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Group antenatal care: new pedagogic method for antenatal care—a pilot study
ARTICLE IN PRESS Midwifery 26 (2010) 389–393
Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
Group antenatal care: new pedagogic method for antenatal care—a pilot study Kathe Wedin, RN, RM (Midwife, Care Development Co-ordinator)a, Johan Molin, MD (Consultant)a, Elizabeth L. Crang Svalenius, RN, RM, PhD (Associate Professor)a,b, a b
¨, Sweden Department of Obstetrics and Gynaecology, University Hospital MAS, SE 205 02 Malmo Department of Health Sciences, Division of Nursing, P.O. Box 157, SE 221 00 Lund, Sweden
a r t i c l e in fo
abstract
Article history: Received 16 June 2008 Received in revised form 18 September 2008 Accepted 26 October 2008
Objective: to investigate how women who attended group antenatal care experienced the information they received, compared with women who attended traditional antenatal care, and their satisfaction with the form of care. The aim was also to determine the effect of group antenatal care on women’s social networks compared with traditional antenatal care. Design and setting: a pilot study with an intervention group (group antenatal care) and a control group (traditional antenatal care). Both groups were selected through informed choice. A questionnaire and a follow-up telephone call, using a structured questionnaire, were used to evaluate both groups. Participants: for each woman who had chosen to be in the intervention group, two women who had chosen traditional antenatal care were selected from the same antenatal clinic and given the same questionnaire. Findings: 35/45 (77%) women in the intervention group returned a completed questionnaire, compared with 40/85 (48%) women in the control group. There was little difference in satisfaction with information between the two groups, and overall satisfaction was high. Key conclusions: at six months post partum, the women who attended group antenatal care still met others from the group more regularly than the women who attended traditional antenatal care. Implications for practice: group antenatal care is well accepted by women, and can better utilise midwives’ time. & 2008 Elsevier Ltd. All rights reserved.
Keywords: Group antenatal care Information Satisfaction Social networking
Introduction Antenatal care is designed for the early detection of deviations from normal pregnancy, and the early treatment of medical conditions that can have an unfavourable effect on the mother and/or the infant. In Sweden, it has been suggested that routine standard care (for normal pregnancies, nine visits to the midwife and one or two ultrasound examinations) is excessive and can turn a healthy woman, and her pregnancy, into a potential pathological state. Resources can be better used for those that need care due to pathological conditions and special needs (Schindler-Rising et al., 2004).
Group antenatal care The first reports about group antenatal care, for women expected to have normal pregnancies and their partners, came Corresponding author at: Department of Health Sciences, Division of Nursing, P.O. Box 157, SE 221 00 Lund, Sweden. E-mail address: [email protected] (E.L. Crang Svalenius).
0266-6138/$ - see front matter & 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2008.10.010
from Minnesota, USA in the early 1970s. The philosophical point of origin of the Minnesota model was that ‘the dynamics between the midwife and the woman-patient gives maximum potential for personal maturity and development for both parties’ (Rising and Lindell, 1982), In the early 1990s, Schindler-Rising started what she termed ‘centering pregnancy’ based on this model. In this, Schindler-Rising presupposes that the woman herself is an expert about her needs. The woman weighs herself, checks her own urine sample and the group members check each others’ blood pressure. The results are written into the notes by the woman herself. In this way, the woman is more active in her own health care, which brings about increased understanding of the tests and their significance for her health (Grady and Bloom, 2004). Most of the studies reported have focused on teenage pregnancies (Klima, 2003; Grady and Bloom, 2004) and women who have previously given birth to underweight infants (Ickovics et al., 2003). Ickovics et al. described the centering pregnancy group model as an innovative model for prenatal care integrating broad health education and group support with prenatal investigation’. They found that group antenatal care for women with a low socio-economic status resulted in infants with greater birth weight, even when born prematurely. Grady and Bloom (2004)
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studied 124 teenage girls participating in group antenatal care. They found that the participants were more satisfied with their care, fewer infants were born prematurely and fewer infants were underweight at birth, compared with teenagers attending traditional antenatal care (Grady and Bloom, 2004). All of these studies have reported that group antenatal care promotes normalisation of the physical and psychological changes during pregnancy. Another advantage of group antenatal care is the possibility of forming a social network (Ickovics et al., 2003; Grady and Bloom, 2004). According to Novick (2004) reseach into satisfaction with this type of prenatal care is lacking. The Danish model The Danish National Social Welfare Board Guidelines for Pregnancy Care (Sundhedsstyrelsen, 1998, 1995) recommend that group antenatal care should be offered as an alternative to individual visits. One aim was to encourage networking between pregnant women, but the model also allowed the midwife to devote more time to pregnant women with special needs within the same time frame. For women choosing group antenatal care, preparations for delivery and parenthood should be integrated (Danish National Social Welfare Board, 1998). No published studies reporting on the effects of group antenatal care have been found from Denmark. Maternal health care in Sweden Maternal health care in Sweden started on a limited scale at the beginning of the 20th Century and was provided by a midwife. Since the 1960s, maternal health care has consisted of pregnancy check-ups and care up to and including 12 weeks after childbirth. Parent education is also included (Faxelid et al., 2001). In 1991, the present basic programme for pregnant women was introduced, consisting of eight check-ups during pregnancy and one postnatal check-up. A visit to an obstetrician is not considered necessary for healthy women with a normal pregnancy, and this is only carried out on medical grounds (National Swedish Board of Health and Welfare, 1996). Another aspect is that during the last 10–20 years, there has been an explosive development of easily available facts via the Internet. A recent study of 182 pregnant women showed that 91% had access to the Internet and had used this to acquire information concerning pregnancy (Larsson, 2007). This means that the present young generation has acquired a wealth of more or less evidence-based knowledge before their first visit to a midwife. The midwife’s role has, therefore, gradually changed from being the primary source of knowledge and information for the pregnant woman, to helping with balancing and sorting the knowledge already acquired by the woman/couple. A Swedish study of women’s experiences of childbirth found that women considered that the time available for them to ask questions at the antenatal clinic was inadequate. This shows that there is great need for personalised information (Hildingsson and Ra˚destad, 2005). Nowadays, pregnant women do not have the same social network as in the past, when mothers and other female relatives were close at hand. It is also less common for women in Sweden to continue to live in the same place where they grew up, so friends and relatives can live hundreds of miles away (Ra¨mga˚rd, 2006). The Internet has replaced the previous social network to a certain extent. The need to meet others, face-to-face, in the same situation is, therefore, great. Group antenatal care is a new pedagogic method in Sweden which is combined with traditional antenatal care. The method
