Group Antenatal Education vs. Individual or No Education

Introduction and Rationale

Antenatal education is a key component in reducing and preventing the pain and discomfort associated with pregnancy and childbirth. Recently, policy documents in various countries have been reviewed to pave the way for antenatal education programs (National Childbirth Trust, 2007). These policy documents emphasize the fact that antenatal education programs play a key role in preparing the mother and the family for childbirth, improving the expectant mother's confidence and self-esteem, and preparing them for care and feeding of the newborn. In addition, antenatal education programs help to enhance the overall experience during pregnancy and childbirth (Singh and Newburn, 2000; Schneider, 2001).

These programs have become common in many developed countries, but developing countries have lagged behind in their adoption of antenatal education programs. The major reason why developed countries have been faster in adopting such programs is that they recognize the importance of preparing expectant families for pregnancy, labor, childbirth, and care of the newborn baby. In particular, they recognize the significance of expectant women achieving the best possible physical and psychological health during pregnancy (Svensson et al., 2006). They also see the value of accessing good social support by attending sessions with a family member or a friend (Robertson et al., 2009; Lumbiganon et al., 2011).

Antenatal education is founded on the premise of using physical and psychological education methods to help mothers understand changes during pregnancy and learn how they can prevent and reduce pain and discomfort associated with pregnancy and childbirth (Billingham, 2011; Bergstrom et al., 2013; Artieta-Pinedo et al., 2010; Artieta-Pinedo et al., 2013). In developed countries, antenatal education classes have recently featured prominently in policy documents. These emphasize their impact on preparing the mother for childbirth, improving behaviors of mothers and others — such as the father and other family members — during pregnancy, increasing self-esteem and confidence, and preparing the mother for feeding and providing care for the baby throughout infancy (Ferguson et al., 2012; Schachman et al., 2004).

Antenatal education, often referred to as childbirth education or prenatal education, offers a wide range of information for mothers to identify and prevent complications and ensure the wellbeing of the mother and baby during the pregnancy period and after childbirth. As argued by Brixval et al. (2014), antenatal education classes are principally supported by the importance of preparing mothers for labor, childbirth, and postnatal care. The authors posit that there is great significance in these classes for influencing health-seeking behavior during pregnancy — to reduce overuse of healthcare services, optimize health during pregnancy, and provide social support that improves the mother's wellbeing and self-esteem (Redman et al., 1991).

Until recently, it was largely unknown whether antenatal education classes were effective in positively influencing the psychological and physical wellbeing of pregnant women and their families. However, recent studies have shown an increase in knowledge as a result of these classes and have also highlighted the importance of using a wide range of techniques to improve the health and wellbeing of the pregnant mother (Su et al., 2007a).

The impact of antenatal education classes on maternal emotional states — one of the key psychological wellbeing factors — is an important consideration in understanding the effect of these classes (Schachman et al., 2004). Maternal emotions can influence the health and social wellbeing of both the mother and the baby, making them important for the behavioral and psychological wellbeing of the fetus and the mother alike (Malata et al., 2007). One important question is the effect of antenatal education classes on the psychological wellbeing of the mother and the baby during fetal development and infancy, since this is a psychologically stressful time (Dennis, 2005).

It is also important to understand the influence of antenatal education classes on the information and preparation that pregnant mothers make for parenthood (Schmied et al., 2002). Though studies have shown that antenatal education classes are among the main sources of information for parents-to-be, it is important to understand the extent of this effect (Ahlden et al., 2012). Policy makers have often questioned the purpose and justification for antenatal education classes since they require significant infrastructural and other resource investment (Jaddoe, 2009). Therefore, it is important to understand the purpose of these classes and suggest how they can positively influence the knowledge that parents-to-be have about parenthood (Al-Shammari et al., 1994).

A review conducted by Gagnon and Sandall (2007) identified studies that conducted antenatal education programs on individuals and groups. The authors found that structured antenatal educational programs are essential for both childbirth and parenthood. Other available literature bears the same conclusion, showing that many healthcare professionals and researchers around the world recommend antenatal education for pregnant women (Svensson et al., 2007). Other authors assessed the effect of antenatal educational programs in helping women handle labor, pain, and anxiety prior to childbirth (Svensson et al., 2008).

