I S S U E S A N D IN N O V A T I O N S IN N U R S I N G P R A C T I C E

Chinese womens perceptions of the effectiveness of antenatal

education in the preparation for motherhood
Irene Ho BA MN RN RM
Nursing Officer, Ward D54, Tuen Mun Hospital, Tuen Mun, Hong Kong, China

and Eleanor Holroyd BNurs MSc PhD RN RM

Associate Professor, Department of Nursing, Chung Chi College, Chinese University of Hong Kong, Shatin, Hong Kong, China

Submitted for publication 19 February 2001

Accepted for publication 3 January 2002

Correspondence:
Eleanor Holroyd,
Department of Nursing,
630 Esther Lee Building,
Chung Chi College,
Chinese University of Hong Kong,
Shatin,
Hong Kong,
China.
E-mail: eholroyd@cuhk.ed.hk

HO I. & HOLROYD E. (2002)

Journal of Advanced Nursing 38(1), 7485

Chinese womens perceptions of the effectiveness of antenatal education in the
preparation for motherhood
Aim of the Study. This was an exploratory descriptive study using mixed
methodology to investigate Hong Kong Chinese womens perceptions of the
effectiveness of antenatal education in their preparation for motherhood.
Design. In the first phase, the structure and process of five antenatal classes on the
topic of motherhood were observed using an observation guide. In the second phase
11 women who had attended the antenatal classes were interviewed in two focus
groups, using a semi-structured interview guide.
Findings. In respect to the structure of the classes women revealed that large class
sizes and the didactic mode of teaching inhibited learning. While they were satisfied
with the date and time of antenatal classes, and the information about self and baby
care being provided, they felt unprepared for the demands of motherhood. Further
themes identified from the analysis were: anticipating personal needs for antenatal
preparation for motherhood, unrealistic preparation for breastfeeding problems,
inadequate preparation for baby care, unfulfilled informational needs and
conflicting advice from antenatal educators.
Conclusion. The conclusion highlights Chinese culturally specific changes needed in
the content and mode of antenatal education. In addition, recommendations are
made for antenatal educators to work within a framework of adult Chinese learning
styles in order to meet the educational needs of Chinese women.
Keywords: antenatal education, motherhood, Hong Kong, maternal role transition,
midwifery

Introduction
Formal and informal antenatal education has a long
history. In earlier times, women were prepared informally
for childbearing and childrearing by coresiding with
extended family members such as aunts and grandmothers
(Lindell 1988, Liu-Chiang 1995, Nolan 1997). Formal
antenatal education began in western countries in a
response to a need to improve antenatal care and
74

maternal-infant outcomes at the beginning of the 20th

century (Zwelling 1996). Much research has been undertaken worldwide to evaluate antenatal education programme,
resulting in a range of findings measured from a range of
perspectives. Most of this work has focused on the
preparation of women for labour, but minimal work has
been carried out to investigate the specific preparation of
women for motherhood. Furthermore, little research has
looked at these issues in non-western cultures.
2002 Blackwell Science Ltd

Issues and innovations in nursing practice

Chinese womens perceptions of antenatal education

Motherhood and maternal role attainment

The Hong Kong context

Motherhood, like any other social role, displays a range of

complex attitudes and behaviours in combination with
developmental stages. With time and experience, mothers
acquire skills and refine ideas in a process that has been
described as maternal role attainment (Rubin 1967).
Maternal role attainment is further defined as a process in
which mothers achieve competence in their new role and
integrate the mothering behaviours into an established role
set, so that she is comfortable with her identity as a mother
(Mercer 1985, p. 198). One comprehensive international
study reported that women view antenatal classes as enabling
them to seek a safe maternal role transition (Ball 1987).
Australian mothers were identified as shocked at realizing
the impact a child had on their lives (Barclay et al. 1997).
While the majority of these women had attended antenatal
classes and found them helpful for labour, they did not feel
prepared for motherhood.

The health services in Hong Kong, in line with the climate of

cost-containment, routinely discharge women 2448 hours
after a normal delivery. Therefore, the majority of new
mothers are at home when they first experience the
competing demands of motherhood. In many non-Asian
countries, education and support of mothers after discharge is
undertaken by community midwives (Thomson 1996).
However, in Hong Kong comparable community midwifery
services do not exist, with current services providing limited
nursing support in the form of checking episiotomy or
cesarean wound healing.
In Hong Kong, the rapid growth of nuclear households and
breakdown of social support from the extended family (Choi
& Lee 1997) have isolating mothers from mainstream
society. Here parallels can be drawn with the modern
condition of women in a metropolis with early motherhood
being described as a period of disorientation, depression and
despair (Rubin 1984, p. 107). As a result, the transference of
informal information about motherhood from family
members and female friends is less certain and formal
programmes have come to the forefront. In Hong Kong,
hospital-based antenatal education programmes have been
established since the 1960s. Attendance at these classes is
high, particularly for women having their first baby (estimated as approximately 90% in the antenatal education
programme under investigation). The educational content
covers antenatal care, pain relief in labour, the process of
labour, a tour of the labour ward, management of emotional
problems, care of the newborn, postnatal care, breastfeeding
and common problems in neonates. The educators involved
are health care professionals including midwives, obstetricians, and paediatricians.
In Hong Kong little work has been carried out to evaluate
antenatal education. Leung (1996) used Donabedians framework of structure, process and outcome of the classes to
reveal overall satisfaction with the education programme and
found the most successful components to include the knowledge on labour process, pain management, baby care,
psychological preparation, general maternal discomfort,
breastfeeding, new life experiences, and postnatal care. In
addition, Wong (1998) studied Hong Kong Chinese womens
perceptions of the effectiveness of antenatal classes in the
preparation for labour and found concerns with the teaching
format and time scheduling of the classes. This study,
however, failed to investigate womens perceptions of their
preparation for maternal role transition.
It has been suggested that the influence of childbirth
education should not be evaluated in terms of satisfaction

