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non-attendance at antenatal classes
Too much like school: social class, age, marital status and attendance/non-attendance at antenatal classes Dallas Cliff and Ruth Deery Objective: to investigate patterns of attendance and non-attendance at National Health Service antenatal classes of first-time mothers in the indigenous white population of a large northern city of the UK. Design: survey using questionnaires, and selected participants were then given an in-depth interview.
Setting: five maternity wards in two large northern hospitals in the UK. In-depth interviews took place in the respondents' homes. Participants: fifty newly delivered women were surveyed of whom 18 took part in the follow-up interviews. Findings: there was a clear hierarchy in attendance and non-attendance based on social class, with middle class women being the most regular attenders, closely followed by older, married, working class women. However, overall social class differences were found to be accounted for by the overwhelming non attendance of young, unmarried, working class women. Older, married, working class women were found to have attendance patterns which were close to their middle class counterparts, and what differences there were seemed to be based on material factors.
Key conclusions:the majority of women felt that antenatal classes were too technical and did not address emotional and psychological issues. However, young, single, unmarried women perceived the classes most negatively. If midwives are to attract such young women, their fears and their need for peer support will have to be recognised.
INTRODUCTION
Dallas Cliff BTech(Hons), MA, PhD, Head of Department of Behavioural Sciences, School of Human and Health Sciences, University of Huddersfield HDI 3DH, UK Ruth Deer/ BSc(Hons), RGN, RIH, ADM, Senior Lecturer, Division of Midwifery, School of Human and Health Sciences, University of Huddersfield HDI 3DH, UK Correspondence to DC Manuscript accepted 8 November 1996
Social class differences in health, particularly those relating to prenatal, neonatal and infant mortality, are well documented in the UK (Wilkinson 1986, Townsend et al 1990, Graham 1992, Davey et al 1995, Wilkinson 1996) and the subject of some controversy. The Black report highlighted the debate between behavioural/cultural explanations based on the attitudes and actions of individuals, and material/structural explanations based on the unequal distribution of the resources necessary to good health. In the latter view, poor health does not stem from inferior choices but is the result of the way in which resources are distributed in society with those who receive the least resources suffering from the worst health. Whilst those supporting Midwifery(1997)
13, 139-145 © 1997 Pearson Professional Ltd
behavioural/cultural explanations pointed to the importance of class differences in behaviours associated with 'irresponsible lifestyles', such as smoking, alcohol use, exercise and diet, material/structuralists pointed to the correlation between ill health and poverty, especially as measured by housing tenure, income and car ownership. A further aspect of the inequalities in health debate was that although the working classes were shown to have poorer health, it was the middle classes who made most use of the health services. Again it is not clear whether this should be seen as stemming from differences in attitudes towards health service provision, or from the material and other difficulties which lower class groups might have in attending and making use of health services (Graham 1987, Graham 1992, Wilkinson 1996).
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Within the sociology of health literature more recent commentators have tended to emphasise the relationship between structural and cultural factors with regard to behaviour, such as smoking (Hart 1985, Graham 1987), and to argue that healthrelated behaviours are not best conceptualised as free choices, but must be seen as being constrained by the situations in which people find themselves. In the field of political policy making, however, the two positions have tended to remain polarised. Cultural/behavioural explanations have tended to be associated with individual responsibility for health. Material/structural explanations, on the other hand, have been taken up by those who want to stress the role of material inequalities in contributing to ill health and the continuing importance of the link between ill health and poverty. This paper is concerned with social class differences in attendance at antenatal classes. Emerging from the twin traditions of public health (Williams & Booth 1985) and pain control (Kitzinger 1974, Skelton 1985) mother-craft classes had been established throughout the country since 1948 (MurphyBlack 1990). Research into the attendance patterns and effectiveness of such classes has been patchy and hampered by a lack of consistency in measurement. A retrospective study by Boswell (1979) found no association between social class and attendance, but did find that young, single women were less likely to attend. More recently, two studies based on large random samples of women having live births found non-attendance rates of 57% in Sunderland (Milner 1990) and 21% in Bath (Taylor 1985). The Bath study found a close association between social class and attendance with 90% of middle class women attending compared to 73% of working class women, whilst the Sunderland study highlighted the special problems of the attendance of 16-21 year olds, unmarried and divorced women, and women in social class V (Milner 1990). A smaller study of 379 women in Belfast found a nonattendance rate of 78% (McKnight & Merrett 1986). A study of attenders at National Childbirth Trust classes found that those who went were both middle class and older than the national average for child bearing. Very young women and women from social classes IV and V were almost entirely unrepresented (Nolan 1995). Problems arise in comparing such data, however, because of widely different measures and inconsistencies, such as the inclusion of women who for a variety of reasons were not aware of the classes. However, all four studies found a low percentage of women attending most or all classes, with McKnight and Merrett (1986) reporting only 15% attending more than 5 out of 8, and Milner (1990) reporting only 16% attending all classes. A national study carried out by Jacoby (1988) found that only 41% of women attended any classes. However, this rose to 75% amongst first-time mothers suggesting a certain disenchantment. Indeed, only 6% of the firsttime mothers thought they were the most useful
source of information. Informal sources, such as the woman's mother, relatives or friends, being considered most helpful by 43% of the women. The existing literature, thus, strongly suggests that attendance at antenatal classes is associated with being conventionally married, having middle class status and being in the older age range for child-bearing women. An important debate concerns the appropriateness of social class as the key variable in measuring structural inequalities. Some have rightly suggested that more specific indicators, such as education, income or housing tenure, might be more sensitive indicators. Indeed, Husband (1983) has suggested that level of education is more closely associated with attendance than social class. Social class has been retained in this study, however, in order to afford some comparability with other studies.
