A common criticism of antenatal education is that too much emphasis is based on labour and delivery, while not enough attention is paid to parent-craft and post-delivery issues
Client Education
In the definition of the midwife as described by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC), the importance of the midwife's role in antenatal education and preparation for parenthood is highlighted (UKCC 1998). Antenatal education was initially introduced to educate expectant mothers in good hygiene practices to reduce high levels of infant mortality in the 19th century (Wilson 1990), however in recent times the emphasis of classes has changed. A more recent definition of education for parenthood states that classes should allow parents "to develop a confident and relaxed approach to pregnancy, childbirth and parenthood" (Brayshaw and Wright 1994:8), and using a team approach, should enable parents to make informed choices about their care (Robertson 2000c), based on safe, accurate and consistent advice which is up-to-date and evidence based (Brayshaw and Wright 1994).
A common criticism of antenatal education is that too much emphasis is based on labour and delivery, while not enough attention is paid to parent-craft and post-delivery issues (Collington 1998, Robertson 1999a, Nolan 1999, Smith 1999). In a study by Lavender et al (2000) less than 40% of parents interviewed felt adequately prepared for parenthood in the early postnatal weeks. It is important therefore, that in their roles as educators, midwives address this issue and adopt a more client centred approach to antenatal education provision (Department of Health 1993).
One aspect of parent-craft many prospective parents are keen to explore in more depth is that of infant feeding (Britton 1998, Hoddinott and Pill 1999, Frossell 1998, Newburn 2000,Department of Health 1993). In particular, recent concerns have been raised about the lack of support that midwives offer to women that bottle-feed their babies (Kaufmann 1999). The World Health Organisation and UNICEF (cited by Martyn 1998) published the International Code of Marketing of Breastmilk Substitutes in 1981, which states that while infant formula should not be promoted, parents that have made an informed decision to use artificial milk should be provided with adequate information to do this safely (cited by Martyn 1998). This was also re-iterated in Changing childbirth (Department of Health 1993) and Maternity care in action (Maternity Services Advisory Committee 1982). However, many health professionals have been identified as pressurising women into breast-feeding (Battersby 2000), and have even reported that allowing informed choice in infant feeding is inappropriate (Robertson 2000a). It has been identified that prospective parents are not usually provided with adequate information on artificial feeding, and as a result, unsafe practices often occur (Kaufmann 1999), and truly informed choices are not made (Minchin 2000). For this reason, the topic of 'reconstitution of an artificial feed' was chosen for the teaching session. It should be considered as an excerpt of a larger teaching session covering all aspects of infant feeding to allow informed decision-making and safe practice, in accordance with the wishes of the client group.
The session was organised in advance, using a teaching plan (appendix one). This has been identified as a helpful teaching aid (Wilson 1990) and clearly identifies the desired outcomes for the session. In this case, the objective is that all attending clients feel able, by the end of the session, to prepare a bottle of formula milk safely and confidently.
The client group involved was actually a group of 17 student midwives, and two assessors, but for the purpose of this essay, they will be regarded as a mixed group of antenatal women at about 26 weeks into their pregnancy and their partners. Although 26 weeks may seem early to be discussing infant feeding, Robertson (1999a) states that as pregnancy progresses, parents tend to become more focussed on labour and delivery, however, too early in the pregnancy, and the practicalities of parenting may seem too distant to the client (Wilson 1990). Also, starting classes earlier in pregnancy allows the development of an improved support network among the parents, particularly with a closed group (Robertson 1999b, Wilson 1990). Partners would be encouraged to attend. A recent study demonstrates the perceived inadequacies of current parent-craft classes by the attending men, but also, their desire to be more involved (Smith 1999). This implies we should tailor course content to suit both parents (Smith 1999, Wilson 1990, Priest and Schott 1991, May 2000).
