Becoming a parent is a significant transition, and is characterised by challenges as well as opportunities. New demands and responsibilities can increase emotional vulnerability and may strain couple relationships. Furthermore, the foundations for the parent-infant relationship are laid during pregnancy (Dubber et al, 2015) and parental attitudes towards the baby, and the quality of interactions between parent and infant can have a long-lasting impact on children's cognitive and emotional development (Meins, 2013).
The transition to parenthood can also be an opportunity for growth and development. Relevant information, realistic expectations and a sense of feeling prepared can create a positive transition to parenthood, as do effective coping strategies (Meleis et al, 2000). These are often central to antenatal education programmes. Although the focus of these programmes has traditionally been on preparation for labour and birth, and practical care of the newborn baby, there has been an increased recognition over the past two decades of the importance of preparing expectant parents for the impact of parenthood on their emotional wellbeing and on the couple relationship, and laying the foundations of a positive parent-infant relationship (Schrader McMillan et al, 2009). Pregnancy is considered a ‘critical time of learning’ (Svensson et al, 2008:40) and therefore an opportunity to support individuals in making behaviour changes, including building positive parent-infant relationships, constructive communication between partners, and caring for one's own wellbeing (Lawson and Flocke, 2009).
Welcome to the World (WTTW) was developed by the UK charity Family Links and is a relationship-based nurturing programme for groups of expectant couples. The aims of WTTW are to improve attunement, bonding and attachment; parental wellbeing; breastfeeding; and practical care of the new baby. It is delivered by parent group leaders (PGLs) and consists of eight weekly 2-hour sessions with an introductory session at the start of the programme (Table 1). Some groups also have a postnatal reunion session. It is generally aimed at couples, although partners do not always attend. The programme is commissioned by a range of organisations, including local authorities and the NHS. In some areas, it is available to all expectant parents, while in others it is targeted at those who are perceived to be more vulnerable.
| Week 0 | Establishing a group: what's the nurturing programme all about? Introducing the antenatal nurturing programme for parents; evaluation |
| Week 1 | Welcome to the World: aims of the antenatal nurturing programme for parents; building blocks: the four constructs, group rules, touching and talking to my baby in the womb, the power of praise |
| Week 2 | Loving attentiveness: bonding, attachment and brain development; family values and family rules; nurturing my baby's development and growing brain |
| Week 3 | A celebration of birth: empathy and the four constructs; a celebration of birth; ‘Welcome to the World’ baby books; changes in me and you |
| Week 4 | Personal power: self-esteem and healthy eating choices; influences on behaviour, self-esteem, personal power; healthy eating choices |
| Week 5 | Boundaries, beliefs and values: babies and children need security; consistency and boundaries; helping my baby calm him/herself; nurturing ourselves |
| Week 6 | Feelings and how we communicate: feelings … and what we do with them; managing anger; perinatal depression; dealing with stress; communication between adults, and adults and babies |
| Week 7 | Family life with a new baby: empathy for adults; special gifts for my baby and a gift for me |
| Week 8 | Off to a good start: the midwife; labour day; breastfeeding my baby; post-training evaluation; celebration |
| Reunion | Welcome to the babies! How are we all doing? (Optional in local setting) |
The aim of this study was to evaluate the effectiveness of the programme in supporting participants during the transition to parenthood. Specific objectives were:
Methods
Study design
This study was part of a mixed methods evaluation of WTTW. In addition to the focus groups, the results of which are presented here, the study included longitudinal questionnaires that collected quantitative data on parents' experiences as well as open-ended questions regarding parents' expectations of the programme (Jones et al, 2019), satisfaction with the programme and experiences of breastfeeding.
Focus groups were chosen as they enable a topic to be explored by analysing discussion and interaction between participants (Kitzinger, 2005). The researchers therefore hoped to gain a deeper understanding of parents' experiences of attending the programme. Focus groups took place after completion of the programme, when almost all participants had already given birth. Discussions were guided by a schedule that included questions about participants' experiences of attending the programme, interaction with the baby, practical care, relationships and support.
