- Email: [email protected]
Contemporary Childbirth Education Models
Contemporary Childbirth Education Models Deborah S. Walker, CNM, DNSc, WHNP-BC, FNP-BC, Joan M. Visger, CNM, MSN, and Debra Rossie, CNM, MSN Since the 1960s, childbirth education advocates have attempted to persuade pregnant women that educational preparation for labor and birth is an essential component of the transition to motherhood. Initially, pregnant women who were seeking unmedicated births as a refuge from the inhumane childbirth treatments of the mid-20th century embraced this view. However, with the changing childbirth climate, including a growing preference for medicated birth, scheduled inductions, and cesarean sections, attendance has diminished and childbirth education finds itself at a crossroads. Commonly used childbirth education models/organizations and several new emerging models along with the available research literature and recommendations for clinical practice and research are presented. J Midwifery Womens Health 2009;54:469–476 Ó 2009 by the American College of Nurse-Midwives. keywords: antepartum, childbirth education, intrapartum, pregnancy
INTRODUCTION The childbearing year encompasses experiences that have profound and long-lasting effects on women, babies, and families. For this reason, health professionals have long felt that education and preparation are key ingredients to successful pregnancy and birth experiences. Before the late 1930s, most births occurred in the home. Birth was viewed as a normal event in women’s lives, and they were primarily supported in pregnancy and birth by other women, often mothers, grandmothers, or sisters. Formal education and preparation for childbirth were not available and likely not felt to be necessary. However, with the movement of childbirth into the hospital setting, women’s relationship to birth and to those who attended them changed. Women who gave birth in the hospital no longer had the unlimited support of women friends or family members. They were often alone and isolated from support persons and attended primarily by nursing and medical personnel. During this most vulnerable time, women were often ill-prepared for hospital routines and procedures, which led to increased fear and anxiety about the birth process. Childbirth education, as a formal structure, began in the 1960s in the United States. The development was in part a response to the treatment that women experienced during hospital births. The focus of formal childbirth education has primarily been on preparation for childbirth with an emphasis on ‘‘natural’’ processes and, to a lesser extent, newborn care and parenting. In the ensuing decades, the class content has attempted to keep pace with the needs of childbearing women while still maintaining a primary focus on natural processes and education for labor and birth.
Address correspondence to Deborah S. Walker, CNM, DNSc, WHNP-BC, FNP-BC, FACNM, Wayne State University, College of Nursing and School of Medicine, Obstetrics/Gynecology, 5557 Cass Ave., Rm. 248, Detroit, MI 48202. E-mail: [email protected]
Journal of Midwifery & Women’s Health www.jmwh.org Ó 2009 by the American College of Nurse-Midwives Issued by Elsevier Inc.
Almost 50 years has elapsed since the inception of formal childbirth education, and today there are a variety of educational models available. The three types of classes most often attended by pregnant women are taught by educators certified by Lamaze, the Bradley Method, and the International Childbirth Educators Association (ICEA). Many hospital organizations also offer their own childbirth preparation classes tailored to reinforcing the institution’s policies and procedures. In recent years, other models have emerged, such as HypnoBirthing – The Mongan Method, Mindfulness-Based Childbirth preparation, and Birthing from Within. In addition to Lamaze, the Bradley Method, and the ICEA, there are at least three other certifying organizations: the Association for Labor Assistants and Childbirth Educators (ALACE), Birth Works, and Childbirth and Postpartum Professional Association (CAPPA). Despite the continuing expansion of available childbirth education options, research has not shown strong associations between class attendance and the childbirth experience.1–4 In addition, recent national surveys have demonstrated a startling decline in formal childbirth education class participation. In the national survey Listening to Mothers II, just over half (56%) of new mothers who gave birth in 2005 said that they would take childbirth classes.5 This represents a disconcerting decrease of 14% from the 2002 Listening to Mothers survey, when 70% of new mothers answered this question affirmatively.6 The decline in childbirth education class attendance is variously attributed to more women choosing epidural anesthesia,5 elective induction,7 and elective cesarean birth.8 In addition, the decline is due to the basic content and philosophy of childbirth education classes not keeping up with the changing needs of childbearing women.9 Childbirth education is at a crossroads.7 Attendance at classes is down at a time when we are experiencing a crisis in maternity care and education and preparation are needed more than ever. Women look to their health care providers as a source of childbirth information and for direction and 469 1526-9523/09/$36.00 doi:10.1016/j.jmwh.2009.02.013
recommendations. Knowing which types of childbirth education classes are available and which might be the best fit for a particular woman and family with the everexpanding range of choices available can be challenging to the provider. In this article, we review both older, well-established childbirth education models and organizations and new emerging models to help providers as they counsel pregnant women and families. We chose to focus on the 3 most commonly used childbirth education models/organizations (Lamaze, the Bradley Method, and the ICEA) and three of the emerging models (HypnoBirthing, Mindfulness-Based Childbirth, and Birthing from Within). In addition, we present the research literature on the effects of childbirth education on outcomes and recommendations for clinical practice and research. CHILDBIRTH EDUCATION MODELS AND ORGANIZATIONS Grantly Dick-Read, an early 20th-century obstetrician, observed that some women did not experience pain during childbirth. In 1933, he described his theory of pain-free birth in the absence of fear in his first book, Natural Childbirth. The title was changed to Childbirth Without Fear for its second printing in the 1950s. Dick-Read was a pioneer whose theories had a profound impact on childbirth education and provided the foundation for three of the childbirth education models available today: Lamaze, the Bradley Method, and HypnoBirthing. Lamaze The Lamaze Method was introduced in 1951 by the French obstetrician Fernand Lamaze. He was influenced by Ivan Pavlov, an early pioneer in behavioral psychology who was well known for his scientific work on conditioned reflexes. The Lamaze Method consisted of childbirth education, relaxation, and breathing techniques. Lamaze advocated for more aggressive emotional support from the father of the baby, including their involvement with the birth.
Deborah S. Walker, CNM, DNSc, WHNP-BC, FNP-BC, FACNM, is an Associate Professor in the Department of Obstetrics and Gynecology, Wayne State University College of Nursing and School of Medicine, Detroit, MI, and the Graduate Program Director of the Nurse-Midwife and Women’s Health Nurse Practitioner graduate education specialties. Dr. Walker has been active in nursing and midwifery practice, research, and education for more than 30 years. She is a member of the Board of Directors of Lamaze Family Center in Ann Arbor, MI, and was educated as an International Childbirth Education Association Childbirth Educator. Joan M. Visger, CNM, MSN, is a doctoral student at Wayne State University College of Nursing, Detroit, MI. She is certified as a Lamaze instructor and is a HypnoBirthing – The Mongan Method Practitioner. Debra Rossie, CNM, MSN, is a lecturer in the Wayne State University College of Nursing Nurse-Midwifery and Women’s Health Nurse Practitioner specialties, Detroit, MI. She has been a certified nurse-midwife for more than 12 years and is in private practice in southeastern Michigan.