METHODS In this paper the findings of a small exploratory study carried out within two maternity units in a large northern city in the UK are reported. Permission to undertake the investigation was granted by the Director of Midwifery Services, who wrote to inform all the midwives in the clinical area of the work that was being undertaken. Ethics committee approval was sought at an early stage in the planning of the investigation, and was granted with the proviso that an explanatory leaflet should be provided to the respondents before the administration of the questionnaire. A leaflet was therefore designed and distributed prior to prospective respondents being approached and asked to participate in the investigation. A time sample procedure was used which involved a short questionnaire being administered to each first-time, newly-delivered woman in five maternity wards over a two-week period. A decision was taken to exclude those who were from an ethnic minority background. Clearly, a larger study would have to include such women, but at this stage in the research process it was not felt appropriate to include such a large confounding factor. The sample size was based on the number of first-time mothers delivering a baby in the five wards over a two-week period. No mother was approached if she was offering her baby for adoption, had had a stillbirth, had a baby who was critically ill or was distressed in any way. Only two women refused to participate when approached and as far as it was possible to judge these wards were typical of the area as a whole. The final number of women to whom the questionnaire was administered was fifty. The questionnaire asked for information concerning age, marital status, own occupation, the occupation of partner or spouse, whether an invitation to antenatal classes had been received, the type of class attended and frequency of attendance.
T o o much like school: attendance o f antenatal classes
Respondents were then asked if they would be willing to take part in a follow-up interview and all agreed. Women were allocated to broad social class categories on the basis of the Registrar Generals Classification System. Classes I, II, and IIIn were counted as middle class whilst class IIIm, IV and V were counted as working class. The debate as to whether social class should be seen as an individual or a family attribute and the implications of this for the social class of women is complex (Goldthorpe 1983, Stanworth 1984, Evans 1996). A highly pragmatic approach was taken here, in that where women gave an occupation for themselves only, this was the basis of the classification; where women did not give an occupation, but gave one for their partner or spouse this was made the basis for the classification; and where women gave one for themselves and a partner or spouse the higher classification was used. The data from the questionnaires were analysed using Statview software. Frequency distributions were used to analyse the sample descriptively, whilst cross tabulations using Z2 and analysis of variance were used to test for significant relationships between variables. Analysis of this numerical data indicated that the women grouped into six broad categories: 1. Working class, married or in a partnership, attending some classes; 2. Working class, married or in a partnership, attending all or most classes; 3. Working class, single, non-attendances; 4. Working class, single, some attenders; 5. Middle class, married or in a partnership, attending some classes; 6. Middle class, married or in a partnership, attending all or most classes. The women who agreed to take part in the study were allocated to the above categories and three in each category were chosen at random for interview. The interviews were semi-structured and involved the exploration of the actual pregnancy and birth experiences of the women that lay behind the statistical patterns found. The interviews took place four weeks after the initial administration of the structured questionnaire. The interview took place in the women's own homes where respondents could be expected to feel relaxed and be more open. Women were given the opportunity to reflect on how well the birth had gone, how well they were coping with their babies, how useful antenatal classes now appeared in retrospect and what factors affected their attendance/non attendance at the time. In the main, the women did appear to be relatively relaxed and open, although in some cases the interview reinforced negative feelings that the women had about the actual birth experience. Respondents were asked to allow the interview to be taped and all gave their consent. Two slightly dif-
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ferent interview schedules had been devised, one for attenders and one for non-attendances. The 18 interviews were transcribed and the data were analysed and coded into thematic categories. This was done by narrowing similar categories down to broader categories in what Burnard (1991) refers to as a funnelling process. The final categories were then related to the appropriate social class groupings which were the same six broad classifications indicated previously.
FINDINGS S t a t i s t i c a l p a t t e r n s of a t t e n d a n c e non attendance
and
Twenty-nine women were rated as middle class and 21 as working class. Whilst there was no significant differences in the relationship between social class and attendance and non attendance, with 22 middle class and 11 working class women attending some classes, and a further 7 middle class and 10 working class mothers not attending any classes (Z2 = 20.4, df = 3,p = 0.1534), there was, as is shown in Table 1, a significant difference in the relationship between social class and frequency of attendance with middle class women being far more frequent attenders. However, attendance at the classes was significantly related to both marital status and age of motherhood as shown in Table 2. There was a further strong relationship between the age of women and their marital status with the mean age for married women being 27.1 years of age, and that of single women being 21.3 (F = 20.77, p = 0.0001). There was also a strong relationship between social class and marital status (Table 3). What the information from this sample suggests is a complex inter-relationship between social class, age and marital status with respect to attendance at antenatal classes. It appears that overall class differences are the result of the inclusion of a significant number of young unmarried women within the working class group. When the frequency of attendance at classes of only married working class and middle class women was compared, no significant difference was found (~2 = 1.34, df = 2, p = 0.5112). This analysis strongly suggests that social class is not in itself the key variable in accounting for differences in the attendance patterns of first-time mothers
Middle class Attended Attended Attended Attended Total
all classes
some classes most classes no classes
II 4 7 7 29
Z 2 = 9.38, df = 3, p = 0.0247.
Working class
3 7
I 10 21
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Attended classes Did not attend classes Total
Midwifery
Marital status Married Single
)~2
df
p
27 5 32
6 12 18
13.375*
I
0.0008
Under 21
Over 21
~2
df
p
12 12 24
2I 5 26
3.983*
I
0.046
Age Attended classes Did not attend classes Total * With
continuity correction.
at antenatal classes. Age and marital status are equally important and each of these interact with social class. Older, married, working class women had an attendance pattern which was similar to that of middle class women. However, analysis of these patterns cannot directly enable us to understand the experiences which gave rise to them. The next section discusses the findings from the eighteen followup interviews and concentrates particularly on the differences between younger, single, working class women and their older married counterparts.
