Examining the pathways of pre- and postnatal health information.
Youash, Sabrina ; Campbell, M. Karen ; Avison, William 等
It has been suggested that giving and receiving information is the
fundamental function of prenatal care. (1,2) Information acquisition is
important because pregnancy is a time when health behaviours are more
salient as they affect both the mother and the developing fetus. (3)
Current literature suggests that some women may not be receiving
adequate pre- and postnatal health information. (4)
Information gaps have been identified in broad areas such as the
benefits and risks of routine procedures used at childbirth. (5) This
raises concerns about the quality of available prenatal education in
Canada. A UK qualitative study reported specific aspects of inadequate
information provision which included a need for better information about
the purpose of each prenatal appointment, the distinction between
different health care providers' roles and how to access advice and
care should unforeseen concerns arise. (2) Information gaps have also
been noted in more specific areas of pre- and postnatal health such as
psychosocial topics like physical, emotional and sexual abuse. In a
survey of the College of Family Physicians of Canada and the Society of
Obstetricians and Gynaecologists of Canada, over 90% of obstetricians or
gynecologists had not discussed these topics with their patients. (6)
These findings are mirrored in a US systematic study of maternal
experiences, "Listening to Mothers II", which found that less
than 35% of mothers reported that they were asked about abuse and less
than 60% were asked about postpartum depression during the postnatal
visit. (7) While many national or large maternity surveys have been
conducted in various countries, (8) a comprehensive study that examines
levels of pre- and postnatal health information in Canadian women is
still lacking. The Maternity Experiences Survey (MES) marks the first
pan-Canadian survey on maternity experiences and is used in this study
to identify areas of insufficient health information specific to
Canadian women. (9)
Research has implicated several variables that may play a role in
women's levels of pre- and postnatal health information. For
instance, both perceived and received social support have been shown to
influence acquired health information levels. A 2005 study of five
Ontario hospitals demonstrated that low levels of social support were
associated with unmet informational needs. (10) This study also
identified education level as a predictor of information needs. In a
study based on 2003 Health Information National Trends Survey data, it
was found that non-seekers of information had lower income than persons
who sought information about general health topics. (10) There is also
evidence that women of low socio-economic status have learning needs
that differ in nature and magnitude from women of a higher
socio-economic status. (11,12) For example, women from low-income
families were not as concerned with control issues in pregnancy and
childbirth, but were more interested in having their own doctors and
maintaining continuity of care. (12) A national study examining
Canadian-specific barriers to accessibility of this information is
lacking. Understanding the relationships between different pre- and
postnatal health information components and the influences of factors on
health information levels may provide insight as to how health
information-seeking behaviour and acquisition can be ameliorated in
Canada.
METHODS
Data source and study population
Data from the 2006 MES were used in this study. The MES includes
6,421 women [greater than or equal to]15 years of age at the time of
birth, who had a singleton live birth in Canada during a three-month
period preceding the 2006 Census and who lived with their infants at the
time of the survey. Detailed information about the sample can be found
in Dzakpasu et al. (13) Of the 6,421 participants in the MES, 304 were
excluded from the analysis due to missing values, leaving a sample size
of 6,117.
Factors associated with pre- and postnatal information
The associations between a number of variables and information
levels were assessed. Low Income Cut-Offs (LICOs) as determined by
Statistics Canada (14) were used to create a binary variable for income.
Education categories included: <high school, high school, community
college/trade certificate and [greater than or equal to]bachelor's
degree. Marital status categories included: married, common law, single
and a heterogeneous category combining separated/divorced/single women.
Region was divided into urban and rural according to the Forward
Sortation Area of postal codes. (15) Age was divided into four
categories: 15-24, 25-29, 30-34 and [greater than or equal to]35. Type
of prenatal care provider was categorized into
obstetrician/gynecologist, family doctor and general practitioner, nurse
and midwife, and "other" because providers within these groups
share similar information-delivery roles. (16) The most useful
information source as perceived by respondents was divided into:
family/friends, the health care system (includes
obstetrician/gynecologist, family doctor/general practitioner, midwife,
nurse/nurse practitioner, and prenatal/childbirth classes) and other
(doula, books and the Internet). Prenatal classes were grouped into the
health care system category because this is a formalized source of
information provided by licensed nurses or childbirth educators
certified by agencies such as Childbirth and Postpartum Professional
Association of Canada. (17)
[FIGURE 1 OMITTED]
Two different constructs--received support and perceived support
(18) --were used to measure the social support. We used a nominal
variable which measured who was present during labour/birth (no one,
companion only, husband/partner only and both companion and
husband/partner) as proxy for received support, as this was the only
variable in the MES that was related to received support. The most
frequently identified support person in the literature is the
husband/domestic partner (19) and studies have indicated that the
effects of support from husbands or partners can be distinguished from
that of other family members or friends. (19) Perceived support is an
ordinal variable with five categories ranging from "none of the
time" to "all of the time".
