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Chapter Highlights

This chapter describes how to do the following:

  • Establish group rules and encourage participation.

  • Help couples develop shared and realistic expectations about infant care, and share parenting responsibilities.

  • Assist couples to identify and plan for their support needs after the birth.

This chapter describes some practical issues about how to structure the running of Couple CARE for Parents (CCP) in a group delivery format, which is what we recommend for the pre-birth units. This chapter also describes in detail how to provide the first unit of CCP, which helps the couple prepare for the major changes that will occur after the birth. The aim of these pre-birth activities is to help couples develop realistic and shared expectations of parenthood (e.g., infant care demands, gender roles, preferred parenting practices), and to identify what additional support might be helpful in the early phases of parenthood.

The content and activities of the first unit of CCP are summarized in Table 2.1. Typically, it takes about 2½ to 3 h to cover the content and activities. Usually we combine these activities with the activities on couple communication described in Chap. 3, and deliver the combined content described in Chaps. 2 and 3 to small groups of couples in a full-day workshop (5–6 h contact plus appropriate breaks).

Table 2.1 Content and activities for expectant parents
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Practical Issues in Delivery of Couple CARE for Parents in Groups

There are four issues that you need to consider before starting to run a CCP group. The first is the number of couples to include in group sessions. This might be influenced by the rate of couples expressing interest in your program. We usually run group sessions for between four and six couples. Any less than four couples and it can be hard to develop an effective group process. To maintain active skill training and attention for each couple, which is central to the Couple CARE approach, about one educator to every four couples is desirable. Groups with more than six couples can be run effectively, but require more than one educator to be present. If you have more than one educator, having an educator of each gender present is an advantage.

A second consideration is the venue. You will need a large enough room to comfortably seat all the couples in movable seats, and to allow the couples to space themselves out from each other when they are doing couple exercises. The spacing provides some privacy, and prevents the noise of others from being too distracting. Arrangement of seats into a half circle is helpful, as it allows the participants to see and talk to each other, while being able to see and hear the educator(s) when they are at the front.

Equipment is a third consideration. Couples and the educator(s) will need to write. Providing clipboards for the participants allows them to complete written exercises without desks or tables acting as barriers to interaction. A whiteboard or flip chart is essential for the educator(s) and group members to write up comments and key points during the session. If the group is larger, with more than six couples, it can be very helpful to have a radio microphone (to allow moving around the group) and an amplifier for the educator(s), so they do not have to strain to project their voices in order to be heard. Women, who typically have softer voices than men, might want to use a microphone even in smaller groups.

The final issue is care for the women who are in an advanced stage of pregnancy. Fatigue can be a problem in the third trimester of pregnancy, a desire to urinate frequently is common, and sitting for long periods can be uncomfortable. You may find that some women will need to leave the room every hour, so discuss the best way for them to leave the room without distracting others. Provide comfortable, supportive chairs and perhaps suggest that couples may like to bring a cushion to class for extra back support for the woman. Finally, giving the group a short break at least every 90 min, and encouraging gentle movement during the breaks, can be helpful.

One other issue you might want to consider is how you will manage if a couple, or a partner, misses a session. You might want to offer the chance of an extra session for the couple (possibly with a fee attached) to catch up on the material that was missed. Alternatively, you might give the opportunity to make up a missed session with flexible delivery, and provide the couple with self-directed materials to allow them to complete the work in their own time.

Sending couples a letter (or email) ahead of the first session is useful. We send a letter that welcomes the couple to the program, and congratulates them on the decision to invest time in enhancing their parenting and relationship. The letter provides people with directions on how to get to the centre, with a map and clear directions for public transport and parking. In the letter couples are encouraged to arrive at least 10 min before the scheduled starting time. We indicate that the sessions will start promptly at the designated time, and we will complete the sessions at the specified time. Providing these key pieces of information can help get the first session off to a good start.

Clinical Connection

In order to make the Couple CARE for Parents program easy to access for couples, what venue, what time of the day, and what day of the week might work best? What things can you do before starting the program to ensure people will find the venue easily, and be comfortable when they arrive?

