CHILDREN & SOCIETY VOLUME 20 (2006) pp. 348–359
DOI:10.1111/j.1099-0860.2006.00010.x
Understanding Mothers’ Engagement
with Antenatal Parent Education
Services: A Critical Analysis of a local
Sure Start Service
Charlotte Pearson and
Miranda Thurston*
Centre for Public
Health Research,
University of Chester,
Parkgate Road,
Chester, UK
This article discusses the issue of engagement in antenatal parent
education for women living in deprived areas. The article focuses
on the findings of a local evaluation of a Sure Start parent education programme designed to improve parental engagement with
antenatal services. The article discusses the re-orientation of this
service, the impact on service users and the implications for professionals. Evidence suggests that this service has been beneficial for
those involved and resulted in improved levels of engagement, with
9 per cent of eligible women attending prenatal sessions prior to
the introduction of the Sure Start local programme’s parent education service and 34 per cent of eligible women attending after its
introduction. Despite this, the service only reaches a small proportion of the eligible population. The article also discusses the issue
of professional resistance from mainstream services as an unintended consequence of the introduction of the Sure Start local programme and considers the implications of this for effective delivery.
Copyright ! 2006 The Author(s).
Introduction
*Correspondence to: Miranda
Thurston, Centre for Public
Health Research, University of
Chester, Parkgate Road, Chester
CH1 4BJ, UK.
E-mail: m.thurston@chester.ac.uk
Parenting has been described as ‘the least prepared-for occupation’ (Hicks and Williams, 1981, p. 580), yet the family setting continues to play a major role in the early socialisation
of children. Evidence suggests that experiences during the
very early period lay the foundations for individual health,
well-being, cognitive development and emotional security,
improving the likelihood of success at school and in later life
(Home Office, 2003). Einzig (1998) argued that outcomes for
children can be strongly determined by the quality of these
early experiences with caregivers when patterns of attachment are established. It is unsurprising therefore that the
new Labour Government has placed considerable emphasis
on the importance of parenting and the need to raise standards of parenting, particularly in areas of high socioeconomic
deprivation where outcomes for children are worse than for
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349
those in the wider, more affluent, population. Sure Start has emerged as the main
government response to these issues. Sure Start local programmes have been set up to
develop early co-ordinated and sustained provision for the under-four age group, with
an emphasis on the use of innovative methods to engage people living in deprived
areas in services. However, whilst Sure Start programmes are working to help families
deal with the challenges of parenthood, there is little evidence about the success of
their approaches in engaging parents in antenatal parent education.
This paper explores the issue of engaging women in deprived areas in antenatal parent
education. It presents some of the findings from an evaluation of an antenatal parent
education service in a local Sure Start programme in the north-west of England. Specifically, it reports on findings relating to service usage and the experiences of service
users and providers, as well as considering some of the unintended consequences of
introducing local community-based programmes. In using the term ‘engagement’ we
are concerned with issues of access to services—the location, timing and quantity of
service provision—as well as the quality of provision in respect of the ways the service
may lead to satisfying experiences for clients from which they perceive they benefit,
such that they choose to return to repeat such experiences. Engaging parents in this
sense then is not simply about providing opportunities for offering information and
advice relating to pregnancy and birth, but also about generating confidence through
interactions with staff about becoming a parent and caring for a baby. Engagement
can therefore contribute towards reducing social isolation through the development of
networks of social support, created through the informal interactions between professionals and parents/caregivers via the delivery of the service.
We start by examining the evidence relating to antenatal parent education services and
their use by women in general and those living in deprived areas in particular.
Engaging women in antenatal parent education
Despite improvements in maternal and child health, inequalities in access to quality
maternal health care still exist for many women, domestically and internationally
(World Health Organization, 2003). Furthermore, women who are poor are more likely
to experience adverse pregnancy outcomes than those who are not (Sheppard and
others, 2004; Wilkins and others, 1986). The Black Report (Black and others, 1980) highlighted that in the case of antenatal care, those most in need of services make the least
use of them, illustrating the ‘Inverse Care Law’ (Hart, 1971) and this is particularly the
case with regard to preventative services. The report made reference to a Scottish study
by Brotherston (1976, cited in Black and others, 1980), which found a clear occupational
class variation in antenatal booking. Since then, several studies have found that women
from manual classes are more likely to book late for antenatal care and/or attend less
frequently (Arnold, 1987; Department for Education and Skills, 2003; Lewis, 1982).
