Characteristics of Swedish women who do not attend childbirth and parenthood education classes during pregnancy

doi:10.1016/j.midw.2004.01.003

Midwifery

Volume 20, Issue 3, September 2004, Pages 226-235

https://doi.org/10.1016/j.midw.2004.01.003 Get rights and content

Abstract

Objective:

to investigate the attendance rate at childbirth and parenthood education classes during pregnancy in a national Swedish sample and describe the characteristics of women who did not attend.

Design:

a cohort study utilising a postal questionnaire in early pregnancy and at 2 months after birth.

Setting:

women were recruited from 97% of all antenatal clinics in Sweden at their first ‘booking’ visit during three different weeks spread over 1 year in 1999–2000.

Participants:

2546 women, who were 77% of those who consented to participate in the study and 55% of all women eligible for the study.

Measurement and findings:

most primiparous women (93%) attended classes and the majority of the multiparae (81%) did not. Having a native language other than Swedish was associated with non-attendance in both primiparae and multiparae (OR 2.7, 95% CI 1.3–5.4; OR 2.1, 95% CI 1.4–3.1). In addition, the following factors were associated with non-attendance in the primiparae: unemployment (OR 2.0, 95% CI 1.1–3.8), smoking during pregnancy (OR 2.7, 95% CI 1.2–5.8), having considered abortion (OR 4.3, 95% CI 1.2–16.1), and having had few antenatal check-ups (OR 2.0, 95% CI 1.1–3.7). The following factors were associated with non-attendance in the multiparae: age older than 35 years (OR 1.6, 95% CI 1.1–2.3), low level of education (OR 3.6, 95% CI 2.3–5.7), and pregnancy unplanned but welcome (OR 1.5, 95% CI 1.1–2.0), having had counselling because of fear of childbirth (OR 1.6, 95% CI 1.1–2.4), and expressing a need of such counselling (OR 1.9, 95% CI 1.1–3.1).

Key conclusions:

the childbirth and parenthood education programme reached the majority of pregnant women, and that non-attendees were more disadvantaged in terms of socio-demographic background and feelings about the approaching birth. These women should be given special attention during the antenatal check-ups so that childbirth and parenthood education could be adapted to their specific needs.

Introduction

Swedish childbirth and parenthood education classes aim to prepare expectant parents for labour and delivery and for their new life with a newborn baby. The classes also aim to facilitate the communication and sharing of experiences between expectant and new parents (SOU, 1997:161). The political intention was to give expectant parents a social network for support and help during the transition to parenthood as a compensation for decreasing support and help from the older generation in the modern society (SoS Report, 1996:7). In 1979, a Swedish national commission recommended childbirth and parenthood education classes as an option for all pregnant women and their partners. The suggested number of sessions was eight to 10, and the number of expectant parents in each class eight to 12 (SOU, 1978:5). This reform was allocated special funding, and the National Board of Health and Welfare was given the responsibility to initiate the training of midwives and other health personnel at the antenatal clinics that provide the services (SoS Report, 1984:12). The parents’ allowance also changed in order to compensate for loss of income when attending classes during regular working-hours (SOU, 1978:5).

The major part of the childbirth and parenthood education was organised by the midwives at the antenatal clinics. Since the first classes started more than 20 years ago, the financial problems in the health care sector have forced many clinics to restrict their invitation to first-time parents (SOU, 1997:161). In 1994 and 1997, national surveys of antenatal clinical practices in Sweden showed that about 92% of first-time parents attended childbirth and parenthood education classes, but only 20% of the multiparous women attended. However, some antenatal clinics offered separate classes for multiparae, and for expectant parents who may have special needs, such as those with diverse cultural backgrounds, young parents, single mothers, and couples expecting twins. Some clinics also provided separate classes for expectant fathers (Clinical Guidelines, 1996; SoS Report, 1996:7; Ds, 1997:6). Besides the childbirth and parenthood education classes some clinics offer counselling to women who fear childbirth.

