Opportunities to improve maternal health literacy through antenatal education: an exploratory study

HEALTH PROMOTION INTERNATIONAL Vol. 16, No. 4© Oxford University Press 2001. All rights reserved Printed in Great Britain

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INTRODUCTION

This paper examines the concept of maternalhealth literacy. It does so by considering the feasi-bility of using the concept of health literacy toguide the content and delivery of antenatal classes.

Health literacy has been identified as a meas-urable outcome of health education interventions(Nutbeam, 1996). The World Health Organ-ization (WHO) defines health literacy as follows:

‘Health literacy represents the cognitive and socialskills which determine the motivation and ability of

individuals to gain access to, understand, and use theinformation in ways which promote and maintain goodhealth. Health literacy means more than being able toread pamphlets and successfully make appointments.By improving people’s access to health informationand their capacity to use it effectively, health literacy iscritical to empowerment’ (WHO, 1998).

In an earlier paper in this series, a continuumof health literacy was proposed. This continuumincludes basic or ‘functional’ health literacy,

Key words: antenatal education; empowerment; health education; health literacy

SUMMARYThis paper examines the concept of maternal healthliteracy, defined as the cognitive and social skills that deter-mine the motivation and ability of women to gain access to,understand, and use information in ways that promote andmaintain their health and that of their children. Specifically,it investigates the feasibility of using the concept of healthliteracy to guide the content and process of antenatalclasses. The paper reports on the results of focus groups andinterviews conducted with a range of health care providers,pregnant women and new mothers to obtain different per-spectives on the issues surrounding antenatal education andparenting. The results give us a realistic look at what womenare learning from existing antenatal education and how itcan be improved. Comparing the results from the educatorsand the women, the same basic issues surface. Both recog-nize that there are serious time limitations in antenatalclasses. These limitations, combined with natural anxietyand curiousity about childbirth, generally ensure that the

content of classes is confined to pregnancy and childbirth.The limitations of time are also cited as a reason for theteaching methods being heavily weighted towards the transferof factual information, as distinct from the development ofdecision-making skills, and practical skills for childbirthand parenting The results indicate clearly that antenatalclasses cannot possibly cover all there is to know aboutpregnancy, childbirth and parenting. If the purpose of ante-natal classes is to improve maternal health literacy, thenwomen need to leave a class with the skills and confidenceto take a range of actions that contribute to a successful preg-nancy, childbirth and early parenting. This includes know-ing where to go for further information, and the ability toanalyse information critically. The authors conclude thatthis would represent a very challenging change in orientationfor both the educators and pregnant women included in thisstudy. Work continues on the development of the tools thatwill be needed to support this change.

Opportunities to improve maternal health literacythrough antenatal education: an exploratory study

SUSAN RENKERT and DON NUTBEAMDepartment of Public Health and Community Medicine, A27, University of Sydney, NSW 2006, Australia

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communicative/interactive health literacy andcritical health literacy. Such a continuum suggeststhat the different levels of literacy progressivelyallow for greater autonomy in decision makingand personal empowerment, demonstrated throughthe actions of individuals and communities(Nutbeam, 2000). By using the concept of healthliteracy to guide the content and delivery of healtheducation, attention is focused on the develop-ment of the skills and confidence to make choicesthat improve individual health outcomes, ratherthan being limited to the transmission of infor-mation. Ideally, a level of critical health literacywill be reached in which an individual has theability to seek out information, assess thereliability of that information and use it to exertgreater control over the determinants of health,and make well informed health choices.

In applying this concept of health literacy todefine the outcomes of maternal and child healtheducation, we refer to maternal health literacy.Specifically, maternal health literacy can bedefined as the cognitive and social skills whichdetermine the motivation and ability of womento gain access to, understand, and use informa-tion in ways that promote and maintain theirhealth and that of their children.

ANTENATAL EDUCATION

Pregnant women in general, and first-timemothers in particular are provided with a vastamount of information. Many women, especiallyfirst-time mothers, attend antenatal classes whichprepare them for labour and delivery, and usuallyinclude basic babycare skills. Although thisknowledge and related skills are important for asuccessful pregnancy and childbirth, women needdifferent knowledge and skills for successfulparenthood.

