Having a Baby Antenatal Parent Education Class

Themes this local practice example relates to:

  • Early Years 

Organisation submitting example

Barnsley MBC

Local authority/local area:

Barnsley MBC

Summary

The Having a Baby Programme was a multi-agency idea with the aim of redesigning antenatal classes in Barnsley.  The idea was to develop classes that supported the health and wellbeing of parents-to-be in their transition to parenthood, thus giving their babies the best start in life.  

1. The context and rationale

Historically antenatal classes were delivered by midwives at a central location focusing predominantly on the birth of the baby, and very little support/education was given about being a parent. Emerging evidence and government drivers around early intervention and effective parenting suggested that outcomes for children and adults are strongly influenced by factors that operate during pregnancy and the first years of life. It was felt that the Having a Baby programme could be designed to meet the needs of all client groups and delivered within the local communities by a multi-agency workforce, creating peer support opportunities as well as learning opportunities.

The service redesign would also support the increasing service demand for antenatal classes which was leading to the hospital base classes being oversubscribed. Our idea to involve a multi-agency workforce with a breadth of experience and skill was to ensure that every contact counted and families were supported by the professionals within their own locality, thus building trusting relationships throughout pregnancy and beyond. For those parents-to-be that do not want to attend an extended programme, a standalone Active Birth class is still run by midwives at Barnsley hospital.

The Having a Baby programme covers:

• Parental relationships
• Healthy lifestyle choices / emotional health and well-being/Healthy Start
• The developing child / neurosciences
• Active birth
• Breastfeeding
• Baby Cares /understanding baby cues
• Attachment and bonding
• Communication and language development including coping with crying
• The developing child –brain and emotional development

Knowledge base

The content within the Having a Baby programme was underpinned by the Department of Health (2011) resource ‘Preparation for Birth and Beyond’. It embeds the learning and positive outcomes from the local Family Nurse Partnership programme around child development/neuroscience and attachment. The programme fits within the Healthy Child Pathway 0-19 and support the Unicef Baby Friendly Initiative.

The aims:
The Having a Baby programme is a multi-agency approach to antenatal parent education in Barnsley. It is delivered by Children’s Centre staff (both LEA and charitable providers), Midwives, Health Visitors and the Breast Feeding Link workers (Voluntary Action Barnsley). The aims of the programme are predominantly to prepare parents for a realistic expectation of parenting, to encourage healthy lifestyles in pregnancy and beyond and to equip the family with the emotional wellbeing to meet the challenging demands of parenting. The programme is a strength-based approach to enhance and build upon the skills and knowledge already in place, increasing parenting capacity and boost self-esteem.

The Science
Pregnancy and birth are a key time for change – parents have an instinctive drive to protect their young and want their child to be healthy and happy and do well in life

A child’s early experience has a long lasting impact on the architecture of their brain and their behaviour and development

There is evidence that effective preventive interventions in early life can produce significant cost savings and benefits in health, social care, educational achievement, economic productivity and responsible citizenship

The Goals

Helping parents to give their child an optimal start in life

Guiding the parents-to-be through the transition to parenthood

Promote resilience and self-efficacy and social support

Reducing inequalities in outcomes for children by focusing on enhanced, evidence based programmes for the most needy

People who attend the Having a Baby programme will demonstrate:

  • Higher levels of breastfeeding initiation rates, 6-8 weeks sustained breastfeeding rates compared to the borough average
  • Lower levels of mothers smoking at delivery compared to borough average
  • Low numbers of mother’s scoring high on the Edinburgh Postnatal depression score at 6-8 weeks

Through moving antenatal classes to community locations within children’s centres, there will also be an increase of parents accessing postnatal parent education programmes.

2. The practice

A multi-agency steering group was created, which was responsible for reviewing the evidence base to develop a new model of intervention and service provision. A scheme of work was created through consultation with parents-to-be in the traditional classes, existing parents and professionals.

The initial scheme of work was run as a pilot to ensure that we could capture the outcomes that we were expecting. The pilot was delivered over 3 blocks incorporating 8 sessions.

Block 1 – Early pregnancy
Relationships and how life may change.
Encouraging healthy lifestyles and well-being messages for parents and wider family members.
Baby’s development including brain development.

Block 2 - Late Pregnancy
Preparing for birth
Breastfeeding
Practical Baby cares (Nappies, bathing, sterilising)
Emotional impact of becoming a parent
Life with a new baby / further attachment and bonding and coping with a crying baby

Block 3 – Postnatal
Further bonding and attachment
Understanding your baby’s cues
Parenting guidance and support.

