Running head: RESEARCH STUDY PROPOSAL 1

Research Study Proposal:

Comprehensive Pre- and Postnatal Education Series for Low-Income Parents Expecting their

First Child

Tessa Eckhardt, Ivy LeGrand, and Alyssa Matulich

University of Tennessee at Chattanooga

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Research Study Proposal: Comprehensive Pre- and Postnatal Education Series for Low-Income

Parents Expecting their First Child

Both practitioners and researchers in healthcare have long known the positive impact an

intact family unit has on the physical and mental health of children. Numerous studies have been

conducted showing the negative impacts divorce and separation of parents have on children, and

conversely numerous studies have shown the protective benefits children who live with both

parents experience (Al Gharaibeth, 2015; Anderson, 2014; Uphold-Carrier & Utz, 2012). The

last census data in the United States shows that children living in married-parent households are

least likely to live in poverty, while children in single-mother households and different-sex

cohabitating households have roughly the same likelihood of living in poverty (48% and 47%,

respectively). Living in poverty, in turn, poses significant obstacles for children’s upward

mobility; children in poverty have higher rates of behavioral health problems, physical health

problems, and poorer academic performance (American Psychological Association, n.d.). These

obstacles make it difficult for children to become successful, productive adults who are able to

break the cycle of familial poverty.

While research confirms the significant impact the family unit has on all areas of

children’s lives, much research has also been conducted that confirms that the transition to

parenthood causes greater declines in relationship satisfaction than experienced by couples

without children in the same time period (Doss, Rhoades, Stanley, Markman, & Simpson, 2009).

There is little wonder, to those already entrenched in parenthood, why this may be the case.

Parenthood is rife with new responsibilities, both foreseen and unforeseen, and there is a constant

shift in roles and division of labor that both partners are learning to navigate. Stepping into the

roles of parents rather than simply partners also leaves less time and less emotional and physical
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energy to expend towards the parental relationship, which can leave both partners feeling

increasingly stressed and more distant from each other than ever before.

Because of the significant impact marital and relationship separation has on the children

involved, it is imperative that healthcare providers develop interventions and education that may

better prepare parents for the role of co-parent, and better equip them in protecting and nurturing

their relationship with one another. This protection of the parental relationship and the family

unit would increase the number of children growing up in homes with both of their biological

parents, one of the strongest predictors for upward mobility overall (Anderson, 2014).

Unfortunately, most prenatal education is focused on labor and delivery and breastfeeding. Few

opportunities exist for parents to learn about the care of the newborn, the sick infant, the

transition to a family unit with a child, the impact parenthood has on relationships, positive

communication techniques, or relationship therapies to increase cohesion as parental units. Our

plan is to develop a comprehensive education series with prenatal and postnatal classes aimed at

low-income parents expecting a first child, and to ascertain whether these educational

interventions may prove beneficial to parents’ stress levels and overall relationship satisfaction.

Research Question

For this study, we would attempt to answer the following research question: Does more

extensive prenatal and postnatal education for first time parents of low socioeconomic status

affect parental stress and relationships in the first three years following birth? We chose to use

the structure of a research question due to the lengthy time period of our proposed the study as

PICOT questions are typically used for studies focusing on a shorter time period. The research

question concisely identifies the intervention (extensive prenatal and postnatal education), the
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population (first-time parents of low socioeconomic status), and the time period that will be

studied (three years following birth of the child).

Purpose

The purpose of this study is to determine if a more comprehensive and multidisciplinary

approach to prenatal education may improve parents’ stress levels and perceived relationship

satisfaction. Our hope is that by equipping parents with tools they need to step into the role of

co-parent as well as tools they need to protect and nurture the parental romantic relationship, we

may keep more family units intact. In keeping more family units intact and functional, the

children’s lives of those households are given a more stable foundation on which to grow and

succeed in all aspects of their lives in addition to becoming both mentally and physically

healthier than they would be in a broken home.