Antenatal education
Recent research has attempted to assess the effectiveness of
antenatal education in preparing women for pregnancy,
birth and childcare, but the evidence has been inconclusive.
Research has focused on evaluating antenatal education in
terms of maternal satisfaction using such measures as
increased knowledge and reduced anxiety (Hibbard et al.
1979, Redman et al. 1991, Bechelmayr 1995) or measuring
obstetric outcome (Lumley & Brown 1993, Sturrock &
Johnson 1990). While sound educational outcomes have
been reported following antenatal classes, it is not clear
whether these outcomes could be attributed to the knowledge that the women brought with them to classes, or
whether the knowledge acquired during classes reflected
their effectiveness in preparing women for the postnatal
period.
International studies have indicated that antenatal classes
prepare women for birth but not for the social role
expectation of parenting (Hillan 1992, OMeara 1993a,
Fichardt et al. 1994, Nolan 1997). In these studies the most
consistent criticism has been that the syllabus did not
prepare women in particular for baby care and motherhood.
With respect to the structure of the classes, numbers
attending were another important element (OMeara
1993a, 1993b), particularly the perception that hospitalrun classes were too large for effective questioning and
discussion. In addition, childbirth educators were
highlighted as not seeking appropriate feedback from
participants.

2002 Blackwell Science Ltd, Journal of Advanced Nursing, 38(1), 7485

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I. Ho and E. Holroyd

and obstetric outcomes, but rather in terms of the ways in

which the information is helpful to women of specific cultures
in preparing for motherhood (Enkin 1990, Zwelling 1996,
Nolan 1997). The study reported here examined Hong Kong
Chinese womens perceptions of the effectiveness of current
hospital-based antenatal education in the preparing women
for the first month of motherhood.

The study
The objectives were:
to describe the structure and process, including content and
modes of teaching, of the antenatal classes that pertain to
motherhood;
to examine retrospectively Hong Kong Chinese womens
perceptions of the effectiveness of the classes in preparing
them for motherhood in the first postpartum month;
to identify specific directions for further development of
antenatal education in Hong Kong and to make recommendations for midwives working with Chinese clients.

Methods
An exploratory descriptive design was employed using qualitative methodology encompassing observations and focus
group interviews.
Sampling
The sample for the observation of classes was a total
sample of all participants (women and their partners/
relatives) attending the five sessions on the topic of
motherhood (see Table 1). Purposive sampling was used
for the focus groups. All women attending at least four of
the five designated sessions on preparation for motherhood
at a specific hospital-based antenatal education programme
were approached and asked if they would participate in a
focus group interview following the birth of their baby.
The inclusion criteria included married primiparous
women and those who had delivered a healthy baby
(3842 weeks gestation) with no diagnosis of neonatal
complications except neonatal jaundice, as well as not
having had any medical complications during the postpartum. Husbands were not included in the focus groups
as Hong Kong husbands seldom attend the majority of
antenatal classes.
Ethical considerations
Ethical approval was obtained from ethics committees of
both the university and hospital concerned. All participants
were assured of confidentiality regarding information-giving,
76

Table 1 Hospital-based antenatal education programme, sessions

marked * were observed by the researcher
Topic

Speaker

Antenatal care & pain relief

in labour
Management of emotional
problems*
Labour process & tour of labour
ward (1)
Care of newborn*
Postnatal care and infant feeding*
Breast feeding*
Common problems of neonate*
Labour process & tour of labour
ward (2)

Midwife/anaesthetist
Social worker/psychiatrist
Midwife/obstetrician
Midwife
Midwife
Midwife/lactation consultant
Paediatrician
Midwife/obstetrician

the use of video recording, anonymity and the option to

withdraw from the study at any time.
Non-participant observation
The aim of the observation was to describe the content of the
antenatal education and the interactions between attendees
and between attendees and antenatal educators. The same
observer, a Registered Midwife, was present at each class and
observations were recorded in a free-flow format under the
categories of class structure and educational process.
Recording field notes helped to validate the data from the
focus group interviews, so that any discrepancies between
what was observed and what was said could be clarified (Polit
& Hungler 1997).
Focus group interviews
Focus group interviews were used in the second phase to
encourage the women to share their experiences of mothering, and to recall the usefulness of the antenatal education
in meeting their needs. The researcher conducted two focus
groups, with 5 and 6 mothers in the 1st and 2nd group,
respectively. Each focus group lasted for approximately
2 hours and was conducted in an office within the hospital
in which the antenatal classes were conducted. This site was
being also accessible by public transport.
Prior to the focus groups taking place, a pilot study with
one focus group interview was conducted with three previous
antenatal class attendees. This was undertaken to test the
response to the format of the interviews, and minor modification were then made.
The researcher assumed the role of discussion facilitator.
Semi-structured questions were used to guide the discussion, for example: What were the difficulties in becoming
a new mother?, Did the antenatal classes prepare you for