Table 1 Time requirement for the midwife per woman for group antenatal care and traditional antenatal care. Number of hours/pregnancy
Woman Midwife
Group antenatal care
Traditional antenatal care
Nine visits
Eight visits
20.5 4.20
12.5 7.0
does not change the medical content, and follows the basic programme and timing of visits as recommended by the Swedish National Social Welfare Board. However, it allows more opportunities for preventive health work and networking. The model is based on the fact that all maternal health visits are carried out in a group consisting of approximately six women/couples, with eight meetings during pregnancy and one follow-up session post partum. The method integrates traditional parent education with medical check-ups, conducted by the midwife, and discussions between midwife and woman/couple during a pregnancy. After revision of the Danish model to suit Swedish circumstances, the model was first introduced in southern Sweden in 2000. In order to demonstrate that the method does not require extra time (it is actually time saving), a calculation was made concerning the time required for group antenatal care compared with that for traditional antenatal care. In spite of the method giving more time for the woman/couple with the midwife, it means that the midwife saves three hours and 10 minutes per woman when the group consists of six women/couples (Table 1). One hour of each meeting is spent with the whole group covering different themes, and during the second hour, the midwife spends approximately 10 minutes with each woman performing routine checks. The rest of the group continues to discuss whatever they feel important and relevant. The longer individual booking visit takes place either before or after the group meeting, or on another occasion the same week. Some of the time saved can be used for pregnant women with special needs, without requiring extra resources. The disadvantage of presenting this method as time saving is that the focus is removed from the most important gain; the improvement in quality. It should be added that group antenatal care does not replace individual meetings, but is an addition. In this pilot study, the first group sessions started in 2003 in an antenatal clinic in a large city in southern Sweden. During Spring 2004, two additional antenatal clinics started to offer group antenatal care as an alternative. The aim was that all five antenatal clinics in the city would offer group antenatal care to women as an alternative to conventional care by 2005. Anecdotal information has indicated that group antenatal care has been practised in different parts of Sweden, but a search of the literature, in both Swedish and English, has not brought any reports to light. The aim of this study was to investigate how women who attended group antenatal care experienced the information they received, compared with women who attended traditional antenatal care, and their satisfaction with the form of care. Another aim was to determine the effect of group antenatal care on women’s social networks compared with traditional care.
Methods Before starting the project, all the midwives at the five antenatal clinics in the catchment area were given information. One of the authors, who had experience of the method from Denmark, met with all of the midwives at each antenatal clinic
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and offered suggestions regarding subject matter and practical advice. All women, both low and high risk, who booked for antenatal care in 2005–2006 were given information about the study and offered the choice of traditional antenatal care (control group) or group antenatal care (intervention group) provided that they had a workable command of the Swedish language. The recommendation was six women per group, but this was not always possible. At the first meeting, the women were told that they could discontinue group antenatal care at any time during their pregnancy, and transfer easily to traditional care with the same midwife or another midwife if required. The women who attended group antenatal care were given a questionnaire when they were in the 36th week of gestation to answer before leaving postnatal care. A locked post box was provided at each of the venues offering postnatal care for the women to return the completed questionnaires. The questionnaire asked for background facts and the woman’s opinions on group antenatal care, e.g. if they felt they had adequate time with the midwife and if they had been given the information they felt they needed prior to childbirth. They were also contacted by telephone approximately six months post partum, where their views were sought again and questions about continuing social networks were included. A structured questionnaire was used for the telephone interviews, which ended with an open question asking for spontaneous comments. The control group (two controls were included for each woman who attended group antenatal care, with approximately the same expected date for delivery) was selected by the midwife running the group antenatal care sessions, from the women who had chosen to attend traditional antenatal care with the same midwife during the same time period. The controls took part in parental preparation classes. This approach was chosen as it gave a similar base concerning information and the possibility of meeting other women during pregnancy. In this area, parental preparation classes are predominantly offered during the first pregnancy, due to a lack of resources. The women in this group were given the same questionnaire in the 36th week of gestation, and a follow-up telephone call was made at six months post partum asking the same questions. All spontaneous comments, from both groups, were written down and categorised using manifest content analysis. All questionnaires were marked with a running number, and the code list for this was locked away in a different locality. The results were computer analysed, using only the running number for identification, in a password-secure computer.
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tionnaire. One woman was also lost to follow-up for clerical reasons. In the control group, 45 questionnaires were not returned for different reasons. In one case, the woman had experienced intrauterine fetal death, and in four cases, clerical errors prevented follow-up. A later check showed that the completed questionnaires from both the intervention group and the control group originated from only three of the five antenatal clinics included in the pilot project. In the intervention group, 23 women had been in groups of first-time mothers, two women had been in a group for women with at least one other child, and 10 women were in mixed groups. In the control group, 39 women were nulliparous. Of the women in the intervention group, 34 women had been given the information about the possibility of group antenatal care by their midwife and one woman had heard about it from a friend. The women were asked if they felt they had been given enough personal time with the midwife and enough time with the group during their pregnancy. The women in the intervention group scored an average of 3.57 on a four-point scale, and the control group scored an average of 3.51. The women were also asked to give their opinions on the importance of group sessions and subjects discussed using a scale of one (unimportant) to four (very important). The results are shown in Table 3. Both groups considered that all subjects were important, although both groups gave the lowest score to discussions about relationships. The highest scores in the intervention group were given to knowledge about how the body works during labour and childbirth, while the control group considered knowledge about labour and childbirth most important, and ranked how the body works in second place.
