Proposed Model for

Improving Childbirth Practice

for Adult Parents-to-Be
by Natsai L. Zhou, PhD MSN FNP-BC BSN-RN BA LNC

Keywords: Childbirth educator, Adult learner, Prenatal/Childbirth,

Parents-to-be

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

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

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

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

Natsai Zhou

Abstract: Whether a childbirth educator

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

Proposed Model for Improving Childbirth Practice

continued from previous page

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

The goal of prenatal information is to

allow parents to make informed choices
for themselves for a satisfying childbirth.
Tips to Improve Practice
There is no standardized technique for teaching prenatal
classes. However, the ideal teaching approach is conducive
for learning, keeping in mind that individuals have different
learning styles. Visual, auditory and kinesthetic approaches
can be implemented. In addition, the presentation does not
have to follow a traditional school room format, but can

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

Adult as a Learner
Since it has been established that most participants in
the prenatal classes are likely to be adults who come with
lived experiences, and have different issues revolving around
them, an andragogy approach to teaching prenatal classes
is recommended. Andragogy is a strategy that focuses on
teaching adults. Knowles (1980) conceived the andragogy
model based on the idea that adult education requires a
unique way of teaching. Knowles (1980) assumed that:
Adults are independent or self-directed learners.
They have vast experiences that can be used as a foundation to learning.
Their readiness to learn is related to the developmental
tasks of social roles.
Their time and course perspectives are immediacy of application and are performance-centeredness.
Using this model as a foundation might facilitate learning of information to adult parents-to-be, and decrease
challenges that might be faced by the prenatal educator. Adult learners come with unique characteristics. For
instance, adults feel that they need to know why they should
learn something, therefore, for them learning is based on
what they perceive as beneficial (Knowles, 1996). In addition, Knowles (1996) acknowledged that adult learners have
a deep need to be self-directing, be responsible for making
their own decisions and being in charge. Therefore, prenatal education can incorporate as much self-discovery and
involve as many options for learning as possible (Knowles,
1996).
Adult learners bring into the learning environment
a background of life experience that affects the way they
learn. Adults have a broader base of experience on which to
attach new ideas and skills and give them richer meaning.
Childbirth education activities can be designed to reflect the
skills that can actually be performed by the parents. These
activities can permit parents-to-be to be able to compare the
theoretical models with the expected experiences (Knowles,
1996). The more explicit these skills are made through
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Proposed Model for Improving Childbirth Practice

continued from previous page
discussion and reflection, the deeper, meaningful, and more
permanent the learning will be (Knowles, 1996). Openended questions can be used to draw out any knowledge and
experiences the parents-to-be might have. This will honor
any experiences and values they bring.
Adult learners enter into a learning experience with a
task-centered, problem-centered, or life-centered orientation to learning (Knowles, 1996). Although childbirth might
be the most important thing in their lives during pregnancy,
it is surrounded by demanding events such as jobs and
other family and social roles. Therefore, prenatal education information is provided in a manner that is more than
just knowing the information, but providing how and when
it is applied, and whether it will take care of the issue at
hand. Research has revealed that if education does not have
specific results in mind or does not lead to expected results,
mothers tend to drop out of childbirth classes (Morton &
Hsu, 2007).
Adult learners become ready to learn when life situations bring a need to know in order to perform more effectively and satisfyingly (Knowles, 1996). Childbirth education
emphasizes the critical importance of the womans own
emotional response to her labor and birth; with the goal that
she remembers it as a satisfying experience (Morton & Hsu,
2007). Childbirth education can then relate or apply directly
to the parents perceived needs, be timely, cost effective, and
appropriate for their current lives, beliefs and values.

Rationale for Practice

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

Based on the content to be taught, every identified issue

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

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

Literacy
Not every parent-to-be will have the same education
background. In addition, even those with high level of
education will not necessarily have healthcare education,
let alone prenatal education. In any case, no matter how
educated one is, when one is a new parent, childbirth is
new territory due to lack of exposure to the experience.
Knowledge deficit in prenatal education is not only related
to those with limited cognition, but applies to everyone, and
therefore during prenatal classes, childbirth educators have
to be careful to avoid jargon. Parents-to be will already be
overwhelmed with the unknown, anticipation, and expectations, therefore prenatal education should accommodate
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Volume 28 Number 2 April 2013 | International Journal of Childbirth Education | 27