Outcome variables: Pre- and postnatal health information
Pre- and postnatal health information was measured using indicators
summarized in Table 1. These 19 indicators were used to define latent
variables through exploratory factor analysis (EFA) and in structural
equation models described below. EFA was conducted to extract common
factors within the 9 prenatal and the 10 postnatal health questions.
(20) Indicators with a minimum factor loading of 0.32 were considered to
be part of a factor because this value implies that the factor has
approximately 10% of overlapping variance with other items on that
factor. (21) In the case of cross-loading, wherein an item loads above
0.32 on two or more factors, it was retained for the factor onto which
it loaded the highest, unless the literature suggested otherwise.
Statistical analysis
Given that the outcome variables are latent constructs not directly
measured, we used Structural Equation Modeling (SEM) in the analysis.
Weighting was conducted according to published Statistics Canada
guidelines. (8) The sample was stratified by parity into two groups:
primiparous and multiparous. Parity is defined as "the number of
live births a woman has had to date (excludes fetal deaths or
stillbirths)". (22)
We split the sample into two random subsamples of equal size. EFA
was performed in the first subsample, and confirmatory factor analysis
(CFA) was performed in the second subsample to cross-validate results
from the EFA. Results of the cross-validation were measured using
Chi-square and RMSEA (Root Mean Square Error of Approximation).
SEM was conducted using an approach as suggested by Schumacker and
Lomax (23) and Bollen. (24) The Multiple-Indicator Multiple-Cause
(MIMIC) model is a special case of SEM that integrates predictor
variables for both the prenatal and postnatal structural models (24)
(Figure 1). Four MIMIC models were constructed, by adding the factors
that were associated with pre- and postnatal health information to the
four structural models: prenatal and postnatal health information models
for each of the primiparous and multiparous samples. Model fit was
assessed using several global indices: Chi-square, RMSEA and the
Adjusted Goodness-of-Fit Index (AGFI). Backward selection was used to
create a parsimonious model. All analyses were conducted using R version
2.12.1.25
RESULTS
Final model
Table 2 presents weighted sample characteristics. Table 3 presents
results for EFA; there are three prenatal factors ("pregnancy
experience", "labour/birth experience", "medical
concerns") and two postnatal factors ("postnatal
concerns" information and information on "negative
feelings"). CFA in the cross-validation subsample resulted in
impressive goodness of fit indices (Chi-square p=0.10, RMSEA=0.03),
suggesting that results from EFA are valid in this population. Overall,
both the primiparous prenatal and postnatal MIMIC models (RMSEA <0.05
for both models) fit better for the primiparous sample when compared to
the multiparous sample (RMSEA <0.08 for both models). Examination of
the frequency of responses for the 19 questions on pre- and postnatal
health indicated that both primiparous and multiparous groups did not
have sufficient information on the same topics (results not shown). Of
all the information topics examined, the topics for which the fewest
participants (both primiparous and multiparous women) felt they had
sufficient information included: formula feeding, pain
medication/anesthesia, warning signs/complications, and changes in
sexual responses. For example, only 72% of the primiparous women and
79.4% of the multiparous women reported having sufficient information on
changes in sexual responses. Approximately 79.8% of primiparous and 83%
of multiparous women felt they had sufficient information on pain
medication/anesthesia while 80.6% of primiparous and 85.3% of
multiparous women felt they had sufficient information on warning
signs/complications. Additionally, only 72.7% of primiparous and 83.6%
of multiparous women felt they had sufficient information regarding
formula feeding.
Influence of various factors on information levels
Table 4 presents results of the MIMIC models. Income, most useful
information source (prenatal) and perceived level of social support
(prenatal and postnatal) were found to be significantly associated with
pre- and postnatal health information components in both primiparous and
multiparous samples.
Participants above the LICO were more likely to have greater
information on all three prenatal information components as well as
postnatal information on "negative feelings" for both samples.
Individuals whose most useful prenatal information source was their
family/friends were more likely to have information on "pregnancy
experience" in both the primiparous and multiparous samples.
However, this informational source was also associated with an increase
in "medical concerns" information for the primiparous sample
only. Those whose most useful information source was the health care
system were more likely to have information on "labour/birth
experience" and "medical concerns" for both samples. In
both samples, perceived level of prenatal and postnatal social support
were associated with all prenatal and postnatal information components,
respectively.