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In the late 1950s, Marjorie Karmel, inspired after reading Dick-Read’s book, was assisted at her birth by Lamaze and subsequently described the birth in her own book, Thank You, Dr. Lamaze. This book helped open the door for fathers to participate in the births of their children in the United States. Soon after her birth experience, Karmel met Elisabeth Bing, and together they established the American Society for Psychoprophylaxis in Obstetrics (ASPO) to promote the Lamaze Method in the United States. Lamaze became synonymous with childbirth education, and hospitals soon modified their childbirth course content and began teaching their own ‘‘Lamaze’’ classes. An early focus of the Lamaze Method was controlled breathing to cope with the discomfort of labor. Breathing and progressive relaxation techniques are no longer the hallmark of Lamaze. Today, Lamaze is not a method but a philosophy that ‘‘provides the foundation and direction for women as they prepare to give birth and become mothers.’’ ASPO was renamed Lamaze International to reflect the philosophy and its international scope. The mission of Lamaze International is to promote, support, and protect normal birth. The overall goal of Lamaze International classes is that ‘‘every woman gives birth confidently, free to find comfort in a wide variety of ways, and supported by family and health care professionals who trust that she has within her the ability to give birth.’’ Lamaze International identifies six care practices to support normal birth (Table 1). Childbirth preparation classes focus on preparing women and their support person(s) for normal birth. Women are encouraged to register for classes early in their third trimester. Courses include at least 12 hours of classroom time and may be held weekly or in weekendintensive formats. The class size is limited to 12 pregnant women and their support person(s). Each class has activities for all learning styles, with an emphasis on experiential learning. The curriculum includes strategies to incorporate the cultural values and beliefs of the participants. The cost of Lamaze classes varies from $35 to $150, depending on geographic location and available resources. Lamaze International offers the only certification program for childbirth educators accredited by the National Commission for Certifying Agencies (NCCA).11 Three flexible pathways are offered for certification based on previous experience: experienced educators, health care professionals, or those new to childbirth education. There is a midwifery pathway that recognizes the training and experience of midwives and student-midwives. Training requirements vary according to the chosen pathway. A rigorous examination is administered after completion of the childbirth educator training. The Bradley Method The Bradley Method is a husband-coached natural childbirth model designed to prepare couples to birth in Volume 54, No. 6, November/December 2009
Table 1. Lamaze’s Six Care Practices and Bradley’s Six Needs of Laboring Women Lamaze Six Care Practices Labor should begin on its own Laboring women should be free to move throughout labor Laboring women should have continuous support from others throughout labor There should be no routine interventions during labor and birth Women should not give birth on their backs Mothers and babies should not be separated after birth and should have unlimited opportunity for breastfeeding
Six Needs of Laboring Women Darkness and solitude Quiet Physical comfort during the first stage of labor Physical relaxation Controlled breathing Need for closed eyes and the appearance of sleep
a normal and natural way without unnecessary medical interventions or medication. The model was developed by Robert A. Bradley, an obstetrician/gynecologist who grew up on a farm in Nebraska. He developed the model after observing the instinctual way that animals give birth compared to the artificial conditions in the hospital setting and how these conditions adversely affected the way women gave birth. He described in Husband-Coached Childbirth what he believed to be the six needs of laboring women (Table 1). The role of the husband as coach is foundational in the Bradley Method. Bradley incorporated these beliefs into his practice and began to teach classes that were focused on the role of husbands who would be able to provide support to their wives while in labor and ensure that the environment met those needs.12 One father expressed it as ‘‘Really feeling like I was a partner and needed. I had a defined role and equally shared decision making with my wife. One week I didn’t do my homework, and it really affected our work in the class.’’ A unique bonding between couples occurs when the vision for birth is clear and mutually shared. This focus evolved as Bradley observed the change in husbands as they were allowed to be present with their wives during labor and birth. His method helped move husbands from being passive observers to having an active role ensuring and protecting the supportive, safe environment necessary for birth. A chapter in Husband-Coached Childbirth12 focuses on the father’s perceptions and responses to birth. The reference to ‘‘coach’’ is used throughout the Bradley book; however, in an effort to keep pace with societal changes, the updated edition13 clarified the use of the word ‘‘husband’’ as the person designated to love and protect the woman in labor. The commitment and attendance to the 12-week Bradley Method classes provides quality time for a couple to secure the emotional, physical, and interpersonal skills to achieve their birth goals. Journal of Midwifery & Women’s Health www.jmwh.org
Not surprisingly, the husband is not the only focus of the Bradley Method. It stresses that birth is a shared experience for the couple. The Bradley Method encourages acceptance of pain and emphasizes a mind–body connection to enhance relaxation. This model also promotes avoidance of medical intervention, specifically medications, which are assumed to have effects on the baby or interfere with the birth process unless very specific indications are present (Table 1). This is in contrast to the Lamaze Method, which allows for the use of medication as an intervention for pain management.10 In making the choice to avoid the use of medication and minimize the fear of the experience childbirth pain, the couple commits to accept that the body knows what to do and in essence to work with the woman’s body and mind to achieve natural birth.12 Couples who are interested in assuming an active role in decision-making surrounding their birth are attracted to the Bradley Method. It requires their active participation and preparation for childbirth in a natural and unmedicated way. Bradley equated birth to an athletic event and developed a 12-week series of classes designed to prepare a family for birth mentally, physically, and emotionally. In addition to nutrition, these classes teach relaxation methods, education on the birth process, labor support, coaching, and becoming a wise consumer and advocate for sound evidence-based birth decisions. Information on how to accept and manage physical pain so unnecessary interventions can be avoided is the foundation that empowers families to successfully achieve their birth goals. Bradley also places great emphasis on being a good consumer and taking responsibility for one’s birth. Relaxation is taught through the use of normal, rhythmic, abdominal breathing during contractions. Husbands are equally trained in the 12 classes to be able to provide emotional support and assist in maintaining the focus on the shared goal of a safe and unmedicated birth. Their role is to shoulder this responsibility and act as environmental stewards, thereby freeing the woman to labor without concerns for her comfort. After 14,000 births, Bradley reported that 96% of the women had unmedicated births.12 The American Academy of Husband-Coached Childbirth trains candidates to become Bradley Method instructors. The majority of instructors are women who have experienced medication-free childbirth and have attended a Bradley childbirth education series themselves. In contrast to other methods, the Bradley classes are often conducted by couples. The cost of a class series is calculated to be about 10% of the cost of a local birth, and varies throughout communities across the country. Instructors strive for a 90% unmedicated, spontaneous vaginal birth rate. Statistics are submitted yearly to the national headquarters. According to the most current statistics, 87.7% of the couples have an unmedicated vaginal birth.14 The most recent cesarean section rate is 17% (American Academy of Husband-Coached Childbirth National Office, personal communication, August 5, 2008). 471
International Childbirth Educators Association With the evolution of hospital-based childbirth classes from a Lamaze curriculum to one more institutionally focused, classes that were taught by Lamaze instructors are increasingly taught by ICEA-certified childbirth educators. ICEA is a professional nonprofit organization formed in 1960 with approximately 4000 members.5 This organization supports childbirth educators and other health care providers who have an informed choice orientation that promotes freedom of choice based on knowledge of alternatives in family-centered maternity and newborn care. The goals of ICEA are to provide: 1) training and continuing education programs; 2) quality educational resources; and 3) professional certification programs.15 The primary goal and basis of ICEA’s philosophy is family-centered maternity care.15 ICEA members and member groups are autonomous in establishing their own policies and programs. There are no membership requirements other than a commitment to family-centered maternity care and the freedom of choice philosophy based on knowledge of alternatives in childbirth.15 ICEA-certified childbirth educators employ a broad repertoire of techniques to teach women and their partners how to cope with labor. ICEA-certified childbirth educators draw from other childbirth education models, such as the Lamaze and Bradley Methods, in addition to discussing medical options and how to make informed choices. The educator emphasizes ‘‘freedom of choice based on knowledge of alternatives.’’15 The ICEA offers three different tracks to become certified as a childbirth educator. The traditional track is for someone with little or no experience in childbirth education, including health professionals, whereas the other two tracks are for experienced childbirth educators and/ or those certified with another organization. The ICEA also certifies perinatal fitness educators, postnatal educators, and doula and labor support persons.15 Childbirth education classes taught by ICEA-certified educators vary in the number of classes in a series and in cost. Both private and group classes may be arranged. The series sessions range from one meeting to four or more. The cost is variable and depends on the number of sessions, the region of the country, and whether it is a private or group class. These three models of childbirth education all primarily follow a similar group education format, with a series of one or more in-person sessions. All focus on normal, natural birth processes, but each has a unique emphasis, such as husband-coached (Bradley), family-centered (ICEA), or normal birth (Lamaze).