Understanding attendance/non attendance and the evaluation of classes For most of the women, attending antenatal classes was seen as a significant, but usually not the most important, element in their preparation for the birth of their first baby. As sources of information the classes were seen as less significant than relatives, friends or books. In fact, for most women the one major benefit of the classes was the opportunity to get together with those in a similar situation. The social support that women gave each other through meeting at the classes was by far the most significant benefit perceived by these women: You're not on your own, you're sat with other girls and you can have a chat together. (Middle class, married, attender) Another described the best aspects of her classes as: Oh, meeting people and having a laugh. (Middle class, married, attender)
motivation which keeps women going. They clearly valued classes as an opportunity to 'meet people like me'. Those who did not attend regularly did not do so because of perceived faults with the classes themselves, but because of practical difficulties such as transport, inconvenient timing and location of classes. Surprisingly, these more structural reasons for non attendance were as likely to be experienced by middle class as working class women. This was especially the case with those who were in employment. Many women worked up to the 34th week of their pregnancy and found it difficult to fit in classes: Monday afternoon was the only time I was offered. I'd have to catch a bus up but, like I say, I was at work. (Middle class, married, attended some) Even where work was not an issue, others found the timing of classes difficult: The classes were just too late, especially with me having difficulties towards the end. (Middle class, married, attended some) One common complaint was that appointments at antenatal clinics were given on the same day as classes and, therefore, entailed two journeys to the hospital on the same day. Most women resolved this problem by opting to attend the clinic but not the class. Whilst the classes were valued in terms of social support and some of the information was seen as useful, the classes were not always evaluated positively in terms of preparation for both the experience of giving birth and for looking after a newborn baby. Women in this study consistently reported a lack of opportunity to ask questions and discuss worries, and also felt that there was often a lack of specific advice and information. Many of these women found that the classes, whilst technically competent, had not prepared them for the emotional and psychological aspects of first time motherhood: Maybe that's what parent craft is lacking in. They tell you all about the birth, all about getting ready for it and breast feeding and bottle feeding. They do that. And then what about all these bits when you get home, sleepless nights, why the baby cries and why it could be crying, all sorts of
Many of the women mentioned that they had forged friendships through classes that they maintained afterwards: I enjoyed the relaxation, the talks, the coffee, videos making up bottles. So it was really good. I've kept in touch with all my friends from it too. (Working class, married, attender) Clearly such experiences ensure that classes are lively and interesting and provide much of the
Married Single Total
Middle class
Working class
24 5 29
8 13 2I
%2 = 8.696 (with continuity correction), df = I, p = 0.0032.
Too much like school: attendance of antenatal classes
things they don't prepare you for. It's such a shock when you come home and you don't know what the hell to do. (Middle class, married, attended all) In general these respondents were critical of classes for being rather unrealistic and painting too rosy a picture of childbirth and motherhood. Those who had had relatively easy births tended to evaluate classes more positively, but those who had experienced more problematic deliveries were often resentful that they had not been better prepared and forewarned: You should be prepared for the worst, they weren't truthful. You're terrified not knowing what's happening and why you feel like this. I felt a bit resentful. If I ' d known what were happening I ' d have taken it a lot better. (Working class, married, attended all) On being asked what additional topics would have been useful in the classes, one women said: Worries. You have lots of worries don't you? I ' m still waking up in the night now and checking that he's breathing and not too hot. Plus he's snuffly and all bunged up. I use snuffle babe you know. (Working class, married, attended all) The single working class non-attendances, however, had an entirely different perspective on the classes. Whilst attenders valued the classes because they involved coming into contact with 'people like me', these women took the opposite view that the classes were not for 'people like them'. They expressed fears of being stigmatised and looked down on: I just thought when I went to classes I would be sitting in a group of women that were all in their thirties and married and that they would look at me. (Working class, single, non-attendance)
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than helpers and advisers. Hancock (1994) has recently argued that there has been a lack of emphasis on the specifically educational aspects of antenatal classes. Indeed, the material in these interviews resonates with the large body of work on the experience of working class girls in the school system written by sociologists of education (Deem 1978, Stanworth 1981, Griffin 1985, Lees 1986, Delmont 1990). The comparative failure of working class children in British schools is well documented, and some version of the 'culture clash' thesis that stresses the continuity of experience for middle class children as they move from home to school in contrast to a complementary discontinuity of experience for working class children making the same transition is widely accepted (Cliff 1980, Lee 1989, Chazan 1992). Whilst working class male adolescents may react to the experience of being out of place within the system by engaging in potentially violent and disruptive behaviour (Willis 1978), young working class women tend to be less disruptive though no less alienated from the values of the school (De!mont 1990). This is most commonly manifested in an attitude of passive acquiescence, young working class women try to become invisible but often resent the schooling system with equal vehemence. As one of Griffin's 'typical girls' put it: I hate this school. Especially Mrs Neville. She's so surly. She says, 'I can see what sort of homes you come from you'll never get anywhere'. Really gets at us about our homes. (Griffin 1985, p. 13) Older married working class women appeared to have moved on from these experiences and accomplished their own achievements. The younger, single, working class women by contrast clearly perceived the classes to be an extension of school and the midwives as agents of the middle class establishment in whose eyes they were not 'proper mothers'.
Another voiced a similar view and was particularly concerned about her lack of partner: What it was really was my boyfriend' s in prison. I just didn't want to go on my own. I thought they'd all be there with their husbands. (Working class, single, non-attendance) In making the decision not to attend antenatal classes these women draw on images of education from their past experience. Unsurprisingly, these images were typically drawn from school: I just had this picture of being stuck in a room and being given a doll. I thought it would be too much like school. (Working class, single, nonattendance) The content of these interviews was qualitatively different from that of the older married women. Antenatal classes were seen as somewhat threatening and alien. The midwives who ran them were seen rather more as censorious and distant teachers
DISCUSSION There are clearly some major limitations to this research in that it represents only one, small, exploratory study. It is, however, highly suggestive and points the way for further potentially fruitful research. Larger studies with greater generalisability are clearly needed in this area. Women belonging to the ethnic minorities had been excluded from the study because it was felt that they would introduce too many confounding cultural variables and a larger study would clearly have to include such women. This, therefore, renders the findings of the study even less generalisable and inclusive. However, the sample of white women chosen did reflect the demographic make up of the city in which the study was undertaken. It is clear from evidence reported in this investigation that women who are considered to be more in
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need of antenatal education, by virtue of poorer levels of existing information, restricted access to other sources of information, poorer access to health services and greater chances of ill-health, are not attending antenatal classes. This study highlights that it is largely the young, single, working class woman who does not attend antenatal classes and this corresponds with previous work carried out by Cartwright (1979), Macintyre (1981) and McIntosh (1988) who have argued that some women do not see the need for, and are sceptical about, the value of such classes. However, it would be misplaced to draw the conslusion that other women have no problems in attending classes. As has been seen, many women experienced difficulties in attending classes because of practical difficulties in timing and transport. The position of working women is particularly relevant here. Some women work until 34 weeks' gestation or later, and this factor needs to be remembered when planning antenatal education. It is suggested that consideration should be given to midwives going into large companies or organisations to promote antenatal education during work time. This can be seen as being of benefit to, not only the women, but also to the managers of such companies in that they will be seen to be promoting the outcome of successful childbirth and the interests of women at work. Antenatal classes offer an opportunity for women to be provided with education, support and advice in relation to pregnancy, labour and child care. Not only are factors such as marital status, social status, age and previous education of the women of importance, but, as Townsend et al (1990) have highlighted in other health contexts, socially based inequalities exacerbate the attendance patterns of women even further. The findings from this investigation have reiterated earlier work carried out into the relationship between social class and attendance at antenatal classes (Boswell 1979). It is alarming to find out, that some 20 years later, women are still revealing practical difficulties such as transport and inconvenient times and locations of classes. Other criticisms of antenatal classes voiced by the respondents in this investigation, included a lack of preparation for labour and associated complications, and avoidance of talking about the feelings and experiences that women may undergo. These criticisms reinforce the findings of other work carried out by Combes and Schonveld (1992), which concluded that the emotional and psychological needs of women are not being met through antenatal classes. However, the findings of this study have highlighted that the main reason that young, single working class women did not attend antenatal classes was that they felt threatened by virtue of their social status. Moreover, this group of women has special needs arising from their under use of the health services (Townsend et al 1990) through factors relating to poor housing, low income and social isolation.
