The challenge in perinatal programs is not only to prepare couples for childbirth but also to sensitize them to the transition to parenthood and all that it entails. Preparation for the transition to the couple partnership* within the parent role requires the educator to devote time to the couple's relationship and help them to reconnect as needed. This includes teaching the couple how to be more in tune with each other, increase their sense of intimacy, improve conjugal support and communication, and enhancetheir sexual relationship. The author believes that perinatal education is entering a new era as perinatal educators become well educated, expand their knowledge base, conduct research, and experiment and evaluate different approaches. She proposes that the expanded practice of perinatal education include a primary family intervention framework for couples experiencing the transition to parenthood. This article will present an approach that has evolved from the author's development and experimentation with various programs for perinatal education. What information would assist perinatal educators to prepare couples for the transition to parenthood? This can be done in separate classes, or it is possible to include this information in traditional childbirth education classes without compromising preparation for the birth experience (Polomeno, 1997e). How can this be done, if at all? When is it best done? Should perinatal education be expanded so couples can be better prepared for the transition to parenthood?

Today, perinatal education is becoming a recognized specialty with a firmly established scientific basis. It has grown from a one-to-one approach in the early years to a comprehensive program, and it has developed from the practice of childbirth education (Nichols & Zwelling, 1997). Perinatal education has been defined as “health education for the family unit during pregnancy, childbirth, and the early parenting period … [It] is composed of a variety of different types of classes that address the needs of all family members as the family moves from one developmental life cycle stage to another during the childbearing years” (Nichols & Zwelling, 1997, p. 590). It has become family oriented by focusing on this transition period of the family (Peterson & Peterson, 1993). Malnory (1996) stipulates that, as a developmental stage, pregnancy is not only critical for the well-being of the person, the infant, and the family but also for the well-being of the couple. The perinatal educator has a supportive role of providing information about the normal processes and changes that are common during this time of transition (Lothian, 1993). Starn (1993) indicates that perinatal education may be “looked upon as an opportunity to strengthen family systems through anticipatory guidance and skill building that family members may use throughout the life cycle” (p. 35).

Zwelling (1996) indicates that “childbirth education, for the most part, has been accepted by the health care community and most childbirth classes have moved into the health care system” (p. 428). She specifies that a favorable outcome of this movement is twofold: more parents can be reached and childbirth educators can have a positive influence on the health care system. Ernst (1994) explains, “Science supports the expansion of education ofparents and family-centered childbirth, mainstreaming midwifery, and developing alternatives to the acute care hospital for childbirth. These three major efforts … promote the fundamental need for consumers to take more responsibility for their health and for the way they use the medical care system. This basic shift of responsibility is essential to effective, long-term reform” (pp. 134-135).

Thus, if parents are to be part of effective, long-term health care reform with increased responsibility, it follows that educating parents only for childbirth is no longer sufficient but should be expanded to include the whole transition to parenthood. Sheila Kitzinger, author and long-time birth advocate, challenges perinatal educators to re-examine the content and the structure of prenatal classes. She and others recommend that educators help prepare families for fulfilling births and making smooth transitions to parenthood (Elliott, 1995). In a recent critique of the author's perinatal education program for the health promotion of expectant fathers (Polomeno, 1998a, 1998b), Budin (1998) quotes a perinatal educator who was part of the analysis: “ … [W]e as childbirth educators have always put so much emphasis on an event that occurs in a few hours (labor and birth) and we have not focused on issues that affect these couples for a lifetime” (p. 38).

Issues that influence the preparation of couples for the transition to parenthood lie partly with trends that occur in both society and the health-care system. In this new century, these trends will influence adults, their relationships, family making, and childrearing. Perinatal education must broaden its base to prepare couples not only for childbirth and early parenting but also for the entire transition to parenthood. Broadening the base of perinatal education involves modifying current programs to include knowledge about the transition to parenthood, relational skills such as communication and emotional support, family health promotion, and enrichment of marital intimacy and sexuality.

Several changes occurring in society will influence men and women, their relationships with each other, and how they will birth and parent their children. Perinatal educators have the opportunity to respond to these trends in order to meet the future needs of childbearing and childrearing couples.