ing and empowering women have been emerging and finding a growing audience. HypnoBirthing – The Mongan Method The premise of HypnoBirthing is that ‘‘.every woman has within her the power to call upon her natural instincts to bring about the best possible birthing for her baby and herself.’’16 HypnoBirthing is as much a philosophy as a method17 and was started by Marie ‘‘Mickey’’ Mongan in 1990. Mongan read Dick-Read’s book, Childbirth Without Fear, in preparation for her own births in the 1950s. After becoming certified in hypnotherapy, she realized that she had used self-hypnosis during her four births ‘‘to achieve the degree of relaxation that made it possible for me to experience painless childbirth.’’17 Mongan notes that Dick-Read ‘‘emphatically denied that his method was at all connected with hypnosis.’’17 Mongan used the hypnosis techniques with her daughter, Maura, who became the first HypnoBirthing mother. HypnoBirthing helps mothers and their families frame birth expectations and experiences in a positive manner. The language of pregnancy, labor, and birth has been changed from the usual medical model terms to more positive, empowering terms. For example, uterine contractions are ‘‘surges,’’ ‘‘coach’’ is instead termed ‘‘birthing companion,’’ and membranes are ‘‘released,’’ not ‘‘ruptured.’’ HypnoBirthing does not teach methods of coping with labor pain—instead, it teaches deep relaxation, visualization, and self-hypnosis, and stresses that childbirth does not need to be painful. The HypnoBirthing teachings are based on Articles of Birth Affirmation.17 Women and their birth companions are encouraged to begin classes early enough in the pregnancy to permit several weeks of practice before birth. The total class time is 12 hours and may be scheduled in either four or six sessions. Information is presented on anatomy and physiology, self-hypnosis, deep relaxation, visualization, and breathing techniques. Information is presented on preparing the body for birthing, birth preferences, releasing negative emotions and fears, and family bonding. Books and CDs are provided at the classes. HypnoBirthing offers a Practitioner Certification program that invites health care professionals, hypnotherapists, and anyone interested in maternal health and birthing. Students without a background in birthing services complete a course, ‘‘Birthing Basics,’’ in addition to the HypnoBirthing curriculum. Nonhypnotherapists complete a course entitled ‘‘Introduction to Hypnosis for Birthing’’ in addition to the certification workshop.16 Mindfulness-Based Childbirth and Parenting
EMERGING MODELS OF CHILDBIRTH EDUCATION While the preceding childbirth education models may meet the needs for some women, newer models for educat472
Another emerging childbirth education model applies the Mindfulness-Based Stress Reduction (MBSR) program developed in the 1970s by Kabat-Zinn and colleagues at Volume 54, No. 6, November/December 2009
the University of Massachusetts Medical School to childbirth and parenting. Kabat-Zinn’s MBSR technique emphasizes skills that cultivate moment-to-moment, nonjudgmental awareness of one’s present experience through meditation. Mindfulness practice can induce states of relaxation, but it is not designated as a relaxation technique. It focuses on developing the capacity to simply observe or witness changing mental and physiologic states without trying to alter those states and achieve some desired state of mind.18 Since its inception, MBSR has been applied in many settings, from schools to technology companies to prisons.19 Recent studies show that MBSR decreases anxiety and depression17 and improves chronic pain, quality of life, and sleep.20–22 Nancy Bardacke, who teaches privately and at the Osher Center for Integrative Medicine at the University of California–San Francisco, applied the methodology used in MBSR to childbirth education. Ms. Bardacke, a nursemidwife and childbirth educator and longtime meditation practitioner herself, participated in a training session for health care providers with Kabat-Zinn in the early 1990s and began teaching the MBSR course soon after.19 In 1998 she began adapting MBSR into MindfulnessBased Childbirth and Parenting (MBCP). The course includes nine 3-hour weekly meetings, a day-long retreat, and a postpartum reunion. An important component of the model is that in addition to attending the course meetings, women and their partners commit to practice meditation and yoga for 30 minutes a day, 6 days a week and to practice mindfulness in daily life. A workbook and 2 CDs are supplied for home practice. Participants also read Full Catastrophe Living by Kabat-Zinn. Results from a recent pilot study of the effects of MBCP conducted at the University of California–San Francisco Osher Center for Integrative Medicine indicate that women who take MBCP experience significant reductions in depression and pregnancy-related anxiety and increases in positive emotion and mindfulness over the course of pregnancy (N. Bardacke, personal communication, January 14, 2009). Given these findings and the positive impact mindfulness skills have in a wide variety of settings, it is a natural fit with newer models of prenatal care, such as CenteringPregnancy. Currently a project is underway to create a Mindfulness-Enhanced CenteringPregnancy curriculum. Birthing From Within Pam England conceived and developed a holistic approach to childbirth education and postpartum preparation after her own births inspired her to think deeply about the needs of childbearing women. She is the creator and coauthor, along with Rob Horowitz, of Birthing from Within: An Extra-Ordinary Guide to Childbirth Preparation. The Birthing from Within childbirth class curricula model encourages freedom and creativity in the teaching Journal of Midwifery & Women’s Health www.jmwh.org
process. Introspective, experiential self-discovery processes are offered along with practical information.23 Parents learn about birth from the mother’s, father’s, baby’s, and the cultural point of view. For example, when mothers learn about labor and birth from the professional’s point of view (complex physiology, complications, and hospital procedures), Birthing from Within states that they are learning about their births from the outside. In contrast, when they learn about what labor will be like as experienced from the mother’s point of view (nonverbal, internally focused, and vulnerable), they are learning about birth from the inside and are energized to take responsibility for protecting the birth space and at less risk of becoming intimidated, passive or defensive.23 According to the Birthing from Within Web site, England has taught thousands of childbirth teachers, doulas, nurses, midwives, natural health practitioners, mothers, and therapists nationally and internationally the Birthing from Within model since 1999. A brief summary of the childbirth education models presented here can be found in Table 2. EVIDENCE-BASED CHILDBIRTH EDUCATION Koehn’s3 integrative literature review of childbirth preparation research examined 12 published studies (11 nonexperimental and 1 experimental) of the effect of childbirth education on outcomes. She found that the studies were methodologically different and contained critical flaws to the extent that no conclusion about childbirth education outcomes could be drawn.3 Koehn proposed four recommendations for future childbirth education studies to advance knowledge about the field in a more effective manner: 1) studies are guided by a model that expects and accounts for input differences in client motivation, birth attendant philosophies, attitudes and practices of obstetric caregivers, and other factors that influence a woman’s perception of childbirth2,24,25; 2) include health-focused outcomes; 3) operationally define the measures of health-focused outcomes and continue the development and use of tools that measure these outcomes; 4) establish standardization/categorization of the childbirth education intervention; and 5) perform a meta-analysis.3 Following Koehn’s review, the Cochrane Collaboration evaluated studies on individual or group antenatal education for childbirth or parenthood, or both.26 The most scientifically sound studies selected were 9 published trials involving 2284 women.26 The authors reviewed randomized controlled trials of any structured group or individual prenatal educational program attended by either parent that included information related to pregnancy, birth, or parenthood.26 The measured variables included knowledge acquisition, sense of control, factors related to infant-care competencies, and some labor and birth outcomes. The effects of general prenatal childbirth (or parenthood) education were determined to be inconclusive.26 473
Table 2. Comparison of Childbirth Education Models/Organizations Childbirth Education Model/Organizations
Main Teaching Points
Average Cost Per Couple
No. of Classes
Lamaze Childbirth Education
Natural childbirth Breathing and relaxation techniques Communication skills Evidence-based Comfort measures
At least 12 hours of instruction; small or large no. of couples in class, check with instructor
The Bradley Method (aka husband-coached childbirth)
Natural childbirth Partner’s active participation Avoidance of medications and medical procedures Nutrition and exercise Relaxation techniques Coping mechanisms
International Childbirth Educators Association
Web Site
$125–$250
www.lamaze.org
12 sessionsa; small classes of 2–6 couples
$300–$350
www.bradleybirth.com
Family-centered maternity care Freedom of choice Alternatives in childbirth Draw from other models
Varies from private class(es) to 1 or more group classes
Varies
www.icea.org
HypnoBirthing – The Mongan Method
Calm, peaceful, natural childbirth Relaxation techniques Negate the fear-tension-pain cycle Education Evidence-based
5 sessionsa; small classes of 2–6 couples
$350 for group classes; $500 for private classes
www.hypnobirthing.com
Mindfulness Childbirth
9 weekly sessions or 1 weekend session; classes vary in size
Contact instructor for pricing
www.mindfulbirthing.org
Birthing from Within
Natural childbirth Soulful and holistic approach Creative self-expression Instructor and couples cocreate class together Coping with challenges
Various sessions (teacher’s choice)
$300–$350
www.birthingfromwithin.com
Natural childbirth Mindfulness Meditation and yoga Stress reduction Awareness Breathing Group dialogue
a
Adapted with permission from D. Jesus. Which childbirth education class is right for you? Available from: www.birthingbabies.com/images/Childbirth_Ed_Comparison.doc [Accessed September 16, 2008]. a
Per the ‘‘official’’ Web site, the course must be taught in this many sessions/hours.
