Correspondence:
Eleanor Holroyd,
Department of Nursing,
630 Esther Lee Building,
Chung Chi College,
Chinese University of Hong Kong,
Shatin,
Hong Kong,
China.
E-mail: eholroyd@cuhk.ed.hk
Introduction
Formal and informal antenatal education has a long
history. In earlier times, women were prepared informally
for childbearing and childrearing by coresiding with
extended family members such as aunts and grandmothers
(Lindell 1988, Liu-Chiang 1995, Nolan 1997). Formal
antenatal education began in western countries in a
response to a need to improve antenatal care and
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Antenatal education
Recent research has attempted to assess the effectiveness of
antenatal education in preparing women for pregnancy,
birth and childcare, but the evidence has been inconclusive.
Research has focused on evaluating antenatal education in
terms of maternal satisfaction using such measures as
increased knowledge and reduced anxiety (Hibbard et al.
1979, Redman et al. 1991, Bechelmayr 1995) or measuring
obstetric outcome (Lumley & Brown 1993, Sturrock &
Johnson 1990). While sound educational outcomes have
been reported following antenatal classes, it is not clear
whether these outcomes could be attributed to the knowledge that the women brought with them to classes, or
whether the knowledge acquired during classes reflected
their effectiveness in preparing women for the postnatal
period.
International studies have indicated that antenatal classes
prepare women for birth but not for the social role
expectation of parenting (Hillan 1992, OMeara 1993a,
Fichardt et al. 1994, Nolan 1997). In these studies the most
consistent criticism has been that the syllabus did not
prepare women in particular for baby care and motherhood.
With respect to the structure of the classes, numbers
attending were another important element (OMeara
1993a, 1993b), particularly the perception that hospitalrun classes were too large for effective questioning and
discussion. In addition, childbirth educators were
highlighted as not seeking appropriate feedback from
participants.
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I. Ho and E. Holroyd
The study
The objectives were:
to describe the structure and process, including content and
modes of teaching, of the antenatal classes that pertain to
motherhood;
to examine retrospectively Hong Kong Chinese womens
perceptions of the effectiveness of the classes in preparing
them for motherhood in the first postpartum month;
to identify specific directions for further development of
antenatal education in Hong Kong and to make recommendations for midwives working with Chinese clients.
Methods
An exploratory descriptive design was employed using qualitative methodology encompassing observations and focus
group interviews.
Sampling
The sample for the observation of classes was a total
sample of all participants (women and their partners/
relatives) attending the five sessions on the topic of
motherhood (see Table 1). Purposive sampling was used
for the focus groups. All women attending at least four of
the five designated sessions on preparation for motherhood
at a specific hospital-based antenatal education programme
were approached and asked if they would participate in a
focus group interview following the birth of their baby.
The inclusion criteria included married primiparous
women and those who had delivered a healthy baby
(3842 weeks gestation) with no diagnosis of neonatal
complications except neonatal jaundice, as well as not
having had any medical complications during the postpartum. Husbands were not included in the focus groups
as Hong Kong husbands seldom attend the majority of
antenatal classes.
Ethical considerations
Ethical approval was obtained from ethics committees of
both the university and hospital concerned. All participants
were assured of confidentiality regarding information-giving,
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Speaker
Midwife/anaesthetist
Social worker/psychiatrist
Midwife/obstetrician
Midwife
Midwife
Midwife/lactation consultant
Paediatrician
Midwife/obstetrician
Findings
The ages of women in both focus groups ranged from 24 to
35 years with a mean of 30 years. All women were married
and first time mothers. Ten participants had completed
secondary education and one had completed tertiary education. The range of total family income was between HK
$19 000 to 40 000. In summary, focus groups members
consisted of women who had higher education levels and a
higher median household income than the average Hong
Kong population (HK Population Census & Statistics
Department 1996). The mode of delivery for nine mothers
was normal vaginal delivery, while the other two had had an
emergency cesarean section. All women had attended at least
four out of five classes, but six did not attend the class on
management of emotional problems.
Findings from both the focus group and observational data
fell broadly into two common themes of structure and
process of the classes. Within these themes were further
subcategories including unfavourable learning environment,
lack of culturally relevant material, length of the classes,
predicting personal need for antenatal preparation for motherhood, feeling prepared physically and emotionally for some
demands of motherhood, unrealistic preparation for breastfeeding problems, inadequate preparation for baby care,
unfulfilled informational needs, and conflicting advice from
different professionals.
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I. Ho and E. Holroyd
All women were dissatisfied with the class size and physical
arrangement of the room. Furthermore, in all classes the
microphone was not functioning properly and emitted a
great deal of vibrations. It was further observed that the
display board captions were too small for attendees at the
back to read, and the use of flip charts for illustration was
too quickly delivered, suggesting that attendees were unable
to absorb the message in time. Problems such as not being
able to see and hear, having difficulty in asking questions and
the perception that personal problems were not adequately
addressed were reported in the focus groups, a finding
further repeated in international and Hong Kong literature
on antenatal education (Lindell 1988, OMeara 1993c,
Wong 1998).
A large class size is incongruent with the principles of
adult education and does not allow the use of experience
as a resource for learning (Burns 1996). An alternative
option would be to bring prospective parents together in
small groups to enhance the sharing of information,
exchange of views and validation of feelings, and to
enable interactive learning (Knowles 1984). Adults in most
cultures need to feel that they have some control over their
education, and the ability to develop coping strategies
which are informed by and therefore applicable to their
own personal and social situations (Nolan & Hicks 1998).