Young, single, working class women in this investigation clearly viewed classes as being aimed at older married women and felt, in some way, that the classes were 'not for them', This leads to question whether older married middle class mothers are actually the preferred clientele of midwives and whether young, single working class women are viewed as problematic and non-conforming. In other words, midwives may actually perceive these women as 'awkward'. This in turn may be sensed by these women on initial contact with the midwife and as a result, this may reinforce the negative image young single women have of antental classes. Further research is necessary to determine whether or not midwives are turning to 'victim-blaming' too easily when in contact with these women, and it is recommended that all midwives examine their own ideologies underpinning the work that they carry out. If midwives consider young, single, working class women to be irresponsible and, as a result, blame them for their non attendance, then these women may become stigmatised and negative stereotyping may result. The negative image of classes held by these women may then become real perceptions, as they pick up non-verbal cues from midwives which serve to reinforce their negative image of antental classes. One thing is clear, however, peer support, which the majority of women find is so vital to their enjoyment of the classes, is lacking in the experience of young single women. Given that one of the major motivations and satisfactions of attendance at antenatal classes is the opportunity to meet and share experiences with 'people like me', midwives might consider how best this might be accomplished and whether separate classes for these young women would be appropriate.
REFERENCES
BoswellJ 1979Are classes 4 and 5 paying attention?Nursing Mirror 148:25-25 BurnardP 1991 A method of analysinginterviewtranscripts in qualitativeresearch. Nurse EducationToday 11: 464-466 Cartwright A 1979The dignityof labour?A studyof childbearingand induction.Tavistock,London ChazanD 1992The home and the school. In: ColemanJ (ed.) The school years. Routledge,London Cliff D 1980Familyand education.In: King R, RaynorD (eds) The middleclass. Longman,London Combes C, SchonveldA 1992Life will neverbe the same again. Learningto be a first-timeparent. LondonHealth EducationAuthority,London Davey B, Gray A, Seale C (eds) 1995 Health and disease. Open UniversityPress, Buckingham Deem R 1978 Womenand schooling.Routledge,London DelmontS 1990 Sex roles and the school, 2nd edn. Routledge, London Evans G 1996 Puttingmen and womeninto classes: an assessmentof the cross-sex validityof the Goldthorpe schema. Sociology30:211-232 Goldthorpe JH 1983Womenand class analysis:in defence of the conventionalview. Sociology 17:465-488 Graham H 1987Women's smokingand familyhealth. Social Science and Medicine1:47-56
Too much like school: attendance of antenatal classes
Graham H 1992 Health and welfare. Nelson, Walton-onThames Griffin C 1985 Typical girls? Routledge, London Hancock A 1994 How effective is ante natal education? Modem Midwife 4:13-15 Hart N 1985 The sociology of health and illness. Basic Books, London Husband L 1983 Antenatal education: its use and effectiveness. Health Visitor 56:409-410 Jacoby A 1988 Mother's views about information and advice in pregnancy and childbirth: findings from a national study. Midwifery 4:103-110 Kitzinger S 1974 The experience of childbirth, 3rd edn. Penguin Books, Harmondsworth. Lee J 1989 Social class and schooling. In: Cole M (ed.) The social contexts of schooling. Falmer Press, Lewes Lees S 1986 Losing out. Heinemann, London Macintyre S 1981 Expectations and experiences of first pregnancy: report of a prospective interview study of married primagravidae in Aberdeen. Occasional paper No 5. Institute of Medical Sociology, University of Aberdeen McIntosh J 1988 A consumer view of birth preparation classes: attitudes of a sample of working class primiparae. Midwives Chronicle and Nursing Notes 101 : 8-9 McKnight A, Merrett D 1986 Availability and acceptance of health education among socially 'at risk' pregnant women attending health centres in Belfast. Family Practice 3:85-91
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Milner S 1990 Ante natal education: evaluation report. Health Promotion and Education Services, Sunderland Health Authority Murphy-Black T 1990 Antenatal education. In: Alexander J, Levy V, Roch S (eds.) Antenatal care: a research-based approach. Macmillan, London Nolan ML 1995 A comparison of attenders at antenatal classes in the voluntary and statutory sectors: education and organisational implications. Midwifery 11: 138-145 Skelton I 1985 Acupuncture in labour. In: Robinson S, Thomson AM (eds) Proceedings of the 1984 Research and the Midwife Conference Nursing Research Unit. Kings College, University of London Stanworth M 1981 Gender and schooling. Routledge, London Stanworth M 1984 Women and class analysis: a reply to Goldthorpe. Sociology 18:159-170 Taylor A 1985 Antenatal classes and the consumer: mother's and fathers' views. Health Education Journal 44:79-82 Townsend P, Davidson N, Whitehead M 1990 The Black Report and the health divide, 2nd edn. Penguin Books, Harmondsworth Wilkinson R 1986 (ed.) Class and health: research and longitudinal data. Tavistock, London Wilkinson R 1996 (ed.) Unhealthy societies; the afflictions of inequality. Routledge, London Williams M, Booth D 1985 Antenatal education guidelines for teachers, 3rd edn. Churchill Livingstone, Edinburgh Willis P 1978 Learning to labour. Saxon House, Farnborough
Setting: five maternity wards in two large northern hospitals in the UK. In-depth interviews took place in the respondents' homes. Participants: fifty newly delivered women were surveyed of whom 18 took part in the follow-up interviews. Findings: there was a clear hierarchy in attendance and non-attendance based on social class, with middle class women being the most regular attenders, closely followed by older, married, working class women. However, overall social class differences were found to be accounted for by the overwhelming non attendance of young, unmarried, working class women. Older, married, working class women were found to have attendance patterns which were close to their middle class counterparts, and what differences there were seemed to be based on material factors.