Participants were recruited from six WTTW groups in five locations. To take part, participants had to be aged over 16 years old and able to communicate in English. PGLs approached attendees of the programme with information about the focus groups and arranged the time and venue. A total of 36 parents took part in six focus groups. Table 2 shows details of the composition of focus groups.
| Group | Participants | Location | Characteristics |
|---|---|---|---|
| FG1 | 6 (5 women, 1 man) | Northern Ireland | All first babies; 2–8 weeks old; one woman still pregnant |
| FG2 | 5 (4 women, 1 man) | North England | All first babies; 6 months–1 year old; one couple still pregnant; targeted |
| FG3 | 8 (4 women, 4 men) | South west England | All first babies; 9 weeks–6 months old |
| FG4 | 4 (all women) | North England | 2 first babies, one second, one third; 9 weeks–1 year old |
| FG5 | 7 (6 women, 1 man) | North England | One first baby, two second babies, others third or more; 2 weeks–3 months old |
| FG6 | 6 (5 women, 1 man) | North England | Four first babies, one third; 3 weeks–2 months old |
Analysis
All focus group discussions were audio recorded, transcribed and analysed using thematic analysis (Braun and Clarke, 2006). Transcripts were read and re-read and searched for repeated patterns of meaning that were relevant to the research questions. Codes were used to capture relevant concepts; these were collated and used to construct themes and sub-themes. This iterative process was undertaken by one of the authors (FW) and codes and themes were then reviewed by another author (CJ). The final themes and sub-themes were agreed jointly.
Findings
Analysis of the focus group discussions resulted in four themes, each with several sub-themes (Table 3). The first theme related to the experience of attending the programme, while the other three were concerned with the impact of WTTW on coping behaviour, relationships and wellbeing. Participant quotes have been included to illustrate the themes. Each quotation is taken from a female participant, unless otherwise specified.
| Themes | Sub-themes |
|---|---|
| Expectations and experiences | Expectations |
| A safe, supportive space | |
| Information | |
| Relationships | Interacting and communicating with the baby |
| Couple relationships | |
| Other relationships | |
| Coping | Practical baby care |
| Expectations and reality | |
| Coping strategies | |
| Wellbeing | Nurturing oneself |
| Growth |
Expectations and experiences
Expectations
Participants gave a number of specific reasons for attending, including meeting others, support, curiosity and wanting information. Participants generally expected to obtain information and learn new skills, but many were unsure what to expect of programme, and many initially felt apprehensive.
‘You want to do your best, try your best and, you know, knowledge is power.’
‘I expected it to be about practical care and it was more about nurturing, which was good.’
‘The emotional, the physical, it included all that. So, yeah, it definitely exceeded my expectations.’
A safe, supportive space
Participants liked the informal and relaxed atmosphere, which allowed them time to talk and make friends. Some initially worried about being judged, but sessions were described as non-judgemental and supportive, and participants felt confident to ask questions. The programme was experienced as a safe space, providing participants with a chance to think and talk about their concerns. Interaction with other participants was overall said to be as positive, providing opportunities for new friendships and support. PGLs played an important role in participants' positive experiences.
‘I was 15 when I had him, so I was worried … but it wasn't like that, there was no judging.’
‘Yeah, it was different to what I thought it would be. I thought it would be quite regimented. This is more … not just about the baby but how you, like, as a couple as well, and how you do things as a family.’
‘It was lovely to meet the other mummies and daddies in the same situation and ‘cause we didn't really know many people beforehand in our situation.’
‘I stayed back to talk to her [PGL] and stuff, which was very helpful.’
Information
On the whole, participants found the information provided both in the booklets and during sessions helpful, but sometimes the information (about labour, for example) caused concern. Participants liked that the information was not prescriptive, but encouraged them to find what worked for them. Some said that they were not interested in some of the information until it became more relevant to them later on.
‘[The booklet] was scary, but it was helpful […] labour and all that … expect to read it and you know what you're gonna go through.’
‘In general, a lot of things you can't remember, but you knew when it comes to doing it, you just do it naturally, things you've learned in here.’
Relationships
Interacting and communicating with the baby
Participants enjoyed the focus on communicating and interacting with the baby and expressed amazement at the baby's perceptual abilities. Several participants said that initially they had felt self-conscious when trying some of the suggested activities, but the programme had clearly encouraged participants to interact and communicate with their babies. WTTW had helped them understand the importance of responding to the baby and enabled them to do so despite other people telling them they were spoiling their baby. Parents were also reassured that a connection with the baby may not develop straight away, but might take time.
‘It's hard when you're talking to something that you can't see or interact with, I think it helps to bond with it.’
‘I found it much better after doing the course. With [older child] I didn't know what to do with him. I know there was a baby there and you know you've got to feed him, change him but I didn't understand any of the interaction with him, that came much later. Whereas when it came to [baby], I knew what I was supposed to do.’
‘We've been told a thousand times by our parents, “You're spoiling that baby, you can't be picking her up.” But at the nurturing group they told us that you can't love your baby too much, and they do need you all the time, so don't think you're spoiling them.’