One small, randomized trial (n = 31) that was not included in either of the above reviews evaluated a mindfulness-based intervention during pregnancy on prenatal stress and mood.18 Women who received the intervention had significantly less anxiety (effect size, 0.89; P < .05) and negative affect (effect size, 0.83; P < .05) during the third trimester compared to those who did not.18 CLINICAL IMPLICATIONS When counseling women prenatally, a knowledge of the various models of childbirth education and the available 474
research findings will help the provider ensure a fit between the woman/family’s goals and belief system and that of the childbirth education model’s philosophy and objectives. According to the Cochrane review,1 individualized prenatal education directed at avoidance of repeat caesarean birth did not increase the vaginal birth rate, and so clinicians cannot recommend this as an evidencebased strategy for cesarean birth prevention if that is the woman/families primary motivation for attending classes. Because childbirth information is more easily accessible and widely available than ever before, today’s families need assistance in sorting through the information and Volume 54, No. 6, November/December 2009
evaluating what is accurate and most relevant to them. The goals of today’s expectant parents differ from those in the past and may require newer teaching modalities. In our faster-paced society, they may feel that an 8-week, in-person class series is too large of a commitment and may opt for a shorter class schedule or for online learning. Clinicians and educators must employ more creative strategies, such as using online modalities, starting classes earlier in gestation, and in collaboration with others, such as yoga and fitness instructors. FUTURE RESEARCH DIRECTIONS Rigorous evaluations of childbirth education models are badly needed. The weaknesses noted in the literature reviews reveal that the current advancement of knowledge in this field is not occurring in an effective manner.3 This area is fertile ground for researchers and doctoral students. The effectiveness of childbirth education overall is worth exploration as well as a comparison childbirth education between methods. Other possible avenues of inquiry are the congruency of childbirth education models and maternal culture and beliefs about birth and the effect of childbirth education on the perception of the birth experience. Studies that operationally define measures of health-focused outcomes and establish standardization of the intervention of childbirth education are badly needed.3 In addition, studies that evaluate the stated goals of each type of childbirth education would add to the knowledge about the field. CONCLUSION Childbirth education is indeed at a crossroads.7 Women have access to more information about pregnancy than ever before. What additional education could be best added to childbirth education classes? Childbirth educators must assist women in making sense of the plethora of information available today. They must provide a perspective not seen on most of the popular reality-based birth television shows or commonly heard in the stories shared between women in our culture, many of which suggest that some of the current maternity care practices put mothers and babies at risk. Many younger women come to pregnancy being exposed to only one view of maternity care and believing that all technology and medical interventions increase the safety for mother and baby.7 Childbirth educators can and must provide education to balance this knowledge and clarify the confusing and inaccurate information that is so readily available. Childbirth education proponents are rising to the challenges by changing the curricula to keep pace with societal changes and to address consumer demands and evolving maternity care practices. New ways of partnering are being proposed, such as childbirth educators collaborating with CenteringPregnancy group prenatal care.27 Although Journal of Midwifery & Women’s Health www.jmwh.org
CenteringPregnancy has some similarities to childbirth education; it does not take its place. The group model used by CenteringPregnancy and childbirth education covers similar educational topics, but childbirth education classes continue to be an important component of pregnancy care and are particularly important for first-time parents.27 Another revolution is brewing in childbirth education, one that is similar yet different from the women’s health movement that occurred in the 1960s. Women need to take back birth once again! But childbirth education must meet women on their own terms and help them understand the power of normal birth in ways that are relevant to them. Women and families of this generation have different needs and interests from those in the last century. Childbirth education needs to be an integral part of the family’s experience from the beginning of pregnancy because of the powerful influences of the media and the wealth of information available (both accurate and inaccurate) that contribute to the long-lasting effects of pregnancy and birth. In this article, childbirth education models/organizations and the current research literature were reviewed and recommendations for clinical practice and research were discussed. The current evidence base on the effectiveness of childbirth education on most outcomes is inconclusive, but there is also a dearth of scientifically sound research. In childbirth education practice and research, there are gaps but also abundant opportunities for creative educators and researchers who are passionate about inspiring confident women, facilitating the growth of healthy families, and helping babies get the best start possible.
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8. Zwelling E. The emergence of high-tech birthing. J Obstet Gynecol Neonatal Nurs 2008;37:85–93. 9. Morton CH, Hsu C. Contemporary dilemmas in American childbirth education: Findings from a comparative ethnographic study. J Perinat Educ 2007;16:25–37. 10. Lamaze International Web site. Position paper—Lamaze for the 21st century. Available from: www.lamaze.org/Portals/0/ Policies/3_Lamaze21stCentury.pdf [Accessed on July 14, 2008]. 11. Lothian J, DeVries C. The official Lamaze guide: Giving birth with confidence. New York: Meadowbrook Press, 2005. 12. McCutcheon S. Natural childbirth the Bradley way: Revised edition. London: Penguin Books Ltd, 1996. 13. Bradley RA. Husband-coached childbirth. New York: Bantam Deli, 2008. 14. Cosans C. The meaning of natural childbirth. Perspect Biol Med 2004;47:266–72. 15. International Childbirth Education Association Web site. Available from: www.icea.org [Accessed on December 21, 2008]. 16. HypnoBirthing Web site. Available hypnobirthing.com [Accessed on July 14, 2008].
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17. Mongan M. HypnoBirthing: The Mongan Method. Deerfield Beach, FL: Health Communications, Inc., 2005. 18. Vieten C, Astin J. Effects of a mindfulness-based intervention during pregnancy on prenatal stress and mood: Results of a pilot study. Arch Womens Ment Health 2008;11:67–74. 19. Raguso E. The mindful birth. Greater Good 2008;5:30–3.