Beginning the First Group Session

Since this is the first time couples come into contact with the educator(s) and the other couples participating in Couple CARE for Parents, the impression the couples form will likely influence their commitment and engagement in the program. When a couple arrive we show them into the room, provide a pre-prepared name badge of their first name, make a point of introducing ourselves to each couple, and ask some questions of them to get them talking. We then introduce them to at least one other couple. We make a point of trying to start the first session on time. In order for the workshop to engage participants, the educators need to facilitate group interaction, and maintain a good balance between the didactic and experiential components of the workshop.

Ground Rules for Group Couple CARE for Parents

When conducting group sessions of Couple CARE for Parents it is helpful to establish some basic ground rules for group sessions, which maximize the advantages of that format. Table 2.2 lists some ground rules that are useful to review. There are three guidelines that are really important to emphasize at the start of the first session, and you could introduce the ground rules with words like the following:

Table 2.2 Suggestions for group ground rules
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“Welcome, it is great to see you all. Congratulations on taking a really important step, working together to be good parents, and to having the very best relationship you can. Great families don’t just happen, partners need to nurture and care for their growing family. We are pleased to work with you to help you nurture your family and your relationship together.

There are a few ground rules about how we run the group sessions that seem to make them work better for everybody. First, after years of running sessions we are confident that there is no one right way to raise a child or have a great couple relationship. These sessions are not about telling you what to do. The whole point of the Couple CARE for Parents is to help each of you define as a couple how you want to care for your child, and how you want your couple relationship to be as you parent together. Second, respect for the views and opinions of others – the partner and other group members – is really important. Let people finish what they are saying. Do not immediately disagree with someone. Instead, think about what has been said, and be open to new ways of doing things. Third, some bits of your relationship are private. Different couples will have different boundaries about what they want to discuss in a group like this. A lot of the work we do will involve you talking with your partner. We will invite you to discuss things with the rest of the group, but you should feel free to say: ‘I would rather not talk about this to the group’ – and that is fine.”

Icebreakers

One goal early in the first group session is to help group members get to know each other a little, and to feel comfortable talking with each other. A common method of breaking the ice is to have people introduce themselves to the group. That works satisfactorily most of the time, though for people who are less comfortable in groups that can be a slightly daunting way to start. Table 2.3 describes three different possible icebreaker exercises that focus on couple relationships, but also provide a comfortable way for couples to talk together. Any of these exercises can be effective and you might like to experiment to find what works best for you with the couples you are working with.

Table 2.3 Possible icebreaker exercises for Couple CARE for Parents group
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Infant Care Demands

The content of the CCP program begins with an activity aimed at eliciting participants’ understanding of the tasks of caring for a newborn, the time those tasks will take, and the frequency with which they will likely need to be done. The couples are then led into an activity which asks partners to rate how much of each infant care task they themselves will do versus what they hope or expect their partner will do. Partners are invited to share their infant care expectations with each other. It is often helpful to provide some psycho-education about infant care demands and to normalize couples’ growing awareness of the demands of parenthood. The session then moves to the different types of support that new parents might want, and participants individually write down their current support needs during the pregnancy and future support needs they think they will have during the newborn period.

Couples who have shared and realistic expectations of the demands of infant care may better manage the stresses associated with parenthood. Even though there is a lot of information available about baby care, most parents report that they felt unprepared for the demands of a newborn baby who requires constant, 24-h care, and is totally dependent upon them. Table 2.4 presents the common infant care tasks, how often these tasks typically need to be done, and how long the tasks typically take.

Table 2.4 Infant care tasks: how long and how often they are typically needed to occur
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The activity requires couples to map out the needs of a newborn across a typical day, which can be introduced with words along the following lines:

“Many new parents report that they are surprised by the amount of time it takes to care for their new baby. In this activity we use a 24 hour clock diagram to help us identify the parenting tasks you will be doing in those first months of parenthood, and estimate the average amount of time that is needed for those parenting tasks. This will help you get a feel of a typical 24 hours in a new parent’s life.”

Practice Tip

Educators can write tasks on the whiteboard so all couples can see the diagram. Couples also can complete the 24 h clock face on paper which they can keep for future reference and discussion.

