An investment in strategies to promote ‘a healthy start to life’ is thought to reduce health inequalities across the entire course of life (Marmot et al, 2012). Extensive research has been conducted examining various indices of maternity care to measure success across the perinatal period. For example, with respect to antenatal care, researchers have explored aspects of the content and timing of care, so as to promote healthy outcomes for women and their infants (Beeckman et al, 2011). Of equal importance is quality of care, although a major evidence gap exists with respect to our knowledge of how to implement care that is both clinically relevant and a positive experience for the woman, so that she is encouraged to seek assistance and timely care (Graham et al, 2013). Quality care is therefore an important aspect of the wider challenge towards effective programme implementation in perinatal health.
Existing literature reports maternal dissatisfaction with various aspects of maternity care (Buultjens et al, 2013; Jenkins et al, 2014). In the Australian context, the literature has long shown that Australian maternity care is not reliably meeting the needs of all Australian families, with issues including fragmented care and limited options for women and their families in rural regions (Australian Government Department of Health and Ageing, 2009). From such reports (Australian Government Department of Health and Ageing, 2009; Australian Health Ministers Conference, 2011), visions for Australian maternity services have included the provision of collaborative multidisciplinary care; continuity of care; and assisting women in being better able to make decisions about their maternity options. Similarly, not all informational needs are being met through antenatal education, as evidence shows that existing classes are not adequately equipping women with the skills and information necessary for optimally childbirth and successful early parenting (Buultjens et al, 2017).
In an attempt to improve care, CenteringPregnancy was designed as an antenatal group care model (Gaudion et al, 2011; Teate et al, 2011; McDonald et al, 2014). While there are a number of benefits to this model of care, such as lower rates of preterm birth (Ruiz-Mirazo et al, 2012) and women feeling more prepared for labour (Ickovics et al, 2007), limitations of this model have been noted. For example, CenteringPregnancy is typically limited to obstetrically low-risk women (Picklesimer et al, 2012), despite the fact that high-risk women could also benefit from the education and social support, in addition to individual consultations. In consideration of the above evidence, and as a new response to the challenge of providing timely education and continuity of care across the entire perinatal period, a psycho-educational programme was designed for women experiencing their first pregnancy and their partners.
A psycho-educational programme
The group-based psycho-educational programme consisted of a broad range of activities that combined education and supportive intervention, led by a multidisciplinary team of perinatal health professionals, such as midwives, women's health physiotherapists, and lactation consultants. The programme began in the third trimester and was run until approximately the 8th week after birth, because in the researcher's clinical experience, and as prevalence data of depression show (Gavin et al, 2005), it is by this time that the higher initial levels of stress of being a parent have been experienced and many of the life changes associated with having a baby have become established. Additionally, this is a window of opportunity for parents to master numerous new tasks, such as mothercraft skills, breastfeeding and fostering a secure mother-infant attachment. The group process provides the opportunity for women to normalise their experiences in the transition to parenthood, such as changes in the physical body, changes to partner relationships and hormonal and emotional changes (Duncan and Bardacke, 2010). Collectively, the intervention programme was based on a proactive rather than reactive approach to perinatal care. The programme was aimed at first-time parents, and was a blended approach, combing parents' individual primary clinical maternity care model with a group psycho-educational programme. Although other qualitative studies have described the experience of group prenatal care (Kennedy et al, 2009; Novick et al, 2011; McNeil et al, 2012), this is the first that sought to understand a group psycho-education programme that incorporated a blended approach and a programme that considered the total perinatal period.
The purpose of this study was to gather information from women regarding their experiences with a model of care that combined their individual clinical maternity care with a group psycho-educational programme to enable a successful transition to parenthood.
Methods
Design
A qualitative descriptive design (Colorafi and Evans, 2016) was applied, incorporating thematic analysis to identify themes in the data. Data from this research were collected as part of a larger programme evaluation, and therefore this method was judged most appropriate given the overarching research questions, which focused on examining the efficacy of a multifaceted group-based psycho-educational programme (Buultjens et al, 2018). Although beyond the scope of this article, the descriptions of the experience and insights gained from women participating in the programme could be further applied to develop and refine the programme.
This article will report a qualitative descriptive study to understand women's experiences of participating in a group psycho-educational programme. As noted by Sandelowski (2000), qualitative description is especially useful in obtaining direct descriptive answers to questions of special relevance to practitioners and policymakers.
