- Email: [email protected]
Education for Childbirth: A Time for Change
thoughts and opinions
for Change SANDRA G. LINDELL, CNM, MS In earlier times, people were well-acquainted with childbearing and childrearing through their contacts within the extended family. However, during this century, several factors have affected changes in traditional birthing attitudes and practices and have precipitated the need for formal education in childbirth. This position article reviews the history and literature of the development of contemporary education for childbirth classes as well as the research on the effects of formal childbirth education instruction. Suggestions for further research and future directions of change are provided.
~
AN HISTORICAL PERSPECTIVE
In earlier times, young people were well acquainted with childbearing and childrearing through their contacts within the extended family. Childbirth was characterized by a social orientation in which birth was a social event, centered in the home, with family and friends in attendance. During the nineteenth century, however, the Industrial Revolution and its subsequent urban crowding and severe health problems affected changes in societal attitudes toward childbirth. During this time, maternal mortality secondary t o childbirth was not uncommon, and infants who survived delivery often succumbed to sepsis o r infant diarrhea.’ Concurrently, significant advances in the fields of
Accepted: July 1987
108
medicine, in particular the discovery of antibiotics to reduce morbidity/mortality and anesthesia, and public health were made.2 Of t h e several a d v a n c e s that emerged in America during this e r a and that had a fundamental impact and influence on changing childbirth attitudes and practices, t h e most influential included 1) the emergence of obstetrics as a male-do m i na t e d profession ; 2) continued urbanization and industrialization with multiple effects on the family and sex-roles; and 3) the introduction of various drugs and obstetric techniques to control pain a n d combat puerperal (childbed) fever.’ T h e s e factors combined to move childbirth far from nature a n d t h e control of women. As a result, women who entered the health-care system to give birth were rendered powerless to participate in their childbirth experiences, a n d t h e s e women acquiesced because they
believed childbirth would be safer.’ After 1930, and only gradually, did women begin to realize that centralization in hospitals and routinization of birth practices had brought fundamental alterations a n d new problems to childbearing. By the 1950s and 1960s, women began to question the safety of extensive manipulation, strong medications, a n d t h e many routine p r o c e d u r e s commonly used in labor and delivery. In addition, a societal reemphasis on domesticity encouraged women to believe that motherhood was women’s fundamental purpose, a n d a s women, mothers should be awake a n d aware while giving birth. Slowly, this cultural movement toward natural childbirth, encouraging women to enhance their birth experiences, took o n a social a s well a s a political tone. Women began to organize, to educate each other, and to try to change or to
March/April 1988 JOG”
avoid t h e rigid s t r u c t u r e that changes in societal mores, t h e health-care field, a n d medical practice had succeeded in imposing on the birth process.’
Technological advances and social changes combined to make childbirth an unnatural process and to remove the birth process from the control of pregnant women. Society was, thus, ripe for a popular book written by a British obstetrician, Grantley Dick-Read. The 1944 classic, Childbirth Without Fear, was based on the concept that the pain of labor can be eliminated through reducing the fear, apprehension, and tension associated with Dick-Read’s approach continues to be a popular method for t h e management of labor pain. Dick-Read was followed by Ferdinand LaMaze, whose structural a p p r o a c h of carefully prescribed breathing patterns and neuromuscular relaxation was based on the techniques of Russian physiologist Pavlov. A variety of psychological paincontrol techniques h a s emerged as a result of the natural childbirth movement. For the most part, all pain-control techniques are modifications of Dick-Read a n d LaMaze’s original programs. Cenerally, the emphasis of each of the alternatives is placed on t h e woman’s active participation in the process of birth and on her ability to practice techniques and regulate her performance. The underlying principle of childbirth education is that the woman can use her intellect and follow certain prescribed methods to control her body during ~ h i l d b i r t h . ~ T h e preparatory a p p r o a c h e s described herein were organized
March/April 1988 JOGNN
according to personal and informal, not systematic, empirical re~earch.~ RESEARCH REVIEW
Research reports of childbirth outcomes resulting from formal preparation have been inconsistent. Programs have been shown from a psychological viewpoint to promote positive attitudes towards labor and delivery and to foster early maternal-infant attachment.6-” However, opinions on the physiological effectiveness of these methods in terms of duration of labor, amount of analgesia/ anesthesia used during labor, and effect of labor upon the infant a r e wide and divergent. Some investigators claim that formal preparation reduces the amount of analgesia and anesthesia necessary during labor and del i ~ e r y . ’ ~ ”The - ’ ~ results of investigations led by Melzack et a1.I6 and Copstick et aI.l7 d o not support these claims, while other writers note difficulty in differentiating between women p r e p a r e d for childbirth and those women unprepared for childbirth.’0,18-‘o McClearly points out that enhancing t h e couple’s knowledge about childbirth by prenatal education decreases fears that might otherwise cause stress at the time of d e 1 i ~ e r y . lHorowitz ~ and Horowitz claim that t h e techniques learned in the various classes, the repetition of the step-by-step sequence of labor and birth, and the group support provided in classes are all instrumental in developing coping capabilities for the birth process.2’ Walker and Erdman found that women’s abilities t o c o p e with labor are significantly greater after attending classes, according to their own assessments.” Several authors suggest that formal preparation enables the woman to experience a s h o r t e r duration of