Knowledge about childbirth and parenting hashistorically been gained informally from otherwomen, mainly family members, and throughpractical experience of assisting with child-rearing in extended families. However, changesin family structure and women’s increased par-ticipation in higher education and the workforce,combined with the increasing medicalization ofchildbirth, have meant that women are far morelikely to depend upon formally organized ante-natal education as the mechanism through whichthey develop their knowledge and skills (Zwelling,1996; Nolan, 1997b).

Typically, antenatal education tends to focuson facts surrounding pregnancy, labour and basicbabycare skills. In addition, there are a range of options for pain management (both medicaland non-medical) and obstetric interventions forwomen to learn about, which tend to take up a large amount of time in antenatal classes. As a consequence, what women do not necessarilygain from antenatal classes is the confidence andemotional insight traditionally gained throughinformal communication with other women, andthe practical experience of child care in extendedfamilies (Nolan, 1997b). Thus, the content of ante-natal classes prepares women to manage decisionsduring their pregnancy and childbirth, yet givesrelatively little attention to preparing women(and their partners) for parenthood. The deliverytends to be instructional rather than orientedtowards empowering women to make informeddecisions about their health and the health oftheir baby.

Standards and guidelinesThere are few examples of widely adoptedstandards or guidelines for antenatal education,and a lack of systematic certification for ante-natal education teachers (O’Meara, 1993b). Forexample, in Australia, research into the quality ofmaternity services in Victoria and WesternAustralia identified concerns about effectiveness,curriculum content, standards of practice andteacher training for childbirth and parenting edu-cation programmes, despite acknowledgement oftheir importance (O’Meara, 1993b). Similar con-cerns emerged from a study done in the AustralianCapital Territory regarding lack of teachercertification and standards for course content(O’Meara, 1993b). In the United States, stand-ards of practice for antenatal education are alsolacking with respect to the timing of classes offered,length and size of classes and most importantly,content of classes (Nichols, 1993). Certificationof childbirth educators in the US, although it has existed for years, is not often required ofemployers or valued for its benefits (Zwelling,1996).

Variations in qualityBecause there are no widely applied guidelinesor standards for antenatal education, child-birth classes vary widely in length, instructortraining, sponsorship, goals, focus and content

382 S. Renkert and D. Nutbeam


(Shearer, 1996). Each hospital, clinic or privatechildbirth educator designs a class as they seeappropriate. Most health professionals wouldagree that antenatal classes are informative andthey are highly recommended for expectantparents. They are something that ‘everyone isdoing’, but are often found to be beneficial dueto the socialization with other expectant parents,rather than the knowledge and skills transferred(Zwelling, 1996). Client satisfaction is generallyused as a measure of success of antenatal classes.There are few studies on the effect of antenatalclasses on birth outcomes. Generally theseindicate positive benefits in terms of successfulchildbirth, and show that a positive childbirthexperience may have a positive effect on thetransition to parenting (Nichols, 1995).

Antenatal classes are often designed to preparewomen for childbirth in that particular hospitalor setting (Gilkison, 1991). Instead of learning all options available to them, parents may onlyhear about options available or preferred in thesponsoring hospital (Gilkison, 1991). This mayproduce positive results in terms of childbirth,but does not necessarily prepare women forparenthood or empower them to make informedhealth choices.

As well as being highly variable in content, the delivery of antenatal education often lacksgrounding in the field of adult education (NSWDepartment of Health, 1998). Antenatal classteachers are most often trained as midwives, butmay be nurses or physiotherapists (Nolan, 1997).These clinicians have good content knowledge,but are not necessarily trained and competent inteaching.