That review's search strategy involved searching different electronic databases such as the Cochrane database, CINAHL for studies published between 1982 and April 2006, ERIC between 1984 and April 2006, EMBASE between 1980 and April 2006, and PsycINFO between 1988 and April 2006. The authors also searched the Journal of Psychosomatic Research for studies published between 1956 and April 2006. The review included randomized controlled trials and found that antenatal education programs for parenthood or childbirth have effects on: anxiety; knowledge acquisition; general social support; obstetrical interventions; infant care abilities; breastfeeding success; self-confidence; and maternal sense of control. The review authors used quantitative techniques for data analysis using the Cochrane statistical package RevMan (The Nordic Cochrane Centre and The Cochrane Collaboration, 2013), with 95% confidence intervals. The results reveal that antenatal educational programs generally enhance the outcomes of childbirth.

Unlike the UK, where the main providers of antenatal care are the National Health Service (NHS) and the National Childbirth Trust (NCT), developing countries have a wide range of antenatal care providers (Vieira et al., 2008). These range from large providers such as private and government hospitals to smaller providers such as clinics (Su et al., 2007b). As a result of this fragmentation in provision of antenatal care services, formal deployment of antenatal education classes remains a challenge, with most developing countries relying on inefficient information dissemination channels (Renkert and Nutbeam, 2001). In many cases, pregnant mothers rely on their own mothers to provide information regarding childbirth and parenthood (Al-Nasser et al., 1994). This informal channel has several drawbacks, including distortion of information and the absence of benefits such as increased confidence and self-esteem.

As argued by Nylander and Adekunle (1990), the problem of antenatal education in developing countries is twofold. First, there are insufficient or highly fragmented sources of antenatal care for pregnant women. Second, in areas where antenatal care is provided, these services are often underutilized — possibly due to lack of knowledge about their existence (Nolan, 2012). The authors propose two solutions to these problems. The first is to provide adequate facilities to ensure inclusiveness of antenatal education programs within the overall antenatal care landscape, which is extremely difficult where antenatal care centers are inadequate or highly fragmented (Miquelutti et al., 2013). The second is to include existing facilities that provide some form of antenatal care in the wider antenatal care network (Nigenda et al., 2003). The challenge will be to streamline the delivery of antenatal education services, ensure consistency of content, and make programs affordable (May and Fletcher, 2013).

In Saudi Arabia, "at present, there is no established plan for antenatal education interventions in terms of content and delivery methods" (Otaiby and Bawazir, 2013, p. 14). This is despite previous systematic reviews by Gagnon and Sandall (2007) and McMillan et al. (2009), which found that antenatal education classes have a positive effect on the knowledge of expecting mothers and fathers. However, these reviews also note that the effect of antenatal education classes on other aspects of pregnancy and motherhood — particularly in developing countries — remains unknown due to a paucity of studies in those settings.

Al-Ateeq et al. (2013) conducted a study evaluating the level of knowledge of 300 women in Saudi Arabia. The results revealed that nearly all subjects had not received important information about pregnancy, childbirth, and motherhood, pointing to the ineffectiveness of existing antenatal education efforts. The authors further noted a clear need for antenatal education classes in order to achieve better childbirth and motherhood outcomes in Saudi Arabia. Another study by Habib et al. (2011) showed that in Saudi Arabia, pregnant women without formal education are three times less likely to receive antenatal care compared to educated women, which can lead to increased anxiety during pregnancy, childbirth, and parenthood. A further study confirms that pregnant women who do not receive antenatal care face increased risk of poor childbirth outcomes (Rosenberg, 2002).

Despite the importance of antenatal education being demonstrated in these studies and in the practices of developed countries such as the UK and the US, there is still a scarcity of research focusing on antenatal education interventions in Saudi Arabia and other developing countries. This study attempts to systematically review the evidence on the effectiveness of antenatal education classes. The review focuses on studies conducted in both developing and developed countries due to the limited volume of research in developing-country settings.

The author currently works as a staff nurse in the Obstetrics and Gynecology ward at a specialist hospital and research centre that delivers the highest level of specialized healthcare within an integrated clinical practice and research setting. The hospital delivers 24-hour emergency care, dentistry services, medical oncology, cardiovascular services, short-stay surgery, and ophthalmology services. Despite the range of healthcare services delivered, the hospital does not have antenatal education programs to educate pregnant women in preparation for childbirth and parenthood, nor does it have a program to train clinical nurse specialists in patient education for this purpose.