The data collected from the pilot was extremely positive. The pilot consisted of 7 couples (and one Grandmother–to-be). 50% of attendees were from a lower super output area of less than 20% with the remaining 50% being in a lower super output area less than 50%.

The English Indices of Deprivation identified seven key issues linked to living in an area of high deprivation, these being: income deprivation, employment deprivation, health deprivation and disability, education skills and training deprivation, barriers to housing and services, living environment deprivation, and crime (English Indices of Deprivation, 2010). Each of these factors can have a huge negative impact on individuals and family life.

The key health outcomes monitored for the 7 participants in the pilot resulted in:

• Breastfeeding Initiation - 87.5% (Barnsley rate was 61.3% 2011-12)
• Breastfeeding 6-8 week continuation – 50% (Barnsley rate 29% 2011-12)
• Registered to engage with Children’s Centres postnatally - 100% (Barnsley 67% 2011-12)

Following feedback from parents they suggested that the postnatal block be a separate programme that incorporated more detail and longer sessions about parenting within the first 6 months of life. A new programme has been developed entitled ‘Now I am Here’ for parents with children 0-6 months and this is the first in a series of parenting programmes that support parents when their children reach 1, 2, 3 and 4 years of age.

The success of the pilot programme was recognised by commissioners within public health and following the amendment of the programme to focus purely on the antenatal period with signposting to the postnatal programmes, they have funded the recruitment of a parent education co-ordinator to support the roll out of the programme across all Barnsley children’s centres. This allowed us to develop a transition plan aimed at full service redesign using a staggered approach.

All staff within the locality were trained to deliver the programme through the team that was part of the multi-agency steering group and also received extra training on brain development, baby cues and attachment. Not only did this support the programme, but created a stronger, more knowledgeable workforce who could use the evidence based information with all contact with parents. Within 12 months all 19 children’s centre and partner agencies within the borough were trained in the programme and each centre was given a toolkit which incorporated the scheme of work and resources to aid the delivery of the sessions.

The programme calendar was set around the midwifery teams, ensuring that delivery capacity was not an issue and the programme coordinator, pulled this together ensuring a smooth roll out. Classes run early and late evening and at weekends to try and accommodate the needs of all client groups.

Since the roll out of the programme and its success at engaging father’s as well as mothers, we have been selected to include the NSPCC ‘Coping with Crying’ research into the Block 2 module. This gives further evidence based approach to the work we do around coping with a crying baby.

The Having a Baby programme is delivered through a multi-agency approach by:

Children’s Centre staff – Family Support Workers and Outreach Workers from local authority, commissioned and charity led centres; responsible for the facilitation of the whole programme and the delivery of the parenting elements.

Midwives – NHS responsible for the delivery of the Active Birth session and liaison with the programme coordinator to ensure appropriate contact with expectant mothers when inviting on to the programme.

Health Visitors – SWYFT responsible for the delivery of the session incorporating the role of the health visitor and early days with a newborn.

Breastfeeding Link Workers – Voluntary Action Barnsley responsible for the infant feeding session within the programme. The Link workers work across the Borough supporting women both antenatally and postnatally to promote, support and protect breastfeeding. They work as part of an integrated team of professionals which includes midwives, health visitors, school nurses and children’s centre staff.

The Family Nurse Partnership was represented on the original steering group and supported the writing of the scheme of work based on their evidence based practice. Since the success of the roll out in 2012- 2013, we are now part of a pilot piece of research being conducted by the NSPCC which requires us to show and evaluate a DVD entitled ‘Coping with Crying’. This pilot runs until September 2015.

Referral Process:

Parents-to-be are told about the Having a Baby programme at the antenatal booking clinic which are now also run in partnership between midwifery and children’s centre staff. Parents-to-be self-refer by completing an application form given to them at the clinic. This is forwarded to the parent education coordinator who then contacts parents-to-be inviting them to the centre nearest to their home address that has classes running to suit their expected due date. If these dates/times are unsuitable alternative centres are offered. The coordinator then ensures that the attendance register is shared with the children’s centre so they are aware who to expect at the sessions. Pregnancies are always confirmed as viable on the day the invite is sent, to avoid any unnecessary upset in the event of miscarriage.