labor. 14.23-25 Yet, both Patton et al. a n d Reid found evidence that labor was not significantly shorter in those women who had formally p r e p a r e d for natural childbirth ,20.26 Copstick et al. and Sosa et al. report studies in which women in labor derived significant benefits simply from the presence of support p e r ~ o n s . ’ ~Furthermore, *‘~ a s t u d y of first-time parents by Markham a n d Kadushin concluded that Lamaze-type training may prevent decreases in marital satisfaction and increases in anxiety and postbirth problems.’* To t h e list of claimed benefits, Thomas and Karlovsky-conducting a s t u d y of 2,000 deliveries under a childbirth training program at Yale-added a “greatly lessened number of depressed infants at birth, fewer operative deliveries, less blood loss, smoother convalescence, and finally happier
mother^."'^
Criticism has been directed at current childbirth education methods for being instructive rather than enlightening and rigid rather than flexible and personal. All of these studies and claims a r e brought into question by two comprehensive reviews of the literature. A review and analysis conducted by Beck a n d Hall in 1978 and another done by Beck and Siege1 in 1980 concluded that the research on the outcomes of childbirth education a s a whole was characterized by serious methodologic shortcomings, including the use of inappropriate control groups and failure to assign subjects randomly to treatment group.^.^^.^" These reviewers also acknowledged the difficulties
109
inherent in conducting well-controlled outcome research in clinical settings. Only recently have childbirth education r e s e a r c h e r s begun to address these experimental problems. Groups at the University of M is sour i -Columbia a r e conduct ing analogue research o n labor pain and are scientifically studying t h e effects of various paincoping s t r a t e g i e ~ . ~ . ~In' . a" ~1980 study of 80 nulliparous women comparing t h e efficacy of relaxation training, informative lectures, a n d breathing exercises, Beck and Siege1 found relaxation to be the most therapeutically active component of a pain-coping program.") Subsequently, Geden et al. conducted a study to examine the efficacy of more recently developed pain-coping strategies. Geden et al. studied t h e self-reported pain and the psychophysiological effects of relaxation, sensory transformation, and imagery and stress inoculation with a laboratory analogue of labor in 100 nulliparous women.3' Only o n e strategy, sensory tranformation, the use of imagination to transform painful sensations into pleasant feelings, was found to have a significant effect on self-reported pain. Clinicians have little factual information on which components of a regimen produce therapeutic benefits. Geden e t a ] . contend that the effects of preparation might be enhanced by deleting the less effective strategies such a s breathing patterns, abdominal stroking, a n d timing contractions, while adding emphasis to those strategies that have been proven to be more effective such a s relaxation techniques, sensory transformation, and husband presence."' Further criticism h a s been directed at current childbirth education methods for being instructive, rather than e n l i g h t e n i ~ ~ Noble g.~ c o n t e n d s that childbirth educa-
110
tors have taken a linear approach to preparation by considering the process of childbirth t o be orderly a n d manageable. Noble believes that behavior control is inappropriate in the birthing process and that n o single form of preparation will suffice, regardless of t h e claimed outcomes. Women's needs vary widely, and as a result, women react differently to pain a n d anxiety a n d find different techniques helpful in coping with the intensity of labor and delivery. Even though t h e individual prescription varies from o n e type of class to the next, the typical preparation for childbirth class offers a set prescription for childbirth success. From a historical perspective, o n e can understand that proponents of natural childbirth needed to provide a total program of active mastery over pain control that could be substituted for the pain relief offered by scopolamine and general anesthesia. For today's couples, however, that battle has been won, and a less rigid regimen is more appropriate for pain control. Nevertheless, many contemporary childbirth educators have been slow to appreciate this need for c h a n g e in t h e s t r u c t u r e of childbirth education. As a result, couples continue t o be trained according to the philosophy of work, control, and achievement, and a s Noble states, "rehearsed, resolute, and goal-oriented, these couples go into labor a s into omb bat."^:' Scant data is available concerning the reasons why women seek childbirth education a n d how their motives may influence participation and the results of this parti~ipation."~ Too often, classes a r e chosen o n the basis of cost, proximity, o r a friend's recommendation, r a t h e r than o n t h e basis of content, approach, a n d t h e woman's/couple's learning style and needs. Indeed, the reasons couples attend classes a r e as