In his book Psychotrends, Frazier (1994) highlights some of these predicted major changes:

• The family will become the psychological unit, as opposed to the primarily economic unit. The result will be towards healthier relationships and less concern over holding a marriage together. This may result in dissociating childbearing and childrearing from marriage, yet simultaneously increasing men's interest in home and parenting.
• There will be major emphasis on the protection and proper care of children. Frazier states, “We should strengthen those social contracts that ensure the health, well-being, and freedom of individuals, including parents, and particularly those individuals who nurture children. Families in all their diverse new forms need help especially when the family, whatever its makeup, includes children” (p. 117).
• A genuine gender détente characterized by enhanced cross-gender communication will prevail. “Those who master cross-gender literacy are likely to enjoy the most satisfying relationships humans can achieve” (p. 57).
• Today, the sexes are finally making an honest effort to understand one another, so that “the sexual revolution made possible a serious inquiry into the ways in which men and women are alike and the ways in which each is unique” (p.67).
• There will be a shift from reproductive sexuality to psychological sexuality. The latter viewpoint will involve the fulfillment of people's needs for nurturance, security, and connectedness.
• Women will become more demanding, sexually.
• The public will continue to expand its interest in sex and increased sexual expression. A new freedom to talk openly about erotic matters will emerge.

Other authors (as cited below) predict additional societal trends will affect partnering and sexuality in the next century:

• Western society is moving from a patriarchy model to a partnership one: “The partnership model is a way to structure human relationships based on linking … women and men together expressing their full potential—neither superior nor inferior” (Aburdene & Naisbitt, 1992, p. xxiii).
• There is a generational movement toward wholeness. Women are developing their masculine side while men are moving toward activating their feminine side. It appears that partnership is the secret to creating a lasting and passionate relationship. However, gender differences have been described in that a woman feels partnership when she and her partner are doing things together in a cooperative manner, while a man must have his own department over which he has control (Gray, 1996).
• Men and women must become fluent in each other's language of caring and commitment so they can develop skills in a variety of ways of feeling and expressing intimacy (Wood, 1993).
• According to Monsour (1994), “Competent communication of information about oneself, as well as the competent gleaning of infomation about one's partner, should facilitate a sharing of meaning and understanding in a relationship” (p. 133), thus leading to intimacy. It is only through the processes of interaction and communication that intimacy is created and maintained (Keeley & Hart, 1994).
• “Being a good lover” and “keeping the excitement of sex alive” in a committed relationship will require that men and women take more direct responsibility for communicating what they want or desire, sexually (Winstead, Derlaga, & Rose, 1997).

At the same time, a paradigm change is occurring in health care delivery in both the lay and professional literature. Overall, there is a rapidly emerging emphasis on establishing a prevention and wellness focus. This shift will create sweeping changes in all arenas of the health-care marketplace. Arnold and Kirby (1996) mention some of these sweeping changes: the consolidation of affiliations within communities, regions, and across continents; the improvement of the health status of communities with more integrated community efforts; the designing of accessible health care systems compatible with quality and cost containment indicators; and the expansion and dissemination of technology. The perinatal specialty is one that has profoundly and rapidly been impacted by these changes.

Jones and Maestri (1997) explain how alternative health care delivery systems such as Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Independent Practice Organizations (IPOs) are being developed in the United States: “These new delivery systems further challenged the traditional functioning of the health care system by adding services that emphasize preventive maintenance, in addition to the treatment of illness … [H]ospitals have responded by reducing operating costs, decreasing the average length of stay (ALOS), and implementing market strategies that target the health care needs of women. Thus, the interaction of consumer demand and economic constraints mandated that hospitals replace outmoded obstetric systems with maternity services that are high in quality, cost efficient, and consumer sensitive” (p. 38). Canada, which has a social medicine model of health care delivery, has also reorganized its health care system due to escalating health care costs.

Some predict that the relationship between the health care team and their clientele will change more towards partnership, collaboration, and consumer empowerment and participation (Cox, 1997; Jewell, 1994; Sheer, 1996; Skelton, 1994). As a result, health care workers will need to support families by putting more emphasis on health promotion and disease prevention, increasing the significance of parenting to society, working with families to reduce fragmented care, achieving optimal outcomes, promoting a more consumer-friendly system with increased focus on primary health care/promotion education outside the walls of academic health centers, and inviting family participation in primary prevention and early treatment of illness (Cox, 1997).