3. Evidence and evaluation - making a difference to children, young people and families

2013 was the first full year that the Having a Baby programme was fully delivered across all agencies, and the data collated replicated that of the pilot and has become the benchmark for future years.

A database was compiled by the parent education co-ordinator of all parents-to-be and their support partners who attend Having a Baby. Birth details and postnatal data is collected and added to this to measure programme impact. Barnsley already have information sharing protocols in place and centres receive monthly booking and birth data which is used to populate the Having a Baby database. All attendees complete evaluation forms at the end of each block of classes which allows the compilation of qualitative data that helps quality assure the programme or instigates the need for programme change.

Data collected on attendees of the programme includes:

• Number of pregnant women accessing the programme
• Number of fathers-to-be accessing the programme
• % of parents-to-be from lower super output areas under 30% and under 10%
• Number of women smoking at delivery
• Breastfeeding initiation rates / 6-8 weeks sustained breastfeeding rates
• Mother’s Edinburgh Postnatal depression score at 6-8 weeks

Data: There were 2815 live births in Barnsley in 2013

Pregnant women attending:
54 Having a Baby programmes were run across Barnsley children’s centres in 2013 with 360 pregnant women attending. (Barnsley hospital ran 96 standalone ‘Active Birth’ only classes with 470 pregnant women attending.) In 2011/12 the percentage of women (who experienced a live birth) accessing antenatal classes in the Borough was 20.1%. Following the introduction of the Having a Baby programme in 2013 as the main source of parent antenatal classes the percentage of women accessing increased to 29.5%

Whilst these engagements are low in comparison with the number of live births in the Borough, it does show that there was an increase of 9.4% of pregnant women now accessing antenatal parent education classes following the introduction of the programme.

Support Partners Attending HAB only:
310 support partners attended the Having a Baby programmes with the pregnant women with 292 (94.2%) of these being expectant fathers. Active Birth classes did not begin recording how many support partners were fathers until October 2013, so we do not have the comparative figures for this period.

Engaging with fathers regardless of age and social circumstances increases the likelihood of positive changes to lifestyle and subsequently the health and wellbeing of mother, baby and the father himself. (Bottorff, 2006; Flouri & Buchanan A. 2003). It will promote confidence in fathers as valued co-parents (Bailey, 2007).

Demographics:
We can only collate the LSOA data for those families from Barnsley. Each year we have a number of births from outside the borough; these families can also access HAB. In 2013 we had 41 births from outside the borough. Of the 319 women that accessed HAB from Barnsley, 43.6% of the women came from the lower 30% deprived areas of the borough with 28.7% being from the lowest 10% deprived areas. This is a significant amount of families that are from the borough’s most disadvantaged areas. Active Birth classes have no comparator on this.

Parents living in poverty are much more likely than more affluent parents-to-be facing a range of issues other than material deprivation which may affect their parenting (Joseph Rowntree Foundation, 2007). Analysis by Tunstall and Lupton (2003) shows that area-based support programmes are more effective in reaching some subgroups than others.

Breastfeeding Data:

Data Headings

Year: 2013

HAB Breast feeding Initiated (including 41 out of Borough)

 290 (out of 360): 80.6%

Borough Average (Chimat 2012-2013)

   61.7%

Breastfeeding 6-8 Weeks (Barnsley data only excludes 41 out of Borough)

 127 (out of 319): 39.8%

Borough Average (Chimat 2012-2013)

   27.3%

Initiation: There is missing data for 35 of the 360 women who accessed Having a Baby and gave birth in 2013. This is due to women delivering out of area or because babies were transferred to SCBU at birth and therefore mode of feeding was not recorded.

Breastfeeding 6-8weeks figures: Again there is missing data for 6-8 week breastfeeding figures for 76 women (21.1%). This is due to information missing from system one, baby still being in special care or the family moving out of area. We were also unable to follow the outcomes of two families as we had infant deaths prior to 6-8 weeks due to medical abnormalities.

Co-parenting intervention involving fathers results in significant improvements in breastfeeding duration, paternal breastfeeding self-efficacy, and maternal perceptions of paternal involvement and assistance with breastfeeding (Abbass-Dick et al, 2014). Evidence has also demonstrated that a child from a low-income background who is breastfed is likely to have better health outcomes than a child from a more affluent background who is formula-fed (Wilson et al, 1998).

Smoking Data for HAB:
16 of the 360 women (4.4%) were reported to be smoking at delivery compared to borough average of 21.9% (Chimat 2012-2013).