variable as the methods of preparation available. Presumably, motivations have a significant influe n c e o n how (or whether) the m e t h o d s taught a r e used and whether the use of various techniques relates to the couple's perceptions of success in t h e birth process. In previous studies, the participant populations have been divided into attenders and nonatt e n d e r s of childbirth education classes. Perhaps a more appropriate subpopulation assignment for s t u d y of childbirth educati o n wou 1d d ivi de participants into compliant and noncompliant groups. To t h e author's knowledge, only o n e study to date has investigated whether women actually perform a s they have been instructed.3s In this 1986 study, Lindell and Kossi found that women did not d o what they were taught in childbirth classes. Ninety-four percent of the women who were taught traditional pushing did not use breath holding a n d 60% did not maintain t h e position they were taught. These women moved and breathed in response to their physiological direction during second stage of labor when they were allowed and encouraged to d o so. IMPLICATIONS FOR PRACTICE
This review of history and the research literature calls attention to the emphasis of current preparation for childbirth classes that has been based on what expectant couples should know and do. Educators and researchers have concentrated o n teaching techniques rather than o n developing a way to enhance t h e couple's understanding of childbirth a s well a s their personal, individual responses to the birth process. Rather than offering classes which mold couples to the requirements of the healthcare system, childbirth educators
March/April 1988 JOG"
should provide education according to the consumers’ needs. These needs include information about the processes of pregnancy, labor and delivery, assistance in preparing a realistic birth plan, and an understanding of the couples’ roles in the decision-making process. Active participation and self-responsibility are the fundamental goals of such an approach. Educators need to examine current methods of instruction. Currently, the same type of approach, providing information and teaching breathing and relaxation techniques, is most often used by all educators. Perhaps , educators should begin to recognize the different learning needs and styles of the wide variety of people served. At the very least, groups could separately address teenagers, first-time parents, older first-time parents, and single women. A cogent example of the implementation of such a recommendation was recently reported by SlagerEarnest, Hoffman, and Beckmann in a study demonstrating the positive effects of a specialized prenatal education program on the perinatal outcomes of 50 pregnant adolescent^.^^ Combining a multidisciplinary team approach and comprehensive health-care services in coordination with prenatal education resulted in significantly fewer obstetric, postnatal, and neonatal complications among those adolescents who participated in the educational program. Classes tend to be very large as providers attempt to efficiently and cost-effectively market their products. However, large classes may not be as effective as smaller, more individualized classes. Croups of five to seven couples afford individual attention and incentive to participation. Large numbers inhibit group process, and as Dorsey points out, the experiential learning that can be derived from the group process can be a s signifi-
March/April 1988 J O G N N
cant as the learning of specific skills.37 The philosophy behind childbirth preparation is more significant than the actual teaching technique. An important component of the educative process that educators need to impart to couples preparing for childbirth is confidence, an all-abiding belief that the natural processes of labor and birth can be trusted. Only by instilling basic confidence can the educator provide individualized and appropriate guidance without usurping the couple’s abilities to manage their preparation for and the actual birth of the child. Perhaps, what couples need most is guidance on how to tune into themselves.
Childbirth educators need to recognize the different learning needs of various groups such as teenagers, first-time parents, older first-time parents, and single women. A woman can do this by becoming aware of her natural, individual response t o a contraction rather than immediately starting a prescribed pattern of breathing. In this way, a laboring woman gives herself a chance to find her own way to work with her labor. For the husband’s part, a heightened awareness and attention to his partner’s needs as well as support of her work in labor provides a strong sense of partnership and accomplishment to both partners. The husband can demonstrate his awareness and support by his physical presence as well as with concrete comfort measures. Thus, rather than learning a rather rigid set of information and techniques to control their bodies, women can learn to respond to felt
messages such as to breathe faster or to change position. Much of the research conducted to date has been called into question and many more studies are needed. Research that would add valuable insights includes investigating the effectiveness of techniques, outcome parameter differences between educators who use a given technique and those who do not, and comparison of the difference in benefit gained from a given technique or from presence of a supportive companion without a prescribed technique. Care givers and educators need concrete data on all aspects of preparation by which to justify methods of education and practice and/or to motivate and give direction to change. SUMMARY
