Antenatal Education

Antenatal classes, including those run by the National Childbirth Trust (NCT) offer instruction and an opportunity to meet a network of women all at the same stage of pregnancy. This can be particularly useful when you are going to be at home with your baby for several months. These classes can provide a lot of information about birthing options and should include information about caesarean delivery. There is however, some debate about the bias found in such classes. So it is really worth bearing in mind that to many antenatal teachers, caesareans are still viewed as an intervention best avoided. This may affect both the perspective that you are given about the caesarean experience and the amount and accuracy of the information provided. Your NHS antenatal classes will likely tell you a hospital birth is best. Other antenatal classes may tell you a homebirth is best. In both cases, unless you have particularly progressive educators, it is highly likely that caesareans will be represented as the last resort best avoided.

In reality, 1 in 4 women will experience a caesarean delivery. Antenatal education has a duty to prepare women for this and support them with ideas and information about how to make such an eventuality as positive as possible. This level of support is not always available and we recommend you search out as many sources of information as you feel comfortable with.

Maureen Treadwell of the Birth Trauma Association says "far too often ideology takes precedence over individuals 'needs'. The consequences can be unbelievably cruel. The truth is that what suits some women can be distressing and wholly unacceptable to others." Robbie E. Davis-Floyd from the Department of Anthropology at University of Texas at Austin suggests that "The dominant mythology of a culture is often displayed in the rituals with which it surrounds birth. In contemporary Western society, that mythology-the mythology of the technocracy-is enacted through obstetrical procedures, the rituals of hospital birth." 139 Education that covers all birth choices is essential if women are to positively manage their birth experience. Yet when interviewing mothers, a recent study looking at antenatal information available to pregnant women found that "acquiring unbiased information was a concern for many women; some sources, especially internet sites or television programmes, were felt to have an agenda in the way they presented information, i.e. to promote VBAC or to sensationalize birth." 136

A midwife reporting on the Association for Improvements in Maternity Services (AIMS) website commented that she was "rather fed up with women who have had extensive classes. I used to be an avid NCT teacher, many years ago; however, they dupe women into believing that they can easily get through. Tell them the truth for a change, tell them it is damned painful, tell them they will need resilience, tell them breastfeeding is flipping well hard work for six or so weeks, and they will feel like a prize dairy cow for months! But tell them it is all worth it and they will have support - they will have a midwife who will help them through the whole process, because most of us will, given the chance. A registrar once said to me that the NCT was the cause of many problems in midwifery. I argued with him then; I now agree with him and just wish they would stop trying to portray childbirth as something you can join the dots with!" 34

The importance of accurate information in ensuring realistic birth expectations has been validated by a recent study led by Joanne E Lally from the Institute of Health and Society at Newcastle University, "If women are well prepared during pregnancy, then they are more likely to have realistic expectations of the levels of pain, less likely to feel a failure and have increased confidence, which in turn can lead to more a positive experience. Women may have ideal hopes of what they would like to happen, but they need to be educated or informed to ensure that they are prepared for what might actually happen and give them the tools to deal with this" 109

Many women do actually want more facts says Allison Farnworth from Newcastle University (Surgical and Reproductive Medicine Dept.)"Although some of the information about risk was considered anxiety provoking, there was a general consensus across all participants that it was necessary; once the relative rarity of the more serious complications was understood, it could then be reassuring. It was also widely felt that it was difficult for women to know what information they needed so information should be actively given to them" 136

Lally, from the Institute of Health and Society at Newcastle University, says "the importance of antenatal education [is] high, with its potential to empower women with realistic expectations and to enable them to make informed decisions...Without some form of education from health professionals, or childbirth educators, women have to rely on media, family and friends for information, which may not help in forming realistic expectations." 109

Jennifer Fenwick writing recently in her article on "childbirth expectations" in the 'Midwifery' journal says "choices that are made throughout labour are made on the basis of how women anticipate labour pain. 137 For example, if a woman views labour as a medical condition with risks, she may be more likely to choose pain relief to eradicate the pain. If, however, she views labour as a normal and natural process, she may be more likely to employ natural methods of coping and pain relief." It is important that education covers all eventualities as women cannot truly predict in advance how things will proceed and indeed how they will want to proceed.

Even the 'best' antenatal classes are unlikely to entirely remove fear of labour. One study found that "even though nine out of ten women attended antenatal class, fear of labour remained high." 138 But at least in providing accurate and realistic information women can feel more in control of their decision-making. This feeling of control is something that has been found to be of fundamental importance. "Even if the birth was not natural as planned, women were still pleased with the experience if they felt they had been in control of the decisions made." 139 A detailed study looking specifically at women's antenatal needs found that "information and support gave women confidence in their decision, and ultimately, the power to own and justify the decision that they had made...for example, Kirsten (IG) described how she found other women very judgmental of her choice to have an ERCS [elective repeat caesarean] but, as she felt her decision was informed, she was able to dismiss their opinions. Having the confidence to ask questions, understand information, assert a choice to health professionals, were also considered important." 136

The timeliness of this education seems to play an important part in its effectiveness. "Given the importance of this sense of control, preparation of women for labour is crucial to allow them to take control and is...not something that ought to be left to the last few weeks of pregnancy." 140 Education in particularly needs to be covered early on to ensure that those few women whose births occur early and result in an emergency caesarean are able to feel in control and still make the experience a positive one.

Agendas are, all too often, allowed to creep into the education provided by antenatal groups. According to one study, women attending NCT antenatal education "expected a natural drug-free labour [Reference 46 of this paper]." This may be desirable but cannot be guaranteed. And as far as hospital based antenatal education is concerned one study questioned "whether some hospital-based education serves to socialise women about the "appropriate" ways of giving birth rather than educating them" 141

Antenatal education has been shown to have a significant impact on the expectations and experience of birth. It is essential that all groups and individuals currently responsible for the education of women facing birth review their processes and their material. We would go as far as to suggest that such an important aspect of health education ought to be supervised.