Women who are unemployed or born outside Britain and those who have difficulties
in understanding English (Chisholm, 1989; Florey and Taylor, 1994), women who are
single parents and young mothers (Florey and Taylor, 1994) all book late. Furthermore,
fathers are rarely involved in antenatal care (Ghate and others, 2000; Lloyd and others,
2003). A substantial proportion of women do not have access to timely and adequate
care and disparities have been found in the receipt of care, in terms of quality and
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Charlotte Pearson and Miranda Thurston
content (Magadi and others, 2000; Mekonnen and Mekonnen, 2003; Zambrana and
others, 1997). More recently, engaging disadvantaged and vulnerable women in antenatal care was the focus of the Parliamentary Health Select Committee inquiry ‘Inequalities in Access to Maternity Services’ (2003). This report found that women from a range
of backgrounds, including Travellers; those on a low income; those living in poverty;
those from ethnic minority groups; those who are homeless and those who live under
the threat of domestic violence are unlikely to demand or receive the attention required
during pregnancy, labour and the early postnatal period.
These findings highlight the need for prenatal and postnatal services that challenge these
patterns of engagement (Magadi and others 2000; World Health Organization, 2002) by
providing services which actively address the needs of the population in question. Such
provision is seen as the primary prevention strategy for reducing maternal and infant
death (Confidential Enquiry into Maternal and Child Health, 2003; Sheppard and others
2004). Yet the reasons for poor attendance are complex and not fully understood,
although the following have been identified: cultural and communication issues; racism;
the cost of transport/ease of access; not having a GP; regular Travelling and, for those
women who experience domestic violence, fear (Health Committee, 2003). Factors associated with poor male carer involvement include a lack of male workers and opening
times for those who are employed (Ghate and others, 2000; Lloyd and others, 2003).
The World Health Organization has argued that pregnancy outcomes can be
improved by increasing access to health services through community-based initiatives,
such as home-visiting programmes (Sword, 1999). Ease of access however, comprises
more than the availability of services. It also incorporates quality service-user/serviceprovider relationships (given that poor relationships may deter women from accessing
services), built from professionals’ detailed understanding of the social and cultural
issues affecting disadvantaged groups (Confidential Enquiry into Maternal and Child
Health, 2003), including their local population. More recently, traditional antenatal
and postnatal classes for new parents have been shown to be unsuccessful in assisting the adjustment to parenthood (Policy Research Bureau, 2000) because they focus
largely on helping women prepare for childbirth and the practical aspects of looking
after a baby. This suggests a need to develop services which go beyond the medical
and the practical.
Sure Start has been the Government’s primary delivery vehicle for reducing the disparity between outcomes for children living in poverty and the wider child population by
focusing on the earliest years of life. Prenatal and postnatal services that focus on the
quality of parental interaction with children are central to this endeavour (Sure Start,
2001). The Government White Paper, Saving Lives: Our Healthier Nation (Department
of Health, 1999) identified midwives as being ‘uniquely placed’ to address health
inequalities in antenatal and postnatal care through the provision of innovative services, such as those provided by Sure Start, to women, their partners and babies. More
recently, the National Service Framework for Children, Young People and Maternity
Services (Joughin and Law, 2005) has emphasised the benefits of antenatal services for
women and their babies. However, given the difficulties identified above, encouraging
parents to engage with these services is a major challenge for Sure Start local programmes. This article reports on findings from a study carried out as part of the evaluation of a Sure Start local programme in the north-west of England, which focused on a
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parent education programme which had been designed to engage local parents and
parents-to-be in prenatal activities.
The development of the parent education service
Prior to the introduction of Sure Start, attendance at parent education classes in the
area (run over six sessions and only a few times each year) was reported as poor. A
key objective of the new, local Sure Start service was to improve attendance and retention figures by offering an alternative service to that provided by mainstream providers.