2002 Blackwell Science Ltd, Journal of Advanced Nursing, 38(1), 7485

Issues and innovations in nursing practice

these experiences and tasks of motherhood in the first

postpartum month?, Were the antenatal classes successful
in building up your confidence about motherhood in the
first postpartum month?, What else was not taught in the
antenatal classes that you consider important? and How
could antenatal classes be improved?.
At the end of discussion, participants were asked to fill in a
demographic profile. The extracts presented below have been
transcribed verbatim and hence may not necessarily appear as
grammatically correct in English.
Validity and reliability
For the focus groups, content validity was addressed by the
researcher by conducting the discussion purely in Cantonese
(the dialect of Hong Kong) to maintain consistency in the use
of language. In addition, inferences drawn from the observations were also checked with the participants (Morse
1991). Content validity was further enhanced by asking an
experienced midwifery educator to read the transcripts of one
focus group to independently identify major categories
(Burnard 1991).
In the focus groups reliability was addressed through the
use of a video camera to accurately record the interactions
and non-verbal communications of participants (Appleton
1995, Polit & Hungler 1997). While the intrusive nature of
video recording is acknowledged as having the potential to
disturb group dynamics and violate confidentiality it was
also considered important to collect highly salient observational data on the communication process as well as to
maximize the group leaders focus on the verbal interactions.
All focus group members were previously informed of the
use of the video and their right to refuse the recording.
Group members raised no objections to this process. A tape
recorder was also used to record the focus group conversations and to facilitate transcription during the process of
data analysis. After each focus group, the researcher made
field notes to highlight areas of key significance in the
interview.
Data analysis
The focus group interview data was translated from
Cantonese to English and then transcribed. Then both focus
groups interviews were coded line-by-line, read and re-read
by both researchers. Thematic analysis was undertaken by
identifying main phrases from the narrative transcripts and
reducing these phrases to create sub-clusters of similar
phrases, which were then collapsed to produce categories
and subcategories. Data analysis involved comparison both
within and between groups. In addition, comparisons and
contrasts were then made with the previous observational

Chinese womens perceptions of antenatal education

data collected to prudce a summary of what said and what

was carried out.

Findings
The ages of women in both focus groups ranged from 24 to
35 years with a mean of 30 years. All women were married
and first time mothers. Ten participants had completed
secondary education and one had completed tertiary education. The range of total family income was between HK
$19 000 to 40 000. In summary, focus groups members
consisted of women who had higher education levels and a
higher median household income than the average Hong
Kong population (HK Population Census & Statistics
Department 1996). The mode of delivery for nine mothers
was normal vaginal delivery, while the other two had had an
emergency cesarean section. All women had attended at least
four out of five classes, but six did not attend the class on
management of emotional problems.
Findings from both the focus group and observational data
fell broadly into two common themes of structure and
process of the classes. Within these themes were further
subcategories including unfavourable learning environment,
lack of culturally relevant material, length of the classes,
predicting personal need for antenatal preparation for motherhood, feeling prepared physically and emotionally for some
demands of motherhood, unrealistic preparation for breastfeeding problems, inadequate preparation for baby care,
unfulfilled informational needs, and conflicting advice from
different professionals.

Structure of the class

Unfavourable environment
The antenatal education programme was held in a conference
room large enough to hold about 100 attendees and had
chairs positioned in rows. The air conditioners were not in
good condition and, given the high temperature, the room
was very warm. The researcher observed that several
attendees used sheets of paper to fan themselves. One mother
commented:
It was too hot and noisy, I wanted to leave as I failed to concentrate
my listening, I stayed because I had to learn baby care.

The number of attendees in the five classes attended ranged

from 48 to 95, including women, their husbands and
mothers. In each class there were consistently more women
than men, indicating that not all husbands accompanied
their wives to the talk. The highest attendance was 95 in the
class titled Care of newborn, and the lowest was 48 in the

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I. Ho and E. Holroyd

class titled management of emotions. The majority of

women were first-time mothers. Attendees at the back of the
room had to stand up regularly to watch the video and
demonstrations. In the focus group several women
commented that they did not like to ask questions because
there were too many people in the class and that this was
inhibiting:
There was too many people, and the room was too warm. I had to
shout if I wanted to ask questions, so I didnt ask questions. My view
was blocked and it was even worse during demonstration.