Preparation for parenthoodResearch in the area of antenatal education showsthat classes often do not have a suitable balancebetween preparation for labour and childbirthand preparation for parenthood (O’Meara, 1993c).The majority of antenatal classes cover thebirthing process itself, and only a relatively smallproportion of time available will focus on what todo after the baby is born. In these circumstances,women are leaving antenatal classes with a goodknowledge of birthing options, but feel insuffi-ciently prepared for what lies ahead. O’Meara, inher evaluation of consumer perspectives of child-birth and parenting education, found a high levelof dissatisfaction among women attending child-birth education classes in Australia. She notes that

women lacked timely knowledge for the caring oftheir newborn, and did not have the confidence tomake decisions for the family’s care (O’Meara,1993c). Other research has indicated that womendo not have a realistic understanding of theburden of parenthood, or the changes in lifestyleand relationships that come with it (Hillan, 1992).To address this deficiency, O’Meara suggests thata comprehensive curriculum designed to meetthese expectations needs to be developed(O’Meara, 1993c).

It seems that many childbirth educators feelthat their clients are not interested in parentingtopics before childbirth and simply want to get through the labour and delivery. Yet Nolan’sresearch indicates that couples desire a balancebetween labour and delivery and post-natalissues (Nolan, 1997a). Results from Nolan’sstudy of antenatal education noted that both pre-natally and post-natally, fear of labour pain wasonly a ‘minor’ part of a woman’s motivation forchildbirth education (O’Meara, 1993c).

In summary, antenatal education is valuedboth by prospective parents and by health careprofessionals as an important factor in achievingpositive health outcomes for mother and baby.The content of antenatal education tends to focuson health during pregnancy, and on options forchildbirth—often limited only to those preferredby the hospital or clinic. In delivery, antenataleducators are usually untrained in principles ofadult education, and generally focus on know-ledge transfer and the development of basic skillsassociated with childbirth. Although this approachto antenatal education undoubtedly contributes tosafer and more successful childbirth, it representsa missed opportunity to develop the knowledgeand skills that have more enduring applicationduring the early years of parenthood. This failureto address issues of parenting has consistently beenidentified by parents after the birth of their children.

This paper reports on a series of interviewswith health care providers, pregnant women andnew mothers to explore how both the content and delivery of antenatal education could beimproved to address some of these shortcomings.The concept of maternal health literacy was usedto provide a framework for the enquiry.

METHODS

A series of focus groups and interviews wasconducted with a range of health care providers,

Maternal health literacy and antenatal education 383


pregnant women and new mothers. These werecarried out at a large maternity hospital inSydney and an early childhood centre in CentralSydney.

The questions were developed using the healthliteracy concept as a framework for enquiry.Specifically, the questions sought to explore theextent to which both the content and delivery ofthe teaching and learning supported the develop-ment of knowledge, skills and confidence to act,which characterize the different levels of healthliteracy described in an earlier paper (Nutbeam,2000).

Those selected for the interviews and focusgroups were volunteers, who were willing andable to give their time to explore these issues, and are not considered a representative sampleof women or health care providers. All discus-sions were audio-taped and transcribed by theresearchers. This data collection forms part of alarger research project that aims to develop andtest an instrument to measure maternal healthliteracy in pregnant women.

Two focus groups were conducted. The first wasa group of five pregnant women, all >28 weeksinto their pregnancy and expecting their first child.These women were recruited by a health educatorat antenatal classes at a large maternity hospitalin Central Sydney. The health educator spokebriefly at the beginning of the classes about thepurpose of the focus group and answered anyquestions. A flyer was also posted in the sectionof the hospital where the antenatal classes tookplace. Incentives were not offered but refresh-ments were served. The focus group lasted 45 min, and nine questions were put to the groupfor discussion. These included women’s expecta-tions of the classes, the breadth and depth of classcontent areas, confidence, personal attention inclasses, pre- versus post-natal classes, and parent-ing. The discussion was facilitated by the healtheducator.