The reshaping of the local service was preceded by a consultation exercise carried out
by the two Sure Start midwives with members of the local community in order to find
out what local parents wanted in terms of parent education. This information was used
to design a service that was more in tune with people’s articulated needs. The service
that emerged was one that was described by the midwives as being based on a model
of social and emotional care, not solely a medical model, and which was seen as
improving access by reducing the number of sessions from six to four and delivering
sessions as a rolling programme throughout the year. The Sure Start midwives did not
have an allocated caseload of women, but were dependent on referrals from mainstream midwives, who remained the first point of contact, at booking, with a pregnant
woman. At this point, women who lived in the Sure Start area were offered a referral
to the local Sure Start programme, and, if consent was obtained, the Sure Start
midwives would subsequently make contact.
Methodology
The evaluation of the service was based on a case-study approach. This focuses on circumstances and dynamics and is a suitable approach for exploring multifaceted social
settings, typically utilising several methods of data collection (Bowling, 2002). Thus, it
was important to consider both the circumstances surrounding the pre-birth parent
education sessions and the dynamics of the sessions in order that a detailed understanding of the organisational elements and the impacts of the service could be fully
explored.
Engagement was explored in relation to the processes by which parents were recruited
to and retained within the service (that is, ‘engaged’) and were considered using a combination of semi-structured interviews with parents and professionals and observation
of sessions. These qualitative data were complemented by quantitative data in the form
of routinely collected statistics on attendance at parent education sessions before and
after Sure Start services were established in the area, as well as referrals into the service
by community midwives. Records dated back to November 1996 and up to December
2002. It is not known what provision was available for pregnant women between January 2003 and the commencement of the Sure Start provision in April 2003, as no data
were recorded on the central attendance database. Sure Start records dated from April
2003, when the service became operational.
The sampling method for the interviews was purposive, in order that those recruited to
the study had first-hand knowledge of the service. Purposive sampling is a deliberately
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Charlotte Pearson and Miranda Thurston
non-random method which is often used in qualitative work, which seeks to select
people who have knowledge of a subject which is of value to the research process
(Bowling, 2002). Purposive sampling constitutes a judgement by the researcher as to
who can provide the best information to achieve the objectives of the study.
In consultation with the programme manager and lead professionals, all those staff
who had a significant role in the delivery of the parent education service were identified. This included those directly providing a service as well as those involved in managing it, from both a Sure Start and generic midwifery service perspective. Thus, eight
professionals were identified as key informants and were recruited to the study. The
process for recruiting parents was opportunistic. Parents who were attending the
parent education programme during the period of the fieldwork (June 2004) were
approached by the Sure Start midwives who obtained consent from the parents for the
researcher to make telephone contact. It was not known how many parents were
approached, or how many declined at this stage. However, all of those who agreed to
be contacted by the researcher took part in the study, a total of 11 parents (three males
and eight females). The interviews with both professionals and parents explored their
experiences and perceptions of the parent education service in the Sure Start area. With
the permission of participants all interviews were audio taped and subsequently
transcribed. A thematic analysis was carried out, with data being coded by theme.
Non-participant observation work was carried out on all four parent education sessions
provided by the Sure Start midwives:
d
d
d
d
Session
Session
Session
Session
1:
2:
3:
4:
oral health/smoking cessation/feeding methods
preparing for labour and birth/the role of the father/emotions
relaxation/breathing/exercise
care needs/early bonding/postnatal depression/safety in the home
Sessions were observed in order to gain an insight into the approach used in the delivery of parent education sessions and the dynamics of the group, and to examine to
what extent sessions were working towards the Sure Start principles. Observation can
be regarded as a useful tool for learning about the interaction in a group and ascertaining the functions performed by a worker (Kumar, 1999); therefore this approach offered
an opportunity to understand the ways in which professionals worked to engage
parents with the service.
Ethical approval was gained in December 2003 from the local NHS Research Ethics
Committee.
Findings
The quantitative and qualitative data relating to the evaluation were used to explore
the process of engagement of women in prenatal parent education in relation to initial
referral to Sure Start and attendance. This analysis revealed that to understand adequately the engagement of women in Sure Start it is necessary to consider both servicerelated factors, including the processes through which services are delivered, as well as
the perceptions of parents themselves.