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20. Speca M, Carlson LE, Goodey E, Angen M. A randomized, wait-list controlled clinical trial: The effect of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients. Psychosom Med 2000; 62:613–22. 21. Carlson LE, Speca M, Patel KD, Goodey E. Mindfulnessbased stress reduction in relation to quality of life, mood, symptoms of stress and immune parameters in breast and prostate cancer outpatients. Psychosom Med 2003;65:571–81. 22. Carlson LE, Ursuliak Z, Goodey E, Angen M, Speca M. The effects of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients: 6-month follow-up. Support Care Cancer 2001;9:112–23. 23. England P, Horowitz R. ‘‘The birthing from within holistic sphere’’: A conceptual model for childbirth education. J Perinat Educ 2000;9:1–7. 24. Nichols FH. The meaning of the childbirth experience: A review of the literature. J Perinat Educ 1996;5:71–7. 25. Shearer MH. Effects of prenatal education depend on the attitudes and practices of obstetric caregivers. Birth 1990; 17:73–4. 26. Gagnon AJ, Sandall J. Individual or group antenatal education for childbirth or parenthood, or both. Cochrane Database Syst Rev 2007;3:CD002869. 27. Walker DS, Worrell R. Promoting healthy pregnancies through perinatal groups: A comparison of CenteringPregnancy group care and childbirth education classes. J Perinat Educ 2008; 17:27–34.
Volume 54, No. 6, November/December 2009
INTRODUCTION The childbearing year encompasses experiences that have profound and long-lasting effects on women, babies, and families. For this reason, health professionals have long felt that education and preparation are key ingredients to successful pregnancy and birth experiences. Before the late 1930s, most births occurred in the home. Birth was viewed as a normal event in women’s lives, and they were primarily supported in pregnancy and birth by other women, often mothers, grandmothers, or sisters. Formal education and preparation for childbirth were not available and likely not felt to be necessary. However, with the movement of childbirth into the hospital setting, women’s relationship to birth and to those who attended them changed. Women who gave birth in the hospital no longer had the unlimited support of women friends or family members. They were often alone and isolated from support persons and attended primarily by nursing and medical personnel. During this most vulnerable time, women were often ill-prepared for hospital routines and procedures, which led to increased fear and anxiety about the birth process. Childbirth education, as a formal structure, began in the 1960s in the United States. The development was in part a response to the treatment that women experienced during hospital births. The focus of formal childbirth education has primarily been on preparation for childbirth with an emphasis on ‘‘natural’’ processes and, to a lesser extent, newborn care and parenting. In the ensuing decades, the class content has attempted to keep pace with the needs of childbearing women while still maintaining a primary focus on natural processes and education for labor and birth.
Address correspondence to Deborah S. Walker, CNM, DNSc, WHNP-BC, FNP-BC, FACNM, Wayne State University, College of Nursing and School of Medicine, Obstetrics/Gynecology, 5557 Cass Ave., Rm. 248, Detroit, MI 48202. E-mail: [email protected]
Journal of Midwifery & Women’s Health www.jmwh.org Ó 2009 by the American College of Nurse-Midwives Issued by Elsevier Inc.
Almost 50 years has elapsed since the inception of formal childbirth education, and today there are a variety of educational models available. The three types of classes most often attended by pregnant women are taught by educators certified by Lamaze, the Bradley Method, and the International Childbirth Educators Association (ICEA). Many hospital organizations also offer their own childbirth preparation classes tailored to reinforcing the institution’s policies and procedures. In recent years, other models have emerged, such as HypnoBirthing – The Mongan Method, Mindfulness-Based Childbirth preparation, and Birthing from Within. In addition to Lamaze, the Bradley Method, and the ICEA, there are at least three other certifying organizations: the Association for Labor Assistants and Childbirth Educators (ALACE), Birth Works, and Childbirth and Postpartum Professional Association (CAPPA). Despite the continuing expansion of available childbirth education options, research has not shown strong associations between class attendance and the childbirth experience.1–4 In addition, recent national surveys have demonstrated a startling decline in formal childbirth education class participation. In the national survey Listening to Mothers II, just over half (56%) of new mothers who gave birth in 2005 said that they would take childbirth classes.5 This represents a disconcerting decrease of 14% from the 2002 Listening to Mothers survey, when 70% of new mothers answered this question affirmatively.6 The decline in childbirth education class attendance is variously attributed to more women choosing epidural anesthesia,5 elective induction,7 and elective cesarean birth.8 In addition, the decline is due to the basic content and philosophy of childbirth education classes not keeping up with the changing needs of childbearing women.9 Childbirth education is at a crossroads.7 Attendance at classes is down at a time when we are experiencing a crisis in maternity care and education and preparation are needed more than ever. Women look to their health care providers as a source of childbirth information and for direction and 469 1526-9523/09/$36.00 doi:10.1016/j.jmwh.2009.02.013
recommendations. Knowing which types of childbirth education classes are available and which might be the best fit for a particular woman and family with the everexpanding range of choices available can be challenging to the provider. In this article, we review both older, well-established childbirth education models and organizations and new emerging models to help providers as they counsel pregnant women and families. We chose to focus on the 3 most commonly used childbirth education models/organizations (Lamaze, the Bradley Method, and the ICEA) and three of the emerging models (HypnoBirthing, Mindfulness-Based Childbirth, and Birthing from Within). In addition, we present the research literature on the effects of childbirth education on outcomes and recommendations for clinical practice and research. CHILDBIRTH EDUCATION MODELS AND ORGANIZATIONS Grantly Dick-Read, an early 20th-century obstetrician, observed that some women did not experience pain during childbirth. In 1933, he described his theory of pain-free birth in the absence of fear in his first book, Natural Childbirth. The title was changed to Childbirth Without Fear for its second printing in the 1950s. Dick-Read was a pioneer whose theories had a profound impact on childbirth education and provided the foundation for three of the childbirth education models available today: Lamaze, the Bradley Method, and HypnoBirthing. Lamaze The Lamaze Method was introduced in 1951 by the French obstetrician Fernand Lamaze. He was influenced by Ivan Pavlov, an early pioneer in behavioral psychology who was well known for his scientific work on conditioned reflexes. The Lamaze Method consisted of childbirth education, relaxation, and breathing techniques. Lamaze advocated for more aggressive emotional support from the father of the baby, including their involvement with the birth.
Deborah S. Walker, CNM, DNSc, WHNP-BC, FNP-BC, FACNM, is an Associate Professor in the Department of Obstetrics and Gynecology, Wayne State University College of Nursing and School of Medicine, Detroit, MI, and the Graduate Program Director of the Nurse-Midwife and Women’s Health Nurse Practitioner graduate education specialties. Dr. Walker has been active in nursing and midwifery practice, research, and education for more than 30 years. She is a member of the Board of Directors of Lamaze Family Center in Ann Arbor, MI, and was educated as an International Childbirth Education Association Childbirth Educator. Joan M. Visger, CNM, MSN, is a doctoral student at Wayne State University College of Nursing, Detroit, MI. She is certified as a Lamaze instructor and is a HypnoBirthing – The Mongan Method Practitioner. Debra Rossie, CNM, MSN, is a lecturer in the Wayne State University College of Nursing Nurse-Midwifery and Women’s Health Nurse Practitioner specialties, Detroit, MI. She has been a certified nurse-midwife for more than 12 years and is in private practice in southeastern Michigan.