The second focus group comprised of sevennew mothers, all with newborns ~5–6 weeks old.These women attended a weekly mother’s groupat an early childhood centre in Central Sydney.They attended daytime classes and were full-timemothers, and all seven had attended antenatalclasses. This group was recruited by one of thecentre’s nurses, using one of the focus groupflyers. Twenty-dollar gift certificates to a localbabycare store were offered as an incentive toparticipate. An incentive was used because theresearchers anticipated a low response rate

compared with the focus group of pregnantwomen. A similar format to the antenatal groupwas followed, with questions regarding their expect-ations of motherhood before the birth versusreality with a new baby, reflections on whichtopics in antenatal classes they found helpful andwhat they thought was lacking, and advice theywould give to pregnant women.

Interviews were conducted with five antenataleducators who taught classes at a large maternityhospital in Sydney. Their backgrounds varied,and the group included three practising mid-wives, one physiotherapist, and one RegisteredNurse (RN) who was also a midwife but notcurrently practising. Each interview lasted 30 minto 1 h in duration, and included eight questionsregarding their views on the needs of pregnantwomen, class expectations, parenting versus child-birth preparation interest, and their opinions onthe best ways for women to prepare for parent-hood. Names of interview candidates wereprovided by the Clinical Midwifery Consultantfor Parent and Patient Education at the hospital,and all contacted agreed to provide an interview.The interviews were informal and all participantsappeared to be highly motivated in their teaching.

In order to obtain the perspective of healthcare providers that saw women post-natally,three other health care professionals were inter-viewed. One was the Early Childhood Nurse UnitManager at an early childhood center in CentralSydney, and the second was an RN at the samecentre. The third person interviewed was theNurse Unit Manager for the hospital’s early dis-charge support programme. Nine questions,addressing the same topics asked of the antenataleducators, were discussed. The results arepresented differentially for the four groups.

RESULTS

Antenatal educatorsPriority topics in antenatal classesIn speaking with antenatal educators, themajority thought that the women in their classeswere mainly concerned with getting through thelabour and delivery. Most felt that fewer thanhalf of the women attending classes were think-ing past the birth, and that even those womenseemed to be interested only in skills neededimmediately after birth. The educators did feelthat education tailored toward parenting, given



in the antenatal period, would be useful but allhad concerns about time restrictions and provid-ing ‘too much’ information. They feared losingthe attention of some participants who weremore focused on only labour and delivery.

By contrast, one new educator said:

‘I’m just finding out now that women want lessinformation on the birth and some more on parenting.From my expectations and training, I thought they didwant mostly information on childbirth, but I just got back my first set of evaluations from the first classand they did express a desire for more parentinginformation.’

Pregnant women’s interest in parentinginformationOn the topic of women’s interest in parentinginformation, one antenatal educator said:

‘It doesn’t seem to be an issue. The women don’t believewhat you tell them, and it’s not until they have their babyand are at home that they realize how difficult it is.’

She said that the resources for them are out inthe community but that many women are afraidto admit that they need help. Several educatorsshared this belief that society puts a lot of pressureon women to be able to take on new motherhoodwith ease, and that women fear that asking forparenting advice or assistance will be viewed as asign of weakness.

ConfidenceConfidence was cited by the educators as one ofthe most important issues in antenatal classes.The educators commented that although a lot of women that attend have control over manyaspects of their life, such as career or finances,they feel unprepared and lack the confidence totake on both labour and parenting. Women canbe given information and even taught skills, butthey also need confidence and reassurance inorder to successfully apply what they’ve beentaught.

Timing of parenting skills taughtWhen prompted about when the best time toteach parenting skills is, the majority of educatorsfelt that post-natally would be the most appro-priate. The reason for this was mainly due to timerestrictions in antenatal classes as they are nowstructured. This was also due to the lack ofinterest in some of the participants with respectto information needed post-natally. By providing

classes or drop-in information sessions in the post-natal period, many educators felt that women maybe more likely to listen to the information pro-vided. Time didn’t seem to be a concern for thosesuggesting post-natal groups, however there mayhave been an underlying assumption that motherswill stop working and will have the time to attend.

Improving health literacyOne educator in particular explained that preg-nant women are a vulnerable target group:

‘I tell them to push hard when buying something forthe baby. People are out there to make money andmany mothers can be naïve.’

She also discussed the use of the internet as aninformation source, and warns the women in herclass to be sceptical because anybody can putinformation on the internet and it is not alwaysreliable.