The members of the health care team themselves will need to work in an interdisciplinary mode rather than a multidisciplinary one so that each member of the health care team will understand and be conversant in the cognitive maps or thought processes of the other team members. The new knowledge base, then, will be greater than the sum of the knowledge of the participants (Sheer, 1996). Quimby (1994) states, “Finally, the dialogues must take place in all health care arenas and with professionals, patients, families, policy makers, and business leaders; in short, everyone with an interest in the outcomes must participate” (p. 122). How will perinatal educators participate in these dialogues and respond to the above trends? How can perinatal education be modified? The author proposes that perinatal education be considered a primary family intervention. She has developed an intervention framework, which is presented in this next section.

In this section, the Polomeno Family Intervention Framework for Perinatal Education will be introduced. Each component of the framework is presented below. (See Figure 1.)

The Polomeno Family Intervention Framework for Perinatal Education: Couple's Preparation for the Transition to Parenthood

• Perinatal education can provide primary prevention. Keeney (1982) has defined interventions with families as the introduction into the family systems of new pieces of information that may help families behave differently. Bloom (1984) has categorised interventions as primary, secondary, and tertiary. “Primary prevention programs are designed to prevent problems before they develop by modifying the external conditions that cause problems or by helping people cope with these conditions. In contrast, secondary prevention programs are designed to intervene with people who have developed ‘early signs' of a problem, and tertiary prevention programs are meant to help people cope with existing problems and to decrease the chances of the problem developing again” (Duncan & Markman, 1988, p. 272). Perinatal education can be considered a primary family prevention because it helps couples deal with the normal transition to parenthood (Polomeno, 1999d, 1999e).
• Family health promotion is a central component of comprehensive primary prevention programs. Preventive interventions can be in the form of preventive programs (McPheeters, 1976). Prevention programs that “view goals in terms of promoting health rather than preventing disease … are aimed at healthy targets during a life transition, and their goals are to promote [general] well-being” (Duncan & Markman, 1988, p. 272-273). Bomar (1996) defines family health promotion as “behaviors of the family that are undertaken to increase the family's well-being or quality of life … [and] activities families engage in to strengthen the family as a unit. The goal of these activities is to attain, retain, or regain the emotional and physical health of all family members” (p. 182). Perinatal education is not only a means of preparing parents for childbirth but also of helping families move toward wellness. “Pregnancy is a time in people's lives when they are particularly open to considering lifestyle changes” (Nichols & Humenick, 1988, p. 319). Thus, family health promotion is at the heart of primary intervention for families.
• The family is the logical unit of primary care during the perinatal transition. The family becomes the logical unit for health promotion intervention during the life transition to parenthood (Pender et al., 1990). Emphasis is placed on the woman because she is the one who is pregnant. The fetus is taken care of both directly and indirectly (Nichols & Zwelling, 1997). The father's health is also important for the family unit (Polomeno, 1998a, 1998b). Together, all three family members should be recipients of health care because the total well-being of the family unit is affected by the multiple changes occurring. Health of the family is physical and emotional; however, health of relationships also exists. Over time, an emotional and psychological distance may creep into any couple's relationship. However, the fetus can be the ideal medium through which the partners come together to enrich their conjugal relationship, especially when care is taken to nourish this opportunity (Polomeno, 1998e, 1997a).
• Anticipatory guidance in the form of education is the primary intervention modality in family health promotion related to perinatal transition. Anticipatory guidance is an educational modality aimed at strengthening family systems in the transition to parenthood (Goldberg & Michaels, 1988). This anticipatory guidance may consist of discussion of the changes the couple is experiencing and exercises to deal with some of the issues, as well as both support and nurturing to help the couple negotiate more successfully the potential pitfalls of the transition (Starn, 1993). Thus, with the couple's gradual acquisition of new responsibilities and the implementation of new skills, education becomes a primary modality for creating optimal conditions for the transition (Schumacher & Meleis, 1994). Education can also strengthen relationships, create family environments conducive to self-growth, health, and well-being for both family members and the family as a unit (Botelho & Skinner, 1995; Roth, 1989). Felner, Farber, & Primavera (1983) suggest that a life transition preventive approach focus on the entire transitional period with its adaptive needs resulting from the change being experienced. They state that “the degree to which an individual is able to recognize and to master changes in the way they view themselves and in the way they are perceived by others may significantly influence the level of success he or she has in coping with life transitions” (p. 211). Such programs typically contain three qualities: (a) They are group-oriented; (b) they are directed to well people; and (c) they strengthen psychological health and reduce psychological maladjustment (Cowen, 1983). Indeed, comparing common experiences provides ongoing support (Lothian, 1993).
• Partner relationship enrichment is a key strategy for preventative health care for couples. Lenz, Solken, Rankin, and Fischman (1985) write that “[c]hildbirth education classes … have typically limited discussion of nurturance to labor, delivery, and infant care. Increased attention could justifiably be given in these classes … [especially] to spouses' nurturance of one another and to the potential benefits of sex-role attributes and behaviors for perceptions of [conjugal] quality” (p. 60). Perinatal educators can convey a message to couples that conjugality, like family life, has predictable stages of development and that conjugal strain is a normal experience, especially at critical points over the life of a marriage or conjugal relationship (Martin & Starling, 1989). Educators can also help couples tune in or increase their awareness of the changes in their relationship, especially of intimacy. The educator can prepare couples for the stresses associated with their relationship during transition to parenthood by discussing them in advance and normalizing them as they occur.