Couples use the 24 h clock diagram to write the task down according to the time of day it occurs and the amount of time it takes up. The 24 h clock is just a circle that can be divided off into sections as shown in Fig. 2.1. Figure 2.1 is an example of a completed 24 h clock. In a group workshop it is often useful to draw the blank 24 h clock on the whiteboard and then invite participants to start describing the infant care tasks, how long that task might take, and how often that task might need to be done in a 24 h period. When drawing tasks into the clock it is useful to ask participants when (i.e., what time of day) the task might occur and for the educator to draw the task into the clock like slices in the day so that participants gain an understanding of how the day might look like when caring for a newborn. This activity provides ample opportunity to provide psycho-education about infant needs and best-practices for parenting. It is important to emphasize that the clock is not a precise guide to how a baby will behave, but rather an opportunity to discuss the typical challenges of caring for a newborn baby. Asking participants to identify these tasks, time and frequency of the task, is key to engaging group members early on in CCP.

Fig. 2.1
figure 1

24 h clock of infant care tasks

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Practice Tip

As can be seen in Table 2.4 there is a wide range in the suggested times it takes to do tasks like soothing infant fussing, and attending to crying. These ranges are so wide because each child is different, and each parent attends and manages these demands differently. The educator should highlight that infants vary greatly in their behavior from one day to the next, and that some babies are much more demanding than others.

The 24 h clock activity often identifies misconceptions and unrealistic expectations about infant care. For example, many prospective parents are unaware of the frequency with which a newborn baby is breastfed and the length of time each breastfeed can take. Another helpful point to share with couples is that it is quite normal for a newborn to have four to six short feeds over 1 h in the first week of life. There are many potential negative influences on breastfeeding success, including worry about insufficient breast-milk supply, painful breasts (e.g., engorged, mastitis, cracked nipples) usually as a consequence of poor suckling attachment, as well as low support or negative views and attitudes about breastfeeding from partners, family, and friends. Women with supportive partners are more likely to successfully breastfeed and do so for longer. Without accurate and realistic information about the benefits of breastfeeding couples often have unrealistic or divergent expectations of breastfeeding, leading to disappointment, stress, and conflict.

Another example of the importance of discussing expectations relates to sleep and crying. Many new parents are surprised by the haphazard and broken pattern of sleep in newborns, and the extent to which infant crying can be a frequent source of distress to parents. Providing expectant parents with realistic expectations of normal newborn sleeping, crying and need for attention, helps each partner prepare and plan for the reality of infant care demands. It is also important to introduce the idea of sensitive and responsive parenting, which involves attending to infant needs in a timely and appropriate way. It is important to normalize that during the first few months of life almost all (95 %) infants cry when awakened, and that a timely parental response which assists the infant to return to sleep, or calm down, is considered sensitive and responsive parenting.

Sharing Parenting and Other Tasks

The 24 h clock activity helps couples clarify potential infant care challenges, and can usefully lead to discussion of how the partners will share the required tasks after the birth of their child. The educator can invite couples to complete the handout that appears as Table 2.5. This handout is designed to encourage couples to discuss ideas about who will do what infant care tasks and household chores in those first few months of parenthood. It is useful to have each partner independently complete the handout, and then to have each couple discuss their answers, identifying where they have similar and different expectations.

Table 2.5 Who will do what? My expectations of housework and childcare
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The activity of exploring the sharing of parenting and other household tasks can be introduced with an explanation something like the following. “As a couple you probably have some patterns established around how you share household chores. I mean things like who does the cooking, the washing up, pays the bills, changes the bed sheets, shops for food, does household repairs, and mows the lawn. Having a baby adds to the tasks to be done, and it is important to have shared and realistic expectations about how all the work will be managed. This next activity lets you explore what your expectations are about who will do what in those first few months of parenthood. Please individually complete the hand out, and then we will ask you to discuss your answers with your partner.”

While many couples share household chores equitably in early stage relationships, it is common for new parent couples to become more traditional in their division of chores with the woman doing more of the household and child care tasks. This traditional division of labor might or might not be what each partner expected to happen. Women who expected a continuation of equitable sharing of roles can become highly dissatisfied with traditional gender roles. It is therefore worth exploring expectations with each couple. The educator’s role in this activity is to support the couple to discuss any divergent expectations and facilitate the couple reaching a realistic, shared set of expectations (Table 2.5).

