Birth and Family Preparation
From: Wenn Kinder – wann Kinder? (If children – when children?), published by Deutsche Familienstiftung; Parzeller Buchverlag, Fulda, 2014; ISBN 978-3-7900-0490-8
A combined birth and family preparation course as an opportunity to improve the partnership between parents, optimise bonding and education. A primary prevention measure
Ludwig Spätling
Summary
Expectations regarding the performance of partners and parents are high, but neither in the parental home nor at school is knowledge about a successful partnership and parenthood imparted. The resulting excessive demands often lead to separation, usually with significant disadvantages for mothers and especially for children. A good partnership between parents facilitates a secure parent-child bond. This is a prerequisite for optimal education of children. The couples‘ high level of willingness to learn at the transition to parenthood offers a great opportunity to impart knowledge to strengthen the parental partnership. The German Family Foundation has therefore expanded the Germany-wide birth preparation programme to include family preparation, integrating topics such as realistic expectations, task and time management, stress management, conflict management, partnership care, the role of the mother and father in the family, and signals from the newborn. A matched pairs comparison of 175 pairs showed positive effects. Clarification of the reimbursement of additional expenses is a prerequisite for the dissemination of birth and family preparation. Continuous scientific optimisation of this primary prevention tool is necessary.
Introduction
While society places great demands on the family (Wingen, 1997), the preparation of young people who want to start a family is inadequate. Neither parents nor schools nor the media impart the necessary knowledge. The biologically and culturally assigned distribution of tasks between men and women ended with the development of hormonal anticonception. It enabled equality. However, this increases the demands on the abilities of the individual to live together in partnership.
The lack of knowledge about how to live a good partnership leads to considerable stress and excessive demands, which parents often cannot master, resulting in divorce or separation. The high divorce rate has levelled off in recent years, but this does not indicate stabilisation, since an increasing number of couples are not marrying and a separation of unmarried couples is not recorded. Half of those divorced are children under 18. (Federal Statistical Office, 2014). In most cases, mothers have to bear the brunt of the consequences after divorce and are economically worse off than fathers (Heß-Meining U, Tölke A. Gender Report, BMFSFJ, 2005). Often, not only the parents are psychologically significantly affected during and after the separation, but the long-term consequences for their children can also be significant (Franz, 2004).
The causes of the stress involved in the transition to parenthood are: lack of knowledge about the new life situation, irrational expectations of life with a child, inability to resolve conflicts together and a lack of conflict resolution skills. As a result, respect for the partner is reduced and often excessive demands are placed on the partner. After the birth of the first child, communication and affection between couples decreases, while arguments and dissatisfaction with the partner increase (Fthenakis et al., 2002). The resulting stress plays an important role here (Bodenmann and Cina, 2006).
A good relationship between the parents not only improves their individual well-being, it also facilitates the attachment between the children, which is the basis for their good development. (Zimmermann and Spangler, 2001) (Overview: Grossman and Grossmann, 2009). The influence of good attachment to caregivers was impressively demonstrated in the ‘Bucharest Interventions Study’ with children in care (Fox et al, 2011).
Physical and physical violence, sexual abuse and neglect are more frequently observed in the case of poor attachment. Once a child has experienced violence, there is a significantly increased likelihood that they will commit violence in later life. This spiral can be broken if a child has the opportunity to form a good attachment or, later on, to live in a satisfying relationship with a partner (Cierpka and Cierpka, 2012).
Including preparation for the family in birth preparation:
Birth and family preparation
In order to influence the problem described in terms of primary prevention, an attempt must be made to facilitate the development of a good bond. Pregnancy and birth are ‘episodes’ in the life course with a potentially high risk for women. The transition to parenthood is associated with emotional changes for both mother and father and the feeling that they have a lot to learn in order to master all of this in terms of their life with the child. The motivation of expectant parents is reflected in the high level of participation in birth preparation throughout Germany. Around 70% of all pregnant women take part in birth preparation, as well as around 30% of partners (Chrzonsz, 2006). The preparation provided by the Society for Birth Preparation (Gesellschaft für Geburtsvorbereitung, GfG) is not widely available because it is not reimbursed by health insurance funds.
Men’s participation is relatively low, although it could be increased if the preparation took their needs into account more systematically.
Experience shows that before the birth of the first child, there is no awareness of possible partnership problems later on, which is why explicit events on this topic are not attended. Content to prepare for the family can be implemented in the preparation for the birth. The German Family Foundation has developed a module with midwives, educators and psychologists that consists of three double periods and can be combined with the usual birth preparation of seven double periods. The topics included in the family preparation are: realistic expectations, task and time management, stress management, conflict management, partnership care, the role of the mother and father in the family, and signals from the newborn.