Table 2 Characteristics of study respondents.
Age (years) Nullipara Multipara Swedish Born outside Sweden
Group antenatal care
Traditional antenatal care
29.8 33 12 29 6
29.4 39 1 36 4
Table 3 What was the most important aspect of taking part in the group?.
Results During the time period over which the pilot project took place, six groups were started, completed and given the questionnaire. Of the 45 women who attended group antenatal care, 35 (77%) completed and returned the questionnaire, compared with 40 out of 85 (48%) women in the control group; a total of 75 fully completed questionnaires. Age, parity and nationality are shown in Table 2. In the intervention group, 34 of 35 women attended all of the sessions, while in the control group, 36 of 40 women attended all three parental preparation classes in addition to their antenatal check-ups. All of the women who chose to have group antenatal care continued with this for the whole of their pregnancy. In the intervention group, 10 questionnaires were not returned. Four women had given birth at another hospital and were lost to follow-up, one woman gave birth at term but had not been given the questionnaire, and four women did not return the ques-
To To To To To To To To To To
meet others in the same situation gain knowledge about childbirth gain knowledge about pain relief gain knowledge about breast feeding gain knowledge about how to take care of the baby discuss parenting discuss relationships learn breathing and relaxation exercises learn how the body functions during pregnancy learn how the body functions during childbirth
1 ¼ not at all important, 4 ¼ very important. a Most important. b Second-most important. c Third-most important.
Group antenatal care
Traditional antenatal care
3.67 3.62b 3.34c 3.28 3.42
3.10 3.75a 3.47b 3.52 3.67
3.40 2.40 3.40
3.20 2.21 3.30c
3.57
3.17
3.74a
3.72
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Meeting others in the same situation was the second most important aspect in the intervention group. The women were asked to grade (from one to three) what they felt they had learnt most about, and if they felt the discussion came at the most suitable time during pregnancy (yes/no). In the intervention group, 32 of 35 women felt that the timing of the different subjects was right, and 38 of 40 women in the control group felt the same way. The women were also asked if they felt they personally could influence the subjects discussed. The intervention group felt that they had more influence on the subjects discussed (32/35 vs. 27/40). Both groups were satisfied with the time given for their own questions (34/35 vs. 37/40). In the intervention group, 16 of the partners took part in six to nine of the meetings, and one partner was only present at the booking visit. In the control group, 33 of 38 partners were present at all three parental preparation classes. Interview six months post partum All women were contacted by telephone by one of the authors when their baby was approximately six months old. The telephone interviews took between 10 and 60 minutes. All of the women considered it positive that someone from the department had contacted them to hear how they were. The women were given the time they needed to talk about antenatal care, childbirth and the postpartum period. All of them were asked the same questions using a standardised questionnaire. Women in the intervention group were asked an additional question about their satisfaction with group antenatal care. All of the women reported that this form of antenatal care was effective. One of the main study questions was regarding whether group antenatal care encouraged social networking. Of the 35 women in the intervention group, 28 still met others from the group regularly. In the control group, 10 of 40 women still had some contact with women they had met in the parental preparation classes. The women from the intervention group met, on average, 2.4 times a month, while women in the control group met, on average, 1.6 times a month. A final question concerned the woman’s overall impression of her pregnancy, labour, childbirth and postnatal care. In the intervention group, 30 women felt predominantly positive about their pregnancy, compared with 38 women in the control group. Labour and childbirth was a positive experience for 28 women in the intervention group and 37 women in the control group. Postnatal care was regarded less positively; only 25 women in the intervention group and 28 women in the control group were satisfied with their care. Spontaneous comments At the end of the interview, the women were asked if there was anything they would like to add. All comments were written down and grouped according to area, subject and intervention group/ control group. Representative quotations were chosen to illustrate the different areas. Eight women in the intervention group gave spontaneous comments about group antenatal care. Four were very positive about this form of antenatal care. The negative comments concerned preparation for childbirth (requested more practical training) and the postnatal period (requested more information). One mother expressed the opinion of her group, as they had discussed this recently: Now, when our babies are six months old, we have a new need to talk about pregnancy and delivery again. At our first group meeting, we all felt we probably had nothing in common but
our solidarity grew at every meeting. (Mother, intervention group) Six of the women in the control group gave comments about the parental preparation classes; four negative and two positive. The negative comments dealt mainly with the lack of follow-up: No follow-up for the group (after delivery). I really wanted it. (Mother, control group) Three women commented on childbirth, mentioning their need for support and a good relationship with the midwife: The most important thing was my relationship with my midwife. (Mother, control group) Postnatal care was the area most often mentioned by both groups. The main sources of discontent were treatment, locality and breast-feeding support/information. Virtually all comments were negative: Too many conflicting instructions about breast feeding. Made it much too complicated. (Mother, control group)
Discussion Discussion of chosen method No existing instrument was found that dealt with this aspect of antenatal care. The questionnaire that was constructed was tested on a number of midwives before the start of the study. Only one of the questions posed problems, and this concerned grading ‘what you learnt most about’; some respondents had not understood that they should grade their answers one to three. This question gave examples, but it could have been advantageous to let the respondents suggest the important subjects themselves, although the risk here was that the answers would only have dealt with childbirth and not covered other aspects of parenthood. It may have been a disadvantage that this pilot study was undertaken when group antenatal care was being introduced, and was new to all the midwives leading the groups. On the other hand, this may have been an advantage as the midwives followed the suggested plan and had not had the experience to personalise it, which means all parents were given approximately the same information, at the same time, at the meetings. Another disadvantage could be that the control group mainly consisted of first-time mothers. This was due to the fact that parental preparation classes are only offered to nulliparas and occasionally to multiparas with special needs. As information and social networking were the areas of interest, it was considered better to have a control group of predominantly nulliparas from the same antenatal clinics than not to have a control group or to have a control group from another area where multiparas are given the option of attending parental preparation classes. Two of the antenatal clinics did not return any questionnaires from the intervention groups or the control groups. These clinics had offered group antenatal care. It is unclear if questionnaires were given out and not returned, or if they were not given out. One of these clinics serves an area where the majority of women of childbearing age are immigrants, with a poor understanding of Swedish, while the other clinic has a population with low socioeconomic status. One of the weaknesses of this study was that the researchers had no control over the administrative process concerning the distribution of questionnaires to the women. In future studies, it could be an advantage to centralise this distribution so that all
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women taking part are given the questionnaire. A location outside each antenatal clinic was used for the collection of completed questionnaires; this was considered best to avoid any feeling of pressure regarding completing the questionnaire and for the sake of anonymity. It was an advantage that one person carried out all the followup telephone interviews. This method was considered to be the most suitable considering the number of participants. All women who were contacted were willing to answer the questionnaire. The anonymity of a telephone call can mean that answers are given honestly.