All women were dissatisfied with the class size and physical
arrangement of the room. Furthermore, in all classes the
microphone was not functioning properly and emitted a
great deal of vibrations. It was further observed that the
display board captions were too small for attendees at the
back to read, and the use of flip charts for illustration was
too quickly delivered, suggesting that attendees were unable
to absorb the message in time. Problems such as not being
able to see and hear, having difficulty in asking questions and
the perception that personal problems were not adequately
addressed were reported in the focus groups, a finding
further repeated in international and Hong Kong literature
on antenatal education (Lindell 1988, OMeara 1993c,
Wong 1998).
A large class size is incongruent with the principles of
adult education and does not allow the use of experience
as a resource for learning (Burns 1996). An alternative
option would be to bring prospective parents together in
small groups to enhance the sharing of information,
exchange of views and validation of feelings, and to
enable interactive learning (Knowles 1984). Adults in most
cultures need to feel that they have some control over their
education, and the ability to develop coping strategies
which are informed by and therefore applicable to their
own personal and social situations (Nolan & Hicks 1998).
Internationally participants in small antenatal education
groups tend to report feeling more satisfied (Lindell 1988,
Rees 1996).
Lack of cultural relevance in audiovisual aids used
The use of audiovisual aids seemed to help to stimulate the
interests of attendees. Antenatal educators should, however,
consider the relevance of some of audiovisual aids used.
Although all women agreed that visual aids could help to
arouse their interest, some commented on a specific lack of
cultural relevance, saying that the videos were about the
practice and feelings of Westerners and they felt that this did
not apply to their situation. A mother who was not
successful in breastfeeding her baby strongly expressed the
78

need for a live demonstration on breast feeding techniques,

stating:
It would be better to have real demonstration by woman on how to
breastfeedThe video was showed by a Caucasian, she was not
Chinese and they are different from usCaucasian babies are more
toughThey are smarter. But my baby, I held him and even pushed
him, he still did not know how to suck.

It was observed that the antenatal educators did not hand out
their lecture notes; instead only a few pamphlets (for
example, on breastfeeding, nutrition during pregnancy) were
distributed. Most mothers said that written notes should be
available to reinforce their knowledge because they found it
difficult to remember all the information. This was summed
up in the following comment:
It could be better to have some notes to refer after the talk. Even if I
forget the content, I could read the materials so as to reinforce my
memory.

Length of the class

The researcher observed attendees falling asleep, and several
men slept through all five talks. When the researcher
discussed this observation with participants in the focus
groups, they explained that the room was too warm and they
found it difficult to cope with long lectures and this might be
the reason why some husbands dozed off. Furthermore, the
mode of didactic teaching and minimal educatorattendee
interaction might also have contributed to womens perception of the lengthy class. Focus group members revealed a loss
of attention and memory, attributed to the length of the class.
One woman vividly commented that:
It could be better to cut it shortIt seemed that I was having a dream
after the lecture, I felt very tired, and I forgot most of the talk after I
went home.

Process of the class

Formal teaching and minimal interaction
The teaching mode was primarily didactic teaching. While all
speakers covered the material stipulated in the programme
content list, interaction between attendees and educators, and
between attendees were minimal. This appeared to be further
exacerbated by the enormous amount of information that the
existing curriculum stipulated needed to be delivered during
each class. Furthermore, it was observed that there was very
little chance for attendees to practise any of the skills
demonstrated during the classes. Question time for each
class varied from 5 to 10 min and 05 questions were asked
during these periods.

2002 Blackwell Science Ltd, Journal of Advanced Nursing, 38(1), 7485

Issues and innovations in nursing practice

Irrelevant content on common problems of neonate

In general, observations revealed that the content of the
classes was relevant to the title. However, the topic of
common neonatal problems seemed less relevant to the
womens educational needs. The paediatrician showed slides
of uncommon conditions or even rare abnormalities, including grossly malformed babies. Four couples were observed
leaving in the middle of this class and after the break, and this
phenomenon was not observed in other classes. Attendees
revealed in the focus groups that they left because of the
unpleasant and sometimes frightening scenes on the slides.
All focus group participants said that the talk on common
neonatal problems was not relevant and was very frightening.
A 29-year-old said:
I remembered that some couples left after the break. Some slides were
of congenital abnormalities, it was very frighteningbut the content
was about rare casesHe shouldnt talk about such cases in the
programme.

Antenatal educators performance

Most of the antenatal educators in the programme under
study were midwives and were seen by women to demonstrate warmth and emotion in their teaching. All mothers
expressed that the midwives were their preferred educators
for the programme. A 24-year-old said:
I didnt know whether they were nurses or midwives, but they talked
better, it was more easy to understand, however, some doctors were
not very motivatedthey could not answer questions up to the point,
they were not as good as the midwives.

The researcher observed that the more experienced the

midwife, the more confident she appeared when conducting
the teaching and this observation was validated in the focus
groups, with one woman expressing that:
The most impressive talk was by the lactation consultant, I thought
she was a very experienced midwife, very active, and she gave the
best talk. She used many vivid examples to illustrate breast feeding
skills.