Table 2.6 Types of support
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Practice Tip

It is worth drawing out in discussion four key points about the division of child care and household tasks.

1. Some couples share most tasks and each partner does about 50 % of the chores. This type of division of labor is reflective of egalitarian gender roles. Other couples have more traditional gender roles, in which the man goes to paid work while the woman stays at home (or goes to paid work part time). In traditional gender roles the woman does most of the child care and household chores.

2. There is no one correct way to share household chores but if partners disagree about the sharing of tasks, or see the sharing as unfair, this can create problems.

3. Many of our expectations about gender roles are learned when we are young and living with our parents. These expectations are sometimes not spoken about and sometimes we are not aware of them.

4. A common occurrence is for the woman to do a lot more of the child care and household chores than the man, even if both partners are employed full time. This arrangement is a common source of unhappiness for women.

Other expectations you may wish to explore with couples include the following. (1) What are the expectations about feeding the baby? For example, will the baby be breastfed and for how long? Will they feed their baby on demand or on a schedule? Who will do night feeds? When will they introduce a bottle, when will they introduce solids? (2) What are the expectations about sleeping? For example, will the baby sleep in a cot in the parents’ room, or in a different room? Will they settle the baby to sleep, or let their baby cry to sleep? At what age will they expect baby to soothe him/herself to sleep? (3) How they will manage their baby crying? For example, will they always attend to the baby crying? What is the best way to attend to the crying? (4) What are their expectations about family and friends caring for their baby? For example, who will be allowed to hold the baby—young cousins? Who will babysit the baby—overnight, or on weekends? (5) Will the couple use day care? At what age? How often? Once partners have discussed a range of expectations it can be helpful to ask the couple to first summarize the expectations they agree on; second summarize the expectations they differ on, and how they differ on those expectations; and third, identify what expectations they will need to discuss further.

Support from Partner and Others

Many partners with a new baby benefit greatly from support they provide to each other, as well as support provided to the couple by extended family and friends. This next activity is intended to help couples anticipate what support they each might need as new parents, and plan how to access that support.

A useful way to introduce the idea of support needs is to discuss the type of support that people need in different situations. Table 2.6 is a useful handout describing different types of support. We ask couples to comment on what sort of support is needed (emotional, problem solving, practical, or information) and who might best provide such support for some common challenges faced by parents of new babies. Table 2.7 sets out some common challenges experienced by new parents that can serve as a useful basis for discussion. Table 2.8 is a handout that can be used to prompt spouses to discuss what sort of support they currently provide to each other, and how they might refine that support.

Table 2.7 Common challenges of parenthood that might benefit from support
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Table 2.8 Support needs: complete this individually
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Sometimes this activity highlights key differences between partners in their views of who should provide what sort of support. For example, one partner might be keen to seek support from extended family while the other partner feels the couple should be able to manage on their own. On average women are more likely than men to want a close relative (e.g., the child’s maternal grandmother) to stay at their home for the first few weeks after the baby is born. Such a support person can provide invaluable support around baby care, meal preparation, and helping with some of the housework. Indeed, in many cultures it is expected that a woman’s mother will come and stay for several weeks. It can be useful to highlight that the expectations people hold about involvement of grandparents, and other extended family, often varies across cultures and genders.

There is another common gender difference in support needs. In general, women particularly value emotional support. Women are more likely than men to seek emotional support for themselves, and to provide emotional support to others. The woman’s focus is often on talking about experiences and feelings, with the idea that the talking itself is helpful. Men, on the other hand, tend to particularly value practical and problem solving support. Men are more likely than women to seek to generate solutions to problems when discussing stress. This gender difference can be highlighted by asking the men in the group a question like the following.