Result discussion One of the central questions in this study was regarding whether group antenatal care can facilitate networking. From this pilot project, group antenatal care seemed to encourage continued contact within the group. The original group, as a whole, was more intact and they met more frequently. This could be due to the fact that the intervention groups were more established as they had met on more occasions. It could also be due to the fact that the women who had chosen this form of care felt more at home in groups, or had a greater need to meet others. Both group and individual meetings give an opportunity for the midwife to observe women in two different situations, which can be an advantage in detecting special needs. Both groups were satisfied with the time they had been given during pregnancy. The intervention group was satisfied with both the one-to-one contact time with their midwife and the group time, although only multiparas in the intervention group could compare the two different types of antenatal care. As group antenatal care requires less overall time of each midwife, while increasing the woman’s time with the midwife (although not all on a one-to-one basis), it can be argued that this form of antenatal care is more economical while maintaining or increasing the quality of care. The time saved with group antenatal care allows for a number of individual consultations for the women in the group with special needs. A previous extensive study in Sweden (Hildingsson and Ra˚destad, 2005) reported that women did not feel they had been given the time they needed for their own questions. This was not the case in this pilot study. The women in the intervention group also felt that they could steer the subjects discussed at the meetings to a greater degree than women in the control group. Neither of the groups felt that it was necessary to discuss partner relationships. This may be because the subject was approached in the wrong way, or the information was given at the wrong time. Other studies have shown that couples feel a need to talk about partner relationships (Hildingsson and Ra˚destad, 2005).
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The answers also showed that midwives discuss the same subjects with pregnant women as they did 30 years ago; considering today’s technology and the information available on the Internet, this may be an outdated approach. The generation giving birth today has a greater need to select and validate the information they have sought by themselves (Larsson, 2007). The dissatisfaction shown with postnatal care may be due to the fact that the women are less well prepared for this, and their expectations are not met. This seems to be a general problem, as the same type of comments about postnatal care were reported in a large population-based study in Sweden (Rudman and Waldensto¨m, 2007).
Acknowledgements The authors wish to thank Eva Strobel, Quality Assurance Coordinator and Maria Blixt-Lindsjo¨, Co-ordinator for Midwives for their help at the initiation of this project. The authors would also like to thank all the midwives who helped to distribute the questionnaires, and all the women who took the time to fill them in. References Danish National Social Welfare Board, Sundhedsstyrelsen, 1998. Retningslinier og redogo¨relse. Sundhedsva¨senets indsats i forbindelse med graviditet, fo¨dsel och barselperiod (Guidelines and Report: Danish Department of Health’s Role in Connection with Pregnancy, Delivery and the Post-partum Period), Sundhedsstyrelsen, Copenhagen, (in Danish). Faxelid, E., Hogg, B., Kaplan, A., Nissen, E., 2001. La¨robok fo¨r barnmorskor (Textbook for Midwives). Studentlitteratur, Lund, Sweden, 2001 (in Swedish). Grady, M.A., Bloom, K.C., 2004. Pregnancy outcomes of adolescents enrolled in a centering pregnancy program. Journal of Midwifery & Women’s Health 49, 412–420. Hildingsson, I., Ra˚destad, I., 2005. Swedish women’s satisfaction with medical and emotional aspects of antenatal care. Journal of Advanced Nursing 52, 239–249. Ickovics, J., Kershaw, T., Westdahl, C., et al., 2003. Group prenatal care and preterm birth weight: results from a matched cohort study at public clinics. Obstetrics and Gynecology 102, 1051–1057. Klima, C., 2003. Centering pregancy: a model for pregnant adolescents. Journal of Midwifery & Women’s Health 48, 220–250. Larsson, M., 2007. A descriptive study of the use of Internet by women seeking pregnancy-related information. Midwifery, in press, doi:10.1016/j.midw. 2007.01.010. National Swedish Board of Health and Welfare, 1996. SoS rapport. Ha¨lsova˚rd fo¨re, under och efter graviditet (Health Care Before, During and After Pregnancy), Socialstyrelsen, Stockholm, (in Swedish). Novick, G., 2004. Centering pregnancy and the current state of prenatal care. Journal of Midwifery & Women’s Health 49 (5), 405–411. Ra¨mga˚rd, M., 2006. The Power of Place: Existential Crises and Place Security in the Context of Pregnancy. Lunds universitets geografiska institution, Lund. Rising, S., Lindell, S., 1982. The childbearing childrearing center: a nursing model. Nursing Clinics of North America 17, 11–22. Rudman, A., Waldensto¨m, U., 2007. Critical views on postpartum care expressed by new mothers. BMC Health Services Research 7, 178. Schindler-Rising, S., Kennedy, H., Klima, C., 2004. Redesigning prenatal care through centering pregnancy. Journal of Midwifery & Women’s Health 49 (5), 398–404.
Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
Group antenatal care: new pedagogic method for antenatal care—a pilot study Kathe Wedin, RN, RM (Midwife, Care Development Co-ordinator)a, Johan Molin, MD (Consultant)a, Elizabeth L. Crang Svalenius, RN, RM, PhD (Associate Professor)a,b, a b
¨, Sweden Department of Obstetrics and Gynaecology, University Hospital MAS, SE 205 02 Malmo Department of Health Sciences, Division of Nursing, P.O. Box 157, SE 221 00 Lund, Sweden
a r t i c l e in fo
abstract
Article history: Received 16 June 2008 Received in revised form 18 September 2008 Accepted 26 October 2008
Objective: to investigate how women who attended group antenatal care experienced the information they received, compared with women who attended traditional antenatal care, and their satisfaction with the form of care. The aim was also to determine the effect of group antenatal care on women’s social networks compared with traditional antenatal care. Design and setting: a pilot study with an intervention group (group antenatal care) and a control group (traditional antenatal care). Both groups were selected through informed choice. A questionnaire and a follow-up telephone call, using a structured questionnaire, were used to evaluate both groups. Participants: for each woman who had chosen to be in the intervention group, two women who had chosen traditional antenatal care were selected from the same antenatal clinic and given the same questionnaire. Findings: 35/45 (77%) women in the intervention group returned a completed questionnaire, compared with 40/85 (48%) women in the control group. There was little difference in satisfaction with information between the two groups, and overall satisfaction was high. Key conclusions: at six months post partum, the women who attended group antenatal care still met others from the group more regularly than the women who attended traditional antenatal care. Implications for practice: group antenatal care is well accepted by women, and can better utilise midwives’ time. & 2008 Elsevier Ltd. All rights reserved.
Keywords: Group antenatal care Information Satisfaction Social networking
Introduction Antenatal care is designed for the early detection of deviations from normal pregnancy, and the early treatment of medical conditions that can have an unfavourable effect on the mother and/or the infant. In Sweden, it has been suggested that routine standard care (for normal pregnancies, nine visits to the midwife and one or two ultrasound examinations) is excessive and can turn a healthy woman, and her pregnancy, into a potential pathological state. Resources can be better used for those that need care due to pathological conditions and special needs (Schindler-Rising et al., 2004).
Group antenatal care The first reports about group antenatal care, for women expected to have normal pregnancies and their partners, came Corresponding author at: Department of Health Sciences, Division of Nursing, P.O. Box 157, SE 221 00 Lund, Sweden. E-mail address: [email protected] (E.L. Crang Svalenius).
0266-6138/$ - see front matter & 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2008.10.010
from Minnesota, USA in the early 1970s. The philosophical point of origin of the Minnesota model was that ‘the dynamics between the midwife and the woman-patient gives maximum potential for personal maturity and development for both parties’ (Rising and Lindell, 1982), In the early 1990s, Schindler-Rising started what she termed ‘centering pregnancy’ based on this model. In this, Schindler-Rising presupposes that the woman herself is an expert about her needs. The woman weighs herself, checks her own urine sample and the group members check each others’ blood pressure. The results are written into the notes by the woman herself. In this way, the woman is more active in her own health care, which brings about increased understanding of the tests and their significance for her health (Grady and Bloom, 2004). Most of the studies reported have focused on teenage pregnancies (Klima, 2003; Grady and Bloom, 2004) and women who have previously given birth to underweight infants (Ickovics et al., 2003). Ickovics et al. described the centering pregnancy group model as an innovative model for prenatal care integrating broad health education and group support with prenatal investigation’. They found that group antenatal care for women with a low socio-economic status resulted in infants with greater birth weight, even when born prematurely. Grady and Bloom (2004)
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studied 124 teenage girls participating in group antenatal care. They found that the participants were more satisfied with their care, fewer infants were born prematurely and fewer infants were underweight at birth, compared with teenagers attending traditional antenatal care (Grady and Bloom, 2004). All of these studies have reported that group antenatal care promotes normalisation of the physical and psychological changes during pregnancy. Another advantage of group antenatal care is the possibility of forming a social network (Ickovics et al., 2003; Grady and Bloom, 2004). According to Novick (2004) reseach into satisfaction with this type of prenatal care is lacking. The Danish model The Danish National Social Welfare Board Guidelines for Pregnancy Care (Sundhedsstyrelsen, 1998, 1995) recommend that group antenatal care should be offered as an alternative to individual visits. One aim was to encourage networking between pregnant women, but the model also allowed the midwife to devote more time to pregnant women with special needs within the same time frame. For women choosing group antenatal care, preparations for delivery and parenthood should be integrated (Danish National Social Welfare Board, 1998). No published studies reporting on the effects of group antenatal care have been found from Denmark. Maternal health care in Sweden Maternal health care in Sweden started on a limited scale at the beginning of the 20th Century and was provided by a midwife. Since the 1960s, maternal health care has consisted of pregnancy check-ups and care up to and including 12 weeks after childbirth. Parent education is also included (Faxelid et al., 2001). In 1991, the present basic programme for pregnant women was introduced, consisting of eight check-ups during pregnancy and one postnatal check-up. A visit to an obstetrician is not considered necessary for healthy women with a normal pregnancy, and this is only carried out on medical grounds (National Swedish Board of Health and Welfare, 1996). Another aspect is that during the last 10–20 years, there has been an explosive development of easily available facts via the Internet. A recent study of 182 pregnant women showed that 91% had access to the Internet and had used this to acquire information concerning pregnancy (Larsson, 2007). This means that the present young generation has acquired a wealth of more or less evidence-based knowledge before their first visit to a midwife. The midwife’s role has, therefore, gradually changed from being the primary source of knowledge and information for the pregnant woman, to helping with balancing and sorting the knowledge already acquired by the woman/couple. A Swedish study of women’s experiences of childbirth found that women considered that the time available for them to ask questions at the antenatal clinic was inadequate. This shows that there is great need for personalised information (Hildingsson and Ra˚destad, 2005). Nowadays, pregnant women do not have the same social network as in the past, when mothers and other female relatives were close at hand. It is also less common for women in Sweden to continue to live in the same place where they grew up, so friends and relatives can live hundreds of miles away (Ra¨mga˚rd, 2006). The Internet has replaced the previous social network to a certain extent. The need to meet others, face-to-face, in the same situation is, therefore, great. Group antenatal care is a new pedagogic method in Sweden which is combined with traditional antenatal care. The method