In the UK, health inequalities between people of higher and lower socioeconomic status are widening (NCSCT, 2013).

43.6% of the pregnant women accessing the Having a Baby programme were from super output areas less than 30% and deprivation is linked to higher levels of smoking however, the number of women still smoking at delivery is well below the borough average.

Maternal Mental Health:
All pregnant women are seen by the health visitor at 6-8 weeks postnatal. Health visitors conduct an assessment of their mental well-being using the Edinburgh Postnatal Depression Score (EPDS). A score of 12 or greater would highlight a cause for concern with further support given. Only 17 women out of the 360 who accessed HAB were recorded as having a high EPDS of 12 or above, indicating that the emotional and mental well-being of the mothers who had come through the HAB programme were positive.

The mental and emotional health of a woman while pregnant and in her infant’s early years will have a lifelong effect (Marmot, 2010). A mother’s mental health during pregnancy is an important factor in determining the child’s mental health. Better maternal mental health is associated with better outcomes for the child, including better relationships, improved learning and academic achievement, and improved physical health (DoH, 2010)

Overall the data collated from the Having a Baby programme shows high levels of positive health outcomes for women and their families; giving babies the best start in life.
Group based antenatal programmes that include topics on relationships, co-parenting, father involvement, parenting skills, bonding and attachment and problem-solving skills are associated with improved maternal well-being and with an increase in the confidence and satisfaction of both parents with the couple and the mother-infant and father-infant relationships (DOH, 2011).

Alongside monitoring of each individual to be able to evidence outcomes, qualitative evaluation is undertaken at the end of each programme. 228 completed evaluation forms were obtained in 2013. (Couples often completed one between them rather than one each.)

Evaluation Feedback from Parents:
When asked to rate the programme content out of 10 (1 being poor – 10 excellent)
94.3% of participants rated the course content as a 7 or more.

Comments included:
• “Wouldn’t change anything”
• “Feeling more confident the second time round”
• “Learned about all the services available to us”
• "Increased knowledge and understanding - know what to expect now!"
• "Enjoyed the infant feeding session, since attending now considering breastfeeding compared to formula"
• "Feel more relaxed about the months to come"
• “Started taking vitamins”
• "My mum has stopped smoking as a result of information I have passed on from the course"
• “I’ve got rid of my cot bumper because of the information on safety”
• “My partner has stopped smoking since we started the programme”

When asked to rate whether they would recommend the Having a Baby Programme to others on a scale of 1-10 (1 wouldn’t recommend – 10 definitely recommend)

55.3% of people rated the programme a 10 with 97.4% of people rating the programme 7 or more.

Comments given included:
• “Better to discuss in a group than read books or the internet”
• “Gained good support and made friends”
• "Very good course; especially for dads to be who may not read the books!"
• “Great for sharing experiences”
• “Being introduced to the children’s centre”
• “Getting to meet other people in the community”
• “Feeling part of a community and knowing we have somewhere to go”
• “You get to interact with other parents and realise that your feelings are shared”
• "Feel comfortable coming to Sure Start centre, not sure I would have if I hadn't come to this course"
• "Great to meet other mums and dads to be and knowing we all have the same fears/issues"
• "Good to meet my midwife and health visitor"

In 2014 further outcomes are being collated:
• Number of same sex couples accessing the programme
• Ethnicity of parents-to-be
• Breakdown of the ages of pregnant women coming through the programme
• Number of people that engage with the now embedded ‘Now I Am…’series of postnatal programmes

The difference that integrated working has made to partner agencies:
The Having a Baby programme is now fully embedded across all multi-agencies and because this was a new approach to working for all partners, a piece of research was undertaken in 2014 by the programme coordinator to evaluate the impact the delivery of a multi-agency antenatal parent education programme across local children’s centres had on partner agencies and frontline staff (Hudson, 2014 unpublished).

Children’s Centres staff state that better links and positive working relationships have been formed with effective communication across all agencies.
Midwives stated that there is a better understanding of roles and responsibilities and communication between locality teams.

Health visitors believe that it has consolidated working relationships with staff from a wider disciplinary team and allows them to maintain stronger links with children’s centres and the programme helps start early trusting relationships with parents and helps them promote their service in a positive manner. Having met parents in the antenatal period has also helped them when carrying out home visits as their faces are familiar to the parents and their role is better understood.