The current approaches taken to childbirth education developed, at least in part, in response to the medical management of labor and delivery. Attitudes toward the birth process as well as medical necessities for safety have changed. However, childbirth education classes have been slow to follow suit. In light of these changes and of new research in the area, the time is right for educators to look critically at what has been done, build on what has proven effective, and discard what is no longer appropriate for childbirth education. REFERENCES
and D. W e r t z . 1979. Lying in: A history of childbirth in America. New York: Schocken Books. 2. Garbarino J. 1982. The ecology of childbearing und childrearing in children and families in the social enuironment. New York: Aldine Pub. Co. 3. Read, G.D. 1944. Childbirth without fear. New York: Harper and Brothers Publishers. 1. Wertz, R.,
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4. Noble, E. 1983. Childbirth with insight. Boston: Houghton Mifflin Co. 5. Geden. E., N. Beck, G. Hauge, and S. Pohlman. 1984. Self-support and psychophysiological effects of five pain-coping strategies. Nurs. Res. 33( 5):260-65. 6. Doering, S., and D. Entwisle. 1975. Preparation during pregnancy and ability to cope with labor and delivery. Am. J . Orthopsychiatry 45:a25-37. 7. Caziano, E.. and M. Garvis. 1976. An evaluation of childbirth education for the clinic patient. Birth 6189-96. 8. Newman, L.. J. Kennell, M. Klaus, a n d J . Schreiber. 1976. Early human interaction: Mother a n d child. Primary Cure 3:491-95. 9. Nunnally, D., and M. Aguiar. 1974. Patients' evaluation of their prenatal and delivery care. Nurs. Res. 23:469-74. 10. Tanzer, D., and J. Block. 1972. Why natural childbirth. New York: Doubleday and Co. 11. Zax, M., A. Sameroff, and J. Farnum. 1975. Childbirth education, maternal attitudes, and delivery. Am. J. Obstet. Cynecol. 123:185-90. 12. Davenport-Slack, B., and C. Boyland. 1974. Psychological correlates of childbirth pain. Psychosom. Med. 36215. 13. McCleary. E. 1974. New miracles of childbirth. New York: David McKay co. 14. Shapiro, H., and L. Schmitt. 1970. Evaluation of the psychoprophylactic method of childbirth in the primigravida. Conn. Med. 37:34143. 15. Vellay, P. 1972. Painless labor. In Modern perspectives in psychoobstetrics, ed. J. Howell. New York: BrunnerJMazel, 328-39. 16. Melzak, P., P. Taenzer, P. Feldman, and R. Kinch. 1981. Labour still painful after prepared childbirth training. Can. Med. Assoc. J. 125: 357-63. 17. Copstick, S.M., K.E. Taylor, R. Hayes, a n d N. Morris. 1986. Partner support a n d t h e u s e of
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coping techniques in labour. J. Psychosom. Res. 30(4):497-503. 18. Davis, C., and F. Morrone. 1962. An objective evaluation of a prepared childbirth program. Obstet. Gynecol. 84:1196-206. 19. Leonard, R. 1973. Evaluation of selection tendencies of patients preferring prepared childbirth. Obstet. Cynecol. 42:371-77. 20. Patton, L.L., E.C. English, and J.D. Hambleton. 1985. Childbirth preparation and outcomes of labor and delivery in primiparous women. J. Fam. Prac. 20(4):375-78. 21. Horowitz, M., a n d N. Horowitz. 1967. Psychological effects of education for childbirth. Psychosomatics 8:196-202. 22. Walker, B., and A. Erdman. 1984. Childbirth education programs: The relationship between confid e n c e a n d knowledge. Birth 11: 103-08. 23. Huttel, F. 1972. A quantitative evaluation of psycho-prophylaxis in childbirth. J . Psychosom. Res. 16:81-92. 24. T h o m a s , H., a n d E. Karlovsky. 1954. 2000 deliveries u n d e r a training for childbirth program. Am. J. Obstet. Gynecol. 68:279-84. 2.5. Velvovky, T., K. Platanov, V. Plotichen, and E. Shugom. 1960. Painless childbirth through psychoprophylaxis. Moscow: Foreign Language Publishing House. 26. Reid, D. 1972. Principles and management for human reproduction. Philadelphia: W.B. Saunders Co. 27. Sosa, R., J. Kennell, and M. Klaus. 1980. T h e effect of a supportive companion o n perinatal problems, length of labor, and motherinfant interaction. N. Enyl. J. Med. 303( 11):597-600. 28. Markham H.J., and F.S. Kadushin. 1986. Preventive effects of Lamaze training for 1st-time parents: A short-term longitudinal study. J. Consult. Clin. Psychol. 54(6):87274. 29. Beck, N., and D. Hall. 1978. Natural childbirth: A review and analysis. Obstet. Cynecol. 52(3):371-79.
30. Beck, N., and L. Siegel. 1980. Preparation for childbirth and contemporary research on pain, anxiety, and stress reduction: A review and critique. Psychosom. Med. 42(4): 429-47. 31. Geden, E., N. Beck, G. Brouder, and E. O'Connell. 1983. Identifying procedural components for analogue research of labor pain. Nurs. Res. 32(2):80-83. 32. Geden, E., N.C. Beck, G. Brouder, J. Glaister, and S. Pohlman. 1985. Self-report and psychological effects of Lamaze preparation: An analogue of labor pain. Res. Nurs. and Health 8(2):155-65. 33. Noble, E. 1981. Controversies in maternal effort during labor and delivery. J. Nurs. Midwif 26(2): 13-22. 34. McCraw, R., a n d J . Abplanalp. 1982. Motivation to take childbirth education: Implications for studies of effectiveness. Birth 9:179182. 35. Lindell, S., and M. Rossi. 1986. Compliance with childbirth education instruction. Birth 13(2):9699. 36. Slager-Earnest, S.E., S.J. Hoffman, and C.J.A. Beckmann. 1987. Effects of a specialized prenatal adolescent program on maternal and in16(6):422fant outcomes. JOG" 29. 37. Dorsey, E. 1978. Group process and childbirth education: A position paper. JOCN Nurs. 7(4):51-54.
Address for correspondence: Sandra G. Lindell, CNM, MS, University of Minnesota, School of Nursing, 308 Harvard Street, 6-101 Unit F. Minneapolis, M N 55455-0342.
Sandra Lindell is an instructor in the NurseMidwifery Program at the University of Minnesota School of Nursing in Minneapolis, Minnesota. Ms. Lindell is a member of the American College of Nurse-Midwives.