Family Intimacy. Conjugal intimacy is foundational for intimacy within the total family. “Family intimacy is critical … since the family will [ideally] become the safe haven for each of its members. The sense of security the family produces will have beneficial consequences, both short-term and long-term, for their unborn's development and the development of other children to follow” (Polomeno, 1998e, p. 20). Schaef's definition of intimacy can be adapted for family intimacy: “True [family] intimacy is a process that grows with time. It is a process of knowing and being known, and it requires openness and willingness from each person involved. [Family] intimacy has no techniques … [and] cannot be orchestrated. It starts with the self, knowing the self and being present to the self … [Family] intimacy is not static. It is always moving to a new level. It is an energy flow with no barriers … [and] cannot be controlled. Like a feeling, it cannot be held onto or reproduced at will. We notice [family] intimacy. We do not produce it” (1989, pp. 136-137).

The Scope of Conjugal Intimacy. Street (1994) defines intimacy as interactions that relate to open self-disclosure and close personal exchanges. This includes the sharing of feelings, hopes, fears, and vulnerabilities. Conjugal intimacy includes—but is more than—sexual intimacy (Schaefer & Olson, 1981). Intimacy can exist between any two persons, but conjugal intimacy is seen as a crucial component of a healthy relationship (Kenny & Acitelli, 1994). Indeed, intimate couples report feeling the presence of their partner even though he or she is not physically present (Monsour, 1994). Knowing that the other is always in one's thoughts is essential to the maintenance of intimacy. Adults have described it as “feeling the other in one's blood!”—a statement that reflects the strong mind-body-spirit connection.

Intimacy must be recreated daily and renewed in each stage of conjugal life. The feeling that each partner is in tune with the other is also important (Keeley & Hart, 1994). If a couple feels out of synchrony, they can develop strategies to re-establish this bond and/or admit they are temporarily out of synchrony. Conjugal intimacy is a wonderful healer and a support in the hassles of everyday life. However, the changes associated with the transition to parenthood can disturb the feeling of synchrony or harmony. If so, with effort the couple can re-establish intimacy in their relationship (Clulow & Mattinson, 1989; Polomeno, 1997e), leading to a renewal of love and sexuality.

Couples should be aware that physical love is not sufficient to maintain a long-term committed relationship such as marriage (Clulow & Mattinson, 1989; Dinkmeyer & Carlson, 1989; Polomeno, 1999d, 1999e). The successful transition to parenthood necessitates emotional and psychological intimacy, the most difficult of all intimacies to experience (Carlson, Sperry, & Dinkmeyer, 1992), and include the following traits:

• an understanding of one's self and a willingness to share feelings and thoughts;
• flexibility and responsibility for one's behavior in the relationship;
• self-acceptance and acceptance of both the other and the relationship;
• commitment to the permanence of the relationship, especially if children are involved;
• trust and faith with honest, open exchanges;
• ability to live in the present and see new ways of achieving mutually compatible goals;
• ability to negotiate; and
• ability to focus, emphasize, and share positive feelings.

At least two authors, Framo (1981) and White (1998), state that the greatest gift parents can give their offspring is a viable, happy, healthy, and loving relationship. Assuming this is so, perinatal education can make a major contribution to society by helping couples tune in to the changes in the emotional and psychological intimacy of their relationship, while simultaneously promoting the emotional and physical health of the next generation. Thus, promoting a couple's relationship through the perinatal transition is a foundational aspect of family health promotion.