Key conclusions:the majority of women felt that antenatal classes were too technical and did not address emotional and psychological issues. However, young, single, unmarried women perceived the classes most negatively. If midwives are to attract such young women, their fears and their need for peer support will have to be recognised.
INTRODUCTION
Dallas Cliff BTech(Hons), MA, PhD, Head of Department of Behavioural Sciences, School of Human and Health Sciences, University of Huddersfield HDI 3DH, UK Ruth Deer/ BSc(Hons), RGN, RIH, ADM, Senior Lecturer, Division of Midwifery, School of Human and Health Sciences, University of Huddersfield HDI 3DH, UK Correspondence to DC Manuscript accepted 8 November 1996
Social class differences in health, particularly those relating to prenatal, neonatal and infant mortality, are well documented in the UK (Wilkinson 1986, Townsend et al 1990, Graham 1992, Davey et al 1995, Wilkinson 1996) and the subject of some controversy. The Black report highlighted the debate between behavioural/cultural explanations based on the attitudes and actions of individuals, and material/structural explanations based on the unequal distribution of the resources necessary to good health. In the latter view, poor health does not stem from inferior choices but is the result of the way in which resources are distributed in society with those who receive the least resources suffering from the worst health. Whilst those supporting Midwifery(1997)
13, 139-145 © 1997 Pearson Professional Ltd
behavioural/cultural explanations pointed to the importance of class differences in behaviours associated with 'irresponsible lifestyles', such as smoking, alcohol use, exercise and diet, material/structuralists pointed to the correlation between ill health and poverty, especially as measured by housing tenure, income and car ownership. A further aspect of the inequalities in health debate was that although the working classes were shown to have poorer health, it was the middle classes who made most use of the health services. Again it is not clear whether this should be seen as stemming from differences in attitudes towards health service provision, or from the material and other difficulties which lower class groups might have in attending and making use of health services (Graham 1987, Graham 1992, Wilkinson 1996).
140
Midwifery
Within the sociology of health literature more recent commentators have tended to emphasise the relationship between structural and cultural factors with regard to behaviour, such as smoking (Hart 1985, Graham 1987), and to argue that healthrelated behaviours are not best conceptualised as free choices, but must be seen as being constrained by the situations in which people find themselves. In the field of political policy making, however, the two positions have tended to remain polarised. Cultural/behavioural explanations have tended to be associated with individual responsibility for health. Material/structural explanations, on the other hand, have been taken up by those who want to stress the role of material inequalities in contributing to ill health and the continuing importance of the link between ill health and poverty. This paper is concerned with social class differences in attendance at antenatal classes. Emerging from the twin traditions of public health (Williams & Booth 1985) and pain control (Kitzinger 1974, Skelton 1985) mother-craft classes had been established throughout the country since 1948 (MurphyBlack 1990). Research into the attendance patterns and effectiveness of such classes has been patchy and hampered by a lack of consistency in measurement. A retrospective study by Boswell (1979) found no association between social class and attendance, but did find that young, single women were less likely to attend. More recently, two studies based on large random samples of women having live births found non-attendance rates of 57% in Sunderland (Milner 1990) and 21% in Bath (Taylor 1985). The Bath study found a close association between social class and attendance with 90% of middle class women attending compared to 73% of working class women, whilst the Sunderland study highlighted the special problems of the attendance of 16-21 year olds, unmarried and divorced women, and women in social class V (Milner 1990). A smaller study of 379 women in Belfast found a nonattendance rate of 78% (McKnight & Merrett 1986). A study of attenders at National Childbirth Trust classes found that those who went were both middle class and older than the national average for child bearing. Very young women and women from social classes IV and V were almost entirely unrepresented (Nolan 1995). Problems arise in comparing such data, however, because of widely different measures and inconsistencies, such as the inclusion of women who for a variety of reasons were not aware of the classes. However, all four studies found a low percentage of women attending most or all classes, with McKnight and Merrett (1986) reporting only 15% attending more than 5 out of 8, and Milner (1990) reporting only 16% attending all classes. A national study carried out by Jacoby (1988) found that only 41% of women attended any classes. However, this rose to 75% amongst first-time mothers suggesting a certain disenchantment. Indeed, only 6% of the firsttime mothers thought they were the most useful
source of information. Informal sources, such as the woman's mother, relatives or friends, being considered most helpful by 43% of the women. The existing literature, thus, strongly suggests that attendance at antenatal classes is associated with being conventionally married, having middle class status and being in the older age range for child-bearing women. An important debate concerns the appropriateness of social class as the key variable in measuring structural inequalities. Some have rightly suggested that more specific indicators, such as education, income or housing tenure, might be more sensitive indicators. Indeed, Husband (1983) has suggested that level of education is more closely associated with attendance than social class. Social class has been retained in this study, however, in order to afford some comparability with other studies.
METHODS In this paper the findings of a small exploratory study carried out within two maternity units in a large northern city in the UK are reported. Permission to undertake the investigation was granted by the Director of Midwifery Services, who wrote to inform all the midwives in the clinical area of the work that was being undertaken. Ethics committee approval was sought at an early stage in the planning of the investigation, and was granted with the proviso that an explanatory leaflet should be provided to the respondents before the administration of the questionnaire. A leaflet was therefore designed and distributed prior to prospective respondents being approached and asked to participate in the investigation. A time sample procedure was used which involved a short questionnaire being administered to each first-time, newly-delivered woman in five maternity wards over a two-week period. A decision was taken to exclude those who were from an ethnic minority background. Clearly, a larger study would have to include such women, but at this stage in the research process it was not felt appropriate to include such a large confounding factor. The sample size was based on the number of first-time mothers delivering a baby in the five wards over a two-week period. No mother was approached if she was offering her baby for adoption, had had a stillbirth, had a baby who was critically ill or was distressed in any way. Only two women refused to participate when approached and as far as it was possible to judge these wards were typical of the area as a whole. The final number of women to whom the questionnaire was administered was fifty. The questionnaire asked for information concerning age, marital status, own occupation, the occupation of partner or spouse, whether an invitation to antenatal classes had been received, the type of class attended and frequency of attendance.