‘They need to know where to go if something comes upthat we don’t cover in class. We can’t do everything.’

A similar view was expressed by a nurse mid-wife. She said that often women make decisionsbefore they cover things in class, such as whatkind of cot or car seat to buy, or whether or notthey are going to breastfeed, before they have allthe information. She tries to give women a rangeof options and let them decide what is best forthem personally. Her vocabulary includes ‘Ithink’ rather than ‘the correct way is …’ so theyunderstand her view is not the only view.

From the feedback gained from the antenataleducators, it’s obvious that they believe thatwomen need both factual information, as well asthe opportunity to develop skills and confidenceto cope with labour and parenting. The educatorsall seemed concerned that women needed morethan just information transfer and all tried toincorporate that into their class, but they seemedsomewhat reluctant to include a wider variety of educational strategies, partly due to the timerestrictions they are faced with.

Pregnant womenPriority topics in antenatal classesIn a focus group discussion with a group of preg-nant women, the need for more parentinginformation was expressed, but it was secondaryto the issue of labour and delivery and not



brought up until the end of the discussion whenthe facilitator prompted specifically on the topic.When asked about expectations women hadabout antenatal classes, one woman commented:

‘I was pretty keen to get a lot of information on theactual labour. I know it’s important to look beyondthat and what to do with a newborn … but I was reallyexpecting the main focus to be on labour …’

ConfidenceConfidence and reassurance was a key issue forthese women, in both labour and parenting. Onewoman commented that information, in and ofitself, brings a sense of reassurance. When askedabout what women still didn’t feel confidentabout, one reply was that

‘there is so much to learn, that you just can’t learn untilyou’ve got the baby, and until you are actually home …’

Time restrictions and other barriersJust as the antenatal educators were concernedwith time restraints, so too were the expectantmothers. One woman felt that she was alreadysaturated enough to receive more informationabout parenting while still pregnant.

Aside from time restraints and interest area,the women agreed that they simply wanted toenjoy their new baby without any pre-conceivedideas of what makes good parents, or what theyshould be doing or not doing. In other words, dis-covering the baby’s personality before worryingabout what parenting skills to apply.

Timing of classesWhen asked about post-natal classes for newparents, the women were definitely interested,not simply for learning new information andskills, but for the support and contact with othernew parents.

In one woman’s reasoning as to why parentingeducation would be best left until the post-natalperiod, she said:

‘I think that is why antenatal classes are so good that they are so focused on labour and what happensimmediately afterwards … you feel like you are in anemergency situation, like “I need to know this right now”.’

Post-natal health professionalsPreparation for parenthoodThose health care professionals that saw womenpost-natally were all in agreement that women

are never really prepared for how difficult parent-hood really is. One RN at an early childcare centresaid that in her opinion:

‘how prepared a woman is for parenthood depends alot on their age, insight, reading prowess, experienceswith kids, relationships and job—but not necessarilytheir education level.’

The same RN described labour almost as a ‘men-tal obstacle’ needed to get over before women couldopen themselves up to more parenting information.

‘They are prepared for labour, but for the parentingpart, they’ll prepare after the event. The fear of labour,survival of the baby and survival of themselves hasbeen nullified, so then they can go to the next step.’

Antenatal educationWith regards to the topic of antenatal education,one RN said ‘projected knowledge is good, butnot useful’. She explained that it doesn’t alwaysfit a woman’s experience, particularly with respectto culture.

‘The cultural gap is a huge chasm. There iscommunity culture, family culture etc.’, notingthat even within families, cultural beliefs can bedifferent.

When asked what their thoughts were on thebest way to prepare women for parenthood, all those interviewed suggested some kind ofreal-life experience with children—however, all acknowledged that the idea was not veryrealistic. Suggestions included having high schoolstudents be paired with a family with a new baby,and having mothers in the maternity ward comedown to antenatal classes.