Knowledge gained about prenatal education in the UK influenced the decision to choose antenatal education programs as the subject of this dissertation. There is a large difference between antenatal practice in the UK and Saudi Arabia. In the UK, antenatal education programs are offered free of charge to all pregnant women, assisting them in understanding how to prepare for childbirth and imparting knowledge on aspects of parenthood such as breastfeeding. While pregnant women with a supporting person are allowed to receive antenatal education in the UK, the situation differs in Saudi Arabia, where Islamic law prohibits male and female individuals from being in the same location, making it difficult for a mother to be accompanied by her spouse during antenatal education classes.

The aim of this systematic review is to assess the effect of antenatal education programs on various outcomes for pregnant women. The specific research questions are:

1. In expectant mothers in Saudi Arabia, what are the effects of antenatal education compared to no antenatal education, or individual antenatal education, on psychological and social wellbeing?

2. In expectant mothers in Saudi Arabia, what is the effect of antenatal education compared to no antenatal education, or individual antenatal education, on knowledge and preparation for childbirth and parenthood?

The objective of this systematic review of secondary research is to evaluate the literature to assist in answering the following questions: What is the target population for the antenatal education program? What is the particular age group to be targeted? What content should be used to educate the target population? What is the method of comparing or evaluating the intervention program? What will be the desired outcome of the antenatal education program? How will the program affect the target population?

The PICO format for the research question is as follows:

P — Pregnant or expectant women and/or their partners or accompanying person

I — Antenatal education classes for expectant women

C — No intervention or antenatal care without antenatal education

O — Outcomes of labor and childbirth, and parenthood; psychological and social wellbeing; and cost-effectiveness of antenatal education

Methods

This systematic review was conducted following the guidelines of the Cochrane Collaboration (Higgins and Altman, 2008). The review included peer-reviewed literature identified from searching electronic databases such as Medline, EMBASE, and CENTRAL (Cochrane Central Register of Controlled Trials).

The search strategy involved the use of standard keywords relevant to the study. Search terms included: antenatal education, prenatal education, childbirth education, education in pregnancy, pain management during labor, and breastfeeding classes. Several electronic databases were searched for the systematic identification of relevant studies on antenatal education programs. Further searches of relevant health journals and grey literature were also conducted to ensure comprehensiveness.

After identifying the initial search results, reference lists of these studies were reviewed to identify further studies. Individual researchers and other parties involved in antenatal education programs in organizations such as the World Health Organization and other non-governmental organizations were also contacted to identify unpublished trials or studies not captured in the database searches.

Eligible studies included randomized trials using individual or cluster randomization techniques, published in English irrespective of publication year, publication type, or publication status, dealing with the implementation of antenatal education programs.

How expectant mothers prepare for childbirth and parenthood greatly depends on their culture and other contextual issues such as how the health system is organized. Therefore, the study attempted to include only studies conducted in developing countries. However, due to the paucity of research, Western studies were also included depending on the number of studies from developing countries identified. Participants in the studies were pregnant or expectant mothers and their partners or accompanying persons who had provided some form of informed consent to participate.

The experimental intervention in all included studies was antenatal education classes offered by a trained patient educator to groups of more than two individuals or couples, addressing issues of childbirth and preparations for parenthood. The control intervention was no antenatal education — defined as standard antenatal care without antenatal education — or individual antenatal education classes. Studies comparing two antenatal education programs were excluded, since this review focused solely on group antenatal education as the desired intervention.

Quantitative measures were required for outcomes in order to enable meta-analysis. The review assessed the outcomes reported in identified studies, and clarifications were sought where needed. If outcomes were measured more than once during the follow-up period, the review used the first measure before or after the intervention started or ended, and the last measure at the end of follow-up, in order to cater for inherent heterogeneity in the identified studies.

Primary outcomes for this systematic review were: proportion of patients who felt relieved of pain during labor; proportion of patients receiving obstetric interventions; mean of the measure of psychological or social wellbeing; and proportion of participants who felt they had increased their knowledge about childbirth and parenthood.

Secondary outcomes included the involvement of partners during childbirth and parenthood, success rate of breastfeeding, ability to care for the infant, and the measure of active decision making by the expectant mother during labor and childbirth.

After identifying the search results, the initial results were screened. Full-text copies of studies marked as potentially eligible for inclusion were then retrieved. Each trial report was checked against the inclusion criteria and for evidence of multiple or duplicate publication from the same dataset. Any conflicts or disagreements in screening and judging studies for inclusion were resolved through discussion or consultation. After completing the selection process, a PRISMA study flow diagram was generated to document how inclusion and exclusion criteria were applied to the final set of studies.