T o o much like school: attendance o f antenatal classes
Respondents were then asked if they would be willing to take part in a follow-up interview and all agreed. Women were allocated to broad social class categories on the basis of the Registrar Generals Classification System. Classes I, II, and IIIn were counted as middle class whilst class IIIm, IV and V were counted as working class. The debate as to whether social class should be seen as an individual or a family attribute and the implications of this for the social class of women is complex (Goldthorpe 1983, Stanworth 1984, Evans 1996). A highly pragmatic approach was taken here, in that where women gave an occupation for themselves only, this was the basis of the classification; where women did not give an occupation, but gave one for their partner or spouse this was made the basis for the classification; and where women gave one for themselves and a partner or spouse the higher classification was used. The data from the questionnaires were analysed using Statview software. Frequency distributions were used to analyse the sample descriptively, whilst cross tabulations using Z2 and analysis of variance were used to test for significant relationships between variables. Analysis of this numerical data indicated that the women grouped into six broad categories: 1. Working class, married or in a partnership, attending some classes; 2. Working class, married or in a partnership, attending all or most classes; 3. Working class, single, non-attendances; 4. Working class, single, some attenders; 5. Middle class, married or in a partnership, attending some classes; 6. Middle class, married or in a partnership, attending all or most classes. The women who agreed to take part in the study were allocated to the above categories and three in each category were chosen at random for interview. The interviews were semi-structured and involved the exploration of the actual pregnancy and birth experiences of the women that lay behind the statistical patterns found. The interviews took place four weeks after the initial administration of the structured questionnaire. The interview took place in the women's own homes where respondents could be expected to feel relaxed and be more open. Women were given the opportunity to reflect on how well the birth had gone, how well they were coping with their babies, how useful antenatal classes now appeared in retrospect and what factors affected their attendance/non attendance at the time. In the main, the women did appear to be relatively relaxed and open, although in some cases the interview reinforced negative feelings that the women had about the actual birth experience. Respondents were asked to allow the interview to be taped and all gave their consent. Two slightly dif-
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ferent interview schedules had been devised, one for attenders and one for non-attendances. The 18 interviews were transcribed and the data were analysed and coded into thematic categories. This was done by narrowing similar categories down to broader categories in what Burnard (1991) refers to as a funnelling process. The final categories were then related to the appropriate social class groupings which were the same six broad classifications indicated previously.
FINDINGS S t a t i s t i c a l p a t t e r n s of a t t e n d a n c e non attendance
and
Twenty-nine women were rated as middle class and 21 as working class. Whilst there was no significant differences in the relationship between social class and attendance and non attendance, with 22 middle class and 11 working class women attending some classes, and a further 7 middle class and 10 working class mothers not attending any classes (Z2 = 20.4, df = 3,p = 0.1534), there was, as is shown in Table 1, a significant difference in the relationship between social class and frequency of attendance with middle class women being far more frequent attenders. However, attendance at the classes was significantly related to both marital status and age of motherhood as shown in Table 2. There was a further strong relationship between the age of women and their marital status with the mean age for married women being 27.1 years of age, and that of single women being 21.3 (F = 20.77, p = 0.0001). There was also a strong relationship between social class and marital status (Table 3). What the information from this sample suggests is a complex inter-relationship between social class, age and marital status with respect to attendance at antenatal classes. It appears that overall class differences are the result of the inclusion of a significant number of young unmarried women within the working class group. When the frequency of attendance at classes of only married working class and middle class women was compared, no significant difference was found (~2 = 1.34, df = 2, p = 0.5112). This analysis strongly suggests that social class is not in itself the key variable in accounting for differences in the attendance patterns of first-time mothers
Middle class Attended Attended Attended Attended Total
all classes
some classes most classes no classes
II 4 7 7 29
Z 2 = 9.38, df = 3, p = 0.0247.
Working class
3 7
I 10 21
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Attended classes Did not attend classes Total
Midwifery
Marital status Married Single
)~2
df
p
27 5 32
6 12 18
13.375*
I
0.0008
Under 21
Over 21
~2
df
p
12 12 24
2I 5 26
3.983*
I
0.046
Age Attended classes Did not attend classes Total * With
continuity correction.
at antenatal classes. Age and marital status are equally important and each of these interact with social class. Older, married, working class women had an attendance pattern which was similar to that of middle class women. However, analysis of these patterns cannot directly enable us to understand the experiences which gave rise to them. The next section discusses the findings from the eighteen followup interviews and concentrates particularly on the differences between younger, single, working class women and their older married counterparts.