Approval

For our study, we would first obtain approval from the UTC IRB followed by approval

from the Hamilton County Health Department IRB. The study would likely undergo an

expedited review by both IRBs, as it poses minimal risk to participants. Grove, Burns, and Gray

(2013) make certain to note that the determination of what type of review should be performed is

the decision of the IRB committee itself; some IRBs may see our study as exempt from review as

well, since according to Grove et al. (2013), “studies that… are a mere inconvenience for

subjects might be identified as exempt from review by the chairperson of the IRB chairperson”

(p. 185).

Ethical Concerns

Our proposed research will be a minimal risk study, therefore, any discomfort or stress

encountered will be minimally different from what the participants would experience in daily life
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and will cease upon completion or withdrawal from the study (Grove et al., 2013). However,

minimal risk studies are not without ethical concerns. Based on the nature of the study,

participants have the potential to experience emotional distress. Couples examining and

evaluating their relationship status and experiences throughout pregnancy and the postpartum

period following delivery of their first child may experience discomfort, especially if the

outcomes are negative. The importance of informed consent is highlighted through this potential

ethical concern. Providing participants with informed consent will explain to them the purpose of

the study, how it will be implemented, risks and benefits, and their right to withdraw from the

study at any time as their participation is voluntary (Grove et al., 2013).

An additional ethical concern is the potential for the control group to experience a

disadvantage in their relationships because they will not be receiving the same amount or type of

prenatal education as the treatment group. A study by Gambrel and Piercy (2015) provided

mindfulness-based relationship intervention in the prenatal period to a treatment group and a

“waitlist control group” and subsequently allowed the control group to participate following

completion of a questionnaire at the end of the 4-week intervention. Providing a similar

opportunity to our control group could lessen the potential disadvantages they might experience,

but it would be difficult considering our treatment intervention consists of prenatal and postnatal

classes. Further investigation into ways to minimize the disadvantages of the control group is

warranted.

Theoretical Framework

A key concept throughout nursing and during parenthood is transition. Becoming a

parent, especially for the first time, is a major life change consisting of adjustment, new coping

skills, and redefined roles for the mother and father. Our study will follow Afaf Meleis’s middle
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range theory of transitions, which can be utilized to promote “health and well-being prior to,

during, and at the end of the change event” (Meleis, 2010). When evaluating parental stress and

relationships, applying the theory of transitions serves to provide nurses with the opportunity to

implement interventions “based upon the individual’s needs and deprivations created by role

transitions” in order to promote positive outcomes (Meleis, 2010). Meleis (2010) also encourages

nurses identify critical moments within a transition in which teaching moments are most needed;

this goal is in line with our research proposal to provide education on coping with the birth of a

first child before, during, and after the event. Anticipating change and preparing for a transitional

stage in life can be positively influenced by improving knowledge surrounding the event and

identifying ways to cope with it (Meleis, Sawyer, Im, & Schumacher, 2000). By implementing a

prenatal and postnatal education course consisting of a combination of relationship counseling

and newborn care, parents will be armed with the knowledge and skills to face inevitable

challenges that will arise in their relationship.

Literature Review

The extent of a literature review is determined by the amount of previous studies related

to the variables within a proposed research topic (Grove et al., 2013). Determining the need for

more evidence-based practice regarding our topic involved a search of several previous studies

on how the delivery of a first child impacts parental stress and relationships. Search engines used

included CINAHL, PubMed, EBSCOhost, and ProQuest Sociology Database. Key words

searched were “prenatal education,” “parental stress,” “relationship status following pregnancy,”

“transition to parenthood,” “first time parent,” and “resources impact.” Many studies investigated

changes in relationship status, provided prenatal intervention only, or focused mainly on the

mothers’ psychological status following birth. However, we found limited research regarding
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how extensive prenatal and postnatal education with a combined focus on parental relationship

counseling and care of a newborn could impact stress and quality of couples’ relationships

following the birth of their first child.

Relationship Status

A study by Khajehei (2016) investigated relationship satisfaction in Australian women in

the first year following childbirth. The main objective was to determine risk factors in a

relationship that may cause dissatisfaction. Two important risk factors that were statistically

significant for relationship dissatisfaction included a low annual family income and the period

five months and less after giving birth (Khajehei, 2016). A similar study performed in Denmark

by Trillingsgaard, Baucom, and Heyman (2014) examined individual and contextual risk factors

for parental relationship decline following transition to parenthood. Danish couples who were

either married or living together completed questionnaires evaluating risk factors at

approximately 16 weeks gestation, six months postpartum, and thirty months postpartum.