Table 1 Time requirement for the midwife per woman for group antenatal care and traditional antenatal care. Number of hours/pregnancy
Woman Midwife
Group antenatal care
Traditional antenatal care
Nine visits
Eight visits
20.5 4.20
12.5 7.0
does not change the medical content, and follows the basic programme and timing of visits as recommended by the Swedish National Social Welfare Board. However, it allows more opportunities for preventive health work and networking. The model is based on the fact that all maternal health visits are carried out in a group consisting of approximately six women/couples, with eight meetings during pregnancy and one follow-up session post partum. The method integrates traditional parent education with medical check-ups, conducted by the midwife, and discussions between midwife and woman/couple during a pregnancy. After revision of the Danish model to suit Swedish circumstances, the model was first introduced in southern Sweden in 2000. In order to demonstrate that the method does not require extra time (it is actually time saving), a calculation was made concerning the time required for group antenatal care compared with that for traditional antenatal care. In spite of the method giving more time for the woman/couple with the midwife, it means that the midwife saves three hours and 10 minutes per woman when the group consists of six women/couples (Table 1). One hour of each meeting is spent with the whole group covering different themes, and during the second hour, the midwife spends approximately 10 minutes with each woman performing routine checks. The rest of the group continues to discuss whatever they feel important and relevant. The longer individual booking visit takes place either before or after the group meeting, or on another occasion the same week. Some of the time saved can be used for pregnant women with special needs, without requiring extra resources. The disadvantage of presenting this method as time saving is that the focus is removed from the most important gain; the improvement in quality. It should be added that group antenatal care does not replace individual meetings, but is an addition. In this pilot study, the first group sessions started in 2003 in an antenatal clinic in a large city in southern Sweden. During Spring 2004, two additional antenatal clinics started to offer group antenatal care as an alternative. The aim was that all five antenatal clinics in the city would offer group antenatal care to women as an alternative to conventional care by 2005. Anecdotal information has indicated that group antenatal care has been practised in different parts of Sweden, but a search of the literature, in both Swedish and English, has not brought any reports to light. The aim of this study was to investigate how women who attended group antenatal care experienced the information they received, compared with women who attended traditional antenatal care, and their satisfaction with the form of care. Another aim was to determine the effect of group antenatal care on women’s social networks compared with traditional care.
Methods Before starting the project, all the midwives at the five antenatal clinics in the catchment area were given information. One of the authors, who had experience of the method from Denmark, met with all of the midwives at each antenatal clinic
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and offered suggestions regarding subject matter and practical advice. All women, both low and high risk, who booked for antenatal care in 2005–2006 were given information about the study and offered the choice of traditional antenatal care (control group) or group antenatal care (intervention group) provided that they had a workable command of the Swedish language. The recommendation was six women per group, but this was not always possible. At the first meeting, the women were told that they could discontinue group antenatal care at any time during their pregnancy, and transfer easily to traditional care with the same midwife or another midwife if required. The women who attended group antenatal care were given a questionnaire when they were in the 36th week of gestation to answer before leaving postnatal care. A locked post box was provided at each of the venues offering postnatal care for the women to return the completed questionnaires. The questionnaire asked for background facts and the woman’s opinions on group antenatal care, e.g. if they felt they had adequate time with the midwife and if they had been given the information they felt they needed prior to childbirth. They were also contacted by telephone approximately six months post partum, where their views were sought again and questions about continuing social networks were included. A structured questionnaire was used for the telephone interviews, which ended with an open question asking for spontaneous comments. The control group (two controls were included for each woman who attended group antenatal care, with approximately the same expected date for delivery) was selected by the midwife running the group antenatal care sessions, from the women who had chosen to attend traditional antenatal care with the same midwife during the same time period. The controls took part in parental preparation classes. This approach was chosen as it gave a similar base concerning information and the possibility of meeting other women during pregnancy. In this area, parental preparation classes are predominantly offered during the first pregnancy, due to a lack of resources. The women in this group were given the same questionnaire in the 36th week of gestation, and a follow-up telephone call was made at six months post partum asking the same questions. All spontaneous comments, from both groups, were written down and categorised using manifest content analysis. All questionnaires were marked with a running number, and the code list for this was locked away in a different locality. The results were computer analysed, using only the running number for identification, in a password-secure computer.
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tionnaire. One woman was also lost to follow-up for clerical reasons. In the control group, 45 questionnaires were not returned for different reasons. In one case, the woman had experienced intrauterine fetal death, and in four cases, clerical errors prevented follow-up. A later check showed that the completed questionnaires from both the intervention group and the control group originated from only three of the five antenatal clinics included in the pilot project. In the intervention group, 23 women had been in groups of first-time mothers, two women had been in a group for women with at least one other child, and 10 women were in mixed groups. In the control group, 39 women were nulliparous. Of the women in the intervention group, 34 women had been given the information about the possibility of group antenatal care by their midwife and one woman had heard about it from a friend. The women were asked if they felt they had been given enough personal time with the midwife and enough time with the group during their pregnancy. The women in the intervention group scored an average of 3.57 on a four-point scale, and the control group scored an average of 3.51. The women were also asked to give their opinions on the importance of group sessions and subjects discussed using a scale of one (unimportant) to four (very important). The results are shown in Table 3. Both groups considered that all subjects were important, although both groups gave the lowest score to discussions about relationships. The highest scores in the intervention group were given to knowledge about how the body works during labour and childbirth, while the control group considered knowledge about labour and childbirth most important, and ranked how the body works in second place.