OMeara (1993c), in a large scale Australian study, stated

that an effective childbirth educator must have a comprehensive understanding of pregnancy, childbirth and the
changing needs of families. Besides having medical knowledge about pregnancy and childbirth issues, many midwives
have experienced pregnancy, labour and motherhood themselves. From this advantageous position, midwives can be
more sensitive to what women want and are therefore able to
identify and respond to their needs accordingly. OMeara
(1993c) further reported womens communication with

Chinese womens perceptions of antenatal education

midwives to be more satisfactory than with doctors or other

professionals, in parallel with the present study.
A contrast, however, is provided in one womans remark
about an antenatal educator who had recently graduated and
who was not able to answer a question:
There was a question raised about whether the nasal discharge should
be sucked out by mothers mouth if the baby suffered blocked nose.
The midwife answered No, but she didnt explained what should be
done instead.

Such unfavourable comments about some of the midwifeeducators suggest that a lack of knowledge or previous
experience rendered these professional educators unable to
provide plausible information (Nunnerley & Deane-Gray
1988). Limitations of the teaching approach by antenatal
educators previously found in the international literature
included inadequate identification of the needs of groups,
inadequate grasp of the topic taught, ineffective teaching,
poor staff relationships and lack of flexibility (Murphy-Black
1990). Although midwives have been recognized for many
years as having a vital role in teaching, there has been little
educational preparation for this role.
Not every educators performance was satisfactory. Several
mothers stated that they talked very quickly and explained
things inadequately. One woman complained:
I thought any person was better than that paediatricianhe didnt
explain his lecture as if his information given was too high level for
usI honestly felt that I shouldnt attend this talk, he was not serious
at all.

Although women value different inputs from expert professionals, fulfilling individualized needs is considered of great
importance in adult education. Current Hong Kong hospitalbased antenatal education does not address individual needs
and tends to underestimate the clients role in health education (Perkins 1980). While planning antenatal education is
mainly based on the perceptions of professionals, it may not
satisfy the needs of all women (Robertson 1997). Successful
antenatal education should empower women to decide their
own needs.
Furthermore, when the programme is controlled by professionals, couples are less likely to play an active part in their
own learning. In Asia, a cultural expectation is that the
greater the perceived power of the professional and the more
impressive the technological apparatus, the more likely the
couple is to accept the professionals control of the encounter
and not make much effort to learn (Rothman 1996).
Midwives are far better placed than doctors to undertake
antenatal education for Chinese and other Asian populations
precisely because the public perception of their power is less

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I. Ho and E. Holroyd

than that of doctors, and they may therefore be seen as more

approachable.

Predicting personal needs for antenatal preparation

Mothers anticipate their personal need to attend antenatal
education
All focus group participants said that, as they were first time
mothers, they saw attending antenatal classes as their
personal preparation for becoming a mother. When women
related their experience retrospectively on the best timing for
antenatal education, they all suggested that the antenatal
period was the ideal time as opposed to the postnatal period.
They explained that they were too tired during the postnatal
period and did not feel like going out; and time was not
available because of the demands of baby care. A 29-year-old
mother said:
The antenatal talk was held before the birth of the baby, we had time
to sit down and listen to the talk.

All women described attending classes as a type of insurance, enabling them to feel more secure. The high attendance
rate showed that the classes were welcome by many prospective parents in particular first time parents. Women were
generally satisfied with the Saturday afternoon arrangement
for the classes, which enabled both partners to attend.

Antenatal classes prepared mothers for some demands of

motherhood
Learning about baby/self care but not being prepared for
complex emotional problems
All women found the programme useful in giving information
about baby-care and self-care. They learned some basic
concepts and knowledge about self and baby-care after the
classes, yet they felt that they were not in general wellprepared for motherhood during the first postpartum month.
A total of 5 out of 11 women attended the talk on
management of emotional problems. Those who attended
said the class alerted them to the demands of motherhood,
made them aware of the possibility of mood changes, and
advised them to seek help from their husbands. These women
felt that their husbands were more able to appreciate their
moods after the talk. A 35-year-old social worker said:
It prepared us psychologically,cultivated husbands interest in baby
carethough he didnt understand why I was in a bad mood, he still
tried his best tounderstand my feelings.

Although the specific class on management of emotional

problems helped to make women more aware of such
80

concerns, several felt that the talk was too theoretical and did
not prepare them for managing the complexity and realistic
demands of motherhood. While participants were sharing
their experience on social support, one participant suddenly
cried about the profound difficulties she had experienced in
mothering. She commented that the educators over-estimated
the potential help offered by partners and individual cases
were not addressed:
I was not very impressed about the talk. I felt the division of labour
was never fair and I could not cope with itThe talk was very
theoretical, the educator told us to seek help, but no matter how hard
I cried for help, there was nobody available to help me.

