all DHB regions were not possible and someanalyses were underpowered, making it difficult todetect significant effects. Percentages based onrelatively small numbers must be interpretedwith caution.> Sample representativeness – as with virtually allsurveys with modest response rates (about 18percent), there was inevitable bias in the sampleof women who returned their questionnaires.Women who returned the survey were on higherincomes and were more educated than the generalpopulation of women giving birth. Although theproportion of Mäori women returning questionnaires(14.1 percent) was nearly representative of theproportion of Mäori women of reproductive age inthe general population (15.3 percent), this figureunder-represents the proportion of all births toMäori women (19.9 percent). 1 Similarly, Pacificmothers (who account for 10.1 percent of all births)were under-represented in the sample. 1 Resultsshould be interpreted with this bias in mind. Forexample, results from the survey showed that 41.5percent of women attended antenatal education.This figure likely overestimates the true proportionof women attending antenatal education.> The reliability and validity of the two new measuresdeveloped for this project are unknown. However,many of the demographic questions usedstandardised response options widely used in otherNew Zealand instruments (such as the Census).> It was difficult to identify providers of pregnancyand parenting education who do not hold contractswith DHBs. Although several methods were used toidentify non-DHB-funded providers, they are likelyto be under-represented in the sample.> Figures given by DHBs on the number of fundedCBE courses did not always match figures given byproviders. Table 10, which shows the availabilityof antenatal education in different DHB regions(Section 3.3.8), should be interpreted with caution,particularly for those DHBs which had missing data(Table 10).> For some analyses, CBE courses were treatedas if they were a uniform programme across allproviders. For example, differences betweenattenders and non-attenders of CBE courses in theirlevel of emotional readiness to have children wereexamined (Section 3.3.10). However, as has beenshown, there is substantial variability in classesaround the country, even amongst providers whohold DHB contracts. Therefore, such analysesobscure the possibility that some classes may bemore effective than others in helping women andfamilies emotionally prepare for childbirthand parenting.4.6 Final commentsThis project has provided a snapshot of antenataleducation and transitions of maternity care inNew Zealand. It is important to understand suggestionsfor improvement within the context of internationalacknowledgement of New Zealand as a leader in thefield of maternity services.92 Families Commission Research Fund

families commission research fundAntenatal education represents an important componentof maternity services and, more broadly, primary healthcare. It provides a unique opportunity to promote healthybehaviours, increase social support, prepare women andtheir partners for childbirth and parenting and to detectvulnerable women and their families and whänau. Theskills and confidence that can be enhanced in antenatalclasses can help to ensure that the new life phase beginsas a positive, healthy experience.Generally, women and their families and whänau aresatisfied with antenatal education, but there is roomfor improvement in both the quality and availability ofclasses. Changes could be made to antenatal educationto increase its effectiveness in improving parents’ healthliteracy, self-efficacy, emotional preparation for parenthoodand life skills. These changes may require considerablecommitment, but in the words of Andrea Robertson, aconsultant in childbirth education and the principal ofAssociates in Childbirth Education (ACE) in Australia,‘we can’t afford to let this once-in-a-lifetime opportunityfor promoting life skills … slip away through a lack ofcommitment within the system’. 57 In order to ensure theprioritisation of antenatal education with purchasers andproviders, childbirth teachers may need to define thecriteria by which it can be audited more clearly. 58Antenatal education is evolving. 59 It began as childbirtheducation, and as the scope of classes broadened toencompass more than just strategies for coping withlabour and birth, it became antenatal education. It ispossible that with the recognition of the importance ofbetter preparing parents for parenthood and theemotional and relationship issues the transition engenders,that in the future women and their partners mayregularly attend perinatal classes. There have been callsfrom researchers and clinicians to ‘lift our game’. 57 It ishoped that this project may contribute to the ongoingrefinement of antenatal education and transitions ofmaternity care in order to better equip women and theirpartners to navigate the birth experience and thetransition to parenthood.childbirth education: antenatal education and transitions of maternity care in new zealand93

REFERENCES1Ministry of Health. (2007). Report on maternity: Maternaland newborn information 2004. Wellington: New ZealandHealth Information Service.2Health Funding Authority. (2000). Maternity services: Areference document. Hamilton: Health Funding Authority.3Ministry of Health. (2002). National service specification forpregnancy and parenting education. Wellington: Ministry ofHealth & DHBNZ.4Ministry of Health. (2002). The well child framework.Wellington: Ministry of Health. Available at:http://www.moh.govt.nz5Ministry of Health. (2002). Maternity services: Noticepursuant to section 88 of the New Zealand Public Health &Disability Act 2000. Wellington: Ministry of Health.6Ministry of Health. (2007). Maternity services: Noticepursuant to section 88 of the New Zealand Public Health &Disability Act 2000. Wellington: Ministry of Health.7New Zealand College of Midwives. (2005). Midwives’handbook for practice. Christchurch: New Zealand Collegeof Midwives.8Parents Centres New Zealand Inc. (2006). Parents Centreshandbook. Mana, Wellington: Parents Centres NZ Inc.9Aoraki Polytechnic. (2007). Diploma in Childbirth Education:2007 student handbook. Canterbury: Aoraki Polytechnic.10Ministry of Health. (1996). Well child – tamariki ora: Nationalschedule. Wellington: Ministry of Health.11Ministry of Health. (2002). Well child – Tamariki Ora:National Schedule Handbook. Wellington: Ministry of Health.12Ministry of Health. (2003). Well Child services: Currentservice specification. Wellington: Ministry of Health & DHBNZ.13Allen & Clarke. (2006). Well child services: Literature reviewand analysis. Report prepared for the Ministry of Health.Wellington: Allen & Clarke Policy and Regulatory SpecialistsLimited.14Ministry of Health. (2008). Maternity services consumersatisfaction survey 2007. Wellington: Ministry of Health.15Hodnett, E.D. (2000). ‘Continuity of caregivers for careduring pregnancy and childbirth’. Cochrane Database ofSystematic Reviews, 2: CD000062.16Tough, S.C., Johnston, D.W., Siever, J.E., Jorgenson,G., Slocombe, L., Lane, C., & Clarke, M. (2006). ‘Doessupplementary prenatal nursing and home visitation supportimprove resource use in a universal health care system?A randomised controlled trial in Canada’. Birth: Issues inPerinatal Care, 33(3): 183–194.17Dragonas, T., & Christodoulou, G.N. (1998). ‘Prenatal care’.Clinical Psychology Review, 18(2): 127–142.18Having a baby in Europe. . Public Health in Europe, 26.Copenhagen: World Health Organisation (1985), RegionalOffice for Europe.19Lee, H., & Shorten, A. (1999). ‘Childbirth educationclasses: Understanding patterns of attendance’.Birth Issues, 8(1): 5–12.20New South Wales (NSW) Standing Committee onSocial Issues. (1998). Working for children: Communitiessupporting families. Inquiry into parent educationand support programs. Sydney, New South WalesGovernment.21Cliff, D., & Deery, R. (1997). ‘Too much like school: Socialclass, age, marital status and attendance/non-attendance atantenatal classes’. Midwifery, 13(3): 139–145.22Lumley, J., & Brown, S. (1993). ‘Attenders andnonattenders at childbirth education classes in Australia: Howdo they and their births differ?’ Birth, 20(3): 123–131.23Schneider, Z. (2001). ‘Antenatal classes in Victoria:What the women said’. Australian Journal of Midwifery,14(3): 14–21.24Gager, C.T., McLanahan, S.S., & Glei, D.A. (2002).‘Preparing for parenthood: Who’s ready, who’s not?’ In N.Halfon, K.T. McLearn, & M.A. Schuster (Eds.),Child rearing in America: Challenges facing parents withyoung children (pp. 50–80). New York: CambridgeUniversity Press.25Brown, S., Lumley, J., & Small, R. (1998). ‘Early obstetricdischarge: Does it make a difference to health outcomes?’Paediatric and Perinatal Epidemiology, 12: 49–71.26Ministry of Health. (2004). Your pregnancy, To Haputanga:A guide to pregnancy and childbirth in New Zealand.Wellington: Ministry of Health. Available at http://www.healthed.govt.nz/uploads/docs/HE1420.pdf27Ministry of Health. (2006). Primary maternity servicesnotice 2007: Proposal for consultation. Wellington: Ministryof Health.28Kerslake Hendricks, A., & Balakrishnan, R. (2005).Review of parenting programmes. Wellington:Families Commission.29Salmond, C., & Crampton, P. (2002). NZDep2001 Indexof Deprivation. Wellington: Department of Public Health,Wellington School of Medicine and Health Sciences.http://www.moh.govt.nz/moh.nsf/Files/phi-researchreport/$file/phi-research-report.pdf30Thompson, M., Curry, M.A., & Burton, D. (1998). ‘Theeffects of nursing case management on the utilization ofprenatal care by Mexican-Americans in rural Oregon’.Public Health Nursing, 15(2): 82–90.94 Families Commission Research Fund

families commission research fund31O’Hara, M.W., & Swain, A.M. (1996). ‘Rates and risk ofpostpartum depression – A meta-analysis’. InternationalReview of Psychiatry, 8: 37–54.32Dennis, C.L., & Ross, L.E. (2006). ‘The clinical utility ofmaternal self-reported personal and familial psychiatric historyin identifying women at risk for postpartum depression’. ActaObstetricia et Gynecologica Scandinavica, 85(10): 1179–1185.33Murray, L. (1992). ‘The impact of postnatal depressionon infant development’. Journal of Child Psychology andPsychiatry, 33: 543–561.34Welford, H. (1998). National Childbirth Trust, book ofpostnatal depression. Britain: Thorsons.35White, G. (2006). Postnatal moods: Emotional changesfollowing birth. Wellington: Random House.36Horowitz, J.A. (2006). ‘Community-based postpartumdepression screening within the first month after delivery’.Contemporary Nurse Journal, 21(1): 85–93.37Cox, J.L., Holden, J.M., & Sagovsky, R. (1987). ‘Detection ofpostnatal depression: Development of the 10-item EdinburghPostnatal Depression Scale’. British Journal of Psychiatry,150: 782–786.38Murphy, D.J., Pope, C., Frost, J., & Liebling, R.E. (2003).‘Women’s views on the impact of operative delivery in thesecond stage of labour: Qualitative interview study’. BritishMedical Journal, 327.39Nolan, M. (1999). ‘Antenatal education: Past and futureagendas’. The Practising Midwife, 2(3): 24–27.40Nolan, M. (2000). ‘The influence of antenatal classes onpain relief in labour 2: The research’. The PractisingMidwife, 3(6): 26–31.41Nolan, M. (1997). ‘Antenatal education: Failing to educatefor parenthood’. British Journal of Midwifery, 5(1): 21–26.42Svensson, J., Barclay, L., & Cooke, M. (in press).‘Randomised-controlled trial of two antenatal educationprogrammes’. Midwifery. DOI:10.1016/j.midw.2006.12.012.43Smedley, A. (1999). Do childbirth and early parentingprograms meet the needs of the client? International Journal ofChildbirth Education, 14(1): 18–21.44Gulland, A. (1998). ‘Life after birth, midwives should beteaching prospective parents about the psychological impactof having a child’. Nursing Times, 94: 20–26.45Harris, M.J. (1990). ‘How much parenting is a healthresponsibility?’ Medical Journal of Australia, 153(11&12): 696–698.46Fletcher, R., Silberberg, S., & Galloway, D. (2004). ‘Newfathers’ postbirth views of antenatal classes: Satisfaction,benefits, and knowledge of family services’. The Journal ofPerinatal Education, 13(3): 18–26.47Schneider, Z. (2002). ‘An Australian study of women’sexperiences of their first pregnancy’. Midwifery,18(3): 238–249.48Parr, M. (1998). ‘A new approach to parent education.British Journal of Midwifery, 6(3): 160–165.49Dumas, L. (2002). ‘Focus groups to reveal parents’ needsfor prenatal education’. The Journal of Perinatal Education,11(3): 1–9.50Renkert, S., & Nutbeam, D. (2001). ‘Opportunities toimprove maternal health literacy through antenatal education:An exploratory study’. Health Promotion International,16(4): 381–388.51New South Wales (NSW) Standing Committee on SocialIssues. (1998). Working for children: Communities supportingfamilies. Inquiry into parent education and support programs.Sydney: New South Wales Government.52Robertson, A. (1999). ‘A new approach to antenataleducation’. The Practising Midwife, 2(2): 17–18.53NSW Health. (1998). Five year goals, objectives, andstrategies for maternity services. Discussion paper forcomment. NSW, Australia: NSW Health.54Brown, V. (1999). Childbirth education programs in oneAustralian state: A phenomenological inquiry. Master ofNursing. The Royal Melbourne Institute of Technology.Ongoing research thesis.55Renkert, S., & Nutbeam, D. (2001). ‘Opportunities toimprove maternal health literacy through antenatal education:An exploratory study’. Health Promotion International,16(4): 381–388.56Diemer, G.A. (1997). ‘Expectant fathers: Influence ofperinatal education on stress, coping, and spousal relations.Research in Nursing and Health, 20: 281–293.57Robertson, A. (2001). ‘Prenatal education: Time to lift ourgame’. The Practising Midwife, 4(1): 38–39.58Nolan, M.L., & Hicks, C. (1997). ‘Aims, processes andproblems of antenatal education as identified by three groupsof childbirth teachers’. Midwifery, 13(4): 179–188.59Humenick, S.S. (2000). ‘Letter from the Editor: The evolutionof childbirth educator to perinatal educator’. The Journal ofPerinatal Education, 9(1): vi–vii.childbirth education: antenatal education and transitions of maternity care in new zealand95

APPENDIX 1: Questionnaire for womenFrom early pregnancy to early parenting: Childbirth education in New ZealandInstructions: This questionnaire is completely anonymous and will take about 5 minutes to complete. It should becompleted by the mother of the baby. Please circle or write in the best answer that applies to you and/or your family/whänau. Then put your completed questionnaire in the reply paid envelope and post it back to us (Dr Sarah Dwyer,Parents Centres NZ Inc, PO Box 54128, Mana 5247). If you have any questions or would like help to complete thisquestionnaire, please call Dr Sarah Dwyer on 04 476 2424.1. Is this your first baby you have given birth to?a. Yes (Go to Q3) b. No (please circle)2. If not, how many babies have you given birth to? (including this birth) __________________________________3. Did you have a Lead Maternity Carer (LMC) for this pregnancy?a. Yes (Go to next Q) b. No (Go to Q5) c. Don’t know4. Did your LMC suggest you attend (or refer you to) childbirth education or antenatal classes?a. Yes b. No c. Don’t know5. Did you attend childbirth education or antenatal classes while you were pregnant with this child?a. Yes (Go to next Q) b. No (Go to Q10) c. Don’t know6. If you did attend childbirth education or antenatal classes, which organisation did you attend them with?a. Parents Centres e. MAMA (Mothers and h. SAMCL (Southern AucklandMidwives Assoc.)Maternity Care Ltdb. Plunket f. Home Birth i. Hospital-based classesc. Nga Maia g. Birth Wise j. Other (please describe)d. Birthcare ____________________________________7. Which of the following topics were covered in the classes that you attended? (circle all that apply)a. The role of the Lead Maternity Carer (LMC)b. Information on women’s support networks available in the communityc. The complaints procedure for maternity servicesd. The effects of smoking on the health of mother & baby, & options available to help give upe. The effects of alcohol and drugs on the health of mother & baby, & options available to help stopf. Mother’s and baby’s nutritional needs during pregnancyg. Screening and diagnostic tests (eg ultrasounds, HIV, rubella, sugar, rhesus tests, nuchal screening,amniocentesis)h. Warning signs of ill-health or problems during pregnancyi. Physical changes during pregnancy (eg pregnancy discomforts, nausea and sickness)j. Emotional changes during pregnancy (eg tearfulness, mood swings)k. Pelvic floor exercisesl. Stretching and exercisem. Relaxation skills (eg breathing awareness, use of massage and touch)n. Signs of labouro. Ways of managing pain during labourp. Description of normal and other birthing methods (eg caesarean)q. Options available to women in labour & birthing (eg position during labour, drug interventions)r. Risks and benefits of different birthing methodss. The benefits of breastfeedingt. The importance of exclusive breastfeeding for the first six monthsu. How to breastfeed and/or where to go for helpv. Physical changes after birthw. Emotional changes after birth (eg awareness of postnatal depression & preventative steps)x. Early days at home (eg ideas for coping, tiredness)y. Self care as a mother (eg nutrition, exercise)96 Families Commission Research Fund

families commission research fundz. Development of appropriate personal supportaa. Unplanned experiences (eg sick or premature infant, special needs babies)\bb. Safety of the baby (eg how to prevent SIDs - cot death)cc. Early parenting skills (eg bonding with baby, engaging with baby)dd. Parenting programme options availableee. The role of Well Child services and how to access themff. Vaccinations and tests after the baby is borngg. Other (please describe) ____________________8. To what extent did your attendance at these classes help prepare you for the birthing experience?1. 2. 3. 4. 5.Not at allTo a great extent9. To what extent did your attendance at these classes improve your confidence and ability to be a good parent forthis baby?1. 2. 3. 4. 5.Not at allTo a great extent10. If you did not attend childbirth education or antenatal classes, why not? (circle all that apply)a. I did not know about these classes.b. I was aware of these classes but they are not available in my area.c. The classes cost too much.d. I attended childbirth education or antenatal classes during an earlier pregnancy.e. I did not think childbirth education or antenatal classes would be helpful/useful.f. I obtained the information I wanted from other sources (eg LMC, family/whänau, books, internet)g. Other (please describe)11. Do you feel emotionally ready to have this child?1. 2. 3. 4. 5.Not at allCompletely12. What suburb do you live in? __________________________________________(include postcode if you know it)13. What is your date of birth? _______________________(dd/mm/yyyy)14. Which of the following best describes your family situation?a. Living with my partner and our child/ren (married or civil union)b. Living with my partner and our child/ren (de facto)c. Living on my own with my child/rend. Living with my child/ren and a new partner (married or civil union)e. Living with my child/ren and a new partner (de facto)f. Other (please describe) __________________________________________________________________15. What is your highest educational qualification? (for overseas qualifications, circle equivalent)a. No qualificationb. Fifth Form Certificate in one or more subjects, or National Certificate level 1c. Sixth Form Certificate in one or more subjects, or National Certificate level 2d. NZ Higher School Certificate, Higher Leaving Certificate, or National Certificate level 3e. Tertiary degree (1-4 years)f. Masters/Doctorate16. Which ethic group do you identify with?a. New Zealand European e. Cook Island Mäori h. Chineseb. Mäori f. Tongan i. Indianc. Samoan g. Niuean i. Other (pleas describe)________17. What is your approximate total household income per year, before tax?a. Under $15,000 e. $30,001 to $35,000 i. $60,001 to $70,000b. $15,001 to $20,000 f. $35,001 to $40,000 j. $70,001 to $100,000c. $20,001 to $25,000 g. $40,001 to $50,000 k. $100,001 or mored. $25,001 to $30,000 h. $50,001 to $60,00018. How could the quality of childbirth education or antenatal classes be improved?_____________________Thank you for completing this questionnaire. Please put it in the reply paid envelope supplied and post it back to us.childbirth education: antenatal education and transitions of maternity care in new zealand97

APPENDIX 2: Questionnaire for providersFrom early pregnancy to early parenting: Childbirth education in New ZealandInstructions: This questionnaire should be completed by providers of pregnancy and parenting education classes(also called childbirth education or antenatal classes). Some of the questions may require a bit of time, but theywill provide us with important information about the availability and quality of childbirth education in New Zealand,as of 2006. Please type in, bold, or highlight the correct answer that applies to your organisation. Then E-mail yourcompleted questionnaire to Magda Kielpikowski (Research Assistant), kfamily@xtra.co.nz. If you have anyquestions about the questionnaire, please call Dr Sarah Dwyer (Project Manager) on 04 476 2424.1. How many childbirth education or antenatal courses/classes did you deliver (or were contracted to deliver)in 2006? _______________________(NB: If you held a contract from July 2005-June 2006 and another contract from July 2006-June 2007, please only count thecourses that were delivered in 2006.)2. Did you run classes specifically designed for a particular population group?a. Yes b. No (Go to Q4) c. Don’t know (please bold or highlight your answer)3. If yes, which population did your classes target?a. Teens b. Mäori c. Pacificd. Vulnerable families/whänau e. Other (please describe)__________________________________________4. In 2006, was your course based on the national service specifications for pregnancy & parenting education?a. Yes (Go to Q6) b. No c. Don’t know5. If not, was the course based on any other specifications? (please describe)____________________________6. On average, how many sessions was each course? ________________________________________________7. On average, what was the duration of each session? (in hours) ________________8. Is it compulsory for the providers of your antenatal classes to hold a certificate or diploma in childbirtheducation (ie., through Aoraki Polytechnic)?a. Yes (Go to Q10) b. No c. Don’t know9. If not, who are the providers of your antenatal classes?a. Midwives b. Experienced mothers c. Other (please describe)____________________10. To what extent is the content of your antenatal courses based on a structured curriculum or decided byparticipating women and their families/whänau?1 2 3 4 5Totally unstructured/All content decided byparticipating women &families/whänauMostly unstructured Combination Mostly structured Totally structured /All content based on setcurriculum11. Which of the following topics would typically be covered in your courses? (bold all that apply)a. The role of the Lead Maternity Carer (LMC)b. Information on women’s support networks available in the communityc. The complaints procedure for maternity servicesd. The effects of smoking on the health of mother & baby, & options available to help give upe. The effects of alcohol and drugs on the health of mother & baby, & options available to help stopf. Mother’s and baby’s nutritional needs during pregnancyg. Screening and diagnostic tests (eg ultrasounds, HIV, rubella, sugar, rhesus tests, nuchal screening, amniocentesis)h. Warning signs of ill-health or problems during pregnancyi. Physical changes during pregnancy (eg pregnancy discomforts, nausea and sickness)98 Families Commission Research Fund

families commission research fundj. Emotional changes during pregnancy (eg tearfulness, mood swings)k. Pelvic floor exercisesl. Stretching and exercisem. Relaxation skills (eg breathing awareness, use of massage and touch)n. Signs of labouro. Ways of managing pain during labourp. Description of normal and other birthing methods (eg caesarean)q. Options available to women in labour & birthing (eg position during labour, drug interventions)r. Risks and benefits of different birthing methodss. The benefits of breastfeedingt. The importance of exclusive breastfeeding for the first six monthsu. How to breastfeed and/or where to go for helpv. Physical changes after birthw. Emotional changes after birth (eg awareness of postnatal depression & preventative steps)x. Early days at home (eg ideas for coping, tiredness)y. Self care as a mother (eg nutrition, exercise)z. Development of appropriate personal supportaa. Unplanned experiences (eg sick or premature infant, special needs babies)bb. Safety of the baby (eg how to prevent SIDs - cot death)cc. Early parenting skills (eg bonding with baby, engaging with baby)dd. Parenting programme options availableee. The role of Well Child services and how to access themff. Vaccinations and tests after the baby is borngg. Other (please describe)________________________________________________________12. What percentage of families drop out before completing the whole course?_______________13. What percentage of families complete at least 50% of the whole course?________________14. How are you funded?a. DHB-funded b. Fee-for-service (ie client pays) c. Other (please describe)_________________15. Is the demand for antenatal classes in your area greater than what you can provide?a. Yes b. No (Go to Q17) c. Don’t know16. If yes, how do you manage the difference between what is required and what you can provide?(please explain)__________________________________________________________________17. What are the main issues or problems for you as providers of antenatal classes? (What are the gaps betweenwhat you aim to provide and what actually happens in practice?) (please describe)___________________________________________________________________________________________________________________________________________________________________________________________18. We would like to talk to other providers of childbirth education. Do you know of any other providers of childbirtheducation (that do not hold DHB contracts), in your region? (please list below)childbirth education: antenatal education and transitions of maternity care in new zealand99

APPENDIX 3: Key informant interview questionsName:Position:Date:Key Informant Interview QuestionsTransition between LMC and childbirth education1. (Q3*) What proportion of LMCs refer women and their families/whänau to childbirth education?2. (Q4) What are the contractual arrangements and obligations of LMC to refer women to childbirth education?3. (Q5) What process is used to manage the referral between LMC and childbirth education?Childbirth education4. (Q6) Who are the providers of childbirth education?5. (Q7) What are the contractual arrangements and obligations of key childbirth education providers?6. (Q8) What are the minimum qualifications of childbirth educators required by different providers of childbirtheducation?7. (Q9) How is childbirth education funded and by whom?8. (Q10) What information do women and their families/whänau receive as part of childbirth education and whatresources/booklets are made available to women?9. (Q11) How does the childbirth education information given by different providers compare?Breastfeeding10. (Q20) What resources are made available in hospital to help women successfully establish and maintainbreastfeeding, eg access to nurses, written resources?Transition between LMC and Well Child services11. (Q22) How soon after the baby is born, does the transfer between LMC and Well Child services occurin practice?12. (Q21) What are the contractual arrangements and obligations of LMC to refer women toWell Child services?13. (Q23) What process is used to manage the handover from LMC to Well Child services?14. (Q25) To what degree is the transition between LMC and Well Child services left to the mother, father orfamily/whänau?15. (Q24) What processes do Well Child services use to engage women and families/whänau during this transition?*Q = Research questions100 Families Commission Research Fund

families commission research fundWell Child services16. (Q26) Who are the providers of Well Child services?17. (Q27) What are the contractual arrangements and obligations of key Well Child service providers?18. (Q29) What are the barriers to accessing Well Child services?19. (Q30) What screening is done for postnatal depression (PND)?20. What are your perceptions of the gaps between the support that services aim to provide and what actuallyhappens in practice?Other questions• Who else should I interview to find answers to these questions?• How should I access women for focus groups?• How should I access women through LMCs, in hospital and/or through Well Child services to give questionnaire.childbirth education: antenatal education and transitions of maternity care in new zealand101