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In the late 1950s, Marjorie Karmel, inspired after reading Dick-Read’s book, was assisted at her birth by Lamaze and subsequently described the birth in her own book, Thank You, Dr. Lamaze. This book helped open the door for fathers to participate in the births of their children in the United States. Soon after her birth experience, Karmel met Elisabeth Bing, and together they established the American Society for Psychoprophylaxis in Obstetrics (ASPO) to promote the Lamaze Method in the United States. Lamaze became synonymous with childbirth education, and hospitals soon modified their childbirth course content and began teaching their own ‘‘Lamaze’’ classes. An early focus of the Lamaze Method was controlled breathing to cope with the discomfort of labor. Breathing and progressive relaxation techniques are no longer the hallmark of Lamaze. Today, Lamaze is not a method but a philosophy that ‘‘provides the foundation and direction for women as they prepare to give birth and become mothers.’’ ASPO was renamed Lamaze International to reflect the philosophy and its international scope. The mission of Lamaze International is to promote, support, and protect normal birth. The overall goal of Lamaze International classes is that ‘‘every woman gives birth confidently, free to find comfort in a wide variety of ways, and supported by family and health care professionals who trust that she has within her the ability to give birth.’’ Lamaze International identifies six care practices to support normal birth (Table 1). Childbirth preparation classes focus on preparing women and their support person(s) for normal birth. Women are encouraged to register for classes early in their third trimester. Courses include at least 12 hours of classroom time and may be held weekly or in weekendintensive formats. The class size is limited to 12 pregnant women and their support person(s). Each class has activities for all learning styles, with an emphasis on experiential learning. The curriculum includes strategies to incorporate the cultural values and beliefs of the participants. The cost of Lamaze classes varies from $35 to $150, depending on geographic location and available resources. Lamaze International offers the only certification program for childbirth educators accredited by the National Commission for Certifying Agencies (NCCA).11 Three flexible pathways are offered for certification based on previous experience: experienced educators, health care professionals, or those new to childbirth education. There is a midwifery pathway that recognizes the training and experience of midwives and student-midwives. Training requirements vary according to the chosen pathway. A rigorous examination is administered after completion of the childbirth educator training. The Bradley Method The Bradley Method is a husband-coached natural childbirth model designed to prepare couples to birth in Volume 54, No. 6, November/December 2009
Table 1. Lamaze’s Six Care Practices and Bradley’s Six Needs of Laboring Women Lamaze Six Care Practices Labor should begin on its own Laboring women should be free to move throughout labor Laboring women should have continuous support from others throughout labor There should be no routine interventions during labor and birth Women should not give birth on their backs Mothers and babies should not be separated after birth and should have unlimited opportunity for breastfeeding
Six Needs of Laboring Women Darkness and solitude Quiet Physical comfort during the first stage of labor Physical relaxation Controlled breathing Need for closed eyes and the appearance of sleep
a normal and natural way without unnecessary medical interventions or medication. The model was developed by Robert A. Bradley, an obstetrician/gynecologist who grew up on a farm in Nebraska. He developed the model after observing the instinctual way that animals give birth compared to the artificial conditions in the hospital setting and how these conditions adversely affected the way women gave birth. He described in Husband-Coached Childbirth what he believed to be the six needs of laboring women (Table 1). The role of the husband as coach is foundational in the Bradley Method. Bradley incorporated these beliefs into his practice and began to teach classes that were focused on the role of husbands who would be able to provide support to their wives while in labor and ensure that the environment met those needs.12 One father expressed it as ‘‘Really feeling like I was a partner and needed. I had a defined role and equally shared decision making with my wife. One week I didn’t do my homework, and it really affected our work in the class.’’ A unique bonding between couples occurs when the vision for birth is clear and mutually shared. This focus evolved as Bradley observed the change in husbands as they were allowed to be present with their wives during labor and birth. His method helped move husbands from being passive observers to having an active role ensuring and protecting the supportive, safe environment necessary for birth. A chapter in Husband-Coached Childbirth12 focuses on the father’s perceptions and responses to birth. The reference to ‘‘coach’’ is used throughout the Bradley book; however, in an effort to keep pace with societal changes, the updated edition13 clarified the use of the word ‘‘husband’’ as the person designated to love and protect the woman in labor. The commitment and attendance to the 12-week Bradley Method classes provides quality time for a couple to secure the emotional, physical, and interpersonal skills to achieve their birth goals. Journal of Midwifery & Women’s Health www.jmwh.org
Not surprisingly, the husband is not the only focus of the Bradley Method. It stresses that birth is a shared experience for the couple. The Bradley Method encourages acceptance of pain and emphasizes a mind–body connection to enhance relaxation. This model also promotes avoidance of medical intervention, specifically medications, which are assumed to have effects on the baby or interfere with the birth process unless very specific indications are present (Table 1). This is in contrast to the Lamaze Method, which allows for the use of medication as an intervention for pain management.10 In making the choice to avoid the use of medication and minimize the fear of the experience childbirth pain, the couple commits to accept that the body knows what to do and in essence to work with the woman’s body and mind to achieve natural birth.12 Couples who are interested in assuming an active role in decision-making surrounding their birth are attracted to the Bradley Method. It requires their active participation and preparation for childbirth in a natural and unmedicated way. Bradley equated birth to an athletic event and developed a 12-week series of classes designed to prepare a family for birth mentally, physically, and emotionally. In addition to nutrition, these classes teach relaxation methods, education on the birth process, labor support, coaching, and becoming a wise consumer and advocate for sound evidence-based birth decisions. Information on how to accept and manage physical pain so unnecessary interventions can be avoided is the foundation that empowers families to successfully achieve their birth goals. Bradley also places great emphasis on being a good consumer and taking responsibility for one’s birth. Relaxation is taught through the use of normal, rhythmic, abdominal breathing during contractions. Husbands are equally trained in the 12 classes to be able to provide emotional support and assist in maintaining the focus on the shared goal of a safe and unmedicated birth. Their role is to shoulder this responsibility and act as environmental stewards, thereby freeing the woman to labor without concerns for her comfort. After 14,000 births, Bradley reported that 96% of the women had unmedicated births.12 The American Academy of Husband-Coached Childbirth trains candidates to become Bradley Method instructors. The majority of instructors are women who have experienced medication-free childbirth and have attended a Bradley childbirth education series themselves. In contrast to other methods, the Bradley classes are often conducted by couples. The cost of a class series is calculated to be about 10% of the cost of a local birth, and varies throughout communities across the country. Instructors strive for a 90% unmedicated, spontaneous vaginal birth rate. Statistics are submitted yearly to the national headquarters. According to the most current statistics, 87.7% of the couples have an unmedicated vaginal birth.14 The most recent cesarean section rate is 17% (American Academy of Husband-Coached Childbirth National Office, personal communication, August 5, 2008). 471
International Childbirth Educators Association With the evolution of hospital-based childbirth classes from a Lamaze curriculum to one more institutionally focused, classes that were taught by Lamaze instructors are increasingly taught by ICEA-certified childbirth educators. ICEA is a professional nonprofit organization formed in 1960 with approximately 4000 members.5 This organization supports childbirth educators and other health care providers who have an informed choice orientation that promotes freedom of choice based on knowledge of alternatives in family-centered maternity and newborn care. The goals of ICEA are to provide: 1) training and continuing education programs; 2) quality educational resources; and 3) professional certification programs.15 The primary goal and basis of ICEA’s philosophy is family-centered maternity care.15 ICEA members and member groups are autonomous in establishing their own policies and programs. There are no membership requirements other than a commitment to family-centered maternity care and the freedom of choice philosophy based on knowledge of alternatives in childbirth.15 ICEA-certified childbirth educators employ a broad repertoire of techniques to teach women and their partners how to cope with labor. ICEA-certified childbirth educators draw from other childbirth education models, such as the Lamaze and Bradley Methods, in addition to discussing medical options and how to make informed choices. The educator emphasizes ‘‘freedom of choice based on knowledge of alternatives.’’15 The ICEA offers three different tracks to become certified as a childbirth educator. The traditional track is for someone with little or no experience in childbirth education, including health professionals, whereas the other two tracks are for experienced childbirth educators and/ or those certified with another organization. The ICEA also certifies perinatal fitness educators, postnatal educators, and doula and labor support persons.15 Childbirth education classes taught by ICEA-certified educators vary in the number of classes in a series and in cost. Both private and group classes may be arranged. The series sessions range from one meeting to four or more. The cost is variable and depends on the number of sessions, the region of the country, and whether it is a private or group class. These three models of childbirth education all primarily follow a similar group education format, with a series of one or more in-person sessions. All focus on normal, natural birth processes, but each has a unique emphasis, such as husband-coached (Bradley), family-centered (ICEA), or normal birth (Lamaze).