March/April 1988 JOGNN
for Change SANDRA G. LINDELL, CNM, MS In earlier times, people were well-acquainted with childbearing and childrearing through their contacts within the extended family. However, during this century, several factors have affected changes in traditional birthing attitudes and practices and have precipitated the need for formal education in childbirth. This position article reviews the history and literature of the development of contemporary education for childbirth classes as well as the research on the effects of formal childbirth education instruction. Suggestions for further research and future directions of change are provided.
~
AN HISTORICAL PERSPECTIVE
In earlier times, young people were well acquainted with childbearing and childrearing through their contacts within the extended family. Childbirth was characterized by a social orientation in which birth was a social event, centered in the home, with family and friends in attendance. During the nineteenth century, however, the Industrial Revolution and its subsequent urban crowding and severe health problems affected changes in societal attitudes toward childbirth. During this time, maternal mortality secondary t o childbirth was not uncommon, and infants who survived delivery often succumbed to sepsis o r infant diarrhea.’ Concurrently, significant advances in the fields of
Accepted: July 1987
108
medicine, in particular the discovery of antibiotics to reduce morbidity/mortality and anesthesia, and public health were made.2 Of t h e several a d v a n c e s that emerged in America during this e r a and that had a fundamental impact and influence on changing childbirth attitudes and practices, t h e most influential included 1) the emergence of obstetrics as a male-do m i na t e d profession ; 2) continued urbanization and industrialization with multiple effects on the family and sex-roles; and 3) the introduction of various drugs and obstetric techniques to control pain a n d combat puerperal (childbed) fever.’ T h e s e factors combined to move childbirth far from nature a n d t h e control of women. As a result, women who entered the health-care system to give birth were rendered powerless to participate in their childbirth experiences, a n d t h e s e women acquiesced because they
believed childbirth would be safer.’ After 1930, and only gradually, did women begin to realize that centralization in hospitals and routinization of birth practices had brought fundamental alterations a n d new problems to childbearing. By the 1950s and 1960s, women began to question the safety of extensive manipulation, strong medications, a n d t h e many routine p r o c e d u r e s commonly used in labor and delivery. In addition, a societal reemphasis on domesticity encouraged women to believe that motherhood was women’s fundamental purpose, a n d a s women, mothers should be awake a n d aware while giving birth. Slowly, this cultural movement toward natural childbirth, encouraging women to enhance their birth experiences, took o n a social a s well a s a political tone. Women began to organize, to educate each other, and to try to change or to
March/April 1988 JOG”
avoid t h e rigid s t r u c t u r e that changes in societal mores, t h e health-care field, a n d medical practice had succeeded in imposing on the birth process.’
Technological advances and social changes combined to make childbirth an unnatural process and to remove the birth process from the control of pregnant women. Society was, thus, ripe for a popular book written by a British obstetrician, Grantley Dick-Read. The 1944 classic, Childbirth Without Fear, was based on the concept that the pain of labor can be eliminated through reducing the fear, apprehension, and tension associated with Dick-Read’s approach continues to be a popular method for t h e management of labor pain. Dick-Read was followed by Ferdinand LaMaze, whose structural a p p r o a c h of carefully prescribed breathing patterns and neuromuscular relaxation was based on the techniques of Russian physiologist Pavlov. A variety of psychological paincontrol techniques h a s emerged as a result of the natural childbirth movement. For the most part, all pain-control techniques are modifications of Dick-Read a n d LaMaze’s original programs. Cenerally, the emphasis of each of the alternatives is placed on t h e woman’s active participation in the process of birth and on her ability to practice techniques and regulate her performance. The underlying principle of childbirth education is that the woman can use her intellect and follow certain prescribed methods to control her body during ~ h i l d b i r t h . ~ T h e preparatory a p p r o a c h e s described herein were organized
March/April 1988 JOGNN
according to personal and informal, not systematic, empirical re~earch.~ RESEARCH REVIEW
Research reports of childbirth outcomes resulting from formal preparation have been inconsistent. Programs have been shown from a psychological viewpoint to promote positive attitudes towards labor and delivery and to foster early maternal-infant attachment.6-” However, opinions on the physiological effectiveness of these methods in terms of duration of labor, amount of analgesia/ anesthesia used during labor, and effect of labor upon the infant a r e wide and divergent. Some investigators claim that formal preparation reduces the amount of analgesia and anesthesia necessary during labor and del i ~ e r y . ’ ~ ”The - ’ ~ results of investigations led by Melzack et a1.I6 and Copstick et aI.l7 d o not support these claims, while other writers note difficulty in differentiating between women p r e p a r e d for childbirth and those women unprepared for childbirth.’0,18-‘o McClearly points out that enhancing t h e couple’s knowledge about childbirth by prenatal education decreases fears that might otherwise cause stress at the time of d e 1 i ~ e r y . lHorowitz ~ and Horowitz claim that t h e techniques learned in the various classes, the repetition of the step-by-step sequence of labor and birth, and the group support provided in classes are all instrumental in developing coping capabilities for the birth process.2’ Walker and Erdman found that women’s abilities t o c o p e with labor are significantly greater after attending classes, according to their own assessments.” Several authors suggest that formal preparation enables the woman to experience a s h o r t e r duration of