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The process of referral to Sure Start
The first step in the engagement of women with Sure Start was dependent on a referral
from a local community midwife. This is a critical step in the process of engagement as
early referral to preventive, community-based services is a primary aim of Sure Start.
Between April 2003 and May 2004, out of a total of 190 eligible women, 136 (72 per
cent) pregnant women agreed to be, and were, referred to Sure Start, all of whom
subsequently registered. Thirty-four (18 per cent) agreed to be, and were referred but
were never registered, and 20 (11 per cent) were either never referred or declined to be
referred.
Data were also retrieved on attendance at the pre-birth sessions currently being provided by the local Sure Start programme’s parent education service. Between April 2003,
when the programme commenced, and March 2004, of the 120 women invited (this
figure differs from the referral figure of 136 due to the different time span), approximately half (64, or 53 per cent) did not attend any sessions during the year. Twentyfour per cent attended three or four sessions and 22 per cent attended only one or two
sessions. Prior to Sure Start, data on attendance at antenatal sessions were available for
the previous six years from the central midwifery database. Between November 1996
and December 1997, of the 45 women who attended any pre-birth sessions, 73 per cent
(33) did so for four or more sessions. In 1998, 28 women attended pre-birth sessions, 71
per cent (20) of these attended four or more sessions. By 1999, of the 34 who attended
any pre-birth sessions, 15 (44 per cent) attended four or more sessions, falling again
during 2000 to four women out of 24 (18 per cent) recorded as attending four or more
sessions. (Figures relating to the eligible population for these years were not available.)
In 2001, there was a further drop, with none of the 26 women recorded attending four
or more sessions. In 2002, no one from the 17 who attended any sessions went to more
than two sessions. These data reveal a pattern of disengagement of local women in prebirth education over time. Furthermore, in 2003, the number of women who accessed
parent education irrespective of the number of sessions attended was higher (n ¼ 56)
than from any of the previous six years. Looking at attendance data immediately before
and after Sure Start local delivery of parent education shows that in 2002, 9 per cent of
eligible women (17 of 165 births) attended any sessions, compared with 34 per cent (56
of 185 births) in 2003.
Interviews with staff revealed that there was frustration with the referral process
whereby mainstream midwives in the area were perceived as the ‘gatekeepers’ of
women. One professional stated: ‘I think the community midwives hold the key to a
lot of what we do … some women don’t get referred until 36 weeks.
Some community midwives did not refer any eligible women, thus delaying putting pregnant women in contact with the local programme. Some staff thought that the reason they
had experienced such resistance from mainstream services was due to the general autonomy and financial independence of the programme. However, the importance of collaboration, including shared learning, was expressed, as one worker remarked:
It needs to be owned by other professionals … presented to other people so they want to be
a part of it … because it will only exist in one moment of time and learning won’t be translated anywhere else if not … it should always be an outward process.
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Charlotte Pearson and Miranda Thurston
Understanding attendance
Engagement of parents is indicated by repeat attendances (as well as referral and
signposting to other local Sure Start services). However, the qualitative material from
the interviews with parents and professionals revealed a number of attributes of the
parent education service that they described in positive terms and which were
perceived as leading to beneficial experiences. These were improving access to the
service; the use of resources; addressing social exclusion and the Sure Start approach.
Access to the programme was thought by professionals to have been improved by
reducing the programme of sessions from six to four and delivering these on a rolling
basis such that there were opportunities for those who missed sessions—due to work
commitments, holidays and illness—to opt into the next available slot. These relatively
small adjustments to service delivery provided a degree of flexibility that enabled
parents to adjust to the everyday realities of their lives. It was suggested by professionals that the shorter length of the programme was more attractive to people than it had
been in the past and that this enabled parents to commit to learning with greater ease,
and help their retention within the service.
Only small numbers of men have so far attended any sessions and almost all interviewees spoke about the difficulties of involving male partners, a finding consistent with
research into other Sure Start local programmes (Lloyd and others, 2003). Interviewees
explained this, in part, in terms of the timing of sessions. Staff frequently mentioned
the need for evening sessions so that employed women and men might have the opportunity to engage with the service, although there had been problems with finding a safe
and secure place to deliver parent education in the evenings. These factors were considered to be the primary reason for a lack of male involvement in sessions, which concur
with recent research (Lloyd and others, 2003; National Evaluation Sure Start (NESS),
2005a). The view was also expressed by professionals and parents that men were likely
to feel uncomfortable because few other males—fathers or staff—were present. One
parent commented:
My husband came to the first one but there were no other blokes that came along so he
didn’t come to the other ones because he felt a bit uncomfortable.