Sample and recruitment
A purposeful sample was sought from residents of Melbourne, a major city in the south-eastern Australian state of Victoria, and the surrounding metropolitan areas, to understand and describe women's experiences. All women who participated in the research evaluating a group psycho-educational health-promoting programme (Buultjens et al, 2018), were eligible to participate in the qualitative phase of this research. Women were eligible to participate in the research if they were experiencing their first pregnancy, over 18 years of age, and able to read and write English. The sample aimed for variation in age, medical risk status, socioeconomic status and ethnicity and recruited participants through advertisements disseminated in a number of public settings. All women who participated in the programme agreed to a one-on-one interview (n=10).
Data collection
Personal in-depth interviews were used to collect data (Daly et al, 2007). Interviews averaged between 30 and 60 minutes in duration. The interview guide included questions about respondents' experiences of participating in the programme, and more specifically, how it made preparation, access to support, and knowledge easier. Women were also asked for feedback concerning the group format. All interviews were conducted by a researcher (MR-H) unfamiliar to the women, so that they could speak openly without any bias. Women gave permission to have the interviews recorded using audio equipment, to enable production of verbatim interview transcripts (Halcomb and Davidson, 2006).
Data analysis
Transcriptions and preliminary data analysis were undertaken contemporaneously to check for emerging and recurring themes. While using descriptive content analysis in combination with thematic analysis, as a first step, two researchers (MB and MR-H) independently examined each interview transcript to identify concepts and constructs apparent in the data. Meanings in each sentence or paragraph were given descriptive codes. Coding was a method whereby words or statements pertaining to the study objectives were extracted and similar responses identified using the same label (or code) (Polit and Beck, 2010). Following these initial steps, the researchers discussed their interpretations and further refined the codes and emerging themes. Up until the completion of all interviews, new ideas were explored and checked against the data as more themes emerged from women's accounts (Attride-Stirling, 2001). The final step involved developing analytical categories, exploring and grouping them, and writing up comments on each theme that grouped views, experiences and quotes according to their suitable thematic reference.
Rigour
Data were gathered to include the perspectives of all participating women within 1 month of them finishing the programme, enhancing trustworthiness and reducing recall bias (Moore et al, 2015). To ensure interpretative accuracy, cross-checking of codes and themes was undertaken among the research team. Additionally, researchers were able to validate meaning with the women, which allowed the researcher to not just ‘play back’ what the women had said (description), but to clarify and avoid potential inquirer bias (Patton, 2015).
Ethical considerations
The La Trobe University ethics committee approved the study protocol (FHEC09/215). All women were assured that their responses would be kept anonymous and confidential, that their participation was entirely voluntary, and that they could withdraw at any time, although none chose to do so.
Results
A total of 10 women participated in the research. The age range of the women in the study was 24–39 (mean= 32.56 years, SD=3.25 years). Most of the women were tertiary educated, and had a family income greater than $50 000 per annum (Table 1).
| Variable | (n=10) |
|---|---|
| Maternal age (years), mean (SD) | 32.56 (3.25) |
| Country of birth, n (%) | |
| Australia | 9 (90.0) |
| Other | 1 (10.0) |
| Number of years lived in Victoria, mean (SD) | 25.11 (11.96) |
| Marital status, n (%) | |
| Engaged | 0 (0.0) |
| Married | 9 (90.0) |
| De facto | 1 (10.0) |
| Education level, n (%) | |
| Certificate | 0 (0.0) |
| Diploma | 2 (20.0) |
| Undergraduate | 3 (30.0) |
| Postgraduate | 5 (50.0) |
| Household income (AUD) n (%) | |
| <$50000 | 0 (0.0) |
| $50 000–99 999 | 3 (30.0) |
| >$100 000 | 7 (70.0) |
| Type of health cover/maternity care | |
| Private health | 5 (50.0) |
| Private obstetric care | 5 (50.0) |
| Public health | 5 (50.0) |
| Team midwifery care | 2 (20.0) |
| Standard care | 1 (10.0) |
| Shared care | 2 (20.0) |
As a blended model of care, the psycho-educational intervention was in addition to the woman's routine hospital maternity care. The women in the study were evenly distributed across private (n=5) and public (n=5) models of care.
The most important data from the evaluation related to the women's satisfaction with the programme. When asked whether they would choose this programme for subsequent pregnancies, women unanimously agreed that they would participate again if the opportunity arose. Six themes were identified from the womens' reports of their experience of the programme and how it facilitated their transition to parenthood. These themes were:
An efficient and collaborative environment
Group sessions were considered to be an efficient way to disseminate information. Women perceived the collaborative environment to be an advantage, as they could receive information from a range of health professionals, which provided continuity in both the form of care and carer.