“Gentleman, have you ever had your partner tell you about something that is worrying them about the pregnancy, like how the baby is kicking, how her back/hips/legs are aching, or that she is having trouble sleeping? Have you also found no matter what you suggest it seems to be the wrong thing?” You might also pose the following question of women. “Ladies, have you ever gone up to your partner to talk about how your pregnancy is going, how the baby is kicking, your back/hips/legs are aching, or you are having trouble sleeping. You really want to be listened to, but you feel he just keeps telling you what to do?”

Many couples identify with this misunderstanding of what support is desired. Many women feel misunderstood and concerned that their man does not listen. Many men try to provide solutions, as they assume that is what their partner wants, and feel they cannot say the right thing. The activity suggested below allows partners to describe and discuss their support needs, allowing each partner to become more aware of what they can provide in order to support their partner. The activity can be introduced as follows.

“This next activity gives each of you an opportunity to write down what type of support you want now and once you are a parent. I will then ask you to share your notes with each other and come up with a joint plan listing for getting the support you want as a new parent.”

The educator should circulate around the room among the couples helping them to clarify their individual and shared support needs. Some useful questions to pose of partners in this process include the following. (a) What sort of support do you tend to give to your partner most often? (b) What sort of support do you think you will want as a new parent? (c) From whom can you ask for that support? (d) In those early weeks what sort of support will you want from your partner? (e) How will you ask for that support?

Completing the Group

As discussed earlier, we recommend offering both Units 1 and 2 (content addressed in the next chapter) as a single-day long workshop. After completing both units, the session can be drawn to a close by congratulating couples on completing Units 1 and 2 of CCP and providing a summary of the main points covered during the session. The remaining units of CCP follow a similar pattern, with a mixture of individual and couple activities. There will also be DVD resources or reading. In each unit, a self-directed change plan occurs, where each person puts into action what they have been thinking and talking about.

The educator may also ask participants if they have any questions, worries, or ideas from the workshop. Depending on time, these questions could be answered in the group, or followed-up in a telephone call at a convenient time.

Managing Common Challenges in Running This Unit

Disengaged Participants

The ground rules of CCP may help educators prevent disengagement or address it early when they see it. Help engage participants by making the CCP workshop and sessions interesting by: (a) using an engaging and varied tone of voice; (b) including anecdotes, real-life examples, and jokes (but check they are appropriate to the context and participants); (c) using a range of modalities and varying them: e.g., including activities that require some reading, some listening, some talking and some “live” practice of skills in group, couple, and individual activities. If just one or two participants are appearing disengaged you could use the participant’s names when inviting them to share in a group activity, and ensure you talk to each participant during one-on-one activities to hear what their thoughts and comments.

Clinical Connection

Think back to a presentation that you recently really enjoyed. What made it enjoyable? What can you do to make the CCP sessions interesting, dynamic, and engaging for a variety of participants?

Couple Starts Arguing in Session

Chapters 3 and 4 introduce communication and conflict management skills and strategies to assist couples manage conflict. The ground rules at the beginning of CCP may also be helpful to review with the couple one-on-one if the couple conflict arises because the partners are interrupting each other, or immediately disagreeing with something the other partner has said. In this situation the educator might briefly join the couple, ask them to pause their conflict, reflect what is happening, and ask what each partner themselves could do to work through the activity with their partner. If they continue to struggle the educator could also suggest the couple complete the activity individually and write down what key messages they each want to communicate with their partner before speaking those messages aloud to their partner.

Couple Knows Very Little About Infant Care

Couples who know very little about infant care can be very vague about their expectations, or unrealistically optimistic about infant care demands. Psycho-education about infant care (as in the 24 h clock activity) can assist individuals form more realistic expectations of the future needs of their own infant. Another possible strategy to help participants learn more about the variability of infant care and parenting is to ask them to talk to other new parents, read books, blogs or watch shows about what new parents do in a day of caring for their baby, how long things take and how parents manage those challenges.

Couple Has Very Different Expectations

In this first unit it is helpful to normalize that divergent expectations are common for many couples, and that neither partner is right or wrong. It is important that the educator help the partners talk to each other about where their expectations came from and then be open to identifying options for how they as a couple might proceed with finding a mutually agreeable solution.

An example of how an educator might work with this divergence in expectations and support needs is illustrated by Tom and Laura who were 8 months pregnant when attending the pre-birth unit of CCP.