ing and empowering women have been emerging and finding a growing audience. HypnoBirthing – The Mongan Method The premise of HypnoBirthing is that ‘‘.every woman has within her the power to call upon her natural instincts to bring about the best possible birthing for her baby and herself.’’16 HypnoBirthing is as much a philosophy as a method17 and was started by Marie ‘‘Mickey’’ Mongan in 1990. Mongan read Dick-Read’s book, Childbirth Without Fear, in preparation for her own births in the 1950s. After becoming certified in hypnotherapy, she realized that she had used self-hypnosis during her four births ‘‘to achieve the degree of relaxation that made it possible for me to experience painless childbirth.’’17 Mongan notes that Dick-Read ‘‘emphatically denied that his method was at all connected with hypnosis.’’17 Mongan used the hypnosis techniques with her daughter, Maura, who became the first HypnoBirthing mother. HypnoBirthing helps mothers and their families frame birth expectations and experiences in a positive manner. The language of pregnancy, labor, and birth has been changed from the usual medical model terms to more positive, empowering terms. For example, uterine contractions are ‘‘surges,’’ ‘‘coach’’ is instead termed ‘‘birthing companion,’’ and membranes are ‘‘released,’’ not ‘‘ruptured.’’ HypnoBirthing does not teach methods of coping with labor pain—instead, it teaches deep relaxation, visualization, and self-hypnosis, and stresses that childbirth does not need to be painful. The HypnoBirthing teachings are based on Articles of Birth Affirmation.17 Women and their birth companions are encouraged to begin classes early enough in the pregnancy to permit several weeks of practice before birth. The total class time is 12 hours and may be scheduled in either four or six sessions. Information is presented on anatomy and physiology, self-hypnosis, deep relaxation, visualization, and breathing techniques. Information is presented on preparing the body for birthing, birth preferences, releasing negative emotions and fears, and family bonding. Books and CDs are provided at the classes. HypnoBirthing offers a Practitioner Certification program that invites health care professionals, hypnotherapists, and anyone interested in maternal health and birthing. Students without a background in birthing services complete a course, ‘‘Birthing Basics,’’ in addition to the HypnoBirthing curriculum. Nonhypnotherapists complete a course entitled ‘‘Introduction to Hypnosis for Birthing’’ in addition to the certification workshop.16 Mindfulness-Based Childbirth and Parenting
EMERGING MODELS OF CHILDBIRTH EDUCATION While the preceding childbirth education models may meet the needs for some women, newer models for educat472
Another emerging childbirth education model applies the Mindfulness-Based Stress Reduction (MBSR) program developed in the 1970s by Kabat-Zinn and colleagues at Volume 54, No. 6, November/December 2009
the University of Massachusetts Medical School to childbirth and parenting. Kabat-Zinn’s MBSR technique emphasizes skills that cultivate moment-to-moment, nonjudgmental awareness of one’s present experience through meditation. Mindfulness practice can induce states of relaxation, but it is not designated as a relaxation technique. It focuses on developing the capacity to simply observe or witness changing mental and physiologic states without trying to alter those states and achieve some desired state of mind.18 Since its inception, MBSR has been applied in many settings, from schools to technology companies to prisons.19 Recent studies show that MBSR decreases anxiety and depression17 and improves chronic pain, quality of life, and sleep.20–22 Nancy Bardacke, who teaches privately and at the Osher Center for Integrative Medicine at the University of California–San Francisco, applied the methodology used in MBSR to childbirth education. Ms. Bardacke, a nursemidwife and childbirth educator and longtime meditation practitioner herself, participated in a training session for health care providers with Kabat-Zinn in the early 1990s and began teaching the MBSR course soon after.19 In 1998 she began adapting MBSR into MindfulnessBased Childbirth and Parenting (MBCP). The course includes nine 3-hour weekly meetings, a day-long retreat, and a postpartum reunion. An important component of the model is that in addition to attending the course meetings, women and their partners commit to practice meditation and yoga for 30 minutes a day, 6 days a week and to practice mindfulness in daily life. A workbook and 2 CDs are supplied for home practice. Participants also read Full Catastrophe Living by Kabat-Zinn. Results from a recent pilot study of the effects of MBCP conducted at the University of California–San Francisco Osher Center for Integrative Medicine indicate that women who take MBCP experience significant reductions in depression and pregnancy-related anxiety and increases in positive emotion and mindfulness over the course of pregnancy (N. Bardacke, personal communication, January 14, 2009). Given these findings and the positive impact mindfulness skills have in a wide variety of settings, it is a natural fit with newer models of prenatal care, such as CenteringPregnancy. Currently a project is underway to create a Mindfulness-Enhanced CenteringPregnancy curriculum. Birthing From Within Pam England conceived and developed a holistic approach to childbirth education and postpartum preparation after her own births inspired her to think deeply about the needs of childbearing women. She is the creator and coauthor, along with Rob Horowitz, of Birthing from Within: An Extra-Ordinary Guide to Childbirth Preparation. The Birthing from Within childbirth class curricula model encourages freedom and creativity in the teaching Journal of Midwifery & Women’s Health www.jmwh.org
process. Introspective, experiential self-discovery processes are offered along with practical information.23 Parents learn about birth from the mother’s, father’s, baby’s, and the cultural point of view. For example, when mothers learn about labor and birth from the professional’s point of view (complex physiology, complications, and hospital procedures), Birthing from Within states that they are learning about their births from the outside. In contrast, when they learn about what labor will be like as experienced from the mother’s point of view (nonverbal, internally focused, and vulnerable), they are learning about birth from the inside and are energized to take responsibility for protecting the birth space and at less risk of becoming intimidated, passive or defensive.23 According to the Birthing from Within Web site, England has taught thousands of childbirth teachers, doulas, nurses, midwives, natural health practitioners, mothers, and therapists nationally and internationally the Birthing from Within model since 1999. A brief summary of the childbirth education models presented here can be found in Table 2. EVIDENCE-BASED CHILDBIRTH EDUCATION Koehn’s3 integrative literature review of childbirth preparation research examined 12 published studies (11 nonexperimental and 1 experimental) of the effect of childbirth education on outcomes. She found that the studies were methodologically different and contained critical flaws to the extent that no conclusion about childbirth education outcomes could be drawn.3 Koehn proposed four recommendations for future childbirth education studies to advance knowledge about the field in a more effective manner: 1) studies are guided by a model that expects and accounts for input differences in client motivation, birth attendant philosophies, attitudes and practices of obstetric caregivers, and other factors that influence a woman’s perception of childbirth2,24,25; 2) include health-focused outcomes; 3) operationally define the measures of health-focused outcomes and continue the development and use of tools that measure these outcomes; 4) establish standardization/categorization of the childbirth education intervention; and 5) perform a meta-analysis.3 Following Koehn’s review, the Cochrane Collaboration evaluated studies on individual or group antenatal education for childbirth or parenthood, or both.26 The most scientifically sound studies selected were 9 published trials involving 2284 women.26 The authors reviewed randomized controlled trials of any structured group or individual prenatal educational program attended by either parent that included information related to pregnancy, birth, or parenthood.26 The measured variables included knowledge acquisition, sense of control, factors related to infant-care competencies, and some labor and birth outcomes. The effects of general prenatal childbirth (or parenthood) education were determined to be inconclusive.26 473