Data from included studies were extracted using summary tables to obtain information on study characteristics including methodology, participants, interventions, comparison groups, outcomes, and types of effect analysis. This information was then used to present the review findings and assess the risk of bias for the included studies.

The risk of bias of each included study was assessed using a predefined risk-of-bias tool, aimed at helping to determine the likelihood of biases that may have adversely affected the internal validity of the trials. Any discrepancies between review authors were resolved through discussion and consultation. The risk-of-bias assessment tool addressed the following domains:

1. Selection bias — statistical bias arising from errors in choosing participants for the trial; judged on the basis of randomization sequence generation and adequacy of allocation concealment.

2. Performance bias — differences between intervention and control groups; judged by assessing blinding of study participants, study personnel, and outcome assessors.

3. Attrition bias — bias arising from systematic differences in withdrawals from the study between the intervention and control groups; assessed by comparing differences in loss to follow-up across groups.

4. Reporting bias — bias arising from differences between reported and unreported findings; assessed based on the existence of a trial protocol and the extent to which outcomes were reported.

5. Other sources of bias — bias arising from sources such as funding, adequacy of sample size, power calculations, and other potential sources specific to each study.

For each trial, low risk of bias was assumed before assessment. For each domain, the study was judged as having high, low, or unclear risk of bias. This judgment was then used to determine the overall risk-of-bias rating for each study. Studies rated as low risk of bias in all domains were given an overall rating of low risk; those with high risk in more than one domain were given an overall high risk rating.

Data extracted from the included studies were presented as structured summaries organized around the type of intervention, the components of the intervention, the study population, and outcomes reported. Intervention effects for dichotomous outcomes were calculated and reported as risk ratios; for continuous outcomes, they were reported as standardized mean differences. For both types of outcomes, 95% confidence intervals and two-sided P values were reported.

Results: Effectiveness of Antenatal Education

Due to the heterogeneity of the studies, the capability of conducting meta-analyses was expected to be limited. However, the review attempted to pool results from similar studies with similar outcomes using a random-effects model to account for inherent differences between studies. Outcomes reported on ordinal scales were analyzed using the same method reported in the original trial. Studies that did not account for clustering effects were adjusted accordingly, with standard deviations adjusted for the design effect. Heterogeneity was assessed using the I-squared statistic and the chi-square test. I-squared values greater than 50% indicated substantial heterogeneity, which was explored through sensitivity analyses, data permitting.

Where possible, relevant subgroup analyses were conducted separately for each outcome to identify the specific type of content covered (childbirth, parenthood, or labor topics), size of classes, timing of classes, teaching approaches (didactic or practical), and number of sessions. Subgroup analyses based on risk-of-bias assessment were also conducted to compare high-risk and low-risk studies.

The systematic review also used quantitative techniques for data analysis. While quantitative meta-analysis of the included studies is most appropriate for this type of review, it was not possible due to heterogeneity in the studies. Nevertheless, the review findings would assist in understanding the effectiveness of antenatal education programs in decreasing anxiety, expanding knowledge, and preparing women for childbirth and parenthood (Ferguson et al., 2013; Escott et al., 2009; Brixval et al., 2014), and in understanding the effectiveness of these programs in achieving breastfeeding success in Saudi Arabia.

The review found 69 publications of interest. Six were systematic reviews and two were overviews of reviews. After applying the inclusion and exclusion criteria, 56 papers were excluded for various reasons, and five randomized controlled trials (RCTs) were ultimately included. The studies were highly heterogeneous in terms of how the intervention was delivered, the intervention setting, and the measurement of outcomes. This made meta-analysis impossible, and findings are therefore reported on a per-study basis. Because meta-analysis was not possible, it was also not possible to conduct a quality assessment of the evidence for each outcome.

The first study was a multisite RCT conducted in the United States. It assessed the effect of antenatal education programs on 1,047 women. The study compared Centering Pregnancy — a system of prenatal education classes intended to improve prenatal knowledge, satisfaction with antenatal care, clinic attendance, and pregnancy outcomes such as birth weight and overall care of mother and baby — to the ordinary standard of care, whereby women individually attend normal prenatal visits and receive small education sessions on a needs basis (Benediktsson et al., 2013).