Understanding attendance/non attendance and the evaluation of classes For most of the women, attending antenatal classes was seen as a significant, but usually not the most important, element in their preparation for the birth of their first baby. As sources of information the classes were seen as less significant than relatives, friends or books. In fact, for most women the one major benefit of the classes was the opportunity to get together with those in a similar situation. The social support that women gave each other through meeting at the classes was by far the most significant benefit perceived by these women: You're not on your own, you're sat with other girls and you can have a chat together. (Middle class, married, attender) Another described the best aspects of her classes as: Oh, meeting people and having a laugh. (Middle class, married, attender)
motivation which keeps women going. They clearly valued classes as an opportunity to 'meet people like me'. Those who did not attend regularly did not do so because of perceived faults with the classes themselves, but because of practical difficulties such as transport, inconvenient timing and location of classes. Surprisingly, these more structural reasons for non attendance were as likely to be experienced by middle class as working class women. This was especially the case with those who were in employment. Many women worked up to the 34th week of their pregnancy and found it difficult to fit in classes: Monday afternoon was the only time I was offered. I'd have to catch a bus up but, like I say, I was at work. (Middle class, married, attended some) Even where work was not an issue, others found the timing of classes difficult: The classes were just too late, especially with me having difficulties towards the end. (Middle class, married, attended some) One common complaint was that appointments at antenatal clinics were given on the same day as classes and, therefore, entailed two journeys to the hospital on the same day. Most women resolved this problem by opting to attend the clinic but not the class. Whilst the classes were valued in terms of social support and some of the information was seen as useful, the classes were not always evaluated positively in terms of preparation for both the experience of giving birth and for looking after a newborn baby. Women in this study consistently reported a lack of opportunity to ask questions and discuss worries, and also felt that there was often a lack of specific advice and information. Many of these women found that the classes, whilst technically competent, had not prepared them for the emotional and psychological aspects of first time motherhood: Maybe that's what parent craft is lacking in. They tell you all about the birth, all about getting ready for it and breast feeding and bottle feeding. They do that. And then what about all these bits when you get home, sleepless nights, why the baby cries and why it could be crying, all sorts of
Many of the women mentioned that they had forged friendships through classes that they maintained afterwards: I enjoyed the relaxation, the talks, the coffee, videos making up bottles. So it was really good. I've kept in touch with all my friends from it too. (Working class, married, attender) Clearly such experiences ensure that classes are lively and interesting and provide much of the
Married Single Total
Middle class
Working class
24 5 29
8 13 2I
%2 = 8.696 (with continuity correction), df = I, p = 0.0032.
Too much like school: attendance of antenatal classes
things they don't prepare you for. It's such a shock when you come home and you don't know what the hell to do. (Middle class, married, attended all) In general these respondents were critical of classes for being rather unrealistic and painting too rosy a picture of childbirth and motherhood. Those who had had relatively easy births tended to evaluate classes more positively, but those who had experienced more problematic deliveries were often resentful that they had not been better prepared and forewarned: You should be prepared for the worst, they weren't truthful. You're terrified not knowing what's happening and why you feel like this. I felt a bit resentful. If I ' d known what were happening I ' d have taken it a lot better. (Working class, married, attended all) On being asked what additional topics would have been useful in the classes, one women said: Worries. You have lots of worries don't you? I ' m still waking up in the night now and checking that he's breathing and not too hot. Plus he's snuffly and all bunged up. I use snuffle babe you know. (Working class, married, attended all) The single working class non-attendances, however, had an entirely different perspective on the classes. Whilst attenders valued the classes because they involved coming into contact with 'people like me', these women took the opposite view that the classes were not for 'people like them'. They expressed fears of being stigmatised and looked down on: I just thought when I went to classes I would be sitting in a group of women that were all in their thirties and married and that they would look at me. (Working class, single, non-attendance)
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than helpers and advisers. Hancock (1994) has recently argued that there has been a lack of emphasis on the specifically educational aspects of antenatal classes. Indeed, the material in these interviews resonates with the large body of work on the experience of working class girls in the school system written by sociologists of education (Deem 1978, Stanworth 1981, Griffin 1985, Lees 1986, Delmont 1990). The comparative failure of working class children in British schools is well documented, and some version of the 'culture clash' thesis that stresses the continuity of experience for middle class children as they move from home to school in contrast to a complementary discontinuity of experience for working class children making the same transition is widely accepted (Cliff 1980, Lee 1989, Chazan 1992). Whilst working class male adolescents may react to the experience of being out of place within the system by engaging in potentially violent and disruptive behaviour (Willis 1978), young working class women tend to be less disruptive though no less alienated from the values of the school (De!mont 1990). This is most commonly manifested in an attitude of passive acquiescence, young working class women try to become invisible but often resent the schooling system with equal vehemence. As one of Griffin's 'typical girls' put it: I hate this school. Especially Mrs Neville. She's so surly. She says, 'I can see what sort of homes you come from you'll never get anywhere'. Really gets at us about our homes. (Griffin 1985, p. 13) Older married working class women appeared to have moved on from these experiences and accomplished their own achievements. The younger, single, working class women by contrast clearly perceived the classes to be an extension of school and the midwives as agents of the middle class establishment in whose eyes they were not 'proper mothers'.
Another voiced a similar view and was particularly concerned about her lack of partner: What it was really was my boyfriend' s in prison. I just didn't want to go on my own. I thought they'd all be there with their husbands. (Working class, single, non-attendance) In making the decision not to attend antenatal classes these women draw on images of education from their past experience. Unsurprisingly, these images were typically drawn from school: I just had this picture of being stuck in a room and being given a doll. I thought it would be too much like school. (Working class, single, nonattendance) The content of these interviews was qualitatively different from that of the older married women. Antenatal classes were seen as somewhat threatening and alien. The midwives who ran them were seen rather more as censorious and distant teachers
DISCUSSION There are clearly some major limitations to this research in that it represents only one, small, exploratory study. It is, however, highly suggestive and points the way for further potentially fruitful research. Larger studies with greater generalisability are clearly needed in this area. Women belonging to the ethnic minorities had been excluded from the study because it was felt that they would introduce too many confounding cultural variables and a larger study would clearly have to include such women. This, therefore, renders the findings of the study even less generalisable and inclusive. However, the sample of white women chosen did reflect the demographic make up of the city in which the study was undertaken. It is clear from evidence reported in this investigation that women who are considered to be more in
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Midwifery
need of antenatal education, by virtue of poorer levels of existing information, restricted access to other sources of information, poorer access to health services and greater chances of ill-health, are not attending antenatal classes. This study highlights that it is largely the young, single, working class woman who does not attend antenatal classes and this corresponds with previous work carried out by Cartwright (1979), Macintyre (1981) and McIntosh (1988) who have argued that some women do not see the need for, and are sceptical about, the value of such classes. However, it would be misplaced to draw the conslusion that other women have no problems in attending classes. As has been seen, many women experienced difficulties in attending classes because of practical difficulties in timing and transport. The position of working women is particularly relevant here. Some women work until 34 weeks' gestation or later, and this factor needs to be remembered when planning antenatal education. It is suggested that consideration should be given to midwives going into large companies or organisations to promote antenatal education during work time. This can be seen as being of benefit to, not only the women, but also to the managers of such companies in that they will be seen to be promoting the outcome of successful childbirth and the interests of women at work. Antenatal classes offer an opportunity for women to be provided with education, support and advice in relation to pregnancy, labour and child care. Not only are factors such as marital status, social status, age and previous education of the women of importance, but, as Townsend et al (1990) have highlighted in other health contexts, socially based inequalities exacerbate the attendance patterns of women even further. The findings from this investigation have reiterated earlier work carried out into the relationship between social class and attendance at antenatal classes (Boswell 1979). It is alarming to find out, that some 20 years later, women are still revealing practical difficulties such as transport and inconvenient times and locations of classes. Other criticisms of antenatal classes voiced by the respondents in this investigation, included a lack of preparation for labour and associated complications, and avoidance of talking about the feelings and experiences that women may undergo. These criticisms reinforce the findings of other work carried out by Combes and Schonveld (1992), which concluded that the emotional and psychological needs of women are not being met through antenatal classes. However, the findings of this study have highlighted that the main reason that young, single working class women did not attend antenatal classes was that they felt threatened by virtue of their social status. Moreover, this group of women has special needs arising from their under use of the health services (Townsend et al 1990) through factors relating to poor housing, low income and social isolation.