No comprehensive evaluation, which includes a description of the women who are not reached by the programme, of the childbirth and parenthood education programme has been conducted in Sweden. Studies in other countries have reported reasons, such as practical difficulties with transport, location of the classes, inconvenient timing (Cliff and Deery, 1997), insufficient time and no need for additional information (Redman et al., 1991), for not attending antenatal education classes. Non-attendees were younger, less well educated (Sturrock and Johnson, 1990; Redman et al., 1991; Lumley and Brown, 1993; Nichols, 1995; Cliff and Deery, 1997), of lower socio-economic status (Sturrock and Johnson, 1990; Redman et al., 1991; Lumley and Brown, 1993; Cliff and Deery, 1997), and they more often rated their mothers, sisters and friends as helpful during pregnancy and birth compared to attendees (Lumley and Brown, 1993).

The study reported here investigated the attendance rate at childbirth and parenthood education classes during pregnancy in a national sample of Swedish-speaking women and describes the characteristics of the non-attendees.

Section snippets

Methods

This study is part of a longitudinal investigation of women's experiences with childbirth. The Regional Research and Ethical Committee at the Karolinska Institutet, Stockholm, Sweden (Dnr 98-358) approved the study. Women were recruited from all antenatal clinics in Sweden during 3 weeks evenly spread over 1 year (May, September 1999 and January 2000). All midwives providing antenatal care in Sweden were informed of the study via written information and by an advertisement in the Swedish

Findings

A total of 593 antenatal clinics (97%) chose to participate in the study. Seven withdrew because of other ongoing studies, and eight reported heavy workload as reason for not participating. The total number of women ‘booked’ for antenatal care in Sweden during the three weeks of recruitment was approximately 5500, an estimation based on data from the National Medical Birth Register. Of these women, 4600 were eligible for the study after excluding women with miscarriages (275), non-Swedish

Discussion

A limitation of this study was that non-Swedish speaking women were excluded. Having a native language other than Swedish, but mastering the language well enough to participate in this study, was associated with a doubling of the risk of not attending classes. We do not know how many of the non-Swedish speaking women who were excluded from this study had participated in antenatal education. We have no information about the number of classes given in other languages, but we know that this option

Conclusion

In conclusion, the Swedish childbirth and parenthood education programme reaches a large majority of Swedish women but 7% of primiparous women did not attend classes. Non-attendees of childbirth and parenthood education were identified in this study by socio-demographic characteristics and by their feeling about their approaching birth. If we want to tailor the education for these groups, it may be necessary to take a different approach. Fear of childbirth deserves special attention. Moreover,

Acknowledgements

The authors gratefully acknowledge the women who participated in this study. This study was funded by the Vardal Foundation, the Swedish Research Council, the Karolinska Institutet, and the Health Care Sciences Postgraduate School in Sweden.

References (28)

D. Cliff et al.
Too much like schoolsocial class, age, marital status and attendance/non-attendance at antenatal classes
Midwifery
(1997)
A. Jacoby
Mothers’ views about information and advice in pregnancy and childbirthfindings from a national study
Midwifery
(1988)
P. Rautava
The Finnish family competence studycharacteristics of pregnant women with low childbirth knowledge
Social Science and Medicine
(1989)
Clinical Guidelines for Health Care During Pregnancy, 1996. National Board of Health, Welfare, 15 October 1996, Sweden...
J.L. Cox et al.
Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale
British Journal of Psychiatry
(1987)
H.T. Davies et al.
When can odds ratios mislead?
British Medical Journal
(1998)
Ds, 1997:6. Parental Support. Survey of Parental Education. Department of Health, Sweden (in...
S. Georgsson Öhman et al.
Women's worries during pregnancytesting the Cambridge worry scale on 200 Swedish women
Scandinavian journal of Caring Sciences
(2003)
J.D. Hutton et al.
Sociological aspects of attenders and non-attenders of antenatal classes
New Zealand Medical Journal
(1982)
M. Knott et al.
Help or hindrance? Single, unsupported mothers’ perceptions of health visiting
Journal of Advanced Nursing
(1999)

H.-F. Lee et al.