Internationally participants in small antenatal education
groups tend to report feeling more satisfied (Lindell 1988,
Rees 1996).
Lack of cultural relevance in audiovisual aids used
The use of audiovisual aids seemed to help to stimulate the
interests of attendees. Antenatal educators should, however,
consider the relevance of some of audiovisual aids used.
Although all women agreed that visual aids could help to
arouse their interest, some commented on a specific lack of
cultural relevance, saying that the videos were about the
practice and feelings of Westerners and they felt that this did
not apply to their situation. A mother who was not
successful in breastfeeding her baby strongly expressed the
78
It was observed that the antenatal educators did not hand out
their lecture notes; instead only a few pamphlets (for
example, on breastfeeding, nutrition during pregnancy) were
distributed. Most mothers said that written notes should be
available to reinforce their knowledge because they found it
difficult to remember all the information. This was summed
up in the following comment:
It could be better to have some notes to refer after the talk. Even if I
forget the content, I could read the materials so as to reinforce my
memory.
Such unfavourable comments about some of the midwifeeducators suggest that a lack of knowledge or previous
experience rendered these professional educators unable to
provide plausible information (Nunnerley & Deane-Gray
1988). Limitations of the teaching approach by antenatal
educators previously found in the international literature
included inadequate identification of the needs of groups,
inadequate grasp of the topic taught, ineffective teaching,
poor staff relationships and lack of flexibility (Murphy-Black
1990). Although midwives have been recognized for many
years as having a vital role in teaching, there has been little
educational preparation for this role.
Not every educators performance was satisfactory. Several
mothers stated that they talked very quickly and explained
things inadequately. One woman complained:
I thought any person was better than that paediatricianhe didnt
explain his lecture as if his information given was too high level for
usI honestly felt that I shouldnt attend this talk, he was not serious
at all.
Although women value different inputs from expert professionals, fulfilling individualized needs is considered of great
importance in adult education. Current Hong Kong hospitalbased antenatal education does not address individual needs
and tends to underestimate the clients role in health education (Perkins 1980). While planning antenatal education is
mainly based on the perceptions of professionals, it may not
satisfy the needs of all women (Robertson 1997). Successful
antenatal education should empower women to decide their
own needs.
Furthermore, when the programme is controlled by professionals, couples are less likely to play an active part in their
own learning. In Asia, a cultural expectation is that the
greater the perceived power of the professional and the more
impressive the technological apparatus, the more likely the
couple is to accept the professionals control of the encounter
and not make much effort to learn (Rothman 1996).
Midwives are far better placed than doctors to undertake
antenatal education for Chinese and other Asian populations
precisely because the public perception of their power is less
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I. Ho and E. Holroyd
All women described attending classes as a type of insurance, enabling them to feel more secure. The high attendance
rate showed that the classes were welcome by many prospective parents in particular first time parents. Women were
generally satisfied with the Saturday afternoon arrangement
for the classes, which enabled both partners to attend.
concerns, several felt that the talk was too theoretical and did
not prepare them for managing the complexity and realistic
demands of motherhood. While participants were sharing
their experience on social support, one participant suddenly
cried about the profound difficulties she had experienced in
mothering. She commented that the educators over-estimated
the potential help offered by partners and individual cases
were not addressed:
I was not very impressed about the talk. I felt the division of labour
was never fair and I could not cope with itThe talk was very
theoretical, the educator told us to seek help, but no matter how hard
I cried for help, there was nobody available to help me.
I regretted not attending the talk because I was very badly emotion-
enough, he was just too tiredSo I went to steal a bottle for him.
make sure how much milk the baby got every time. My mother inlaw always told me that I might not have enough milk for the baby.
She discouraged me to breastfeed.
I tried breast feeding for more than 10 days, I failed because of not
prepare for this, not only for breastfeeding. They should mention
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I. Ho and E. Holroyd
Mothers in both groups were also frightened by bloodstained discharge from the umbilical cord and complained
that the management of the cord was not taught in detail. A
29-year-old clerk in the second focus group said that:
There was blood stained discharge in the nappyI guessed the cord
stump was infected. I was very frightened,but this was not taught
in the antenatal education programme.
There is a tension between what postnatal women retrospectively see as important and what educators believe they
should be taught. Such a finding has also been documented in
other studies (Hillan 1992, OMeara 1993a). The chief
implication of this concern is the importance of organizing
learning experiences around life situations rather than
82
Furthermore, women were confused about the suture material used for the episiotomy and the reason for persistent pain
from the episiotomy wound. The perception of unfulfilled
informational needs again resulted from too much information given within a limited time. Concentration spans vary in
individuals, and some adult learning theorists claim that after
15 minutes didactic lectures become an ineffective mode of
communication (Jarvis & Gibson 1997). This may explain
why all participants felt that they could only remember about
one third of the information given. All women in the group
complained that certain knowledge had not been taught. This
is in contrast to the observational data, which revealed that
the curriculum had been covered but in a rather superficial
manner.
Study limitations
This study was based on observation of a series of five
sessions from one antenatal education programme at one
hospital and two focus groups involving a total of 11 women.
A clear limitation of the study was the small sample size and
the fact that it was chosen only from one public hospital.
Considering the size and variability of the population of
pregnant women, the information obtained in this study can
only represent the perceptions of a small group of women in
Hong Kong and is not generalisable.
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I. Ho and E. Holroyd
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Becoming a mother- an analysis of womens experience of early
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