Table 2 Characteristics of study respondents.
Age (years) Nullipara Multipara Swedish Born outside Sweden
Group antenatal care
Traditional antenatal care
29.8 33 12 29 6
29.4 39 1 36 4
Table 3 What was the most important aspect of taking part in the group?.
Results During the time period over which the pilot project took place, six groups were started, completed and given the questionnaire. Of the 45 women who attended group antenatal care, 35 (77%) completed and returned the questionnaire, compared with 40 out of 85 (48%) women in the control group; a total of 75 fully completed questionnaires. Age, parity and nationality are shown in Table 2. In the intervention group, 34 of 35 women attended all of the sessions, while in the control group, 36 of 40 women attended all three parental preparation classes in addition to their antenatal check-ups. All of the women who chose to have group antenatal care continued with this for the whole of their pregnancy. In the intervention group, 10 questionnaires were not returned. Four women had given birth at another hospital and were lost to follow-up, one woman gave birth at term but had not been given the questionnaire, and four women did not return the ques-
To To To To To To To To To To
meet others in the same situation gain knowledge about childbirth gain knowledge about pain relief gain knowledge about breast feeding gain knowledge about how to take care of the baby discuss parenting discuss relationships learn breathing and relaxation exercises learn how the body functions during pregnancy learn how the body functions during childbirth
1 ¼ not at all important, 4 ¼ very important. a Most important. b Second-most important. c Third-most important.
Group antenatal care
Traditional antenatal care
3.67 3.62b 3.34c 3.28 3.42
3.10 3.75a 3.47b 3.52 3.67
3.40 2.40 3.40
3.20 2.21 3.30c
3.57
3.17
3.74a
3.72
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Meeting others in the same situation was the second most important aspect in the intervention group. The women were asked to grade (from one to three) what they felt they had learnt most about, and if they felt the discussion came at the most suitable time during pregnancy (yes/no). In the intervention group, 32 of 35 women felt that the timing of the different subjects was right, and 38 of 40 women in the control group felt the same way. The women were also asked if they felt they personally could influence the subjects discussed. The intervention group felt that they had more influence on the subjects discussed (32/35 vs. 27/40). Both groups were satisfied with the time given for their own questions (34/35 vs. 37/40). In the intervention group, 16 of the partners took part in six to nine of the meetings, and one partner was only present at the booking visit. In the control group, 33 of 38 partners were present at all three parental preparation classes. Interview six months post partum All women were contacted by telephone by one of the authors when their baby was approximately six months old. The telephone interviews took between 10 and 60 minutes. All of the women considered it positive that someone from the department had contacted them to hear how they were. The women were given the time they needed to talk about antenatal care, childbirth and the postpartum period. All of them were asked the same questions using a standardised questionnaire. Women in the intervention group were asked an additional question about their satisfaction with group antenatal care. All of the women reported that this form of antenatal care was effective. One of the main study questions was regarding whether group antenatal care encouraged social networking. Of the 35 women in the intervention group, 28 still met others from the group regularly. In the control group, 10 of 40 women still had some contact with women they had met in the parental preparation classes. The women from the intervention group met, on average, 2.4 times a month, while women in the control group met, on average, 1.6 times a month. A final question concerned the woman’s overall impression of her pregnancy, labour, childbirth and postnatal care. In the intervention group, 30 women felt predominantly positive about their pregnancy, compared with 38 women in the control group. Labour and childbirth was a positive experience for 28 women in the intervention group and 37 women in the control group. Postnatal care was regarded less positively; only 25 women in the intervention group and 28 women in the control group were satisfied with their care. Spontaneous comments At the end of the interview, the women were asked if there was anything they would like to add. All comments were written down and grouped according to area, subject and intervention group/ control group. Representative quotations were chosen to illustrate the different areas. Eight women in the intervention group gave spontaneous comments about group antenatal care. Four were very positive about this form of antenatal care. The negative comments concerned preparation for childbirth (requested more practical training) and the postnatal period (requested more information). One mother expressed the opinion of her group, as they had discussed this recently: Now, when our babies are six months old, we have a new need to talk about pregnancy and delivery again. At our first group meeting, we all felt we probably had nothing in common but
our solidarity grew at every meeting. (Mother, intervention group) Six of the women in the control group gave comments about the parental preparation classes; four negative and two positive. The negative comments dealt mainly with the lack of follow-up: No follow-up for the group (after delivery). I really wanted it. (Mother, control group) Three women commented on childbirth, mentioning their need for support and a good relationship with the midwife: The most important thing was my relationship with my midwife. (Mother, control group) Postnatal care was the area most often mentioned by both groups. The main sources of discontent were treatment, locality and breast-feeding support/information. Virtually all comments were negative: Too many conflicting instructions about breast feeding. Made it much too complicated. (Mother, control group)
Discussion Discussion of chosen method No existing instrument was found that dealt with this aspect of antenatal care. The questionnaire that was constructed was tested on a number of midwives before the start of the study. Only one of the questions posed problems, and this concerned grading ‘what you learnt most about’; some respondents had not understood that they should grade their answers one to three. This question gave examples, but it could have been advantageous to let the respondents suggest the important subjects themselves, although the risk here was that the answers would only have dealt with childbirth and not covered other aspects of parenthood. It may have been a disadvantage that this pilot study was undertaken when group antenatal care was being introduced, and was new to all the midwives leading the groups. On the other hand, this may have been an advantage as the midwives followed the suggested plan and had not had the experience to personalise it, which means all parents were given approximately the same information, at the same time, at the meetings. Another disadvantage could be that the control group mainly consisted of first-time mothers. This was due to the fact that parental preparation classes are only offered to nulliparas and occasionally to multiparas with special needs. As information and social networking were the areas of interest, it was considered better to have a control group of predominantly nulliparas from the same antenatal clinics than not to have a control group or to have a control group from another area where multiparas are given the option of attending parental preparation classes. Two of the antenatal clinics did not return any questionnaires from the intervention groups or the control groups. These clinics had offered group antenatal care. It is unclear if questionnaires were given out and not returned, or if they were not given out. One of these clinics serves an area where the majority of women of childbearing age are immigrants, with a poor understanding of Swedish, while the other clinic has a population with low socioeconomic status. One of the weaknesses of this study was that the researchers had no control over the administrative process concerning the distribution of questionnaires to the women. In future studies, it could be an advantage to centralise this distribution so that all
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women taking part are given the questionnaire. A location outside each antenatal clinic was used for the collection of completed questionnaires; this was considered best to avoid any feeling of pressure regarding completing the questionnaire and for the sake of anonymity. It was an advantage that one person carried out all the followup telephone interviews. This method was considered to be the most suitable considering the number of participants. All women who were contacted were willing to answer the questionnaire. The anonymity of a telephone call can mean that answers are given honestly.