Table 2. Comparison of Childbirth Education Models/Organizations Childbirth Education Model/Organizations
Main Teaching Points
Average Cost Per Couple
No. of Classes
Lamaze Childbirth Education
Natural childbirth Breathing and relaxation techniques Communication skills Evidence-based Comfort measures
At least 12 hours of instruction; small or large no. of couples in class, check with instructor
The Bradley Method (aka husband-coached childbirth)
Natural childbirth Partner’s active participation Avoidance of medications and medical procedures Nutrition and exercise Relaxation techniques Coping mechanisms
International Childbirth Educators Association
Web Site
$125–$250
www.lamaze.org
12 sessionsa; small classes of 2–6 couples
$300–$350
www.bradleybirth.com
Family-centered maternity care Freedom of choice Alternatives in childbirth Draw from other models
Varies from private class(es) to 1 or more group classes
Varies
www.icea.org
HypnoBirthing – The Mongan Method
Calm, peaceful, natural childbirth Relaxation techniques Negate the fear-tension-pain cycle Education Evidence-based
5 sessionsa; small classes of 2–6 couples
$350 for group classes; $500 for private classes
www.hypnobirthing.com
Mindfulness Childbirth
9 weekly sessions or 1 weekend session; classes vary in size
Contact instructor for pricing
www.mindfulbirthing.org
Birthing from Within
Natural childbirth Soulful and holistic approach Creative self-expression Instructor and couples cocreate class together Coping with challenges
Various sessions (teacher’s choice)
$300–$350
www.birthingfromwithin.com
Natural childbirth Mindfulness Meditation and yoga Stress reduction Awareness Breathing Group dialogue
a
Adapted with permission from D. Jesus. Which childbirth education class is right for you? Available from: www.birthingbabies.com/images/Childbirth_Ed_Comparison.doc [Accessed September 16, 2008]. a
Per the ‘‘official’’ Web site, the course must be taught in this many sessions/hours.
One small, randomized trial (n = 31) that was not included in either of the above reviews evaluated a mindfulness-based intervention during pregnancy on prenatal stress and mood.18 Women who received the intervention had significantly less anxiety (effect size, 0.89; P < .05) and negative affect (effect size, 0.83; P < .05) during the third trimester compared to those who did not.18 CLINICAL IMPLICATIONS When counseling women prenatally, a knowledge of the various models of childbirth education and the available 474
research findings will help the provider ensure a fit between the woman/family’s goals and belief system and that of the childbirth education model’s philosophy and objectives. According to the Cochrane review,1 individualized prenatal education directed at avoidance of repeat caesarean birth did not increase the vaginal birth rate, and so clinicians cannot recommend this as an evidencebased strategy for cesarean birth prevention if that is the woman/families primary motivation for attending classes. Because childbirth information is more easily accessible and widely available than ever before, today’s families need assistance in sorting through the information and Volume 54, No. 6, November/December 2009
evaluating what is accurate and most relevant to them. The goals of today’s expectant parents differ from those in the past and may require newer teaching modalities. In our faster-paced society, they may feel that an 8-week, in-person class series is too large of a commitment and may opt for a shorter class schedule or for online learning. Clinicians and educators must employ more creative strategies, such as using online modalities, starting classes earlier in gestation, and in collaboration with others, such as yoga and fitness instructors. FUTURE RESEARCH DIRECTIONS Rigorous evaluations of childbirth education models are badly needed. The weaknesses noted in the literature reviews reveal that the current advancement of knowledge in this field is not occurring in an effective manner.3 This area is fertile ground for researchers and doctoral students. The effectiveness of childbirth education overall is worth exploration as well as a comparison childbirth education between methods. Other possible avenues of inquiry are the congruency of childbirth education models and maternal culture and beliefs about birth and the effect of childbirth education on the perception of the birth experience. Studies that operationally define measures of health-focused outcomes and establish standardization of the intervention of childbirth education are badly needed.3 In addition, studies that evaluate the stated goals of each type of childbirth education would add to the knowledge about the field. CONCLUSION Childbirth education is indeed at a crossroads.7 Women have access to more information about pregnancy than ever before. What additional education could be best added to childbirth education classes? Childbirth educators must assist women in making sense of the plethora of information available today. They must provide a perspective not seen on most of the popular reality-based birth television shows or commonly heard in the stories shared between women in our culture, many of which suggest that some of the current maternity care practices put mothers and babies at risk. Many younger women come to pregnancy being exposed to only one view of maternity care and believing that all technology and medical interventions increase the safety for mother and baby.7 Childbirth educators can and must provide education to balance this knowledge and clarify the confusing and inaccurate information that is so readily available. Childbirth education proponents are rising to the challenges by changing the curricula to keep pace with societal changes and to address consumer demands and evolving maternity care practices. New ways of partnering are being proposed, such as childbirth educators collaborating with CenteringPregnancy group prenatal care.27 Although Journal of Midwifery & Women’s Health www.jmwh.org
CenteringPregnancy has some similarities to childbirth education; it does not take its place. The group model used by CenteringPregnancy and childbirth education covers similar educational topics, but childbirth education classes continue to be an important component of pregnancy care and are particularly important for first-time parents.27 Another revolution is brewing in childbirth education, one that is similar yet different from the women’s health movement that occurred in the 1960s. Women need to take back birth once again! But childbirth education must meet women on their own terms and help them understand the power of normal birth in ways that are relevant to them. Women and families of this generation have different needs and interests from those in the last century. Childbirth education needs to be an integral part of the family’s experience from the beginning of pregnancy because of the powerful influences of the media and the wealth of information available (both accurate and inaccurate) that contribute to the long-lasting effects of pregnancy and birth. In this article, childbirth education models/organizations and the current research literature were reviewed and recommendations for clinical practice and research were discussed. The current evidence base on the effectiveness of childbirth education on most outcomes is inconclusive, but there is also a dearth of scientifically sound research. In childbirth education practice and research, there are gaps but also abundant opportunities for creative educators and researchers who are passionate about inspiring confident women, facilitating the growth of healthy families, and helping babies get the best start possible.
REFERENCES 1. Gagnon AJ. Individual or group antenatal childbirth education for childbirth/parenthood. Cochrane Database Syst Rev 2007;3: CD002869. 2. Humenick SS. Program evaluation. In: Nichols FH, Humenick SS, editors. Childbirth education: Practice, research, and theory. Philadelphia: W.B. Saunders, 2000:592–608. 3. Koehn ML. Childbirth education outcomes: an integrative review of the literature. J Perinat Educ 2002;11:10–9. 4. Spilby H, Slade P, Escott D, Henderson B, Fraser R. Selected coping strategies in labor: an investigation of women’s experiences. Birth 2003;30:189–94. 5. Declercq ER, Sakala C, Corry MP, Applebaum S. Listening to mothers II: Report of the second national U.S. survey of women’s childbearing experiences. New York: Childbirth Connection, 2006. 6. Declercq ER, Sakala C, Corry MP, Applebaum S, Risher P. Listening to mothers: Report of the first national U.S. survey of women’s childbearing experiences. New York: Maternity Center Association, 2002. 7. Lothian JA. Childbirth education as the crossroads. J Perinat Educ 2008;17:45–9. 475
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Volume 54, No. 6, November/December 2009