Lloyd and others (2003) also concluded that small numbers of male employees in Sure
Start was a factor affecting male caregiver involvement in local programmes.
The use of a diverse range of resources to deliver parent education was commented on
by many. These included a large food pyramid used by staff and clients to display proportions of food types for a healthy diet, videos showing different types of births,
everyday food and drink items from supermarkets with sugar cubes attached to display
the amount of sugar in each item, a birthing sack containing items associated with birth
and labour, word cards and pictures. Parents said that seeing and handling the labour
instruments was helpful in reassuring them and allaying some of their fears about birth
and different methods of pain relief. The quality of the information was also praised by
parents, some highlighting the difference between this and their previous pregnancy
experiences as a means of explaining their engagement in the service. One woman
commented:
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It was my second baby and it was all different second time around. … the first time round
they didn’t really say what to expect. They just made you figure it out for yourself really.
Staff and parents commented on the way in which information was delivered during
sessions, which was considered by professionals to be the key variant between the
approach of the Sure Start local programme and mainstream services. This related to
both the style of the resources and the approach used, which was based on a participative and informal way of working. Clients also said that the visual aspects of the
classes were beneficial in that this reinforced messages. Using visual aids in this way
was described by professionals and parents as creating a participative atmosphere that
was useful in tackling daunting subjects. One member of staff stated:
I don’t know whether I was surprised or horrified by the fact that somebody was able to
knit a placenta and a uterus and produce them for use. I think it is a fantastic concept and
to use humour to get across some very difficult and scary messages I think that works really
well … I certainly think that the tools … have been great at reducing barriers.
Addressing social exclusion
Many professionals stated that parent education had successfully engaged what they
referred to as ‘hard to reach groups’, including foreign nationals; those whose first language was not English disabled people male caregivers, people with learning difficulties very young mothers and people who have never accessed services before, despite
already having children. Staff explained that, for some parents, there was a need to go
to people’s houses and take them to the groups. Whilst this was considered time consuming, the view of staff was that it was worthwhile if it assisted that person in engaging
with the service and with other local people. It was also reported that the parent education service had been successful in engaging some particularly hard to reach people in
their homes. Here, staff were referring to people who had chaotic lives, which made it
difficult for them to manage day-to-day activities and plan tasks. However, some staff
expressed the view that home visiting was not always successful. For example, one
member of staff said that home visiting might be contributing to some clients continued
exclusion from the community:
Home pre-birth is great but it still isolates people … how do you get people to come that
don’t want to … sometimes you have to accept that there are some that will never come …
that is hard … we see these people but they remain socially isolated.
The Sure Start approach to engaging women
Professionals working within Sure Start identified how the programme enabled them to
work with pregnant women and their partners in a different way from previous
approaches. For example, they said that parents responded well to them because the
service was organised on an informal and flexible basis. The absence of a uniform was
considered a factor in contributing to this informality. One member of staff referred to
this as the elasticity of the service and the local programme more generally, which
enabled her to adapt methods of service delivery in much the same way as when offering
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Charlotte Pearson and Miranda Thurston
individual sessions. Thus, it was explained that staff could take into account the mood
of the group and the language abilities of parents, instead of covering one subject in
one way with every group of people. This was seen as staff being able to provide a
more individualised service which was more responsive to needs. This was echoed in
interviews with parents who considered the approach of the Sure Start team to be
informal and flexible. One parent commented:
The Sure Start team … well they make you feel special. It’s not like formal or anything, so
if you want to know something then you can just ask and they will then talk about that for
a while before they carry on …, they are not set in their ways.
Parents also largely considered the way the service was presented to be of importance
in terms of engagement. This issue was predominantly concerned with ensuring the
community were aware of the Sure Start approach to antenatal parent education, to
avoid parents being put off by thinking sessions were concerned only with the labour
process. In addition, the peer support element of the sessions was considered to be
attractive to parents and therefore an important selling point. One parent commented:
‘Getting the opinions of other parents … was probably the biggest thing I got out of it.’