APPENDIX 4: Information sheet for women about focus groupsFrom early pregnancy to early parenting: Antenatal education and transitions ofmaternity care in New ZealandINFORMATION SHEET ABOUT FOCUS GROUPSThis project is being conducted for Parents Centres, in conjunction with the Families Commission and ParentingCouncil. Thank you for showing an interest. Please read this information sheet carefully before deciding whetheror not to participate in a focus group. If you decide to participate, we thank you. If you decide not to participate,there will be no disadvantage to you of any kind and we thank you for considering our request.What is the aim of the project?The aim of the focus groups is to talk to women and their families/whänau about their experiences with childbirtheducation classes, Well Child services and transitions between different providers of maternity care. We are alsointerested in finding out: (1) if childbirth education classes prepare parents emotionally to have children, (2) whatdecisions do parents make before their child is born about how they will consciously parent their child and (3)the extent to which parents are aware of their entitlements to maternity services under the Section 88 MaternityServices Notice.What type of participants are being sought?We are inviting clients of childbirth education and Well Child providers to participate in focus groups. We will runsome focus groups with women who have not yet given birth as well as focus groups with women who have givenbirth within the last six months. Partners and/or close family/whänau members are welcome and encouraged toparticipate.What will participants be asked to do?Should you agree to take part in this project, you will be asked to participate in a group discussion with 5-10other participants. This discussion will take about 1.5 hours of your time and will be held at your local childbirtheducation or Well Child Service (eg Parent Centre, Plunket). A range of different time options will be offered.What are the possible benefits and risks of participation?One of the main benefits of this project is that it will help us to identify gaps between the support that maternityservices aim to provide and what actually happens in practice. This is important because it has the potential toinform future funding decisions and planning around how to further improve access to and quality of childbirtheducation and Well Child services in New Zealand. There are no risks of participating.Can participants change their mind and withdraw from the project?You may withdraw from participation in the project at any time and without any disadvantage to yourself of anykind. If you do not participate, there will be no disadvantage to yourself or your family/whänau of any kind.What data or information will be collected and what use will be made of it?The focus groups will help us collect information on childbirth education classes, Well Child services and transitionsbetween maternity services from the perspective of women and their families/whänau. We will ask you somequestions about your preparation to be a parent and your awareness of the maternity services to which you areentitled. We will also collect information on the characteristics of your family/whänau, so we understand whoparticipated in the focus groups, but we will not be able to link you to your comments or responses during the focusgroup in any way.The focus group discussion will be recorded and transcribed. All data will be securely stored and only the maininvestigators will have access to it. At the end of the project all recordings will be destroyed. The transcribeddiscussions will be retained in secure storage for five years, after which they will be destroyed. The results of theproject may be published, but you will not be identified in any way. You are most welcome to request a copy of theresults of the project. The Parenting Council will hold copies of the final report for this purpose (Ph Viv Gurrey: 04233 2022 ext: 800).What if participants have any questions?If you have any questions about this project, either now or in the future, please feel free to contact Dr Sarah Dwyeron 04 476 2424 or 021 412 702 (cell) or Viv Gurrey, Ph: 04 233 2022 ext:800. This project has been reviewedand approved by the Plunket Ethics Committee.102 Families Commission Research Fund

families commission research fundAPPENDIX 5: Questions for women in focus groupsFor women who had their baby within the previous six months:• Welcome women (and any family members) to the group and thank them for participating.• Ask women to complete the survey on CBE – provides demographics and relevant information.Questions1. What was the most important thing that you took away with you/learnt from attending CBE classes?2. To what extent does attendance at CBE classes help prepare you emotionally to have children?3. What decisions did you make before your child was born about how you would consciously parent your child?To what extent did attendance at CBE classes facilitate this process? Did any other maternity service help youwith this process?4. What are your entitlements under the Maternity Services Notice (pursuant to Section 88 of the NZ Public Health& Disability Act)? To what extent are you aware of your maternity entitlements?5. What resources were made available to you in hospital to help you successfully establish and maintain breastfeeding?6. How soon after your baby was born did the transfer between LMC and Well Child service occur?7. What was your experience of the handover from LMC to Well Child? To what extent was it left to you to makecontact with the Well Child provider?8. What processes did Well Child services use to engage you at this time?9. What are the barriers to accessing Well Child services?10. Did anyone talk to you about postnatal depression? Were you screened for PND?11. Is there anything else you want to discuss about your experiences with the maternity system?childbirth education: antenatal education and transitions of maternity care in new zealand103

APPENDIX 6: Information sheet for women about brief questionnaireFrom early pregnancy to early parenting: Childbirth education in New ZealandInformation sheet about brief questionnaireThis project is being conducted for Parents Centres, in conjunction with the Families Commission and ParentingCouncil. Thank you for showing an interest. Please read this information sheet carefully before deciding whetheror not to answer the questionnaire. If you decide to participate, we thank you. If you decide not to answer thequestionnaire, there will be no disadvantage to you of any kind and we thank you for considering our request.What is the aim of the project?The aim of the questionnaire is to determine what proportion of women and their families/whänau attend childbirtheducation or antenatal classes and how this differs across different parts of New Zealand. We are also interestedin comparing the topics covered by different providers of childbirth education and your perceptions of the value ofantenatal classes.What type of participants are being sought?This questionnaire is being given to all women in New Zealand hospitals who give birth in April or May 2007.What will participants be asked to do?Should you agree to take part in this project, the only thing you will be asked to do is to complete the attachedquestionnaire and return it in the reply paid envelope. It should take you about five minutes to complete.What are the possible benefits and risks of participation?One of the main benefits of this project is that it will help us to identify gaps in the availability and quality ofchildbirth education across New Zealand. This is important because it has the potential to inform future fundingdecisions and planning around how to further improve access to and quality of childbirth education services in NewZealand. There are no risks of participating.What data or information will be collected and what use will be made of it?This questionnaire will help us collect information on the proportion of women and their families/whänau attendingchildbirth education classes, the content covered in these classes and the value of these classes. We will alsoask you some questions about the characteristics of your family/whänau, but the questionnaire is completelyanonymous, so we will not be able to link you to your questionnaire in any way.The data collected will be securely stored and only the main investigators will have access to it. At the end of theproject all questionnaires will be destroyed. The raw data will be retained in secure storage for five years, afterwhich it will be destroyed. The results of the project may be published. You are most welcome to request a copy ofthe results of the project. The Parenting Council will hold copies of the final report for this purpose (Ph Viv Gurrey:04 233 2022 ext:800).What if participants have any questions?If you have any questions about this project, either now or in the future, please feel free to contact Dr Sarah Dwyer(Project Manager) on 04 476 2424 or 021 412 702 (cell). Alternatively you could contact Viv Gurrey (CEO, ParentsCentres) on 04 233 2022 ext:800.This project has been reviewed and approved by Plunket and the Multi-region Ethics Committee.104 Families Commission Research Fund

families commission research fundAPPENDIX 7: List of hospitals and maternity facilities through whichthe questionnaire was distributedProvider Location PhoneNorthland DHBWhangerei Maternity Unit 09 430 4101ext 8737021 824 618Bay of Islands Maternity Facility 09 405 7709Dargaville Maternity FacilityKaitaia Maternity FacilityRawene Hospital(NB: funded by a trust, not the DHB)Waitemata DHBNorth Shore Maternity,North Shore HospitalWaitakere Maternity,Waitakere HospitalAuckland DHBWomen’s Health,Auckland City HospitalParnell St, RawenePrivate Bag, Kaikohe, NorthlandPrivate Bag 93 503, Takapuna Auckland2nd Floor, North Shore HospitalShakespear Rd, Takapuna Auckland09 405 770909 486 8900Lincoln Rd, Henderson Auckland 09 486 8900PO Box 92024, Auckland 09 307 4949ext 25351Birthcare Auckland 20 Titoki St, Parnell, Auckland 09 374 0771Counties Manükau DHBMiddlemore hospital Women’s Health, Building 43Private Bag 93311, OtahuhuPrimary Unit09 276 0000Bay of Plenty DHB 07 579 8000Tauranga Hospital 07 579 8000WhakataneOther Primary Units in outlying areasWaikato DHB 07 839 8899Waikato HospitalRural Health Waikato Maternity FacilitiesLevel 9, ERBWaikato Hospital, Private Bag 3200, Hamilton07 839 8726ext 8207Huntly Birthcare (private) 5/7 Onslow St, Huntly 07 828 7648Pohlen Maternity Unit(Pohlen Hospital – private)56 Rawhiti Ave, MatamataPO Box 239, Matamata07 881 9099childbirth education: antenatal education and transitions of maternity care in new zealand105

Waihi Hospital (private) Toomey St, Waihi 07 863 8089River Ridge East Birth Centre (private) PO Box 4056, Hamilton 07 839 0425Waterford Birth Centre (private) 27 Tisdall Tce, Hamilton 07 839 0281Tairawhiti DHBGisborne Maternity Unit,Tairawhiti District HealthPrivate Bag 7001, Gisborne 06 869 0500ext 8024Maternity Department, Te Puia Hospital PO Box 2, Te Puia Springs 06 864 6803Taranaki DHBTaranaki Base Hospital, Maternity Unit David St, New Plymouth 06 753 6139Hawera Hospital, Maternity Unit Hunter St, Hawera 06 753 6139Elizabeth R Maternity (ER Hospital – private) 30 Elizabeth Grove, Stratford 06 756 6262027 427 9285Lakes DHBMaternity Unit, Rotorua Hospital Rotorua 07 348 1199Birthing Unit, Taupo HospitalHawkes Bay DHBHawkes Bay Regional Hospital,Ata Rangi Maternity UnitNapier Maternity UnitWairoa Hospital (Primary Unit)TaupoPrivate Bag 9014, HastingsHawkes Bay Regional Hospital,Omahu Rd, HastingsKitchener St, WairoaPO Box 84, Wairoa06 878 810906 838 7099MidCentral DHB 06 350 825906 350 8061(DHB)Women’s Health Unit,Palmerston North HospitalWhanganui DHBRuahine Street, Private Bag 11036,Palmerston NorthWhanganui Hospital 06 348 3216Capital and Coast DHB 04 385 59990274 793 826Wellington Hospital,Delivery Suite & Ward 12 (postnatal)Private Bag 7902, Wellington SouthDelivery Suite, Level D, Grace Neil Block,Wellington Hospital, Newtown04 385 5999Kenepuru Birthing Unit PO Box 50215, Porirua 04 385 5999Paraparaumu Birthing Unit Warrimoo St, Paraparaumu 04 385 5999Hutt Valley DHB106 Families Commission Research Fund

families commission research fundHutt HospitalWairarapa DHBPrivate Bag 31-907, Lower HuttPhysical address: High Street, Lower Hutt04 570 9078Wairarapa Hospital 06 946 9800027 675 1497Nelson Marlborough DHB 03 546 1841Nelson Hospital Private Bag 18, Nelson 03 546 1927Int ext 792703 546 1800(DHB)Wairau HospitalGolden Bay (Primary Unit)Motueka (private contract with DHB – as aresult of RFP)Canterbury DHB 03 364 4106Christchurch Women’s HospitalAnother Primary UnitAshburton Maternity, Ashburton Hospital(Rural Services)Level 5, Christchurch Women’s Hospital,Private Bag 4711, ChristchurchElizabeth StreetPrivate Bag 801, Ashburton03 364 410603 307 848303 308 4149(switch)Lincoln Maternity Hospital James Street, Lincoln 03 325 2802South Canterbury DHB 03 684 4000Timaru Hospital, Maternity Services Queen St, Timaru 03 684 4000West Coast DHBMcBrearty Ward, Grey Base Hospital PO Box 387, Greymouth 03 768 0499027 245 9595Otago DHB 03 474 7948Queen Mary Maternity Centre,Dunedin HospitalOamaru Maternity Centre,Oamaru HospitalMaternity Unit,Clutha Health First HospitalDunedin Hospital, Private Bag 1921, Dunedin 03 474 7948Waitaki District Health Services Ltd,Private Bag 50059, Oamaru (North Otago)03 433 0290PO Box 46, Balclutha 9200 03 419 00380800 288 089Charlotte Jean Maternity Centre (private) 26 Ventry St, Alexandra 03 448 5229021 588 220Southland DHB Southland District Health Board, PO Box 828,InvercargillMaternity Unit03 214 7243027 674 1758childbirth education: antenatal education and transitions of maternity care in new zealand107

APPENDIX 8: Pregnancy and parenting education providers by DHBProvider Location Phone Holdscontractwith DHBNorthland DHBHokianga Health Private Bag, Kaikohe 09 405 7709 ✓Parents Centre Whangarei ✗Waitemata DHBWaitemata DHB Provider Armmaternity servicesRodney Coast Midwives 56 View Rd, Warkworth 09 425 8201 ✓Coast to Coast PHOCoast to Coast PHO, Wellsford Medical 09 423 8745 ✓Centre, PO Box 66, WellsfordMAMA 116 Marsden Avenue, Mt Eden 09 629 5163 ✓Parents CentresOnewaWaitemataBays North HarbourHibiscus Coast✗Auckland DHBBirthcare Auckland 20 Titoki St, Parnell, Auckland 09 374 0800 ✓MAMA (Mothers & MidwivesAssociated)116 Marsden Ave, Mt Eden, AucklandPO Box 56 182, Dominion Rd, Auckland✓09 629 5221 ✓Parents Centres Auckland East and Bays ✗Bethany Centre 35 Dryden St, Grey Lynn, Auckland 09 376 1324 ✗Counties Manükau DHBSouth Auckland Maternity Care 16 Wiri Station Road, Manukau, Auckland 09 263 4012 ✓Limited (SAMCL)Plunket 2 09 274 5026 ✓Turuki Health (via Te Kupenga OHouturoa PHO)2/32 Caning Crescent, Mangere, Auckland 09 270 068309 275 5788✓Parents CentresManukauAuckland EastFranklinBay of Plenty DHBBirthwise Charitable Trust 287 Rowe Road, Tauranga 07 544 4405 ✓Katikati Resource Centre Beach Road, Katikati 07 549 0399 ✓Trust Home Birth Charitable Trust 2 Cambridge Road, Tauranga ✓Ngati Awa Social and HealthServices TrustPO Box 2076, Whakatane 07 571 0559 ✓✗108 Families Commission Research Fund

families commission research fundPlunket 2Parents Centres 1Waikato DHB471 Devenport Road, TaurangaGeographic areas: Kawerau & PapamoaTaurangaWhakataneTe PukeBirthcare Huntly Limited 5 Onslow St, Huntly 07 828 7648 ✓Plunket 2 6 Princes St, PO Box 9359, Hamilton 07 839 5702 ✓Independent ChildbirthEducatorWhitianga 07 866 534408 681 4288Tokorao Council of Social Services Maraetai Rd, PO Box 429, Tokoroa 07 886 6314 ✓Waikato Homebirth AssociationIncorporated (NB: Were advised thatthey no longer provide classes)PO Box 311, Hamilton 07 848 1864 ✓River Ridge East Birth Centre 35 Von Tempsky St, Hamilton 07 839 0425 ✗Waterford Birth Centre 27 Tisdall St, Hamilton 07 839 0281 ✗Birthspirit Ltd 15 Te Arawa Road, Hamilton 07 856 4612 ✗Parents Centres 1CambridgePutaururuOtorohangaMorrinsvilleThames-Hauraki04 233 2022 ✓Parents CentresHamiltonPapakuraTairawhiti DHBParents Centre 1 Gisborne ✓Tairawhiti District Health – ProviderArm1 st Floor Morris Adair Building, GisborneHospital, Private Bag 7001, Gisborne06 869 0500ext 8240Turanga Health Gisborne 06 869 0457 ✗Taranaki DHBPregnancy Help Inc Miranda St, Stratford 06 765 5042 ✓Tui Ora – subcontracted toManaaki Oranga36 Maratahu St, New Plymouth 06 759 4064 ✓Parents Centres 1Plunket 2Lakes DHBTuwharetoa Health Services(advised that no longerprovide classes)New PlymouthStratfordSouth TaranakiPlunket House, 74 Courtney St, NewPlymouth04 233 2022ext 802✓✓✓✗✓✓06 769 5453 ✓Turangi 07 386 6587 ✓childbirth education: antenatal education and transitions of maternity care in new zealand109

Korowai Aroha Trust –subcontracted to Lakes MidwivesPoutiri Charitable Trust MDO –subcontracted to Te Whare HauoraO NgongotahaOld Taupo Road, Rotorua 07 347 6222 ✓Community Health Clinic, 152 Main Road,Ngongotaha07 357 4946 ✓Mäori Women’s Welfare League Through Te Whare Hauora ✗Parents Centre 1 Rotorua ✓Parents Centre Taupo ✗Hawkes Bay DHBHealth Services (DHB ProviderArm) – subcontracts with BirthCare Educators who run theclasses for the Provider ArmCentral Hawkes BayHavelock NorthHastings06 878 810906 878 4774Positive Birth 06 875 1170 ✗Choices – Kahungunu Health and 208 Southampton St, West Hastings 06 878 7616 ✗Community ServicesTe Taiwhenua O Heretaunga(NB: Advised that they do notprovide CBE classes themselves)Parents CentresMidCentral DHBMidCentral Health (PalmerstonNorth Hospital)Dannevirke Health Services Ltd(Dannevirke Community Hospital)NapierHastings,Central Hawkes Bay✓06 873 7244 ✗Palmerston North & Feilding 06 350 8061 ✓Barraud St, PO Box 275, Dannevirke 06 374 5691 ✓Otaki Birthing Centre Ltd 288 Main Highway, Otaki 06 364 8337 ✓Community Birth Services 496 Church Street, PO Box 5443,06 354 6455 ✓Palmerston NorthTe Runanga o Raukawa Inc> Cnr Oxford and Keepa St, Levin> Duke Street, Feilding06 368 867806 323 6446Doula Beginnings Palmerston North 06 353 7153 ✓Parents CentresPalmerston North✗LevinThe Pregnancy Centre3 Amesbury Street,PO Box 5533, Palmerston North✗✓06 354 2273 ✗Wanganui DHBWanganui DHB Provider Division Heads Rd, Private Bag 3003, Wanganui 06 348 1234 ✓Capital and Coast DHBMATPRO (Maternity Project)Marion Square, PO Box 27-380, WellingtonPorirua & Wellington South04 801 7307 ✓110 Families Commission Research Fund

families commission research fundNewlands College CommunityLearning CentreParents CentresPO Box 26 079 Newlands,WellingtonKapitiManaWellington NorthWellington South04 474 1330 ✗Birth Wise PO Box 7370, Wellington South 04 973 9473 ✗Home Birth Aotearoa PO Box 9130, Wellington 04 476 6661 ✗Hutt Valley DHBHVDHB Provider Arm (hospitalmaternity services) – subcontractswith BirthEd who run the classesfor the Provider ArmParents CentresLower HuttUpper Hutt04 934 3426027 245 3541Birthworks 04 802 0771(pager)Wairarapa DHBWairarapa Hospital Maternity Unit Te Ore Ore Rd, PO Box 96, Masterton 06 946 9119ext 4119Parents Centre Wairarapa ✗Nelson Marlborough DHBIndependent Childbirth Educator Blenheim 03 578 5599 ✓Independent Childbirth Educator Rata St 03 546 9029 ✓Nelson Marlborough DHB ProviderArmParents Centres 1No. of fee paying classes alsobeing run in the communityCanterbury DHBHome Birth Classes TrustChristchurchChristchurch Hospital (DHBProvider Arm)Ashburton Maternity CentreParents Centres 1Golden Bay Community Hospital, SH60, RD1,TakakaNelson DistrictMarlborough✗✓✗✗✓03 525 9808 ✓03 528 9332 ✓✗03 366 4574 ✓Private Bag 4711, Christchurch 03 364 469903 364 4421Ashburton & Rural Health Services, OakGrove, AshburtonChristchurchChristchurch South✓03 307 8483 ✓04 233 2022 ✓Parents Centre Ashburton ✗childbirth education: antenatal education and transitions of maternity care in new zealand111

South Canterbury DHBTimaru Hospital and CommunityServices (DHB Provider Arm)Queen St, Timaru 03 684 4000ext 8886Parents Centre 1 Timaru ✓West Coast DHBParents Centre 1 Greymouth 04 476 6950 ✓WCDHB Provider Arm (MaternityServices)Otago DHB03 768 0499ext 2881Dunedin Home Births Association 03 474 0044 ✓Dunedin Independent Childbirth✓Educators – FOCUSArai Te Uru Whare Hauora Stuart St, Dunedin 03 417 9960 ✓Clutha Health First 3–7 Clutha St, Balclutha 03 418 0508 ✓Plunket 2✓Parents Centres 1OamaruDunedinBalcluthaTaieri✓Parents Centre Alexandra District ✗Southland DHBParents Centres 1InvercargillGorePlunket 2 Central Southland ✓Plunket 2 Invercargill ✓Plunket 2 Wakatipu ✓Plunket 2 Te Anau ✓Lumsden Maternity Centre 58 Garden St, Lumsden 03 248 7050 ✓Queenstown Medical Centre 9 Isle St, Queenstown, Wakatipu Region 03 441 0500 ✓Tuatapere Maternity Hospital 69a Orawia Road, Tuatapere, WesternSouthland03 226 6099 ✓1Contracts are held between the DHB and the national organisation, Parents Centres NZ Inc, PO Box 54128 Mana, Porirua,Wellington.2The Royal New Zealand Plunket Society contracts with the DHBs for the provision of CBE services but contracts directly with theMinistry of Health for Well Child services.✓✓✓112 Families Commission Research Fund

families commission research fundAPPENDIX 9: National service specification for pregnancy andparenting educationon behalf of all DHBsPREGNANCY AND PARENTING EDUCATIONSTATUS: CurrentDATE PUBLISHED ON NSF LIBRARY JULY 2002DATE TO BE REVIEWEDchildbirth education: antenatal education and transitions of maternity care in new zealand113

NATIONAL SERVICE SPECIFICATION FORPREGNANCY AND PARENTING EDUCATION1. DEFINITIONPregnancy and Parenting Education is a course on pregnancy, childbirth and early parenting provided to agroup of pregnant women and their whänau/families.2. SERVICE OBJECTIVES2.1. GeneralThe objective of the service is to give expectant women and their whänau the opportunity to acknowledgetheir own experience, knowledge and skills, empowering them to trust themselves and to know how to seekadditional maternity information and support when they need it.2.2. Mäori healthThe service will provide access for women and their whänau to culturally safe information about their careoptions, carers and entitlements.3. SERVICE USERSThe user of this service is one pregnant woman (or prospective adoptive mother), and, where relevant, herpartner or support person or whänau.The service should be accessible to all pregnant women. Strategies should be developed to target women atrisk of adverse outcomes.4. ACCESS4.1 Entry and exit criteriaEach eligible pregnant woman is entitled to receive one Pregnancy and Parenting Education programmeduring the duration of each pregnancy.4.2 CostThe service is to be free to all eligible women with no request for a copayment or donation.4.3 TimeThe service will be provided at a reasonable time that meets the needs of the service users, particularly thoseservice users at risk of adverse outcomes. The antenatal component of the course should be completed withina six-week period.5. SERVICE COMPONENTS5.1 Programme5.1.1 Each course must cover the following:(i) access to maternity services• the role of the lead maternity carer and other health professionals that may be involved in her care• information on women’s support networks available in the community• the complaints procedure for maternity services(ii) pregnancy care• health promotion during the antenatal period, including the benefits of avoiding smoking and alcohol• pelvic floor and stretching exercises• warning signs during pregnancy(iii) labour and birth care• signs of labour• options available for women in labour and birthing• role of support person• common complications of labour and birth and possible interventions114 Families Commission Research Fund

families commission research fund(iv) care following birth• physical and emotional changes including postnatal depression• self-care for the woman postnatally• early parenting skills• safety of the baby, including prevention of SIDs• the role of Well Child services and how to access them.5.1.2 In particular, the course content must comply with the Baby Friendly Hospital Initiative and include:• the benefits of breastfeeding, including nutritional, protective, bonding and health benefits to the mother• the importance of exclusive breastfeeding for the first four to six months• basic breastfeeding management, including the importance of rooming-in, the importance of feeding ondemand, how to ensure there is enough milk and positioning and attachment.5.1.3 The course is to be provided in a manner that enhances the woman’s sense of confidence as sheapproaches childbirth and parenting. The programme content will be flexible, to accommodate the manyand varied learning needs and concerns of clients. A written plan of each session will be available.5.2 SettingsSuitable settings may include community rooms, marae, hospitals, private homes, practice rooms or otherappropriate places. Venues may vary according to the needs of the women attending. Settings should be safeand accessible.5.3 Service levelsThe course will be for a minimum of 12 hours.5.4 Equipment/resourcesService providers are required to develop resources that empower women to make informed choices andto further their own learning. Resources should be up-to-date and relevant to the situation and audience.Resources available at course sessions should include appropriate videos, books and information packs thatwill provide them with information on all aspects of pregnancy and parenting. Clients should have access toreference lists and printed material to take home.5.5 Key inputs5.5.1 Programme co-ordinators for Pregnancy and Parenting Education will preferably be childbirth educatorswith a recognised qualification in childbirth education. Alternatively, programme co-ordinators may be:• midwives or physiotherapists with additional recognised qualifications in adult education and culturalawareness/Treaty issues, or• he kuia whare tapu or other respected teacher, recognised by the respective runanga.5.5.2 In keeping with the principle of continuity of care, each programme will be co-ordinated by one person.6. SERVICE LINKAGESYou will establish and maintain linkages with agencies and organisations who may refer women to Pregnancyand Parenting Education or who may be referred on to by the provider. These will include Lead MaternityCarers, maternity facility providers, Well Child providers, antenatal and postnatal support groups, Family Start.7. EXCLUSIONSThe service is linked to but does not include Lead Maternity Care or maternity facility services.8. QUALITY REQUIREMENTS8.1 Accessibility• free education• a suitable venue• the programme encourages access by women at risk of adverse outcomes.childbirth education: antenatal education and transitions of maternity care in new zealand115

8.2 Acceptability• each class is planned specifically to respond to the individual needs of the participants• resources are of good quality and up-to-date with current maternity practices. You should subscribe toChildbirth Educators NZ or the International Journal of Childbirth Education, or equivalent.8.3 Effectiveness• educational aims and objectives will be learner-centred with the objectives being realistic and measurable• education will be based on the principles of adult learning• information presented in class will be current and based on reputable, reproducible research. Allinformation must be comprehensive and balanced and presented in such a way that it allows theparticipants to examine their expectations, explore possible alternatives and provide their own solutions.• as group size is a significant factor in determining group interaction and satisfaction, the class will notexceed 12 pregnant women• classes will be culturally safe.9. PURCHASE UNITS AND REPORTING REQUIREMENTS9.1 The following purchase units apply to this service. Purchase units are defined in the HFA Data Dictionary.Pu Code PU Description PU Measure Reporting RequirementsW01002Pregnancy andParentingEducationFrequencyReporting UnitCourse Quarterly Number of courses provided9.2 Purchase unitsYou are required to report on the volume of the above Purchase Units provided in this period. This report isto include:• course attended and number of hours each woman attended• NHI of woman.9.3 Quality measuresYou are required to report on the following quality measures:(i) Accessibility• A critical evaluation and summary of non-attendance• The average gestation for admission to a course and any waiting lists(ii) Acceptability• A demonstration of the provider’s commitment to implementing the principles of the Treaty of Waitangi• Evidence that the service is delivered in a manner which recognises and responds to the cultural diversityof the participants(iii) Effectiveness• The qualifications of the educators meet those specified and, if they do not hold a recognised qualificationin childbirth education, the efforts being made to attain this qualification• The occurrence of regular individual performance appraisals of educators’ written plans outlining actiontaken as a result of feedback from attendees’ evaluations of the course• Implementation of the principles of the Baby Friendly Hospital Initiative, as relevant to Pregnancy andParenting Education, using the recommended WHO/UNICEF criteria for assessment:- a written description of the content of the programme116 Families Commission Research Fund

families commission research fund- where mothers are routinely given written or audio-visual educational materials, these give accurateinformation and instruction for breastfeeding, without information on the use of infant formula- group talks are given to the majority of all pregnant women, not just women who already know theywant to breastfeed- group talks are not given routinely to all pregnant women on the use of infant formulae or bottlefeeding.Instead instruction is given on an individual, as requested, basis rather than to thewhole group.• Adherence to the Ministry of Health Infant Feeding Guidelines for New Zealand Health Workers (1997).The volume of courses provided will determine the frequency of reporting.9.4 Service planning informationServices should be planned and developed in the following ways:a) You should facilitate the establishment of linkages with local and appropriate postnatal parentingsupport groups.b) You should explore ways to encourage all women to utilise your Pregnancy and Parenting Educationservice. For example:• working with Mäori providers• offering classes for specific groups of women, for example Pacific Island women, young women• advertising locally• varying your teaching methods• other initiatives to be explored by you and us.c) Co-ordinators should demonstrate their personal effectiveness by:• regularly updating their knowledge of pregnancy and parenting information and issues• training in adult education and group facilitation.childbirth education: antenatal education and transitions of maternity care in new zealand117