Childbirth education classes. Understanding patterns of attendance

Birth Issues

(1997)

J. Lumley et al.

Attenders and nonattenders at childbirth education classes in Australiahow do they and their births differ?

Birth

(1993)

S. Michie et al.

Cognitive predictors of attendance at antenatal classes

British Journal of Clinical Psychology

(1990)

D. Murray et al.

Screening for depression during pregnancy with the Edinburgh Postnatal Depression Scale (EPDS)

Journal of Reproductive and Infant Psychology

(1990)

Cited by (55)

Antenatal care for Somali-born women in Sweden: Perspectives from mothers, fathers and midwives
2019, Midwifery
To explore Somali-born parents’ experiences of antenatal care in Sweden, antenatal care midwives’ experiences of caring for Somali-born parents, and their respective ideas about group antenatal care for Somali-born parents.
Eight focus group discussions with 2–8 participants in each were conducted, three with Somali-born mothers, two with fathers and three with antenatal care midwives. The transcribed text was analysed using Attride-Stirling’s tool “Thematic networks”.
Two towns in mid-Sweden and a suburb of the capital city of Sweden.
Mothers (n = 16), fathers (n = 13) and midwives (n = 7) were recruited using purposeful sampling.
Somali-born mothers and fathers in Sweden were content with many aspects of antenatal care, but they also faced barriers. Challenges in the midwife-parent encounter related to tailoring of care to individual needs, dealing with stereotypes, addressing varied levels of health literacy, overcoming communication barriers and enabling partner involvement. Health system challenges related to accessibility of care, limited resources, and the need for clear, but flexible routines and supportive structures for parent education. Midwives confirmed these challenges and tried to address them but sometimes lacked the support, resources and tools to do so. Mothers, fathers and midwives thought that language-supported group antenatal care might help to improve communication, provide mutual support and enable better dialogue, but they were concerned that group care should still allow privacy when needed and not stereotype families according to their country of birth.
ANC interventions targeting inequalities between migrants and non-migrants may benefit from embracing a person-centred approach, as a means to counteract stereotypes, misunderstandings and prejudice. Group antenatal care has the potential to provide a platform for person-centred care and has other potential benefits in providing high-quality antenatal care for sub-groups that tend to receive less or poor quality care. Further research on how to address stereotypes and implicit bias in maternity care in the Swedish context is needed.
First-time fathers experiences of their prenatal preparation in relation to challenges met in the early parenthood period: Implications for early parenthood preparation
2017, Midwifery
to describe first-time fathers experiences of their prenatal preparation in relation to challenges met in the early parenthood period.
a qualitative study was conducted and data was analysed with a phenomenographical approach.
15 first-time fathers were recruited from three postnatal units in southern Sweden and interviewed approximately one month after their baby was born.
three categories and 14 conceptions about fathers’ experiences of their preparation emerged from the data. ‘Acquiring knowledge and forming realistic expectations’ was essential for ‘Developing strategies’ and ‘Being facilitated and supported’ enhanced these processes.
supporting fathers to develop strategies for life with a new baby and providing expert guidance to fruitful and accurate information may help the construction of a fatherhood identity and strengthen the fatherhood role. The findings can be used to develop a parental preparation for early parenthood that will correspond to fathers’ needs.
Early prenatal interview and antenatal education for childbirth and parenthood: Associated psychosocial and obstetric characteristics in women of the ELFE cohort
2016, Journal de Gynecologie Obstetrique et Biologie de la Reproduction
L’entretien prénatal précoce (EPP) propose d’identifier les besoins des couples en matière de santé physique et psychique et d’apprécier leur environnement social en période périnatale. La préparation à la naissance et à la parentalité (PNP) propose une démarche d’éducation pour la santé. L’objectif de notre étude était d’identifier les caractéristiques psychologiques, sociodémographiques et obstétricales indépendamment associées au fait d’avoir bénéficié : (i) d’un EPP ; (ii) d’une PNP.