‘I also learned too that if they look away, they don't want to us to talk to them, they're bored of us or they want to look around, so that was good, you know, when trying to talk to them more.’
‘I've heard everybody say like, “Oh, you'll know when it's your own baby and you'll know what to do,” and I can remember [PGL] said to me, “You might not know straight away, and I didn't, like, my instincts didn't kick in straight away, it took a few days for me to find my way,” and I just remembered her saying, “It doesn't happen straight away with everybody” and it just settled me down.’
Couple relationships
Taking part in the programme increased couples' understanding and empathy for each other. Women said that it helped their partners to understand how having a baby would affect them, and that it helped women to understand better what their partners might feel. Taking part helped some men to feel more involved in the pregnancy. The programme encouraged participants to express their feelings, needs and concerns openly. Many participants appreciated that WTTW was not just about the baby, but also about them as a couple.
‘It made them aware, they understood, you weren't making it up, that other women in the group were feeling exactly the same.’
‘Yeah, I think that I got a bit more, coming to the group, I got a bit more understanding of what [partner] goes through in the day, so then I give a bit more help when I get home, give her a bit of time to herself, that sort of thing.’
‘And I think it's nice to know how the men feel as well, because usually it's all about the woman … the men are often a bit sidelined.’
‘It definitely made me feel more involved with the pregnancy, like I was part of it as well … And when I came to the group, I came as her partner.’
‘It taught us that it's not all rosy and it's give and take, all about open communication and relationships.’
‘Remembering that you and your husband still need a relationship—don't forget about yourselves, go out for a nice bite to eat or go out for the night, it was nice knowing you could still have a relationship.’
‘We thought we'd talked about everything but the course taught us to talk about more, discipline, parenting styles—helpful discussions before the baby was born which we might not have had.’
Other relationships
Participants enjoyed meeting other expectant parents and many were still meeting up after the course. Social networks centred around women; men were included to some extent, but this appeared to follow the lead of the women. Sharing experiences seemed to be particularly important, allowing them to ‘compare notes’ at different stages of their babies' development. Some participants talked about conversations with other people, such as their own mothers, about their experiences.
‘Having someone to call upon, the peer support. The social element really helped get me out.’
‘[Re meeting up] I don't think so, I haven't, I haven't seen anything of them.’
‘Those days when … you think you're having the worst day ever and you text them and they say, “Oh, [baby] has been a nightmare” and you think, “Thank God it's not justd [baby]”! Yeah, it's the best thing, it's been massive for me.’
‘I was still at school then … I should be there … it was good to get on with other people, forget what was happening at school.’
‘Me getting pregnant and going to the group, it brought me and my mum a lot closer … We'd go through it together basically.’
‘I was also asking my mum stuff about me, I never had those conversations before, like, “What sort of labour did you have?” So that was good.’
Coping
Practical baby care
This theme was clearly important to parents. Participants particularly liked it when new parents attended with their babies and demonstrated practical care, as the use of dolls was considered helpful, but not as good. Many parents said they did not do enough practical activities. Several talked about how helpful discussions on breastfeeding had been. Participants in several groups said they would have liked more coverage of formula feeding.
‘My husband said, “I really wish they had shown us how to put on clothes on a baby” because he was so afraid of hurting him when he was born.’
‘[Bathing the baby] was really good ‘cause I'd never seen anybody turn a baby … she turned him over on his front and back … and so that was interesting just to know that the wee baby was content.’
‘[A doll] is totally different to a real baby.’
‘It was really good to discuss breastfeeding, different people's opinions on whether they were or whether they weren't going to breastfeed … I came in and I was 100% not going to breastfeed, and by the time I left the group I was going to try it.’
‘I'm only still feeding because of the support from my husband because of what we learnt in class.’
Expectations and reality
Knowing what to expect and being prepared helped participants to navigate the transition to parenthood more confidently. While they acknowledged that it was never possible to be fully prepared, they generally felt WTTW had helped them to have realistic expectations. Activities focusing on what life with a new baby might be like were experienced as ‘scary but helpful’ (FG3), making postnatal life more realistic and helping them to prepare. Several said that they appreciated that PGLs had not been prescriptive, but had encouraged them to find strategies that worked for them.
‘I don't think you're ever going to be fully prepared for what it's really going to be like, but it was guiding us.’
‘Little things, like it is going to be hard. They don't brush over it, they don't sugar coat anything.’
‘And also, the way you do it is not always going to be the same as like somebody else does.’