‘It was a relief to go somewhere and receive continuity—in advice, health professionals and other mothers … we had the continuity of the midwife each antenatal session and maternal health nurse at the postnatal sessions.’ (IP04)
Women were asked to consider clinical aspects of the programme or any difficulties they may have experienced. There were many positive affirmations involving continuity, as well as the availability of efficient support and access to healthcare, advice and referrals as provided by the collaborative team, as illustrated by one participant, who said:
‘I think had it not have been for this programme and the range of people I was able to speak to about the breastfeeding issues that I was having, then I wouldn't have eventually found solutions to my problems.’ (IP05)
Furthermore, the practicality of having a collaborative team of perinatal health professionals also became apparent through analysis. As one participant explained,
‘I always think that regardless of whether its pregnancy or say someone experiencing orthopedic surgery, like a knee replacement, I think all the allied health professionals that are involved in that person's care should come together. I think [the programme] does a good job of that. It's all a little bit more comprehensive; a little bit of a one-stop-shop type of thing. I know that there are classes that are being offered by hospitals but it's more isolating to the individual because you often can't share your stories or you can't listen to other people's.’ (IP12)
Feeling supported and gaining confidence in the motherhood role
Women all identified as feeling supported. One example of this included practical support to learn parenting skills, as illustrated by one participant:
‘I found it very supportive … One thing this programme did teach me more than I'd learned elsewhere was sleep settling stuff, so that was good early postnatal. There are stuff [sic] from my council to learn sleep settling, but I wouldn't have known about that till probably too late.’ (IP09)
While offering individualised care to each woman and acknowledging that no experience is the same as another, the health professionals listened to concerns in a non-judgemental manner, and offered more than one potential solution or option. Women perceived the sessions to be unhurried and not routine in nature. As one woman stated,
‘I completely and utterly looked forward to [the programme]. It was almost a home away from home for us, especially considering I got so much positive feedback and I was able to make a connection with people.’ (IP18)
While another shared,
‘And the fact that she [health professional] was able to see my son and to be able to go, “Yep, this is normal” … I felt really at peace.’ (IP10)
In coming away from the programme, women identified that the support of such a programme developed their ‘confidence’ (IP05). Additionally, it facilitated their transition to parenthood or adaption to motherhood through ‘reassurance and participation’ (IP07). This can be seen through the following comment:
‘I think it's helped me really establish what my role is, if that makes sense. You know what your role is, but especially with the post classes, like play, how to play with him and that kind of thing, and what to do in that hour and a half when he's awake.’ (IP11)
Additionally, one woman deemed the continuous support in the early postnatal period as invaluable, stating:
‘Yeah, it was somewhere that was clean and welcoming, which is really important when you're getting out of the house for the first few times with a new baby, and there was always someone to help out just so you could have a cup of tea, somebody would hold your baby and that was a real luxury. I think it was more that sense of friendship.’ (IP05)
And another remarked in reflection:
‘I don't know how I would have done it without the programme now, looking back.’ (IP10)
Women in the group also supported each other by listening to each other and providing encouragement when someone disclosed a potentially sensitive topic. Through this, women received emotional support. Women could share their experiences as well as their highs and lows with other women in the group, including things that they felt they could not disclose to their friends and/or other parenting groups, such as postnatal maternal and child health groups. One woman expressed the overall value of the programme:
‘I came from interstate and the reason I participated in the research was because I thought it might actually complement whatever information I've been given from the hospital. Instead, the hospital information complemented what I was given from [the programme] … I made friends and I gained confidence in a mum role, which I couldn't imagine when I was pregnant.’ (IP12)
Learning valuable and time-relevant information
Women reported that the sessions were detailed, practical and time-relevant in that they did not have to ‘bank’ information in advance to recall later should they need it. Women commented that they were generally bombarded with information from hospital, friends and family, but that they learnt to trust in the programme leaders to inform them of what they needed to know, when they needed to know it; a valuable programme output. One particpant used the example of baby milestones, saying:
‘[The programme] made us aware of what is coming up (milestones) and this is how we can deal with it. And it really was excellent.’ (IP10).