labor. 14.23-25 Yet, both Patton et al. a n d Reid found evidence that labor was not significantly shorter in those women who had formally p r e p a r e d for natural childbirth ,20.26 Copstick et al. and Sosa et al. report studies in which women in labor derived significant benefits simply from the presence of support p e r ~ o n s . ’ ~Furthermore, *‘~ a s t u d y of first-time parents by Markham a n d Kadushin concluded that Lamaze-type training may prevent decreases in marital satisfaction and increases in anxiety and postbirth problems.’* To t h e list of claimed benefits, Thomas and Karlovsky-conducting a s t u d y of 2,000 deliveries under a childbirth training program at Yale-added a “greatly lessened number of depressed infants at birth, fewer operative deliveries, less blood loss, smoother convalescence, and finally happier
mother^."'^
Criticism has been directed at current childbirth education methods for being instructive rather than enlightening and rigid rather than flexible and personal. All of these studies and claims a r e brought into question by two comprehensive reviews of the literature. A review and analysis conducted by Beck a n d Hall in 1978 and another done by Beck and Siege1 in 1980 concluded that the research on the outcomes of childbirth education a s a whole was characterized by serious methodologic shortcomings, including the use of inappropriate control groups and failure to assign subjects randomly to treatment group.^.^^.^" These reviewers also acknowledged the difficulties
109
inherent in conducting well-controlled outcome research in clinical settings. Only recently have childbirth education r e s e a r c h e r s begun to address these experimental problems. Groups at the University of M is sour i -Columbia a r e conduct ing analogue research o n labor pain and are scientifically studying t h e effects of various paincoping s t r a t e g i e ~ . ~ . ~In' . a" ~1980 study of 80 nulliparous women comparing t h e efficacy of relaxation training, informative lectures, a n d breathing exercises, Beck and Siege1 found relaxation to be the most therapeutically active component of a pain-coping program.") Subsequently, Geden et al. conducted a study to examine the efficacy of more recently developed pain-coping strategies. Geden et al. studied t h e self-reported pain and the psychophysiological effects of relaxation, sensory transformation, and imagery and stress inoculation with a laboratory analogue of labor in 100 nulliparous women.3' Only o n e strategy, sensory tranformation, the use of imagination to transform painful sensations into pleasant feelings, was found to have a significant effect on self-reported pain. Clinicians have little factual information on which components of a regimen produce therapeutic benefits. Geden e t a ] . contend that the effects of preparation might be enhanced by deleting the less effective strategies such a s breathing patterns, abdominal stroking, a n d timing contractions, while adding emphasis to those strategies that have been proven to be more effective such a s relaxation techniques, sensory transformation, and husband presence."' Further criticism h a s been directed at current childbirth education methods for being instructive, rather than e n l i g h t e n i ~ ~ Noble g.~ c o n t e n d s that childbirth educa-
110
tors have taken a linear approach to preparation by considering the process of childbirth t o be orderly a n d manageable. Noble believes that behavior control is inappropriate in the birthing process and that n o single form of preparation will suffice, regardless of t h e claimed outcomes. Women's needs vary widely, and as a result, women react differently to pain a n d anxiety a n d find different techniques helpful in coping with the intensity of labor and delivery. Even though t h e individual prescription varies from o n e type of class to the next, the typical preparation for childbirth class offers a set prescription for childbirth success. From a historical perspective, o n e can understand that proponents of natural childbirth needed to provide a total program of active mastery over pain control that could be substituted for the pain relief offered by scopolamine and general anesthesia. For today's couples, however, that battle has been won, and a less rigid regimen is more appropriate for pain control. Nevertheless, many contemporary childbirth educators have been slow to appreciate this need for c h a n g e in t h e s t r u c t u r e of childbirth education. As a result, couples continue t o be trained according to the philosophy of work, control, and achievement, and a s Noble states, "rehearsed, resolute, and goal-oriented, these couples go into labor a s into omb bat."^:' Scant data is available concerning the reasons why women seek childbirth education a n d how their motives may influence participation and the results of this parti~ipation."~ Too often, classes a r e chosen o n the basis of cost, proximity, o r a friend's recommendation, r a t h e r than o n t h e basis of content, approach, a n d t h e woman's/couple's learning style and needs. Indeed, the reasons couples attend classes a r e as