APPENDIX 10: Topics covered by different childbirth educationprovidersTABLE A. Percentage of CBE providers indicating topics that were covered in their antenatal classesas a function of whether the provider was DHB-funded or not (N = 45)DHB-funded(n = 38)Other funded(n=7)Total (n=45)Topic % n % n % na. The role of the lead maternity carer (LMC) 86.8 33 85.7 6 86.7 39b. Information on women’s support networksavailable in the community 97.4 37 85.7 6 95.6 43c. The complaints procedure for maternity services 76.3 29 28.6 2 68.9 31d. The effects of smoking on the health of motherand baby, and options available to help give up 89.5 34 28.6 2 80.0 36e. The effects of alcohol and drugs on the health ofmother and baby, and options available tohelp stop 86.8 33 28.6 2 77.8 35f. Mother’s and baby’s nutritional needsduring pregnancy 92.1 35 57.1 4 86.7 39g. Screening and diagnostic tests (eg, ultrasounds,HIV, rubella, sugar, rhesus tests, nuchalscreening, amniocentesis) 60.5 23 28.6 2 55.6 25h. Warning signs of ill-health or problemsduring pregnancy 97.4 37 42.9 3 88.9 40i. Physical changes during pregnancy (eg,pregnancy discomforts, nausea and sickness) 94.7 36 71.4 5 91.1 41j. Emotional changes during pregnancy (eg,tearfulness, mood swings) 97.4 37 71.4 5 93.3 42k. Pelvic floor exercises 97.4 37 85.7 6 95.6 43l. Stretching and exercise 92.1 35 57.1 4 86.7 39m. Relaxation skills (eg, breathing awareness, useof massage and touch) 94.7 36 100.0 7 95.6 43n. Signs of labour 94.7 36 100.0 7 95.6 43o. Ways of managing pain during labour 94.7 36 100.0 7 95.6 43p. Description of normal and other birthingmethods (eg, caesarean) 94.7 36 85.7 6 93.3 42q. Options available to women in labour and birthing(eg, position during labour, drug interventions) 94.7 36 100.0 7 95.6 43r. Risks and benefits of different birthing methods 89.5 34 85.7 6 88.9 40s. The benefits of breastfeeding 97.4 37 85.7 6 95.6 43t. The importance of exclusive breastfeeding for thefirst six months 92.1 35 85.7 6 91.1 41118 Families Commission Research Fund

families commission research fundu. How to breastfeed and/or where to go for help 97.4 37 71.4 5 93.3 42v. Physical changes after birth 94.7 36 71.4 5 91.1 41w. Emotional changes after birth (eg, awareness ofpostnatal depression and preventative steps) 100.0 38 71.4 5 95.6 43x. Early days at home (eg, ideas for coping,tiredness) 100.0 38 100.0 7 100.0 45y. Self-care as a mother (eg, nutrition, exercise) 94.7 36 85.7 6 93.3 42z. Development of appropriate personal support 86.8 33 71.4 5 84.4 38aa.Unplanned experiences (eg, sick or prematureinfant, special needs babies) 71.1 27 42.9 3 66.7 30bb. Safety of the baby (eg, how to prevent SIDs –cot death) 97.4 37 85.7 6 95.6 43cc.Early parenting skills (eg, bonding with baby,engaging with baby) 97.4 37 71.4 5 93.3 42dd. Parenting programme options available 71.1 27 57.1 4 68.9 31ee.The role of Well Child services and how toaccess them 94.7 36 14.3 1 82.2 37ff. Vaccinations and tests after the baby is born 94.7 36 57.1 4 88.9 40gg. Other (please describe) 63.2 24 42.9 3 60.0 27childbirth education: antenatal education and transitions of maternity care in new zealand119

TABLE B. Percentage of women indicating topics covered in their antenatal classes as a function ofthe organisation through which they attended antenatal classes (N = 364 1 )TopicParentsCentres(n = 136)HospitalClasses(n =116)Birthcare(n = 29)Plunket(n = 15)BirthWise(n = 4)HomeBirth(n =10)MAMA(n =10)% % % % % % %a. The role of the lead maternity carer (LMC) 65.4 60.3 75.9 40.0 88.9 75.0 80.0b. Information on women’s supportnetworks available in the community 60.3 58.6 41.4 46.7 66.7 75.0 90.0c. The complaints procedure for maternityservices 10.3 22.4 17.2 20.0 22.2 50.0 10.0d. The effects of smoking on the health ofmother and baby, and options availableto help give up 49.3 61.2 58.6 40.0 77.8 100.0 50.0e. The effects of alcohol and drugs on thehealth of mother and baby, and optionsavailable to help stop 52.2 60.3 58.6 40.0 77.8 75.0 50.0f. Mother’s and baby’s nutritional needsduring pregnancy 70.6 72.4 82.8 66.7 88.9 100.0 70.0g. Screening and diagnostic tests (eg,ultrasounds, HIV, rubella, sugar, rhesustests, nuchal screening, amniocentesis) 48.5 49.1 44.8 46.7 44.4 75.0 20.0h. Warning signs of ill-health or problemsduring pregnancy 66.9 41.4 62.1 60.0 88.9 50.0 70.0i. Physical changes during pregnancy(eg, pregnancy discomforts, nauseaand sickness) 80.9 81.9 69.0 66.7 66.7 75.0 60.0j. Emotional changes during pregnancy(eg, tearfulness, mood swings) 87.5 76.7 75.9 73.3 77.8 75.0 70.0k. Pelvic floor exercises 93.4 86.2 62.1 80.0 77.8 75.0 90.0l. Stretching and exercise 72.8 70.7 58.6 60.0 66.7 75.0 90.0m. Relaxation skills (eg, breathingawareness, use of massage and touch) 86.0 79.3 82.8 80.0 88.9 100.0 100.0n. Signs of labour 98.5 93.1 93.1 80.0 88.9 100.0 100.0o. Ways of managing pain during labour 97.8 96.6 93.1 86.7 100.0 100.0 100.0p. Description of normal and otherbirthing methods (eg, caesarean) 98.5 93.1 93.1 73.3 100.0 100.0 100.0q. Options available to women in labourand birthing (eg, position during labour,drug interventions) 99.3 96.6 93.1 86.7 100.0 100.0 100.0r. Risks and benefits of different birthingmethods91.9 74.1 82.8 73.3 100.0 100.0 100.0120 Families Commission Research Fund

families commission research funds. The benefits of breastfeeding 96.3 90.5 89.7 93.3 100.0 100.0 100.0t. The importance of exclusivebreastfeeding for the first six months 78.7 72.4 75.9 40.0 100.0 100.0 70.0u. How to breastfeed and/or where to gofor help 90.4 87.1 79.3 93.3 88.9 100.0 80.0v. Physical changes after birth 61.8 54.3 65.5 46.7 66.7 100.0 70.0w. Emotional changes after birth (eg,awareness of postnatal depression andpreventative steps) 89.0 82.8 75.9 73.3 100.0 100.0 80.0x. Early days at home (eg, ideas forcoping, tiredness) 75.7 66.4 69.0 53.3 77.8 100.0 80.0y. Self-care as a mother (eg, nutrition,exercise) 63.2 57.8 65.5 53.3 66.7 100.0 80.0z. Development of appropriate personalsupport 57.4 40.5 41.4 26.7 44.4 50.0 30.0aa.Unplanned experiences (eg, sick orpremature infant, special needs babies) 46.3 37.1 20.7 26.7 88.9 100.0 60.0bb. Safety of the baby (eg, how to preventSIDs – cot death) 79.4 76.7 69.0 60.0 88.9 100.0 90.0cc.Early parenting skills (eg, bonding withbaby, engaging with baby) 60.3 63.8 55.2 33.3 88.9 100.0 90.0dd. Parenting programme options available 55.9 28.4 20.7 33.3 11.1 50.0 40.0ee.ff.The role of Well Child services and howto access them 30.1 33.6 17.2 33.3 44.4 25.0 30.0Vaccinations and tests after the babyis born 60.3 66.4 55.2 60.0 77.8 100.0 70.0gg. Other (please describe) 6.6 6.0 6.9 13.3 0.0 0.0 0.01Includes: other providers = 35; not specified = 10.NB.: No participants reported attending classes through SAMCL or Nga Maia.childbirth education: antenatal education and transitions of maternity care in new zealand121

APPENDIX 11: Well Child providers by DHBProvider Location PhoneNorthland DHBTe Hauora O Te Hiku O Te Ika Trust 49 Redan Rd, Kaitaia 09 408 4024Ngati Hine Health Trust PO Box 141, Kawakawa 09 404 1551Northland DHB Provider Arm 09 470 0000ext 7940Plunket 1Waitemata DHBPlunket 1Northland Plunket, 150c Bank St,PO Box 1753, Whangarei09 438 2508027 440 8629Te Puna Hauora PO Box 36-056, Northcote 09 483 5724Te Runanga O Ngati Whatua PO Box 100, Dargaville 09 439 1690Te Whänau O Waipareira Trust PO Box 21-081, Henderson 09 836 6683Auckland DHBNgati Whatua O Orakei Health ServicesHealthstar PacificTongan Health SocietyWaiheke Health TrustPiritahi HauoraEarly Childhood Health Team, CommunityChild Health & Disability Service, StarshipChildren’s Health, ADHBCounties Manükau DHBPapakura Marae Health Services(Tamariki Ora)South Seas HealthcareRaukura Hauora o Tainui(Mokopuna Ora)Plunket 1Bay of Plenty DHBTe Manu Toroa TrustNgati Awa Social & Health Services Trust128 Apirana Ave, Glen Innes, Auckland121 Apirana Ave, Glen Innes, AucklandPO Box 18-349, Glen Innes, Auckland29 Hill St, Onehunga, AucklandPO Box 13-589, Onehunga, AucklandCommunity Health Centre, 5 Belgium St,Ostend, Waiheke IslandTahatai Rd, Blackpool, Waiheke IslandCornwall Complex, Greenlane Clinical Centre,Greenlane Rd West, AucklandPrivate Bag 92-189, Auckland Mail CentrePapakura Marae Society Inc, 29 Hunua Rd,PO Box 322, Papakura27 East Tamaki Rd, Hunters Corner,PapatoetoeMokopuna Ora / Well Child Team basedat Turuki HealthCare, 2/32 Canning Cres,MangereCounties Manukau Plunket, 10 Halver Rd,PO Box 75566, Manurewa09 298 387709 278 269409 921 36640800 4 Wellbeing09 267 4805122 Families Commission Research Fund

families commission research fundPoutiri Charitable TrustTuwharetoa Ki Kawerau Hauora TrustPresbyterian Support (Northern)Eastern Bay of Plenty PHO Ltd.Te Ao Hou Primary Health OrganisationWaikato DHBHauraki PHO 210 Richmond St, PO Box 605, Thames 07 868 5375Northern King Country Drug & AlcoholCounselling & Education Charitable Trustt/a Te Ngaru o Ngati Maniapoto10–14 Ward St, PO Box 210, Te Kuiti 07 878 8885Parentline Charitable Trust t/a Parentline 48 Palmerston St, PO Box 11077, Hamilton 07 839 4536Raukawa Trust Board t/a RaukawaHealth Services26–32 Campbell St, Private Bag 8, Tokoroa 07 885 0260Raukura Hauora o Tainui Trust 237 Commerce St, PO Box 5158,Frankton Hamilton07 846 1389Te Kohao Health Limited 180 Dey St, PO Box 7107, Hamilton 07 856 5479Te Korowai Hauora o Hauraki Incorporated 210 Richmond St, PO Box 605, Thames 07 868 5375Toiora PHO Coalition 180 Dey St, PO Box 4058, Hillcrest, Hamilton 07 856 5479Waikato Pasifika Health TrustTairawhiti DHBTuranga Health – Well Child Tamariki OraProviderGround Level, 360 Tristram StPO Box 9388, Waikato Mail Centre, Hamilton07 834 7146Turanga Health, 145 Derby St, Gisborne 06 869 0457Plunket 1 Royal NZ Plunket Society, PO Box 814, Napier 06 878 7126Ngati Porou Hauora – Well Child TamarikiOra ProviderTaranaki DHBTui Ora – subcontracted to Piki Te OraNursing ServicesNgati Porou Hauora, 2 Mackenzie St,Te Puia Springs06 864 6803ext 84136 Maratahu St, New Plymouth 06 759 4064Ngati Ruanui Tahua Health Inc 78-80 Argyle St, Hawera 06 278 1310Plunket 1 Plunket House, 74 Courtney St, New Plymouth 06 769 5453Lakes DHBPlunket 1Tipu OraTuwharetoa Health ServicesRaukawa Trust (NB: small numbers; contract heldby Waikato DHB as part of larger contract)Public Health nurse (NB: provides some WCservice, but no current contract with DHB)RotoruaTaupo and Turangi areaMangakinoTurangichildbirth education: antenatal education and transitions of maternity care in new zealand123

Hawkes Bay DHBKahungunu Executive kit e WairoaCharitable TrustWairoa 06 838 6835Kahungunu Health Services – Choices Southhampton St, Hastings 06 878 7616Te Kupenga Hauora Ahuriri 5 Stale St, Napier 06 835 3090Te Taiwhenua O Heretaunga Trust 821 Orchard Rd, Hastings 06 873 0971Plunket 1MidCentral DHBProvide services across Hawkes BayTe Wakahuia Manawatu Trust Hauora 56 Pembroke St, Palmerston North 06 357 3400Best Care Whakapai Hauora Maxwells Line, Palmerston North 06 353 6385Te Runanga O RaukawaPO Box 586, LevinHe Puna Hauora 100 Vogel St, Palmerston North 06 356 7037Te Kete Hauora 6 Ward St, Dannevirke 06 374 4306Whanganui DHBTe Oranganui TrustTaumata Hauora Trust> Te Puke Karanga> Ngati Rangi> O’TaihapeNgati Apa – Integrated contract> Rangitikei> RatanaWanganui DHB Provider Division> RatanaCapital and Coast DHBAti Awa Ki Whakarongotai Inc – Hora Te PaiHealth ServicesTe Oranganui Iwi Health Authority,42 Drews Avenue, PO Box 611, WanganuiTaumata Hauora Trust Primary HealthOrganisation, 8a Bell St,PO Box 566, WanganuiTe Runanga o Nagati Apa,Stewart & High St,PO Box 124, MartonHeads Rd,Private Bag 3003, WanganuiPO Box 688, ParaparaumuPO BOX 149, 11 Elizabeth St, Waikanae06 349 000706 348 9902027 224 542106 348 123404 902 7095Maraeroa Marae Health Clinic PO Box 53006, Porirua 04 235 8000Te Runanga o Toa Rangatira Inc (OratoaHealth Unit)Te Runanga o Toa Rangatira Inc(Oratoa Poneke)Hutt Valley DHBPacific Health ServiceTe Runanganui o Taranaki –Waiwhetu Medical CentreWairarapa DHBWhaiora Whanui – Tamariki Ora Contract(Mäori Health Provider)Plunket 1PO Box 50079, Porirua20 Ngatitoa St, Takapuwahia, Porirua04 237 011004 237 0131PO Box 50079, Porirua 04 237 0110Te MäoriCorner Riverside Drive & Guthrie Street,Lower Hutt04 587 16465 Park St, PO Box 497, Masterton 06 370 082006 378 0140124 Families Commission Research Fund

families commission research fundNelson Marlborough DHBWhakatu Te Korowai Manaakitanga TrustTe Amo HealthTe Korowai Trust(Whänau Ora, Tamariki Ora)StokeMotueka(NB: This provider does not hold a contract withthe DHB, but provides a Well Child service becausethere is an identified need – community is quiterural and has high Mäori population).03 528 5406Nelson 03 547 5958Te Kahui Hauora O Ngati Koata Trust Nelson 03 546 8018Poumanawa Oranga Blenheim 03 577 2350Public Health Services(Well Child)36 Franklyn St, NelsonPrivate Bag 18, Nelson03 546 1537Plunket 1 669 Main Rd, Stoke 03 547 5388Nelson Bays Primary Health Organisation(PHO)PO Box 1776, NelsonKimi Hauora Wairau PHO PO Box 5135, Blenheim 03 578 3561Canterbury DHBTe Puawaitanga Ki Otautahi Trust 03 344 5062021 783 594Pacific Trust Canterbury 03 363 0748Te Tai o Marokura 03 319 6443South Canterbury DHBArowhenua Whänau Services (started May2006 – have 1 FTE nurse)West Coast DHB92A King St, Temuka 03 615 5180Rata Te Awhina Trust (Mäori Health Provider– specifically targets Mäori population)03 755 6572WCDHB Provider Arm (Public HealthNursing Service)WCDHB Provider Arm (Rural NurseSpecialist Service)Otago DHBManiototo Health ServicesOtago Pacific Peoples Health TrustArai Te Uru Whare HauoraSouthland DHBPlunket 1Tokanui region (a small, very rural area)03 768 0499ext 274403 768 0499ext 2744Awarua Social & Health Services1The Royal New Zealand Plunket Society holds a national contract for Well Child services with the Ministry of Health.childbirth education: antenatal education and transitions of maternity care in new zealand125

APPENDIX 12: Clauses from the Well Child services nationalservice specifications specifically relevant to thetransition between LMC and Well Child services4. Access4.1 Entry criteriaEntry to the Well Child/Tamariki Ora service will commence at the time of formal handover by the LeadMaternity Carer (LMC), or where women who do have an LMC, directly from the hospital to the Well ChildProvider (WCP) of their choice.At time of handover the following protocol will be observed:• The formal handover will be made by the LMC by four weeks. This will be made in a written and nationallyagreed form which documents all key information required by a WCP as the basis for initial assessment andongoing care for the child and its family/whänau.• A referral will be made by the WCP to the family’s General Practitioner Team (GPT) at or before six weeksfor the baby’s six-week clinical check and immunisation. This will provide opportunity for the important linkbetween GPT and WCP to be made. (This contact will be claimed under GMS.)4.2 Provider management of accessThe WCP must establish and maintain a system of enrolling clients with their service and ensuring their clientsreceive the service they are entitled to receive. Clients must remain on the service register until the care of thechild/family/whänau has been formally transferred to another WCP.The WCP will work with LMCs, GPTs and other Well Child/Tamariki Ora services within their geographic areato ensure that clients are able to select or change their choice of WCP without prejudice to their future servicedelivery. This may include return to their original provider at a later date.4.3 Location of service deliveryServices will initially be provided in the client’s home. This may also include provision of immunisation (forhigh-need families only) in line with the current immunisation standards and service specification. Serviceprovision may change to clinic/mobile clinic setting when the family/whänau are able to make that transition.5.3 Needs assessmentAt the initial meetings between the family and the Well Child caseworker an assessment process will beundertaken by the caseworker in order to identify needs and the level of service delivery required. Atsubsequent meetings this assessment will be reviewed and adjusted as appropriate.5.4 Interrelationships with other Well Child servicesIn order for the three parallel streams of ‘the Schedule’ to be delivered in a co-ordinated and integrated wayWCPs will require formal links with LMCs and GPTs.LMCThe WCP can expect to be notified of the birth of a baby within 4 weeks, andreceive handover within 4-6 weeks.5.7 Settings for service deliveryServices will primarily be provided in the client’s home. Service provision may change to clinic/mobile clinicsetting if the family/whänau are able to make that transition. Arranging transport may be part of making thattransition acceptable for the family/whänau. A primary consideration at all times will be to encourage andsupport the family’s independence.126 Families Commission Research Fund

families commission research fund6. Service linkagesWell Child/Tamariki Ora service providers will maintain effective and efficient linkages with all services thatmay refer families to them, or to which Well Child/Tamariki Ora service may refer families. Linkages will bemaintained with:Linked providers Nature of linkage Accountabilities associatedLead Maternity Carers (LMC) Liaise and work with relevant LMC. To ensure seamless transfer of care forthe child and their family and whänau.This includes:• Provision of written information about their service to all agencies from which the service receives referrals,to give to potential clients.• A collaborative approach to service provision for families in which both services are involved.• The development and maintenance of formal (two-way) referral processes, which includes documentingoutcome of referral to referee.• The development and implementation of a formal process for the transfer/handover of clients when oneservice will no longer continue to be involved with a family.9. Reporting requirements9.1 RegisterThe WCP will establish and maintain a register of all children accepted into their service.9.2 Quarterly reportingThe WCP will report quarterly to their contract manager (by ethnicity) on:• Total number of children enrolled with the service at the start of each quarter.childbirth education: antenatal education and transitions of maternity care in new zealand127

APPENDIX 13: Number and percentage of Plunket contacts from 1 July2005 to 30 June 2006 as a function of place of contact, type of contact(core versus additional) and NZDep2001 scorePlace ofcontactBus -mobileclinicClinicEarlychildhoodcentreFamilycentreHomeKöhangaReoMaraeType ofTotal Ncontact NZDep 2001 Score 1 (%)CoreAdditionalCoreAdditionalCoreAdditionalCoreAdditionalCoreAdditionalCoreAdditionalCoreAdditional0n(%)15(0.2)49(0.722.51(35.6)1,097(17.4)36(0.6)36(0.6)33(0.5)200(3.2)1,531(24.2)954(15.1)22(0.3)97(1.5)0(0.0)1(0.0)1n(%)10(0.0)106(0.2)19,505(42.9)7,623(16.8)73(0.2)169(0.4)236(0.5)2,876(6.3)9,696(21.3)5,110(11.2)5(0.0)17(0.0)1(0.0)1(0.0)2n(%)18(0.0)146(0.3)18,276(40.1)7,909(17.3)110(0.2)126(0.2)233(0.5)2,938(6.4)10,215(22.4)5,583(12.2)13(0.0)32(0.1)2(0.0)6(0.0)3n(%)17(0.0)79(0.2)18,592(39.2)8,369(17.7)109(0.2)164(0.3)208(0.4)2,736(5.8)10,653(22.5)6,420(13.5)6(0.0)31(0.1)0(0.0)6(0.0)4n(%)46(0.1)143(0.3)17,642(37.5)7,852(16.7)120(0.3)167(0.4)241(0.5)2,781(5.9)11,079(23.6)6,862(14.6)25(0.1)58(0.1)0(0.0)8(0.0)5n(%)49(0.1)173(0.4)15,906(33.8)7,365(15.6)168(0.4)177(0.4)267(0.6)2,824(6.0)11,958(25.4)8,129(17.3)27(0.1)71(0.2)6n(%)68(0.1)226(0.5)14,891(31.9)6,802(14.5)149(0.3)254(0.5)231(0.5)2,658(5.7)12,346(26.4)8,976(19.2)47(0.1)80(0.2)7n(%)67(0.1)310(0.6)13,690(27.8)6,753(13.7)178(0.4)226(0.5)279(0.6)2,502(5.1)14,028(28.5)11,035(22.4)40(0.1)110(0.2)8n(%)169(0.3)546(1.0)12,295(21.8)7,042(12.5)185(0.3)250(0.4)241(0.4)2,336(4.1)16,783(29.8)16,159(28.7)80(0.1)224(0.4)9n(%)182(0.3)574(0.9)10,573(16.7)6,322(10.0)226(0.4)310(0.5)226(0.4)2,278(3.6)20,277(32.0)21,679(34.2)169(0.3)492(0.8)10n(%)673(0.9)1,536(2.0)6,975(8.9)4,978(6.3)398(0.5)717(0.9)169(0.2)1,262(1.6)26,755(34.0)33,975(43.2)292(0.4)816(1.0)1,314(0.2)3,888(0.7)150,596(28.2)72,112(13.5)1752(0.3)2596(0.5)2364(0.4)25,391(4.8)145,321(27.3)124,882(23.4)Total N 6322 45,428 45,607 47,390 47,024 47,116 46,750 49,254 56,359 63,352 78,632 533,234Total % 1.2 8.5 8.6 8.9 8.8 8.8 8.8 9.2 10.6 11.9 14.7 1000(0.0)2(0.0)5(0.0)17(0.0)8(0.0)28(0.1)12(0.0)37(0.1)8(0.0)36(0.1)15(0.0)71(0.1)726(0.1)2,028(0.4)51(0.0)213(0.0)1New Zealand Deprivation Index score based on socio-economic data from Census 2001 – a value of 1 represents the least deprived geographicareas and a value of 10 represents the most deprived geographic areas.128 Families Commission Research Fund