Discussion
The findings presented in this paper are based on a relatively small sample of professionals and parents. The parents in particular were a self-selected group based on those
who were attending the parent education sessions during the period of fieldwork and
who consented to participate in the research. Thus, the diversity of parent perspectives
is unlikely to have been fully revealed in this study, particularly in respect of male
caregivers and those who have not accessed the parent education programme. The process for recruiting parents was carried out by the Sure Start midwives, who may have,
intentionally or unintentionally, selected particular types of parents for inclusion in the
study. Having noted these limitations, this study has, however, provided some insights
into the processes of engagement in Sure Start services that are worthy of further
discussion.
In understanding the success of local Sure Start programmes in achieving outcomes for
families, it is necessary first to understand the process of engagement of parents with
services, as the services offered by a local programme are the vehicles through which
(individually or collectively) outcomes might be reached. This study indicates that the
process of engagement with parent education begins with referral from mainstream
midwifery services. How Sure Start services in general, and parent education in particular, are presented to women at this time is likely to be important in influencing their
decisions about referral. An unintended consequence of locally based Sure Start programmes designed to promote multi-agency working is that they can contribute to creating a culture of professional resistance between those working within a Sure Start
team and those working in mainstream services. Evidence suggests that some of the
tensions surrounding developing innovative local services that are outside mainstream
provision relate to professional autonomy and rivalries. Effective referral processes are
dependent on effective professional relationships such that joined-up working between
the local Sure Start programme and the mainstream midwifery service appears
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seamless, making it more likely that a larger proportion of women will consent to being
contacted by the Sure Start midwives. The development of these processes and relationships was identified by some of the professionals interviewed as a priority for future
work. It is also evident that local Sure Start programmes cannot work in isolation and
that lifting the profile of the local programme with mainstream services by working closely with them has the potential to contribute towards mainstreaming those aspects of
innovation that have been successful. Essential as this is, it appears that this will not be
a straightforward or easy task. Many of the difficulties associated with these developments are likely to relate to tensions over the variations in funding and opportunities
of Sure Start and non-Sure Start services. This was identified in a recent NESS (2005b)
study which concluded that such tensions could prove a challenge for mainstreaming
the Sure Start ethos, an issue that is likely to have continued resonance within the context of developing integrated children’s services as part of children’s trusts.
Local Sure Start programmes currently have greater control over service design than
hitherto and have been encouraged to experiment and innovate. The evidence in this
study suggests that a move away from structured, formal, medically oriented antenatal
care towards a model that emphasises informality, flexibility and fun has been well
received by parents who have used the service. This suggests that services that focus
on ways of developing relationships with parents that are supportive and caring, and
which can be sufficiently individualised to be responsive to parents’ needs, are likely to
be most successful in engaging them. The findings indicate that the practical aspects of
service delivery are important, as well as the dynamics between professionals and parents. Whilst this appears to work well with relatively small and intimate groups, it may
be more difficult to maintain this style of delivery if numbers increase. This is a possible tension that is integral to the target of engaging a larger proportion of parents and
parents to be. Furthermore, despite such a service the positive benefits in offering individual home visits, the contribution of home visits to some community members’ continued isolation remains a challenge when developing services which aim to tackle
social exclusion and strengthen community networks.
Despite the overwhelmingly positive experiences of those who have used the service, it is evident that this service has only engaged a relatively small number of
parents. Whilst an improvement on previous attempts at parent education in the
area, numbers accessing the service remain small, particularly in terms of male caregivers and working men and women. Furthermore, it is necessary to speak to those
who do not consent to referral or who attend intermittently to explore perspectives
of need and how those needs might best be met. The research demonstrates, however, that small changes in delivery can often make services more responsive to the
complexity of the lives of disadvantaged groups and, in so doing, increase the likelihood of leading to beneficial outcomes because individuals are more likely to
engage with them.
Acknowledgements
The authors wish to express their thanks to the parents and staff who gave their time
to this study.
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CHILDREN & SOCIETY Vol. 20, 348–359 (2006)