DISCUSSION
This study provides insight on Canadian women's perceived
knowledge gaps of pre- and postnatal health information and also
identifies factors that influence the levels of information on these
topics. Participants from the multiparous sample reported a sufficient
level of information on a greater variety of pre- and postnatal health
topics compared to the primiparous group. Multiparous women are more
likely to know about pregnancy and childbirth before their index
pregnancy, (11) and having had a previous pregnancy was associated with
greater use of oneself as an information source. (26) However, both
groups lacked information on the same topics. This common finding
underscored the fact that these informational needs had a large impact
on the entire population of pregnant women, rather than being
parity-specific.
In terms of prenatal topics, both groups lacked information on the
side effects of pain medication/anesthesia and warning
signs/complications. This lack of information may affect the health of
the mother and fetus, as well as influence a woman's satisfaction
with labour and delivery. It has been shown that not reporting signs of
pre-term labour during routine prenatal visits can lead to poor birth
outcomes. (27) Having greater knowledge about warning signs of
complications in pregnancy may prevent these outcomes. It has also been
noted that women who were very anxious about their labour pain
prenatally were less satisfied after the birth. (28) Increased education
regarding analgesic options may target the incongruence between expected
and experienced pain management during labour and may increase
satisfaction. For the postnatal topics, both groups lacked information
on changes in sexual responses and formula feeding of the baby. These
postnatal topics may arise after the standard six-week follow-up
appointment with the obstetrician/gynecologist, the most common provider
of prenatal care for both groups. Therefore these findings suggest that
informational resources regarding these postnatal topics may not be
accessible to both primiparous and multiparous women.
Income was a significant predictor of the level of acquired
information in both samples. In particular, being categorized above the
LICO was significantly associated with an increase in acquired
information level for "pregnancy experience",
"labour/birth experience", "medical concerns" and
"negative feelings" for both samples. This finding is
reinforced by the literature which has identified that low-income women
have less exposure to health information compared to women with higher
incomes, and also that information choices for these women are
restricted. (29)
The results illustrate that as perceived level of social support
increases, information levels for all pre- and postnatal components are
significantly likely to increase in both samples. As well, the effect of
perceived social support demonstrated the largest magnitude when
compared with all other factors, underscoring its important,
parity-independent role of information acquirement.
The findings of this study show that both primiparous and
multiparous women who reported the health care system as their most
useful information source were more likely to report having sufficient
information for "labour/birth experience" and "medical
concerns". Because this health care system category is comprised of
medical professionals such as general practitioners and obstetricians,
it is reasonable to believe that these sources would provide adequate
information on the medical components of the labour and birth. For
example, studies indicate that obstetricians/gynecologists are highly
involved in the prenatal care and labour/birth processes, and those
women who used health care professionals as main sources of information
are more likely to have started prenatal care in the first trimester.
(11) Family physicians can be involved in all stages of maternity and
infant care, and the general practitioner is the most likely source of
information for pregnant women overall. (30) The role of nurse
practitioners has recently been expanding in Canada. The perceived role
of the labour and delivery nurse is to be a source of physical comfort
and emotional support, to provide technical and nursing care and to
conduct routine monitoring. (31) Care by the midwife is considered very
valuable, and there are reports that these health care providers were
rated the highest in terms of quality of supportive care during birth.
(7)
Limitations
The fact that study participants were interviewed several months
after the birth may impact their recall of some pregnancy and birth
events, and their evaluation of maternity care. (32-34) This is
important to consider in this study because the information levels were
self-reported. Therefore women whose infants had poor birth outcomes may
have underestimated the level of information they had for a topic
related to that birth outcome. As well, the secondary nature of the data
restricted the information that could be used in the study, such as in
the cases of perceived and received social support where proxy variables
were used rather than validated scales.
CONCLUSIONS
To the best of our knowledge, this is the first study to assess
pre- and postnatal health information using structural equation modeling
analysis. It has been illustrated that pregnant women in Canada require
additional information on a range of topics, and that income and level
of perceived social support have significant influence on these
information levels. This research provides an opportunity for
women's views to be incorporated into the development of perinatal
health policies and practices.
Received: January 9, 2012
Accepted: May 21, 2012
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Sabrina Youash, MSc, [1] M. Karen Campbell, PhD, [1] William
Avison, PhD, [1,2] Debbie Penava, MD, [3] Bin Xie, PhD [1,3]
Author Affiliations
University of Western Ontario, London, ON
[1.] Department of Epidemiology and Biostatistics
[2.] Department of Sociology
[3.] Department of Obstetrics and Gynaecology
Correspondence: Dr. Bin Xie, Department of Epidemiology and
Biostatistics, University of Western Ontario, Room E2-620B, LHSC-VH, 800
Commissioners Road East, London, ON N6A 5W9, Tel: 519-685-8500, ext.