New mothersPriority topics in antenatal classesFocus groups results with new mothers revealedthat these women would have liked to have moreinformation concerning experiences after thebirth in their antenatal classes. However, mostwomen agreed that they were not sure whetheror not they would have been receptive to itbefore the birth, since labour was their primaryconcern. They simply didn’t realize what it wouldbe like until they were actually home with theirbabies. ‘You can’t quite prepare yourself for theemotional change that you are going through’said one new mother. ‘You can’t really explain it,you have to go through it’ expressed another.



When asked specifically how well they thinktheir antenatal classes prepared them for theirexperiences after the birth, most women said thatthey were not very helpful. One woman said:

‘It was good at the time because you felt like youneeded to do something, but in retrospect, no, it wasn’treally that good.’

In response to inquiries about the amount oftime spent on labour versus parenting, one womansaid they spent about an hour on post-natalissues, and:

‘The labour was nothing compared to what I felt whenI got home with the baby.’

In an attempt to sum up the comments aboutantenatal classes, one new mother said ‘I thinkthe thing with antenatal classes is it’s virtuallyimpossible to talk about after the birth becauseno one wants to think about after the birth … It’sjust that your mind can’t cope with that as well.’Another said ‘I had good classes, but I wouldhave liked more psychological stuff for after thebirth.’

Preparation for parenthoodRetrospectively, all mothers agreed that theywould have liked more post-natal information,but were at a loss for suggestions of the best wayto provide that information. Having informationto take home with them was helpful becausealthough they might not have been interested init at that time, they knew they had something to refer to later. Those women that had priorexperiences with children, such as nieces andnephews, discussed how helpful it was when theyhad their own baby. Those with children in theirextended families felt strongly that this helpedthem make the transition to parenthood.

DISCUSSION

This paper reports on results from a study thatforms part of a larger project to design a diag-nostic instrument to measure maternal healthliteracy. The paper reports on exploratory workwith groups of women who may be labelled‘highly motivated’, rather than representative of the wider population of pregnant women, newmothers and health professionals. The resultsshould be treated with caution for these reasons.

The findings indicate that even within a singlehospital there is variability in the goals andeducational methods in the delivery of antenataleducation. Despite this, the findings seem to con-firm that the antenatal education that is offeredensures that mothers are well prepared to achievesuccessful childbirth by following the establishedprocedures of the institution. Our purpose inconducting this study is not to replace thesesuccessful processes and their outcomes, but toconsider whether there is more that could beachieved through the unique educational oppor-tunity represented by antenatal education.

The results from interviews and discussiondescribe the similarities and differences in per-ceptions of the experience of antenatal educationfrom the perspective of both the educators andthe women participating in the programme. Itexplores the extent to which antenatal educationis engaging women in understanding factorsinfluencing successful childbirth and their cap-acity to navigate the early period of parenthoodsuccessfully.

Comparing the results from the educators andthe women, the same basic issues surface. Bothrecognize that there are serious time limitationsin antenatal classes. These limitations, combinedwith natural anxiety and curiousity about child-birth, generally ensure that the content of classesis confined to pregnancy and childbirth. This out-come is reflected in the views of both the edu-cators and pregnant women. Although there issome interest in addressing issues of parenthoodamong pregnant women, it is only among thegroup of recent mothers that there is strongsupport for more parenting information in thecontent of antenatal classes.

In addition to the constraints on time, there isa view reflected among educators in particular,that the pregnant women attending antenatalclasses are just not ‘ready’ for information onparenting at that stage.

The limitations of time are also cited as areason for the teaching methods being heavilyweighted towards the transfer of factualinformation, as distinct from the development ofdecision-making skills, and practical skills forchildbirth and parenting; the latter approach re-flecting better the concept of health literacy thanthe former.

The results from the study indicate scope to develop both the content and delivery ofantenatal education in ways that better reflectthe health literacy concept, but is less conclusive



on the extent to which classes can be developedto address the skills and knowledge needed forearly parenthood. The results are also useful inilluminating some of the potential barriers to thechanges in content and delivery that might betterreflect the health literacy concept, including theextent to which antenatal education is empower-ing rather than passive in its effects on women.