variable as the methods of preparation available. Presumably, motivations have a significant influe n c e o n how (or whether) the m e t h o d s taught a r e used and whether the use of various techniques relates to the couple's perceptions of success in t h e birth process. In previous studies, the participant populations have been divided into attenders and nonatt e n d e r s of childbirth education classes. Perhaps a more appropriate subpopulation assignment for s t u d y of childbirth educati o n wou 1d d ivi de participants into compliant and noncompliant groups. To t h e author's knowledge, only o n e study to date has investigated whether women actually perform a s they have been instructed.3s In this 1986 study, Lindell and Kossi found that women did not d o what they were taught in childbirth classes. Ninety-four percent of the women who were taught traditional pushing did not use breath holding a n d 60% did not maintain t h e position they were taught. These women moved and breathed in response to their physiological direction during second stage of labor when they were allowed and encouraged to d o so. IMPLICATIONS FOR PRACTICE
This review of history and the research literature calls attention to the emphasis of current preparation for childbirth classes that has been based on what expectant couples should know and do. Educators and researchers have concentrated o n teaching techniques rather than o n developing a way to enhance t h e couple's understanding of childbirth a s well a s their personal, individual responses to the birth process. Rather than offering classes which mold couples to the requirements of the healthcare system, childbirth educators
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should provide education according to the consumers’ needs. These needs include information about the processes of pregnancy, labor and delivery, assistance in preparing a realistic birth plan, and an understanding of the couples’ roles in the decision-making process. Active participation and self-responsibility are the fundamental goals of such an approach. Educators need to examine current methods of instruction. Currently, the same type of approach, providing information and teaching breathing and relaxation techniques, is most often used by all educators. Perhaps , educators should begin to recognize the different learning needs and styles of the wide variety of people served. At the very least, groups could separately address teenagers, first-time parents, older first-time parents, and single women. A cogent example of the implementation of such a recommendation was recently reported by SlagerEarnest, Hoffman, and Beckmann in a study demonstrating the positive effects of a specialized prenatal education program on the perinatal outcomes of 50 pregnant adolescent^.^^ Combining a multidisciplinary team approach and comprehensive health-care services in coordination with prenatal education resulted in significantly fewer obstetric, postnatal, and neonatal complications among those adolescents who participated in the educational program. Classes tend to be very large as providers attempt to efficiently and cost-effectively market their products. However, large classes may not be as effective as smaller, more individualized classes. Croups of five to seven couples afford individual attention and incentive to participation. Large numbers inhibit group process, and as Dorsey points out, the experiential learning that can be derived from the group process can be a s signifi-
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cant as the learning of specific skills.37 The philosophy behind childbirth preparation is more significant than the actual teaching technique. An important component of the educative process that educators need to impart to couples preparing for childbirth is confidence, an all-abiding belief that the natural processes of labor and birth can be trusted. Only by instilling basic confidence can the educator provide individualized and appropriate guidance without usurping the couple’s abilities to manage their preparation for and the actual birth of the child. Perhaps, what couples need most is guidance on how to tune into themselves.
Childbirth educators need to recognize the different learning needs of various groups such as teenagers, first-time parents, older first-time parents, and single women. A woman can do this by becoming aware of her natural, individual response t o a contraction rather than immediately starting a prescribed pattern of breathing. In this way, a laboring woman gives herself a chance to find her own way to work with her labor. For the husband’s part, a heightened awareness and attention to his partner’s needs as well as support of her work in labor provides a strong sense of partnership and accomplishment to both partners. The husband can demonstrate his awareness and support by his physical presence as well as with concrete comfort measures. Thus, rather than learning a rather rigid set of information and techniques to control their bodies, women can learn to respond to felt
messages such as to breathe faster or to change position. Much of the research conducted to date has been called into question and many more studies are needed. Research that would add valuable insights includes investigating the effectiveness of techniques, outcome parameter differences between educators who use a given technique and those who do not, and comparison of the difference in benefit gained from a given technique or from presence of a supportive companion without a prescribed technique. Care givers and educators need concrete data on all aspects of preparation by which to justify methods of education and practice and/or to motivate and give direction to change. SUMMARY