Proposed Model for Improving Childbirth Practice

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

Socioeconomic Status

Natsai Zhou

Childbirth educators should also keep in mind that

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

Most important is the observation of the mothers pain

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

Cultural Differences: Personal Beliefs

and Values
Immigrant populations in the US are growing at a fast
pace and births in the US account for a national population
increase of 2.3 million people per year (Camarota, 2005). It
is therefore, likely that prenatal classes are also increasingly
becoming culturally diverse. In addition to culture, classes
will also consist of individuals with personal and spiritual
beliefs and values on childbirth. Therefore, to inspire and
provide prenatal knowledge, childbirth educators have to
consciously set aside any personal judgment about choices
parents-to-be make, avoid stereotyping, and make and incorporate cross-cultural approaches. Leininger (1991) identified
some healthcare decision and action modes that achieve
culturally congruent healthcare.
Cultural preservation or maintenance.
Cultural care accommodation or negotiation.
Due to diversity, some parents-to-be might feel uncomfortable being in cross-cultural prenatal classes related to perceived threat to their own value system, or receiving multiple
sources of information that can lead to clouding personal
values, beliefs, and moral obligations (NANDA, 2013).
Therefore it is crucial that childbirth educators incorporate
cultural competence, be aware of differences, promote and
maintain individuality, spiritual well-being, and allow and
accommodate for personal or traditional non-medical approaches such as use of doulas and breast feeding.

When teaching prenatal or childbirth education classes,

childbirth educators need to consider that the class will
mostly likely be comprised of:
First time parents-to-be.
Adult learners with different learning needs.
Adult learners with vast experiences and social challenges
Culturally diverse participants in need of sensitivity.
When prenatal care education is taught, keeping in
mind that the learner is an adult with personal characteristics
and needs, childbirth educators can empower parents-to-be
to make their own choices about childbirth. It is important
for childbirth educators to examine their own perceptions
about personal values within the framework of individuals and families. It is also crucial for childbirth educators to
provide efficient and practical education, with all options
that afford the parents-to-be to make appropriate choices
and experience satisfying births.

continued on next page

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

Proposed Model for Improving Childbirth Practice

Leininger, M. (1991). Culture care diversity and universality: A theory of

nursing. New York: National League for Nursing Press.

continued from previous page

Morton, C. H. & Hsu, C. (Fall, 2007). Contemporary dilemmas in American

childbirth education: findings from a comparative ethnographic study. Journal of Perinatal Education, 16(4), 2537. doi: 10.1624/105812407X245614

References
Baby Center. (2012). Childbirth classes. Retrieved from http://www.babycenter.com/0_childbirth-classes_161.bc
Bessett, D. (n.d.). Defining the normal pregnancy: Knowledge, emotion,
and embodied experience of women in stratified reproduction (Dissertation
in progress, Department of Sociology, New York University).
Camarota, S. (2005). Birth rates among immigrants in America: Comparing
fertility in the U.S. and home countries. Washington, DC: Center for Immigrant Studies. Retrieved from http://www.cis.org/articles/2005/back1105.pdf
Health Leader Media. (2010). Evidence-based practice and nursing research:
avoiding confusion. Retrieved from http://www.healthleadersmedia.com/
print/NRS-245879/EvidenceBased-Practice-and-Nursing-Research-Avoiding-Confusion
International Journal of Childbirth Education. (2008). ICEA position paper:
The role of the childbirth educator and the scope of childbirth education.
International Journal of Childbirth Education, 22(4), 34-42.
International Journal of Childbirth Education. (2010). Guidelines. Retrieved
from http://www.icea.org/documents/certET1.pdf.
Knowles, M. S. (1980). Modern practice of adult education: From pedagogy
to andragogy. Revised and updated. Chicago: Follett Publishing Company,
Association Press.
Knowles, M. (1996). Adult learning. In Robert L. Craig (Ed.), The ASTD
training and development handbook (pp. 253-264). NY: McGraw-Hill.

American College of Nurse-Midwives (ACNM). (2013) Retrieved from

http://mymidwife.org
North American Nursing Diagnosis Association (NANDA). (2013). NANDA
nursing diagnosis list. Retrieved from http://www.nandanursingdiagnosislist.
org/
Rochester Institute of Technology. (2013). Adult learner. Retrieved from
http://online.rit.edu/faculty/teaching_strategies/adult_learners.cfm
Schultz, J. M., & Videbeck, S. L. (2009). Lippincotts manual of psychiatric
nursing care plans: Manual Psychiatric Nursing Care (8th ed.). Philadelphia,
PA: Lippincott Williams & Wilkins.

Dr. Natsai L. Zhou is a Family Nurse Practitioner who co-owns

a family practice clinic. She is an adjunct faculty at the University of Phoenix teaching undergraduate and graduate nursing
and healthcare students. Natsai sits on the Advisory Board of
Breckenridge School of Nursing. She is also a board member in a
non-for-profit organization (Zimcouncil) that leverages Zimbabweans in diaspora, health, and education resources to improve
the quality of life of citizens in Zimbabwe.

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