In the area of conflict management, the programme refers to the process of a partnership learning programme (EPL) (Hahlweg et al. 1994), which also shows good results in an 11-year follow-up (Hahlweg et al., 2010). Information from the Swiss paarlife® programme, which has also been well evaluated (Bodenmann et al., 2009), is also incorporated. With regard to handling the newborn, excerpts from the course Understanding the Baby are presented to the expectant parents. (Cierpka et al, 2004) To increase the acceptance of men, it makes sense to organise the additional hours with an additional male moderator.
Results
Even though the instruments included in the birth and family preparation programme have been scientifically evaluated, the initiators wanted to evaluate the programme extensively and prospectively. Financial constraints meant that only a small retrospective study could be carried out.
‘Matched pairs’ were formed from couples who had attended the G+FV and couples who had followed the birth book of the gynaecological clinic at the Fulda Clinic and had only attended one birth preparation course. In 2007, 175 couples from 37 courses held between 2002 and 2004 were evaluated. In neither of these years had any couples separated. Nor was there any significant difference in the number of children born later: 17 (GP) and 21 (G+FV). However, it was clear that the couples in the G+FV group were more open about talking about conflicts and problems. They were better at managing their time and the father was more involved. There were fewer conflicts regarding household tasks, financial matters and leisure activities. These results were presented at the 2007 Congress of the German Society of Perinatal Medicine and at the 2013 XIII Midwifery Congress (Spätling et al., 2007).
Discussion
Even if the G+FV cannot be expected to solve all the above-mentioned problems, it is nevertheless a possibility for primary prevention that should not be left untapped. There is no need to create a new structure; an existing one ‘only’ needs to be changed or expanded. To do this, the following is necessary:
Midwives must be trained in the G+FV.
The German Family Foundation has been doing this since 2008. So far, 66 midwives and people from all over Germany who are suitable to carry out the family preparation part have been trained. However, there is little interest in this further training because, on the one hand, the further training is associated with costs, the G+FV with three double lessons is more extensive than the GV alone and no additional revenue can be generated by the midwives for this additional work.
A joint discussion of the responsibilities of the various ministries with regard to this intervention option should be initiated.
Responsibilities lie with both the Ministry for Family Affairs and the Ministry of Health. Reimbursement is handled by the health insurance funds.
Organisation and financing of further training for midwives is necessary.
So far, the German Family Foundation has organised the further training. If the G+FV is remunerated, a high demand for further training can be expected, which can be solved jointly. It is assumed that around 7,000 midwives offer antenatal classes (Petrus, 2014). If the courses generate higher revenues, the midwives can cover the costs of the training. The training lasts 60 hours, spread over three weekends, and currently costs €600. By attending, midwives can fulfil their continuing education requirements.
Financing of the extended courses is necessary.
The health insurance companies reimburse the expectant mother €70 for seven double lessons. According to the calculations so far, an additional cost of €110 per couple is necessary for an average course size for an additional three double lessons. This is considerably less than the monthly child benefit for one child. Reimbursement of partner fees for birth preparation must be reintroduced and transferred to the G+FV in order to effectively design this preparation for the family for men as well.
A scientific optimisation of the content and its optimal anchoring in the ‘minds and hearts’ of expectant parents is necessary.
The German Family Foundation has incorporated the content to be taught into the G+FV based on the best current knowledge. The G+FV that is currently being implemented is already rated as ‘very helpful’ by a large proportion of expectant parents. In Germany, there is knowledge in various scientific disciplines that could optimise the G+FV both in terms of content and from the point of view of anchoring knowledge and current requirements. A committee of midwives, doctors, psychologists and educators should be established to constantly monitor and further develop the G+FV.
The creation of a handbook for the G+FV, which on the one hand facilitates the implementation of the complex integrated course for midwives and on the other hand attempts to standardise the knowledge imparted, is already in the design phase.
If real change is to be achieved, the approach described is a sensible way forward. This is also supported by the work of the Nobel Prize winner in economics, Hackman (2007). He describes how investments in ‘human capital’ have a higher ‘return on investment’ the earlier they benefit people.
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Prof. Dr. Ludwig Spätling
Board of Directors of the German Family Foundation
Director of the Gynaecological Hospital, Fulda Clinic (retired)
Gallasiniring 30, D 36043 Fulda
l.spaetling@deutsche-familienstiftung.de