The setting of the session would ideally be an airy, clean, well-lit room (Priest and Schott 1991), with easy access to toilets and refreshments. The room would be made to feel as comfortable and welcoming as possible, and to help achieve this and to improve group interaction, the chairs would be arranged in a circle (Robertson 1999b, Priest and Schott 1991). After a quick introduction to ensure everyone knew who the session facilitator was, the teaching session was started by ensuring everyone was comfortable with adequate refreshments. A comfortable, relaxed atmosphere will aid group work, and encourage clients ...
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The setting of the session would ideally be an airy, clean, well-lit room (Priest and Schott 1991), with easy access to toilets and refreshments. The room would be made to feel as comfortable and welcoming as possible, and to help achieve this and to improve group interaction, the chairs would be arranged in a circle (Robertson 1999b, Priest and Schott 1991). After a quick introduction to ensure everyone knew who the session facilitator was, the teaching session was started by ensuring everyone was comfortable with adequate refreshments. A comfortable, relaxed atmosphere will aid group work, and encourage clients to return (Wilson 1990).
The clients attending the session were all adults present through choice, so it is important to reflect this through teaching methods and styles (Babcock & Miller 1994). Andragogy may be defined as 'the art and science of helping adults to learn' (Chandler 1992). This identifies that there is a distinct difference between adult and child education (Babcock & Miller 1994). Many of the clients will attend the session with the specific goal of learning new skills and information (Robertson 1999a), however, a client's rationale for attending the session may vary, as all adult learners are unique individuals with differing motivation, life experiences and learning styles (Babcock & Miller 1994). Many people attend antenatal classes for the more social aspect of the group (Robertson 1999b). The desires of these clients to build a social support network should not be ignored, and the opportunity for social network development should be included in the session through group work or discussion (Robertson 1999b). This recognition of the clients as individuals with differing learning needs and styles is regarded as the 'humanistic' approach to teaching (Babcock & Miller 1994).
The session was started using a short homemade video demonstrating some common errors in bottle preparation, followed by discussion on the identified errors. This was primarily used to stimulate discussion, identify and build upon knowledge already possessed by the group, and to enable experienced members to share their knowledge with others (Priest & Schott 1991). It also served as a light-hearted way to introduce the topic, and 'fun' is a vital element of adult learning (Priest & Schott 1991). The use of a visual aid such as a video can help to focus the attention of the client, which in turn can enhance learning (Babcock & Miller 1994). The video was just over one minute long, and the following discussion was limited to a couple of minutes. Although in part this was due to the time constraints, this also introduced lots of variety into the session. Not only does variety of teaching enable more people to absorb information through their preferred method by using a range of senses (Priest & Schott 1991, Chandler 1992), but it also reduces the risk of boredom, and allows the normally limited concentration span of the adult learner (particularly during pregnancy) to be extended (Priest & Schott 1991, Wilson 1990, Chandler 1992). Because the video was homemade, many of the usual pitfalls of using video were avoided e.g. out of date information, irrelevant subject matter, inappropriate length, already seen by clients (Priest & Schott 1991). A video recorder and television were required for the teaching session, and this may not always be available. It should be noted that this equipment was checked prior to the start of the session (Wilson 1990).
The short discussion on the video enabled self-disclosure on the part of the clients and the facilitator. It was emphasised that many people (including the session facilitator) had made some of the mistakes highlighted in the video to promote a non-judgemental and trusting environment. The client-facilitator relationship must be trusting to promote a safe learning environment (Thompson 1992).
Following the discussion, a demonstration of bottle preparation was performed by the facilitator, with a simultaneous mini lecture to explain what was being done and why, with emphasis being placed on how to avoid the common mistakes witnessed in the video. Unbranded baby milk was used for the demonstration, so no specific artificial milk product was seen to be endorsed by the midwife (Royal College of Midwives 2000). Demonstration is one of the preferred methods of teaching a psychomotor skill (Chandler 1992). Because the previous discussion revealed the entry level of the client group to the skill, the demonstration was aimed at the ability of the majority of the group (Chandler 1992), and further help would be made available to any clients requiring it. The limitations on group sizes are a major disadvantage of demonstration methods (Babcock & Miller 1994). In order to facilitate learning, all clients must have a clear view of the demonstration (Babcock & Miller 1994). This was achieved by arranging the chairs around the demonstration table, and checking with the clients that they were all able to see. The mini-lecture emphasised the positive actions that should be taken, rather than the negative points on the video. Using a positive approach will reduce the risk of errors (Babcock & Miller 1994).