Des analyses multivariées ont été réalisées à partir de données collectées lors du séjour en maternité des mères des nouveau-nés inclus dans la cohorte Étude longitudinale française depuis l’enfance (ELFE), étude en population générale française d’une cohorte d’enfants suivis de la naissance jusqu’à l’âge adulte.
Parmi les 14 595 mères, 33 % avaient bénéficié d’un EPP et 52 % d’une PNP. Les mères primipares, nées en France, de niveau éducatif élevé, en situation d’emploi, ou déclarant des difficultés psychologiques, ont plus souvent bénéficié d’un EPP et/ou d’une PNP. Les mères jeunes, bénéficiant de la CMU, ambivalentes quant à leur grossesse, ayant moins de 7 visites prénatales et présentant des complications obstétricales suivaient moins fréquemment la PNP.
L’EPP et la PNP concernent préférentiellement des populations de bon niveau sociodémographique. Ils devraient être intégrés à un système de prévention et de soins élargis afin de concerner les populations les plus vulnérables, et de participer à l’amélioration de l’environnement psychologique et social de toutes les femmes en période périnatale.
Early prenatal interview (Entretien prénatal précoce [EPP]) is aimed at defining with couples their physical, psychological and social needs during perinatal period. Antenatal education for childbirth and parenthood (Préparation à la naissance et à la parentalité [PNP]) is aimed at promoting global perinatal health. The objective was to identify the psychological, demographic and obstetrical characteristics independently associated with participation in: (i) an EPP; (ii) a PNP.
Multivariate analyses were applied to data collected during the maternity stay of mothers whose children were included in the French cohort French Longitudinal Study since the Childhood (ELFE), a nationally representative cohort of children followed-up from birth to adulthood.
Among the 14,595 mothers of the sample, 33% had an EPP and 52% a PNP. Primiparous mothers, born in France, with high educational level, employed or unemployed, with psychological difficulties more often benefit from EPP and/or PNP. Women who were young, benefiting from free health insurance (Couverture Maladie Universelle [CMU]), with unplanned pregnancy, with less antenatal care and obstetrical complications less often benefit from PNP.
The EPP and the PNP reach high sociodemographic level populations. They should be integrated into a wider system of prevention and care, in order to reach the most vulnerable populations and to contribute to the improvement of the psychological and social environment of all the women during the perinatal period.
Challenges and benefits of conducting parental classes in Sweden: Midwives' perspectives
2015, Sexual and Reproductive Healthcare
Citation Excerpt :
This was difficult at small clinics, but easier to manage when services were situated together or when there were professionals who developed their skills in managing groups with specific characteristics [22,23]. The current system does not seem to fulfil its goal to reach all parents [6]. The midwives seemed to realise this and tried to compensate for those not attending by covering topics during regular antenatal visits or accompanying some pregnant women to the maternity ward.
There is lack of knowledge regarding antenatal care midwives' perspectives concerning parental classes provided during pregnancy, and this study aimed to explore midwives' experiences and thoughts about these parental class activities.
Twenty-six semi-structured, individual, telephone interviews were carried out with midwives at antenatal clinics across Sweden, and the data were analysed using systematic text condensation (STC).
The midwives noted that parental classes were a demanding task, and they appeared to lack the confidence and skills required to manage the classes. They expressed a “need for collaborators to achieve the objectives” (theme 1). The midwives felt that “creating new networks is most valuable for parents” (theme 2), and they were also “striving to give the ‘whole picture’ to both parents” (theme 3), i.e. looking beyond just the delivery. Although they had the ambition, midwives realised it was “not possible to reach all” (theme 4).
Organisational resources as well as developing skills to lead groups are imperative for midwives to fulfil the goals of the parental classes. The midwives are aware that they cannot reach all parents with the group format; thus, it is important to acknowledge the needs of minority populations and develop multidisciplinary collaborations to be able to better address their needs.
Women's experiences of dietary advice and dietary changes during pregnancy
2013, Midwifery
Citation Excerpt :
In Sweden most primiparous women attend antenatal classes. Factors such as having a language other than the usual, unemployment, smoking, unplanned pregnancy, and fewer antenatal checkups are associated with non-attendance (Fabian et al., 2004; Cliff and Deery, 1997). Most of the participants were Swedish citizens and were well educated, many with a university degree.