families commission research fundLITERATURE REVIEW1. EFFECTIVENESS OFANTENATAL EDUCATION1.1 IntroductionThe antenatal period represents an ideal opportunityto engage women and their families and whänau inpreventative health care. Women are often concernedabout their baby’s health and the labour and birthprocess. They want ideas on how to manage theenormous changes that pregnancy and parenthoodbring and so are more likely to be receptive to healthinformation. 1 Structured childbirth education (CBE)or antenatal classes are an important component ofprenatal care. The purpose of antenatal educationis to prepare participants for pregnancy, birth andearly parenting, and it can benefit both biological andpsychosocial outcomes for babies, women andtheir families.Historically, these classes have developed as amethod of information sharing, particularly as informalmethods of information sharing, typically betweenfamily members, have declined. As traditional familystructures have broken down and more womenhave moved into the workforce, women have cometo depend more upon formally organised antenataleducation for their childbirth knowledge, 2,3 although notacross all cultures.There are many approaches to antenatal education,with just as many differences in the content andquality of classes, but most have been influenced bythe pioneering efforts of Dick-Read 4 and Lamaze 5as well as later researchers, including the work ofBradley, 6 Kitzinger 7 and Simkin and Enkin. 8 Dick-Readbelieved that women’s anxiety and fear of childbirthresulted in tension and therefore pain during thebirth process. He reasoned that if women could beconditioned to decrease their fear through relaxationand breathing techniques, then the pain would alsodecrease. Lamaze’s philosophy of birth revolvesaround recognition of birth as a normal, natural andhealthy process, with an important place for the careprovider, but no place for routine medical interventions.In Lamaze’s view, CBE is meant to empower womento make informed choices in health care and takeresponsibility for their health (see Appendix 1 for acomplete list of the tenets of the Lamaze Philosophy ofBirth). 9,10 Bradley, too, emphasises natural childbirthand helping women gain confidence about labour, birthand parenting issues through in-depth knowledge (seeAppendix 2 for Bradley’s list of 12 specific teachinggoals or philosophies). 6 Almost all of these programmesinclude several common elements: information aboutwhat happens to the woman physically during birth;hospital procedures; decreasing unnecessary medicalintervention; pain-relief methods and their risks andbenefits; coping strategies for labour, such as bodyrelaxation and breathing techniques; the role of thesupport person; and breastfeeding. 11,12 Many classesalso provide information on infant care and postpartumadjustment. Classes typically consist of six to eightsessions, with the same group of people meeting forabout two hours each week.Estimates on the proportions of pregnant womenattending classes vary enormously from country tocountry, from as little as 10 percent to as many as 90percent. 13,14 In a recent Australian study, 35 percent ofexpectant women attended classes. 15 This is consistentwith findings from the national US ‘Listening to Mothers’survey, which showed about one-third of womenattended childbirth classes. 16 Women who attendclasses are more likely to be first-time mothers. 13,17,18 Inthe US survey, 70 percent of attenders werefirst-time mothers and 19 percent were multiparousmothers. Women who do not attend are more likely tobe younger, less educated, of lower socio-economicstatus and single than women who doattend classes. 19 This is a consistent finding acrossdeveloped countries. 20,21,22,23There has been much research on the topic ofantenatal education. Nearly 30 years ago, researcherssuggested that the evidence concerning theeffectiveness of CBE was unclear. 24 Today, researchersare still saying the same thing, with a recent systematicreview concluding that the effects of antenataleducation remain unknown. 25 Why should this be thecase? There are several reasons. Firstly, there is greatvariation in antenatal education programmes, andstudies investigating their effectiveness have failedto make the philosophy and content of their classesexplicit, making it difficult to know what was beingchildbirth education: antenatal education and transitions of maternity care in new zealand129

compared. Secondly, studies that set out to investigatethe effectiveness of antenatal education have facedconsiderable methodological challenges, not theleast being the difficulty in conducting randomisedcontrolled trials in this area. Not many women wouldaccept, nor would it be ethical to assign women to a‘no intervention condition’. Thirdly, there are a greatmany variables that affect women’s experiences ofpregnancy, birth and parenting, including demographicand personality characteristics of the women andtheir families, prenatal care from midwives, hospitalenvironment, support from caregivers, continuity ofcare and women’s expectations. The complexity of theinteractions between these variables has made it moredifficult to interpret positive or negative findings on theeffectiveness of antenatal education. Pregnancy, birthand parenting can be classified as complex issues,not merely complicated ones. 26,27 Enkin describes acomplicated issue as one that requires specialisedknowledge, sophisticated equipment and a highlytrained team, but if you prepare carefully and followeach step meticulously, you can be reasonablyconfident that you will succeed. 27 On the other hand,with a complex issue, one can never be entirely sure ofwhat is going to happen. For example, in giving birth orraising a child, there is no direct linear effect betweenwhat we do and the outcomes. Randomised controlledtrials, which rely on detecting direct linear relationshipsbetween cause and effect, are therefore less suitable orinformative for evaluating complex issues. 27 So even ifthe obstacles to conducting randomised controlled trialsin this field could be overcome, researchers might stillbe obtaining mixed results.Despite the lack of conclusive evidence for theeffectiveness of antenatal education and thedifficulties in obtaining such evidence, a sufficientnumber of studies have begun to detect some patterns.The purpose of this review is to summarise theseemerging patterns in order to inform the optimaldevelopment of future antenatal education programmesand suggest recommendations for the direction offuture research. The review looks at the evidence forthe effectiveness of antenatal education relatedto a range of outcomes that it may be expected toaffect. It is divided into outcomes related to pregnancy,birth and parenting, and outcomes related to specificpopulation groups.1.2 Search strategyThis review focused on the last 10 years of publications(1997 to 2007), with a few papers also from earlieryears. Four databases were searched: PsycINFO,PubMed, Cinahl and the Cochrane library, includingthe Cochrane Database of Systematic Reviews andthe Cochrane Central Register of Controlled Trials.The search strategy for the Cochrane library was onlyfor the years 2000 to 2007, since the most recentcomprehensive review of the effectiveness of antenataleducation (completed by Gagnon) 25 included allrelevant Cochrane library articles up to the end of 1999.The ‘intervention’ search terms were childbirth class*or antenatal class* or prenatal class*; childbirtheducation or antenatal education or prenatal education;childbirth training or antenatal training or prenataltraining; childbirth preparation, antenatal preparation,prenatal preparation; childbirth intervention or antenatalintervention or prenatal intervention; childbirth program*or antenatal program* or prenatal program*. Theseterms were searched for in article titles, abstracts orkeywords, depending on the combination of fieldsavailable in each database. It was considered thatthis strategy would find articles most relevant to thecurrent review, including studies where antenataleducation was an intervention, such as a programme ofseveral sessions, covering a range of topics relevant topregnancy, birth or parenthood; studies that examinedthe effectiveness of antenatal education; and studiesthat were explicitly relevant to the content or process ofantenatal education. Studies where the intervention wasspecific to one topic or coping strategy, as opposed toantenatal classes as a whole, were only considered ifthey had direct relevance to the optimal development ofantenatal classes in the future. Similarly, studiesthat examined outcomes of a suite of interventionsrelated to prenatal care, of which antenatal classes wereonly a small component, were only considered if theyconcerned the content or process of antenatal education.No ‘outcome’ search terms were added. This was toensure a wide pool of studies relevant to antenataleducation, regardless of the outcomes investigators hadbeen interested in. In addition, the contents of recenteditions (2006 and 2007) of the journal ‘Birth: Issuesin Perinatal Care’ were scanned for relevant articles.Finally, lists of citations from the most relevant retrievedarticles were also searched.130 Families Commission Research Fund

families commission research fundIn June 2007, the search strategy revealed the followingnumbers of articles:PsycINFO [keywords]: 131PubMed [title or abstract]: 466Cinahl [title]: 175Cochrane Database of Systematic Reviews [title,abstract or keywords]: 119Cochrane Register of Controlled Trials [title, abstract orkeywords]: 301There was some overlap in the articles found by thedifferent databases. All titles were scanned, and over500 articles were determined to be relevant to thecurrent review, including descriptive studies; crosssectionalstudies; pretest-posttest designs with nocontrol group; quasi-experimental studies (controlor comparison group present but participants notrandomly assigned to groups); randomised controlledtrials; and systematic reviews. Sixty-seven of themspecifically examined whether the outcomes of interestvaried as a function of attendance at group antenatalclasses (marked with an asterisk* in the reference list).The abstract of each one was read to determine itssignificance and the full text was obtained for the mostrelevant papers wherever possible. In keeping with thetheme of pregnancy, birth and parenting being complexissues, the current review was less concerned about thequality of methods employed by studies investigatingantenatal education, and more concerned withrecognising patterns in the aggregated findings.1.3 Outcomes related to pregnancy1.3.1 NutritionGood nutrition, including adequate vitaminsupplementation, supports healthy foetal developmentand decreases the likelihood of low birthweight inbabies. 28 Deficiencies in nutrients such as iron, 29folate 30 and protein 31 have been linked with pooroutcomes for mothers and babies. Healthy maternalbehaviour, including vitamin intake, has a protectiveeffect against some of the harmful consequencesof substance use during pregnancy. 32 It is thereforedesirable for antenatal classes to positively affectwomen’s dietary behaviour and vitamin intake.The search strategy found only one study over the last10 years of research that specifically looked at theimpact of antenatal classes on pro-health behaviours,including nutrition. The study is written in Polish, butthe abstract (in English) suggests that women’s nutritiondid not improve as a result of the classes, given thatthere was no statistically significant difference betweenthe control and intervention group on measures of bodymass index. 33 It was not clear if this referred to the bodymass index of the mother or infant.Other forms of prenatal nutrition intervention have beenshown to improve women’s nutrition. For example,an in-home prenatal nutrition intervention, involvingone-on-one nutrition assessment and counsellingsupport, increased dietary iron intakes and reduced lowbirthweight in low-income African-American women. 34In this study, the intervention required a minimum ofsix home visits dedicated to the topic of nutrition.Given these findings, it seems likely that antenatalclasses could only improve women’s nutrition if theycontained sufficient information about nutrition anddiet and their link with maternal and child health; therewere sufficient support and resources in the woman’senvironment to enable her to follow the advice;nutritional status were not optimal to begin with; andthe classes were held early enough in the woman’spregnancy for it to make a difference to her nutritionalstatus. The timing of good nutrition is crucial for optimaldevelopment of the foetus. 35 The majority of antenatalclasses probably do not meet all these conditions.1.3.2 Substance useAnother major determinant of poor birth outcomesand subsequent ill-health of the infant is substanceabuse. Smoking, drinking and other drug use duringpregnancy have well-documented negative effects onthe development of the foetus, leading to birth defects,neurodevelopmental and behavioural disorders. 36,37,38,39There are many interventions to help pregnant womenstop substance use and abuse. They differ substantiallyin their intensity, duration and the people involved inimplementation.Interventions to help pregnant women quit smokinginclude information on the risks of smoking to thefoetus and infant; recommendations to quit and settinga quit date; cognitive behavioural strategies for quittingsmoking; provision of rewards; social or peer support;and nicotine replacement therapy. A recent Cochranereview of these types of interventions looked at 64trials conducted between 1975 and 2003. 40 The reviewchildbirth education: antenatal education and transitions of maternity care in new zealand131

showed that both high-and low-intensity smokingcessation programmes can reduce the proportionof women continuing to smoke by about six percentrelative to control groups.Despite the relatively large number of trials testing theefficacy of quit-smoking interventions on pregnantwomen, no trials were found that specifically examinedthe impact of antenatal education on smoking orother substance use. It seems reasonable to assumethat if antenatal classes incorporated similar quitsmokingstrategies, they might likewise contribute tosmoking cessation. The authors of the Cochrane reviewrecommend that smoking cessation programmesshould be implemented in all maternity care settings. 40For antenatal education to achieve these benefits,classes would need to be initiated early in thewoman’s pregnancy.Interventions to help women reduce alcoholconsumption are equally varied. They includepharmacological, psychological or educationalapproaches. Particularly encouraging is thedemonstrated efficacy of brief primary careinterventions. Single-session interventions as briefas five to 15 minutes have produced significantreductions in the proportion of clients drinking athazardous levels. 41 In fact, assessment of alcohol intakealone (without the intervention) can reduce alcoholconsumption. 41,42 Chang et al showed that the benefitsof a brief intervention for pregnant women could befurther enhanced by involving the woman’s partner. 43No trials were found that specifically examined theimpact of antenatal classes on alcohol consumption,therefore it is unknown if antenatal education reducesalcohol consumption. Given the promise of briefinterventions, it is feasible that an antenatal class thatinvolved women in assessing their alcohol consumptionand provided education about the potential effectsmight reduce alcohol-related harm to the mother andinfant. However, the educator would need specialisedknowledge in the area and it remains unclear if the briefintervention would work in the group context. As withquit-smoking interventions, the timing of classes earlyin pregnancy would be critical.1.3.3 Social supportSocial support is considered an effective protectivefactor against a range of negative health outcomes andis related to psychological wellbeing. 44 It is known to berelated to positive health practices during pregnancy,such as decreased alcohol use and smoking,and increased vitamin intake. 45,46 Social support hasalso been found to predict infant birth weight, 47and has been linked with positive postnatal healthpractices, such as breastfeeding. 48 It wouldtherefore be a worthwhile outcome if antenatalclasses successfully increased social supportof participants.The findings from several qualitative studies suggestthat increased social support is one of the benefits ofattendance at antenatal classes. 2 Women frequentlyreport that being able to meet and talk with otherexpectant women is an important aspect of attendanceat antenatal classes. 49,50 Often this social support ismaintained into the postnatal period, with numerousexamples of groups of women continuing to meet afterthe birth of their babies. In Nolan’s research, parentsdid not originally choose to attend classes principally asa way of accessing social support from other parents,but by the end of classes, they rated this as one of themost important things they had gained. 49 Some authorsgo so far as to suggest that the benefits of antenatalclasses may turn out to be primarily due to thesocialisation with other expectant parents, rather thanthe knowledge and skills transferred. 2On the other hand, very few quantitative studieshave examined whether antenatal education classessuccessfully increase social support. One exception isDiemer’s research, which used a quasi-experimentaldesign to compare a ‘father-focused’ antenatal coursethat employed a group discussion format with standardantenatal classes that employed more didacticteaching methods. 51 At post-evaluation, there was nodifference between the groups in the level of socialsupport reported but both groups of fathers reporteda significant increase in social network support. Bothgroups also increased their use of social support as ameans of coping, with the increase greater for men inthe father-focused classes largely because they soughtmore information and emotional support from theirpartner’s physician.In summary, despite virtually no quantitative evidencethat antenatal classes increase social support ofparticipants, there is a wealth of qualitative andanecdotal evidence suggesting that social support isan important benefit for participants. The relationshipbetween antenatal class attendance, increased socialsupport and improved health outcomes merits furtherresearch attention.132 Families Commission Research Fund

families commission research fund1.4 Outcomes related to birth1.4.1 ExpectationsChildbirth expectations influence a woman’s experienceof and satisfaction with her child’s birth. 52,53 Commonexpectations of expectant mothers and fathers arefor a safe and comfortable caregiving environment,to understand available medical interventions, toparticipate in the decision-making process and toreceive medical and nursing support. 54 Expectationsthat are not fulfilled may lead to dissatisfaction withthe birth experience and feelings of guilt, anger,depression, loss and even post-traumatic stressdisorder. 55 Ultimately, these emotions may impedeparents’ ability to form a relationship with their child,and in the long term have negative consequences forthe family’s physical and psychological health. 55It is therefore important that women have realisticexpectations of the childbirth experience and thatthese expectations are fulfilled. Antenatal educationhas the potential to have a marked impact onwomen’s expectations and therefore to facilitatepositive outcomes.One study was found that directly examinedthe influence of antenatal classes on women’sexpectations. 56 The study did not have a control group,but compared women’s expectations for childbirthbefore and after antenatal classes in four areas: fearof the childbearing process; dependence on powerfulothers; desire for active participation; and personalvalues relating to childbearing. The classes, whichemphasised natural childbirth, active participation,and decreased medical interventions, significantlyaltered women’s expectations. After participation, theywere less fearful of childbirth, less reliant on powerfulothers and had a greater desire for active participation(although the difference for dependence on powerfulothers did not reach statistical significance).A second study, conducted in Taiwan, asked 200couples to complete a validated questionnaire ontheir childbirth expectations across several areas,including the caregiving environment, labour pain,spousal support, control and participation and medicalsupport. 54 They found that expectant fathers with ahigher socio-economic status who had participatedin CBE had higher expectations than fathers who hadnot participated, but CBE made no difference to theexpectations of expectant mothers. The cross-sectionaldesign of this study means that it is impossible todetermine whether the antenatal classes were acausative agent in the fathers’ higher expectations, orwhether fathers with higher expectations self-selectedinto the classes. Chen, however, also demonstratedthat greater childbirth knowledge was related to higherchildbirth expectations. 53There is some earlier evidence that antenatal classesinfluence expectations differentially for women withdifferent beliefs at the start of classes. Hallgren et alfound that for women who perceived childbirth as “anormal process, a challenge, and even a trustworthylife event”, the increased knowledge they gained fromantenatal classes served to increase their confidence. 57On the other hand, women who saw childbirth asfrightening or as a threat at the start of the childbirthclass differed in their perceptions at the end of theclass, with some women reporting increased fear andless ability to manage.In summary, it seems likely that antenatal classes doinfluence women’s and men’s expectations of theirchildbirth experience. It is crucial that the wholematernity system helps to fulfil those expectations, lestchildbirth educators unwittingly foster expectationsthat adversely affect childbirth experiences. If aparent’s expectations to be actively involved and notdepend on powerful others are defeated in the deliverysuite because of a hospital medical system’s failureto empower them, it is conceivable that the greatermismatch between expectation and outcome might onlylead to greater frustration and poorer outcomes.1.4.2 Amount of fear or anxietyHaving some degree of fear or anxiety about childbirthis normal. In a study of 329 pregnant women, 78percent expressed fears relating to pregnancy,childbirth or both. 58 However, too much fear or anxietyleads to adverse birth outcomes, such as increasedpain, 59 longer labour 60 and increased medicalinterventions, such as emergency caesareans. 61Antenatal maternal anxiety can also have long-termeffects on the child. A large, prospective cohort studyhas recently linked antenatal anxiety with behaviouralproblems in a four-year-old child, even after accountingfor variation caused by postnatal anxiety. 62The success of antenatal classes in decreasing fearsand anxieties has been mixed. The study described inthe previous section (1.4.1) that successfully changedchildbirth education: antenatal education and transitions of maternity care in new zealand133

women’s expectations showed that classes focusing onnatural childbirth, active participation and decreasedmedical interventions significantly decreased women’sfears about childbirth. 56A study of women in Finland suggests that antenataleducation may reduce certain types of fears. 58 Threehundred and twenty-nine women between 16 and 40weeks pregnant were given a questionnaire about theirfears during their visits to the maternity health careclinic. Women who had completed prenatal classeshad significantly fewer childbirth-related fears (such asfears about pain, prolonged childbirth or panic duringchildbirth) and significantly fewer fears concerninghealth-care staff (such as fears that staff would beunfriendly, of not being allowed to participate indecision making or of being left alone during childbirth)compared with women who had not yet attendedclasses. Antenatal education did not seem to affectfears associated with the child’s wellbeing (such as fearof delivering a dead child, of the child being injuredduring childbirth or having a sick or handicapped child)or fears associated with family life (such as fears ofhaving problems in their relationship with their partner,sexual problems or problems with the child’s care andrearing). The results of a qualitative study by Segeeland du Plessis provide further evidence that antenataleducation can reduce women’s fear. 63 Women whowere interviewed about how antenatal classes hadcontributed to the birthing experience reported that ithad reduced their fear associated with labour.Another study compared Lamaze-style birth-preparationclasses with doula assistance given at birth. 64 A doulais a non-medical birth professional (not a midwife)who provides support, suggestions and comfort to thewoman. The study found women who had receiveddoula assistance were less emotionally distressedand had higher self-esteem than women who did theLamaze classes, who showed a trend in the oppositedirection from pregnancy to four months postpartum.Given the strength of the evidence for the benefit ofcontinuous support during labour, 65 it is perhaps notsurprising that the doula support more effectivelyreduced distress. This study is not comparable toeither the studies mentioned above, as it examinedwomen’s distress from pregnancy to four monthspostpartum rather than looking at whether the Lamazeclasses decreased anxiety or distress from before toafter the intervention. In any case, antenatal educationclasses and support during labour would both usuallybe considered important elements of prenatal care,so the focus of this review is to determine if antenatalclasses add value to the maternity system, rather thancomparing them against other types of prenatal care.A more recent study of more than 8,000 pregnantwomen concluded that there was no clear-cutrelationship between attendance at antenatal classesand a reduction in childbirth fears. 66 It is likelythat some anxiety and fear related to the stressesof pregnancy and labour may be of a particularlyobdurate kind which cannot be easily altered throughthe provision of information in antenatal classes. 67However, other forms of anxiety or fear, related tochildbirth itself or the care providers, may be moreamenable to change. It is these latter fears thatantenatal education can successfully address.1.4.3 Maternal sense of control and activedecision makingPerceived control and involvement in decision makingduring labour are important because they are majorpredictors of women’s perception of pain 68 andsatisfaction with the birth experience. 69,70,71 Personalcontrol is also an integral part of women-centredcare, if the goal is for women to take an active rolein their care during childbirth. 72 Several studies onantenatal education have hypothesised that formalbirth preparation, involving discussion of various copingtechniques, is likely to increase women’s perceivedcontrol during labour. 69In 2000, McCrea et al published the first studyto investigate the factors that influence personalcontrol during labour. 73 Within 24 hours of givingbirth, 100 women from Northern Ireland completedquestionnaires about the pain intensity they hadexperienced, the usefulness of antenatal training inpain relief and their perceptions of control duringdelivery. Women who had completed antenatal trainingrated it as ‘useful’ for pain relief. Perhaps of moreinterest, multiple regression analyses showed thatout of a range of psychosocial variables, antenataltraining emerged as a significant predictor of women’sperceived control in pain relief. Specifically, usefulnessof antenatal training accounted for 5.5 percent of thevariance in women’s perceived ‘control of information’and 21.1 percent of the variance in women’s perceived‘control of emotions’. The implication is that antenataltraining can affect the extent to which women exercisecontrol in pain relief.134 Families Commission Research Fund

families commission research fundA second study examining women’s feelings of controlwas recently published in 2007. Cheung et al collecteddata from 90 Hong Kong Chinese primiparous motherson three occasions: during the latent phase of labour;during the active phase of labour; and within 24 to 48hours after delivery. 74 These researchers found thatwomen who felt less anxiety perceived that they hadmore control, but there were no statistically significantrelationships between women’s attendance at antenatalclasses and feelings of control during labour.It is not clear from either study what the content orformat for antenatal training comprised, so it is difficultto assess the reasons for the inconsistent results.The two studies also used different questionnairesto assess perception of control. A further issue is thelevel of support women received in labour in using thetechniques they had learnt in antenatal classes. If themidwives who support women in labour are not awareof the coping methods women learnt in classes, it isless likely that antenatal education will affect women’ssense of control. 73 The best interpretation of theseresults is that, under particular conditions, antenatalclasses may enhance women’s sense of control.1.4.4 Amount of painChildbirth represents the most painful event in mostwomen’s lifetime. 75 The level of perceived pain inlabour may influence a woman’s ability to cope and herexperience during labour, which, in turn, may influenceher early adaptation to parenthood and decisions aboutpregnancy in the future. 76 It should be noted, however,that pain does not necessarily equate with suffering. 77Variables such as induced labour, the desirability ofpregnancy and caregivers’ helpfulness have been foundto predict sensory pain. Pain intensity has also beenpredicted by physician-anticipated complication andthe motivation to be medication-free. 78 But probablythe best predictor of a woman’s experience of labourpain is her level of confidence in her ability to cope withlabour. 79 The mechanism by which CBE is thought topotentially influence pain is by decreasing women’sanxiety or fear or increasing their sense of control. 77As we have seen above, perceptions of theeffectiveness of antenatal education on either anxietyor fear or the maternal sense of control are mixed. Thesearch found only two studies in the last 10 years thatreported pain outcomes as a function of attendance atantenatal classes. One, conducted in Iran, found thatwomen who participated in birth-preparation classesexperienced significantly less pelvic pain and headachethan patients in the control group. 80 The other,conducted in Sweden, found no statistical differencesbetween participants and non-participants in theirmemory of labour pain. 81 These mixed results aremirrored in earlier studies, which also reportedboth positive 82 and negative effects 19 of antenatalclasses on pain.A recent review shows there is adequate evidence ofreduced pain from the following non-pharmacologicapproaches to pain relief: continuous labour support;baths; intradermal water blocks; and maternalmovement and positioning. 77 One might thereforeexpect that the extent to which CBE successfullypromotes the use of these pain-relief strategies, itmight be effective in decreasing pain. However, as aresult of the conflicting results of earlier studies and thetenuous link between attendance at antenatal classesand the type of coping strategies used in labour (seenext section), the effectiveness of CBE in reducing painremains unclear.1.4.5 Use of medications to reduce pain andcoping strategies used during labourMost of the medications to reduce pain duringlabour have potential negative side effects. 83 It istherefore often considered a worthy goal to minimiseunnecessary use of medical pain-relief methods and toinstead rely more on personal coping strategies. Use ofcoping strategies may be associated with less fear andhigher birth satisfaction. 84 One of the main aimsof many antenatal courses is to help women preparefor labour through the provision of information oncoping strategies.Considerable attention has been paid to whetherantenatal classes decrease women’s use of pain-reliefmedications or facilitate their use of non-pharmacologiccoping strategies in labour. A recent review by Nolanin 2000 showed there have been widely differingresults. 85 She cited Heatherington’s well-known studyof disadvantaged women in Baltimore, in whichclass attenders used far less analgesia in labour thannon-attenders. 86 Another study of nearly 200 womenin Auckland found no difference between attendersand non-attenders in their use of drugs for pain reliefin labour. 87 Nolan concluded that the wide variety ofclasses attended by women could explain differencesin the results and suggested that it is importantchildbirth education: antenatal education and transitions of maternity care in new zealand135

to determine whether antenatal classes influencebehavioural intention.In 2000, Nolan compared pain-relief outcomes fortwo different types of antenatal classes in England. 88Women and men completed questionnaires on threeoccasions: before they started classes; after classes;and after the birth of their babies. Two findings fromthis study stand out: that antenatal classes did notmake much difference to the mothers’ choice of painrelief for labour (ie, the choices that they had madeabout pain relief before classes were the same choicesthey stuck to after classes, suggesting that they makeup their minds on important topics such as painrelief before they attend classes and are not open topersuasion); and that there was a large gap betweenthe pain-relief choices that mothers and fathers wantedto make and the choices they ended up making duringthe birth (ie, there was far more use of pethidine andepidurals during labour than parents had said theywould use). This study suggests that there are farbigger influences at play on women’s use of pain-reliefmethods and coping strategies during labour thanattendance at antenatal classes.Since then, several other studies have investigatedthe relationship between antenatal class attendanceand women’s use of coping strategies, also withmixed results. Johnston-Robledo found that womenwho attended classes learnt more about labour anddelivery and used a wider variety of coping strategiesthan women who had not attended classes. 69 Incontrast, Escott et al suggested that women who hadnot attended antenatal classes used just as wide arange of coping strategies in labour as women who hadattended classes. 89 Henry and Nand looked at women’santenatal sources of pain-management information andfound that virtually all women (98 percent) accessedpain management information, from antenatal classes(55 percent), multimedia (53 percent) and friends orrelatives (46 percent). 90 Regardless of the source, theyfound that increased information access was associatedwith significantly higher use of both ‘natural’ copingmethods and epidural analgesia during labour. Thesestudies challenge the assumption that women who donot attend classes are ‘unprepared’.Taking a new approach to childbirth preparation, Escottet al compared standard antenatal classes that teachwomen particular coping strategies to deal with labourpain with classes that aimed to enhance women’spre-existing coping strategies. 91 They found that thenew approach was associated with greater copingstrategyuse and involvement from the birth companion,although self-efficacy for use of the coping strategiesand subsequent experiences of pain and emotionsduring labour were equivalent between groups.On the whole, it seems that coping strategies taughtin antenatal classes are not consistently being used.Antenatal education is not reliably translating intopractice. 92,841.4.6 Birth experience and satisfaction with thebirth experienceWith increasing emphasis on patient-centred careand responsive services, the importance of assessingwomen’s satisfaction with the birth experience has beenrecognised. The way in which labour is experiencedmay also have significant postnatal implications for themental health of the mother. 93,94The prevalence of negative birth experiences in anational sample of Swedish women was nearly sevenpercent. 71 One year after the birth, these women rated1 or 2 on a 7-point rating scale with the extremesdefined as ‘very negative’ (1) and ‘very positive’ (7). Inthis same study, attendance at antenatal classes wasactually associated with an increased risk of having anegative birth experience, although the authors pointout that the relationship was probably not causal.Rather, the women who attended antenatal classeswere mostly expecting their first baby and primiparitywas associated with a negative birth experience.There were two other studies that specifically examinedsatisfaction with the birth experience as a function ofattendance at antenatal classes, and obtained differentresults. Fabian et al asked a national cohort of 1,197Swedish women to complete questionnaires on threeoccasions: during early pregnancy; two months aftergiving birth; and one year after giving birth. 81 Therewere no reported differences in the birth experiences ofwomen who had attended antenatal classes comparedwith those who had not attended classes. Spinelli et alsurveyed 9,004 women from 13 regions in Italy whodelivered over a four-month period. 23 Twenty-threepercent had attended antenatal classes. In contrastto the results of Fabian et al, these women had areduced risk of being dissatisfied with the experienceof childbirth (Odds Ratio [OR] = 0.72). The womenwho attended antenatal classes were also more likely136 Families Commission Research Fund