When making comparisons between the intervention programme and community maternal and child health groups, which generally do not begin in the immediate postnatal period, one woman commented:
‘It started really late (maternal and child health group), so I was really glad to have these classes, otherwise I would have been tearing my hair out if it wasn't for here. I would have been in the dark for so long on my own.’ (IP11)
Similarly another participant explained that:
‘Yeah the maternal health nurse actually picked up his reflux issues … if I hadn't come to [the programme], potentially I wouldn't have had that resolved as early as I did.’ (IP06)
A shared experience
The group model not only provided a shared learning environment, but the women also got to know each other. As one woman said:
‘The programme has given me confidence … and you know, the group experience … we are all going through the same experience.’ (IP04)
The shared experience of women in the groups provided a safe environment to share expectations and experiences, in addition to normalising many of the aspects in the transition, such as preparing for labour, physical health and rehabilitation following childbirth, and breastfeeding challenges. One woman conveyed the shared experiences of those who were involved, saying:
‘It's just been awesome … having it prior to having a baby, you get to meet the girls and have a relationship with others prior to having a child. And then you can discuss different issues, so you don't feel alone from a pregnancy point of view.’ (IP06)
Sharing the experience with a group of women before the birth was considered a real strength of the programme. Upon reflection, women acknowledged that it was difficult to even get out of the house post-baby, let alone have the headspace to make new friends. As one woman reported, the programme leaders and group members were welcoming, which made friendship with peers easier. Therefore, developing relationships with the women before the birth of their baby removed many potential barriers to seeking support and reduced possible isolation. Women acknowledged that they looked forward to the post-baby sessions, as there was much excitement returning to share their experiences. As one woman stated:
‘Because we'd got to know each other a little bit beforehand, you felt like you were coming back to familiar people so you weren't all starting from scratch, when you're distracted with your babies and all that kind of stuff … I don't enjoy the maternal and child health group nearly as much as this group.’ (IP05)
Comparisons were made with women's experiences of conventional antenatal classes. As one woman said:
‘It was more social than the antenatal classes where you turned up with your partner, nobody really socialised and you went home … so I think that was a really important aspect of the programme.’ (IP05)
Reflections were again made concerning the time between giving birth and traditional maternal and child health groups. While this programme began between 2–4 weeks after birth, many acknowledged the timely group support at a vulnerable time of much change. As one woman commented:
‘I've really appreciated it [postnatal sessions] because it did kick in before the education through the maternal child health centre. I started coming back here when the baby was four weeks old … it was all quite new, and this education was very, very helpful.’ (IP09)
Enabling an active role in decision-making, care and parenting role
One of the frequent comments from the women was that they felt empowered through the transfer of knowledge, which gave them a greater awareness of their options (for giving birth, for example) and of managing their care from a biopsychosocial perspective. Many women associated a positive experience of labour in part due to feeling empowered through knowledge and an increased self-efficacy enabled by the group support. Women recalled various group discussions that had given them options to equip them to manage the labour (including exercises led by the physiotherapist and yoga therapist), as well as the couples' session, which included discussions about how to support your partner. This knowledge combined to increase women's confidence to make informed decisions. Similarly, equipped with knowledge, women felt more empowered and had greater confidence in making day-to-day decisions and fulfilling the maternal role. As one woman said:
‘All the advice was really good … having the lactation person do a session before the baby was born … it was really, really helpful. So, I had no problems with attaching other than this tongue-tie, but that made it a breeze. I just felt like I knew what I was doing.’ (IP11)
Women found that postnatal sessions provided equal value. Learning though participation enabled women to not only care for their baby confidently, but also bond with their baby:
‘The next four weeks was excellent, because we had a different activity for each one. After we had the music session, I then went home and I started doing music every day. Then we had the yoga session … and massage and I went home and I started doing massage with him. And I still continue to do all these things and put it into practice.’ (IP10)
Expertise matters in the transition to parenthood
The group allowed women to collectively share their perinatal experience, while also being supported by a team of maternal health professionals who provided their expertise. A strength of the group was that the diversity of needs and experiences resulted in women gaining more tangible and informative support. When reflecting on their expectations of the transition to parenthood and the group programme, some women had ideas of what they needed, while others were unaware of their needs or how to prepare. One woman admitted her initial surprise when she learnt of the perinatal team in that she couldn't have imagined needing such services:
‘There's all these different health professionals … psychologist and physiotherapist and I'm like, “This can't all be for pregnancy.”’ (IP10)
This highlighted the reality that women are not often aware of what they need to know and who can assist them. In this instance, the programme was ‘a real educational eye-opener’ (IP10).
Regardless of their awareness and perception of preparedness, all women concluded the programme identifying that they came away with more than they could have imagined ever needing. As many commented, there was practical, tangible and informational support, as well as identifying with other women going through the same experience, which normalised their experience.
Having expertise and resources in one place was considered valuable. Again, comparisons were made between the research intervention programme and community groups such as those run by maternal and child health centres.