  • Educator: So, we have been looking at what sort of support you may each want as new parents. What have you identified in your list of support wants?

  • Tom: I don’t think a new baby has to change our life very much. We’ve talked about sharing the baby care and household chores – I do lots of the housework already anyway so I think we will be fine. I haven’t put any new or extra support needs on my sheet.

  • Educator: Uh-huh, and what about you Laura?

  • Laura: I put heaps down!! (laughing). I really want my mum to stay for a few weeks after the baby is born, you know, to help me out with the baby, bathing, settling, and to help with dinner and some housework. I saw how much my friend struggled those first few weeks and she was always so exhausted. Plus, my midwife said the other day that if I could rest as much as possible in those first few weeks and take it easy then I would recover better after childbirth. So, I put down that I want instrumental support mostly, and I would like my mum to help give that to us.

  • Educator: I hear that you have different expectations about what support you want for those early weeks of parenthood. Have you had a chance to talk just now about how you will work through that difference?

  • Laura: I’m going to ask my mum anyway. I really want more support and I want to look after my body and rest. I know Tom doesn’t get along so well with my mum but it will only be for a few weeks.

  • Educator: So, it sounds like you have a strategy to get the support you want Laura but that this strategy may not be Tom’s ideal?

  • Tom: You’re right there. I am going to feel uncomfortable with your mum there; do you mean she’ll sleep over as well? I really think we will be right without her. You know I will do the dinners and stuff.

  • Laura: Yes, you do a lot around the house. I’m just worried though that I will need more help. Mum’s had four kids and so will know a lot about what it is like, you know, if I have any breastfeeding problems, or just be there with me to figure out why the baby is crying, or what if the baby got a rash or sick? Mum would know what to do.

  • Educator: I can hear you have a variety of reasons why you would like your mum to stay. You’ve mentioned instrumental support, I wonder if you can, Tom, identify which other support needs Laura is listing?

  • Tom: I think she might be saying she wants her mum’s emotional and problem solving support as well.

  • Educator: Uh-huh, I agree, does that sound right Laura?

  • Laura: Yes, I think I do want her there for all of the four different types of support. And it is not because I think you won’t be doing enough, its more about me thinking I want nothing to go wrong in those first few weeks, I feel a bit anxious being alone those first few weeks especially when you are at work.

  • Educator: Okay, so I heard that you both have somewhat different expectations about what support will be useful in those early weeks. Laura would like her mum to stay because she feels her mum will be able to provide extra instrumental support, information, emotional support, and problem solving support. Tom however, feels more hesitant about his mother-in-law staying and thinks you two will be able to cope on your own. When I asked before if you had a chance to discuss how you will manage this difference in expectations I heard Laura that you wanted to ask you mum to stay anyway. How do you think Tom will feel if you chose that option?

  • Laura: Umm… he might feel left out, and he said he would feel uncomfortable. (turning to Tom) I don’t want you to feel uncomfortable. What should we do? Maybe I could ask my mum to come only after you go back to work. Then you and I can do it all together in those first two weeks? Or, maybe I could try to have her over for only a few days each week? She would probably be okay with just a night or two, and then you and I can talk about if that is working? If I am coping…if you feel comfortable?

  • Tom: Yeah, I like that idea better. Especially about it just being the two of us for the first 2 weeks. I don’t want you to get stressed out when I am back at work, so maybe we can try having your mum over for the third week and see how that works out.

In the above dialog, the educator assists the partners to clarify Laura’s support needs and facilitates a discussion between the partners to identify a way forward that meets both of their needs. In exploring support needs, it can be useful to make the point that there is no one right way to be supported in the early months of parenthood. The expectations people have vary by culture, in some cultures it is normally expected the woman’s mother or other relative will stay with the couple for an extended period after the birth of a child. Couples need to find the best way for them, based on shared and realistic expectations about how they will manage parenthood.

As noted previously, we most often run the content in the current chapter, and the content in the chapter that follows, as a single-day workshop. If the program is being run so the content of the current chapter stands alone it can be useful to ask couples at the end of the session what each of them found the most useful content that was covered, and if they have any further questions or concerns.