55174, E-mail: bxie5@uwo.ca
Conflict of Interest: None to declare.
Table 1. Indicator Variables for Pre- and Postnatal Health
Information Factors Derived From the MES
Type of Indicator (Did you have sufficient information on...)
Information
Prenatal SI_Q01: Sufficient information on physical changes
health SI_Q02: Sufficient information on emotional changes
information SI_Q03: Sufficient information on warning signs/
complications
SI_Q04: Sufficient information about effects of
medication on baby
SI_Q05: Sufficient information on what to expect
during labour/birth
SI_Q06: Sufficient information on partner support
SI_Q07: Sufficient information about medication-free
pain management
SI_Q08: Sufficient information about potential side
effects of pain medication/anesthesia
SI_Q09: Sufficient information about ultrasound/
amniocentesis (medical procedures)
Postnatal PI_Q01: Sufficient information on effects of baby on
health relationship
information PI_Q02: Sufficient information on physical demands on
body
PI_Q03: Sufficient information about SIDS
PI_Q04: Sufficient information about car seat use
PI_Q05: Sufficient information about negative
feelings following birth
PI_Q06: Sufficient information about postpartum
depression
PI_Q07: Sufficient information about birth control
following pregnancy
PI_Q08: Sufficient information about changes in
sexual responses
PI_Q09: Sufficient information about breastfeeding
PI_Q10: Sufficient information about formula-feeding
baby
Table 2. Weighted Sample Characteristics
Variable Primiparous Multiparous *
Education <High school 8.5% 8.1%
High school 13.5% 13.6%
Trade/College 41.6% 44.0%
greater than or equal
to] Bachelor's 35.3% 33.6%
Missing 1.1% 0.7%
Marital Status Married 60.8% 70.8%
Common law 26.5% 22.1%
Single 11.0% 4.6%
Separated/Divorced/
Widowed 1.3% 2.4%
Missing 0.02% 0.1%
[less than or equal
Income to]Low Income 16.9% 21.3%
>Low Income 83.0% 78.7%
Missing 0.2% 0.0%
Region Rural 17.7% 17.9%
Urban 82.1% 82.1%
Missing 0.2% 0.0%
Age 15-24 24.7% 7.2%
25-29 34.3% 26.2%
30-34 28.0% 39.7%
[greater than or
equal to]35 12.8% 26.9%
Prenatal care Ob/Gyn 53.7% 58.2%
provider Family doctor/GP 36.7% 34.5%
Nurse/midwife 6.7% 6.5%
Other 1.1% 0.4%
Missing 1.7% 0.5%
Most useful Family/Friends 17.4% 4.7%
info. source Health care system 40.1% 37.9%
(Prenatal) Other 41.5% 56.8%
Missing 1.1% 0.6%
Most useful Family/Friends 32.5% 11.0%
info. source Health care system 33.6% 30.1%
(Postnatal) Other 26.9% 52.9%
Missing 7.0% 6.1%
Received None 0.5% 1.7%
social support Companion only 3.6% 3.3%
Husband only 54.3% 70.6%
Both 40.8% 23.5%
Missing 0.7% 0.9%
Perceived None of the time 0.8% 1.9%
social support A little of the time 3.1% 4.3%
(Prenatal) Some of the time 6.7% 8.8%
Most of the time 27.7% 31.1%
All of the time 61.4% 53.7%
Missing 0.3% 0.3%
Perceived None of the time 1.0% 1.8%
social support A little of the time 3.1% 5.2%
(Postnatal) Some of the time 8.8% 11.5%
Most of the time 31.8% 33.6%
All of the time 55.1% 47.7%
Missing 0.3% 0.2%
* Note: Previous pregnancy is included in the "Other"
category as a source of information for multiparous women
only.
Primiparous: 45.3%, Multiparous: 54.3%.