Coping strategies
The programme discussed coping strategies, such as learning to take a step back when getting stressed with the baby, developing a routine, and relaxation techniques. Several participants talked about the challenges of being signed off by the midwife and the partner going back to work; they would have liked more discussions around these topics. The programme also covered the importance of having support from others and helped some participants to realise that asking for help was sometimes necessary.
‘And how to relax, like dropping the shoulders and so. Yeah, that helped me, that really helped.’
‘It's hard when the guys go back to work, I'm not sure how you'd look at covering it, but maybe get couples in to talk about when the bloke goes back to work.’
‘Yes, I think I found being signed off by the midwife probably more daunting than going home from the hospital.’
‘I'm not the kind of person who asks for help but it's made me realise that I'm gonna have to rely on somebody.’
Wellbeing
Nurturing oneself
Participants appreciated that WTTW did not exclusively focus on their baby, but also on nurturing themselves and their relationships, with an emphasis on being kind to themselves and being realistic. They felt the programme had helped them understand their emotions and experiences and the importance of taking time for themselves, both as individuals and as couples.
‘They said, “Spend just a bit of time on yourself each day, spend 5 minutes in the bath or just sat in silence, with no stress, no children … just a bit of time for you,” which I thought was brilliant.’
‘We were talking about how it can be difficult to turn your emotions around when you are feeling that way—it's not just as easy to snap out of it. It's OK to allow yourself to feel that way.’
Growth
WTTW helped to foster an understanding of emotions and needs, and increased participants' awareness of their own upbringing and how this might affect them as parents. This and the emphasis on finding their own way resulted in many participants feeling more empowered and confident to trust their own instincts. There was a sense that WTTW helped to prepare them grow not just as parents, but also as individuals and couples.
‘It taught us to trust our instincts.’
‘The course helped us to challenge the advice from others and think about where you got all your own views from.’
‘It gets you thinking about stuff you haven't thought about before. The emotional side, how you bring the baby up. And it gets you a bit into how you were brought up.’
Discussion
Participants' experiences of WTTW
Participants generally found the programme very positive and enjoyable. The programme mostly met their expectations, although some were unsure what to expect and some men in particular felt a little apprehensive to start with. Giving potential attendees information about what to expect from the course might encourage more to attend, and it may be beneficial to tailor some of this information to men (Fletcher et al, 2004; Jones et al, 2019). Participants appreciated the support provided by PGLs and their knowledge-base. Several said that they liked that their PGL had not been prescriptive, but had talked about their options and encouraged them to make decisions that were right for them. This reflects changes in the approach to antenatal education over the past two decades, with a move away from prescriptive and didactic programmes (Nolan, 2009).
Relationships
WTTW increased couples' mutual empathy and their understanding of the importance of good communication and spending time together. A positive, strong relationship is important for wellbeing and effective parenting, which benefits the whole family (May and Fletcher, 2013); however, evidence for the effectiveness of antenatal education in promoting positive relationships is mixed. A meta-analysis of couple-focused interventions (Pinquart and Teubert, 2010) found only very small effects; these were larger if the intervention lasted for longer than five sessions. There is some evidence that antenatal courses with a focus on the couple relationship, like WTTW, can improve how parents cope with the impact of a new baby on their relationship (Matthey et al, 2004; Feinberg et al, 2009; Daley-McCoy et al, 2015).
Participants in the focus groups appear to have benefitted from the inclusion of expectant fathers. Traditionally, antenatal courses have focused solely on women and research suggests that many do not meet expectant fathers' needs (Fletcher et al, 2004; Deave and Johnson, 2008; Svensson et al, 2008; Murphy Tighe, 2010). Since these studies have been published, there has been an increasing awareness of the importance of including women's partners (Entsieh and Hallström, 2016), and contemporary courses may address both parents' needs more adequately.
Relating to the baby
Improving the parent-infant relationship is an explicit aim of WTTW and consequently this was covered extensively. Parents in the focus groups enjoyed learning about fetal and infant development and the communicative abilities of newborns. Antenatal education can promote the development of the parental-infant bond by increasing parents' ability to identify and interpret infant communication (May and Fletcher, 2013). This may improve parents' satisfaction with their relationship with their baby (Schrader McMillan et al, 2009) and increase sensitivity to infant cues and appropriate responses (Bryan, 2000). This appears to have been the case for many of the parents attending WTTW, as some stated explicitly that it had a profound effect on how they related to their baby.