Young, single, working class women in this investigation clearly viewed classes as being aimed at older married women and felt, in some way, that the classes were 'not for them', This leads to question whether older married middle class mothers are actually the preferred clientele of midwives and whether young, single working class women are viewed as problematic and non-conforming. In other words, midwives may actually perceive these women as 'awkward'. This in turn may be sensed by these women on initial contact with the midwife and as a result, this may reinforce the negative image young single women have of antental classes. Further research is necessary to determine whether or not midwives are turning to 'victim-blaming' too easily when in contact with these women, and it is recommended that all midwives examine their own ideologies underpinning the work that they carry out. If midwives consider young, single, working class women to be irresponsible and, as a result, blame them for their non attendance, then these women may become stigmatised and negative stereotyping may result. The negative image of classes held by these women may then become real perceptions, as they pick up non-verbal cues from midwives which serve to reinforce their negative image of antental classes. One thing is clear, however, peer support, which the majority of women find is so vital to their enjoyment of the classes, is lacking in the experience of young single women. Given that one of the major motivations and satisfactions of attendance at antenatal classes is the opportunity to meet and share experiences with 'people like me', midwives might consider how best this might be accomplished and whether separate classes for these young women would be appropriate.
REFERENCES
BoswellJ 1979Are classes 4 and 5 paying attention?Nursing Mirror 148:25-25 BurnardP 1991 A method of analysinginterviewtranscripts in qualitativeresearch. Nurse EducationToday 11: 464-466 Cartwright A 1979The dignityof labour?A studyof childbearingand induction.Tavistock,London ChazanD 1992The home and the school. In: ColemanJ (ed.) The school years. Routledge,London Cliff D 1980Familyand education.In: King R, RaynorD (eds) The middleclass. Longman,London Combes C, SchonveldA 1992Life will neverbe the same again. Learningto be a first-timeparent. LondonHealth EducationAuthority,London Davey B, Gray A, Seale C (eds) 1995 Health and disease. Open UniversityPress, Buckingham Deem R 1978 Womenand schooling.Routledge,London DelmontS 1990 Sex roles and the school, 2nd edn. Routledge, London Evans G 1996 Puttingmen and womeninto classes: an assessmentof the cross-sex validityof the Goldthorpe schema. Sociology30:211-232 Goldthorpe JH 1983Womenand class analysis:in defence of the conventionalview. Sociology 17:465-488 Graham H 1987Women's smokingand familyhealth. Social Science and Medicine1:47-56
Too much like school: attendance of antenatal classes
Graham H 1992 Health and welfare. Nelson, Walton-onThames Griffin C 1985 Typical girls? Routledge, London Hancock A 1994 How effective is ante natal education? Modem Midwife 4:13-15 Hart N 1985 The sociology of health and illness. Basic Books, London Husband L 1983 Antenatal education: its use and effectiveness. Health Visitor 56:409-410 Jacoby A 1988 Mother's views about information and advice in pregnancy and childbirth: findings from a national study. Midwifery 4:103-110 Kitzinger S 1974 The experience of childbirth, 3rd edn. Penguin Books, Harmondsworth. Lee J 1989 Social class and schooling. In: Cole M (ed.) The social contexts of schooling. Falmer Press, Lewes Lees S 1986 Losing out. Heinemann, London Macintyre S 1981 Expectations and experiences of first pregnancy: report of a prospective interview study of married primagravidae in Aberdeen. Occasional paper No 5. Institute of Medical Sociology, University of Aberdeen McIntosh J 1988 A consumer view of birth preparation classes: attitudes of a sample of working class primiparae. Midwives Chronicle and Nursing Notes 101 : 8-9 McKnight A, Merrett D 1986 Availability and acceptance of health education among socially 'at risk' pregnant women attending health centres in Belfast. Family Practice 3:85-91
145
Milner S 1990 Ante natal education: evaluation report. Health Promotion and Education Services, Sunderland Health Authority Murphy-Black T 1990 Antenatal education. In: Alexander J, Levy V, Roch S (eds.) Antenatal care: a research-based approach. Macmillan, London Nolan ML 1995 A comparison of attenders at antenatal classes in the voluntary and statutory sectors: education and organisational implications. Midwifery 11: 138-145 Skelton I 1985 Acupuncture in labour. In: Robinson S, Thomson AM (eds) Proceedings of the 1984 Research and the Midwife Conference Nursing Research Unit. Kings College, University of London Stanworth M 1981 Gender and schooling. Routledge, London Stanworth M 1984 Women and class analysis: a reply to Goldthorpe. Sociology 18:159-170 Taylor A 1985 Antenatal classes and the consumer: mother's and fathers' views. Health Education Journal 44:79-82 Townsend P, Davidson N, Whitehead M 1990 The Black Report and the health divide, 2nd edn. Penguin Books, Harmondsworth Wilkinson R 1986 (ed.) Class and health: research and longitudinal data. Tavistock, London Wilkinson R 1996 (ed.) Unhealthy societies; the afflictions of inequality. Routledge, London Williams M, Booth D 1985 Antenatal education guidelines for teachers, 3rd edn. Churchill Livingstone, Edinburgh Willis P 1978 Learning to labour. Saxon House, Farnborough