Table 1 Explanation of the Polomeno Family Intervention Framework for Perinatal Education

When a couple feels they are sharing a situation, they will begin to feel that they are similar (Genero, et al., 1992). Similarity (Monsour, 1994) is important as one partner gains understanding about himself/herself, his/her partner, and the situation (Kelly, 1969). The couple will experience feelings of closeness and reciprocity, leading to feelings of being a team, two people in a partnership (Cutrona, 1996). This appraisal-meaning-common-ground building process is mediated by communication, social support, sexuality, intimacy, and equality (Suitor, 1991).

• Increase the couple's awareness of how their families of origin have influenced their beliefs and values regarding parenthood;
• sensitize the pregnant couple to the changes in their relationship during the transition to parenthood;
• encourage the couple to share their thoughts and feelings regarding these changes during each stage of the transition to parenthood;
• enhance communication and emotional support within the couple's relationship during the transition to parenthood;
• assist the couple in the identification of their personal and relational strengths and resources;
• help the couple identify and use sources of support;
• explore each partner's realistic expectations regarding his/her role in the transition to parenthood;
• examine similarities and differences between men's and women's responses to the transition to parenthood;
• support conjugal and family intimacy to create feeling of a team or partnership.

The following theoretical content is offered as a teaching guide for the perinatal educator. Five questions are raised in this section of the article: (a) What are transitions? (b) What happens to family health during transitions? (c) What is the transition to parenthood? (d) What is the connection between the conjugal relationship and the transition to parenthood? and (e) What types of interventions are appropriate for couples coping with this transition? A perinatal educator can choose parts of this theoretical content to explain the transition to parenthood to couples attending perinatal education classes. The integration of the content will depend on the type of program being taught, the nature of the group attending classes, the time factor, the training and comfort level of the educator, and the pertinence of the theoretical background.

Table 2 Transitions: Overview

The author of this article has conceptualized the transition to parenthood as containing nine phases.

• Phase 1 – the decision to become pregnant;
• Phase 2 – physically creating the baby;
• Phase 3 – pregnancy;
• Phase 4 – birth;
• Phase 5 – immediate postpartum, including the first 6 weeks;
• Phase 6 – 1 1/2 to 6 months;
• Phase 7 – 6 to 12 months;
• Phase 8 – 12 to 18 months; and
• Phase 9 – 18 to 24 months.

The transition to parenthood can be considered complete when the child is 2 years old. This belief is based on clinical observations from the domain of family therapy that alludes to the 2-year period demarcating a major life transition (Hetherington & Camara, 1984; Wallerstein & Kelly, 1980). Cowan and colleagues (1991) state, “We believe that it makes sense to describe the end of the transition to parenthood as occurring, on the average, when the first child is about 2 years old” (p. 88). (See Table 3.)

Table 3 The Transition to Parenthood: A Summary

Table 4 Impact of the Conjugal Relationship on the Transition to Parenthood

Several perinatal education concepts or programs are summarized below and represent various aspects of the intimacy intervention useful with transitioning couples. These may be integrated into a traditional childbirth education course or added as separate courses to a comprehensive perinatal program.

To what extent are perinatal educators and/or comprehensive perinatal programs preparing couples for the transition to parenthood? Many are beginning to do so, but some educators may need more knowledge and training in order to better prepare couples for this important life transition. Martin and Starling (1989) believe that clinician educators must especially increase their familiarity with conjugal issues and recent changes in health services. Many couples can benefit from supportive anticipatory guidance and counseling that acknowledges the predictable changes in their relationships (Goldberg & Michaels, 1988). The normalization associated with anticipatory guidance can reduce anxiety and frustration that often surround conjugal conflict and set the stage for adaptation and resolution. One aspect of the perinatal educator's role becomes that of validating the couple's feelings. Additionally, sharing feelings in discussion within a group setting of expectant parents can reopen channels of communication for a participating couple. Cutrona (1996) says, “In the same way that people are not born with the knowledge of how to be good parents, we are not born knowing how to be supportive marital partners” (p. 101). What couples may not have learned from their childhood role models related to partnering and parenting can be addressed in programs of perinatal education. Healthy families is the desired outcome for perinatal education practice, the greater society, and ultimately, the health-care system.