At the end of the session, the group were asked if they had any further questions, and were provided with handouts re-iterating how to make an artificial feed safely (appendix two). These handouts were designed and produced specifically for the teaching session, so contained no endorsements from artificial milk companies (Royal College of Midwives 2000), and were directly relevant to the content of the teaching session (Priest & Schott 1991). The pamphlets used large text with simple diagrams to improve client understanding (Babcock & Miller 1994). The handouts were not distributed until the end of the session, as if they had been handed out at the start of the session, the clients may have been distracted from the teaching and discussion (Babcock & Miller 1994). The handouts were used to build upon the information provided within the session (Babcock & Miller 1994).
Ideally, clients would have had the opportunity to practice their new skills after the demonstration, however, time-constraints made this impossible for all of them, but the opportunity was offered for after the session. The most useful demonstrations are those that the client may practice with guidance to compound their new knowledge (Babcock & Miller 1994, Priest & Schott 1991) however, a large group size and limited time would make this difficult.
An anonymous session evaluation form (appendix two) was also provided, which clients were encouraged to fill out and return. This enabled the facilitator to assess whether the learning outcomes were met (Wilson 1990). Evaluation is a vital tool for the facilitator in improving the quality of the parent-craft programme (Robertson 2000b). The form was structured to include simple tick box answers, which provide limited information, but are relatively easy for the client to fill in (Priest & Schott 1991), and also more open questions inviting more personal responses. A combination of these two approaches works well to enhance the information gained (Priest & Schott 1991).
The session facilitator filled out a self-evaluation questionnaire after the teaching session (appendix three). Self-evaluation is also an important tool when assessing the quality of a teaching session (Anforth 1992, Babcock & Miller 1994). It provides the opportunity to examine and improve the quality of teaching offered (Babcock & Miller 1994).
The assessors present provided an evaluation/feedback form (appendix five) after the teaching session. This gave a professional opinion on the quality of the teaching session, with suggestions for improvements.
The client evaluation forms were collected (appendix four), and the closed question information provided was collated into tables (appendix four). By collating the information provided by all these sources, common themes could be identified.
The feedback provided was generally very positive. All responding clients felt able to prepare a bottle independently, which met the main objective of the session. It should be noted however, that four clients did not return a completed evaluation form, so assumptions cannot be made about their feelings on the session. Positive feedback was received about the use of the video in the session, and the handout was felt by some to be useful. A few respondents felt that further information could have been provided on some points e.g. travelling with a bottle, and the use of pre-prepared feeds. Every effort would be made to address these queries in future sessions, and individual questions were addressed at the end of the session. Although the majority of the group felt that the level of teaching was appropriate for the client group, a few respondents noted that the level appeared aimed at young/first-time mums. Possibly more time could have been allowed for feedback from mums who had bottle-fed before to re-address this balance.
Overall, the session was well received. The facilitator noted that she had felt very nervous at the start of the session (possibly due to the false environment), and that she was worried this had come across in the teaching. However, only one person commented on this in the evaluation forms. The democratic approach appeared to suit the group well, and the teaching methods appeared to demonstrate the subject appropriately. Many of the points raised in the evaluation could have been addressed had more time been permitted, however lack of time and facilities remain major constraints in the provision of parent-craft education (Collington 1998). The facilitator should be enthusiastic, well prepared, and keen to participate in the provision of parent-craft (Rathbone 1973, Collington 1998), and this becomes increasingly difficult when time and facilities are limited. Despite these restrictions, antenatal education remains an important aspect of the midwife's role, which should be entered into enthusiastically, and should adopt a client centred approach (Department of Health 1993).
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