This woman went on to state that she felt helpless because

of the unfair division of work in the home. She described her
husband as offering help by looking after the baby so that
she could prepare a meal, but he handed over the crying
baby to her while she was still busy. Furthermore, her own
mother was in full-time employment and unable to help.
The breakdown of the extended family and pressure of
household work have left Hong Kong Chinese women
feeling isolated in their roles as mothers (Holroyd et al.
1997). In addition, long-term fatigue from inadequate rest
adds additional stress to motherhood. Four other participants echoed that their enjoyment over the birth of baby
was shattered and their initially elated mood hid the
unexpected difficulties experiencing in new motherhood.
Adjustment to a first child is a transition of enormous
consequences, marked by psychological and social changes,
many of which are experienced as losses. The losses inherent
in motherhood are often ignored or underestimated, both by
women themselves and health professionals (Barclay &
Lloyd 1996).
Changing roles for Hong Kong women
Hong Kong-based studies have indicated that a high percentage of young women have considerable involvement in work
outside the home and they shoulder the major responsibility
for taking care of children and performing domestic work
(Choi & Lee 1997). Contemporary Hong Kong womens
roles have changed vastly over the past two decades, to the
extent they frequently share equal financial status with their
husbands. While until recent times Chinese women have
borne most of the responsibilities of household work, shifting
role expectations and the influence of western media have
resulted in them expecting more from their husbands. Thus
childbirth educators working with Chinese women both in
Asia and elsewhere should emphasize the complex re-negotiating strategies needed as a response to role changes in
modern times (Underdown 1998).

2002 Blackwell Science Ltd, Journal of Advanced Nursing, 38(1), 7485

Issues and innovations in nursing practice

Focus group members who did not attend the classes on

emotional problems expressed regret when other members
spoke of the content on emotional preparation for motherhood. Such regret is well reflected in the following testimony
by a 28-year-old mother:

Chinese womens perceptions of antenatal education

natal wards did not help them to establish lactation. When

the first group was talking about breastfeeding difficulties, a
24-year-old housewife, used parallels of criminal behaviour
to describe her situation:
I didnt have milk for the first few days, only two dropsmidwives

I regretted not attending the talk because I was very badly emotion-

discouraged supplementsThe baby slept not because he had

ally upset. My husband told me that it was not necessary to attend

enough, he was just too tiredSo I went to steal a bottle for him.

the talk because every woman gives birth.

I stole, because the midwife would scold me because I had already

Six women outlined that they felt some of the antenatal

education on emotional states was not well taken in because
they considered themselves to be normal in every aspect.
Furthermore, emotional lability is an issue seldom discussed
in the public with the Chinese population as this may lead to
loss of face (Holroyd et al. 1997). Midwives need to be aware
that Chinese women and their partners may not acknowledge
womens own potential for the negative impact of mood
changes after delivery and may not wish to talk about this to
avoid social stigma.
Furthermore, five women were critical of the lack of
opportunities to ask questions and discuss worries, feeling
that classes did not offer preparation for the emotional
aspects of first time motherhood. A large class size was seen
to inhibit discussion of such a topic a finding that concurs
with the observational data from phase one. Smaller classes
are especially good for discussing sensitive issues and
exploring personal feelings and attitudes (Wittig 1998).

decided to breast feed my baby.

This powerful testimony points to personal conflict because

of misunderstanding of the process of lactation. What is
suggested by this testimony is that a woman feels guilty that
she has to take or steal a bottle to care for her baby
properly. Despite favourable comments about the promotion
of breastfeeding by the educators, clearly some of the basic
physiological knowledge about breastfeeding had not been
accurately covered in the classes.
Unrealistic preparation for breastfeeding problems
Three mothers said that the class did not prepare them to
handle the complexity of breastfeeding. A 31-year-old mother
complained that educators did not talk about the realistic
demands of breastfeeding. She was worried about the exact
amount of milk the baby got from breastfeeding, and her
worry was exacerbated by the constant criticism from her
mother-in-law:
I pumped the breast milk into the bottle to feed my babyI could

Unrealistic preparation for breast feeding

Motivation to breastfeeding and guilt induced if failure to
breast feed
All women suggested that content delivered in the breastfeeding class had encouraged them to breastfeed. A 24-yearold housewife said:
The antenatal education programme promoted breast feeding and the
midwife talked about so many advantages, so I decided to breast feed
my baby.

When mothers failed to breastfeed, they felt disappointed,

guilty and distressed. A social welfare officer, who was
determined to breast feed her baby and had given up her job,
said:

make sure how much milk the baby got every time. My mother inlaw always told me that I might not have enough milk for the baby.
She discouraged me to breastfeed.

Furthermore, some mothers expressed dissatisfaction with

their inadequate preparation for weaning off breastfeeding.
This is possibly because the current educational curriculum
suggests that the antenatal period is considered too early a
time to raise the possibility of weaning off breastfeeding in
the class. However, several mothers said that they wanted to
wean the baby off breastfeeding at around 34 weeks in
order to prepare for their return to work at the end of Hong
Kongs statutory 6 weeks postnatal leave. A 29-year-old
mother explained:
I couldnt wait for that long until I took the baby back to maternity

I tried breast feeding for more than 10 days, I failed because of not

home for immunization and asked about weaning. They should

having enough milkstruggled for a few more days, but I failed

prepare for this, not only for breastfeeding. They should mention

againI was very unhappy, very disappointedI felt additionally

some bad cases and prepare us on how to cope with these.

unhappy because of quitting the job.