families commission research fundto be well-educated, primigravidae and office workers.As with any cross-sectional study, it is not possibleto determine if the antenatal class attendance hada significant influence on women’s experience ofchildbirth, or whether other defining characteristics ofthe women played a causal role.In a comprehensive review of the research on women’ssatisfaction with the experience of childbirth, Hodnettconcluded: 70Four factors – personal expectations, the amountof support from caregivers, the quality of thecaregiver-patient relationship, and involvement indecision making – appear to be so important thatthey override the influences of age, socioeconomicstatus, ethnicity, childbirth preparation, the physicalbirth environment, pain, immobility, medicalinterventions, and continuity of care when womenevaluate their childbirth experiences (p. S171).Therefore, despite some mixed results, it appears thatantenatal education is not a good predictor of women’schildbirth experiences.1.4.7 Caesarean rateThere are known risks associated with electivecaesarean section. For example, women who havecaesareans have a higher rate of re-hospitalisationfor uterine infections and wound complications. 95,96They also have an increased risk of future ectopicpregnancies and placental problems. 97 In short,caesarean deliveries are associated with higherrates of maternal and neonatal complications, andconcomitant increases in health costs. 98 The WorldHealth Organisation suggests there is no additionalhealth benefit associated with a caesarean sectionrate greater than 10–15 percent. 99 However, in mostdeveloped countries, the rate of caesarean sectioncontinues to rise. 100 In New Zealand, the caesareansection rate has increased from 11.7 percent ofmothers in 1988 to 23.1 percent in 2003. In Australia,the caesarean section rate was 28.5 percent in 2003. 101Interestingly, an Australian study showed that in thegeneral birthing population, 93.5 percent of womenpreferred a spontaneous vaginal birth, with only 6.4percent preferring a ceasarean section, usually becauseof a current obstetric complication. 102 There is clearlya mismatch between women’s preferences and whatoccurs in practice. There is therefore some hope thatantenatal classes may help to reduce caesarean rates.Two studies were found that specifically examinedcaesarean outcomes as a function of antenatalclass attendance. The first was Spinelli et al’s crosssectionalstudy of Italian women (described in section1.4.6). 23 Women who had attended antenatal classeshad a considerably lower risk of caesarean sectionthan women who had not attended classes (OR =0.60), although given the design of the study, it isimpossible to determine if attendance at classes wasa causal factor for the reduced caesarean rates. Thesecond study evaluated a worksite prenatal educationprogramme. 103 Women were offered financial incentivesto attend classes. The 191 participants had a caesareanrate of 16.2 percent compared with a caesarean rate of22.2 percent among the 815 non-participants.The positive results of these recent studies arecontradictory to the bulk of the remaining evidence.A recent Cochrane systematic review by Horey et al isrelevant. 104 These authors reviewed the effectivenessof giving women information about caesarean section.The review, which included two studies, concluded that“trials of interventions to encourage women to attemptvaginal delivery show no effect”. It should be kept inmind that both of the studies in the review involved theprovision of one-on-one information as opposed to thegroup format of antenatal classes. In addition, bothstudies were conducted with groups of women whoseattitudes might be expected to be more difficult to shift– namely, women who had previously given birth bycaesarean and women who had a fear of childbirth.Nevertheless, several earlier studies investigatingthe relationship between antenatal class attendanceand caesarean rates in the general population ofprimiparous women showed no relationship. Forexample, Bennett et al divided women into three groupsaccording to the number of hours of antenatal classattendance: none; low (one to 12 hours); medium(13–19 hours); and high (20+ hours). 105 The rates ofcaesarean births were not significantly related to theextent of women’s preparation.It is perhaps quite telling that a recent meta-analysis byChaillet and Dumont of evidence-based strategies forreducing caesarean section rates did not even mentionantenatal education 106 . There are many complexfactors that determine whether women end up having acaesarean. For populations where women’s first choiceis for a spontaneous vaginal birth and in the context ofmore proximal medical decisions that are made whilechildbirth education: antenatal education and transitions of maternity care in new zealand137

women are in labour, it may be difficult for studies ofantenatal classes to detect effects on this outcome.Clearly though, more high-quality research is needed.1.4.8 Birthweight and preterm deliveryPreterm labour is a serious problem, and the majorcause of low-birthweight babies and associatedperinatal mortality and morbidity. 107,108,109 Studieshave revealed a consistent relationship between socialdisadvantage and low birthweight. 110A recent Cochrane systematic review investigatedwhether additional support provided to disadvantagedwomen during pregnancy could decrease the numberof low-birthweight babies. 111 Additional supportwas defined as some form of emotional support,information or advice, either in home visits or duringclinic appointments. The review showed that theseprogrammes were not effective in reducing pretermor low-birthweight babies. In comparison, intensivesupport to high-risk women has been shown to improvethe rate of low-birthweight babies. 112 Could it beexpected that antenatal classes could have impact inthis area?Of course, one would not expect antenatal classes tohave an impact on this outcome, unless issues to dowith preterm labour were explicitly discussed in classes.A Canadian study surveyed health professionals,including prenatal teachers, about the educationalmaterials they made available on the prevention ofpreterm birth. 113 Seventy-six percent of the prenatalteachers reported making such educational materialsavailable to women, but the study concluded that mostwomen were not being educated by anyone duringprenatal care about the prevention of preterm birth.In a later paper, these same authors showed thatby providing information and educational materialson preterm labour to health professionals, theyincreased the proportion of women who had access tothe material. 114 It is unclear, however, if thisintervention resulted in fewer preterm births or lowbirthweightbabies.Four studies were found that specifically investigatedthe impact of antenatal education on the outcome oflow birthweight or preterm delivery. First, Burton et al’sworksite prenatal education programme (describedin the previous section 1.4.7) resulted in participantshaving fewer low-birthweight and preterm deliveries(3.1 percent) than non-participants (4.1 percent). 103Second, using a retrospective comparative design, adoctoral study by El-Sabagh found that the length oftime between appearance of preterm labour symptomsand hospitalisation was shorter for women who hadattended CBE compared with non-attenders, suggestingthat women who had attended classes had learntthe importance of seeking medical help early so thatintervention to maintain the pregnancy could begin. 115The resulting infant gestational age at birth was greaterfor antenatal class attenders than that of non-attenders.Third, Albizu et al also found that antenatal classattendance had a favourable influence on women’sability to recognise the onset of delivery. 116 Using acase-control retrospective design, cases being womenwith preterm labour and controls being women withfull-term labour, they found that women with pretermlabour were less likely to have attended antenatalclasses (OR = 0.56, Confidence Interval CI = 0.33-0.96) and concluded that antenatal classes can reducethe rate of preterm labour emergencies. In contrast,the fourth study, also a case control study, showedthat women with fewer than 10 prenatal visits were atthe highest risk of preterm delivery and attendance atprenatal classes made no difference to this outcome. 117To summarise, three of the studies showed positiveeffects of antenatal classes on preterm delivery, andone found no effect. It seems that when informationabout the signs of preterm labour are made available inclasses, it may influence women’s decisions to get to ahospital early to prevent low-birthweight babies.1.5 Outcomes related to earlyparenting1.5.1 Bonding or attachmentThe mother-child bond is thought to lay the foundationsfor good mental health and resiliency in the child. Goodparent-infant attachment is associated with a lovingrelationship, improved infant development, a healthyself-image and better relationships later in life. 118,119Postnatal bonding may be partially determined byprenatal bonding or the level of attachment themother (or father) has to the foetus. Three studiesspecifically examined the influence of antenatal classeson prenatal maternal-foetal attachment. Bellieni etal asked 77 pregnant Italian women to complete thePrenatal Attachment Inventory. 120 The 36 women who138 Families Commission Research Fund

families commission research fundhad completed classes showed significantly higherprenatal attachment scores than women who had notcompleted classes, although it is not clear whetherthis resulted in improved infant or maternal wellbeingafter delivery. A second study, in Korea, examinedthe effect of ‘Taegyo-focused’ prenatal education onmaternal-foetal attachment. 121 These classes werebased on Lamaze content, but included additionaltopics such as understanding the ability of the foetus torespond, training in maternal-foetal interaction, writingletters and making a declaration of love to the unbornbaby. There was no comparison group, but pre-posttest scores showed significant increases in maternalfoetalattachment. Similarly, a study conducted inTaiwan found that attendance at prenatal classes was asignificant predictor of maternal-foetal attachment. 122White and her colleagues showed that the knowledgeand skill of childbirth educators and nursing staffin interpreting infant behavior for parents increasedafter an educational session on infant cues and bodylanguage. 118 Recognition of individualised infant bodylanguage and sensitivity to a baby’s cues is accepted asthe origin of parent-infant attachment. They reasonedthat staff could incorporate information about infantstates, cues and behaviours into prenatal educationto facilitate the basis of high-quality parent-childinteractions.In a separate study, Bryan showed this could beachieved. 123 Using a quasi-experimental design, Bryancompared couples who attended standard CBE classeswith couples who attended an enhanced prenatalcourse. The enhanced course consisted of an additionalthree sessions on the transition to parenthood, roles,communication with baby and relationships andinteractions for the first three months of life. Postnatally,couples in the enhanced group had significantlyhigher scores than couples from the standard groupin the following areas: mothers’ sensitivity to theirinfants’ cues; fathers’ and couples’ social-emotionalgrowth fostering; and mean response to child distress.Although couples were not randomised to the standardor enhanced groups, the findings are noteworthybecause they were based on videotaped parent-childinteractions, rather than solely on more commonlyused self-report measures, and so are less susceptibleto response bias. The findings suggest that antenatalclasses could be enhanced to better facilitate parentchildattachment.Moore’s research comes to the same conclusion. 124She evaluated an enhanced prenatal programmethat aimed to develop expectant parents’ ‘reflectivefunction’, or their understanding of the mental statesunderlying behaviours, which she believed wasimportant for securing infant attachment. There wasno control group, but pre-post test comparisons for 28expectant parents showed that the reflective functionof participants with low pre-programme reflectivefunction increased significantly. She concluded that anenhanced prenatal programme can better develop thecognitions of expectant parents that are associated withsecure infant attachment.In summary, all of the studies obtained positive resultsin their efforts to improve parent-infant attachmentor its precursors. However, almost without exception,these courses were enhanced with additional contentrelevant to parent-infant attachment. At present, themajority of antenatal classes do not incorporate thisadditional content.1.5.2 Breastfeeding successThe health benefits of breastfeeding for both motherand infant are well established. The World HealthOrganisation recommends exclusive breastfeedingfor the first six months of an infant’s life and initiatedthe Baby Friendly Hospital Initiative (BFHI) to supportwomen in achieving this objective 125 . Differentmeasures of breastfeeding success may includeinitiation of breastfeeding, duration of breastfeedingand exclusivity of breastfeeding.There have been several trials of prenatal interventionsspecific to breastfeeding, usually involving theprovision of information to women on the benefits ofbreastfeeding and how to manage it. For example,Noel-Weiss conducted a randomised controlled trialof a prenatal breastfeeding workshop and assessedits effects at four and eight weeks postpartum. 126Compared with the control group, she found that theworkshop attenders had more exclusive breastfeeding(58 percent vs 70 percent) and less weaning (22percent vs 15 percent). Mattar et al also conducted arandomised controlled trial. 127 In this study, mothersreceiving individual counselling and educationalmaterial practised exclusive breastfeeding more oftenthan mothers receiving routine care (OR = 2.4, CI =1.0-5.7) or mothers who were exposed to educationalmaterial alone (OR = 2.5, CI = 1.0-6.3) at sixmonths postpartum.childbirth education: antenatal education and transitions of maternity care in new zealand139

The results of these trials are consistent with a recentCochrane systematic review of interventions forpromoting the initiation of breastfeeding. 128 Seventrials met their inclusion criteria of being a randomisedcontrolled trial of any breastfeeding promotionintervention. Of these, five trials involving 582 womenon low incomes in the US showed breastfeedingeducation had a significant effect on increasinginitiation rates compared to routine care (Relative Risk[RR] = 1.53, CI = 1.25-1.88). The review concludesthat breastfeeding education is effective at increasingbreastfeeding initiation.Does this mean that antenatal education should alsobe effective at increasing breastfeeding rates? The typeof information provided in these specific breastfeedinginterventions is often incorporated into many antenatalprogrammes. Several large cross-sectional studies havebeen conducted in the US. Using data from a NationalSurvey of Early Childhood Health, Lu et al found thatmothers who attended childbirth classes were 75percent more likely to initiate breastfeeding than nonattenders.22 Importantly, this was after controlling formaternal differences in socio-demographic and othercharacteristics (adjusted OR = 1.75, CI = 1.18-2.60).They comment that their findings are remarkablysimilar to those in Lu et al which also showed a75 percent (adjusted OR = 1.75, CI = 1.15-2.67)increase in the odds of breastfeeding initiation amongattenders, using data from a separate cross-sectionalsurvey. 129 A third large US survey was conducted bytelephone with 5,213 new mothers four to six weekspostpartum. 130 This study showed that the womenmost likely to breastfeed were the ones who attendedchildbirth classes (RR = 1.16, CI = 1.11-1.20), thosewho received prenatal breastfeeding advice (RR = 1.24,CI = 1.19-1.27) and those who received postpartumbreastfeeding assistance (RR = 1.31, CI = 1.15-1.34).Similar results have also been obtained by large–scale surveys in France, 131 the Czech Republic, 132Canada, 133 southeast Arkansas (USA), 134 the UK 135and Australia. 136 Without exception, these large surveyshave revealed a positive relationship between antenatalclass attendance and either breastfeeding initiation orduration. Smaller studies in Turkey 137 and Poland 138also suggest positive effects of antenatal programmeson breastfeeding rates.Interestingly, when trials have compared standardantenatal education with modified programmes, oftenincorporating additional breastfeeding content, nodifferences between groups have been found. Forexample, Lavender et al compared outcomes forwomen who had been allocated to routine antenataleducation or an additional single educational groupsession supervised by a lactation specialist. 139 Therewas no difference between the groups in the proportionof women who attained their expected duration ofbreastfeeding, the uptake of breastfeeding on dischargefrom hospital or in the proportion of women exclusivelybreastfeeding at four months. Sheehan used a quasiexperimentaldesign to compare two different methodsof antenatal breastfeeding education. 140 The first wasa woman-centred intervention, incorporating conceptsof peer and partner support run by representatives ofthe Nursing Mothers Association Australia (NMAA).The second group received antenatal breastfeedingeducation led by a midwife childbirth educator aspart of the antenatal course. There was no differencebetween the two groups on measures of maternalperceptions of success or breastfeeding durationrates up to 25 weeks after birth. The study wasinteresting because it suggests that a peer-led model ofbreastfeeding education was as effective as a midwifeledgroup in producing good breastfeeding initiationand duration rates.That access to education and support should increasewomen’s success with breastfeeding is not surprising.It is consistent with studies that have noted a lackof knowledge about breastfeeding management andlack of support as major barriers to breastfeeding. 141A prospective study done in Wellington, New Zealandsurveyed a cohort of 490 women at intervals throughoutpregnancy and after giving birth. 142 They found that,after controlling for socio-demographic variables,women were less likely to be fully breastfeeding at sixto 10 weeks postpartum if they believed they neededmore breastfeeding information before delivery or if theyhad experienced breastfeeding problems.There seems to be no doubt that breastfeeding ismore common among women who attend antenatalclasses than among women who do not attend classes.What is more difficult to determine is the direction ofcausality. However, it does seem likely that antenatalcourses that incorporate education about the benefitsof breastfeeding, breastfeeding management, andhow to deal with breastfeeding problems will increasebreastfeeding initiation and duration.140 Families Commission Research Fund

families commission research fund1.5.3 Relationship between coupleIt is widely acknowledged that the transition toparenthood can create additional challenges for couplesas they adjust to their new roles and the demandsof caring for an infant. The period can be associatedwith increased stress and conflict, and for many, thequality of their relationship declines. 143,144 Given thatthe quality of the couple’s relationship is implicated inthe child’s early development, there is added impetusto try to intervene during this transition. 145 The hopeis for preventive couple interventions to better prepareparents for relationship changes that may occur andhow to cope with them.The search revealed two studies within the last 10years that specifically examined the effectivenessof antenatal classes on the quality of the couple’srelationship. Arcamone surveyed a convenience sampleof women at two weeks postpartum and comparedthree groups of women: those who had attendedPrepared Childbirth Classes; women who had attendedPrepared Childbirth and Baby Care Basics Classes(additional parenting content); and women who hadnot attended any prenatal education classes. 146 Nosignificant differences were found among the threegroups on the quality of women’s relationship with theirpartners. Diemer developed a ‘father-focused’ antenatalcourse that employed a group discussion format andcompared it against standard antenatal classes thatemployed more didactic methods (study describedin section 1.3.3). 51 The father-focused classes hadbenefits over the standard classes on the men’s levelof interpersonal reasoning with partners and theirparticipation in housework, suggesting the interventionhad facilitated a more positive partner relationship.However, the post-assessment occurred immediatelyafter the conclusion of the classes and there was nofollow-up after the birth to determine if these effectswere maintained.Another study presented the results of an interventionthat was designed to fit easily into standard antenatalclasses to prevent relationship deterioration duringthe first year of parenthood. Hawkins et al producedthe ‘Marriage Moments’ workbook for childbirtheducators to hand out in their classes, so that couplescould then work through exercises at home. 147 Arandomised controlled trial compared the outcomesof three groups: a treatment group that received theworkbook and encouragement from their childbirtheducators to work through it; a second treatment groupthat received the workbook but no encouragementfrom childbirth educators; and a control group thatparticipated in the standard antenatal class but did notreceive a workbook. Although participants were highlysatisfied with the programme, disappointingly, therewere no significant differences between the groups onrelationship outcome measures at three or nine monthsafter the baby’s birth.More intensive prenatal psychoeducationalprogrammes, which have focused on developingrelationship skills, have shown some positive results.Bryan reviewed the literature in 2002 and describedtwo relevant studies. 148 A two-class communicationprogramme showed positive effects on couples’relationships and state-trait anxiety after birth 149and a longer couples’ intervention resulted in fewerseparations and divorces in the treatment group overthe first two years, after which effects began to fade. 145Shapiro and Gottman developed a psychoeducationalintervention for new parent couples that was addedonto standard antenatal classes. 150 The curriculumwas delivered over a two-day workshop and coveredcouple exercises, parenting and infant-care instruction.This programme was effective on one-year follow-upmeasures of the couple’s relationship quality and themother’s and father’s self-reported psychopathology.Some of the enhanced prenatal programmes havealso produced negative findings. The enhancedprenatal intervention developed by Bryan (describedin section 1.5.2), which produced benefits for parentchildinteraction, did not produce an effect on couplerelationships. 123 Comparing the enhanced interventionwith standard antenatal classes revealed no observablebenefits for the couples’ relationships at 10 monthsafter delivery. 148 The author, however, does point outthat the lack of randomisation meant that couples inthe enhanced group had greater relationship issues atTime 1, potentially making it more difficult to observe atreatment effect.If the enhanced prenatal programmes struggle toachieve effects, it might not be realistic to expectstandard antenatal classes alone to make muchdifference in this area. 151 Furthermore, even ifconsensus could be reached about the effectivecomponents of prenatal couples’ courses, theseinterventions would probably require highlytrained instructors.childbirth education: antenatal education and transitions of maternity care in new zealand141

1.5.4 Parenting self-efficacy and parentingknowledgeParents who have knowledge about how to care fora newborn are more likely to feel confident about thetransition to parenthood. A strong sense of self-efficacy,or confidence in one’s abilities, is necessary for asense of personal wellbeing and for persisting in effortstowards success. 152 Parenting self-efficacy influencesthe way a parent interacts with their child 151 and isinversely related to stress, 153 so it is not surprising thatparenting knowledge and self-efficacy influence childand parent health outcomes down the track.In the past, antenatal education was more accuratelydescribed by the term ‘childbirth education’, becauseit focused more on preparing expectant parents forlabour and childbirth rather than parenting. As a resultof an increasing number of calls for improvementsin this area, 154,155 many antenatal programmes haveincorporated infant care and parenting.The search strategy revealed five studies that havedirectly investigated the impact of antenatal courseson parenting outcomes. Four showed benefits ofattendance at courses with enhanced parenting contentand one showed no additional benefits. Both Corwin 156and Rolls and Cutts 157 demonstrated that antenatalclasses that incorporated parenting content producedimprovements in parenting knowledge scores that weresuperior to those of standard childbirth control groups.Using a quasi-experimental design, Schmied et al werethe first to examine the influence of antenatal classeson parenting variables in the postnatal period for agroup of Australian parents. 158 The experimental groupparticipated in an antenatal course that used adultlearning principles and focused on parenting skills andrelationship issues, as well as preparation for birth. Akey feature of the programme was that it incorporatedgender-specific discussion groups. Importantly, thenew course was no longer in length than the standardantenatal programme. Results showed that, at eightto 10 weeks postpartum, women in the experimentalgroup were significantly more likely to evaluate theirparenting experience more positively than women in theroutine programme, with a similar but non-significanttrend for men, indicating that experimental groupparents were more comfortable in infant care tasks andperceived themselves more positively as parents.Another Australian team, involving one of the sameresearchers involved in the Schmeid et al study, wenton to conduct a high-quality, randomised controlledtrial comparing two antenatal education programmesto determine their impact on parenting self-efficacyand parenting knowledge. 159 The experimental course,the Having a Baby programme, included increasedparenting content, but was the same length as thestandard control programme (seven two-hour sessionsbefore birth with a reunion meeting about six weeksafter birth). The women who attended the programmehad significantly higher perceived parenting selfefficacyand parenting knowledge about eight weeksafter the birth than women who attended the regularprogramme. There were no differences between thegroups on any other outcomes to do with labour andbirth. Encouragingly, the childbirth educators whofacilitated the experimental programme required onlya four-hour training workshop before delivering thecourse to produce the improved parenting outcomes.A study by Arcamone (described in section 1.5.4)found no differences in outcomes related toconfidence in coping with the tasks of motherhood orsatisfaction with motherhood and infant care activitiesbetween women who received standard antenatalclasses (Prepared Childbirth Class), enhancedclasses (Prepared Childbirth and Baby Care BasicsClass) or women who had not participated in anyantenatal classes. 146Differences in the findings can easily be explainedby differences in the nature of the antenatal courses.Even though Arcamone’s study examined outcomesfor a group of women who had received additionalparenting content, the manner of delivery of thePrepared Childbirth and Baby Care Basics Class wasmore didactic and less grounded in principles of adultlearning than the enhanced classes examined by theother studies.In summary, there is promising evidence that antenataleducation classes can make a difference to parentingconfidence and knowledge, provided they are based onprinciples of adult learning and incorporate additionalparenting content. Importantly, the refocusing of labourand birth content has had no detrimental effect onoutcomes related to labour or birth.1.5.5 Postnatal depression (PND)Postpartum or postnatal depression (PND) canseriously affect a woman’s ability to function andform a relationship with her child and is a predictor ofpoor cognitive, social and emotional development in142 Families Commission Research Fund

families commission research fundinfants. 160 It occurs in 10–20 percent of mothers bythree months postpartum. 161 Antenatal efforts to preventpostnatal depression have often included psychosocialstrategies aimed at enhancing women’s self-esteemand the level of support they receive postpartum.Only one study was found that specifically set out toinvestigate the impact of standard antenatal classeson depressive symptoms. Out of the 1,738 womenwho gave birth between 1988 and 1995 at the MieUniversity hospital in Japan, Okano et al identified allthe women who subsequently consulted a psychiatristfor PND (40). 162 Eighteen of these women had attendedantenatal classes and 22 had not. The mothers wereinterviewed, then followed up again six and 12 weekslater. There were two interesting findings. Firstly, thetime of the first psychiatric consultation after deliverywas much sooner for women who had attendedantenatal classes compared with women who had not.Secondly, the mean score on the Edinburgh PostnatalDepression Inventory of the attenders was significantlylower at the first consultation than the non-attenders,and this difference was found again at the six-weekfollow-up. These results could be interpreted asindicating that attendance at antenatal classes in Japanleads to earlier contact with psychiatric services and areduction in the severity of depression. However, it isnot possible to rule out that the observed differencescould simply be due to differences in the characteristicsof women who decided to attend or not attend classes.The majority of studies in this area have investigatedpsychosocial interventions, ranging in length from twoto 11 sessions, 163 some of which could be incorporatedinto standard prenatal classes. Brugha et al comparedoutcomes for women who did an enhanced prenatalcourse that focused on reducing risk factors andincreasing social support with women who receivedroutine antenatal care only. 164 The interventioncomprised six structured two-hour weekly classesand one postpartum class. There were no differencesbetween the two groups on rates of PND or riskfactors for depression at three months postpartum.Buist et al 165 compared outcomes for at-risk womenwho completed a 10-session course that spannedpregnancy and the postpartum with women whoattended a standard six-session antenatal class. Atsix weeks postpartum, there were no differencesin depression scores between groups. Hayes et alconducted a randomised controlled trial to investigatewhether an education package could prevent PND. 166The package consisted of a written informationbooklet designed for pregnant women that containedinformation about PND, its causes and where to go forhelp, as well as an audio tape of one woman’s journeythrough postnatal clinical depression and back again.A midwife guided women through the package in aclinic session or in their own homes. There were nodifferences in levels of depression at either eight to12 weeks or 16 to 24 weeks postpartum between theexperimental group and control group who had notreceived the education package. These negative resultsbuild on the findings from earlier studies that havealso failed to find any beneficial effects for prenatalpsychosocial interventions in preventing PND. 167In contrast to the negative findings described above,two studies achieved more promising results.Elliott et al invited ‘vulnerable’ pregnant women toparticipate in an 11-session psychosocial intervention,consisting of five prenatal sessions and six postnatalsessions. 168 Compared with the control group ofvulnerable women who received only routine prenatalcare, women in the intervention showed significantlymore positive moods at three months postpartum,as measured by the Edinburgh Postnatal DepressionScale. The other noteworthy result was that only 19percent of the intervention group had depression at anytime in the first three postpartum months, comparedwith 39 percent of the control group. By 12 monthspostpartum, no beneficial effect was evident. Ininterpreting these results, it must be recognised thatthe three-month assessment took place before theconclusion of the intervention (which went on until sixmonths postpartum). The authors themselves point outthe possibility of the effective ingredient being the socialsupport provided by the group.The other study with positive results was a randomisedcontrol trial by Matthey et al 163 They comparedoutcomes for attendance at three different antenatalinterventions: the standard Preparation for Parenthoodprogramme (control group); the standard programmeplus one extra session focusing on psychosocial issuesrelated to becoming first-time parents (experimentalgroup); and the standard programme plus oneextra session focusing on baby play (non-specificcontrol group). Men and women were categorisedinto low, medium and high levels of self-esteem. Atsix weeks postpartum, women with low self-esteem,who had received the intervention, were significantlychildbirth education: antenatal education and transitions of maternity care in new zealand143