Emotional wellbeing
There is a clear need for including emotional aspects and effective coping strategies in antenatal education (Svensson et al, 2006; May and Fletcher, 2013; Entsieh and Hallström, 2016). Participants talked about how WTTW had benefitted their emotional wellbeing. Some described some of the information discussed as ‘scary’, and although this issue was raised by a minority of participants, it is important that the implications are considered carefully. Providing information can be a balancing act: it should be useful and realistic, but not increase anxiety. Programme leaders need to be aware of participants' needs and sensitively address issues that may arise.
Evidence for the effectiveness of antenatal courses in improving emotional wellbeing is mixed. A meta-analysis (Pinquart and Teubert, 2010) found only small effects on psychological wellbeing, although these were larger with longer courses. Another review (Schrader McMillan et al, 2009) suggested that antenatal education could be effective in supporting women with below-threshold symptoms of depression and anxiety. There is also evidence that programmes focusing on emotional aspects are beneficial (Bryan, 2000; Matthey et al, 2004).
Parenting skills
Parents have a strong need for information on early parenting and practical skills for looking after a baby (Bryan, 2000; National Childbirth Trust, 2007; Deave and Johnson, 2008; Deave et al, 2008; Jones et al, 2019) and expect this to be met in antenatal courses (Ahldén et al, 2012). However, parents often feel that antenatal courses do not prepare them adequately (Fabian et al, 2005; Svensson et al, 2006; Schrader McMillan et al, 2009). There is some evidence that antenatal courses can increase parents' confidence (Matthey et al, 2004; National Childbirth Trust, 2007; Svensson et al, 2009) and enhance their approach to parenting (Feinberg et al, 2009). A good sense of competence in early parenting skills is important not just because it can help to ensure that babies receive adequate care, but also because it is linked to parents' sense of achievement and failure (Svensson et al, 2006) and can therefore affect their emotional wellbeing. Participants wanted to learn practical skills, but not all felt that this had been achieved. The attendance of a couple with a new baby enabled expectant parents to learn directly learning from new parents (Murphy Tighe, 2010); and previous studies have found that the opportunity of ‘seeing and hearing the real experience’ can be very valuable (Svensson et al, 2008:39).
Support
Support from other parents can reduce isolation and validate experiences and feelings (Jones et al, 2014), as well as providing practical support. Antenatal courses provide an opportunity to meet others in a similar situation, to form new friendships and build a support network (Svensson et al, 2006; Murphy Tighe, 2010). While there is some evidence that antenatal courses meet this need (Fabian et al, 2005; Schmied et al, 2002), this is not always the case (National Childbirth Trust, 2007). The extent to which participants in this study built support networks varied between groups; it is unclear whether this was due to personal characteristics or the format of the group and how it had been led. Organising postnatal reunions, although not standard practice for WTTW, may encourage groups to meet up (National Childbirth Trust, 2007).
Strengths and limitations
The number of focus groups participants (n=36) are a strength of this study. Participants came from a wide range of backgrounds and geographical locations. On the other hand, only a few men took part and all couples were in heterosexual relationships. A further issue was that to protect the anonymity of participants and to facilitate recruitment, participants were recruited through WTTW leaders, who therefore acted as gatekeepers. It is possible that this affected who participated. In retrospect, it would have been beneficial if focus group discussions had included more questions about postnatal contact between group members to enable a more in-depth exploration of factors contributing to support networks.
Implications for practice
The study highlighted aspects of WTTW that work well in supporting expectant parents, including the focus on couple relationships, the relationship with the baby, emotional health and nurturing, and the non-didactic approach. To further enhance the effectiveness of antenatal programmes, couples may benefit from receiving more information about what to expect before attending; this could increase attendance and reduce initial apprehension. Participants may benefit from the inclusion of more practical baby skills, particularly the attendance of new parents with their baby.
Conclusions
The WTTW programme focuses on the emotional health of individuals, couples and babies and aims to create a nurturing environment for participants in order to enable them to nurture their relationships with their partner, their baby and other family members. The programme addresses the needs of couples and participants clearly appreciated this focus on emotional health and relationships. Parents also liked that it gave them information and presented them with options and a safe space for discussion, thereby empowering them to make decisions that were right for them as a family. Further research is needed to explore why some groups developed stronger support networks than others, and routinely providing postnatal reunions may be one way of supporting this. This study demonstrated how expectant parents could benefit from a relationship-based antenatal programme focused on emotional health. It underlines the importance of well-trained, sensitive programme leaders who take a person-centred, non-didactic approach and provide a safe, nurturing environment to support participants in their journey through the transition to parenthood.