Trillingsgaard et al. (2014) determined increased relationship satisfaction was dependent on

minimal levels of anxiety and depression, longer length of relationship, and strong

communication qualities.

Doss, Rhoades, Stanley, and Markman (2009) also examined relationship satisfaction, but

they performed a longitudinal study over eight years to compare couples who had a child in the

first eight years of marriage versus those who did not. Variables examined consisted of marital

satisfaction, negative communication, relationship confidence and dedication, conflict

management, and problem intensity. Doss et al. (2009) concluded that marriage is significantly

impacted by the transition to parenthood and the changes in relationship satisfaction tend to be

sudden and persistent over time.

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Prenatal Intervention

A randomized control trial by Gambrel and Piercy (2015) implemented a Mindful

Transition to Parenthood program in an effort to improve relationship satisfaction, mindfulness,

empathy, and emotional well-being in couples expecting their first child. The prenatal

intervention took place over four weeks with a weekly two-hour class, homework of couple

activities, and the requirement of mindfulness practice 15 minutes per day, six days a week

(Gambrel & Piercy, 2015). While the women did not experience significant outcomes, the men

showed improvement in relationship satisfaction and mindfulness and a significant decline in

negative affect.

Ateach (2011) performed a qualitative study investigating first time parents’ evaluation

of education regarding several topics of infant safety: safe sleeping environment, shaken baby

syndrome, physical punishment risks and positive parenting, and expected development and

safety. The intervention was applied during the last class of a public health prenatal education

series. The general consensus of participants was that the information was helpful, useful, and

should be a part of prenatal programs.

Similar to our proposed study, Feinberg et al. (2016) implemented a program called

Family Foundations which offered five prenatal and four postnatal classes to first time parents.

The psychoeducational program focused on conflict resolution, problem solving,

communication, and mutual support strategies. There was a statistically significant positive

impact on the treatment group versus the control group at ten months postpartum. Jones,

Hostetler, Roettger, Paul, and Ehrenthal (2018) evaluated the same sample involved in the

Family Foundations program two years later. They found the couples involved in the

intervention reported greater relationship satisfaction and lower parenting negativity.

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Additionally, the children of intervention couples had fewer internalizing problems and better

sleep quality (Jones et al., 2018).

In another study similar to our proposed study, Wood, Moore, Clarkwest, and Killewald

(2014) studied how a relationship skills education program given to new and expectant first-time,

low-income, unmarried parents affected relationship quality, co-parenting skills, father

involvement, and in turn, child well-being. Eight different sites in different parts of the country

were chosen as implementation sites for the study, and each site chose one of several available

formats they felt would be best suited to their participants. Unfortunately, the program showed

no significant positive impact on any of the outcomes and actually found some modest negative

impacts on a few of the outcomes.

Method

Sample Characteristics

Our target population will be first time parents of low socioeconomic status. The CDC

(2014) defines low socioeconomic status as “a composite measure that typically incorporates

economic, social, and work status.” In order to identify couples of low socioeconomic status, we

will advertise the study to women signing up for the WIC program at local health departments

within Chattanooga. WIC will be used as a screening tool for qualification in the study as WIC

eligibility is determined by income per household size; therefore, a primigravida woman’s

annual income must be at or below $12,140 (USDA, 2018). Additional inclusion sampling

criteria are heterosexual couples living together and in a committed relationship, age 18 and

older, and able to read and write in English and Spanish. We plan to recruit couples between 20

and 30 weeks gestation prior to initiating the study and aim to collect a sample size of 26

couples.
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Sampling Method

Our sampling method will follow guidelines for a simple random sampling method in

order to determine the control group and treatment group. Selection with replacement will be

used to create equal opportunity for all participants to be chosen for the treatment group (Grove

et al., 2013). Names of couples will be placed in a container, selected one at a time, then replaced

with the rest of the participants prior to choosing the next name in order to minimize differences

in the probability for any couple to be drawn for the treatment group. This process will continue

until equal treatment and control groups have been selected.