etter adjusted on measures of mood and sense ofcompetence than low-self esteem women in either ofthe two control conditions. There were no differencesbetween groups by six months postpartum. Matthey etal comment that the beneficial effect at six weeks wasrelated to partners of these women being more aware ofhow the mother was feeling, and women reported moresatisfaction with the sharing of home and baby tasks.The study is important because the brief interventioncan readily be incorporated in antenatal classes,and it was the first to demonstrate the differentialeffectiveness of such programmes for women withdifferent levels of self-esteem.To summarise, the strength of the current evidencesuggests preventive psychosocial interventions, onthe whole, do not reduce the number of women whodevelop PND. Indeed, a recent Cochrane systematicreview of psychosocial and psychological interventionsfor preventing PND reached the same conclusion. 169A separate review of non-biological interventions forpreventing postpartum depression, which includedthe studies of antenatal classes described above,concluded there was insufficient evidence tounequivocally recommend any particular intervention. 170It may be a tall order for standard antenatal classesto affect rates of PND. At best, it could be speculatedthat under certain conditions, antenatal classes thatincorporate particular psychosocial interventions mayreduce some symptoms of distress.1.6 Outcomes related to specificpopulation groups1.6.1 FathersThe positive role that fathers can play duringpregnancy, labour and childbirth has been recognisedfor some time now. 171 The benefits of positiveinvolvement by the father for a child’s development arealso well documented. 172 Emerging evidence suggeststhat many men want to be involved in their partner’spregnancy 173 and feel unprepared for parenting. 174Fathers may have feelings of anxiety or helplessnessduring labour. Consequently, there has been greateracknowledgement of the support needs of men duringtheir transition to fatherhood 176 and more men nowattend antenatal classes. 177In recent years 175 , studies have considered fathers’experiences of childbirth and antenatal education, andthe impact of antenatal classes on men. Many of thesestudies have been qualitative in nature, investigatingmen’s experiences and satisfaction with antenatalclasses, and have less often involved comparison orcontrol groups.Not uncommonly, men have been dissatisfied withantenatal classes. 178 Male participants in programmeshave reported a lack of involvement and recognitionin groups, often only attending out of duty to theirpartners. 179,180 Men have felt alienated by the way inwhich information is presented and have ‘enduredbut not enjoyed’ antenatal education. 181 These studieswould support the conclusion that antenatal classes arenot meeting most men’s needs.In contrast, Galloway et al found that on completion ofantenatal classes, fathers “felt more confident abouttheir role as a support person in labour and betterprepared for the changes in lifestyle after the birth”pp 38-41. 182 Similarly, when Fletcher et al askedfathers for their immediate post-class response, fatherspredicted they had been well prepared in all areas. 176However, when asked for their reactions to antenatalclasses after the experience of labour and childbirth,fathers reported that antenatal classes had preparedthem for childbirth but not for lifestyle and relationshipchanges after the birth. 176In one of the few quasi-experimental studies in thisarea, Diemer investigated whether outcomes for fathersand couples could be improved by making antenatalclasses more ‘father-focused’ (study cited in section1.3.3 and section 1.5.4). 51 The father-focused classesincluded the same content regarding pregnancy, birthand parenting, but used a group discussion format andfocused more on teaching coping skills and increasingsocial support. The father-focused groups did producesome benefits in the men’s level of reasoning andparticipation in housework over the standard classes;however, there were no differences between groups onmeasures of coping, or, on the whole, on levels of socialsupport.Greenhalgh et al provide a caution against assumingantenatal classes may be beneficial for all fathers. 183She and her colleagues found that, while attendance atantenatal classes may have benefits for some fathers,for fathers whose coping style was to blunt or avoidthreatening information, attendance was associatedwith less fulfilling childbirth experiences than forfathers who had similar coping strategies who did notattend classes.144 Families Commission Research Fund

families commission research fundIn summary, antenatal classes can be of benefit tofathers, but childbirth educators should strive tounderstand fathers’ needs and ensure their classesare conducive to involvement by fathers. There havebeen plenty of suggestions for how to better meetthe needs of fathers in antenatal classes, 180,184 with arecurring suggestion to incorporate gender-specificdiscussion groups into the antenatal class. 185,186,187,188There needs to be ongoing evaluation of whetherfollowing such suggestions is associated with morepositive experiences for fathers of attending labour andemotional adjustment after delivery.1.6.2 TeensAdolescent pregnancy is associated with many negativehealth outcomes. 189 Pregnant teens have a highrate of unhealthy behaviours, such as smoking anddrinking, 190 and are often unprepared for pregnancyand in unstable relationships, with the potential fortremendous negative effects on the teen, infant andsociety. After giving birth, they are also less likely tobreastfeed than older mothers. 191 Consequently, thereis a great need for effective prenatal care.In this context, it is of concern that teenagers aremuch less likely to attend antenatal classes thanolder women. In a recent Australian pilot study of 30pregnant teenagers, 53 percent attended prenatalclasses. 192 Although this rate was higher than expected,it is significantly lower than the overall rate of 80percent of first-time mothers who attend classesin Australia. 193Dieterich lists the factors that could affect the pregnantadolescent’s health perceptions and self-efficacyexpectations. 189 They include lack of support, feelingisolated and needing help; inadequate teaching byproviders related to a lack of knowledge about howteens learn, coupled with teens’ tendency not torecognise the value of education and their relianceon misinformation; external barriers of cost andtransportation; system barriers of long waiting timesand short visits in delivery of prenatal care; cognitiveand emotional factors including negative attitudes andfear of pregnancy, birth and parenting, low self-esteemand difficulty with problem-solving and decision-makingskills. These are the same barriers that contribute toteens’ low attendance rates at antenatal classes.Perhaps because teenagers are far less likely to attendantenatal classes, there have been very few studies oftheir effectiveness for teenagers. One exception wasa quasi-experimental study by Covington et al thatshowed that a special nine to 10-session antenatalprogramme for adolescents resulted in significantlyfewer low-birthweight babies for participants in theintervention group compared with a historical controlgroup (who had received antenatal classes at thesame health department before the introduction of thenew teen programme). 194 The authors acknowledgethat differences found between the interventiongroup and historical controls may be due to othersocial, demographic or clinical changes over time,rather than any programme effects. This possibilitywas strengthened given that no differences werefound between the intervention group and eithercontemporary ‘geographically close’ controls orcontemporary ‘resource-similar’ controls, using a posttest-onlydesign.It may be that alongside antenatal classes, moreintensive interventions are necessary to positivelyinfluence outcomes for high-risk teens. Studiesinvestigating intensive early intervention programmes,involving home visitation support over many months,have shown health benefits for high-risk pregnantadolescents in reducing the number of infanthospitalisation days 195 and preventing later child abuseand neglect. 196In an effort to increase the number of teens receivingadequate prenatal care, many professionals arerecognising the importance of designing antenatalclasses tailored to the pregnant adolescent’s uniqueneeds. 189,197,198 Further research into these speciallytailored antenatal classes must now be conducted toprove their worth.1.6.3 Minority cultural groupsThere are marked differences in expectations andreactions to childbirth in different cultures. 199,200Perhaps not surprisingly, there are also large racialethnicdisparities in attendance at antenatal educationclasses, with women from indigenous or minoritycultural groups far less likely to attend antenatalclasses than Caucasian women. 22 For many minoritycultures, formal childbirth preparation is not a culturalnorm 201 and women prefer to rely on their mothersor other family members to acquire informationabout childbirth. 202,203childbirth education: antenatal education and transitions of maternity care in new zealand145

While the support that families provide to expectantparents should be applauded, the accuracy of theinformation exchanged cannot be relied upon andmany important health messages are not exchangedat all. An example of lack of information exchange isillustrated by a recent New Zealand study of Pacificmothers’ awareness of the risk factors for sudden infantdeath syndrome (SIDS). 204 The study showed thatamongst other things, lack of awareness of SIDS riskfactors was significantly associated with Samoan andCook Island Mäori ethnicity, being born in the PacificIslands, not being fluent in English and not attendingantenatal classes.The low participation rate of minority cultural groupsin antenatal classes is of particular concern givenpoorer health outcomes for these groups. 205 A largestudy carried out from 1988 to 1997 in London showedthat women from ethnic minority groups (African,West Indian, Bangladeshi, Indian or Pakistani) hadstrongly elevated risks of operative delivery comparedwith Caucasian women, after adjusting for importantconfounders. 206 Minority cultural groups also oftenrepresent the more socio-economically disadvantagedsections of the community. Women on lower incomeshave been found to have lower perceived control andreport higher levels of pain during childbirth. 69,202Several studies have noted barriers to participationin antenatal classes for minority cultural groups. 203,207Frequently mentioned barriers include transportationissues, childcare, language barriers and cost. Coupledwith the barriers, there is a lack of understandingamongst health providers of how prenatal healthinformation can best be presented to couples fromdifferent cultural backgrounds. Berman’s survey of59 Hispanic women revealed that the overwhelmingmajority had a preference for the health educator tohave a similar cultural background. 203 Such findingssuggest that antenatal classes need to have greateremphasis on relevant cultural practices. To facilitatethis prospect, Ottani describes common childbearingbeliefs among the Cambodian community andrecommends ways in which providers can incorporatesome of the practices into childbirth preparation. 201 Sheis very clear that if the aim is to increase participation ofwomen from minority cultures in antenatal classes, wemust involve members of their own communities.New Zealand has sought to increase the access ofMäori to prenatal programmes through two widelysupported policies: cultural safety education,particularly for mainstream providers of health services,to help them recognise conscious or unconsciouscultural and social attitudes that may affect the carethey provide; and increasing the number of MäoriHealth Care providers, or kaupapa Mäori services(developed by Mäori for Mäori). 208 Although there arepromising signs, it is not yet clear to what extentsuch initiatives have boosted Mäori access toantenatal education.On the rare occasion that culturally sensitive classeshave been formally evaluated, the results have beenencouraging. Mehl-Madrona provided training forhealth educators to offer culturally sensitive classesto Native American and Hispanic women in their owncommunities. 209 When 320 women who attendedsubsequent classes run by these educators werecompared against a matched comparison group,they had significantly fewer caesarean deliveries andless use of analgesia to reduce pain. This was not arandomised controlled trial, but it demonstrated thatwhen women from minority cultural groups attendedclasses, the results could be positive.For many minority groups, it is likely that havingculturally sensitive classes available will not beenough to improve access to antenatal classes. Thesecommunities will need to be mobilised to endorsewomen’s participation in prenatal preparation.Bhagat et al describe one such project to addressthe prenatal health needs of immigrant Punjabiwomen in Canada. 210 These authors collaboratedwith representatives from various service agenciesand the community to create a platform forcommunicating with the community about prenatalhealth care. The effectiveness of such mobilisationefforts on improving prenatal care or antenatal classattendance is unknown.To summarise, culturally competent childbirtheducation requires educators to consider the beliefsof the expectant parents, the cultural environment ofthe class and the teaching strategies used to presentthe class content. Offering prenatal education thatis sensitive to the beliefs and wishes of minorities isa starting point for increasing expectant women’swillingness to participate in classes. Once women fromminority cultural groups begin participating in classes,we can then turn to the question of determining theimpact of antenatal education for minority groups.146 Families Commission Research Fund

families commission research fund1.7 Discussion and conclusionsStudies have investigated the impact of antenataleducation on various outcomes. The methodology ofmany of these studies can be criticised. In particular,there is a lack of randomised controlled trials and anover-reliance on cross-sectional survey methodologyto deduce the impact of classes. The main implicationis that the differences found between attenders andnon-attenders using the survey methodology may beassociative, not causal. Attendance at antenatal classesmay be a marker for other differences in personalcharacteristics, motivation, behaviour or environmentalfactors that are more influential determinants of healthoutcomes. Indeed, older, more-educated, higherincome,Caucasian women, who are more likely toattend antenatal classes, tend to have better outcomesacross a range of health indices than the younger,less-educated, lower-income, minority culture groups,who are less likely to attend. Despite this criticism,researchers have argued that demographics alone donot account for the differences in outcomes betweenattenders and non-attenders. 11,211Another issue is that the antenatal programmesreviewed are not homogeneous. There is a greatdeal of variety in class timing, purpose, content,format, theoretical perspective, philosophy and thequalifications of instructors. Nolan pointsout that “almost all studies have made the mistake oftreating attendance at classes as a single, uniform,intervention”. 85 This makes it difficult to compareoutcomes across studies and to draw conclusionsabout the effectiveness of antenatal education on anyone outcome.The number of different populations served isalso noteworthy. These studies have been conductedin many different countries, making generalisabilityof results limited. However, given the consistentfinding in different countries that attenders are morelikely to be white, middle-class women, it couldperhaps be argued that the findings apply primarily tothis group.These limitations notwithstanding, there havebeen a sufficient number of studies to begin to detectsome patterns in the aggregated findings. It wasfelt that a summary that relied solely on the strengthof the evidence would not provide a complete pictureof antenatal education’s potential role andeffectiveness within the wider maternity system,and would therefore limit the ability of the review tocontribute to the optimal development offuture antenatal education programmes. The findingsare therefore summarised according to two dimensions.Table 1 categorises each outcome accordingto both the strength of evidence for the effectivenessof antenatal classes in this area and the likelihood,based on the broader literature, that antenatal classescan have impact in this area. In determining thestrength of the evidence, the quality and number ofstudies was considered. In determining antenataleducation’s ‘likelihood’ of affecting a particularoutcome, the wider literature was considered. Inparticular, the existence of effective interventionsthat could easily be incorporated into antenatalclasses was taken into account, as wasthe demonstrated effectiveness of ‘enhanced’antenatal classes.childbirth education: antenatal education and transitions of maternity care in new zealand147

TABLE 1. Summary of findings: strength of evidence for the effectiveness of antenatal education on eachoutcome as a function of the likelihood of antenatal education affecting each outcomeGood evidence Mixed evidence Very little evidenceLikely to impact > Bonding or attachment> Breastfeeding success> Parenting self efficacyand parentingknowledge> Expectations> FathersMay impact > Nutrition> Amount of fear or anxiety> Maternal sense of control> Amount of pain> Use of medications toreduce pain or copingstrategies used in labour> Birthweight or pretermdeliveryLess likely toimpact> Birth experience> Caesarean rate> Couple relationship> Postnatal depression> Substance use> Social support> Teens> Minority cultural groupsAs the table shows, there is good evidence thatantenatal education can improve bonding orattachment, breastfeeding rates, parenting self-efficacyand parenting knowledge. These positive outcomeshave been demonstrated consistently in severalstudies. Despite some mixed results, it also seemslikely that antenatal education can benefit fathers’confidence about their role as support person in labourand on women’s expectations for labour and delivery.No study specifically investigated the relationshipbetween antenatal education and substance use,although the existence of other effective brief, prenatalinterventions for smoking and drinking suggests thatantenatal classes incorporating such interventionscould affect these outcomes if delivered at the righttime. Importantly, there is anecdotal and qualitativeevidence suggesting that antenatal education canincrease women’s social support networks, which may,in itself, help women to prepare emotionally for the birthexperience and beyond.What antenatal education has not achieved with anyconsistency is benefits in terms of nutrition, amountof fear or anxiety, maternal sense of control, amountof pain, use of medications to reduce pain, thecoping strategies used during labour or the numberof premature or low-birthweight babies. It is likely thatthe mixed results for these outcomes are a function ofthe variety of antenatal classes tested and the differentmethodologies used across the studies. Given theright conditions, antenatal classes may yet be able toimprove outcomes in these areas. Similarly, if classescould be modified to better address the unique needsof teens or minority cultural groups, it seems likelythere could be benefits for these groups. To date, theeffectiveness of antenatal education has rarely beenexamined for these groups, probably at least partlybecause of the difficulty in engaging them in classes.Finally, for other outcomes, the bulk of the evidenceand consideration of the wider literature suggests thatantenatal education is less likely to have impact. These148 Families Commission Research Fund

families commission research fundoutcomes are women’s birth experience, caesareanrates, couple relationships and postnatal depression(PND). It is likely there are far better predictors of theseoutcomes than attendance at antenatal classes. Forexample, continuity of care and the far more proximaldeterminant of the quality of midwifery support duringlabour have been shown to predict satisfaction with thebirth experience. 65 Any additional benefit of attendanceat antenatal classes is likely to be small and virtuallyimpossible to detect in the complex interplay of otherfactors surrounding prenatal care, birth and the healthof parents.It is clear that there are some outcomes that antenataleducation is more likely to affect than others. Despitea lack of evidence and mixed results, women and theirpartners continue to attend antenatal classes and, onthe whole, are satisfied with them. Clearly, we must relyon more than our linear modelling equations to drawconclusions about the effects of antenatal classes. Atleast in part, classes must give information relevantto becoming a parent. At the same time, there areconcerns about the structure, process and content ofprogrammes and a growing body of literature on whatcan be done to improve antenatal education.1.7.1 Recommended future format and content ofantenatal classesA review of parenting education services in NewSouth Wales, Australia provided support for antenataleducation but criticised programmes that continue topresent information in a didactic manner, and thusdo not address the particular learning needs of theirparticipants. 193 Indeed, there are consistent calls forclasses to be based on principles of adult learning. 193These principles include allowing choice and selfdirectionin the learning process; having clearly definedgoals; respecting current viewpoints; building onprevious experience and providing opportunities forparents to learn from each other’s experiences andideas; incorporating small-group discussions (includingsame-sex discussion groups); and treating people asequals in the learning process. In addition, classesshould provide more opportunity for experientiallearning (learning by doing). Providing time for womenand men to practise the use of strategies taught isimportant, not only for developing skills, but also as ademonstration of commitment to a method. 212 Slade etal suggest that facilitating the translation of training inantenatal classes to practice in the delivery suite mayalso require more effort to strengthen women’s beliefin the benefits of using the strategies as well as furtherdeveloping their self-efficacy in the use of strategies. 84In terms of structure, there have been suggestions thatclasses should be offered on a broader timescale, 213 attimes that are best aligned with parents’ informationneeds. For example, such a programme may includecontent on nutrition and substance use early in thepregnancy, classes on coping with labour later inpregnancy and classes on infant care and parentingeither late in pregnancy or soon after the baby is born.Robertson suggests that spreading the sessions overseveral months in this way helps people to developfriendships and support networks, as it gives themlonger to connect, compared with the shorter durationof most programmes. 213In terms of content, a useful resource to guideevidence-based practice is Enkin et al’s A Guide toEffective Care in Pregnancy and Childbirth. 214 Theauthors describe how the primary content of antenatalclasses used to be on the use of psychological orphysical, non-pharmaceutical strategies to prevent painin childbirth. They go on to list the goals of expanded,modern-day classes, including good health habits,stress management, anxiety reduction, enhancementof family relationships, feelings of empowerment,enhanced self-esteem and satisfaction, successfulinfant feeding, smooth postpartum adjustmentand advice on family planning. Dumas, too, hassuggestions for the essential categories and contentof antenatal classes. 215 In practice, though, thereis frequent acknowledgement of the pressure to fiteverything in and the problem with providing too muchinformation. 215,216At least partly as a consequence of the fact thatantenatal classes cannot cover all the relevantinformation about pregnancy, childbirth and parenting,there have been several suggestions to refocus classesso that they concentrate on developing, in participants,the related concepts of empowerment, self-efficacyand health literacy. 215,216,217,218 Empowerment refersto acquiring self-help abilities and attitudes during adifficult period and involves not just allowing parentparticipation in classes, but showing parents howto develop the tools to solve their own problems. 215Taking an empowerment approach, the educator wouldfocus more on the development of abilities, such ascommunicating and verbalising feelings and needs,childbirth education: antenatal education and transitions of maternity care in new zealand149

ecoming self-assertive, expanding one’s network andimproving one’s self-confidence and self-efficacy. 215Bingham describes a range of CBE techniquesdesigned to empower women and increase their selfefficacy.217 These techniques involve ideas to maximisewomen’s voice and influence by methods such asencouraging women to carefully select a birth settingand caregiver, encouraging them to ask questions,encouraging them to talk to administrators and nursingsupervisors, responding to patient-satisfaction surveysand encouraging women to write letters about theirexperience. That empowerment and self-efficacyare important to women’s outcomes was illustratedby Lowe’s research showing that self-efficacysignificantly predicted childbirth fears in nulliparouspregnant women. 219Self-efficacy and empowerment are closely relatedto the concept of health literacy. The World HealthOrganisation (WHO) defines health literacy as follows:Health literacy represents the cognitive and socialskills which determine the motivation and abilityof individuals to gain access to, understand, anduse the information in ways which promote andmaintain good health… Health literacy meansmore than being able to read pamphlets andmake appointments. By improving people’saccess to health information and their capacityto use it effectively, health literacy is critical toempowerment. 220Renkert and Nutbeam advocate that health literacyshould be promoted through antenatal classes. 216They argue that when the concept of health literacyis used to guide the content and delivery of healtheducation, attention is focused on the developmentof skills and confidence to make choices that improveindividual health outcomes, rather than being limitedto the transmission of information. Antenatal classesthat are based on simple knowledge transfer and thedevelopment of basic skills are viewed as a missedopportunity to develop the knowledge and skills thathave more enduring application during the early yearsof parenthood.For the content that does end up being included, onecriticism has been a lack of realism, with women feelingunprepared for deviations from the normal course oflabour or criticising classes for their lack of honesty. 218For example, in a qualitative study by Schneider,women found the onset of labour distressing becauseit did not correspond with what they had been told inclasses. 50 Similarly, in an earlier study by McKay et alwomen expressed surprise at the difference betweenwhat they had been told about the bearing-down stageof labour and what they actually experienced. 221 Alack of realism in classes has been suggested as apossible reason why couples who strongly desire toavoid pharmacological methods of pain relief duringlabour frequently do not achieve their goal. 88 In fact,mothers whose expectations of labour are unrealisticexperience worse pain than mothers with more realisticexpectations. 222 A lack of realism in classes has alsobeen blamed for women being dissatisfied with thebirth experience. 223 It is therefore important thatantenatal classes aim to help parents achieve realisticexpectations of the birth experience and transitionto parenthood.Several studies have argued that antenatal classesshould focus more on parenthood 155,159,224 and thepsychological impact of having a child. 225 One of themain issues concerning the inclusion of content onparenting has been the timing of the classes. Parentsappear more receptive to information delivered whenit is most needed, and Australian research suggeststhat parents are not predisposed to absorb informationabout postnatal issues during the prenatal period. 226Similarly, it has been argued that men and womenare possibly so preoccupied with the issues of labourand childbirth that they are not ready to absorbinformation on relationship and lifestyle changes, andparenting, until the challenge becomes a reality. 176 Onthe other hand, antenatal programmes should not becompromised by educators who believe that pregnantwomen cannot learn. 227 In addition, Nolan’s researchindicates that couples desire a balance between labourand delivery and postnatal issues. 155 Furthermore, thereis now good evidence that information provided duringantenatal classes on parenting has positive effects onparenting knowledge and self-efficacy after the birth. 159Information on parenting should therefore form a keycomponent of antenatal classes, rather than a smallsection covered right at the end of the course.A final content area that childbirth educators shouldbe skilled in is discussing emotional and relationshipissues related to the transition to parenthood. There isperhaps no other life event that has such a profoundeffect on people’s relationships and emotionalwellbeing as becoming parents. The quality of parents’relationships with each other and the family system150 Families Commission Research Fund

families commission research fundthey create before the birth has a strong impact ontheir transition to parenthood. 228 And yet, qualitativeresearch shows that many women feel that antenatalclasses are too technical and do not address emotionalor psychological issues. 17 There is growing evidencethat couples are, in fact, more concerned aboutemotional and relationship issues than practical issuesof childbirth and infant care. 229 Antenatal classes alsoprovide a valuable opportunity for educators to singleout vulnerable women and families and organise forthem to receive extra appropriate support.In summary, for particular outcomes, benefits canbe maximised if antenatal education is done well, atthe right time and includes the right content. Futureantenatal education programmes should use adultlearning principles to empower women and increaseboth women’s and men’s self-efficacy and healthliteracy; prepare women in a more realistic way forchildbirth; educate parents about early parenting; anddiscuss emotional and relationship issues related to thetransition to parenthood.1.7.2 Implications for facilitators and childbirtheducatorsThe process and content recommendations containedin this review have implications for who should bedelivering antenatal education. The focus on improvinghealth literacy and empowering women may challengechildbirth educators to adopt new models of education.Both Kelly 230 and Svensson et al 159 note that educatorsmay require additional training to be able to facilitateeffective parenting sessions.It is clear that, at present, facilitators of antenatalclasses are not necessarily trained in the principles ofadult education 231 and may not have good teachingskills, relying instead on less effective didactic teachingmethods. Brown found that of the 14 childbirth andparenting educators she interviewed in one Australianstate, only one had undertaken a short eighthourcourse. 232Encouragingly, different studies have shown that asmall amount of additional training may be all that isrequired to achieve positive outcomes. For example,in Svensson et al’s study, childbirth educators whohad received only an additional four hours of trainingwere able to refocus the content and process of theirclasses to include more experiential activities, smallgrouplearning and parenting content. 159 The changesresulted in increased self-efficacy and knowledge forparents, relative to parents who had completed thestandard course. Similarly, in Diemer’s study, childbirtheducators received only brief training in how to shift thefocus from preparation for labour to parental adaptationand a more father-focused curriculum, including smallgroupmethods. 51 The refocused classes resulted inbenefits for fathers over standard antenatal classes thathad been run by the same educators.It is clear that it takes expertise and skill to facilitateeffective education and it is “not something that anyonecan do if they are a midwife” pp 38-39. 1 Childbirtheducators need adequate training and support torealise the potential of antenatal classes for parents.At a minimum, they should have knowledge and skillin the use of adult learning principles; experientiallearning; empowering parents and increasing parentalself-efficacy and health literacy; discussing difficultemotions and relationship issues; being sensitive toparticipants’ individual situations, cultures and learningdesires; professionalism; and understanding how otherparts of the maternity system work.1.7.3 Future researchThere have been a number of recommendationsfor future research. Koehn’s review suggests thatcontinued advancement of knowledge about antenataleducation is not occurring in an effective manner, andmakes five recommendations in an attempt to directfuture research efforts. 233 These recommendations are:1. Conduct studies guided by a model that expectsand accounts for differences in client motivation,birth attendant philosophies, attitudes and practicesof obstetrical caregivers and other factors thatinfluence a woman’s perception of childbirth. Thisis in recognition that these variables will continueto vary across studies, so it is critical that they arecategorised and defined so they can be comparedacross studies.2. Conduct studies that include health-focusedoutcomes, as opposed to being limited to illnessfocusedoutcomes.3. Conduct studies that operationally define themeasures of health-focused outcomes and thecontinued development and use of tools thatmeasure these outcomes.4. Establish standardisation and categorisation ofthe intervention of CBE in order to understandvariations and to have an operationally defined setof terms for defining variables.childbirth education: antenatal education and transitions of maternity care in new zealand151