Table 3. Exploratory Factor Analysis--Factor Loadings
Prenatal Model: Primiparous Sample
Item Factor 1- Factor 2- Factor 3-
"Pregnancy "Labour/Birth "Medical
Experience" Experience" Concerns"
SI_Q01 0.803 0.221 0.117
SI_Q02 0.739 0.340 0.137
SI_Q03 0.758 0.149 0.398
SI_Q04 0.531 0.221 0.326
SI_Q05 0.353 0.686 0.299
SI_Q06 0.260 0.883 0.223
SI_Q07 0.204 0.640 0.454
SI_Q08 0.227 0.433 0.753
SI_Q09 0.402 0.275 0.502
Prenatal Model: Multiparous Sample
Item Factor 1- Factor 2- Factor 3-
"Pregnancy "Labour/Birth "Medical
Experience" Experience" Concerns"
SI_Q01 0.805 0.252 0.230
SI_Q02 0.751 0.351 0.282
SI_Q03 0.701 0.275 0.396
SI_Q04 0.582 0.317 0.377
SI_Q05 0.457 0.738 0.253
SI_Q06 0.381 0.684 0.411
SI_Q07 0.222 0.574 0.602
SI_Q08 0.296 0.387 0.770
SI_Q09 0.435 0.214 0.557
Postnatal Model: Primiparous Sample
Item Factor 1- Factor 2-
Postnatal "Negative
Concerns Feelings"
PI_Q01 0.726 0.384
PI_Q02 0.741 0.382
PI_Q03 0.362 0.551
PI_Q04 0.331 0.320
PI_Q05 0.447 0.832
PI_Q06 0.334 0.940
PI_Q07 0.561 0.270
PI_Q08 0.767 0.406
PI_Q09 0.413 0.250
PI_Q10 0.467 0.149
Postnatal Model: Multiparous Sample
Item Factor 1- Factor 2-
Postnatal Negative
Concerns Feelings
PI Q01 0.726 0.384
PI_Q02 0.741 0.382
PI_Q03 0.362 0.551
PI_Q04 0.331 0.320
PI_Q05 0.447 0.832
PI_Q06 0.334 0.940
PI_Q07 0.561 0.270
PI_Q08 0.767 0.406
PI_Q09 0.413 0.250
PI Q10 0.467 0.149
Table 4. MIMIC Model
Primiparous
Factors Pregnancy Labour/
Experience Birth
Income 0.2179 * 0.1030 *
Education <High school -0.0025 0.0061
High school 0.0192 0.0039
College/Trade 0.0196 0.0114
Age 15-24 0.0181 0.0695
([double
dagger])
30-34 -0.0376 0.0054
[greater than 0.0276 0.0046
or equal to]35
Most Family/Friends 0.0577 0.0620
useful ([double
info. dagger])
source Health care -0.0127 0.0776
(Prenatal) system ([dagger])
Perceived social support
(Prenatal) 0.2351 * 0.2328 *
Perceived social support
(Postnatal) -- --
Primiparous
Factors Medical Postnatal Negative
Concerns Concerns Feelings
Income 0.1531 * 0.0263 0.1910 *
Education <High school -0.0199 -0.0049 0.0029
High school 0.0090 0.0213 0.0370
College/Trade -0.0296 0.0070 0.0055
Age 15-24 0.0084 -0.0182 -0.0628
([double
dagger])
30-34 -0.0171 0.0177 -0.0072
[greater than 0.0279 0.0176 0.0176
or equal to]35
Most Family/Friends 0.0528 -- --
useful ([section])
info.
source Health care 0.0776 -- --
(Prenatal) system ([dagger])
Perceived social support
(Prenatal) 0.1655 * -- --
Perceived social support
(Postnatal) -- 0.2161 * 0.2177 *
Multiparous
Factors Pregnancy Labour/
Experience Birth
Income 0.1983 * 0.1435 *
Education <High school -0.0056 -0.0231
High school -0.0211 -0.0043
College/Trade 0.0117 0.0027
Age 15-24 -0.0356 -0.0001
30-34 0.0030 0.0052
[greater than -0.0151 -0.0313
or equal to]35
Most Family/Friends 0.0611 0.0340
useful ([double
info. dagger])
source Health care -0.0153 0.0578
(Prenatal) system ([section])
Perceived social support
(Prenatal) 0.3514 * 0.2618 *
Perceived social support
(Postnatal) -- --
Multiparous
Factors Medical Postnatal Negative
Concerns Concerns Feelings
Income -0.0899 -0.0028 0.065
([section]) ([dagger])
Education <High school 0.0169 0.0274 0.0225
High school 0.0672 0.0032 0.0193
([section])
College/Trade -0.0208 0.0121 -0.0037
Age 15-24 0.0084 0.0110 0.0026
30-34 0.0092 -0.0047 -0.0053
[greater than -0.0145 -0.0113 -0.0170
or equal to]35
Most Family/Friends 0.0081 -- --
useful
info.
source Health care 0.1493 * -- --
(Prenatal) system
Perceived social support
(Prenatal) 0.3223 * -- --
Perceived social support
(Postnatal) -- 0.3572 * 0.2875 *
* p<0.0001, ([dagger]) p<0.001, ([double dagger])
p<0.01, ([section]) p<0.05