Antenatal classes cannot possibly cover allthere is to know about pregnancy, childbirth andparenting. If the purpose of antenatal classes is toimprove maternal health literacy, then womenneed to leave a class with the skills and confi-dence to take a range of actions that contribute to a successful pregnancy, childbirth and earlyparenting. This includes knowing where to go forfurther information, and the ability to analyseinformation critically.

In developing this study, our hypothesis hasbeen that a focus on improving health literacy as an outcome may help reframe thinking aboutthe content and method of antenatal classes. Byfocussing more on providing women with skillsthey can use, and empowering women to makeeducated choices, it is hypothesized that educatorswon’t have to struggle to include everything thereis to know about labour, delivery and parenthoodin the education programme. Clearly, this repre-sents a very challenging change in orientation forboth the educators and pregnant women includedin this study.

Building confidence and self-esteem, as well asencouraging parents to take responsibility fortheir families’ health, have previously been advo-cated as an integral part of antenatal education(Nolan, 1997b).

‘The aim of antenatal education now must be to workwith the information, skills, and life experience thewoman already has and to build on those in order to help her grow in confidence as a consumer of thematernity services and as the mother of their child.’(Nolan, 1997a)

The health literacy concept offers us theopportunity to shift our thinking in antenataleducation away from a simple transfer of know-ledge, to a more active process of empoweringwomen for parenthood. The results from inter-views and focus groups gives us a realistic look atwhat women are learning from existing antenataleducation and how it can be improved. By work-ing towards the development of health literacy as an outcome in antenatal education, we may

be able to bring women the confidence andemotional insight which they no longer gain fromextended families and other women (Nolan,1997b). We may better equip women with skillsand confidence, so that when the labour processis over, the reality of parenthood is a positive,healthy experience.

Address for correspondence:Susan RenkertDepartment of Public Health and Community

MedicineA27, University of SydneyNSW 2006Australia

REFERENCES

Gilkison, A. (1991) Antenatal education—whose purposesdoes it serve? New Zealand College of Midwives Journal,1, 13–15.

Hillan, E. (1992) Issues in the delivery of midwifery care.Journal of Advanced Nursing, 17, 274–278.

Imle, M. A. (1990) Third trimester concerns of expectantparents in transition to parenthood. Holistic NursingPractice, 4, 25–36.

Monto, M. A. (1996) Lamaze and Bradley childbirth classes:contrasting perspectives toward the medical model ofbirth. Birth, 23, 193–201.

Nichols, M. R. (1995) Adjustment to new parenthood:attenders versus nonattenders at prenatal educationclasses. Birth, 22, 21–26.

Nolan, M. (1997a) Antenatal education: failing to educatefor parenthood. British Journal of Midwifery, 5, 21–26.

Nolan, M. (1997b) Antenatal education—where next?Journal of Advanced Nursing, 25, 1198–1204.

NSW Health (1998) Five Year Goals, Objectives, andStrategies for Maternity Services. Discussion paper forcomment.

Nutbeam, D. (2000) Health Literacy as a public health goal:a challenge for contemporary health education andcommunication strategies into the 21st Century. HealthPromotion International, 15, 259–267.

O’Meara, C. M. (1993a) A diagnostic model for the evalu-ation of childbirth and parenting education. Midwifery, 9,28–34.

O’Meara, C. M. (1993b) Childbirth and parenting education—the provider’s viewpoint. Midwifery, 9, 76–84.

O’Meara, C. M. (1993c) An evaluation of consumerperspectives of childbirth and parenting education.Midwifery, 9, 210–219.

Parliament of New South Wales Legislative Council (1998)Working for Children: Communities Supporting Families.Inquiry into Parent Education and Support Programs.

Shearer, E. L. (1996) Commentary: randomized trialsneeded to settle question of impact of childbirth classes.Birth, 23, 206–208.

Zwelling, W. (1996) Childbirth education in the 1990s andbeyond. Journal of Obstetric, Gynecologic, and NeonatalNursing, 25, 425–432.



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Opportunities to improve maternal health literacy through antenatal education: an exploratory study