‘What was better with this group as opposed to, say, my community group was the actual centre was lovely and I suppose everyone [health professionals] came to us; we didn't have to go to anyone else. Whereas with the community health centre they'll give you things on classes and music and, you know, information about different places but you have to go somewhere different for each thing.’ (IP07)
Discussion
This study aimed to understand women's experience of participation in a perinatal group psycho-educational programme when delivered in combination with their primary maternity care model. The qualitative results clarify the contextual experience of participating in the study. As outlined above, six themes were identified: an efficient and collaborative environment; feeling supported and gaining confidence in the motherhood role; learning valuable and time-relevant information; a shared experience; enabling an active role in decision-making, care and parenting role and expertise matters in the transition to parenthood.
Women identified the programme as a positive experience that provided the opportunity to develop strong social networks and resources, as well as emotional and informational support from peers and health practitioners alike. The benefit of social support is not new information: social support has frequently been found to help with the transition, particularly support from partners and peers and health professionals (Leahy-Warren et al, 2011). Although these results do not suggest that women would have been inadequately supported without the programme, the results indicate women could gain more from a programme that is accessible alongside their existing hospital care. Brief antenatal visits in the hospital do not allow much time for in-depth discussions and education, and rapport is difficult to develop when women do not have repeat consultation with the same health professional. Moreover, even in the case of women who experienced a private model of care (such as a private physician), there is limited time during each consultation to develop rapport, and women may not always feel comfortable to ask all questions. This study highlighted the benefit of the group in disseminating more information, in that the group setting allowed women to ask questions that others may not have had the confidence to ask, or even considered. The midwifery care experience has been shown to be more positive when the woman and her partner have been able to develop a relationship with their practitioner during the antenatal period (Homer et al, 2002); this programme was able to go one step further, providing additional continuity across the postnatal period.
Existing literature recognises social support as a key element that can influence the way in which the transition to parenthood is experienced. Darvill et al (2010) reported that women wanted support from their mothers, partners and peers, while Seefat-van Teeffelen et al (2011) found that women also wanted professional support. In this study, women reflected on their experience of the group support, from multidisciplinary health professionals and peers alike. Women in the group had a variety of needs met, such as being positively connected to other women and not feeling alone in the transition to parenthood experience, as well as timely professional support. Earlier research substantiates these findings in that social connections with other mothers, formed or strengthened during pregnancy, can affect the experience of new motherhood (Darvill et al, 2010). Furthermore, findings revealed that a lack of support led some women feeling more vulnerable, whereas for those women who felt supported, it increased confidence. A strength of this programme was the dual support, particularly acknowledging that new mothers' confidence in infant care is important in assisting adaptation to and experiences of parenthood (Leahy-Warren et al, 2012).
Existing evidence regarding enablers and barriers to engagement in parenting programmes highlighted important influences on parenting programmes (Mytton et al, 2014), such as the opportunity to learn skills, finding trusted or well-known people to lead the course and the chance to meet others and exchange ideas; all features that women in this study rated positively. In addition, this intervention acknowledged that in many instances of maternity care, professional collaboration goes no further than referral to other services, and that it is also rare for information to be fed back to the referring practitioner or service (Kruske et al, 2006). This intervention therefore illustrated greater benefits in that the health professionals involved worked collaboratively, enabling information to be fed back to all staff, to reduce conflicting information and increase continuity of care for the women.
Limitations of the study
Women in the sample were predominately white, Australian-born women in a relatively stable relationship with a partner, and in general were quite well educated, middle-class women. Likewise, the sample for this study included only first-time mothers, and it would be valuable to investigate the potential for a programme that included all childbearing women.
Conclusions and recommendations
The positive evaluations from the women suggests that group perinatal care can play a significant role in facilitating the transition to parenthood. Qualitative narrative analysis identified many benefits, including positive comments of social interaction and group cohesion, the practicability of the intervention with sustained continuity of care, and the noted benefits of a collaborative team of health professionals. Replication of this programme in a different setting (such as rural regions), with a larger, more diverse sample of women would allow for greater generalisability of results. Furthermore, this programme could complement existing models of hospital maternity care, with the potential to decrease the number of hospital antenatal visits, as well as increasing continuity of care, educational opportunities and social capital. In addition, the extension of postnatal care by way of a brief group intervention improves access to timely support and referral. Enhanced maternal and infant care may also contribute to reduced risk of hospital re-admission, and have economic benefit. The cost-effectiveness of such a programme therefore merits further investigation.
The findings of this study suggest that group perinatal education has the potential to not only improve health outcomes and positive practices, but also increase maternal self-efficacy through the provision of information and social support.