The current approaches taken to childbirth education developed, at least in part, in response to the medical management of labor and delivery. Attitudes toward the birth process as well as medical necessities for safety have changed. However, childbirth education classes have been slow to follow suit. In light of these changes and of new research in the area, the time is right for educators to look critically at what has been done, build on what has proven effective, and discard what is no longer appropriate for childbirth education. REFERENCES
and D. W e r t z . 1979. Lying in: A history of childbirth in America. New York: Schocken Books. 2. Garbarino J. 1982. The ecology of childbearing und childrearing in children and families in the social enuironment. New York: Aldine Pub. Co. 3. Read, G.D. 1944. Childbirth without fear. New York: Harper and Brothers Publishers. 1. Wertz, R.,
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4. Noble, E. 1983. Childbirth with insight. Boston: Houghton Mifflin Co. 5. Geden. E., N. Beck, G. Hauge, and S. Pohlman. 1984. Self-support and psychophysiological effects of five pain-coping strategies. Nurs. Res. 33( 5):260-65. 6. Doering, S., and D. Entwisle. 1975. Preparation during pregnancy and ability to cope with labor and delivery. Am. J . Orthopsychiatry 45:a25-37. 7. Caziano, E.. and M. Garvis. 1976. An evaluation of childbirth education for the clinic patient. Birth 6189-96. 8. Newman, L.. J. Kennell, M. Klaus, a n d J . Schreiber. 1976. Early human interaction: Mother a n d child. Primary Cure 3:491-95. 9. Nunnally, D., and M. Aguiar. 1974. Patients' evaluation of their prenatal and delivery care. Nurs. Res. 23:469-74. 10. Tanzer, D., and J. Block. 1972. Why natural childbirth. New York: Doubleday and Co. 11. Zax, M., A. Sameroff, and J. Farnum. 1975. Childbirth education, maternal attitudes, and delivery. Am. J. Obstet. Cynecol. 123:185-90. 12. Davenport-Slack, B., and C. Boyland. 1974. Psychological correlates of childbirth pain. Psychosom. Med. 36215. 13. McCleary. E. 1974. New miracles of childbirth. New York: David McKay co. 14. Shapiro, H., and L. Schmitt. 1970. Evaluation of the psychoprophylactic method of childbirth in the primigravida. Conn. Med. 37:34143. 15. Vellay, P. 1972. Painless labor. In Modern perspectives in psychoobstetrics, ed. J. Howell. New York: BrunnerJMazel, 328-39. 16. Melzak, P., P. Taenzer, P. Feldman, and R. Kinch. 1981. Labour still painful after prepared childbirth training. Can. Med. Assoc. J. 125: 357-63. 17. Copstick, S.M., K.E. Taylor, R. Hayes, a n d N. Morris. 1986. Partner support a n d t h e u s e of
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coping techniques in labour. J. Psychosom. Res. 30(4):497-503. 18. Davis, C., and F. Morrone. 1962. An objective evaluation of a prepared childbirth program. Obstet. Gynecol. 84:1196-206. 19. Leonard, R. 1973. Evaluation of selection tendencies of patients preferring prepared childbirth. Obstet. Cynecol. 42:371-77. 20. Patton, L.L., E.C. English, and J.D. Hambleton. 1985. Childbirth preparation and outcomes of labor and delivery in primiparous women. J. Fam. Prac. 20(4):375-78. 21. Horowitz, M., a n d N. Horowitz. 1967. Psychological effects of education for childbirth. Psychosomatics 8:196-202. 22. Walker, B., and A. Erdman. 1984. Childbirth education programs: The relationship between confid e n c e a n d knowledge. Birth 11: 103-08. 23. Huttel, F. 1972. A quantitative evaluation of psycho-prophylaxis in childbirth. J . Psychosom. Res. 16:81-92. 24. T h o m a s , H., a n d E. Karlovsky. 1954. 2000 deliveries u n d e r a training for childbirth program. Am. J. Obstet. Gynecol. 68:279-84. 2.5. Velvovky, T., K. Platanov, V. Plotichen, and E. Shugom. 1960. Painless childbirth through psychoprophylaxis. Moscow: Foreign Language Publishing House. 26. Reid, D. 1972. Principles and management for human reproduction. Philadelphia: W.B. Saunders Co. 27. Sosa, R., J. Kennell, and M. Klaus. 1980. T h e effect of a supportive companion o n perinatal problems, length of labor, and motherinfant interaction. N. Enyl. J. Med. 303( 11):597-600. 28. Markham H.J., and F.S. Kadushin. 1986. Preventive effects of Lamaze training for 1st-time parents: A short-term longitudinal study. J. Consult. Clin. Psychol. 54(6):87274. 29. Beck, N., and D. Hall. 1978. Natural childbirth: A review and analysis. Obstet. Cynecol. 52(3):371-79.
30. Beck, N., and L. Siegel. 1980. Preparation for childbirth and contemporary research on pain, anxiety, and stress reduction: A review and critique. Psychosom. Med. 42(4): 429-47. 31. Geden, E., N. Beck, G. Brouder, and E. O'Connell. 1983. Identifying procedural components for analogue research of labor pain. Nurs. Res. 32(2):80-83. 32. Geden, E., N.C. Beck, G. Brouder, J. Glaister, and S. Pohlman. 1985. Self-report and psychological effects of Lamaze preparation: An analogue of labor pain. Res. Nurs. and Health 8(2):155-65. 33. Noble, E. 1981. Controversies in maternal effort during labor and delivery. J. Nurs. Midwif 26(2): 13-22. 34. McCraw, R., a n d J . Abplanalp. 1982. Motivation to take childbirth education: Implications for studies of effectiveness. Birth 9:179182. 35. Lindell, S., and M. Rossi. 1986. Compliance with childbirth education instruction. Birth 13(2):9699. 36. Slager-Earnest, S.E., S.J. Hoffman, and C.J.A. Beckmann. 1987. Effects of a specialized prenatal adolescent program on maternal and in16(6):422fant outcomes. JOG" 29. 37. Dorsey, E. 1978. Group process and childbirth education: A position paper. JOCN Nurs. 7(4):51-54.
Address for correspondence: Sandra G. Lindell, CNM, MS, University of Minnesota, School of Nursing, 308 Harvard Street, 6-101 Unit F. Minneapolis, M N 55455-0342.
Sandra Lindell is an instructor in the NurseMidwifery Program at the University of Minnesota School of Nursing in Minneapolis, Minnesota. Ms. Lindell is a member of the American College of Nurse-Midwives.
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