Some women, despite being motivated to breastfeed,

commented that the rigid breast-feeding policy in the post-

Women felt that the educators only stressed the positive

aspects of breastfeeding and failed to highlight the difficulties
that can arise in establishing this method. Had they discussed

2002 Blackwell Science Ltd, Journal of Advanced Nursing, 38(1), 7485

81

I. Ho and E. Holroyd

these potential problems, women might have been better able

to cope with difficulties as they arose (Hillan 1992). Another
useful alternative suggested by one mother is to invite a
woman who had successfully breastfed to share her experience to add peer relevancy to the learning process (Perkin
1980, Kirkham 1991). However, public demonstrations of
breastfeeding cause cultural embarrassment for Chinese
women. Breasts and the act of breastfeeding are seen as
highly private, with few young women witnessing their
mothers or sisters breastfeeding. In addition, many Chinese
husbands tend to find breastfeeding embarrassing. One
resolution might be to arrange a tour to the postnatal ward,
where mothers could watch other women breastfeeding
within a facilitative environment.

according to subject matter. Furthermore, mothers often

experienced a sense of estrangement when this topic was
presented prior to the babys arrival; this was heightened
when the teaching session involved bathing a doll rather than
a live baby. Perhaps such topics as the baby bath could be
instead conducted in the postnatal ward with smaller groups
(Perkin 1980). Another alternative is to provide videotapes
on baby bathing which mothers can watch in their own
homes before the arrival of the baby (Rankin & Stallings
1996). Extending childbirth education classes into the postnatal period might be particularly valuable given the
demands on these highly urbanized mothers. New parents
could be encouraged to describe personally how they will
organize the daily care of their baby and to demonstrate this
in class (Kirkham 1991, Nolan 1997).

Inadequate preparation for baby care

All women said that they lacked confidence in baby care, such
as not being sure whether the baby was getting enough milk,
being unable to perform a baby bath and being unable to
manage common neonatal problems.
Newborn behaviours and common neonatal problems not
taught
The most common postpartum worries of participants were
not knowing whether their babies were getting enough milk.
Four mothers pumped breast milk into bottles to feed their
babies and were concerned that their babies were still hungry
after breastfeeding. Mothers complained that many common
concerns regarding care of the newborn were not taught in
the class. A 31-year-old clerk said:
The baby was twitching while he was sleeping. I didnt know why,
and I was frightened. He was yelling suddenly, with his eyes
closedhe also appeared frightened, and his face gone redbut I
didnt understand the reason for his behaviour.

Mothers in both groups were also frightened by bloodstained discharge from the umbilical cord and complained
that the management of the cord was not taught in detail. A
29-year-old clerk in the second focus group said that:
There was blood stained discharge in the nappyI guessed the cord
stump was infected. I was very frightened,but this was not taught
in the antenatal education programme.

There is a tension between what postnatal women retrospectively see as important and what educators believe they
should be taught. Such a finding has also been documented in
other studies (Hillan 1992, OMeara 1993a). The chief
implication of this concern is the importance of organizing
learning experiences around life situations rather than
82

Unfulfilled informational needs for self care

All women thought that the antenatal class educators delivered information from books and did not solicit feedback
from attendees. In addition, they also reported that they were
not satisfied with the information provided. Women were
confused about the difference between the terms of lochia
and menstruation, as both terms were explained by antenatal educators as blood discharging from the vagina. A
29-year-old secretary mentioned that:
The concept on the clearing of lochia was very blurred. I still got on
and off vaginal spotting for a month and I was confused. I then went
to see a GPthe speaker did not explain clearly.

Furthermore, women were confused about the suture material used for the episiotomy and the reason for persistent pain
from the episiotomy wound. The perception of unfulfilled
informational needs again resulted from too much information given within a limited time. Concentration spans vary in
individuals, and some adult learning theorists claim that after
15 minutes didactic lectures become an ineffective mode of
communication (Jarvis & Gibson 1997). This may explain
why all participants felt that they could only remember about
one third of the information given. All women in the group
complained that certain knowledge had not been taught. This
is in contrast to the observational data, which revealed that
the curriculum had been covered but in a rather superficial
manner.

Conflicts between lay and professional advice

Women received conflicting advice on nutrition and perineal
wound care from midwives and other health care professionals in both the classes and the postnatal ward, and from

2002 Blackwell Science Ltd, Journal of Advanced Nursing, 38(1), 7485

Issues and innovations in nursing practice

midwives and family members. Maternal nutrition was

another area in which they received conflicting advice, with
women complaining that they become confused between
Chinese folk approaches and scientific nutritional knowledge
approaches. The 35-year-old social worker from the second
group reflected on her feeling of helplessness and distress
originated from the differing advice:
Educators told me not to take any ginger vinegar unless the lochia
was clear, but my mother told me to take it once after day
12asparagus soup was offered for dinner in the hospitalmy mum
said to me: You must be mad taking these cold foodThe hospital
dietitian told me not to take beef and egg for better wound healing.
But my mum told me to take the eggs with the ginger vinegar soup. I
didnt know who should I follow.