to describe women's experiences of dietary information and the change of dietary habits during pregnancy.
a qualitative design was used. In 2007 we conducted six focus group interviews using open-ended questions.
five rural and city antenatal clinics in northern Sweden were included
twenty-three women in mid-pregnancy participated in groups of three to seven
three domains were found ‘Dietary information gain’, ‘Reactions to dietary information’ and ‘Dietary management’. The women had to discover dietary information by themselves, and only when health problems or symptoms occurred did they receive guidance from the midwife. Their reactions to the dietary information were ‘being confused’, ‘feeling fear and guilt’ and ‘being monitored’, summed up in ‘being uncertain’. The diet was managed by ‘checking food content’, ‘following bodily signals’, ‘using common sense’, and ‘making exceptions’, summed up as ‘being responsible but with a pinch of salt’.
the women expressed problems with dietary changes, but they could mostly manage them on their own. The pregnant women experienced that the midwives gave dietary information and advice first when problems arise. When struggling with diet, the women experienced confusion, and they had to seek information by themselves.
sources of information about diet during pregnancy were experienced as inconsistent and contradictory. Midwives are important in motivation for healthy lifestyle during pregnancy and with sufficient dietary knowledge and counselling skills they can help pregnant women effect dietary changes by providing guidance and support in early pregnancy.
Mental training during pregnancy. Feelings and experiences during pregnancy and birth and parental stress 1year after birth - A pilot study
2012, Sexual and Reproductive Healthcare
Background: Parental stress has been recognized as a problem despite governmental support of parent education programs aiming to prepare parents for parenthood.
Aim: to compare parents who underwent a mental training program during pregnancy with a control group to measure feelings and experiences during pregnancy and birth and perceived parental stress.
Methods: A comparative pilot study of 46 self-selected parents who underwent a mental training program during pregnancy, and 1408 parents living in the same catchment area (control group). Data was collected in mid-pregnancy, 2 months and 1 year after birth. The main outcome was parental stress.
Results: Parents in the mental training group were more often expecting their first baby and had a higher level of education compared to parents in the control group. Parents participating in the mental training program had less positive feelings about expecting a baby (OR 14.0; 6.7–29.3), the upcoming birth (OR 2.0; 1.1–3.8) and the newborn baby (OR 3.1; 1.6–6.2). Parents who attended the mental training program attended an antenatal parent education to a higher degree (OR 2.0; 1.6–2.4) and were more likely to stay in contact with other participants in the antenatal education (OR 4.1; 1.9–8.6). Mothers in the mental training program used psycho prophylaxis to a higher extent (OR 3.0; 1.2–7.1) There was no difference in the birth experience or the perceived parental stress.
Conclusion: Participating in a mental training program for birth and parenthood was not associated with the birth experience or the assessment of parental stress 1 year after birth.

View all citing articles on Scopus

View full text

Characteristics of Swedish women who do not attend childbirth and parenthood education classes during pregnancy

Abstract

Objective:

Design:

Setting:

Participants:

Measurement and findings:

Key conclusions:

Introduction

Section snippets

Methods

Findings

Discussion

Conclusion

Acknowledgements

Midwifery

Midwifery

Social Science and Medicine

Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale

British Journal of Psychiatry

When can odds ratios mislead?

British Medical Journal

Women's worries during pregnancytesting the Cambridge worry scale on 200 Swedish women

Scandinavian journal of Caring Sciences

Sociological aspects of attenders and non-attenders of antenatal classes

New Zealand Medical Journal

Help or hindrance? Single, unsupported mothers’ perceptions of health visiting

Journal of Advanced Nursing

Childbirth education classes. Understanding patterns of attendance

Birth Issues

Attenders and nonattenders at childbirth education classes in Australiahow do they and their births differ?

Birth

Cognitive predictors of attendance at antenatal classes

British Journal of Clinical Psychology

Screening for depression during pregnancy with the Edinburgh Postnatal Depression Scale (EPDS)

Journal of Reproductive and Infant Psychology