Result discussion One of the central questions in this study was regarding whether group antenatal care can facilitate networking. From this pilot project, group antenatal care seemed to encourage continued contact within the group. The original group, as a whole, was more intact and they met more frequently. This could be due to the fact that the intervention groups were more established as they had met on more occasions. It could also be due to the fact that the women who had chosen this form of care felt more at home in groups, or had a greater need to meet others. Both group and individual meetings give an opportunity for the midwife to observe women in two different situations, which can be an advantage in detecting special needs. Both groups were satisfied with the time they had been given during pregnancy. The intervention group was satisfied with both the one-to-one contact time with their midwife and the group time, although only multiparas in the intervention group could compare the two different types of antenatal care. As group antenatal care requires less overall time of each midwife, while increasing the woman’s time with the midwife (although not all on a one-to-one basis), it can be argued that this form of antenatal care is more economical while maintaining or increasing the quality of care. The time saved with group antenatal care allows for a number of individual consultations for the women in the group with special needs. A previous extensive study in Sweden (Hildingsson and Ra˚destad, 2005) reported that women did not feel they had been given the time they needed for their own questions. This was not the case in this pilot study. The women in the intervention group also felt that they could steer the subjects discussed at the meetings to a greater degree than women in the control group. Neither of the groups felt that it was necessary to discuss partner relationships. This may be because the subject was approached in the wrong way, or the information was given at the wrong time. Other studies have shown that couples feel a need to talk about partner relationships (Hildingsson and Ra˚destad, 2005).
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The answers also showed that midwives discuss the same subjects with pregnant women as they did 30 years ago; considering today’s technology and the information available on the Internet, this may be an outdated approach. The generation giving birth today has a greater need to select and validate the information they have sought by themselves (Larsson, 2007). The dissatisfaction shown with postnatal care may be due to the fact that the women are less well prepared for this, and their expectations are not met. This seems to be a general problem, as the same type of comments about postnatal care were reported in a large population-based study in Sweden (Rudman and Waldensto¨m, 2007).
Acknowledgements The authors wish to thank Eva Strobel, Quality Assurance Coordinator and Maria Blixt-Lindsjo¨, Co-ordinator for Midwives for their help at the initiation of this project. The authors would also like to thank all the midwives who helped to distribute the questionnaires, and all the women who took the time to fill them in. References Danish National Social Welfare Board, Sundhedsstyrelsen, 1998. Retningslinier og redogo¨relse. Sundhedsva¨senets indsats i forbindelse med graviditet, fo¨dsel och barselperiod (Guidelines and Report: Danish Department of Health’s Role in Connection with Pregnancy, Delivery and the Post-partum Period), Sundhedsstyrelsen, Copenhagen, (in Danish). Faxelid, E., Hogg, B., Kaplan, A., Nissen, E., 2001. La¨robok fo¨r barnmorskor (Textbook for Midwives). Studentlitteratur, Lund, Sweden, 2001 (in Swedish). Grady, M.A., Bloom, K.C., 2004. Pregnancy outcomes of adolescents enrolled in a centering pregnancy program. Journal of Midwifery & Women’s Health 49, 412–420. Hildingsson, I., Ra˚destad, I., 2005. Swedish women’s satisfaction with medical and emotional aspects of antenatal care. Journal of Advanced Nursing 52, 239–249. Ickovics, J., Kershaw, T., Westdahl, C., et al., 2003. Group prenatal care and preterm birth weight: results from a matched cohort study at public clinics. Obstetrics and Gynecology 102, 1051–1057. Klima, C., 2003. Centering pregancy: a model for pregnant adolescents. Journal of Midwifery & Women’s Health 48, 220–250. Larsson, M., 2007. A descriptive study of the use of Internet by women seeking pregnancy-related information. Midwifery, in press, doi:10.1016/j.midw. 2007.01.010. National Swedish Board of Health and Welfare, 1996. SoS rapport. Ha¨lsova˚rd fo¨re, under och efter graviditet (Health Care Before, During and After Pregnancy), Socialstyrelsen, Stockholm, (in Swedish). Novick, G., 2004. Centering pregnancy and the current state of prenatal care. Journal of Midwifery & Women’s Health 49 (5), 405–411. Ra¨mga˚rd, M., 2006. The Power of Place: Existential Crises and Place Security in the Context of Pregnancy. Lunds universitets geografiska institution, Lund. Rising, S., Lindell, S., 1982. The childbearing childrearing center: a nursing model. Nursing Clinics of North America 17, 11–22. Rudman, A., Waldensto¨m, U., 2007. Critical views on postpartum care expressed by new mothers. BMC Health Services Research 7, 178. Schindler-Rising, S., Kennedy, H., Klima, C., 2004. Redesigning prenatal care through centering pregnancy. Journal of Midwifery & Women’s Health 49 (5), 398–404.