5. Conduct a meta-analysis of the effects of CBE fromstudies in the last 20 years so that future researchcan build on the knowledge and facts learnt frompast studies.These are sensible recommendations that, if followed,will help make sense of the wide variety of studiesand begin to advance our knowledge about antenataleducation in a more effective way.Table 1 can also be used to indicate future researchdirections. For example, researchers could aim tosubstantiate the effectiveness of antenatal educationon outcomes that it is likely to affect, but for which sofar there is very little evidence, such as substance useor social support. Alternatively, being careful to specifythe content and philosophy of their classes, researcherscould aim to provide more solid evidence of the impactof antenatal education on the outcomes for which thereis currently mixed evidence and uncertainty, such asthe mother’s nutrition or amount of fear or anxiety. It isalso important that future research examines and canarticulate the conditions under which improvements inparticular outcomes are likely. For example, just howmuch class time needsto be dedicated to parenting content in order to benefitthis outcome and how little time can educatorsspend on birthing before there is a noticeable declinein benefit?In addition, a number of more specificrecommendations can be made in relation to researchon particular outcomes or programme designs. Theseare summarised in Table 2.TABLE 2. Recommendations for future research1. Investigate the feasibility of designing educationprogrammes that straddle the birth experience, ie,run classes both before and after birth.2. Investigate whether offering classes on a broadertimescale, at times that are best aligned withparents’ information needs, is more effective thanclasses offered in one cluster towards the end ofpregnancy.3. Investigate the relationship between antenatalclass attendance, increased social support andimproved health outcomes.4. Investigate how women’s expectations ofchildbirth are modified by antenatal education asa function of their demographic characteristics.5. Investigate optimal ways of engaging minorityculture groups in antenatal education andexamine whether classes modified to be moreculturally appropriate have benefits forminority groups.6. Investigate the effectiveness of antenataleducation on psychosocial variables and healthfocusedoutcomes beyond the birth experience.7. Investigate whether antenatal classes can affectthe variables that have been shown to predict painand satisfaction with the birth experience, such asquality of relationship with caregiver, continuity ofcare and support in labour.In summary, antenatal classes provide an importantopportunity to promote healthy behaviours, increasesocial support, prepare women and their partnersfor childbirth and parenting and to detect vulnerablewomen and their families. As both Gagnon’s 25 andKoehn’s 233 reviews have shown, the recent studies are,as a group, so different and flawed that it is difficult todraw conclusions about the effectiveness of antenataleducation. However, this review is different in thatby considering the wider literature and drawing froma wide range of experimental designs, it has allowedconclusions to be drawn about which outcomesantenatal classes are likely to be effective.It must be remembered that antenatal classesrepresent just one small part of the complex maternitysystem, with a myriad of factors interacting to influencehealth outcomes. Nurses conceptualise childbirthpreparation as “an educational moment towardshealth” pp 190-198. 234 Enkin reminds us that thereis no comprehensive formula for maternity care orantenatal education and that many aspects of ourcurrent practices work very well. 27 Indeed, sufficientevidence of their benefits exists that increased effortsmust be directed to recognising barriers to andreducing disparities in attendance of these classes.Regardless of their effects, for some women,attendance at antenatal classes may be an importantpart of the journey into motherhood, where there areopportunities to hear other women’s birth stories and toform relationships with other expectant mothers. 235Antenatal education is evolving. 236 It began aschildbirth education, and as the scope of classesbroadened to encompass more than just strategies152 Families Commission Research Fund

families commission research fundfor coping with labour and birth, it became antenataleducation. It is possible that with the recognition of theimportance of better preparing parents for parenthoodand the emotional and relationship issues the transitionengenders, in the future women and their partners mayregularly attend perinatal classes. There have been callsfrom researchers and clinicians to “lift our game”. 1 It ishoped that some of the emerging patterns summarisedin this review may contribute to the format and contentof future classes, in order to better equip women andtheir partners to navigate the birth experience and thetransition to parenthood. The skills and confidencethat can be enhanced in antenatal classes can helpto ensure that the new life phase begins as a positive,healthy experience.childbirth education: antenatal education and transitions of maternity care in new zealand153

REFERENCES1Robertson, A. (2001). ‘Prenatal education: Time to lift ourgame’. The Practising Midwife, 4(1): 38–39.2Zwelling, W. (1996). ‘Childbirth education in the 1990s andbeyond’. Journal of Obstetric, Gynecologic, and NeonatalNursing, 25: 425–432.3Nolan, M. (1997). ‘Antenatal education – Where next?’Journal of Advanced Nursing, 25: 1198–1204.4Dick-Read, G. (1944). Childbirth without fear. Harper & Row,New York.5Lamaze, F. (1958). Painless childbirth: Psychoprophylacticmethod. Burke, London.6Bradley, L.P. (1995). ‘Changing America birth through childbirtheducation’. Patient Education and Counseling, 25: 75–82.7Kitzinger, S. (1988). The experience of childbirth. PenguinBooks, London.8Simkin, P., & Enkin, M. (1989). ‘Antenatal classes’. In I.Chalmers, M. Enkin, & J. Keirse (Eds.), Effective care inpregnancy and childbirth. Vol 1, Oxford University Press,Oxford.9Lothian, J.A. (2001). ‘Really teaching Lamaze: Evidence-basedpractice’. The Journal of Perinatal Education, 10(1): viii–xi.10Lamaze International, Inc. (2000). Lamaze philosophy ofbirth. Lamaze International, Inc. [Online]. Available at:http://www.lamaze.org/2000/aboutlamaze.html11Broome, M.E., & Koehler, C. (1986). ‘Childbirth education:A review of effects on the woman and her family’. Family andCommunity Health, 9(1): 33–44.12American Academy of Pediatrics and the American Collegeof Obstetricians and Gynecologists. (1997). Guidelines forperinatal care (4th ed.). American Academy of Pediatrics,Elk Grove Village, IL.13Dragonas, T., & Christodoulou, G.N. (1998). ‘Prenatal care’.Clinical Psychology Review, 18(2): 127–142.14World Health Organisation (1985), Having a baby in Europe.Public Health in Europe, 26. Copenhagen: Regional Officefor Europe.15Lee, H., & Shorten, A. (1999). ‘Childbirth education classes:Understanding patterns of attendance’. Birth Issues, 8(1): 5–12.16DeClerq, E., Sakala, C., Corry, M., Applebaum, S., & Risher,P. (2002). Listening to mothers: Report of the First NationalU.S. Survey of Women’s Childbearing Experiences. MaternityCentre Association, New York.17Cliff, D., & Deery, R. (1997). ‘Too much like school: Socialclass, age, marital status and attendance/non-attendance atantenatal classes’. Midwifery, 13(3): 139–145.18O’Brien, M., & Smith, C. (1981). ‘Women’s views andexperiences of antenatal care’. Practitioner, 225: 123.* 19 Lumley, J., & Brown, S. (1993). ‘Attenders andnonattenders at childbirth education classes in Australia: Howdo they and their births differ?’ Birth, 20(3): 123–131.20Vinal, D. (1982). ‘Childbirth education programs: Astudy of women participants and nonparticipants’.Birth, 9(3): 183–186.21Cwiek, D., Luczynska, V., Jurczak, A., & Augustyniuk, K.(2004). ‘Sources of women’s knowledge relating pregnancyand childbirth’. Wiad Lek, 57(1): 52–58.* 22 Lu, M.C., Prentice, J., Yu, S.M., Inkelas, M., Lange,L.O., & Halfon, N. (2003). ‘Childbirth education classes:Sociodemographic disparities in attendance and theassociation of attendance with breastfeeding initiation’.Maternal and Child Health Journal, 7(2): 87–93.* 23 Spinelli, A., Baglio, G., Donati, S., Grandolfo, M.E., &Osborn, J. (2003). ‘Do antenatal classes benefit the motherand her baby?’ Journal of Maternal-Fetal and NeonatalMedicine, 13(2): 94–101.24Astbury, J. (1980). ‘The crisis of childbirth: Can informationand childbirth education help?’ Journal of PsychosomaticResearch, 24: 9–13.25Gagnon, A.J. (2000). ‘Individual or group antenataleducation for childbirth/parenthood’. Cochrane Databaseof Systematic Reviews, Issue 4. Art. No.: CD002869. DOI:10.1002/14651858.CD002869.26Westley, F., Zimmerman, B., & Patton, M.Q. (2006). Gettingto maybe: How the world is changed. Random House, Canada.27Enkin, M. (2006). ‘Beyond evidence: The complexity ofmaternity care’. Birth, 33(4): 265–269.28Ramakrishnan, U. (2004). ‘Nutrition and low birth weight:From research to practice’. American Journal of ClinicalNutrition, 79(1): 17–21.29Cogswell, M.E., Parvanta, A., Ickes, L., Yip, R., &Brittenham, G.M. (2003). ‘Iron supplementation duringpregnancy, anemia, and birth weight: A randomised controlledtrial’. American Journal of Clinical Nutrition, 78: 773–781.30Lumley, J., Watson, L., Watson, M., & Bower, C. (2001).‘Periconceptional supplementation with folate and/ormultivitamins for preventing neural tube defects’5.Cochrane Database of Systematic Reviews, Issue 3.DOI: 10.1002/14651858.CD001056.154 Families Commission Research Fund

families commission research fund31Kramer, M.S. (2003). ‘Effects of energy and proteinintakes on pregnancy outcome: An overview of the researchevidence from controlled clinical trials’. Cochrane Database ofSystematic Reviews, Issue 1.32Faden, V.B., Hanna, E., & Graubard, B.I. (1997). ‘The effectof positive and negative health behaviour during gestation onpregnancy outcome’. Journal of Substance Abuse, 9: 63–76.* 33 Cwiek, D., Grochans, E., Sowinska-Glugiewicz, I., &Wysiecki, P. (2004). ‘Analysis of some pro-health behavioursof pregnant women after a childbirth education class’. WiadLek, 57(1): 48–51.34Briley, C., Flanagan, N.L., & Lewis, N. (2002). ‘In-homeprenatal nutrition intervention increased dietary iron intakesand reduced low birthweight in low-income African-Americanwomen’. Journal of the American Dietetic Association,102(7): 984–987.35Susser, M., & Stein, Z. (1994). ‘Timing in prenatalnutrition: A reprise of the Dutch Famine Study’. NutritionReviews, 52(3): 84–94.36Behnke, M., & Eyler, F.D. (1993). ‘Consequences ofprenatal substance use for the developing fetus, newbornand young child’. International Journal of the Addictions,28(13): 1341–1391.37Coles, C.D., & Platzman, K.A. (1993). ‘Behavioraldevelopment in children prenatally exposed to drugs andalcohol’. International Journal of the Addictions,28(13): 1393–1433.38Day, N.L., Richardson, G.A., Geva, D., & Robles, N. (1994).‘Alcohol, marijuana, and tobacco: Effects of prenatal exposureon offspring growth and morphology at age six’. Alcoholism:Clinical and Experimental Research, 18(4): 786–794.39Streissguth, A.P., Barr, H.M., Sampson, P.D., & Bookstein,F.L. (1994). ‘Prenatal alcohol and off-spring development:The first fourteen years’. Alcohol and Drug Dependence,36(2): 89–90.40Lumley, J., Oliver, S.S., Chamberlain, C., & Oakley, L.(2004). ‘Interventions for promoting smoking cessation duringpregnancy’. Cochrane Database of Systematic Reviews, Issue4. DOI: 10.1002/14651858.CD001055.pub2.41Fleming, M.F., Barry, K.L., Manwell, L.B., Johnson, K., &London, R. (1997). ‘Brief physician advice for problem alcoholdrinkers. A randomized controlled trial in community-basedprimary care practices’. Journal of the American MedicalAssociation, 277: 1039–1045.42Mengel, M.B., Searight, R., & Cook, K. (2006). ‘Preventingalcohol-exposed pregnancies’. Journal of the American Boardof Family Medicine, 19(5): 494–505.43Chang, G., McNamara, T.K., Orav, J., Kolby, D., Lavigne,A., & Wilkins-Huang, L. (2005). ‘Brief intervention for prenatalalcohol use: A randomized trial’. Obstetrics and Gynecology,105: 991–998.44Giurgescu, C., Penckofer, S., Maurer, M.C., & Bryant, F.B.(2006). ‘Impact of uncertainty, social support, and prenatalcoping on the psychological well-being of high-risk pregnantwomen’. Nursing Research, 55(5): 356–365.45Cannella, B.L. (2006). ‘Mediators of the relationshipbetween social support and positive health practices inpregnant women’. Nursing Research, 55(6): 437–445.46Harley, K., & Eskenazi, B. (2006). ‘Time in the UnitedStates, social support and health behaviors during pregnancyamong women of Mexican descent’. Social Science andMedicine, 62(12): 3048–3061.47Feldman, P.J., Dunkel-Schetter, C., Sandman, C.A., &Wadhwa, P.D. (2000). ‘Maternal social support predicts birthweight and fetal growth in human pregnancy’. PsychosomaticMedicine, 62(5): 715–725.48Ekstrom, A., Widstrom, A., & Nissen, E. (2006). ‘Doescontinuity of care by well-trained breastfeeding counselorsimprove a mother’s perception of support?’ Birth: Issues inPerinatal Care, 33(2): 123–130.49Nolan, M. (1998). Empowerment and antenatal education.Unpublished PhD thesis, University of Birmingham.50Schneider, Z. (2002). ‘Pregnant women’s experiencesof models of care in some hospitals in Victoria’. AustralianJournal of Advanced Nursing, 19(3): 32–38.* 51 Diemer, G.A. (1997). ‘Expectant fathers: Influence ofperinatal education on stress, coping, and spousal relations’.Research in Nursing and Health, 20: 281–293.52Tumblin, A., & Simkin, P. (2001). ‘Pregnant women’sperceptions of their nurse’s role during labor and delivery’.Birth, 28(1): 52–56.53Chen, L.F. (2000). A correlation study of expectations aboutwomen’s childbirth and birth experience. Unpublished thesis,National Defense Medical Center, Taiwan.* 54 Kao, B.C., Gau, M.L., Wu, S.F., Kuo, B.J., & Lee, T.Y.(2004). ‘A comparative study of expectant parents’ childbirthexpectations’. Journal of Nursing Research, 12(3): 191–202.55Soet, J.E., Brack, G.A., & Dilorio, C. (2003). ‘Prevalenceand predictors of women’s experience of psychological traumaduring childbirth’. Birth, 30(1): 36–46.* 56 Maestas, L.M. (2003). ‘The effect of prenatal educationon the beliefs and perceptions of childbearing women: 2000Virginia Larsen Research Grant winner’. International Journalof Childbirth Education, 18(1): 17–21.* 57 Hallgren, A.M., Kihlgren, A., Norberg, A., & Forslin, L. (1995).‘Women’s perceptions of childbirth and childbirth educationbefore and after education and birth’. Midwifery, 11(3): 130–137.* 58 Melender, H. (2002). ‘Experiences of fears associated withpregnancy and childbirth: A study of 329 pregnant women’.Birth: Issues in Perinatal Care, 29(2): 101–111.childbirth education: antenatal education and transitions of maternity care in new zealand155

59Wuitchik, M., Hesson, K., & Bakal, D.A.(1990). ‘Perinatalpredictors of pain and distress during labour’. Birth, 17: 186–191.60Hesson, K.I. (1996). ‘Maternal distress and breathing inlatent labor.’ Dissertation Abstracts International. Section B:The Sciences and Engineering, 56(10-B): 5768.61Ryding, E.L., Wijma, B., Wijma, K., & Rydhstrom, H. (1998).‘Fear of childbirth during pregnancy may increase the risk ofemergency caesarean section’. Acta Obstet Gynecol Scand,77: 542–547.62Glover, V., & O’Connor, T.G. (2005). ‘Effects of antenatalmaternal stress or anxiety: From fetus to child’. In B. Hopkins& S.P. Johnson (Eds.), Advances in infancy research (pp.221–245). Praeger Publishers/Greenwood Publishing Group,Westport, CT.63Segeel, I.B., & du Plessis, D. (2006). ‘The childbirth andbreastfeeding experiences of primigravidas who attendedchildbirth education classes’. Health SA Gesondheid,11(2): 62–74.* 64 Manning-Orenstein, G. (1997). A birth intervention:Comparing the influence of doula assistance at birth versusLamaze birth preparation on first-time mothers’ workingmodels of caregiving. Dissertation Abstracts International.Section B: The Sciences and Engineering, 58(5-B): 2689.65Hodnett, E.D. (2000). ‘Continuity of caregivers for careduring pregnancy and childbirth’. Cochrane Database ofSystematic Reviews, Issue 1. DOI: 10.1002/14651858.CD000062.* 66 Geissbuehler, V., & Eberhard, J. (2002). ‘Fear of childbirthduring pregnancy: A study of more than 8000 pregnantwomen’. Journal of Psychosomatic Obstetrics and Gynecology,23(4): 229–235.* 67 Astbury, J. (1980). ‘The crisis of childbirth: Can informationand childbirth education help?’ Journal of PsychosomaticResearch, 24: 9–13.68Brewin, C., & Bradley, C. (1982). ‘Personal control and theexperience of childbirth’. British Journal of Clinical Psychology,21: 263–269.* 69 Johnston-Robledo, I. (1998). The impact of childbirthpreparation and support on labor and birth outcomes.Dissertation Abstracts International. Section A: Humanities andSocial Sciences, 58(8-A): 3000.* 70 Hodnett, E.D. (2002). ‘Pain and women’s satisfaction withthe experience of childbirth: A systematic review’. AmericanJournal of Obstetrics and Gynecology, 186(5): 160–172.* 71 Waldenstrom, U., Hildingsson, I., Rubertsson, C., &Radestad, I. (2004). ‘A negative birth experience: Prevalenceand risk factors in a national sample’. Birth: Issues in PerinatalCare, 31(1): 17–27.72Department of Health. (1993). Report of the expertmaternity group “Changing Childbirth”, Part 1. Department ofHealth, HMSO, London.* 73 McCrea, H., Wright, M.E., & Stringer, M. (2000).‘Psychsocial factors influencing personal control in pain relief’.International Journal of Nursing Studies, 37: 493–503.* 74 Cheung, W., Ip, W.Y., & Chan, D. (2007). ‘Maternal anxietyand feelings of control during labour: A study of Chinese firsttimepregnant women’. Midwifery, 23(2): 123–130.75Brownridge, P. (1991). ‘Treatment options for the relief ofpain during childbirth’. Drugs, 41: 69–80.76Gottvall, K., & Waldenstrom, U. (2002). ‘Does a traumaticbirth experience have an impact on future reproduction?’British Journal of Obstetrics and Gynaecology, 109: 254–260.* 77 Simkin, P., & Bolding, A. (2004). ‘Update onnonpharmacologic approaches to relieve labor pain andprevent suffering’. Journal of Midwifery and Women’s Health,49(6): 489–504.78Dannenbring, D., Stevens, M.J., & House, A.E. (1997).‘Predictors of childbirth pain and maternal satisfaction’.Journal of Behavioral Medicine, 20(2): 127–142.79Lowe, N. (2002). ‘The nature of labor pain’. AmericanJournal of Obstetrics and Gynecology, 186: S16-24.* 80 Mehdizadeh, A., Roosta, F., Chaichian, S., &Alaghehbandan, R. (2005). ‘Evaluation of the impact of birthpreparation courses on the health of the mother and newborn’.American Journal of Perinatology, 22(1): 7–9.* 81 Fabian, H.M., Radestad, I.J., & Waldenstrom, U. (2005).‘Childbirth and parenthood education classes in Sweden:Women’s opinion and possible outcomes’. Acta ObstetGynecol Scand, 84(5): 436–443.* 82 Melzack, R., Kinch, R.H., Dobkin, P., et al. (1984).‘Severity of labor pain: Influence of physical as well aspsychologic variables’. Canadian Medical Association Journal,130: 579–584.83Buckley, S.J. (2003). ‘Undisturbed birth: Nature’s blueprintfor ease and ecstasy’. Journal of Prenatal and PerinatalPsychology and Health, 17(4): 261–288.84Slade, P., Escott, D., Spiby, H., Henderson, B., & Fraser,R.B. (2000). ‘Antenatal predictors and use of coping strategiesin labour’. Psychology and Health, 15: 555–569.* 85 Nolan, M. (2000). ‘The influence of antenatal classes onpain relief in labour: A review of the literature’. The PractisingMidwife, 3(5): 23–26.* 86 Heatherington, S.E. (1990). ‘A controlled study of the effectof prepared childbirth classes on obstetric outcomes’. Birth,17(2): 86–90.156 Families Commission Research Fund

families commission research fund* 87 Gunn, T.R., Fisher, A., Lloyd, P., & O’Donnell, S. (1983).‘Antenatal education: Does it improve the quality of labour anddelivery?’ New Zealand Medical Journal, 96: 51–53.* 88 Nolan, M. (2000). ‘The influence of antenatal classes onpain relief in labour 2: The research’. The Practising Midwife,3(6): 26–31.* 89 Escott, D., Spiby, H., Slade, P., & Fraser, R.B. (2004).‘The range of coping strategies women use to manage painand anxiety prior to and during first experience of labour’.Midwifery, 20(2): 144–156.90Henry, A., & Nand, S.L. (2004).’Women’s antenatalknowledge and plans regarding intrapartum pain managementat the Royal Hospital for Women’. Australian and New ZealandJournal of Obstetrics and Gynaecology, 44(4): 314–317.* 91 Escott, D., Slade, P., Spiby, H., & Fraser, R.B. (2005).‘Preliminary evaluation of a coping strategy enhancementmethod of preparation for labour’. Midwifery, 21(3): 278–291.92Spiby, H., Henderson, B., Slade, P., Escott, D., & Fraser,R.B. (1999). ‘Strategies for coping with labour: Does antenataleducation translate into practice?’ Journal of AdvancedNursing, 29(2): 388–394.93Czarnocka, J., & Slade, P. (2000). ‘Prevalence andpredictors of post traumatic stress symptoms after childbirth’.British Journal of Clinical Psychology, 39(1): 35–51.94Righetti-Velterma, M., Conne-Perreard, E., Bousquet, A.,& Manzano, J. (1998). ‘Risk factors and predictive signs ofpostpartum depression’. Journal of Affective Disorders,49(3): 167–180.95Lydon-Rochelle, M., Holt, V.L., Martin, D.P., & Easterling,T.R. (2000). ‘Association between method of delivery andmaternal rehospitalisation’. Journal of the American MedicalAssociation, 283: 2411–2416.96Henderson, E., & Love, E.J. (1995). ‘Incidence of hospitalacquiredinfections associated with caesarean section’. Journalof Hospital Infections, 29: 245–255.97Hemminki, E., & Merilainen, J. (1996). ‘Long-term effectsof caesarean sections: Ectopic pregnancies and placentalproblems’. American Journal of Obstetrics and Gynecology,174: 1569–1574.98Hager, R.M., Daltveit, A.K., Hofoss, D. et al. (2004).‘Complications of caesarean deliveries: Rates and risk factors’.American Journal of Obstetrics and Gynecology,190(2): 428–434.99World Health Organisation. (1985). ‘Appropriate technologyfor birth’. Lancet, 2(8452): 436–467.100Anderson, G.M. (2004). ‘Making sense of rising caesareansection rates’. British Medical Journal, 329: 696–697.101Laws, P.J., & Sullivan, E.A. (2005). Australia’s mothers andbabies 2003. Perinatal Statistics Series (no. 16). AustralianInstitute of Health and Welfare. Sydney. Available at:http://www.aihw.gov.au/npsu/ps9high.htm102Gamble, J.A., & Creedy, D.K. (2001). ‘Women’s preferencefor a caesarean section: Incidence and associated factors’.Birth, 28(2): 101–110.* 103 Burton, W.N., Hutchinson, S., Helgeson, L., & Connor,J. (2000). ‘An evaluation of a worksite prenatal educationprogram: Five year experience’. AWHP Worksite Health,7(1): 30–33.104Horey, D., Weaver, J., & Russell, H. (2004). ‘Information forpregnant women about caesarean birth’. Cochrane Databaseof Systematic Reviews, Issue 1. DOI: 10.1002/14651858.CD003858.pub2.105Bennett, A., Hewson, D., Booker, E., & Holliday, S. (1985).‘Antenatal preparation and labor support in relation to birthoutcomes’. Birth, 12(1): 9–16.106Chaillet, N., & Dumont, A. (2007). ‘Evidence-basedstrategies for reducing caesarean section rates: A metaanalysis’.Birth, 34(1): 53–64.107Dorling, J., D’Amore, A., Salt, A., Seward, A., Kaptoge, S.,Halliday, S., & Ahluwalia, J. (2006). ‘Data collection from verylow birthweight infants in a geographical region: Methods,costs, and trends in mortality, admission rates, and resourceutilization over a five-year period’. Early Human Development,82(2): 117–124.108Picard, E.M., Del Dotto, J.E., & Breslau, N. (2000).‘Pediatric neuropsychology: Research, theory, and practice’. InK.O. Yeates, M.D. Ris, & H.G. Taylor (Eds.), The science andpractice of neuropsychology: A Guilford series (pp. 237–251).Guilford Press, New York.109Hack, M., & Fanaroff, A.A. (1999). ‘Outcomes of childrenof extremely low birthweight and gestational age in the 1990’s’.Early Human Development, 53(3): 193–218.110Giscombe, C.L., & Lobel, M. (2005). ‘Explainingdisproportionately high rates of adverse birth outcomesamong African Americans: The impact of stress, racism, andrelated factors in pregnancy’. Psychological Bulletin,131(5): 662–683.111Hodnett, E.D., & Fredericks, S. (2003). ‘Support duringpregnancy for women at increased risk of low birthweightbabies’. Cochrane Database of Systematic Reviews, Issue 3.DOI: 10.1002/14651858.CD000198.112Reece, E.A., Lequizamon, G., Silva, J., Whiteman,V., & Smith, D. (2002). ‘Intensive interventional maternitycare reduces infant morbidity and hospital costs’.Journal of Maternal-Fetal and Neonatal Medicine,11(3): 204–210.childbirth education: antenatal education and transitions of maternity care in new zealand157