Setting

For the purpose of this study, the Pediatric Clinic located in the Hamilton County Health

Department located on 3rd street would be the primary location to collect data. Secondary

locations would include the Hamilton County Health Department offices located in Sequoyah

and Ooltewah. The pediatric clinic is the location within the Health Department where WIC

assessments occur. To take part in WIC, patients have to provide proof of income and come to

the Health Department for assessment and education every three months in order to receive food

vouchers. We plan to advertise throughout the Health Departments with posters targeting

pregnant women who are between 20-30 weeks on initiation to take part in the prenatal and

postnatal education courses. We chose this range in order to miss the window for first trimester

miscarriages and also allow for adequate spacing of the classes before giving birth. Participants

will attend 4 prenatal educational classes and 4 postnatal educational classes which will take

place in the Health Department. Treatment participants will then complete a survey at 3, 6, 9, 12,

and 36 months after the birth of their child when they attend their WIC appointments.

Data Collection and Analysis

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The method we have chosen to collect data is through the use of pre- and post-surveys

and questionnaires. These surveys will aid us in collecting quantitative data to determine if there

is any statistical significance of our findings. The surveys will collect general demographic data

of participants as well as data pertaining to the educational classes. The questions asked will

have a Likert type five-point rating scale where participants would express how much the agree

or disagree with a particular statement. (1 – strongly disagree, 2 – disagree, 3 – neutral, 4 –

agree, and 5 – strongly agree). A Likert type rating scale would collect ordinal data levels of

measurement. Ordinal variables have a meaningful order to them; with ordinal data, percentages,

frequencies, and certain non-parametric statistical tests like the Kruskal-Wallis test or Friedman

test can be used (Statistics Solutions, n.d.).

An example of a questionnaire that we would use is based off of the Relationship

Assessment Scale (RAS) which has yes or no questions. Tools like the RAS result in nominal

data that can be used to run cross tabulations, which then can be used for the chi-square test

(Statistics Solutions, n.d.). The surveys and questionnaires will be administered to participants at

their follow-up WIC appointments or emailed to the participants if that is their preferred method.

Nursing Involvement

When considering who should be involved in the study, nursing staff within both the

pediatric and obstetric units would play an important role. Nurses are the ones who conduct WIC

assessments and would have direct contact with participants each time they come to the Health

Department. Pediatric nurses would play a key role in distributing post-education surveys at the

three-month, six-month, nine-month, one-year and three-year visits. Obstetric nurses would also

be helpful in the recruiting area. They could inform prenatal patients who fall between 20-30

weeks about the study.

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Resources Needed

For the purpose of this study we would need a number of resources. First of all, a

classroom or boardroom, preferably located in the Health Department, would be needed to

conduct educational classes. Once a location to hold classes was obtained, resources pertaining

to class material would be next. For example, a certified teacher in CPR education as well as

CPR dummies would be needed for one class. Licensed counselors would manage the topic of

marriage and relationship communication, social workers would provide education on

community resources, and certified health care professionals would teach parents about what to

expect with labor and delivery and breastfeeding. Once the course curriculum is developed, all

resources could be better determined.

Conclusion

While the transition to parenthood is a major life-changing event full of joy and

excitement, it is also a time in which many first-time parents experience new stressors created by

uncertainty, redefined roles, and relationship changes. Several studies have found that the rising

rates of parental separation and divorce in the United States negatively impact child growth and

development (Al Gharaibeth, 2015; Anderson, 2014; Uphold-Carrier & Utz, 2012). Add to that

growing up socioeconomically disadvantaged and you have several children who face negative

physical and behavioral health outcomes. Considering the fact that a major goal of healthcare

providers is primary prevention, how do we intervene to promote better adaptation to becoming a

parent in order to create more positive child outcomes? By providing first-time parents with the

tools to improve and maintain a quality relationship both during and after pregnancy, we hope to

decrease the incidence of broken family units and place children at a greater advantage for

success in adulthood.
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synthesis, and generation of evidence. St. Louis, MO: Elsevier.

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