Antenatal classes are a great way to help women learn more about pregnancy, labour and postpartum care for them and their babies. They also may provide answers to any additional questions on their side and give the opportunity to share any concerns (Walker and Worrell, 2008). One of the most obvious advantages of attending antenatal appointments is to meet and chat with women and their partners who are in a similar situation. Antenatal classes are designed to be fun and can be a source of great support and confidence, especially for first time parents, who may be feeling very scared by the prospect of soon having a baby. Antenatal classes are described as opportunities for women to meet other pregnant women who have the same experiences and keeping in touch till they deliver their babies. For women who live in isolated areas far from their family and friends’ support, antenatal classes are regarded as a great source for information and support during child caring. Antenatal education classes are not new because they have been provided for pregnant women for more than 50 years. Education was prepared by midwives for women about natural childbirth and then it progressed by including healthy lifestyle, anxiety reduction, stress management, enhancement of family relationships, successful infant feeding, and advice on family planning and postpartum care (Olander et al., 2015; Walker and Worrell, 2008).
Antenatal education
However, as stated before, in Kurdistan, antenatal classes are in infancy stage and women receive education haphazardly from different sources: friends, relatives, family and some
time from health care providers. Although, there are antenatal care in Kurdistan, as mentioned in previous sections, pregnant women are not provided with antenatal education classes in most cases. Thus, there are no known designed antenatal classes aimed to educate pregnant women, as such providing an environment to share their experiences, with the ultimate goal of impacting positively on pregnancy outcome emotionally and physically.
Advantages of antenatal classes in group discussion style are that they may encourage women to actively participate. In addition, participants in the class share common reasons for attendance resulting in a more efficient use of time, and can provide more time to discuss the topic because of time availability unlike the traditional type (one-to-one education). In one-to-one education, the educator feels pressured because of the number of participating women and limited time slots available to each participant which could result in shorter appointment and longer waiting time, which can be discouraging to participants (Bronson, 2005). The common topics offered in group discussion style resemble the topics in one-to-one sessions with a midwife, took 90 minutes instead of 10- 15 minutes. In group discussion style, result in between and healthy refreshment are available for participants. Usually, nurses and midwives lead the group discussion style with the help of a facilitator to direct the flow of the discussions. The common educational elements in group discussion are hand-outs, videos, and worksheets which facilitate the discussion. In group discussion, women learnt how to adjust their activities to decrease their chance to adverse pregnancy outcomes (such as prematurity, developing GDM and congenital abnormalities). For example, rising (1998) stated that in group discussion women learnt how to give up smoking, have healthy food intake, normal and healthy weight gain during pregnancy. He stated that all above mentioned activities can be
positively influenced by group discussion. Rising (1998) further reports the benefit of group discussion is not just about the topics which were discussed, but also about the feeling of participants which empowered and motivated them to take an active role in their health care, feel confident and comfort during asking questions since they are participating with others who are in a similar situation like them. Furthermore, Baldwin (2006) who tested the efficacy of group discussion on women health outcomes, suggested that women preferably received prenatal education in groups. Evidence has reported the same findings. In a prospective cohort study, Ickovics et al. (2003) examined the impact of group discussion compared to individual prenatal care on birth weight of infants and gestational age at birth. Pregnant participants (N = 458) were of low socio-economic status and predominantly of black or Hispanic ethnic background. Birth weight was higher for infants of women receiving prenatal group classes compared to individual prenatal care (p < .01) due to an increased gestational age at birth. Additionally, if the infant was born preterm to a woman who was in a group that received prenatal care, the new-born was also heavier (Ickovics et al., 2003). Moreover, in a 5-year, randomised controlled trial within the same population (N = 1,047), funded by the National Institutes of Health, Ickovics et al. (2007) reported that women attending group prenatal care sessions were significantly less likely to have preterm birth and they were more likely to have better prenatal knowledge, more ready and prepared for labour, higher level of satisfaction with their care and higher breastfeeding initiation rates. These are similar with the findings by Grady and Bloom (2004) from a study conducted in the United States (US) on 124 adolescent pregnant women. The researchers found that women in group discussion were less likely to have preterm babies compared to women who participated
in individual format. Therefore, according to the above research findings, women in group discussion style showed higher rate of knowledge than individual care style.
The Cochrane Database Review (Gagnon, 2000) examined the literature on individual or group antenatal education for childbirth/parenthood. The review included results from six randomised controlled trials (N = 1,443) of structured educational programmes provided during pregnancy by an educator that included information related to parenthood, pregnancy and birth. Whereas, cessation of smoking and increased breastfeeding were excluded as they were reviewed by other Cochrane Library reviews. Although, the author acknowledged that a great deal of variation exists in the prenatal education programme literature, ranging from individual to group offerings, which must be taken into consideration. The conclusion of the Cochrane Database Review was “that individualized prenatal education directed toward avoidance of a caesarean birth does not increase the rate of vaginal birth after caesarean section, and that the effects of antenatal education for childbirth and/or parenthood remain unclear” (Gagnon, 2000).
Another Cochrane Database Review (Gagnon and Sandall, 2007), which included nine trials (2284) women, aimed was to assess the effects of individual and group education on knowledge acquisition, anxiety, sense of control, pain, labour and birth support, breastfeeding, infant-care abilities, and psychological and social adjustment. From this review, Gagnon and Sandall (2007) concluded that “the effects of general antenatal education for childbirth or parenthood, or both, remain largely unknown. Individualized prenatal education directed toward avoidance of a repeat caesarean birth does not increase the rate of vaginal birth after caesarean section”.
Nolan (2009) on the other hand encourage educators to empower women to change their behaviour toward healthy lifestyle during their educational programme in order to
decrease women’s chance to adverse pregnancy outcomes such as maternal, labour and neonatal adverse outcomes (GDM, PIH, prolonged labour, prematurity, and congenital abnormalities) (Nolan, 2009). Motivational interviewing is regarded as an effective tool for intervention during pregnancy and was also used by current educator during educational programme.
However, to make more extensive health to promote changes to behaviour, requires women to believe that not only should they improve their diet and physical activity, but that they are capable of changing and maintaining those healthy behaviours. From the literature, it is evident that in the absence of clinical guidelines, there is limited information on current clinical practice regarding the management of gestational weight gain. Little is known about how pregnant women in the Kurdistan region feel about their weight gain management during pregnancy, and what would be the most appropriate methods to support them to maintain a healthy diet and appropriate physical activity levels. This research project seeks to address this gap in knowledge.