In this study all women found it particularly unacceptable

when the midwives taught them not to take hot food until
the lochia had ceased. A Chinese cultural practice is to take
hot food after the twelfth day to expel wind and dirty
blood and thus facilitate recovery. Postnatally Chinese
women usually take hot food during the period of Cor
Yue or Doing the Month. Doing the month means Chinese
women are expected to be restricted to long periods of lying
in bed and be housebound during the month after delivery in
order to recover from labour. Chinese women believe that
childbirth is the time when the body is open and vulnerable to
winds and cold (Chang 1995). Thus any external assistance
during childbirth should aim to restore the equilibrium of
heat and cold, rather than focus on the management of local
pathology (Spector 1991). However, midwives espouse a bioscientific model in relating postpartum haemorrhage to
following cultural food practices. Thus these Chinese mothers
were confused about which advice they should follow and
found that such conflicting information posed tensions in
their role transition, and their confidence was reduced as a
result of not knowing whether to follow bio-medical or
cultural advice (Ball 1987, Hallgren et al. 1995).
The non-participant observation showed that educators
acted as the experts, portraying an image of competence and
responsibility. However, the explanation of some hospital
procedures, for example the technique for wearing sanitary
pads and what items to bring for admission, appeared to be
present as more of an indoctrination (Hallgren et al. 1994).
The atmosphere was formal, with minimal interaction, and
there was limited intercommunication between attendees.
Such teaching approaches often promote dependency
amongst clients rather than independent decision-making
skills (Nolan 1997).
Perhaps Hong Kong midwives and professionals are too
eager to mould women to the requirements of the health care

Chinese womens perceptions of antenatal education

system by outlining only hospital policy and routines.

Instead, educators should provide information according to
consumers needs to develop their understanding of childbirth
as well as their personal, individual responses to the birth
process. Active participation and self-responsibility are the
fundamental goals of such an approach (Lindell 1988).
On one occasion a participant suddenly burst into tears
while she was sharing her difficulties in mothering, indicating
the emotional intensity of the experience. Although all
participants were strangers to each other, they demonstrated
a very caring and supportive attitude to this woman by
patting her shoulder and acknowledging her difficulties and
feelings. The emotional atmosphere created by this incident
suggested that participants enjoyed the focus group as it gave
them a chance to share their experiences. Some participants
later told the researcher that they became friends and kept in
touch with each other.

Study limitations
This study was based on observation of a series of five
sessions from one antenatal education programme at one
hospital and two focus groups involving a total of 11 women.
A clear limitation of the study was the small sample size and
the fact that it was chosen only from one public hospital.
Considering the size and variability of the population of
pregnant women, the information obtained in this study can
only represent the perceptions of a small group of women in
Hong Kong and is not generalisable.

Conclusions: implications for midwifery practice

Currently in Hong Kong, health education teaching approaches are an expression of a patriarchal and bio-medical
system of health care (Nolan & Hicks 1998). While health
professionals may have been educated on the principles of
adult education, many fail to put these into practice.
Given that large classes inhibit group processes and impede
discussion of sensitive matters, small informal classes using
role-play, problem-solving activities and experience-sharing
sessions would promote interaction. Women in the interviews
suggested that 810 couples would be an ideal class size.
Physical arrangements for conducting the classes need to be
reconsidered, for example a semi-circle to facilitate watching
demonstrations and to promote an atmosphere appropriate
to more open discussion. The use of first names to introduce
the teacher and each member in the class would make it
easier for participants to feel involved and be more relaxed.
Inevitably antenatal classes will have participants of mixed
needs and abilities and good antenatal teaching requires

2002 Blackwell Science Ltd, Journal of Advanced Nursing, 38(1), 7485

83

I. Ho and E. Holroyd

educators to be responsive to the needs of individual women

and their partners. The ideal situation is to assess individual
mothers and couples educational needs. Educators may need
to spend some time in the first session getting to know
attendees backgrounds and what their experiences have been.
Midwives who are familiar with the skills of assessment should
use these skills in the teaching situation. This involves allowing
participants to direct the choice of topics and taking a
proactive rather then reactive approach (Hillan 1992). It is
also suggested that the teaching materials should be revised
periodically and notes could be sent to attendees for prereading
before the classes. Teaching should be illustrated with locally
and culturally (Chinese specific) relevant examples.
Murphy-Black (1990) makes the points that, although
much of midwifery involves teaching, the main skills are
more frequently those of one-to-one teaching, whereas
teaching a group demands different skills. Therefore postbasic training should prepare midwives to hold effective
education classes, and staff involved in the classes should be
trained in group methods.
It is also clear from the study that Chinese mothers were
not well-prepared for role transition in the early postpartum
month and it is unrealistic to rely solely on antenatal classes
for this. Midwives should initiate new programmes to
introduce family centred care into the home setting and to
assist women in their transition (Brown & Johnson 1998).
Internationally, midwives working with Chinese women
should aim to approach childbirth from a culturally specific
perspective which includes coping strategies, support systems,
and the importance of cultural beliefs about pregnancy and
childbirth instead of trying to deliver materials developed for
another culture. Midwives need further education on culturally specific problems, in particular the tensions posed for
women of minority cultures within a host society. In a
Chinese population this should include hot-cold food preferences, postnatal hygiene practices and encouraging women to
speak about how they can balance bio-medical approaches
with folk traditions.

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