The Centering Pregnancy program was facilitated by physicians from a low-risk clinic and supported by antenatal educators. Women attended classes in groups of 8 to 12 and completed ten sessions of approximately two hours each. Women were allowed to come with their spouse or another family member or friend for support. Each session consisted of two parts: the first assessed the health status of the expectant women, including an individualized physical assessment and recording of vital signs such as weight, blood pressure, and complaints. The second part involved discussion of general pregnancy topics such as safety and care during pregnancy, labor and childbirth, and parenting. Content was standardized across sessions to ensure all women received the same level of education. Expectant mothers also had the opportunity to interact socially with each other during sessions (Benediktsson et al., 2013).

The program was run in a region where the majority of women had low socioeconomic status, so no fee was charged for the prenatal education program. It was offered within the context of routine care, keeping it as close as possible to the natural environment for the mothers (Mehdizadeh et al., 2005).

The study found that most women attended 6 of the 10 planned sessions. There were no significant differences between women attending Centering Pregnancy and those attending individual classes, although women in the Centering Pregnancy program had lower levels of education, lower household income, and English was not their primary language — possibly because the study was conducted in a region with a high immigrant population (Benediktsson et al., 2013).

There were significant differences between the Centering Pregnancy cohort and the prenatal care cohort. Women in the Centering Pregnancy group had lower levels of depressive symptoms, anxiety, and stress. They also felt they received higher levels of social support as a result of attending group sessions, though this difference was not statistically significant (Mehdizadeh et al., 2005).

The study showed that women who attended individual sessions and those who attended group sessions did not differ significantly in levels of recall. Both groups were able to recall most of the information they received, though recall in the third trimester was higher than in the first and second trimesters. Women in the group sessions had higher chances of recalling information on smoking and second-hand smoke, alcohol consumption, nutrition, and various aspects of parenting than women who attended individual sessions (Corwin, 1998).

There were no differences between the groups in nutritional intake or ability to meet daily recommended dietary intake. Women who attended group sessions consumed less alcohol during their pregnancy, though the group sessions had no significant effect on smoking rates. In fact, the study showed that women who attended group antenatal education sessions were less likely to stop smoking during pregnancy or after childbirth (Benediktsson et al., 2013).

In terms of parenting behaviors, the study did not find any significant differences between parents who attended group sessions in the Centering Pregnancy program and those who attended individual education sessions. There were no differences in attendance at antenatal and postnatal checkups or infant vaccination appointments between the two groups. There was also no difference in the timing of breastfeeding initiation, plans made for breastfeeding, or postnatal care for the baby. However, women in the group sessions were less likely to sustain breastfeeding past 4 months of the infant's age and had greater chances of introducing solid food at 4 months or slightly afterwards — possibly because they needed to return to work due to their low socioeconomic status (Benediktsson et al., 2013).

The study findings highlight the significance of educational and socioeconomic status in the outcomes of expectant mothers. Women who attended the Centering Pregnancy group sessions were less educated, of lower socioeconomic status, and spoke English as a second language. These factors may have greatly influenced the effectiveness of the group antenatal education classes and the decisions mothers made after the program. The study found that most expectant mothers in this group stopped breastfeeding early, which could be closely linked to these demographic characteristics (Corwin, 1998).

The conclusion of this study is that group-based antenatal education programs lead to improved or equal outcomes in terms of mental health, behaviors, and knowledge during and after pregnancy for expectant women, compared to the individualized standard antenatal care package. There is also no cost implication of the group-based package when provided in a routine care setting, since it reduces deviation from the norm and significantly lowers costs (Benediktsson et al., 2013).

A similar study was conducted in Sweden, focusing on antenatal education classes in a manner analogous to the Centering Pregnancy program. Women were allowed to attend classes with their supporting partners and were randomly assigned to either a natural education package or a standard care package reflecting common practice in Sweden. The natural education package focused on preparation for natural childbirth and included training in breathing and relaxation techniques during labor — commonly referred to as psycho-prophylaxis. The standard care package focused on both childbirth and parenting but did not include psycho-prophylaxis training. Both groups received four sessions of two hours each, consisting of twelve participants, undertaken during the third trimester. The follow-up period for evaluation of effectiveness was up to one month after delivery (Bergstrom et al., 2009).

The study used trained midwives to deliver the education package, and midwives were randomly allocated to the two groups to improve validity. The natural education package focused on alternative, largely non-pharmacological methods of pain relief during labor. In each session, women spent about 30 minutes on practical training in breathing, relaxation, and other techniques such as massage. This psycho-prophylaxis training was supported by booklets for reading at home. The educator was trained to exhibit a positive attitude toward natural birth and psycho-prophylaxis and did not focus on postnatal issues. Where possible, sessions included a visit to the hospital maternity and delivery wards (Bergstrom et al., 2009).