Breastfeeding link workers believe that there is improved information sharing between agencies and they are better able to liaise with appropriate partners and build better relationships with staff. The HAB programme allows them to meet parents antenatally giving them the opportunity to build early relationships. The consensus was that these early face to face contacts impact positively on the home visits they carry out postnatally and parents are happier approaching them for support in the postnatal period.

Engaging and building relationships with parents is vital to the work of children centres many workers highlighted how the programme allows engagement with families at the earliest possibility, stating that the HAB programme also encourages the engagement of fathers. It introduces families to the centres before birth, leading to an increase in the number of families engaging in other activities such as baby massage, baby yoga and the postnatal Now I Am series of parenting classes delivered by the children centres.

Getting dads into the centre has been a real bonus of HAB as they have previously been difficult to engage. Family support workers also explained how the programme helped them recognise vulnerable families early and offer them appropriate intervention. One worker highlighted that “with the one or two service users who have been more vulnerable and needed family support referral, it has helped to have that relationship early”.

Engagement of Families in the postnatal period:
Of the 360 families that accessed the HAB programme, 41 were from outside the Barnsley area, leaving 319 families eligible to access Barnsley Children’s Centres in the postnatal period.

Of the 319 families eligible, 303 (95%) have registered their child with a centre and 267 (83.7%) families have engaged with other postnatal programmes.

4. Sustaining and replicating your practice

The programme was initially run as an evaluated pilot and then rolled out across the borough. 2013 was the first full year of embedded delivery and we are just receiving the postnatal data to be able to report back on the outcomes from 2014.  The programme is well embedded across all agencies with agreement for continued support.  Ongoing training and updates in key health issues are rolled out to all staff. 

Costs and benefits:

2013 Salary and on costs for the programme co-ordinator and a small operational budget to cover stationery and postage costs.  Midwifery and Health visiting services each deliver one session of each programme as part of their professional remit with antenatal education, as do the Infant Feeding Team (Breastfeeding Linkworkers) and Children’s Centre staff.

Learning from the experience:

The Golden threads that the Having a Baby programme lend themselves to are:  

  • You can do it - Promoting resilience: Resilience is key to promoting positive outcomes.  Through the opportunity to create peer support networks parents have commented that they feel more confident from attending the programme. 
  • Together with children, parents and families - Involving service users in the design and delivery of interventions makes the intervention more likely to engage those who most need support.  Before the pilot programme, consultations took place with parents to see what they wanted from antenatal classes.  Their feedback and comments have shaped the programme and uptake is very good. 
  • It takes a community to raise a child - Services need to consider the wider family and environmental context when seeking to meet the child’s needs.  Having a Baby programme is open to all pregnant women and support partners of their choice. Grandparents and wider family members are encouraged to attend so that we can build in community capacity, after all they may be the ones caring for the child at some point. 
  • Culture not structure - Learning together: Multi-agency working is vital to the success of this programme.  This requires effective communication, strong information sharing protocols and effective leadership across all partners.  
  • From good to great - Leadership, vision and embedding is key:  The Having a Baby programme is a joint approach across partner agencies.  It has been embedded in each organisation and their planned work in supporting children, young people and families from birth and beyond.  

In order to meet the demands of the programme, particularly flexible working due to the early evening and weekend work, services have had to organise their teams to ensure that the day to day service provision is not affected when staff take back time in lieu.

As well as the programme being successful in increasing the health outcomes for attendees and their families, the staff involved in the delivery have stated that they have gained an increase in knowledge around key areas such as brain development and attachment, multi-agency training days have taken place. 

There is a clearer understanding of agencies remits and the roles of professionals which has created better working relationships and ultimately better co-ordination of provision and early intervention for those families most in need in the antenatal/postnatal period.  Children’s Centre staff have been able to work 1:1 more quickly with vulnerable families because they were known to them in the antenatal period.

Challenges:

The initial embedding of the programme after the pilot was problematic as we went through the transition stage; numbers engaging with the programme were low.  However, through the belief of the agencies involved, staff remained committed to the programme and eventually numbers increased and continue to do so.  To help raise the profile of the programme details have been placed on the Maternity Services website and is also advertised through the Families information Service on Facebook.

Replication:

The programme could be replicated in other areas, provided that there is strong information sharing protocols across all agencies and a commitment to flexible working patterns to meet the needs of all clients groups.  The authority have been approached by other localities to share their good practice in a view to other areas creating a similar programme.

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