113Davies, B.L., Stewart, P.J., Sprague, A.E., Niday, P.A.,Nimrod, P.A., & Dulberg, C.S. (1998). ‘Education of womenabout the prevention of preterm birth’. Canadian Journal ofPublic Health, 89(4): 260–263.114Sprague, A., Stewart, P., Niday, P., Nimrod, C., & Walker,R. (2002). ‘Community education on preterm birth. Does itchange practice?’ Canadian Family Physician, 48: 727–734.* 115 El-Sabagh, N.E. (2002). Comparison of the responsesto preterm labor, discomforts and pains of pregnancy andpreterm birth between formal childbirth education attendeesand non-attendees. Doctoral dissertation, Health Sciences,Case Western Reserve University.* 116 Albizu, L., Goni, J., & Mejias, A. (2000). ‘Antenataleducation and recognition of the onset of labour’. An Sist SanitNavar, 23(2): 337–342.* 117 Tough, S.C., Newburn-Cook, C.V., White, D.E., Fraser-Lee, N.J., Faber, A.J., Frick, C., Svenson, L.W., & Sauve,R. (2003). ‘Do maternal characteristics and past pregnancyexperiences predict preterm delivery among women aged20 to 34?’ Canadian Journal of Obstetrics and Gynaecology,25(8): 656–666.118White, C., Simon, M., & Bryan, A. (2002). ‘Using evidenceto educate Birthing Center nursing staff: About infant states,cues, and behaviours’. MCN The American Journal ofMaternal and Child Nursing, 27(5): np.119Donovan, W., Leavitt, L., Taylor, N., & Broder, J. (2007).‘Maternal sensory sensitivity, mother-infant 9-monthinteraction, infant attachment status: Predictors of mothertoddlerinteraction at 24 months’. Infant Behavior andDevelopment, 30(2): 336–352.* 120 Bellieni, C.V., Ceccarelli, D., Rossi, F., Buonocore, G.,Maffei, M., Perrone, S., & Petraglia, F. (2007). ‘Is prenatalbonding enhanced by prenatal education courses?’ MinervaGinecol, 59(2): 125–129.* 121 Chang, S., & Chung, C. (2004). ‘Effect of Taegyo-focusedprenatal education on maternal-fetal attachment and selfefficacyrelated to childbirth’. Taehan Kanho Hakhoe Chi,34(8): 1409–1415.* 122 Hsu, T.L., & Chen, C.H. (2001). ‘Stress and maternal-fetalattachment of pregnant women during their third trimester’.Kaohsiung J Med Sci, 17(1): 36–45.* 123 Bryan, A. A. (2000). ‘Enhancing parent-child interactionwith a prenatal couple intervention’. MCN American Journal ofMaternal and Child Nursing, 25(3): 139–144.* 124 Moore, M.H. (2006). Parents’ reflective functionand caregiving representation: Implications for attachmenttheory and intervention. Dissertation AbstractsInternational. Section B: The Sciences and Engineering,66(10-B): pp. 5703.125World Health Organisation. (2001). Expert consultation onthe optimal duration of exclusive breastfeeding: Conclusionsand recommendations. Available at: http://www.who.int/inf-pr-2001/en/note2001-07.html126Noel-Weiss, J. (2005). The effect of prenatal educationon maternal breastfeeding self-efficacy and breastfeedingduration. Masters thesis, University of Ottawa, Canada.127Mattar, C.N., Chong, Y.S., Chan, Y.S., Chew, A., Tan,P., Chan, Y.H., & Rauff, M.H. (2007). ‘Simple antenatalpreparation to improve breastfeeding practice: A randomizedcontrolled trial’. Obstetrics and Gynecology, 109(1): 73–80.128Dyson, L., McCormick, F., & Renfrew, M.J. (2005).‘Interventions for promoting the initiation of breastfeeding’.Cochrane Database of Systematic Reviews, Issue 2. DOI:10.1002/14651858.CD001688.pub2.* 129 Lu, M.C., Lange, L.O., Slusser, W., Hamilton, J., &Halfon, N. (2001). ‘Provider encouragement of breastfeeding:Evidence from a national survey’. Obstetrics and Gynecology,97: 290–295.* 130 Deshpande, D.E., & Gazmararian, J.A. (2000). ‘Breastfeedingeducation and support: Association with the decisionto breast-feed’. Effective Clinical Practice, 3(3): 116–122.* 131 Crost, M., & Kaminski, M. (1998). ‘Breast feeding atmaternity hospitals in France in 1995: National perinatalsurvey’. Arch Pediatr, 5(12): 1316–1326.* 132 Schneidrova, D., Mullerova, D., Janout, V., Paulova, M.,& Kudlova, E. (2003). ‘Impact of breast-feeding promotionon infant feeding in the Czech Republic’. Journal of NutritionEducation and Behaviour, 35(5): 228–235.* 133 Evers, S., Doran, L., & Schellenberg, K. (1998).‘Influences on breastfeeding rates in low income communitiesin Ontario’. Canadian Journal of Public Health,89(3): 203–207.* 134 Zaghloul, S., Harrison, G.G., Fendley, H.F., Pierce, R.,Morrisey, C. (2004). ‘Correlates of breastfeeding initiationin southeast Arkansas’. South Medical Journal. J.,97(5): 446–450.* 135 Bartington, S., Griffiths, L.J., Tate, A.R., Dezateux,C., Millennium Cohort Study Health Group. (2006). ‘Arebreastfeeding rates higher among mothers delivering in babyfriendly accredited maternity units in the UK?’ InternationalJournal of Epidemiology, 35(5): 1178–1186.* 136 Forster, D.A., McLachlan, H.L., & Lumley, J. (2006).‘Factors associated with breastfeeding at six monthspostpartum in a group of Australian women’. InternationalBreastfeeding Journal, 1:18.* 137 Turan, J.M., & Say, L. (2003). ‘Community-basedantenatal education in Istanbul, Turkey: Effects on healthbehaviours’. Health Policy Plan, 18(4): 391–398.158 Families Commission Research Fund

families commission research fund* 138 Cwiek, D., Czajka, R., & Grochans, E. (2005). ‘Influence ofeducation at The Childbirth School on Breast Feeding’. RoczAkad Med Bialymst., 50(1): 185–188.* 139 Lavender, T., Baker, L., Smyth, R., Collins, S., Spofforth,A., & Dey, P. (2005). ‘Breastfeeding expectations versusreality: A cluster randomised controlled trial’. British Journal ofGynaecology, 112(8): 1047–1053.* 140 Sheehan, A. (1999). ‘A comparison of two methodsof antenatal breast-feeding education’. Midwifery,15(4): 274–282.141Hogan, S.E. (2001). ‘Overcoming barriers to breastfeeding:Suggested breastfeeding promotion programs for communitiesin Easter Nova Scotia’. Canadian Journal of Public Health,92(2): 105–108.142McLeod, D., Pullon, S., & Cookson, T. (2002). ‘Factorsinfluencing continuation of breastfeeding in a cohort ofwomen’. Journal of Human Lactation, 18(4): 335–343.143Demo, D.H., & Cox, M.J. (2000). ‘Families with youngchildren: A review of research in the 1990s’. Journal ofMarriage and the Family, 62(4): 876, 20 pp.144Cowan, C.P., & Cowan, P.A. (2000). When partners becomeparents: The big life change for couples. Erlbaum, Mahwah, NJ.145Cowan, C.P., Cowan, P.A., Heming, G., & Miller, N.B.(1991). ‘Becoming a family: Marriage, parenting and childdevelopment’. In P.A. Cowan & M. Hetherington (Eds.), Familytransitions (pp.79–109). Lawrence Erlbaum, Hillsdale, NJ.* 146 Arcamone, A.A. (2005). The effect of prenatal educationon adaptation to motherhood after vaginal childbirth inprimiparous women as assessed by Roy’s four adaptivemodes. Doctoral dissertation, Widener University Schoolof Nursing.* 147 Hawkins, A.J., Fawcett, E.B., Carroll, J.S., & Gilliland,T.T. (2006). ‘The Marriage Moments program for couplestransitioning to parenthood: Divergent conclusions fromformative and outcome evaluation data’. Journal of FamilyPsychology, 20(4): 561–570.* 148 Bryan, A.A. (2002). ‘Couple relationships over thetransition to parenthood: Methodological issues in testingfor an intervention effect’. Journal of Family Nursing,8(3): 201–220.* 149 Midmer, D., Wilson, L., & Cummings, S. (1995).‘A randomized, controlled trial of the influence of prenatalparenting education on postpartum anxiety and maritaladjustment’. Family Medicine, 27(3): 200–205.* 150 Shapiro, A.F., & Gottman, J.M. (2005). ‘“Bringingbaby home”: Effects on marriage of a psych-educationalintervention with couples undergoing the transition toparenthood, evaluation at 1-year post-intervention’. Journal ofFamily Communication, 5: 1–24.151Perry, M. (1992). ‘Prenatal education: How effective is it?’Journal of Australian College of Midwives, 5(1): 15–20.152Reece, S.M. (1992). ‘The Parent Expectations Survey: Ameasure of perceived self-efficacy’. Clinical NursingResearch, 1: 336–346.153Reece, S.M., & Harkless, G. (1998). ‘Self-efficacy,stress, and parental adaptation: Applications to the care ofchildbearing families’. Journal of Family Nursing, 4: 198–215.154Corwin, A. (1998). ‘Integrating preparation for earlyparenting into childbirth education: Part I: A curriculum’.Journal of Perinatal Education, 7(4): 26–33.155Nolan, M. (1997). ‘Antenatal education: Failing to educatefor parenthood’. British Journal of Midwifery, 5(1): 21–26.* 156 Corwin, A. (1999). ‘Integrating preparation for parentinginto childbirth education: Part II: A study’. Journal of PerinatalEducation, 8(1): 22–28.* 157 Rolls, C., & Cutts, D. (2001). ‘Pregnancy-to-parentingeducation: Creating a new approach’. Birth Issues, 10: 53–58.* 158 Schmied, V., Myors, K., Wills, J., & Cooke, M. (2002).‘Preparing expectant couples for new-parent experiences: Acomparison of two models of antenatal education’. The Journalof Perinatal Education, 11(3): 20–27.* 159 Svensson, J., Barclay, L., & Cooke, M. (in press).‘Randomised-controlled trial of two antenatal educationprogrammes’. Midwifery. DOI:10.1016/j.midw.2006.12.012.160Murray, L. (1992). ‘The impact of postnatal depressionon infant development’. Journal of Child Psychology andPsychiatry, 33: 543–561.161O’Hara, M.W., & Swain, A.M. (1996). ‘Rates and riskof postpartum depression – A meta-analysis’. InternationalReview of Psychiatry, 8: 37–54.* 162 Okano, T., Nagata, S., Hasegawa, M., Nomura, J., &Kumar, R. (1998). ‘Effectiveness of antenatal education aboutpostnatal depression: A comparison of two groups of Japanesemothers’. Journal of Mental Health, 7(2): 191–198.* 163 Matthey, S., Kavanagh, D.J., Howie, P., Barnett, B.,& Charles, M. (2004). ‘Prevention of postnatal distress ordepression: An evaluation of an intervention at preparation forparenthood classes’. Journal of Affective Disorders, 79: 113–126.* 164 Brugha, T.S., Wheatley, S., Taub, N.A., Culverwell, A.,Friedman, T., Kirwan, P., Jones, D.R., & Shapiro, D.A. (2000).‘Pragmatic randomised trial of antenatal intervention to preventpost-natal depression by reducing psychosocial risk factors’.Psychological Medicine, 30(6): 1273–1281.* 165 Buist, A., Westley, D., & Hill, C. (1999). ‘Antenatalprevention of post-natal depression’. Archives of Women’sMental Health, 1(4): 167–173.childbirth education: antenatal education and transitions of maternity care in new zealand159

* 166 Hayes, B.A., Muller, P., & Bradley, B.S. (2001). ‘Perinataldepression: A randomised controlled trial of an antenataleducation intervention for primiparas’, Birth: Issues inPerinatal Care, 28(1): 28–35.* 167 Stamp, G.E., Williams, A.S., & Crowther, C.A. (1995).‘Evaluation of antenatal and postnatal support to overcomepostnatal depression: A randomized, controlled trial’.Birth, 22: 138–143.* 168 Elliott, S.A., Leverton, T.J., Sanjack, M., Turner, H.,Cowmeadow, P., Hopkins, J., & Bushnell, D. (2000).‘Promoting mental health after childbirth: A controlled trial ofprimary prevention of post-natal depression’. British Journal ofClinical Psychology, 39(3): 223–241.169Dennis, C.L., & Creedy, D. (2004). ‘Psychosocial andpsychological interventions for preventing postpartumdepression’. Cochrane Database of Systematic Reviews, Issue4. DOI: 10.1002/14651858.CD001134.pub2.170Dennis, C.E. (2004). ‘Preventing postpartum depressionPart II: A critical review of nonbiological interventions’.Canadian Journal of Psychiatry, 49(8): 526–538.171Kroelinger, C.D., & Oths, K.S. (2000). ‘Partner support andpregnancy wantedness’. Birth, 27(2): 112–119.172Lamb, M.L. (1997). ‘Fathers and child development: Anintroductory overview and guide’. In M.E. Lamb (Ed.), Therole of fathers in child development (3rd ed., pp.1–18).Wiley, New York.173Draper, J. (2002). ‘“It’s the first scientific evidence”: Men’sexperience of pregnancy confirmation’. Journal of AdvancedNursing, 39(6): 563–570.174Nagamori, K., Horiuchi, S., & Ito, K. (2005). ‘Experiences ofexpectant first-time fathers attending small group participativechildbirth education class’. Journal of Japan Academy ofMidwifery, 19(2): 28–38.175Vehvilainen-Julkunen, K., & Liukkonen, A. (1998). ‘Fathers’experiences of childbirth’. Midwifery, 14: 10–17.176Fletcher, R., Silberberg, S., & Galloway, D. (2004). ‘Newfathers’ postbirth views of antenatal classes: Satisfaction,benefits, and knowledge of family services’. The Journal ofPerinatal Education, 13(3): 18–26.177May, K.A., & Perrin, S.P. (1985). ‘Prelude: Pregnancy andbirth’. In S.M.H. Hansen & F.W. Bozett (Eds.), Dimensions offatherhood (pp. 64–91). Sage, Beverly Hills.178Bradley, E., Mackenzie, M., & Boath, E. (2004). ‘Theexperience of first-time fatherhood: A brief report’. Journal ofReproductive and Infant Psychology, 22(1): 45–47.179Hallgren, A., Kihlgren, M., Forslin, L., & Norberg, A. (1999).‘Swedish fathers’ involvement in and experiences of childbirthpreparation and childbirth’. Midwifery, 15(1): 6–15.180Smith, N. (1999). ‘Men in antenatal classes. Teaching “thewhole birth thing”’. Practising Midwife, 2(1): 23–26.181Barclay, L., Donovan, J., & Genovese, A. (1996). ‘Men’sexperiences during their partner’s first pregnancy: A groundedtheory analysis’. Australian Journal of Advanced Nursing,13(3): 12–24.182Galloway, D., Svensson, J., & Clune, L. (1997). ‘Whatdo men think of antenatal classes?’ International Journal ofChildbirth Education, 12(2): 38–41.* 183 Greenhalgh, R., Slade, P., & Spiby, H. (2000). ‘Father’scoping style, antenatal preparation, and experiences of laborand the postpartum’. Birth, 27(3): 177–184.184Burke, S. (1997). ‘Childbirth classroom. Reluctant dads:Getting them involved’. Childbirth Instructor Magazine,7(1): 28–29.185Robertson, A. (1999). ‘Get the fathers involved! Theneeds of men in pregnancy classes’. The Practising Midwife,2(1): 21–22.186Lee, J., & Schmied, V. (2001). ‘Fathercraft. Involvingmen in antenatal education’. British Journal of Midwifery,9(9): 559–561.187Symon, A., & Lee, J. (2003). ‘Including men in antenataleducation: Evaluating innovative practice’. Evidence BasedMidwifery, 1(1): 12–19.188Premberg, A., & Lundgren, I. (2006). ‘Fathers’ experiencesof childbirth education’. Journal of Perinatal Education,15(2): 21–28.189Dieterich, L. (1997). ‘Assessment and developmentof adolescent childbirth education (CBE) to improve healthbehaviours.’ Journal of Perinatal Education, 6(1): 25–33.190Kaiser, M.M., & Hays, B.J. (2005). ‘Health-risk behavioursin a sample of first-time pregnant adolescents’. Public HealthNursing, 22(6): 483–493.191Greenwood, K., & Littlejohn, P. (2002). ‘Breastfeedingintentions and outcomes of adolescent mothers in the StartingOut program’. Breastfeeding Review, 10(3): 19–23.192McVeigh, C. (2002). ‘Teenage mothers: A pilot study’.Australian Journal of Midwifery, 15(1): 26–30.193New South Wales (NSW) Standing Committee on SocialIssues. (1998). Working for children: Communities supportingfamilies. Inquiry into parent education and support programs.New South Wales Government, Sydney.* 194 Covington, D.L., Peoples-Sheps, M.D., Buescher, P.A.,Bennett, T.A., & Paul, M.V. (1998). ‘An evaluation of anadolescent prenatal education program’. American Journal ofHealth Behavior, 22(5): 323–333.160 Families Commission Research Fund

families commission research fund195Koniak-Griffin, D., Mathenge, C., Anderson, N.L., &Verzemnieks, I. (1999). ‘An early intervention program foradolescent mothers: A nursing demonstration project’. Journalof Obstetrics, Gynecology and Neonatal Nursing, 28(1): 51–59.196Honig, A.S., & Morin, C. (2001). ‘When should programsfor teen parents and babies begin? Longitudinal evaluationof a teen parents and babies program’. Journal of PrimaryPrevention, 21(4): 447–454.197Atkinson, A., & Hagfor, S. (2000). ‘Focal point on childbirtheducation: Developing a teen prenatal series that works’.International Journal of Childbirth Education, 15(2): 9–10.198Martis, R. (2004). Teenage and pregnant: An exploratorypilot study of pregnant adolescents and their antenataleducation needs in the Palmerston North Region.Paper presented at the New Zealand College of Midwives,8th Biennial National Conference, 16–18 September 2004,Wellington Convention Centre, Wellington, New Zealand.199Scopesi, A., Zanobini, M., & Carossino, P. (1997).‘Childbirth in different cultures: Psychophysical reactionsof women delivering in US, German, French, and Italianhospitals’. Journal of Reproductive and Infant Psychology,15(1): 9–30.200Raines, D.A., & Morgan, Z. (2000). ‘Culturally sensitive careduring childbirth’. Applied Nursing Research, 13(4): 167–172.201Ottani, P.A. (2002). ‘When childbirth preparation isn’t acultural norm’. International Journal of Childbirth Education,17(2): 12–15.202Johnston-Robledo, I. (1998). ‘Beyond Lamaze:Socioeconomic status and women’s experiences withchildbirth preparation’. Journal of Gender, Culture, and Health,3(3): 159–169.203Berman, R.O. (2006). ‘Perceived learning needs of minorityexpectant women and barriers to prenatal education’. TheJournal of Perinatal Education, 15(2): 36–42.204Paterson, J., Tukuitonga, C., Butler, S., & Williams, M.(2002). ‘Awareness of sudden infant death syndrome riskfactors among mothers of Pacific infants in New Zealand’.New Zealand Medical Journal, 115(1147): 33–35.205Johnson, D., Jin, Y., & Truman, C. (2002). ‘Influence ofaboriginal and socioeconomic status on birth outcome andmaternal morbidity’. Journal of Obstetrics and GynaecologyCanada, 24(8): 633–640.206Ibison, J.M. (2005). ‘Ethnicity and mode of delivery in “lowrisk”first-time mothers, East London, 1988–1997’. EuropeanJournal of Obstetrics, Gynecology and Reproductive Biology,118(2): 199–205.207Beckman, C., Buford, T., & Witt, J. (2000). ‘Perceivedbarriers to prenatal care services’. Maternal Child Nursing,25(1): 43–46.208Ellison-Loschmann, L., & Pearce, N. (2006). ‘Improvingaccess to health care among New Zealand’s Mäori population’.American Journal of Public Health, 96(4): 612–617.* 209 Mehl-Madrona, L.E. (2000). ‘Psychosocial prenatalintervention to reduce alcohol, smoking and stressand improve birth outcome among minority women’.Journal of Prenatal and Perinatal Psychology andHealth, 14(pp. 3–4).210Bhagat, R., Johnson, J., Grewal, S., Pandher, P., Quong, E.,& Triolet, K. (2002). ‘Mobilising the community to address theprenatal health needs of immigrant Punjabi women’. PublicHealth Nursing, 19(3): 209–214.211Nelson, M. (1982). ‘The effect of childbirth preparation onwomen of different social classes’. Journal of Health and SocialBehaviour, 23: 339–351.212Arntz, A., & Schmidt, J.M. (1990). ‘Perceived controland the experiences of pain’. In A. Steptoe & A. Appels (Eds.),Stress, Personal Control and Health (pp. 131–162).Wiley, Chichester.213Robertson, A. (1999). ‘A new approach to antenataleducation’. The Practising Midwife, 2(2): 17–18.214Enkin, M., Keirse, M.J.N.C., Neilson, J., Crowther, C.,Duley, L., Hodnett, E., & Hofmeyr, J. (2000). A guide toeffective care in pregnancy and childbirth (3rd ed.). OxfordUniversity Press, New York.215Dumas, L. (2002). ‘Focus groups to reveal parents’ needsfor prenatal education’. The Journal of Perinatal Education,11(3): 1–9.216Renkert, S., & Nutbeam, D. (2001). ‘Opportunities toimprove maternal health literacy through antenatal education:An exploratory study’. Health Promotion International,16(4): 381–388.217Bingham, D. (2005). ‘Helping hospitals change Part 2:Childbirth education techniques to empower women’. TheJournal of Perinatal Education, 14(3): 51–55.218Nolan, M. (1999). ‘Antenatal education: Past and futureagendas’. The Practising Midwife, 2(3): 24–27.219Lowe, N.K. (2000). ‘Self-efficacy for labor andchildbirth fears in nulliparous pregnant women’. Journal ofPsychosomatic Obstetrics and Gynaecology, 21(4): 219–224.220World Health Organisation. (1998). Health promotionglossary. WHO, Geneva.221McKay, S., Barrows, T., & Roberts, J. (1990). ‘Women’sviews of second-stage labor as assessed by interviews andvideotapes’. Birth, 17(4): 192–198.222Melzack, R. (1984). ‘The myth of painless childbirth’. Pain,19: 321–337.childbirth education: antenatal education and transitions of maternity care in new zealand161

223de Costa, C.M., & Robson, S. (2004). ‘Throwing out thebaby with the spa water?’ Medical Journal of Australia,181(8): 438–440.224Smedley, A. (1999). ‘Do childbirth and early parentingprograms meet the needs of the client?’ International Journalof Childbirth Education, 14(1): 18–21.225Gulland, A. (1998). ‘Life after birth, midwives should beteaching prospective parents about the psychological impactof having a child’. Nursing Times, 94: 20–26.226Harris, M.J. (1990). ‘How much parenting is ahealth responsibility?’ Medical Journal of Australia,153(11&12): 696–698.227Schneider, Z. (2002). ‘An Australian study of women’sexperiences of their first pregnancy’. Midwifery,18(3): 238–249.228Sitrin, A.G. (2001). The impact of the quality of maritaladaptation on prenatal maternal representations and postnatalsatisfaction with social support. Dissertation AbstractsInternational. Section B: The Sciences and Engineering,62(3-B): 1599.229Parr, M. (1998). ‘A new approach to parent education’.British Journal of Midwifery, 6(3): 160–165.230Kelly, S. (1998). ‘Parenting education survey’. RCMMidwives Journal, 1:23–25.231NSW Health. (1998). Five year goals, objectives, andstrategies for maternity services. Discussion paper forcomment. NSW Health, NSW.232Brown, V. (1999). Childbirth education programs inone Australian state: A phenomenological inquiry. Masterof Nursing, The Royal Melbourne Institute of Technology.Ongoing research thesis.233Koehn, M.L. (2002). ‘Childbirth education outcomes: Anintegrative review of the literature’. The Journal of PerinatalEducation, 11(3): 10–19.234Couto, G.R. (2006). ‘Nurses’ conceptualization on childbirthpreparation’. Revista Latino-Americana de Enfermagem,14(2): 190–198.235Nelson, F.A.L. (2006). In the other room: Entering theculture of motherhood. Dissertation Abstracts International.Section A: Humanities and Social Sciences, 66(10-A):3823.236Humenick, S.S. (2000). ‘Letter from the Editor: Theevolution of childbirth educator to perinatal educator.’ TheJournal of Perinatal Education, 9(1): vi–vii.162 Families Commission Research Fund

families commission research fundAPPENDIX 1: The Lamaze philosophy of birth> Birth is normal, natural, and healthy.> The experience of birth profoundly affects women and their families.> Women’s inner wisdom guides them through birth.> Women’s confidence and ability to give birth is either enhanced or diminished by the care provider and place ofbirth.> Women have the right to give birth free from routine medical interventions.> Birth can safely take place in birth centres and homes.> Childbirth education empowers women to make informed choices in health care, to assume responsibility fortheir health, and to trust their inner wisdom.Source: Lamaze International, Inc. (2000). Lamaze philosophy of birth. Lamaze International, Inc. [Online].Available at: http://www.lamaze.org/2000/aboutlamaze.htmlAPPENDIX 2: The Bradley teaching goals or philosophies1. Natural childbirth.2. Active participation by the husband as coach (or thorough preparation of mother’s chosen helper if not marriedor if husband unable to attend).3. Excellent nutrition.4. Avoidance of drugs during pregnancy, birth and breastfeeding, unless absolutely necessary.5. Training, ‘early bird’ classes followed by weekly classes starting in the sixth month and continuing until birth.6. Relaxation and natural breathing.7. ‘Focusing in’ and working with your body in labour.8. Immediate and continuous contact with your new baby.9. Breastfeeding, beginning at birth.10. Consumerism and positive communications.11. Parents taking responsibility for the safety of the birth-place, procedures, attendants and emergency back-up.12. Parents prepared for unexpected situations such as sudden childbirth and caesarean.Source: Bradley, L.P. (1995). ‘Changing America birth through childbirth education’. Patient Education and Counseling, 25: 75-82.childbirth education: antenatal education and transitions of maternity care in new zealand163

164 Families Commission Research Fund

families commission research fundThis report is available on the Commission’s website www.nzfamilies.org.nz or contact the Commissionto request copies.Families CommissionPO Box 2839Wellington 6140Telephone: 04 917 7040Email: enquiries@nzfamilies.org.nzchildbirth education: antenatal education and transitions of maternity care in new zealand165