The standard care package allocated equal time across the four sessions to childbirth issues and parenting concerns, reflecting standard practice in other antenatal clinics across the country. Educators discussed childbirth, including pharmacological pain relief, and aspects of parenting. They did not cover breathing, relaxation, or psycho-prophylactic techniques. External experts were invited as co-educators, and visual teaching aids such as films were used. Visits to the maternity and delivery wards were also included (Bergstrom et al., 2009).

Women were asked to complete versions A and B of the Wijma Delivery Expectancy/Experience Questionnaire to measure their expectations and experiences of childbirth. Version A was a baseline questionnaire, while Version B was administered as a follow-up after childbirth. The questionnaire measured antenatal and postnatal psychosocial aspects including fear of childbirth, father's expectations, and postnatal outcomes. Pain was measured using a Likert scale, and epidural rates in both groups were recorded (Bergstrom et al., 2009).

The study did not find any differences in the baseline characteristics of participants. In both groups, women attended four sessions totaling eight hours of antenatal education. According to prenatal and postnatal evaluation scores, the natural education model group spent just under 6 hours on labor and birth issues, approximately half of which was dedicated to psycho-prophylaxis, and about 1.7 hours on postnatal issues, primarily breastfeeding. The remaining half hour was spent on mixed topics and questions raised by participants (Bergstrom et al., 2009).

In the standard care group, about 3.9 hours was allocated to childbirth preparation and 3.5 hours to newborn and postnatal issues, with no psycho-prophylaxis content. Films were used as a teaching method, with 95% of women and 90% of men reporting having watched at least one film about childbirth. Co-educators also featured in the sessions (Bergstrom et al., 2009).

Psycho-prophylaxis was significantly more practiced in the natural group, with 85% of women practicing it compared to 45% in the standard care group. However, both groups had similar epidural rates at 52%. In both groups, 66% of women had a normal spontaneous vaginal delivery, with a mean labor duration of 11 hours. The Caesarean section rate was also not significantly different between groups: 20% in the natural care group versus 21% in the standard care group. The rate of instrumental vaginal delivery was 14% for the natural group compared to 12% in the standard care group (Bergstrom et al., 2009).

There was no significant difference in the overall childbirth experience ratings between groups. The majority of women in both groups rated childbirth as a negative or very negative experience. Memory of labor pain was also similar in both groups, with most women reporting a very positive reflection on their experience approximately three months after delivery (Bergstrom et al., 2009).

The study found two noticeable differences between the groups. First, significantly more women in the natural care model group practiced psycho-prophylaxis at home compared to the standard care group. However, the standard care group also used psycho-prophylaxis during labor after receiving information from other sources, potentially introducing contamination. The study authors evaluated this cross-over effect and concluded that, because educators adhered to the study protocol, contamination was introduced only by participants, and the results therefore remain valid. The second noticeable difference was that more women in the natural care group practiced psycho-prophylaxis during labor (Bergstrom et al., 2009).

The study concludes that group antenatal education focused on childbirth issues — including psycho-prophylactic training — can aid preparation for childbirth by equipping mothers to cope with pain through non-pharmacological means. It also highlights the importance of focusing on specific topics and the value of practical sessions in effectively disseminating information (Bergstrom et al., 2009).

This was a randomized controlled trial with two arms. The intervention arm required women to attend group antenatal education classes balanced by age, providing an integrated intervention grounded in learning theory and attachment theory (Corwin, 1998). The intervention was based on the premise that expectant mothers should be able to adjust to their new situation in order to improve the outcome of pregnancy for both mother and newborn. Attachment theory guided the curriculum by informing participants of the importance of building trust between mother and baby during the first year of the infant's life — a trusting relationship that defines the predictability of the infant's environment and shapes the mother-infant interaction. The authors noted that expectant parents are often unaware of the importance of attachment to the newborn, hence the need to integrate this topic into antenatal education classes (Corwin, 1998).

The antenatal education curriculum developed for this study focused on providing information on mother-fetus interaction both before and after birth and how this interaction improves psychological, physical, and emotional outcomes of pregnancy. It also focused on the importance of mutually reinforcing communication between mother and baby. Other topics covered included the needs of the infant — evident in crying, trust, and dependence — and coping with childbirth for the expectant mother (Corwin, 1998).